air transport safety

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This presentation has been given in 2007 when I was a student at the Nation School of Computer Science.

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AIR TRANSPORT SAFETY

By

National School of Computer Studies

English Course Professor : Mr. DAKHLAOUI Faysel

Group : II 1 C

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http://www.youtube.com/watch?v=lksDISvCmNI

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THE PLAN

1. Why do aircraft accidents happen ?

Human factors

Aircraft reliability

Weather and flight conditions

A. Reasons

B. James Reason’s "Swiss Cheese" Model

Companies

The theory


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THE PLAN

2. Example : TUNINTER Flight 1153

Informations about the flight

A. Story Reconstruction

B. Investigation

Design of the low level alarm

Aircraft specifications : ATR-72

Problem of interchangeability

Crew qualification


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THE PLAN

3. Other examples in Tunisia

Sekorsky HH-3 helicopter : crash

A. Airforce accidents

C-130 Hercules : take-off missing

F-5 fighters : crashs

B. Civilian air transport accidents

EGYPTAIR : crash of B-737


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THE PLAN

4. Recommendations and conclusion

B. Conclusion

A. General recommendations

The importance of air transport

The low rate of accidents

Studying air transport accidents

Developing new systems

Crew training

Maintenance


8AIR TRANSPORT SAFETY

Introduction

Nowadays, aircraft is the most important mean of transport :

Faster : higher speed and longer distance

Efficient : hundreds of passengers and tonnes of freight

Safer : One accident for 1.000.000 flights

Inspite of security mesures and defenses, accidents can takeplace because of these following reasons :



A. Reasons

Human capabilities and limitations can influence task performance and safety inside the aircraft cockpit and within the maintenance environment.

A.1 Human factors

Pilots, technicians and air traffic controllers are often the principal actors of many tragedies because of :



A. Reasons

Bad attitude towards work and colleagues

Poor communication skills

Etc …

A.1 Human factors

Physical fatigue, tiredness …

Insufficiency of technical knowledge

Routine: same job, same tasks …

Synchronization (time zone, date/night shifts)



A. Reasons

Systems failures : avionics, engines …

Etc …

A.2 Aircraft reliability

Problems of fuselage and structure

Aircrafts not in accordance with regulations

Problems of design and conception



A. Reasons

Problems with maintenance and spare parts : Charter operators

Etc …

A.3 companies

High workload for pilots and technicians

Incompetence of some directors : bad decisions taken



A. Reasons

Precipitation, fog and ice

A.4 Weather and atmospheric conditions

Engineers can never control the weather and atmospheric parameters :

Wind, wind shear, whirlwind : while take off, approch or landing

Problem of visibility and runway condition



A. Reasons

A.5 Statistics




A series of Human Factor problems form an error chain. If any one of the links in this chain had been broken the incident may have been prevented. It might be done by building in measures/defenses, which may not permit an error at one or more of the stages. A good example is J.Reason’s ‘Swiss Cheese’ Model.


B.1 The theory




B.2 J.Reason’s ‘Swiss Cheese’ Model – fig -




A.1 Aircraft specifications : ATR-72

Capacity………………….....68

Length…………………27,17m

Wingspan……….…….27,05m

Height…………….……..7,65m

Maximum weight………..21,5t

Freight………………….….7,3t

Flight range…………. 2222km

Maximum speed…….516km/h




A.2 Informations about the flight

Saturday, 6th of August, near Palermo:

During daily flight from Bari to Djerba, at 15:24 (local time) the crew of the flight 1153 (TUINTER) contacted Palermo for an emergency landing.




A.2 Informations about the flight

The aircraft (ATR-72) had lost both engines.

The crew tries to reach the nearest airoport. But They did not make it to Palermo and ditchedin the sea around 15:40.




A.3 Cockpit voice recorder CVR

Captain: Please confirm the distance...

Palermo ATC: 20…

Captain: Please confirm the distance..

Palermo ATC: The distance is 20 miles

Captain: I think…we are not able, we

are not able to reach the terrain. We are

4.000ft and we are not able, we lose

both engines. Can you send us

helicopters or something like that?

Quick, quick, quick…

http://www.youtube.com/watch?v=6OnwwE1s1hg




A.4 Casuality

Crew (total 4)……….victimes: 2Pax (total 35)……..victimes: 14 Total on bord 39….victimes: 16

Aircraft: during the ditshing, the fuselage had been broken in several parts. Only the wings remains on the seasurface.The rest falls in 12 meter depth.


