Accident Investigation and Incident Reporting

Space Shuttle Columbia Report

Investigation of any serious air accident demands an in-depth analysis of the root causes that preconditioned the emergence of the unexpected situation and failure of a flight. It helps to avoid the repetition of similar accidents and increases the level of safety in the future. For this reason, in all cases, the special committee analyses all aspects related to particular cases staring with the air vehicle and ending with the functioning of the organization responsible for it and the organization of a safe flight.

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For instance, the Space Shuttle Columbia accident attracted public attention because of the importance of the project, its complexity, and possible causes of the crash. By the dominant perspective on the failure, the culture at NASA at that period was one of the central reasons for the accident, which means that there were multiple drawbacks in the way the organization worked.

On February 1, 2003, the Space Shuttle Columbia was going to re-enter the earth’s atmosphere after 16 days in space. However, soon after it headed toward a landing, the accident happened; observers were able to see glowing pieces falling from the shuttle and signalizing that a serious problem emerged (Edmondson & Herman 2012). In several minutes, the aircraft was destroyed, and all seven astronauts died. The given accident became the second disaster in the Space Shuttle Program as previously Challenger also disintegrated and all seven crew members died.

For this reason, the existence of flaws in the whole project became one of the most discussed topics associated with the given accident. The specially created committee engaged in the in-depth investigation of the crash concluded, that along with the mechanical damage caused to the space shuttle, nonphysical factors should also be mentioned (Edmondson & Herman 2012). The culture at NASA was often called one of the possible causes of the failure.

Analyzing this statement, several factors should be mentioned. First of all, the existence of the improvement in funding should be emphasized because of its critical role in the accident. Due to the significant lack of financing the incentive “faster, better, cheaper’, was suggested as the dominant one (Edmondson & Herman 2012). It impacted the culture of the organization and the functioning of the whole team by decreasing their effectiveness and deteriorating outcomes.

Shuttle managers and leading engineers who worked with the most critical aspects of the project had to ignore obvious signals of danger because of the dominant approach that disregarded or even condemned perspectives and opinions different from the suggested one (Edmondson & Herman 2012). Moreover, the shuttle workforce was downsized because of the lack of financing, and some essential operations were devoted to other agencies (Edmondson & Herman 2012).

These radical alterations in culture preconditioned the emergence of critical flaws in the maintenance and support of the Space Shuttle Project. For instance, foam strikes on the orbital thermal protection system were normalized because of the need to decrease spending and considered as not risky (Edmondson & Herman 2012). This act demonstrates the negative effect of the existing culture and it is one of the primary causes of the crash. Moreover, employees were not able to dispute about particular solutions if they were different from the ones suggested by the official doctrine. In such a way, the following inference can be formulated:

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Formula

However, the given aspect was not mentioned as the official cause of the accident for several reasons. First of all, the whole project can be considered as a compromise required to gain approval for the program and launch a shuttle (Edmondson & Herman 2012). For this reason, including the culture as one of the main reasons would result in the deterioration of NASA’s image and the emergence of multiple questions about its existence and functioning.

It will also decrease the motivation and mood of workers and result in an increased risk of new mistakes. Second, a significant reduction of financing was the background for the alterations in the culture which meant that multiple agencies, including the governmental ones, were responsible for the occurrence of problems and fatal results. That is why regarding the fact that culture preconditioned this disaster, it was impossible to mention it among primary cases.

British Airways Flight 268

The safety of any flight critically depends on the decisions of the crew as its members are responsible for the successful take-off, landing, and all processes that should be performed to guarantee security to all passengers. For this reason, training that is provided to the captain and pilots is a fundamental aspect of modern aviation as they should possess a high level of skills and extensive knowledge on how to react in various situations.

Especially important crew’s actions become in case of emergency as they might result in the elimination of main problems or crash. Agencies such as FAA, IATA, or ICAO also accept the importance of the issue and offer a list of regulations regarding this aspect that should be observed by pilots and captains to act most effectively and safely (Freeman & Mead 2008). However, these recommendations can be ambiguous regarding the fact that every incident is unique and demands a specific approach that can be different from the existing rules. The case of British Airways Flight 268 evidences that there are still various perspectives on how to act in complex situations.

