On June 10th 1990 in the UK, a BAC1-11 (British Airways flight 5390) was climbing through 17,300 feet on departure from Birmingham International Airport when the left windscreen, which had been replaced prior to flight, was blown out under the effects of cabin pressure when it overcame the retention of the securing bolts, 84 of which, out of a total of 90, were smaller than the specified diameter. The commander was sucked halfway out of the windscreen aperture and was restrained by cabin crew whilst the co-pilot flew the aircraft to a safe landing at Southampton Airport. 1 The sole intention for executing this project is to develop a clear understanding of various effects of air crash due to variables including, but not limited to, human error, maintenance faults, poor communication, management failures and financial restraints of aircraft organisations, examining British Airways specifically. The aims of this study are to closely investigate the incident of the British Airways BAC-One Eleven G-BJRT over Didcot Oxfordshire in 1990 and to understand the influence of human factors in the aviation industry.
According to the International Journal of Aviation Psychology; “General aviation accidents represent 70% to 90% of all aviation accidents. Human error is implicated as a contributory factor in 85% of these crashes.” 2 These statistics show that the aviation industry has acknowledged that human error causes most aviation accidents. The expected benefits of this study are wildly extensive. Harnessing the growing body of human behaviours’ awareness will boost the performance of Civil Aviation Authority (CAA) to minimise the number of incidents by diminishing human error and refining worker skills, through trainings and programs, and other personnel to avoid accidents related with other causes. If the findings of this study are thoroughly understood and followed, the changes in the way organisations handle design, training, adhere to policies and procedures will most likely improve.
AIMS The aims of this project are to successfully investigate the accident of British Airways BAC- One Eleven G-BJRT over Didcot, Oxfordshire in 1990. In over a decade, technologies have and will, inevitably, continue to improve and evolve so the question of whether the investigation report, completed by Mr D F King – an Inspector of air accidents, on the accident of the BAC-One Eleven G-BJRT was the best they could have concluded or if all aspects were covered and thoroughly examined so if it were to happen in this day of age, how different would circumstances be and severity of its impact – is the main reason why this study is conducted. Furthermore, this study aims to understand human behaviours contribution in air accidents and its effects on safety performance. This study aims to discover whether the incident was a simple software glitch that failed to alert the pilots on-board during safety checks or was it a lack of safety awareness for the maintenance crew. In this report, all the findings and conclusions will aim to cover these topics.
OBJECTIVESTo achieve the aims stated, the following will be necessary: Explore different departments that could have influenced the occurrence of the accident – questions such as “Was there ever a recruitment problem in the years leading up to 1990? Could it be lack of training? Does BA fail to emphasise safety?” these are examples of what this study will conclude. In-depth analysis on maintenance unit covering topics such as maintenance plans, how materials and items are tracked and looking in on the regularity of maintenance inspections and transit checks with a review on governing bodies e.g. CAA Examine problems within the management sector – analysis on company culture and possible financial restraints BA experienced. Discuss the evolution of aircraft technologies – using a chart to show comparisons of how tools used then vs what is being used currently Analyse the fundamentals of human behaviours effect on safety performance Investigate the importance of human error by conducting an experiment Review the programs and required trainings British Airways provide for staff 1.3 MOTIVATION AND TARGET AUDIENCE Each individuals are responsible for ensuring safety and rules and regulations are being adhered to.
The results and findings from this study could possibly have applications in the industry that could encourage organisations to consider implementation for improved airworthiness of aircraft, lower the levels of the effects, improve accessibility to materials and even for improving company’s management skills. This study will promote the needs to continue to invest in trainings, equipment, and systems that have long-term implications as technology continues to advance rapidly. This project is executed to deliver real-world recommendations founded from data found on the investigation of BAC One- Eleven G-BJRT, supported by primary and secondary data including published records, journals, articles, and a practical experiment to gather primary data. 2.0 PLANNING The Gantt chart (figure 1.0 and 1.2) shows the key deadlines and task specifications for this study. They are displayed in “summary” and the tasks required to complete the report follow below. This effectively shows the workload distribution – helping put problems or tasks into perspective and how to proceed with the project.
