AVIATION ACCIDENT INVESTIGATION AND INCIDENT REPORTING
Abstract
Aviation safety is enhanced by establishing the causes of aircraft accidents and incidents. Identifying the causes of accidents ensure that future incidents can be averted. According to the Chicago Convention, Article 26 of the convention that countries where aircraft accidents have occurred to carry out investigations. The ICAO states that investigation authorities shall be granted all authority when conducting the investigations. The investigations are to be independent with no outside interference. The paper aims to analyse five aircraft accidents and incidents by looking into how investigations were conducted. At the end of each analysis, recommendations will be provided for each accident or incident.
Introduction
Safety in the aviation industry is important in preventing the loss of lives and the destruction of aircraft. Therefore if there has been an incident, it should be investigated properly to prevent future occurrences. The Chicago Convention requires that there is no interference in the investigations to come up with conclusive results and recommendations to avert future disasters. The paper will discuss five aircraft incidents and accidents highlight ways they could have been prevented. Don't use plagiarised sources.Get your custom essay just from $11/page
Space Shuttle Columbia
Organisation culture at NASA
On January 28, 1986, the Space Shuttle Challenger broke up seven three seconds into its flight. The space shuttle disintegrated into the Atlantic, killing all its seven crew members. The space shuttle was allowed to take off despite concerns over the decrease of temperatures to below freezing point. The extremely low temperatures would comprise the integrity of the solid rocket boosters (Edy, p.131). Allan McDonald, director of the Space Shuttle Solid Rocket Motor Project, had refused to authorise the launch recommendation of the Challenger.
After the crash, a task force led by William P. Rogers, the former attorney general, was commissioned to look into the incident. The task force concluded that bad weather conditions were to blame as the cold temperatures degraded the seal of the solid rocket boosters. The rocket boosters ensure that the space shuttle can power its way into orbit. The report also concluded that NASA was also to blame for the crash. The culture at NASA was responsible for the crash as the launch decision team was not provided with enough information to decide whether it was safe for the shuttle to launch (Edy, p.132). The report stated that the Challenger’s flight rate could not be sustained due to the size of the workforce. NASA vowed to address the technical aspects that led to the crash of the Challenger and also agreed to transform its culture.
However, the agency has been unable to learn from its mistakes, as witnessed in the crash of the Columbia Space Shuttle. In a 248 page report, the Columbia Accident Investigation Board stated that NASA and other institutions were to blame for the crash. On the first of February 2003, Columbia Space Shuttle disintegrated while returning to earth and killed all the seven crew members. This was the second crash after the Challenger crashed back in 1986. Investigations concluded that the accident was caused by a huge piece of foam that had fallen off from the shuttles’ external tank (McDaniels p.15). The disintegration of the foam damaged the shuttle’s wing causing it to crash. NASA received heavy criticism issues to do with the foam that has been present for a long time. The agency had been aware of the issue but had not made efforts to rectify the issue. After the crash of Columbia, NASA was forced not to continue with space shuttle flights.
The investigation board claims that NASA lacks an independent safety program and does not have checks and balances in place. The organisation at culture is that off reacting when an incident occurs and then goes back to normal when the incident is forgotten. The culture at NASA was blamed for not identifying threats the foam posed to the shuttle (Seife, p.1001). The report stated that NASA culture was equally to blame for the crash just as the foam. Several aspects contributed to NASA’s culture, such as lack of enough resources and increased pressure to set up an international space station. Budget constraints meant that the agency had to downsize its workforce and also outsource some responsibilities, such as enhancing safety. The pressure to set up an international space station meant that NASA was overlooking certain risks to stay on schedule. The political atmosphere at the time was also to blame as it was during the Cold War era (Edy, p.134). The USSR ceased to be a competitor in the space program; hence NASA’s space program lacked an objective. The defeat of the Soviet Union meant the NASA could not secure enough budgets for its operations. The investigation board comes up with several recommendations, but NASA has a history of adhering to external communications.