The problem was that immediately after the take-off, the dispatcher informed the crew that flames were coming out of one of their engines. However, all three pilots already knew that some accidents happened because of the surge in one of their engines and they also heard the sound of the explosion (Freeman & Mead 2008). In such a way, the need for an emergent decision whether to continue the flight or not occurred.

The fact is that the given model was designed and certified to fly on three engines with no serious threats to passengers (Freeman & Mead 2008). For this reason, the pilots shut the engine down to fight the fire. It was a correct decision as it helped to prevent the explosion of fuel and critical damage to the craft. The captain also sent the co-pilot to check if there were any flames or the problem was localized and eliminated (Freeman & Mead 2008). It was also an appropriate step that helped to ensure that the most dangerous aspect of the flight is under control and further discussion is possible.

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Because of the accident, the air traffic control wanted to return the plane to the airport to avoid possible risks. However, having consulted with the airline dispatcher, the captain decided to set off on their flight plan, not dumping all fuel and landing (Freeman & Mead 2008). The given decision can be considered a wrong one because of the multiple hazards associated with it. The main reason for accepting this plan was the desire to avoid significant financial losses as $30,000 will be spent on fuel (Freeman & Mead 2008). Additionally, by new regulations, all passengers should be compensated for the delay which presupposed about $275,000 for reimbursement (Freeman & Mead 2008).

Regarding these aspects, and the fact that the craft was certified to fly on three engines, the crew decided to continue the flight. However, it was an erroneous decision as the high level of risks emerged. Flying an unairworthy plane is dangerous while speaking about the safety of passengers and their lives. Additionally, there was no clear understanding of the main causes for the emergence of the accident and if other engines would work appropriately. Under these conditions, it was critical to dump all fuel and land at the closest airport as per the existing FAA regulations disregarding all possible financial losses and trying to protect people

From this premise, one can also conclude that the captain should be charged by the FAA for this decision as the main motive for his actions was not the desire to select the most secure option; however, he tried to avoid extra spending and accepted the risky decision to fly on three engines with the broken one. It should be considered a serious violation of existing regulations and disregard of human lives’ value which is inappropriate in the modern aviation sphere. That is why the captain is responsible for this decision and should be provided with the appropriate punishment or additional training to avoid situations of this sort in the future and minimize risks associated with various incidents.

Valujet 592

The modern passenger aviation can be considered a competitive sphere that provides an opportunity to generate a stable and high income. For this reason, many airline companies are offering their services to clients trying to create the basis for their further evolution. At the same time, regarding the high need for a competitive advantage, numerous strategies are used to fill a particular niche and find a target audience. Valujet has managed to achieve this goal and boost its development and growth by utilizing a unique strategy.

Analyzing the company’s growth, several factors should be admitted as critical ones. First of all, Valujet entered a direct competition with Delta Airlines that had a dominating position in the market (Dana n.d.). To attain success, the company decided to occupy the sphere of low-cost flights that can help passengers to save money and reach the needed place of destination. One of the main components of this strategy was the elimination of the traditional ticket system and the implementation of the new one.

Ticketless travel provided people with the opportunity to reduce the time needed for the registration and save costs because the elimination of additional sums demanded to create traditional cards. Additionally, Valujet emphasized the necessity to provide inexpensive service with the absence of unnecessary spending, increased effectiveness, low base wages for staff members, and creation of the corporate culture oriented on productivity (Dana n.d.). The utilization of this strategy also demanded several changes if compare with traditional companies that resulted in the increased safety risks which are related to the company’s growth and it’s becoming one of the leaders in the sphere.

Thus, cost-saving was achieved mainly due to the use of second-hand models of McDonnell Douglas DC-9-30 aircraft that were purchased from Delta, Turkish firms, and other sources (Dana n.d.). Using these planes, the company managed to reduce spending on every flight and provide passengers with cheap tickets. At the same time, it meant that the risks of failure increased because of the need for modernization and exhaustion of these models. This fact evidences that direct correlation between the focus on the rapid growth and the emergence of safety concerns.