It is critical for the tasks to be completed on time as this could slow down the process of the study. E.g. getting in-touch with a maintenance crew in British Airways, if the allocated time is not adhered to and potentially exceeds time, that delays the following tasks as findings for that particular study is needed to make progress. In a similar way if there are delays in ordering parts, practical work cannot proceed with incomplete parts. Therefore, the consistency of ensuring the tasks set in that certain time-frame are completed is important to meet the deadline for the final report submission date.
The Gantt chart aids as a visual guidance to assist with the distribution workload and ensuring work is completed on time. 3.0 SOURCES OF INFORMATIONthe books, journals and articles identified in the following are aids to this study’s completion. It must be considered that these are potentially not as accurate as they are not up-to-date and could be falling behind in information. Beyond Aviation Human Factors Daniel E Maurino, James Reason, Neil Johnston and Rob B Lee – 1998 Daniel E Maurino et al, believes that a systematic organisational method of approach to flight safety requires altering methods preferred in the past.
Identical safety faults are becoming recurring features in accident reports rather than displaying new varieties. This indicates the necessity to analyse and study the traditional accident prevention strategies, looking in-depth on the activity or in-activity of operational personnel. The book has been adopted by ICAO, IMO and many others. 3 Investigating Human Error: incidents, accidents and complex systems Barry Strauch – 2002 This book appears beneficial as it shows references to both systematic research and investigative studies in a widespread of applications.
Maintenance Resource Management: A key process initiative to reduce human factors in aviation maintenance Muhammad Habibullah Siddiqui, Assad Iqbal, Irfan Anjum Manarvi – 2012 MRM is a process for improving communication, effectiveness and safety in aircraft maintenance operations. This study covers the different aspects of human factors and how MRM training can reduce the human error coefficient from an aviation maintenance setup. 4 Additional articles and journals include: Human factors in aviation maintenance: how we got to where we are? By Anand K. Gramopadhyea Human Factors in Aviation Maintenance: Challenges for the Future. By Anand K. Gramopadhye, Colin G.
Drury et al. ICAO: human factors, management and organization. By Jose D Perez Gonzalez. RISK AND THREAT ASSESSMENTAPPENDIX B: Project Resources ChecklistThis appendix must be included with the Project Plan. Student’s Name: Cleo De Guzman SRN: 15043359 Project Title: RETROSPECTIVE INVESTIGATION INTO THE ACCIDENT OF BAC- ONE ELEVEN G-BJRT OVER DIDCOT OXFORDSHIRE Supervisor’s Name: Dr. Rachel Cunliffe Date: 26/10/2018 Please enter below your BEST ESTIMATES for the information requested.
You will not be penalised for small errors and later genuine changes – only for not bothering! 1 Will materials or components be ordered? Yes No 2 Will you be designing a PCB or drawing which will require manufacture during the course of your project? (Note that this should only be contemplated where absolutely necessary for the success of the project!) Yes No 3 Will PCB or drawing assemblies already designed and manufactured within the School be required? Please specify: Yes No 4 Will a PC be required for work other than for report writing? Yes No 5 If the answer to 4 is Yes, will you require any special hardware installed/attached (f.e. PROM emulation, USB interface). Please specify: Yes No 6 Will you require specific software, other than word processing? (Please specify): Yes No 7 Will your project require technical staff to make items requiring workshop facilities? Yes No 8 If the answer to 7 is Yes, which of the following workshop activities will be required (please circle): Drilling Sheet metal forming Lathe work Milling Other (Please specify) 9 Are there other resources required, not covered above? (Please specify): Yes No APPENDIX C: Project Risk, Ethics and Threat Assessment ChecklistThis appendix must be included with the Project Plan. In addition, it is important that a university Risk Assessment Form is also completed and submitted as a separate item on StudyNet. Please PRINT all information CLEARLY Student’s Name: Cleo De Guzman SRN: 15043359 Project Title: RETROSPECTIVE INVESTIGATION INTO THE ACCIDENT OF BAC- ONE ELEVEN G-BJRT OVER DIDCOT OXFORDSHIRE Supervisor’s Name: Dr. Rachel Cunliffe Date: 26/10/2018 Please enter below your BEST ESTIMATES for the information requested.