Efforts that could have prevented the crash
News that the Columbia Space Shuttle had crashed while re-entering the earth reminded people of the crash of the Challenger back in 1986. The investigation board highlighted similarities between the two incidents. In both cases, there was danger as the Challenger had been delayed to take off due to bad weather conditions. Even though engineers were reluctant to allow the Challenger to take off, the go-ahead was still given. Eventually, the bad weather was the reason the Challenger crashed seventy-three seconds into its flight. Columbia also experienced problems during take-off as insulating foam disconnected from the external fuel tank and damaged the shuttle’s external wing (Edy, p.135). NASA was asked whether there was a need for concern, but the agency gave assurances that the damage was no reason for concern.
Both disasters, though caused by technical problems, were still caused by the culture at NASA. The culture at NASA did not favour bottom-up communication as the junior staff did not communicate their concerns to the top management (Hall, p.241). The reason was that junior employees feel that they were not qualified to express their concerns. They were also fear of being reprimanded by the top executives since they lacked evidence to support their claims. In both incidents, there those were calling for abolishing the mission due to safety concerns (Mahler, p.3). However, the concerns were ignored, and employees had become frustrated that their concerns were not put into consideration.
Both incidents could have been avoided if NASA had an effective communication policy. A communication policy that allows opinions from junior employees and does not lead to intimidation of employees would have helped avoid the two accidents. The disintegration of the insulating foam had occurred in other missions, but NASA concluded that it would not result in accidents (Mahler, p.10). Therefore efforts to look into the damage Columbia had experienced during take-off were ignored. Proper safety standards and checks and balances would have seen the damage to Columbia addressed immediately it occurred. If NASA had gotten spy photos to evaluate the extent of the damage, then the incident might have been averted. NASA’s objectives of cost reduction and meeting flight schedules meant that safety was not a top priority for the agency. Safety should be a top priority to avoid future incidents from occurring.
British Airways Flight 268
Decision making by the crew
On February 20, 2005, British Airways Flight 268 departed from LAX Airport in Los Angeles, destined for London. However, during take-off, one of the plane’s engines burst into flames. The events that followed after the plane lost one of its engines shocked the flight control at LAX. It was assumed that the plane would make an emergency landing, but the pilot decided to continue with the 5400-mile journey on three engines. Air traffic control has witnessed the engine burst into flames and initiated contact to guide the plane back to the airport. Though the plane could run on the remaining engines, concerns was whether the pilot had made the right call (L.A Times, 2006).
The plane was not operating on full capacity and due to engine loss, and this meant that the aircraft was consuming a lot of fuel. The pilot was forced to make an emergency landing in Manchester due to concerns that the aircraft might run out of fuel. Once Flight 268 has lost one of its engines, the pilot shut down the affected engine. The pilot soon contacted the operations control team and the British Airways technical team to come up with a solution. The final decision lay with the pilot who opted to proceed with the flight. An aircraft can fly on three engines, but the move taken by the pilot seemed dangerous. Lack of one engine meant that the flight would not be efficient as it would running on four engines (Morris, 2006). The plane would not be fast and could not fly over high altitudes. Flying at low altitudes means the plane was consuming a lot of fuel, and with one engine out, the plane experienced rudder deflection, which further consumed fuel.
Instead of proceeding with the flight to London, the pilot had the option of an emergency landing back at LAX. However, for this to be achieved, the plane had to dump fuel estimate to be worth thirty thousand dollars. The airline would have to pay out $275000 in compensation to passengers for delays caused by repairing the engine. The repairs would take approximately five hours or even more, and according to European law, the figure mentioned above would be paid for delays of more than five hours (McCartney, 2020). The law which came into effect on February 17, 2005, stated that passengers would each receive $523 if there was a delay of more than five hours on trips of more than 2215 miles. The concern was whether the decision to proceed with the flight was made to ensure the airline did not incur any loss (BBC, 2005). However, the airline refuted claims that the decision was an economic one claim it was legal under British law. An inquiry done by the British government concluded that it was safe for the aircraft to continue with the flight. The decision made by the pilot was also communicated to the passengers, and the flight continued with its journey. British Airways indicated that flying with three engines was within normal protocols and that the decisions were not aimed to save the aircraft money.