B. Investigation


B.1 Friday 5th of august (end of the day)

The crew noted on the LogBook that the FQI (Fuel QuantityIndicator) had three dispaly-bars misfunctionning.


B. Investigation


B.2 The maintenance

The technician asked the warehouse for ATR-72 FQI using a special management software: AMASIS system.

He didn’t find the right FQI but AMASIS system told him that an ATR-42 FQI can be installed in place of the ATR-72 one


B. Investigation


B.2 The maintenance

The technician did not check the compatibility of the ATR-42 FQI in the ATR-72 documentation.

<< AMASIS program


B. Investigation


B.3 First error : Maintenance error

FQI of ATR72 & ATR 42 ARE NOT INTERCHANGEABLE.


B. Investigation


B.3 First error : Maintenance error

After replacement of the FQI, the quantity of fuel indicated is3050 kg, instead of 790 kg.


B. Investigation


B.4 Second error : Pilot error

During preparion for flight 152F to Bari. An amount of 465 kg fuel was added for the flight. 3800 Kg is indecated (real quantity is 1255 Kg).

After landing in Bari, the FQI shows 2300 Kg. 1500Kg of fuel hadbeen consumed in stead of 1050Kg . The crew noticed this but doesnot react.

The A/C took off Bari with only 305 kg. 26Km north of Palermo the fuel tanks are empty ( the indicator shows 1800Kg). The Captain tries to joint the airport, but the A/C ditched near the coast.


B. Investigation


B.5 Third error : Design and conception error

On the ATR Family, The Fuel Level Alarm : « LO LVL » isdepending on the FQI.

The quantity of fuel computed by the FQI is erroneusand the alarm had never been triggered.

TANKWARNING


B. Investigation


B.6 Application of J Reason’s Model

Maintenance

Crew qualification

Design and conception


http://www.youtube.com/watch?v=tnRKp8d_0OQ




A.1 C-130 Hercules : take-off missing

Date…..………..……….…April 1994

Location…….…Gafsa Airforce base

Accident…..………Take-off missing

Cause…………..…3rd engine failure

………………..…Pilot incompetence

..…Unit commander irresponsability

Damages…….Aircraft out of action


http://www.youtube.com/watch?v=fhxGn_MsDQo




A.2 Sekorsky HH-3 helicopter : crash

Date…..………..……….…April 2002

Location……….…….…Mejez el Beb

Accident….…………………….Crash

Cause………………………Unknown

Damages…………+20 officers killed

…...Helicopter completely destroyed




A.3 F-5 fighter : crashs

Date…..………..between 1990-2003

Location……….………Training zone

Accident….…………………...Crashs

Cause………………Engines failures

……………………..Hard manœuvre

………………………Pilots limtations

Damages…………+6 officers killed

…...Fighters completely destroyed





7th of mai 2002, Tunis, whilestarting the landing to Tunis Cathage airport, the B-737 of EGYPTAIR hit the hill of Nahlipark.

The visibility was very bad and the pilot has forgetten to adjust his altimeter.





14/62 passengers killed


A. Recommendations


Technology and new systems can improve the aircraft performance and help pilots to take the right decision.

companies should review its maintenace system and procedures.

companies should review its monitoring procedures and training exercises.

Aircraft crashs must be studied and analysed to correct anomalies in orderto avoid any futur accident.


A. Recommendations


B-737 simulator>>


B. Conclusion


Inspite of accidents, the international air traffic is still growing and new machines: powerful, larger, faster, more modern and sophisticated are under production to transport passengers safely and smoothly : A-380, B-787

If we believe in a future without accidents, we will be able to make the air transport more popular, less expensive and more reliable.

Aircraft crashs are not the result of one error but of several errors doneby the different actors of the accident.


4. Bibliography

Documentary : « pourquoi les avions tombent? » arte

Internet: www.airdisaster.com

Documentary : FATAL DITCHING T-BRO production :

Part 1 : http://www.youtube.com/watch?v=Xvkdwnr1AncPart2 : http://www.youtube.com/watch?v=IIXKDUQHILMPart3 : http://www.youtube.com/watch?v=aO_-GiJyJys


Thank You !

air transport safety

Engineering