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Report Name: Registered owner: Operator: Aircraft Type and Model: Registration : Place of incident: Date and Time: First flight: Total airframe hrs: Crew: Passengers: Total: Phase: Departure airport: Destination airport: Category: 2/1995 Airbus A320-212, G-KMAM Guinness Peat Aviation Ltd Excalibur Airways Ltd Airbus A320-212 G-KMAM London Gatwick Airport 26 August 1993 at 1531 hrs. 1992 4643 hours 7 185 192 Takeoff London-Gatwick Airport (LGW/EGKK), United Kingdom Faro Airport (FAO/LPFR), Portugal Public transport - Fixed Wing
and in particular.) The incident occurred when. . The media reports implied that it was a "maintenance problem". United kingdom to Faro Airport. Portugal. The following summary of this incident analyses the way in which computer systems (both ground-based maintenance management systems and airborne avionics systems) contributed to this incident. The flight is from London-Gatwick Airport. had the flight crew not reacted in the right way. a condition which persisted until the aircraft landed back at London Gatwick Airport 37 minutes later.On February 1995. during its first flight after a flap change. had they blindly followed the advice presented to them automatically by the warning systems. the outcome might have been a total hull loss and the deaths of 192 people. A reading of AAIB 2/95 reveals that there was rather more to it than that. (Although the particular failure condition was not critical. which had to return to Gatwick after the pilot found that he could not turn left. the aircraft exhibited an un-demanded roll to the on takeoff. the UK media carried an item based on the newly published final report by the Air Accidents Investigation Branch (AAIB) of the UK Department of Transport (referred to as AAIB 2/95) on an incident concerning an A320 operated by Excalibur Airways Ltd. Control of the aircraft required significant left side stick at all the time and the flight control system was degraded by the loss of spoiler control..
The flight control check was performed independently by each pilot exercising his side stick in both roll and pitch axes in order to check correct movement of the flight controls. After their independent checks. when completed . During climb to the flap retraction altitude of 1. the co-pilot attributed the un-demanded roll to crosswind and applied left side stick but the aircraft continued to roll to the right and he had to apply full left side stick to contain the un demanded roll. as the aircraft became air borne .700 feet the ECAM sounded a repetitive chime to indicate a significant failure. it started an un demanded roll to the right. The take-off roll began at 1530 hrs and the ground phase was normal. during which they observed nothing amiss.700 feet there were no ECAM warnings but as the aircraft passed 1.THE CRONOLOGY AIRCRAFT INCIDENT TRAGEDY After the replacement of the right-hand outer flap (following damage from an earlier bird strike) the aircraft was handed over to the flight crew at 1500 hours UTC on 26 August 1993. and began the take-off roll at 15. The pilots carried out the usual pre-flight checks. each action . thinking that his side stick might be faulty . At an indicated airspeed at about 153 knot the co-pilot initiated rotation and. At first. Both pilots recalled that at no time was any affected system page displayed on the lower ECAM display.30. the co-pilot handed control to the commander. was cleared from ECAM display by pressing appropriate button. The co-pilot looked at the Quick Reference Handbook (QRH) and at the . At about 300 feet above ground level . The pilot then reviewed and realised the ECAM warnings. both pilots believed that the flight controls were responding correctly to side stick and the rudder pedal movement.
where the passengers disembarked normally. it was observed that several spoilers were up. (Runway 08 was easily long enough to accommodate the increased landing distance required. The commander then pulled from his flight bag a photocopy of the relevant section from an earlier version of FCOM 3.Flight Crew Operating Manual. on which he had renumbered the pages according to the latest release. During taxiing. They landed in FLAPS 1 configuration at 168 kt in "direct law" and came to a stop without difficulty. 30% increase in required landing distance). With the help of this the co-pilot was able to locate the correct manual page. for advice on a FLAPS 1 landing. but could not find the pages he wanted (containing the corrections to be made to the normal approach speed and required landing distance in various flight surface failure conditions).) The aircraft was towed to the stand. Section 2 "Abnormal and Emergency Procedures". The Factor That Lead To The Incident . These were returned to "operation mode". 4 and 5 were in "maintenance mode". Volume 3 (FCOM 3). 3. a duplicate inspection of the spoiler function was carried out. and obtain the correction data for a FLAPS 1 landing (25% increase in approach speed. and the aircraft was returned immediately to service. and they left the runway at an exit 370m from the end. and inspection revealed that righthand spoilers 2.
