Question

Investigate Aloha Airlines (AA) Flight 243 incident and:

Discuss the human factors issues related to the conduct of maintenance and general staff attitudes at AA prior to the incident. Include actions that could have been taken to reduce the likelihood of the maintenance errors contributing to the incident.

RELEVANT REPORT: Accident Investigation Aloha Airlines AAR89-03

PLEASE PROVIDE ANY REFERENCES USED.

Answer 1

The human factors issues related to the conduct of maintenance and general staff attitudes at AA prior to the incident are:

Insufficient quality manpower with inadequate knowledge and doing poor reporting of problems

Quality of inspection was questionable. The maintenance programs had shortcomings: The program didn’t detect the weakening bond and fatigue damage that resulted in breaking of lap joint at S-10L. Fuselage scrutiny happened during night that affected quality of needed inspection of the outside area of aircraft.

The supervision was not up to mark by the maintenance officers at AA: The checking of airworthiness of aircraft was insufficient.

The airframe manufacturers can provide operators with an independent perspective which often avoids the "blind spots" that

The internal maintenance audits were laced with “home born-and bred cultures". There was no feedback from independent party that could evaluate systems and methods used by organization for knowing status of airplanes condition, maintenance machines and capabilities of core employees as well as structure. In ALO accident the purpose of maintenance concept failed. The factors responsible were:

• Lack of a corrosion evaluation program
• Extremely increased flight cycles
• Faulty way of structural sampling
• Not able to understand SSID program
• Inadequate reporting of deficiencies found in planes to the manufacture

Recommendations:

• Placing priority for overhauling technical policies & Procedures Manual
• Going for job rotation and imparting trainings to inspectors on inspection methods. Motivating them to voice them properly when dealings with Aircraft Services
• Directing Quality Assurance for performing surprise audits
• Using data of maintenance on airplanes in past set the norms for evaluating future performance
• Good communication established between the Flight Operations and Technical divisions
• Hire more quality personnel for technical division. Give them safe working environment.
• There should be a provision of training to all maintenance staff, with at least a week of refresher training annually with specific trainings on structural repair, corrosion containment and testing.

Source:

https://www.faa.gov/about/initiatives/maintenance_hf/library/documents/media/human_factors_maintenance/aloha_airlines.pdf

https://livingsafelywithhumanerror.wordpress.com/2016/04/29/lessons-learned-from-aloha-flight-243-aircraft-registration-n73711/