The crash of any aircraft is a serious incident demanding an in-depth and comprehensive analysis of factors resulting in the emergence of an unexpected situation and failure. The data collected during these investigations is vital for improved risk assessment and the creation of new guidelines to avoid similar scenarios and guarantee higher safety to passengers. The committee created for the evaluation of the crash considers all possible root causes and factors related to the flight and provide conclusion and recommendations. For instance, the Space Shuttle Columbia disaster triggered vigorous debates because of the project’s scope and possible causes of the given crash. Numerous officials blamed NASA for establishing the poor working and safety culture, which resulted in serious problems.
The accident happened on February 1, 2003, when the Space Shuttle Columbia was returning after its mission in space. As it reentered the atmosphere, the Shuttle disintegrated, killing all members of the crew (CAIB, 2003). The disaster became a second incident in the program as Challenger was the first shuttle that exploded and killed all astronauts (Mahler, 2009). The accident demonstrated serious flaws in the project and initiated the in-depth investigation and discussion of the causes preconditioning such results.
Using all existing evidence, the investigation board concluded that the mechanical damage caused to Columbia and non-physical factors, such as the culture at NASA, at that moment could be viewed as the central reasons for the failure (Edmondson and Herman, 2012). This statement triggered debates over agency’s actual state and its approach to working with shuttles and the management of such projects.
The critical evaluation shows that the culture at the time of the accident was inappropriate. NASA experienced a serious lack of financing, while the Space Shuttle Project demanded significant investments (Mahler, 2009). For this reason, the idea of reducing spending and increasing speed was adopted as the central one (Edmondson and Herman, 2012). The employment of this model decreased the effectiveness of work and deteriorated outcomes. The reports show that engineers working with critical parts of equipment had to disregard some recommendations and signs of problems because of the demand to follow the dominant idea (CAIB, 2003).
The lack of financing resulted in cutting jobs and decreased performance quality (Edmondson and Herman, 2012). Moreover, some half-wat solutions to reduce spending were accepted (Edmondson and Herman, 2012). It resulted in the accumulation of multiple adverse effects and problems peculiar to the Space Shuttle Project. Specialists were also prohibited from discussing recommendations offered by leaders (CAIB, 2003). It preconditioned the establishment of the culture, which negatively affected Columbia’s safety. The following
Moreover, there is an idea that the disaster could have been avoided using the information acquired after the Challenger disaster. The first failure in the project helped to reveal some systematic problems, such as the lack of communication between engineers and management (Mahler, 2009).
The report showed that O-ring seals failed and preconditioned the explosion; however, these parts had already been recognized as hazardous ones several years before the disaster (Edmondson and Herman, 2012). Yet, they were still used in the project, showing the flaws in its culture and poor management practices. Similar issues occurred during the Columbia flight, meaning that the Challenger disaster was not taken into account and lessons from it were disregarded, as no improvements to the culture were introduced (Mahler, 2009). The inability to change the dominant paradigm resulted in crush and astronauts’ deaths.
British Airways Flight 268
Crew’s decisions are vital for the safety of any flight as their correct actions ensure the successful take-off and landing. Moreover, in emergent cases, the captain and pilots’ decisions can help to avoid disaster and save lives. That is why the crew’s competency, skills, and experience are the pillars of aviation necessary to guaranteeing safe flights. International Air Transport Association (IATA) and International Civil Aviation Organization (ICAO) offer specific guidelines for pilots to ensure they have an improved vision of how to act in difficult situations (Cusick, Cortes and Rodrigues, 2017). However, the case of British Airways Flight 268 demonstrates that various visions of what decisions can be considered appropriate ones.
The incident started after the take-off, and the dispatcher reported to the crew about flames in one of the engines. The three pilots also heard the explosion and realized the need to decide whether to continue the flight or return (Freeman and Mead, 2008).
