AIRBUS 320, UK, AUGUST 1993 incident

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

PROLOGUE

On February 1995, 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., which had to return to Gatwick after the pilot found that he could not turn left. The media reports implied that it was a "maintenance problem". The flight is from London-Gatwick Airport, United kingdom to Faro Airport, Portugal. A reading of AAIB 2/95 reveals that there was rather more to it than that. 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. (Although the particular failure condition was not critical, had the flight crew not reacted in the right way, and in particular, 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.) The incident occurred when, during its first flight after a flap change, the aircraft exhibited an un-demanded roll to the on takeoff, a condition which persisted until the aircraft landed back at London Gatwick Airport 37 minutes later. 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 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. The pilots carried out the usual pre-flight checks, during which they observed nothing amiss, and began the take-off roll at 15.30. 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, both pilots believed that the flight controls were responding correctly to side stick and the rudder pedal movement. The take-off roll began at 1530 hrs and the ground phase was normal. At an indicated airspeed at about 153 knot the co-pilot initiated rotation and, as the aircraft became air borne , it started an un demanded roll to the right. At first, 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. At about 300 feet above ground level , thinking that his side stick might be faulty , the co-pilot handed control to the commander. During climb to the flap retraction altitude of 1,700 feet there were no ECAM warnings but as the aircraft passed 1,700 feet the ECAM sounded a repetitive chime to indicate a significant failure. The pilot then reviewed and realised the ECAM warnings, each action , when completed , was cleared from ECAM display by pressing appropriate button. Both pilots recalled that at no time was any affected system page displayed on the lower ECAM display. The co-pilot looked at the Quick Reference Handbook (QRH) and at the

Flight Crew Operating Manual, Volume 3 (FCOM 3), Section 2 "Abnormal and Emergency Procedures", 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 commander then pulled from his flight bag a photocopy of the relevant section from an earlier version of FCOM 3, on which he had renumbered the pages according to the latest release. With the help of this the co-pilot was able to locate the correct manual page, and obtain the correction data for a FLAPS 1 landing (25% increase in approach speed, 30% increase in required landing distance).

They landed in FLAPS 1 configuration at 168 kt in "direct law" and came to a stop without difficulty. (Runway 08 was easily long enough to accommodate the increased landing distance required, and they left the runway at an exit 370m from the end.) The aircraft was towed to the stand, where the passengers disembarked normally. During taxiing, it was observed that several spoilers were up, and inspection revealed that righthand spoilers 2, 3, 4 and 5 were in "maintenance mode". These were returned to "operation mode", a duplicate inspection of the spoiler function was carried out, and the aircraft was returned immediately to service.

The Factor That Lead To The Incident

Time pressure existed - The maintenance teams worked in a repeated shift cycle consisting of: 12 hour day-shift, 12 hours off, 12 hour day-shift, 24 hours off, 12 hour night-shift, 12 hours off, 12 hour night-shift, 4 days off. Shift changes occurred at 07.00 and 19.00 local time. The night-shift were at the end of their cycle, and the day-shift were at the beginning of theirs. Circadian rhythms were de synchronized. In such circumstances adherence to defined procedures and written instructions are essential to avoid human error. Pressure must be avoid. They should control their cycle life routine. They must have enough rest, maintain the body fitness, avoid injury, eating regular meals and a well balanced diet. Manuals were confusing
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The nightshift engineer was unfamiliar with the Excalibur A320 Maintenance Manual and found it confusing. The manual should be amend in the flap , flap re-fitting and spoiler de-activation chapters must be more clearer n specific.

All error occurred at night shift - The shift handovers took place, for the nightshift engineer, at a time when he could be expected to be tired and with circadian rhythms desynchronized . This problem can be settled by ensuring adequate rest and good quality sleep are obtained. It also best not to eat a large meal shortly before trying to sleep but the engineer should avoid going bed hungry. There was inadequate pre-planning, equipment, and spares
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The damaged flap removal was carried out generally in accordance with the Maintenance Manual except where tooling deficiencies made

this impracticable. The flight crew were unaware of delays in the response of the on-board warning systems to certain fault modes. As a result, their pre-flight check procedures were ineffective. These delays are not documented in the manuals, nor covered in training. The Authority should formally remind engineers of their responsibility to ensure that all work is carried out using the correct tooling and procedures, 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. Shift or task handover were involved
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The purpose of spoilers functioned was not fully recognize by the engineers. 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. For prevention, even if engineers think that they are going to complete a job, it is always necessary to keep the record work up-to-date just in case the job has to be handed over. This record is usually recorded in written form.

Interruption occurred
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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. The warning systems also responded inappropriately. The management should identify the problem occurred from the start. They should ready the steps to be taken if the first plan does not work. Reference

AAIB(1993)Report on the incident to Airbus A320-212,at London Gatwick Airport,on 26 August 1993,Aircraft incident Report 2/95.

Human factor notes.

ASSIGNMENT 2
1. Human factors concentrates on the interface between the human (you) and other elements in your workplaces. In your own words,

clearly describe those interfacing element. It will be helpful to use of an aid in your description. Human factors refer to the study of human capabilities and limitation in the workplace and also researchers study system performance. which mean to optimize the relationship between maintenance personnel and system with a view to improving safety, efficiency and well being. Its include Psychology, environmental condition and anthropometrics. SHEL MODEL is an aid to give more understanding about human factor. Name derived for SHEL MODEL: S- Software (e .g maintenance procedure and maintenance manuals) H- Hardware (e. g Tools, test equipment and design of flight deck) E- Environment (e. g Physical environment and management structure) L- Livewire (e. g Person at the center of the model) Human factor is to recognize human performance limitations In themselves and others, and able to avoid, detect and rectify errors or error prone behavior and practices. As Maintenance aircraft engineer, he must intense his knowledge,skill and abilities, and must adapt with their physical environment. They must work within the system. Human error, all aspects of system may contribute towards error that engineer might make. Responsibility should be spread across all those who play a part in activity. An Aircraft engineer must fulfill MASLOWs hierarchy that is physiological needs, safety needs, love and belongingness, esteem needs, cognitive needs, aesthetic needs and self actualization.

2. In your own words , clearly state the key factors which are likely to affect your performance in the working environment. Fatigue

Fatigue is a condition when someone is extremely tired in metal caused by repeated variations of stress. These symptoms occur when someone doing works rapidly without break. It will affect the circadian rhythm. The solutions I sleeps n exercise regularly. Ask others to check your work.

Pressure Pressure is a condition when continuous physical force exerted on or against an object by something contact with it. They are many pressure when work in an organization, for example management, and run the flight schedule. Be sure that pressure isnt self-induced and ask for extra help if needed. Stress Stress results from the imposition of any demand or set of demands which required us to react , adapt or behave in a particular manner in order to cope with or satisfy them. From these , we get acute stress typically intense but in short duration and chronic stress that frequent recurrence or of long duration respectively.

Lack of awareness
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People are lack of awareness. They dont aware about what going to happen in the future. They think they are too good too handle the situation. They should think of what may occur in the event of an

accident. And ask others if they can see any problems with the work done.

Fitness and Health - Fitness and health can have a significant affect upon job performance both in physical and cognitive. There is an obvious effect upon an engineers ability to perform maintenance or carry out inspections if through poor physical fitness or health. The maintenance engineer should take care of their health and always fit when doing an inspection.

3.

As maintenance personnel you are often assigned to teams in the workplace as a Part in the maintenance activity. It is therefore , the responsibility for fulfilling overall goal would fall on the entire team. In your own words, discuss some of advantages and disadvantages of

team working.

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