Finding the Dirty Dozen errors in Incidents mentioned in the notes

1. Portland Oregon Incident

Distraction: pilots too focused on solving the land gear problem they didn’t notice the fuel
status.
Lack of communication/team work: while one pilot was solving the problem, the other pilot
should be dealing with the normal flight instructions.
Pressure: Situations like these will lead to work under pressure as lives are at stake.

2. Kegworth

Lack of Assertiveness/communication: The pilots informed the flight they were shutting
down engine 2 while the cabin crew and passengers clearly can see the smoke/fire in
engine 1.
Pressure: lives at stake so there will be pressure when an incident occurs.
Complacency: the displays in the cockpit will show that engine 1 had problems. But pilots
chose not to look at it after all before taking action.

3. Aloha Airlines Flight 243

Complacency: Didn’t think about the aging of the aircraft

Pressure: 1300 rivets were to be inspected and time was limited to do the work.
Fatigue: Some inspections were done at night. Less manpower available so the work to be
done by the personnel was more.
Lack of resources: some inspectors were suspended by the safety harnesses and the hangar
lighting designed for D- 3’s
Lack of knowledge: Documentation complicated and subject to interpretation.
Lack of communication/teamwork: Engineering dept was outsourced.

4. British Airways BAC-1-11 Windscreen Blowout

Lack of resources/knowledge: staff was taken hostage, some failure to use approved data or
company procedures and manuals were confusing. No pre planning, equipment or spares.
Distraction: Interruptions occurred
Complacency: there was a “can do” attitude
Lack of communication/teamwork: Supervisors did long hand on tasks and there was task
handover to another shift.
Fatigue/pressure: errors made at night and time pressure existed which they had to work
with no flexible time periods.

5. B737 Double Engine Oil Loss

 Complacency: Aircraft maintenance manual was not achieved in numbers of areas. Ground
idle engine runs were not taken place.
Fatigue: The Inspections carried out at night.
Norms: non-procedural conduct of borescope inspections by company engineers.
Pressure: The inspections took place in night and there is work pressure. Time was limited
and they didn’t even carry out ground idle engine runs.
Lack of Resources: The quality Assurance team had limitations in some aspects.

6. TUNNITER Flight 1153 Ditching

Complacency: The FQI was installed wrongly, should have referred the AMM manual to do
so. The pilot didn’t check the fuel levels before departure.

7. Air Midwest Flight

Complacency: Incorrect rigging of the elevator control system and coupled with the
improper aircraft weight and balance. These should be carried out according to the AMM.

INCIDENT TAKEN FROM INTERNET

China Airlines Flight 676 (16th February 1998)

Lack of Knowledge: The pilot thought the autopilot feature will initiate the plane’s go around.

Pressure: Sudden steep turn was taken by the pilot causing stall.

Lack of awareness: It took 11 seconds for the pilot to notice the Autopilot didn’t initiate the go
around

Poor Communication: Instructions from the ATC was not properly obeyed by the pilot