The crew had all information about the plane and its ability to fly using only three engines with no risks of collapse or failure. Using this knowledge, they insisted on continuing the flight with the damaged engine shut down as it helped to struggle with the fire (Freeman and Mead, 2008). The captain also asked for visual proof that the fire was localized and did not threaten the aircraft or other engines (Freeman and Mead, 2008). These two decisions were correct at that moment as they helped to avoid the explosion of fuel and collapse, moreover, the visual check guaranteed that there were no other threatening signs. Correctly realizing the plane’s peculiarities and how the fire in engines should be managed, they saved the aircraft and all passengers.
However, the further decisions of the crew are more disputable. The air traffic control wanted the plane to return to ensure that all passengers would be safe. However, regardless of existing recommendations, the captain refused to dump all fuel and land and decided to set off on the current flight plan (Freeman and Mead, 2008). This solution was impacted by the high potential losses of about $30,000 on fuel and compensations for passengers, which presupposed about $275,000 for reimbursement (Freeman and Mead, 2008).
Considering the plane’s ability to fly using three engines and the high financial risks, the captain made the wrong decision. In accordance with the existing guidelines, the crew should not fly an unairworthy plane because of the emergence of multiple risks to passengers (Kritzinger, 2016). Moreover, the fire causes were not determined, meaning that new problems could emerge and more engines might be affected. For this reason, the decision to continue the flight was the wrong one.
For this reason, the captain should have been charged by the FAA. First, he disregarded the existing guidelines and created a situation characterized by high risk (Kritzinger, 2016). Although the plane is designed to fly with one engine shut down, it remains an emergent situation demanding landing. Second, trying to save money for the company and reduce spending, he decided to fly on three engines, which is not safe. Using the unairworthy plane with no solid reasons is a serious violation of the existing rules and regulations. Because the captain’s decision-making was affected by financial, not security concerns, the FAA can apply severe measures and punish him for creating a potentially dangerous situation. The safety of passengers should always the leading factor affecting the crew’s choice of methods and solutions; otherwise, the ground for the accident can be created.
Valujet 592
Civil aviation is a highly attractive business sector with high incomes and fierce rivalry. For this reason, airlines today look for new ways to attract clients and remain competitive. Valujet is a company that has a strategy allowing it to evolve and generate stable revenues. There are several success factors explaining the fast growth of the firm and its ability to struggle with other players. Valujet accepted a vital strategic decision to operate in the sphere of low-cost flights, which becomes more popular at the moment (Dana, n. d.). Passengers benefit from the chance to spend less and arrive at areas they want (Dana, n. d.).
Moreover, to save time and effort needed to use the company’s services, Valuejet refused from using the traditional ticket system and introduced a new one, focusing on the development of ticketless travel, with no registration (Dana, n. d.). This step helped to save money and improve the brand’s image among a specific group of clients.
The company also cultivated the idea of saving spending among clients by using low-cost services, eliminating unnecessary services that are obligatory in other companies, and creation of the corporate culture with the emphasis on clients’ satisfaction, high speed of operations, and their accuracy (Dana, n. d.).
At the same time, along with the fast evolution of Valuejet and its becoming one of the leaders in the niche of low-cost flights, it also faced multiple concerns associated with the growing risks and chances for failure (Roberto, Bohmer and Edmondson, 2006). For instance, the company uses second-hand models of aircraft, such as McDonnel Douglass DC-9-30 previously used by other airlines (Dana, n. d.). Along with the reduction in costs, it increases the risks of failure because of the exhaustion of all plains and the urgent need for their improvement (NTSB, 1997). In other words, the extremely fast development of Valuejet affected its operations and made safety concerns more topical.
The company also saves money by using low entry-level salaries. Using mainly temporary personnel, Valujet invests in the further development of the firm by attracting new clients and rewards to workers (Dana, n. d.). However, this approach increases the importance of human factors and mistakes made by the ground personnel (Price and Forrest, 2016). For instance, the less qualified workforce attracted by low salaries can make wrong decisions resulting in failures (NTSB, 1997). In such a way, it is possible to conclude that the fast evolution of Valuejet is directly correlated with the growing number of threats and problems with security. The reduction in costs preconditions the poor quality of services and employment of inexperienced personnel, meaning that safety concerns are disregarded.