Should have the FAA charged the Captain
British Airways Flight 268 is a Boeing 747 which is designed to fly one three engines if one of the engines fails. However, investigations carried out by the FAA indicated that the aircraft was flying in an unairworthy condition. The FAA concluded that the airline be fined $25000, but the FAA opted for an out of court settlement. The decision to fine the airline is welcomed since the flying such an aircraft posed serious security concerns. The airline could run on three engines but would not be efficient (L.A Times, 2006). Flying on three engines meant that the aircraft would be slow and flying over low altitude. All these conditions would cause the aircraft to drag, consuming more fuel. If the plane had lost fuel and lacked a place for an emergency landing, then that would be a disaster. The flight would also face serious difficulties if it lost another engine, especially if the engines were on the same side. The plane would have thrust coming from one side, and the plane would have to use the rudder to keep it straight extensively. This would, in turn, would lead to more fuel consumption, and if the plane were on the ocean, then chances of reaching an airport would be minimal.
ValuJet 592
ValuJet’s growth
On October 26, 1993, ValuJet began its operations, and the goal of the airline was to provide cheap fares daily on all destinations the airline. ValuJet flew different locations and offered cheap fares, mostly targeting leisure travellers. The move was successful as the airline started generating a profit and was performing well compared to other airlines. The airline began operations with two DC-9 aircraft, mainly flying to Jacksonville, Tampa, and Orlando (Cook, p.213). Two years after the airline began operations, it announced that it was purchasing an additional fifty aircraft and would be flying to thirty-one new destinations. The airline was performing well, making it a successful start-up. However, on May 11, 1996, tragedy struck the airline after a ValuJet DC-9 crashed into the Florida Everglades. The flight, which was headed to Atlanta from Miami, crashed, killing all one hundred and ten passengers on board.
Investigations into the cause of the crash did not provide a conclusive reason for the crash. However, investigators believe that the crash was caused by oxygen canisters containing flammable substances present in the plane (Burkland, p.50). The crash raised questions on the safety of the airline. ValuJet operations were not similar to those of other airlines. The airline did not have advanced seating or first class, no full meal services, and operated a ticketless passenger system. The airline also charged cheaper fares and relied on older aircraft raising concerns over safety. The rapid growth of ValuJet had adverse effects on its operations, especially several delays and cancellations during winter. The airline also experienced issues such as aircraft having broken landing gear or veering off the runway. The quick growth of ValuJet and its reliance on old aircraft meant that the airline was unable to deal with its growth comprising on safety (Matthews, p.282). The FAA was forced to ground operations at ValuJet until it established airworthiness. The airline had grown very fast by offering low fare prices and acquiring old aircraft. The growth strategy was criticised for compromising on safety.
Response
The issue of growth is one of the reasons ValuJet Flight 952 crashed into the Florida Everglades, killing everyone on board. It would be difficult to move on with investigations of the issue that is not addressed to prevent future accidents. Competition in the airline industry made ValuJet embarked on a strategy to purchase old aircraft and offer lower prices. The focus was on cost reduction instead of guaranteeing safety. If safety were a primary concern, then the oxygen canisters would not have been filled with flammable substances. The employees tasked with ensuring the oxygen canisters were properly installed had slept on the job. Therefore airlines focused on growth, and ignoring safety will result in serious disasters in the industry.
Alaska Airlines 261
CVR data and crew actions
On January 31, 2000, Alaska Airlines Flight 261 crashed and plunged into the Pacific Ocean. Everyone aboard the ill-fated aircraft was killed in the crash. Investigations concluded that the flight was caused by the plane losing pitch control. The loss was attributed to the lack of lubrication of the jackscrew assembly (Board, p.127). The lack of lubrication jammed the stabilizer causing the aircraft to lose pitch control (Board, p.135). The flight crew tried to restore the jammed stabilizer for close to twelve minutes to maintain the aircraft’s’ altitude. During this time, the crew ensured that every passenger had fastened their seatbelts and safely seated in their seats (Board, p.135).
The cockpit voice recorder captured pilots explaining to air traffic control on the issue of the jammed stabilizer. The voice recorder also captured that loud noise that was produced when the aircraft lost its stabilizer. When this occurred, the crew were heard instructing the passengers on the cause of the sound. Another loud bang could also be heard before the aircraft plunged into the Pacific. The pilots had managed to navigate the plane in the air and had even requested an emergency landing at Los Angeles Airport (Morris, p.28). The CVR captured traffic control asking why the pilot preferred LAX to San Francisco. The pilot cited that LAX had favourable weather conditions than San Francisco. The pilots also requested for assistance to troubleshoot the jammed horizontal stabiliser but received no response. Air traffic control instructed that Flight 261 would have to land after one and a half hours due to the high flow of traffic at the airport. The aircraft was cleared to descend but plunged into the ocean before it could land at LAX (Woltjer, p.83).
