html5-img
1 / 13

Kegworth Air disaster

Kegworth Air disaster. Example of multiple levels of analysis What causes a plane to crash? [1 min.]. What causes a plane to crash?. A laundry list is required, or, a swiss cheese loaf lined up A lot, in safety critical systems. Kegworth Air Disaster. Why? Near Ritter, Baxter & Churchill

manasa
Télécharger la présentation

Kegworth Air disaster

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Kegworth Air disaster Example of multiple levels of analysis What causes a plane to crash? [1 min.]

  2. What causes a plane to crash? • A laundry list is required, or, a swiss cheese loaf lined up • A lot, in safety critical systems

  3. Kegworth Air Disaster • Why? • Near Ritter, Baxter & Churchill • A lovely example • Often used

  4. Storyline • Flight, jan 1989, Heathrow to Belfast, Midland 192 • Experienced pilots, new plane (737) • Part of one of the safest systems in the world • Upon take-off, no problems • Shuddering, fire in an engine at ~10 min. • Shut off #2 engine, RHS (the good one!) • This is the pilot error

  5. Hardware and Mischance badly designed new engine, failure at 3 months, approx. t=300 h, should be t=500,000 h, not tested at altitude /unlucky choice of diversion airport [BMI hub]

  6. Auto throttle problem poor mental model of plane [system](turned off good engine, which disengaged autothrottled, solving the judder problem) lack of engine feedback [interface design]

  7. Vibration Dial 1 vibration dial harder to read [design] vibration dial not required to fly [regulation] dial and plane not trained with simulator technology updated but not announced

  8. Vibration Dial 2 • vibration dial small [design] • Without range marking [design]

  9. During descent lots of interruptions pilots can’t see the engines no protocol: no checking/confirmation visually from cabin • Passengers could see fire but explained it away, perhaps also flight attendants diffusion of social responsibilities Social distance between aircrew and pilots

  10. crash • 900 m short • 43+4 out of 118+8 die

  11. At crash • Not documented: noise abatement hillocks

  12. Afterwards • If any 13or 3 missing, no loss of life • What was the pilot error? • Thus, systems require understanding people, technology, and systems and environment

  13. References • Wikipedia on kegworth • BBC. (1991). Fatal error: Taking liberties [television series]. • Youtube has videos as well

More Related