Responding to the pressure, it is vital to admit the high risk of crashes in the future if the evaluation is prohibited. The existing paradigm presupposes that revenues are more important than safety, and passengers might experience multiple troubles during their flight. If no results of the investigation are reported, the risks will at least double. Valujet will continue using the same practice in the future and use similar or even more cost-saving approaches resulting in new flaws. Under these conditions, the investigation cannot be stopped as it can provide data critical for saving lives in the future and introducing measures to improve the current situation and avoid disasters. Valujet’s model can be enhanced only using the results of the assessment, meaning that all possible vulnerabilities should be outlined and discussed.
Alaska Airlines 261
Alaska Airlines Flight 261 crashed on January 31, 2000, into the Pacific Ocean. The disaster occurred because of technical problems and preconditioned the death of 83 passengers and all crew members (NTSB, 2002). One of the central reasons for the crash is the loss of pitch control which means that the plane experienced an unexpected situation. The committee investigated the cockpit voice recorders’ (CVR) data and all available information to create the case’s final report. Thus, the data shows that all decisions accepted by the crew were correct and were aimed at saving the aircraft and avoiding crashes (NTSB, 2002).
The CVR records evidence that the pilots recognized the problem with the horizontal stabilizer on the tail and its inability to perform its functions (NTSB, 2002). The severity of the breakage demanded immediate actions to guarantee that all passengers are safe. The crew refused to use the autopilot as the malfunction of one of the systems onboard was considered one of the possible problems for the failure (NTSB, 2002). Following the current guidelines, the captain asked for assistance from the airline maintenance department (Krause, 2003). CVR shows that after the first dive, the pilots asked for recommendations regarding the situation and their following actions (NTSB, 2002). However, due to the lack of support from the ground services, the planed dived for the second time and crashed.
The accident created the basis for the in-depth analysis of the current maintenance procedures and planes’ conditions. FAA investigated the airline’s work, its major aspects, and things linked to the safety of flights. In the course of the research, the agency concluded that 22 of the findings were critically important (NTSB, 2002). They were linked to the area of planes’ maintenance and checks. FAA also assumed that the on-time and a more effective technical inspection could have helped to avoid the disaster as it would show the existence of technical issues, such as the defects in the work of pitch control systems (Watkins and Slack, 2001). The report provided by the organization proved the idea that airlines should organize and support comprehensive inspections of aircraft as the central aspect leading to improved safety.
The FAA’s investigation and the following report proved the high competency of pilots and the correctness of their decisions. The crew members selected the right strategy and realized the critical risk of the situation caused by the defect; however, as far as the accident was caused by the technological problem, their capabilities were limited (Krause, 2003). Pilots could not repair the breakage and save the aircraft. The existence of the issues with technical inspection, maintenance, and the absence of pilots’ fault allowed to include such statements in the final report. There was the need to attract attention to the problems with management, poor quality of risk assessment and control.
Regarding the acquired information, FAA creates a report including the most common problems and how to eliminate them. Second, the in-depth and regular inspections of planes’ conditions should be a must for any company. That is why FAA should research the work of different airlines to determine problems at early stages and respond to them. Finally, it is critical to teach ground personnel how to support crew members in highly emergent situations to avoid collapses and crashes. Following these recommendations, it is possible to reduce incidents and ensure that pilots would have an opportunity to resolve problems in the air and save passengers’ lives.
Japan Airlines Boeing 787-8 JA829J
Considering the fact that safety is the central aspect of modern civil aviation, the demands to on quality of aircraft’s manufacturing process are extremely high. It is critical to ensure that all components function appropriately and can ensure that no accidents will occur during the flight because of technological problems. Otherwise, the disaster leading to people’s deaths can happen. The necessity of strict quality control is evidenced by the Japan Airlines Boeing 787-8 case. During the inspection, workers found smoke in the aft cabin. Luckily, the airplane was not in the air, and the passengers and crew members were not aboard (NTSB, 2013).
The plane stood close to the gate at the Boston Federal Airport (NTSB, 2013). The in-depth analysis of the situation discovered that the APU batter and the electrical connector were the sources of smoke (NTSB, 2013). The case demonstrated the necessity of improved control over the parts of aircraft and suppliers.
