INVESTIGATION REPORT 3

  • Category:
    Other
  • Document type:
    Essay
  • Level:
    Undergraduate
  • Page:
    2
  • Words:
    1414

Aircraft Investigation:

Aircraft accidents are not frequent but fatal when they occur, most of these accidents are always caused either by negligence in the part of the crew, and some are as a result of mechanical errors while others are caused by uncontrollable factors such as weather conditions. Despite the occurrence of these accidents measures should be put prior to the occurrence in order to control the situation or after the occurrence to prevent future accidents from taking place. Investigations are always carried out after the occurrence of these aircraft accidents in order to determine the cause of the accident, the impact caused and possible sources of errors, these investigations always give a report on the final findings including recommendations of possible remedies to be out in place. The Qantas Boeing 747-438 aircraft is an example of such occurrence that involved an accident caused and contributed by several surrounding factors.

The Qantas Boeing aircraft incident occurred on 23rd September in the year 1999, the incident involved an aircraft landing error which put the lives of around 410 people who were on board, this involved three flight crew, 16 cabin crew and 391 passengers whose lives were put at risk but none of them sustained serious injuries. The incident was as a result of weather complications which disrupted the normal landing criteria, despite the weather interference, negligence in the part of the crew and miscommunication among the relevant personnel who are involved in ensuring safe landing.

The investigations conducted by the Australian Transport and Safety Bureau as directed by the Aircraft Accident Committee of Thailand after the occurrence of the incident. The investigations were conducted as per the required standards. It was estimated that the majority of runway overruns contributed to the majority of accidents involving aircrafts.

The investigation conducted indicated several parties were at fault in the event that led to the accident, this included the crew, captain the airport officials and the management at large. The investigation found out that the crew had been informed the weather changes had caused interference with visibility but did not receive an earlier communication on the same. According to the investigations conducted, the crew members came to realize of the effect that the heavy rain falling at that moment had caused on visibility at a later stage when they were nearing to land. Because of the water in the runway that had been caused by the rains, the procedure of landing was also altered as a result of confusion in the mode of communication. According to the investigations, the tyres of the aircraft aquaplaned on the runway that had been affected by the runway, the water effect limited the effectiveness of the wheelbrakes for a third of their normal efficiency on a dry runway. Despite the fact that the landing procedure that had been used by the crew was the preferred procedure by the company, it was not the appropriate step to be taken at that moment. A lower landing approach would have instead be used which was easier to control and provided a maximum aerodynamic drag after the plane had touched down. Part of the blame on the procedure of landing was directed to the company management as it was claimed that the company had not provided the crew with appropriate procedure and training in order to evaluate properly the effect of weather conditions on the stopping procedure at the airport.

As a result of the incident, the investigation conducted outlined various failures that led to the occurrence of the incident. It was established that the flight crew failed to use the appropriate risk management strategy approach while landing. There was failure in the part of the first officer since the manner in which he flew the aircraft during landing was not accurate. The flight crews were also to blame when they failed to select the idle reverse thrust and the full reverse thrust during landing. The rains had also affected the runway surface which caused major landing problems. The inadequate defences found out by the investigation included the deficient information published by the company concerning the procedures and flight crew training for landing on water-affected runways. There was laso deficiency inflight crew training concerning the evaluation of procedural and configuration options for approach and landing.

After the accident had occurred, there were various events that followed which included the damages that had occurred to the aircraft, various parts of the craft were damaged and other parts became inoperable but there was no incident of fire reported. Information was gathered concerning the extend of the damages; this was however made difficult due to the failure of the passenger address and the cabin interphone systems. It was discovered that important information concerning the cabin environment and the outside weather condition did not reach the flight crew. The post-accident analysis indicated that radio communication between the aircraft and the control tower had been some minutes after the aircraft had stopped. 20 minutes after the occurrence of the accident, there was precautionary disembarkation from the right side of the flight by the use of emergency escape slides, the disembarkation was successfully achieved but there still existed several unknown matters of concern due to the condition of the aircraft and the possible related hazards that could have been involved.

The post-accident analysis indicated that the cabin interphone and passenger address system could not be operated, some relevant issues were not considered before deciding on not to conduct an immediate evacuation. It was also found out that during the emergency period, some of the crew member did not communicate important information. There were inadequate defences which included the deficient procedures and training for flight crew concerning the evaluation of whether or not to conduct an emergency evacuation. The procedures and training for the cabin crew concerning the identification and communication of relevant information during emergencies were also deficient. The redundancy that had been provided by the normal and alternate cabin interphone and public address system had also been compromised since they were both located places that were prone to damage.

The factors that led to the accident were not only as a result of the crew and the craft controllers, the investigation indicated that there were also some organizational issues that could have played a role in the cause of the accident. It was found out that the processes used in the identification of hazards were informal and reactive rather than being formal and proactive, risk assessment processes were also found to be deficient. According to the investigation, there were deficient processes used in managing the development, introduction and the evaluation of changes. The management had also over relied on the experience of individuals hence did not put enough consideration on the structured processes, management training, research and development before making strategic decisions. The regulatory bodies also experienced failures since the regulations that were covering runway operations that had been contaminated were deficient. Some of the regulations that were being used to cover the emergency procedures and the emergency procedures training were not efficient; this included the surveillance of airline flight operations. Previously before the occurrence of the accident, plans to develop a systems-based approach to surveillance as a result inefficiency in the previous approach were underway but this system had not yet reached maturity by the time the accident occurred.

After the occurrence of the accident, the year 2000 saw various safety measures put in place to prevent similar occurrences in future. The flight management introduced changes in their mode of operation and was examining further changes in its management policy and procedures. The areas that experienced the necessary changes and reviews included the operational training and procedures, hazard identification, change management aspect, the design of procedures and training programmes and the management decision making processes. Some of the relevant changes had been put in place before the occurrence of the accident hence was in progress.

Safety analysis deficiency notices were raised by the Australian Transport and Safety Bureau and four of the safety analysis deficiency notices remained open as advised by the company as part of the progress of the changes made. Recommendations were made by the Australians Transport and Safety Bureau in areas where they though still contained safety issues. The changes that were already underway were pushed to completion and new changes implemented to ensure future occurrences are handled in a better and more professional manner.

References

AUSTRALIAN TRANSPORT AND SAFETY BUREAU. (1999). 1st ed. Bangkok, Thailand.