De Havilland/ BOAC Comet Accidents
1954
No prototype
Sir Geoffrey de Havilland built the first commercial jet that reached production, the Comet. On January 10, 1954 a Comet broke up in mid-air.
Flights were temporarily voluntarily suspended, then resumed. On April 8, 1954, another Comet broke up in air. (Both flights were taking off
Testing
from Rome.) The lives of 56 passengers and crew were lost in these two incidents, as well as two planes. Additionally, the prestige of the Inadequate test performed on
British aviation industry suffered a blow. (I'll consider the lost prestige of British aviation a customer service impact.) program section with
AND extended life
Let's look at this incident in a Cause Map. A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple,
intuitive format that fits on one page. Although there were two separate plane breakups, the Cause Maps are the same (based on the
analysis and investigation performed after the accidents). Essentially, the two planes were lost due to a structural failure of the cabin, due to Misleading
fatigue cracking. fatigue tests AND
AND
The fatigue cracking of the cabin occurred because the actual pressure cycles exerted on the cabin were more than the allowable (or where
cracking would occur). This was because the allowable pressure cycles were miscalculated. The allowable pressure cycles were miscalculated
for several reasons. First, the inadequate test program. There was no prototype, and the fatigue tests were misleading. One test used a section Testing results
that was effectively pre-conditioned, extending its life. In another test, the section tested was so small that the test results were influenced by influenced by
boundary conditions. boundary
conditions
Pressurization
stresses
Next, the actual stress was above the predicted stress. This occurred because the pressure stresses were distributed unevenly, and the actual distributed
stresses were increased in some localized areas. Additionally, while the comet was being developed, there was a general lack of knowledge Actual stress
unequally
about fatigue. A last problem was that the design of the Comet stretched the bounds of experience. The comet was designed to fly at twice the above predicted
speed of other airliners, at twice the height, and at twice the cabin pressure (for passenger comfort). stress
AND
Probably the most important lesson to come from the de Havilland Comet accidents is the importance of proper Allowable
testing. Once the cause was discovered, the Comet was redesigned and flew successfully, although by then Boeing presure cycles Actual stress
had mostly taken over the market share. It's tragic that these accidents had to occur before the problem was solved. miscalculated
AND increased in
localized areas
Why?
Effect Cause Lack of
knowledge
about fatigue
Safety Goal 56 passengers, NOTE: Read the Cause Map from left to right
Impacted crew killed with the phrase "Was Caused By" in place of
Flew at twice
Pressure cycles the speed of
Structural other airliners
on cabin AND
Matls/Labor failure of Fatige cracking AND
exceed
Goal pressure cabin
allowable
Impacted AND
Loss of 2
planes Cause Map Stretched Flew at twice
Detail Level beyond bounds the height of
of experience other airliners
Customer Goal Lost prestige of
Impacted British aviation
AND
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Twice the cabin
pressure of
previous aircraft
Copyright ThinkReliability 2009
Pressurization
Aircraft cabin
and
sees pressure
depressurizing
cycles
of cabin