The experiments conducted after the accident revealed several problems. The board concluded that the growing temperature and pressure of a battery could create dangerous conditions and result in a fire (NTSB, 2013). In such a way, the battery became a hazardous component threatening the whole plane (NTSB, 2013). The detail was not tested under pressure or other complex conditions, which resulted in the lack of data about its functioning in real-life situations (NTSB, 2013). Moreover, the drawbacks in the manufacturing process should also be mentioned regarding the battery (NTSB, 2013). NTSB stated that cell defects during the process could result in the emergence and development of critical situations and the destruction of a plane (NTSB, 2013). For Japan Airlines Boeing 787-8, the poor quality control could have resulted in severer problems.
Inspection of the manufacturing process and the investigation of GS Yuasa’s facilities discovered additional problems. These included problematic cell welding operations, poor quality control after the assemblage, and the lack of supervision during the different stages (NTSB, 2013). These flaws affected the emergence of details with defects and the emergence of short-circuiting (NTSB, 2013). This statement evidences the core role the manufacturing process plays in the safety of flights. The defects in details used in aircraft are unacceptable as they might precondition the collapse of the plane. It also means that there is a need for better control.
Altogether, it is possible to make several recommendations to avoid such cases in the future. First of all, the manufacturing process and the following inspection should be given more attention both by companies and agencies, such as FAA. It will ensure the appropriate state of all details and their inability to precondition the crash. Secondly, all components used in the aircraft should be tested in the severest conditions to record their functioning and changes that might be dangerous to the flight (Stolzer and Gogila, 2016). Such tests can be performed following the FAA’s guidelines designed regarding such accidents and information collected during their investigation. Finally, FAA can be recommended to work closely with manufacturers to ensure they follow the exiting guidelines and have practical monitoring systems that can guarantee the absence of serious issues. This set of recommendations is formulated regarding the need to ensure safety for all passengers.
Reference List
Columbia Accident Investigation Board (CAIB) (2003) Columbia accident investigation board report. Washington, DC: Government Printing Office.
Cusick, S., Cortes, A. and Rodrigues, C. (2017) Commercial aviation safety. 6th edn. New York, NY: McGraw-Hill Education.
Dana, J. (no date) ‘ValuJet Airlines’, Kellogg School of Management, pp. 1-11.
Edmondson, A. and Herman, K. (2012) ‘Columbia’s final mission. Abridged’, Harvard Business School. Web.
Freeman, R. and Mead, J. (2008) Flying light: British Airways flight 268 (a). Web.
Krause, S. (2003) Aircraft safety: accident investigations, analyses, & applications. 2nd edn. London: McGraw-Hill Education
Kritzinger, D. (2016). Aircraft system safety: assessments for initial airworthiness certification. New York, NY: Woodhead Publishing.
Mahler, J. (2009) Organizational learning at NASA: the Challenger and Columbia accidents. Washington, DC: Georgetown University Press.
National Transportation Safety Board (NTSB) (1997) Aircraft accident report. In-flight fire and impact with terrain Valujet Airlines Flight 592, DC-9032, N904VH Everglades, Near Miami, Florida. Washington, DC: NTSB.
National Transportation Safety Board (NTSB) (2002) Loss of control and impact with Pacific Ocean Alaska Airlines Flight 261 McDonnell Douglas MD-83, N963AS. Washington, DC: NTSB.
National Transportation Safety Board (NTSB) (2013) Aircraft incident report. Auxiliary power unit battery fire Japan Airlines Boeing 787-8, JA829. Washington, DC: NTSB.
Price, J. and Forrest, J. (2016). Practical airport operations, safety, and emergency management: protocols for today and the future. New York, NY: Butterworth-Heinemann.
Roberto, M., Bohmer, R. and Edmondson, A. (2006) ‘Facing ambiguous threats’, Harvard Business Review, pp. 1-9.
Stolzer, A. and Gogila, J. (2016) Safety management systems in aviation. 2nd edn. London: Routledge.
Watkins, M. and Slack, K. (2001) ‘Alaska Airlines and Flight 261 (A)’, Harvard Business Review, pp. 1-16.