AIRBUS 320 , UK , AUGUST 1993 INCIDENT

HUMAN FACTOR
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INCIDENT DESCRIPTION. Aircraft Accident Report No:2/29 (EW/C93/8/3) Registered owner: Guinness Peat Aviation Ltd 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: Excalibur Airways Ltd Airbus A320-212 G-KMAM London Gatwick Airport 26 August 1993 at 1531 hrs. 1992 4643 hours Fatalities: 0 / Occupants: 7 Fatalities: 0 / Occupants: 185 Fatalities: 0 / Occupants: 192 Takeoff London-Gatwick Airport (LGW/EGKK), United Kingdom Faro Airport (FAO/LPFR), Portugal

Introduction In 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 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". 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.

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Narrative The incident occurred when, during its first flight after a flap change,the aircraft exhibited an undemanded 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 sidestick at all the time and the flight control system was degraded by the loss of spoiler control.

Aircraft incident history

1. During the night before and the day of the incident , the right outer flap , which had been damaged , was changed. It was originally agreed between the operator and the maintenance organisation that the aircraft would be ready for to service at 0700 hrs. However , this proved to be an unrealistic estimate for the aircrafts return to service that putting the engineering team under some pressure to complete the task. 2. The flight control check was performed independently by each pilot exercising his sidestick 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 sidestick and the rudder pedal movement. 3. 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 airborne , it started an undemanded roll to the right. At first, the co-pilot attributed the undemanded roll to crosswind and applied left sidestick but the aircraft continued to roll to the right and he had to apply full left sidestick to contain the undemanded roll. 4. At about 300 feet above ground level , thinking that his sidestick 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 actioned 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.
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5. The co-pilot contacted Gatwick approach by RT and notified the controller of the inability to follow Southampton departure. The pilot followed the ECAM instructions and asked Air Traffic Control (ATC) for radar vectors for right turns. Shortly afterwards the commander informed the passengers on the cabin that the flight would be returning to Gatwick with technical problem.

6. Engine power was increased , the flaps and slats were retracted fully and airspeed was increased which make roll control improvement. The pilot informed ATC that he would have to re-configure the aircraft for a higher speed approach. The aircraft landed at 1607 hours (37 minutes after takeoff) , touchdown was smooth , on the centreline and within the touchdown zone. The Probable Factor That Had Led To The Incident The investigation identified the following causal factors & remedial action: I. All error occurred at night shift. 1 The shift handovers took place , for the nightshift engineer , at a time when he could be expected to be tired and with circadian rhythms desynchronised. This problem is best tackled by ensuring adequate rest and good quality sleep are obtained. Then , it also best not to eat a large meal shortly before trying to sleep but the engineer should avoid going bed hungry. Taking over-the-counter drugs to help sleep should only be used as a last resort. II. Manuals were confusing. 1 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 which included specific , clear warnings of the need to re-instate and function the spoilers after de-activation. III. Shift or task handover were involved. 1 The purpose of the collars and the way in which the spoilers functioned was not fully understood 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
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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. Modern technology is also being implemented to improve the transfer of information in maintenance manuals to worksheets and workcards. IV. There was element of a can do attitude. 1 The engineers who carried out the flap change demonstrated a willingness to work around difficulties without reference to the design authority including situations where compliance with the Maintenance Manual could not be achieved. In addition , the engineers may pick up some bad rules which leading to bad habits. This bad habit can be wipe out by Safety Management System (SMS) which provide mechanisms for identifying potential weak spots and error prone activities and situations. V. There was inadequate pre-planning, equipment, and spares. 1 The damaged flap removal was carried out generally in accordance with the Maintenance Manual except where tooling deficiencies made this impracticable. The Civil Aviation 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 , if full compliance cannot be achieved the engineer is not empowered to certify the work. VI. Time pressure existed. 1 The engineering team under some pressure to complete the task after get unrealistic estimate for the aircraft to return for service. This pressure can be prevent by practice relaxation techniques like deep breathing and take a walk for a while , manage careful regulation of sleep and diet , take a regime of regular physical exercises and willingness to take counselling session which ranging from talking to a supportive friend to seek professional advice.

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Reference

1. AAIB(1993)Report on the incident to Airbus A320-212,at London Gatwick Airport,on 26 August 1993,Aircraft incident Report 2/95. 2. Reason J.T (1995) Remedial implications: some practical applications of the theory,Chapter 4 ,In:Daniel E Maurino,James Reason,Neil Jhonston and Rob B Lee.(1995) Beyond Aviation Human Factors. Aldershot : Avebury Aviation. 3. CAA (2002)CAP 175 An Introduction To Aircraft Engineering Human Factors For JAR 66, Chapter 3 : Social Psychology

Appendix

As the attachment

ASSIGNMENT 2

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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 refers to the study of human capabilities and limitaion in the workplace and also researchers study system performance.which mean to optimise the relationship between maintenance personnel and system with a view to improving safety,efficiency and well being. it can very helpful to use a model aid in the understanding of interfacing between human and system of engineering. And SHEL Model is the best reference,a name derived from the initial letters of its components.which is,Software,Hardware,Environment and Liveware.All these aspects must be designed or adapted to assist the human performance and respect his limitation. the aircraft engineer is the central part of the aircraft maintenance system. It is therefore very useful to have an understanding of how various parts of his body and mental processes function and how performance limitaion can influence his effectiveness at work. aircraft maintenance engineerwork within a system.thus,there are various factors within this system that impinge on the aircraft maintenance engineer,raging from his knowledge,skill and abilities,the environment in which hw works,to the culture of the organisation for which he works.Even beyond the actual company he works for,the regulatory requirements laid down for his trade clearly impact on his behavior. the maintenance system: Wider environment. ie,economic climate,public perception Regulation. ie,safety regulation and safety promotion,regulatory style. Organisation. ie,policies,procedures,quality assurance. Supervision. ie,planning,organisation,performance, Immediate environment. ie,facilities,weather,time pressure,teamwork Maintenance engineer. ie, knowledge,skills,abilities.

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2. In your own words , clearly state the key factors which are likely to affect your performance in the working environment. i. 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 he/she is constrained in some way such as his freedom of movement or his/her sight. ii. Stress Stress results required us to with or satisfy short duration respectively.

from the imposition of any demand or set of demands which react , adapt or behave in a particular manner in order to cope them. From these , we get acute stress typically intense but in and chronic stress that frequent recurrence or of long duration

iii. Workload Workload is the degree of stimulation exerted on an individual caused by a task and can be separated into physical workload and mental workload. The degree of stimulation can be divided into two types which overload and underload. iv. Sleep Sleep is a natural state of reduce consciousness involving changes in body and brain physiology which necessary to human to restore and replenish the body and brain. Sleep can be resisted for a short time but various parts of the brain ensure that sooner or later sleep occurs. v. Fatigue Fatigue is a condition where the performance and alertness in man is drop. Fatigue can be either physiological or subjective which tied by factors such as recent physical activity , current health , consumption of alcohol and with circadian rhythms.

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
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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 Intergroup conflict and group polarisation that something is not right Sharing knowledge among others Tendency to work less harder on a task

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