Human Factor in aviation building essay

aviation / accident / British Airlines / decompression / human factor

Essay Topic:

The influence of the Human factor on the potential airline accidents.

Essay Questions:

How does the human factor influence the aviation building? Why do airline accidents depend so much on the human factor? How does the behavior of people provokes errors leading to accidents?

Thesis Statement:

The failure to detect the aircraft defects has cause a lot of innocent victims and “damaged reputations” for the airline companies.


Human Factor in aviation building essay


Table of contents:

1. Introduction

2. Constructing factors leading to the fault

3. Human factors in the accident

4. Perpetrators and minimization of the re-occurrence probability

5. Conclusion

Introduction. So many aviation accidents have happened throughout the existence of aviation flights, that nothing worries people more than the confidence in their safety while on board the plane. Contemporary business people spend more time “in the air” than on earth and it makes aviation safety one of the most important issues of the modern humanity. It goes without saying that a human being makes mistakes, but when it comes to safety the notion that nothing can be foolproof, stops being acceptable. Nowadays there are numerous advanced flight deck technologies, which work for making the probability of an accident as minimal as it is theoretically possible. Even experiences professionals are still just human beings and the human factor should always be kept in mind. As we all know – the future is impossible without the past and may be it is very important to remember the accidents that were so shocking that lead to a new generation of safety maintenance and safety managing.The failure to detect the aircraft defects has cause a lot of innocent victims and “damaged reputations” for the airline companies. One of such accidents was the famous BAC 1-11 windscreen accident. The accident resulted in no fatalities but by itself reminded the significance of the human factor.

2. Constructing factors leading to the fault

The British Airlines BAC 1-11, G-BJRT from the 528 FL series found itself in a windscreen accident over Didcot, Oxfordshire, on the 10th of June 1990 at 0733 hrs (UTC). At the moment of the accident its latitude was 540 34’ North and its longitude was 0010 10’ West and had 81 passengers and six crewmembers1 on board. It was an ordinary scheduled flight flying from Birmingham with the destination point in Malaga, Spain.The major constructing failure of the flight was the windscreen trouble, as the left windscreen was replaced before the flight and failed to pass a text during the flight. The pressure in the cabin blew out this windscreen at the moment of reaching the 17,300 feet pressure altitude. The 90 securing bolts of the windscreen that required a proper safety check before the flight should have definitely prevented this accident. The most shocking part is the incapability of the securing bolts to resist the pressure due to the fact that 84 out of 90 bolts simply had the wrong diameter, a smaller one.

So it all goes about the selection of the wrong bolts or if to be specific the bolts of a wring diameter for the windscreen, which is an enormous construction mistake. The installation of the bolts is the direct responsibility of the Shift Maintenance Manager who did not use specific techniques to identify the bolts that were required. The reason of the mistakes is the similarity of the A211-8D and the A211-7D bolts. “The IPC2, available to identify the required bolts’ part number was not used; the stores TIME system, available to identify the stock level and location of the required bolts, was not used”[1,p.30]. Technically, the bolts of a smaller diameter left excessive space, which was the reason the windscreen, could not resist the altitude pressure.A quality replacement of the windscreen completely depended on the type of bolts and was the responsibility of the Shift Maintenance Manager. The practical mistake was the choice of the bolts according to the anchor nuts and the thread pitch, which were the same for both of the bolts’ models. In addition to that the work of the Shift Maintenance Manager was not properly checked. As the result during the decompression of the cabin, half of the Commanders body was out of the windscreen and the only reason he remained alive is because the cabin crew managed to deter him for almost half an hour until the moment the co-pilot successfully landed the plane at Southampton Airport. Obviously, all the aviation safety standards of the British Airways were ignored resulting in great constructing and engineering faults which lead to the fact that “the amount of unfilled countersink left by the small bolt heads was not recognized as excessive”[1,p.31].

3. Human factors in the accident

The BAC 1-11 windscreen accident was completely the result of an inadequate inspection of the work of one individual – the shift maintenance manager. This makes the reader start thinking about the true significance of the human factors in the process of work. One individual could have caused the deaths on many people in case the co-pilot had turned out to be less professional. Before speaking about the general human factor facts concerning the BAC 1-11 accident it is necessary to outline the true essence of the human factors itself:

• The behavior of people may vary and some of it can be error provoking and go against the required procedures while performing a task.

• Lack of communication is very often a reason for accidents. The ability to communicate on the task is vital.

