Human Factors in Maintenance Essay

Nationair DC-8 Flight 2120 took the lives of 247 passengers and 14 crew members; 261 in all; during takeoff on July 11, 1991. The jet was owned by Canadian airline Nolisair, and was being operated by a Nigerian company to transport Nigerian pilgrims in and out of Mecca. The DC- 8 caught fire during take-off from Abdulaziz International Airport, Jeddah, Saudi Arabia. Pilots noticed problems during early stages of take-off and only made it 671 meters in elevation before attempting to turn around for a emergency landing. It was too late; the under inflated tires had overheated began to catch fire. The fire grew and blew out the hydraulics which made the emergency landing impossible. This was the worst wreck a DC-8 had ever experienced and has held the record for many years following. The NTSB concluded that the fire could have been handled by leaving the landing gear extended and away from the plane. Although the pilots failed to make the right decision, and added just one more human error to the equation, it was the obvious neglect by the maintenance team that caused this horrific accident. There are many human factors which played a vital role in the crash. The maintenance team failed to inflate the #2 and #4 main gear tires after recognizing the pressure during the pre-flight. An attempt to inflate the tires failed because there was no nitrogen available at the location. Further investigation shows later that the maintenance team recognized and had written up the tires during a previous â€Å"A† inspection but was signed off and overlooked more than twice before the incident. Human Factors Involvement There are many human factors that caused the Flight 2120 crash, and most of them are maintenance related. There was a Liveware-Liveware problem with the lack of communication between the lead mechanic and Director of Production. The Director of Production never questioned the lead mechanic and was said to have little contact with the him prior to this happening. Liveware-Hardware issues developed because of lack of qualified personnel amongst the maintenance team. The maintenance team did not have a qualified person to sign off the jet, leaving the task to the flight engineer who was not in tune with the maintenance team. The responsibility should have landed in the lead mechanics hands to sign off the maintenance write ups and the Director of Production should have been more involved by communicating with the lead mechanic and being more involved. There was a break down in maintenance even in the early stages of this TDY. The tires had been already recognized and written up during prior inspections, but pressure from the Project Manager to make the mission influenced the maintenance team to overlook minor maintenance issues at that time. Although seemingly minor at the time, the issues would later be the ultimate downfall and failure of the mission. Lack of communication and pressure caused the maintenance team to not see the importance of inflating the tires to the standard before going on a long mission. The minor task of inflating the tires to the standards before going on the long sortie would have negated the tires overheating and causing the plane to catch on fire and crash. The maintenance team was not the only factor which added to the human factors. The air crew is also responsible for some bad decision making skills also. During take-off one crew member was recorded stating that he thought he heard a main landing gear tire blow. The pilot failed to act upon and acknowledge this and carried on with the task. Pilots failed to recognize warning lights designed to inform the pilot of landing gear issues. While taking off the crew failed to use proper radio procedures regulations that kept them in contact with the tower. The night before the crash the pilots were out shopping and eating and not returning home until hours before take-off. The lack of crew rest could have played a role in decision making abilities amongst the crew. The crew showed up to the aircraft late which pushed maintenance to hurry and complete the pre-flight, giving them no time to perform a good complete inspection. Lack of leadership in the cockpit added to the advancement in takeoff. If the copilot trusted his own judgment and realized there was a problem in the main gear he could have stopped the aircraft from taking off. Safety Nets The crash of flight 2120 could have easily been avoided by simply following standard procedures set by international and local organizations. The maintenance holds the bulk of the responsibility in terms of human factors. The communication between the lead mechanic and AME could have been solved by following the chain of command. The director of production had very poor communication with the lead mechanic. This caused for a lack in communication from the there up the chain. The communication was broken at this given point in the chain of command and gave little information which is vital in aviation. The AME had direct responsibility to sign off the final for flight and it was handed over to the flight engineer whom had little knowledge of the maintenance operations. The maintenance team failed to complete given checklists and follow standards set by the FFA and international organizations. With the lack of communication, personnel, and leadership, along with added pressure, the aircraft was not mission ready and should have been better managed from top to bottom. The maintenance crew has very stringent tire pressure requirements and the responsibility lies in even the lowest level of operations to complete the task. The warning lights indicated to the cockpit flight crew that problems have arouse and they chose to ignore them. By receiving proper crew rest the night before, they might have had better decision making skills and could have made the right decision at the given moment. They also became complacent and did not use the communication procedures with the tower. Conclusion Human factors is the cause of most aircraft accidents and this one is a major example of how many human factors can play such a vital role. Flight 2120 shows the importance and how human factors can directly affect everything involved. The importance of being alert and aware of your environment can come down to one decision which can be the determining factor in any situation. The maintenance and air crew failed to follow written guidelines and standards of operation to protect the lives of those on board. The mission was doomed from the start by the maintenance communication breakdown. The lack of qualified personnel should have been one of the first red flags. The decision to not fix the problem and over look it several times put them in an environment where the tools needed for the job was not present. The lack of leadership from the bottom level of the maintenance crew to the pilot was a major issue. The lowest level maintenance personnel could have stepped up and brought about the problem. The flight of Nigerian Airway 2120 was that caused by human error. The horrific event shows the importance of following set standards and regulations. The crash exposes the vital role in the chain of command and how human error and lack of communication can break down at any level. References Aviationsafetynetwork.com American-bankruptcy.us.gov