Valujet also used temporary personnel with low entry-level salaries. It helped to reduce costs devoted to wages and achieve the focus on the company’s profitability as it directly impacted additional rewards for employees and motivated them to attract new customers (Dana n.d.). However, it can be considered another reason for the emergence of risks and safety concerns. The low level of salaries means that less demanded and qualified workforce will be attracted. The given fact hurt the functioning of the company because of the poor influence of the human factor and the higher probability of mistake. Moreover, the focus on profitability might mean disregard to some critical aspects of security.

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Altogether, the analysis of Valujet’s growth shows that its rapid evolution became possible due to the utilization of the effective strategy focused on the cheap flights and reduction of costs (Dana n.d.). However, it can be dangerous for passengers and the company as it affects safety by reducing the quality of services and creating the ground for the emergence of incidents. For this reason, there is a direct correlation between the rapid growth and deterioration of safety in airlines.

Responding to the pressure and the demand to stop exploration, it is critical to outline the tendency towards the increase in risks associated with further rapid development. The highest office should understand the fact that if the investigation is stopped, vulnerabilities will emerge and they will remain unrevealed.

It can precondition the emergence of fatal consequences, new accidents, and deaths. In such a way, there is a critical need to continue researching the issue to minimize the number of problematic issues. Moreover, all flaws discovered in the course of the investigation can occur in other fast-growing companies. That is why it is important to create a paradigm that can be utilized in other cases to minimize risks.

Alaska Airlines 261

Alaska Airlines Flight 261 was an international voyage from Mexico to the USA with the intermediate landing at San-Francisco. However, on January 31, 2000, the aircraft experienced a set of technical problems that resulted in its crash into the Pacific Ocean. The given catastrophe killed 83 passengers and all members of the crew including two pilots, and three cabin crew members (NTSB 2002). It became a dramatic accident that happened due to the loss of pitch control. For this reason, the specially created committee engaged in the analysis of all aspects associated with it and ensured the elimination of vulnerabilities that introduced the basis for the emergence of a complex situation. CVR data and the crew actions were also analyzed as one of the possible causes of the crash.

Data from the cockpit voice recorders evidences that the crew members acted appropriately and tried to save the aircraft from its crash. Communication between the pilots shows that they started to realize that the horizontal stabilizer on the tail did not work appropriately as it did not move (NTSB 2002). Regarding the fact that it is a serious technical problem, the crew members started to perform appropriate actions to eliminate the problem and guarantee safety landing.

The decision not to use the autopilot was accepted as a jam of the system was one of the possible reasons (NTSB 2002). The captain also contacted the airline maintenance department asking for assistance and help, but there was no support (NTSB 2002). According to CVR, after the first dive occurred, pilots tried to save the craft again by asking the maintenance service if they can pull down more of the horizontal stabilizer system (NTSB 2002). The lack of competence among the land service and inappropriate answer resulted in the collapse of the plane as the tail of the flap was broken and the craft dived for the second time.

The given accident also resulted in the creation of several new perspectives on how the airlines should work and approaches to craft maintenance. Three months after the catastrophe, the FAA conducted an in-depth investigation of the company and its functioning. The created report incorporated critical information about the work of all systems and possible causes for the emergence of unexpected situations.

Thus, the document states that 22 of the major findings had a high critically baseline (NTSB 2002). Additionally, the report shows that the in-time and effective hazard analysis conducted before the accident could have saved the plane because of the emergence of multiple issues such as ineffective quality of control or deferral system that should be eliminated (NTSB 2002). In such a way, FAA’s oversight shows the importance of in-time interventions and monitoring.