• Fatigue, lack of attention and centrality

• Interruptions while performing the task

• Poor planning

• Pressure

• Personal physical condition (including eyesight and hearing)

These are some of the numerous human factors that may have lead to the BAC 1-11 windscreen accident. It goes without saying that the shift maintenance manager faced certain complications while replacing the windscreen as to the selection of the wrong bolt. But at the same time the wrong selection was made due to the fact of ignoring obvious traces of bolt-problems during the previous installation. In order to completely understand the human factor issue it is necessarily to know some personal details about the person who installed the windscreen. The Shift Maintenance Manager was a person with a 23-year experience of working for British Airlines. He had excellent recommendations from the company and was a respected person by the company staff. He was an “exemplary” employee and the investigation of all this financial transactions did not reveal any fraud3. The investigation also revealed that he had been on leave for approximately five weeks before the night of the installation of the windscreen, as it was his first working night after that period. He got enough sleep before the shift. So his physical conditions was normal, except the fact that he was prescribed reading glass and did not have the habit of using them while working. According to the ophthalmologist report the man needed glassed for detailed work made in close. That Sunday night was not an exception either and he did not put them on while working with the bolts.

The report of a behavioral psychologist described the behavior of the shirt maintenance manager as “…the behavior of a man who, based on experience, changed the mandatory torque setting for the bolts, visually matched the replacement bolts”[1,p.35]. What this means is that this situations might had happened before but remained unnoticed for the company inspectors. Can a person make so many mistakes “accidentally” or is such work simply result of repeated actions? Or could be not. The shit maintenance manager was fulfilling his task at night and the illumination could have been insufficient for his slightly managed eyesight. He was performing a detailed task, probably using a flashlight at night and these factors might have caused the bolt-error occur. Therefore, ”many of the actions taken that night by the Shift Maintenance Manager may be described as evidence of a lack of sufficient care in the execution of his responsibilities”. The human factor is obvious here, as it was due to one individual that the accident took place and it is a great luck that no fatalities took place during the accident and only one person had a serious injury.

4. Perpetrators and minimization of the re-occurrence probability

The process of the installation of the windscreen was accompanied by numerous mistakes, which are primary indicators of poor work practices and a lot of obvious error that should have been eliminated at their early stages of development. The judgments of the maintenance manager seem to be unprofessional as the mistakes were rather easy to detect if to follow the standards of British Airlines. Officially, the shit maintenance manager is definitely a perpetrator of the accident as his lack of professionalism resulted in a critical situation for the whole flight. But this is just the bottom of the whole jar, for the whole system of monitoring the work performance of the shift maintenance manager was weak. All the monitoring sections have to be involved in every single operation performed. One person does not build a plane everything needs to be controlled and revised million of times, so basically our personal opinion is that no one except the policy of British Airline is to be blamed. The accident simply showed that the mechanism of the company does not function properly and has gaps in its work performance.

So it is the fault of the company managers that are not able to supervise the work of their subordinates. This is proved by the fact of the statistics got from the checks held after the accident. “Throughout the British Airways fleet of BAC One-Elevens two aircraft failed the check, having a total of 41 short bolts (A211-7Ds)”[1,p.13]. In order to prevent the re-occurrence of such accidents the company should have quality inspectors whop will monitor the quality of work at each stage of its fulfillment and have signed documents of such checks. The company needs at least monitor the situation of construction and installations satisfactory. Concerning the issues of the physical condition of the shift maintenance manager it is necessary to add that the company should be more attentive to the medical recommendations given to the employees. For instance, special attention to the prescription of glasses if a worker performs a very “fine” work like working with bolts for the windscreen. The company should even include a systematic control of independent observers which will bring to life the effect of social facilitation of the skills of the employees.

Conclusion. The report on the BAC 1-11 windscreen accident states: “the Shift Maintenance Manager’s potential to achieve quality in the windscreen fitting process was eroded by his inadequate care, poor trade practices, failure to adhere to company standards and use of unsuitable equipment, which were judged symptomatic of a longer term failure by him to observe the promulgated procedures”[1,p.3]. But all the listed errors were not just his personal errors, but simply lack of control, which is obvious in the company. And this is the reason that the management of the British Airways did not find any deflection of the work of the Shift Maintenance Manager from the standards of the company, for they did not monitor his working practices and probably the working practices of all the other managers as well.

1 “Four cabin crew and two flight crew the aircraft “[1,p.3]

2 IPC – the International Pier Carousel

3 “No domestic or financial distractions were identified, either by British Airways management, the Behavioural Psychologist engaged by the AAIB who interviewed him or the AAIB Inspectors; the Shift Maintenance Manager denied any such problems”[1,p.28].


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