On April 28, 1988, Aloha Airlines flight 243 underwent an explosive decompression in its passenger cabin at feet 24,000. Although the aircraft underwent extensive structural damage, it was able to land safely. Investigations identified metal fatigue in the skin panel fuselage as proximate cause of accident due to poor maintenance. Nevertheless, the accident analysis revealed a more complex chain of causes, including aging of aircraft structure, structural design, maintenance methodology and safety regulatory failures that lead to the incident. This paper will provide a failure root-cause analysis of the incident within the theoretical framework of safety design and maintenance methodologies. Incident root cause failure analysis
A. Aircraft aging and the limitations of fail-safe design Aloha 243 spent 19 years of accident-free operation in short-haul service. The model was designed with 20 years economic service life, ensuring the aircraft`s structure and components operational reliability for its whole life span, without significant maintenance expenses. However, the aircraft was exposed to an operational environment that resulted in faster ageing of its structure. Firstly, fuselage of its surface panels tended to become mechanically overloaded due to pressurization during short-haul flight cycles (causing more frequent pressurization dilation than in long-haul service).
Secondly, the local climate with humid and salt-laden air also exposed components to corrosion, weakening the skin panel bonding as a result. The joint processes of fatigue and corrosion then resulted in a critical level fuselage and attachment fatigue (a wear-out failure), and finally the separation of surface skin panels of the aircraft.
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In order for an aircraft to maneuver and maintain its stability, this required for aircraft to have control surfaces. Mainly, the aircraft are divided into two main control surfaces which are the primary flight control and the secondary flight control. The primary flight control is a basic control surfaces used to maneuver such as rolling, pitching and yawing. Meanwhile, secondary flight control ...
However, Boeing originally adopted a fail-safe design approach to avoid propagation of cracks through the airplane surface. This included component re-enforcements, secondary load paths and `tear straps` to maintain the integrity of the fuselage structure in the event of individual failure of its components. (Australian Transport Safety Bureau, 2007).
Apparently, the built-in component and structural redundancies failed to stop the crack-propagation. In consequence, the Multiple Site Fatigue Damage (MSD) cascaded into a Widespread Fatigue Damage (WFD), a fatigue failure type that was identified firstly in the history of aviation (see Figure 1 in Appendix).
B. Safety by design and the failure of damage tolerance
Based on early wearing tests results, Boeing was aware of the limitations of fail-safe design, therefore followed a complementary strategy, the damage tolerance approach, in the construction of 737. Damage tolerance or safety by design approach builds on the principles of fracture mechanics and starts out from acknowledging the fact that “it is not possible to eliminate all failures” (Hobbs, 2008).
Instead, the key element is the implementation of a comprehensive programme of inspections to detect failures in a systematic way, before they can affect flight safety. That is, damage tolerant structures are designed to sustain component failures without catastrophic failure. Until the damage is detected in scheduled maintenance inspections and the damaged part is repaired or replaced (see Figure 1 and further details in the Appendix).
(Australian Transport Safety Bureau, 2007).
Accordingly, Boeing issued Service Bulletins (SBs) with detailed inspection procedures for checking the specific bonding failures and fuselage skin panels with defined inspection frequencies (by flight hours).
Although Aloha followed the manufacturers advised general Maintenance Planning Programme, its management did not implement the specific SBs. Consequently, during the standard inspection activities sporadic cracks and first signs of panel bond disintegration were not identified within the safe crack growth period. It has been debated whether the standard maintenance programme (including four level of Checks, A-B-C-D, at different level of inspection detail and frequency) could have revealed the specific failures in question. The answer is negative: Aloha`s on-ground-examinations were made mainly during night, with limited visual inspection conditions and alertness to identify sporadic rivet cracks. (National Transportation Safety Board, 1989) In sum, the aircraft damage tolerance had become seriously limited which resulted in the catastrophic wear-out failure. C. Human errors and organizational failures
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As highlighted before, the investigation identified several types of human failures, including inspection errors and violations of operational procedures. According to Hobbs, maintenance management is critical to ensure aviation safety, and improper maintenance contributes as primary cause to a significant (7-14 %) proportion of aviation accidents and incidents. (Hobbs, 2008) However, individual failures in maintenance activities are usually not the root-causes of failures but affected by the work environment, organizational factors such as procedures, task scheduling and training. To follow Reason`s reasoning, maintenance errors are symptoms of underlying problems within the organization. (Reason, 1990) In case of Aloha, the major determining factors were the missing management focus on operational risk management in general, and the non-compliance to inspection regulations issued by the manufacturer and the Federal Aviation Administration. On the other hand, the active and latent failures on the level of decision-makers, line managers, and inspection operators must have been rooted in “an organizational culture that minimizes consideration of risk”, as in the case of Aloha. (Slack, 2000)
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Recommendations
Based on the analysis of Aloha 243 incident, there are important key learnings for practitioners. In the first place, as the aircraft was still in `normal life stage`, its operational reliability could have been maintained (and the incident avoided), if Aloha management complies with maintenance regulations and ensures the necessary inspections to be made. Beyond counterfactual wisdom, this lesson highlights the strategic importance of operational risk management in the aviation sector. The need for a strategic assessment of safety risk management activities is also supported by the cross-industry safety strategy shift from `safety by compliance` to `prevention by planning`. The key issue here is that reliance on compliance provides only a fixed-scope risk management capability. However, this cannot prevent or mitigate failures derive from organizational structure or culture. Therefore, safety risk management must be based on the people involvement and safety risk-conscious organizational culture.