The inclusion of board member statements at the end of the report can be explained by the fact that the crew acted effectively and tried to save the plane from the crash. The investigation shows that the primary cause of the emergence of the accident was the technical problem that could not be eliminated by the pilots (NTSB 2002). Additionally, the FAA’s analysis shows issues with the maintenance peculiar to the company. For this reason, NTSB allowed these statements to be included in the report as there were no mistakes in their actions. However, it helped to outline the existence of critical problems in management and the operation’s control.

Analyzing the case, it is recommended that the FAA should introduce the practice of more detailed and frequent investigations of the company’s functioning to discover and eliminate problems that might result in the collapse or crash. At the same time, there is a need for a special report incorporating the most frequent causes of failures and considering the necessity to devote attention to some aspects that might become critical during the flight. Finally, airline maintenance services should be provided with additional training to know how to act in unexpected situations and help the crew to solve emerging problems. These recommendations can help to reduce the number of issues and attain better results

Japan Airlines Boeing 787-8 JA829J

The quality of details that are used to manufacture a certain aircraft is one of the central components of the modern aviation sphere. For this reason, the existing agencies regulating the field insist on the introduction of the strict demands to the quality of equipment as it can become one of the main causes of the accident.

For instance, on January 7, 2013, specialists discovered smoke in the aft cabin of Japan Airlines Boeing 787-8 that was near the gate at the Federal Airports in Boston (NTSB 2014). Soon after the investigation, mechanics found the source of smoke which was the lid of the APU battery and electrical connector near it. All passengers and crew members were not aboard and there were no victims; however, the incident raised questions about the quality of manufacturing processes.

In the course of the investigation, the board concluded that the increase in temperature and pressure of a single battery cell resulted in a fire. Despite the fact, that there was a special 787 certification program, the product turned out to be dangerous for the whole craft (NTSB 2014). The two main causes of this situation were the absence of the appropriate testing in complex conditions, and issues in the manufacturing process.

During the investigation, the most severe conditions were not used to determine if the battery can be used. At the same time, during the analysis, NTSB (2014) concluded that cell manufacturing defects can result in the emergence of critical issues like the one mentioned above and precondition a crash. In such a way, one of the central problems with the 787 was the possible flaws in manufacturing and further utilization of details that contain defects.

Having visited GS Yuasa’s production facility, several concerns with foreign object debris, cell welding operations, and post-assembly inspection were discovered. In other words, there was a comparatively high probability of the occurrence of multiple defects in the products and internal short-circuiting (NTSB 2014). The given outcomes are inappropriate for the modern aviation sphere as it can result in fire and collapse of all systems critical for a successful flight. In such a way, the manufacturing process for the discussed case plays a fundamental role. The absence of defects and the ability to resist pressure are two basic elements of the equipment needed for planes. That is why the inspection and more testing are critical for these parts.

Regarding the described case, the FAA can be given a set of recommendations that would increase the level of safety. First, there is a need for a unified list of demands for all details to be tested under the most extreme conditions (NTSB 2014).

Only after this examination, they should be used while creating the aircraft and maintaining a high quality of its work. The introduction of this recommendation will help to minimize the risk of unexpected problems because of the defects or failures in detail. Second, more attention should be given to the manufacturing process and post-assembly inspection to avoid the further use of parts that have defects or do not possess all needed requirements to the quality.

Altogether, modern airlines should devote increased attention to the manufacturing process as it is one of the components of the existing approach to security. The appropriate functioning of all elements of the craft is possible only if all parts meet the high requirements for the quality of details. In such a way, there is a critical need to eliminate all drawbacks and certify equipment, only then it can be safely used.

Reference List

Dana, J n.d., ‘ValuJet Airlines’, Kellogg School of Management, pp. 1-11.

Edmondson, A & Herman, K 2012, ‘Columbia’s final mission. Abridged’, Harvard Business School. Web.

Freeman, R & Mead, J 2008, Flying light: British Airways flight 268 (a). Web.

NTSB 2002, Loss of control and impact with Pacific Ocean Alaska Airlines Flight 261 McDonnell Douglas MD-83, N963AS. Web.

NTSB 2014, Auxiliary power unit battery fire Japan Airlines Boeing 787-8, JA829. Web.

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