FAA oversight
Investigations concluded that Flight 261 had crashed because the jackscrew had not been greased. The report by the National Transport and Safety Board also indicated that the aircraft had been cleared according to FAA regulations. The board also criticised the FAA for not overseeing maintenance procedures implemented by the airline. The FAA allowed the airline not to continue lubricate and jackscrew assembly, which caused the crash. The FAA had failed in its mandate to enhance air safety, and together with Alaska Airlines, they were to blame for the crash.
NTSB board member statements
The NTSB allowed for board members’ statements to be included in the report because it is an important process of writing the report. Public hearings are conducted to collect all the available facts before the final report is prepared. The hearing may involve testimonies for witnesses who may include manufacturers, air traffic control, passengers, or crew that might have survived and FAA regulators. From the hearings, the board will then prepare the final report. Statements from board members will be included in the report since they may contain recommendations that can be immediately implemented. Quick implementation can avert a crisis instead of waiting for the final report to be completed.
Recommendations
A flaw could have also caused the crash of Flight 261 during manufacturing. Therefore, the FAA was required to instruct Boeing to redesign the jackscrew assembly on its aircraft. The FAA should continue inspecting Alaska Airline’s maintenance procedures despite protests from the NTSB. The FAA should have revoked the license of employees who violated safety regulations and fining the aircraft for failing to adhere to safety standards.
Japanese Airlines Boeing 787-8 JA829J
Manufacturing process
An incident occurred at General Edward Lawrence Logan International Airport in Boston. Workers discovered smoke in the cabin of Japanese Airlines Boeing 787-8 JA829J. Another incident was witnessed in the cockpit; the auxiliary power unit had automatically shut down. The APU battery case would later catch fire, but luckily, no passengers or crew members were aboard the plane (Lavoie, p.283). The APU battery model was similar to the one used on the main battery of the 787. In 2013, there was a similar incident with another 787 aircraft belonging to All Nippon Airways. The fires were caused by a short circuit that increased pressure and temperature.
During the manufacture of the Boeing 787, Boeing contracted Thales Electrical Systems to design the 787 electronic system. Thales then contracted GS Yuasa to design the main and APU batteries. Boeing was required to show if the batteries complied with FAA requirements (Walker, p.370). The aircraft manufacturer conducted a safety evaluation to determine potential dangers the electric components posed to the aircraft. After the evaluation that batteries installed in the 787 would experience cell venting one in ten million hours of flight. However, by the time the incident at the Boston airport occurred, the aircraft had flown for more than fifty thousand hours (Kolly, p.7). The incident made Boeing make changes to the design of its batteries. The batteries would be fitted with a duct from the inside the batteries enclosure to the outside of the plane. This was done to ensure that the interior of the plane does not catch fire. The batteries also required testing under extreme conditions to ascertain how they would react when exposed to such conditions (Willard, p.4682).
Recommendations
The FAA should have ensured that the tests carried out on the batteries would have been done under extreme conditions to assess if they would short circuit. An example of such a test was the thermal runaway test, which was required before the FAA ruled that Boeing had complied. The FAA would also have instructed the FAA to provide a framework of how they would mitigate risks once they occurred (NTSB, p.16). The FAA should also outsource the services of independent institutions. Such institutions with the necessary expertise would assist the FAA in ensuring the airworthiness of new aircraft technology.
Conclusion
Aircraft investigations are important as they establish the cause of accidents and come up with ways of preventing future accidents. Aircraft investigations are the reason why air transport is one of the safest modes of transport. The investigations have to be thorough; hence some may go for years before they are completed. The huge pressure investigators face from various stakeholders may negatively affect the investigation process. Therefore investigations authorities must be independent to come up with proper conclusions and recommendations. The future is to increase the number of people using air transport; hence demand will be high. Therefore improvement of safety in the aviation industry is necessary. Airlines should partner with metrological departments to ensure that bad weather conditions are predicted on time. Innovations such as unmanned aircraft, alternative fuels, artificial intelligence enhance the safety of aircraft. Planes should be fitted with technologies to assisting in landing and taking off and preventing runway excursions.
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