Total productive Maintenance offers such a practical approach and continuous improvement framework for failure prevention culture. Improvement is achieved through empowering individuals and teams to run real-time failure analysis (vs. running `analyses after the incident` in the old way).
By training all staff to take responsibility for day-to-day risk prevention activities it enhances a positive safety culture that continually reinforces safe behaviours over unsafe behaviours. Similarly, by initiating transparent reporting and sanction free feedback mechanism, it supports fast information and knowledge transfer in bottom-top direction. However, to assist this development, management must ensure supportive working environment with proper conditions for maintenance activities (optimal stress, fatigue and visual conditions).
Reflections
D. What are the strengths and weaknesses of the systems and process approach? Process thinking means understanding business in terms of all their processes. Process approach permeates our thinking dealing with the optimization of a function`s resources, cost reduction of an end-to-end business process or preparation of an outsourcing decision. And we measure business performance by measuring our processes. Moreover, the mainstream strategic and operational business development approaches all based on the process approach (e.g. Porter`s value chain analysis, JIT, lean and Six Sigma methodologies, or ERP solutions).
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What is Project Management? When we describe the term Project management it is the art of taking uncertainty and transforming it into certainty (near). The process and activities are planning, organizing, motivating, and controlling resources, procedures and protocols to achieve specific goals in scientific or daily problems. Efficient and effective teams with a leader that can encourage ...
However, there is an inherent limitation in process thinking. With a mechanistic and reductionist view of the world of business, it tends to neglect the dynamic interactions between the process and its environment, including technological, human, economic and social factors. A key learning is that the attempt to optimize one element, and neglect the dimension of interactions of other elements, can lead to sub-optimization of the system, as a whole.
Although the question of priority of processes vs systems can be understood as an ontological one, I tend to take it as complementariness of perspectives. As process approach helps to create a visually simple understanding of the operation of business functions along quantifiable parameters. Whilst system approach provides a more comprehensive or holistic` outside-in` view of the interrelated and complementary dimensions of PPTI. E. How has study of the PSP core and your chosen elective pathway influenced your thinking about and your approach to management? Building on the discussion in the preceding paragraph, it is the key idea of `systemic thinking` that currently drives my understanding of business management. The significance of this is that PSP, besides providing a structured overview of service/production operations management, also offers a framework through systems approach where insights from other subjects, such as Managing People and Performance or Managing Financial Resources can be integrated.
The hard and soft system thinking develops further this framework. On the other hand, this approach also helped to extend my understanding of standard project management techniques with theories that place more focus e.g. on managing transition from people`s perspective. With an experience of ERP system implementation I found Lewin`s field theory on the context of change especially exciting. I also enjoyed learning about the emergent thinking on project management related to integrating business purpose, value creation, service delivery or organizations change perspectives. Besides the theoretical side, the PSP group assignment offered an excellent field of practice of project management and team-working.
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Participating in the project exposed me with the challenges of project scheduling and milestone planning, harmonizing (that is, trying to cope with) differences in learning styles and personal backgrounds, under severe time-constraints. A learning with some hindsight: a force-field analysis of PSP group work could have saved several rounds of discussions with limited value add. F. How will you use your learning from PSP in the future? As I plan to continue my career in management consultancy I expect to utilize my PSP knowledge and project management experiences in several areas. Developing my systems thinking will help me to take lead in strategic business planning projects, while deeper understanding of supplier collaboration, CRM or stakeholder management areas will endow me to successfully manage wide-ranging business relationships in supply-networks. An important application of soft system methodology, as a problem structuring technique, will help me e.g in development projects to achieve a shared understanding of projects goals and consensus for further actions.
Works Cited
Australian Transport Safety Bureau, 2007. How Old is Too Old? The impact of ageing aircraft on aviation safety, Canberra: Australian Transport Safety Bureau. FAA, 2005. Fatigue, fail-safe, and damage tolerance evaluation of metallic structure for normal, utility, acrobatic, and commuter category airplanes, Washington DC: Federal Aviation Administration. Hobbs, A., 2008. An Overview of Human Factors in Aviation Maintenance, Canberra: Australian Transport Safety Bureau. McEvily, A. J., 2002. Metal Failures: Mechanisms, Analysis, Prevention. New York: Wiley-IEEE. National Transportation Safety Board, 1989. Aircraft Accident Report, Aloha 243 Flight, Washington D.C.:
National Transportation Safety Board. Reason, J., 1990. Human error. New York: Cambridge University Press. Reason, J., 2000. Human error: models and management. British Medical Journal. Slack, N. C. S. J. R. &. B. A., 2000. Operations and Process Management: Principles and Practice for Strategic Impact. 2nd ed. Harlow: FT Prentice Hall.
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Chapter 3 introduces the Logical Framework Approach (LFA), explaining its role in project design with a simple project example. It explains how sustainability / quality factors can influence a project’s chances for success, and indicates the range of Where to tools that are available to take account of these factors. It also explains how you can find what? use the logframe matrix to develop ...
