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Alaska Airlines and Japan Airlines Boeing: Accident Investigation

CVR Data and Crew Actions

Cockpit Voice Recorder (CVR) is a device in aircraft that records the voice. When the reading was at 1349:51, the horizontal stabilizer changes from 0.25° to 0.4° airplane nose facing down. Response to this action by the crew was that the autopilot was engaged. This is the last and the first time the airplane was in a horizontal stabilizer movement until it dived about 2 hours, 20 minutes later. At 1353:12, the aircraft was rising upwards through 28,557 feet at 296 KIAS, the autopilot disengaged, which was an appropriate action. At 1608:59, the vessel was unable to stabilize horizontally, and the captain addressed the first, and the officer then responded to the mechanic. There is a possibility of missing out on some vital information because the pilot was in a panic, and he was addressing two people at the same time.

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At 1609:14.8, the CVR logged a click and a clunk’s sound and, followed by two weak knocks in short progression at 1609:16.9, and the autopilot disengaged at 1609:16. At 1609:17 and 1609:19.6 logged a sound similar to the horizontal stabilizer-in-motion tone. After autopilot being disengaged in less than 3 to 4 seconds, the horizontal stabilizer moved from 0.4° to a recorded position of 2.5° airplane nose down. The airplane began to pitch nose down, starting a dive that lasted about 80 seconds as the vessel went from about 31,050 to between 24,000 and 23,000 feet.

At 1610:01.9, the CVR logged the over-speed warning’s sound, and the speed continued for the next 33 seconds. The captain contacted Los Angeles Air Route Traffic Control Center to report that he has lost the aircraft’s vertical control. At 1617:02, the first officer replied to the captain by saying thank you, which was the last radio transmission made from flight 261. At 1619:32.8, the CVR recorded the sound of two clicks similar to the sound of slat/flap movement. At 1619:36.6, the CVR recorded a deafening noise in the background, which increased up to the end of the recording with no action from the crew members.

Analysis of the FAA’s Oversight of Alaska Airlines

The Federal Aviation Administration’s oversight analysis of Alaska Airlines will consider pre-accident and post-accident inspections as follows.

Pre-Accident FAA National Aviation Safety Inspection Program

During the inspection by nine FAA members, they found serious problems with the airline’s systems ranging from flight control, contractual arrangements, and maintenance training programs. The NASIP inspection report pointed out 16 serious non-compliances related to operations and airworthiness. In addition to these, Alaska Airlines did not keep well maintenance reports, and the carrier was not following the manufacturer’s approved repair procedures. The serious deficiencies would have triggered FAA not to allow Alaska Airlines to operate.

FAA Air Transportation Oversight System

Air Transport Oversight System (ATOS) is designed to investigate system failure and conduct inspection in route structure, technical administration, flight operation, aircraft configuration control, personnel training, manuals, and qualifications. ATOS officer established that transition was difficult at some point at Alaska Airlines because of the training and staff level issues. This means that Alaska Airlines and some other more airline staff needed more training for a successful transition to ATOS from Program Tracking and Reporting System.

FAA Post-accident Special Inspection of Alaska Airlines

The special examination that was conducted as from 3rd -19th, 2000 due to the flight 261 accident Alaska Airlines, with an aim of determining the Airlines’ compliance with the Federal Aviation Regulations (FARs). The inspection report’s findings include lack of management personnel, training manual does not show curriculums on maintenance training or on-the-job training (OJT) formulas or goals and do not contain copies of audit specifications to be used to administer the Continuous Analysis and Surveillance Programs (Watkins and Slack, 2000, p. 7). The report highlighted that the highest potential of systems breakdowns is in the Maintenance Program, with 15 findings showing violation of the FAR’s. This is probably because Alaska Airlines maintenance personnel are not following the company’s procedures in its manuals, thereby increasing the probability of errors that may result in accidents.

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The board member statements include the following members’ statements: Acting Chairman Carol J. Carmody and Member John J. Goglia. National Transport Safety Board (NTSB) decided to be included at the end of the report and not at the beginning of the report to respond to the raised issue in the report and issue the final verdict on the raised concerns.


Federal Aviation Administration to direct management officers to tell the inspectors to perform an investigation of airline dispatch and repairs control personnel to ensure that their operations and training directives offer appropriate dispatch or support to pilots experiencing a malfunction that may threaten the safety of flight and caution them not to continue with the flight in case of danger for the interest of airline schedules for flights. Federal Aviation Administration to conduct a systematic engineering review to help in identification and elimination of the catastrophic effects of thread failure in the flat stabilizer trim system jackscrew assembly.

The Role of the Manufacturing Process for Boeing 787

The manufacturing process is important for various reasons. The role in the manufacturing process for Boeing 787 is to identify the materials that could not detect defects in manufacturing, like Foreign Object Debri and perturbations that may lead to internal circuiting (Nolan & Suresh, 2005). Analyzing the manufacturing process ensures that the manufacturing process adheres to the established industry standards.

It is true the manufacturing process is when the NTSB can be able to raise the concerns and can form the basis of an investigation in case of any problem. This is clearly evidenced when GS Yuasa stated that the incident battery was manufactured regarding Thales and Boeing’s specifications and quality control requirements. However, the NTSB’s observations on Yuasa’s cell manufacturing process identified some serious mistakes.

Boeing 787 cell manufacturing process helps in minimization of manufacturing defects or developing criteria for a formal inspection of the cells that would identify any defects that were introduced during the manufacturing process. The manufacturing process also improved the engine design for Boeing 787. Boeing’s 787 families would provide a customary engine interface for the two kinds of engines—the GE Next Generation engine and also the Rolls Royce Trent a thousand engine—allowing the new plane to be fitted with either manufacturer’s engine at any purpose in time (Nolan & Suresh, 2005, P.2). The development team believed that engine exchangeability had created the 787 a versatile quality that might be flexible among carriers which is enticing for financiers and leasing corporations.

Recommendations to the FAA

Federal Aviation Administration (FAA) to work with the experts of the aviation industry. Working with experts will help for the development and modification of the existing security standards that relate to the design of long-term installed lithium-ion batteries. Designs that may require monitoring of individual cell temperature and voltage and recording of exceedances to prevent internal cell damage during operations under the most extreme operating temperatures and currents.

Federal Aviation Administration to work with experts in the aviation industry to develop and modify design safety standards for large-format lithium-ion batteries that require excessive heating sources, including electrical contact resistance from connections and components, be minimized, documented and, identified as part of the design. The standards should include minimizing and identifying potential sources of heating that consider the range of operating temperatures. The FAA should also revise and develop processes to establish more effective oversight of production approval and suppliers to ensure that they follow the established regulations.

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Reference List

Nolan, Richard L., and Suresh, K. (2005). Boeing 787: The Dreamliner (TN). Harvard Business School.

United States. National Transportation Safety Board. (2002). Loss of control and impact with Pacific Ocean, Alaska Airlines flight 261 mcdonnell Douglas MD-83, N963AS about 2.7 miles north of Anacapa island, California, 2000.

United States. National Transportation Safety Board. (2014). Auxiliary power unit battery fire, Japan airlines Boeing 787-8, JA829J, Boston, Massachusetts.

Watkins, D. M. & Slack, K. (2000). Alaska Airlines and Flight 261 (A.) Harvard Business School.

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