24 hours off. at a time when he could be expected to be tired and with circadian rhythms desynchronized . The manual should be amend in the flap . The night-shift were at the end of their cycle. and the day-shift were at the beginning of theirs. 12 hour day-shift. This problem can be settled by ensuring adequate rest and good quality sleep are obtained. In such circumstances adherence to defined procedures and written instructions are essential to avoid human error. They should control their cycle life routine. It also best not to eat a large meal shortly before trying to sleep but the engineer should avoid going bed hungry. 4 days off.The maintenance teams worked in a repeated shift cycle consisting of: 12 hour day-shift. flap re-fitting and spoiler de-activation chapters must be more clearer n specific. and spares - The damaged flap removal was carried out generally in accordance with the Maintenance Manual except where tooling deficiencies made .The shift handovers took place. 12 hour night-shift. Pressure must be avoid. for the nightshift engineer. They must have enough rest. equipment. 12 hour night-shift. 12 hours off.Time pressure existed .00 and 19. maintain the body fitness. Manuals were confusing The nightshift engineer was unfamiliar with the Excalibur A320 Maintenance Manual and found it confusing. There was inadequate pre-planning. avoid injury.00 local time. Circadian rhythms were de synchronized. eating regular meals and a well balanced diet. Shift changes occurred at 07. All error occurred at night shift . 12 hours off.
This misunderstanding was due to familiarity with other aircraft and contributed to a lack of adequate briefing on the status of the spoilers during the shift handovers.at London Gatwick Airport. The management should identify the problem occurred from the start. Reference - AAIB(1993)Report on the incident to Airbus A320-212. it is always necessary to keep the record work up-to-date just in case the job has to be handed over. For prevention. The flight crew were unaware of delays in the response of the on-board warning systems to certain fault modes. The warning systems also responded inappropriately. As a result. The Authority should formally remind engineers of their responsibility to ensure that all work is carried out using the correct tooling and procedures. .Aircraft incident Report 2/95. This record is usually recorded in written form. Shift or task handover were involved The purpose of spoilers functioned was not fully recognize by the engineers. These delays are not documented in the manuals. They should ready the steps to be taken if the first plan does not work.this impracticable. and that they are not at liberty to deviate from Maintenance Manual but must use all available channels to consult with a design authority where the problem arise. even if engineers think that they are going to complete a job. nor covered in training .on 26 August 1993. their pre-flight check procedures were ineffective. Interruption occurred - The flight control system was not designed to cope with a failure condition (spoiler in maintenance mode) which has been found to occur relatively frequently in operation.
- Human factor notes. Human factors concentrates on the interface between the human (you) and other elements in your workplaces. In your own words. . ASSIGNMENT 2 1.
which mean to optimize the relationship between maintenance personnel and system with a view to improving safety. g Person at the center of the model) Human factor is to recognize human performance limitations In themselves and others. An Aircraft engineer must fulfill MASLOW’s hierarchy that is physiological needs. Responsibility should be spread across all those who play a part in activity. Human factors refer to the study of human capabilities and limitation in the workplace and also researchers study system performance. SHEL MODEL is an aid to give more understanding about human factor. As Maintenance aircraft engineer. g Tools. Name derived for SHEL MODEL: S. environmental condition and anthropometrics.Software (e . love and belongingness. and must adapt with their physical environment. Fatigue . test equipment and design of flight deck) E. and able to avoid. aesthetic needs and self actualization. efficiency and well being.Livewire (e.g maintenance procedure and maintenance manuals) H. esteem needs. g Physical environment and management structure) L. It will be helpful to use of an aid in your description. safety needs. cognitive needs.skill and abilities.Hardware (e. he must intense his knowledge.clearly describe those interfacing element. all aspects of system may contribute towards error that engineer might make. detect and rectify errors or error prone behavior and practices.Environment (e. 2. They must work within the system. It’s include Psychology. In your own words . clearly state the key factors which are likely to affect your performance in the working environment. Human error.
They think they are too good too handle the situation. Be sure that pressure isn’t self-induced and ask for extra help if needed. Pressure Pressure is a condition when continuous physical force exerted on or against an object by something contact with it. They should think of what may occur in the event of an . They don’t aware about what going to happen in the future. It will affect the circadian rhythm. Lack of awareness People are lack of awareness.- Fatigue is a condition when someone is extremely tired in metal caused by repeated variations of stress. The solutions I sleeps n exercise regularly. They are many pressure when work in an organization. Ask others to check your work. From these . and run the flight schedule. for example management. adapt or behave in a particular manner in order to cope with or satisfy them. These symptoms occur when someone doing works rapidly without break. we get acute stress typically intense but in short duration and chronic stress that frequent recurrence or of long duration respectively. Stress Stress results from the imposition of any demand or set of demands which required us to react .
discuss some of advantages and disadvantages of . It is therefore . As maintenance personnel you are often assigned to teams in the workplace as a Part in the maintenance activity. the responsibility for fulfilling overall goal would fall on the entire team. There is an obvious effect upon an engineer’s ability to perform maintenance or carry out inspections if through poor physical fitness or health. Fitness and Health .Fitness and health can have a significant affect upon job performance both in physical and cognitive. 3. And ask others if they can see any problems with the work done. In your own words.accident. The maintenance engineer should take care of their health and always fit when doing an inspection.
ADVANTAGE DISADVANTAGE Each member of the group ought to feel Potentially act against safety responsible for the output of the group Cross checking others’ work Occur situation which assuming someone else will do it Politely challenging others if you think that Intergroup conflict and group polarisation something is not right Sharing knowledge among others Tendency to work less harder on a task .team working.
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