1 Is your project likely to involve either deliberate, or possible accidental use or contact with:Voltages above 30V High currents at low voltage (f.e. lead acid batteries) Rotating machines High temperatures Hazardous fluids or gases Yes No 2 Will your project involve attaching electrodes to yourself or someone else In such a way as to produce low impedance contact? Yes No 3 If the answer to 2 is Yes, has an assessment of the risk in the planned procedure been carried out? Yes No 4 If the answer to 2 or 3 is Yes, does the analysis show an acceptable level of risk? Yes No 5 Are any substances classified as being ‘Hazardous to Health’ likely to be used in the course of your work? Yes No 6 Are any flammable substances likely to be used in the course of your work? (eg volatile cleaning agents, paint, etc.) Yes No 7 Are there any other aspects of your projected work which might impose a danger to yourself or to others? (Please specify): Yes No Notes: If the answer to any of these questions is YES, it is the responsibility of the Supervisor to ensure that the risk established is evaluated and brought to the attention of the Head of School before work proceeds. Ethical Issues 8 Will your work involve measurements on human subjects or their behaviour? Yes No 9 Will your work involve asking human subjects to answer questions of a personal nature? Yes No 10 Could any aspect of your work cause distress to human subjects participating in your work either knowingly or unknowingly? Yes No Notes: If the answers to any of questions 2, 8, 9, or 10 are YES, the proposed work must be submitted for approval to the Ethics Committee before work proceeds. If you are in any doubt, please consult a member of technical and/or academic staff. Please provide a critical assessment in identifying events or situations that may pose a threat to the successful completion of your project.
Examples include loss of a memory stick containing vital data, delays in obtaining materials, etc. Please extend the table if you need more space. Other Risks / Threats Severity (H/M/L) Mitigation 11 Misplacing memory stick that contains all findings for the project H Delays making progress for the study – causes hassle as the findings will have to be conducted again 12 Unorganised time and scheduling H Failure to allocate time correctly to each task delays in making progress for the study. When changes are needed to be made – it will be rushed 13 Ordering materials incorrectly M Failure to plan the quantity of materials needed delays work from being completed 14 Failing to meet with Supervisor for updates on progress of report M This could delay progress of report as feedbacks are essential to ensure project is being conducted correctly or going the correct path.
REFERENCES
1 Harro Ranter, Aviation Safety Network. 2018.
Aviation Safety Network ; . ONLINE Available at: aviation-safety.net/database/record.php?id=19900610-1Accessed 20 October 2018. 2 Michael G. Lenné, Karen Ashby ; Michael Fitzharris. 2008. Analysis of General Aviation Crashes in Australia Using the Human Factors Analysis and Classification System.
ARTICLE Accessed 20 October 2018. 3 Daniel E Maurino, James Reason, Neil Johnston and Rob B Lee. 1998. Beyond Aviation Human Factors ARTICLE Accessed 20 October 2018. 4 Maintenance Resource Management.
2012. A key process initiative to reduce human factors in aviation maintenance ONLINE Available at: https://ieeexplore-ieee-org.ezproxy.herts.ac.uk/document/6187379/authors#authors. Accessed 20 October 2018. Figure 1.0 A Gantt Chart showing workload distribution and allocated time and date for each task 35560033020000 center38100000Figure 1.2 shows a continuation of a Gantt Chart being used in this study to display workload distribution and the allocated time and date set for each task until the final submission of this project.
