Difference between revisions of "List of maintenance-related failures"

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==Incidents==
 
==Incidents==
  
===British Airways Flight 5390===
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===Eastern Air Lines Flight 855===
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:''Main wikipage: [[Eastern Air Lines Flight 855]]''
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:At 08:56 on May 5, 1983, Eastern Air Lines, Inc., Flight 855, a Lockheed L-1011, with 10 crewmembers and 162 passengers on board, departed Miami International Airport en route to Nassau, Bahamas.
  
British Airways Flight 5390 was a flight from Birmingham Airport in England for Málaga Airport in Spain that suffered explosive decompression, with no loss of life, shortly after takeoff on 10 June 1990. An improperly installed windscreen panel separated from its frame, causing the plane's captain to be blown partially out of the aircraft. With the captain pinned against the window frame for twenty minutes, the first officer managed to land at Southampton Airport.
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:About 09:15, while descending through 15,000 feet, the low oil pressure light on the No. 2 engine illuminated. The No. 2 engine was shut down, and the captain decided to return to Miami to land. The airplane was cleared to Miami and began a climb to FL 200. While en route to Miami, the low oil pressure lights for engines Nos. 1 and 3 illuminated.
  
Human Errors: Windscreen panel is not properly installed on the airplane."
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:At 09:28, while at 16,000 feet, the No. 3 engine flamed out. At 0933:20, the No. 1 engine flamed out while the flightcrew was attempting to restart the No. 2 engine. The airplane descended without power from about 13,000 feet to about 4,000 feet, at which time the No. 2 engine was restarted.
  
===Lufthansa Airbus A320===
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:The airplane made a one-engine landing at Miami International Airport at 09:46. There were no injuries to the occupants.
On March 20, 2001 a Lufthansa Airbus A320 almost crashed shortly after takeoff because of reversed wiring in the captain's sidestick flight control. Quick action by the co-pilot, whose sidestick was not faulty, prevented a crash
 
  
The investigation has focused on maintenance on the captain's controls carried out by Lufthansa Technik just before the flight. During the previous flight, a problem with one of the two elevator/aileron computers (ELAC) had occurred. An electrical pin in the connector was found to be damaged and was replaced. It has been confirmed that two pairs of pins inside the connector had accidentally been crossed during the repair. This changed the polarity in the sidestick and the respective control channels “bypassing” the control unit, which might have sensed the error and would have triggered a warning. Clues might have been seen on the electronic centralized aircraft monitor (ECAM) screen during the flight control checks, but often pilots only check for a deflection indication, not the direction. Before the aircraft left the hangar, a flight control check was performed by the mechanic, but only using the first officer’s sidestick.
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:The [[National Transportation Safety Board]] determines that the probable cause of the accident was the omission of all the O-ring seals on the master chip detector assemblies leading to the loss of lubrication and damage to the airplane's three engines as a result of the failure of mechanics to follow the established and proper procedures for the installation of master chip detectors in the engine lubrication system, the repeated failure of supervisory personnel to require mechanics to comply strictly with the prescribed installation procedures, and the failure of Eastern Air Lines management to assess adequately the significance of similar previous occurrences and to act effectively to institute corrective action.
  
Lock pin
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:Contributing to the cause of the accident was the failure of [[Federal Aviation Administration]] maintenance inspectors to assess the significance of the incidents involving master chip detectors and to take effective surveillance and enforcement measures to prevent the recurrence of the incidents.
  
Figure 14-30. A description of a Lufthansa Airbus A320 that almost crashed due to reversed wiring of the flight controls.
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:The [[FAA]] report is published on [https://www.faa.gov/about/initiatives/maintenance_hf/library/documents/media/aviation_maintenance/eastern_airlines_inc.pdf faa.gov/about/initiatives]
  
 
===Excalibur Airways Airbus 320===
 
===Excalibur Airways Airbus 320===
August 26, 1993, an Excalibur Airways Airbus 320 took off from London-Gatwick Airport  (LGW) and exhibited an undemanded roll to the right on takeoff, a condition which persisted until the aircraft landed back at LGW 37 minutes later. Control of the aircraft required significant left sidestick at all times and the flight control system was degraded by the loss of spoiler control.
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:''Main wikipage: [[Excalibur Airways Airbus 320]]''
  
Technicians familiar with Boeing 757 flap change procedures lacked the knowledge required to correctly lock out the spoilers on the Airbus during the flap change work that was done the day before the flight. Turnover to technicians on the next shift compounded the problem. No mention of incorrect spoiler lockout procedure was given since it was assumed that the 320 was like the 757. The flap change was operationally checked, but the spoiler remained locked out incorrectly and was not detected by the flight crew during standard functional checks. The lack of knowledge on Airbus procedures was considered a primary cause of this incident.
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:On August 26, 1993, an Excalibur Airways Airbus 320 took off from London-Gatwick Airport (LGW) and exhibited an undemanded roll to the right on takeoff, a condition which persisted until the aircraft landed back at LGW 37 minutes later. Control of the aircraft required significant left sidestick at all times and the flight control system was degraded by the loss of spoiler control.
  
===Emery Worldwide Airlines DC-8-71F===
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:Technicians familiar with Boeing 757 flap change procedures lacked the knowledge required to correctly lock out the spoilers on the Airbus during the flap change work that was done the day before the flight. Turnover to technicians on the next shift compounded the problem. No mention of incorrect spoiler lockout procedure was given since it was assumed that the 320 was like the 757. The flap change was operationally checked, but the spoiler remained locked out incorrectly and was not detected by the flight crew during standard functional checks.
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===Lufthansa Airbus A320===
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:''Main wikipage: [[Lufthansa Airbus A320]]''
  
April 26, 2001, an Emery Worldwide Airlines DC-8-71F left main landing gear would not extend for landing.
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:On March 20, 2001 a Lufthansa Airbus A320 almost crashed shortly after takeoff because of reversed wiring in the captain's sidestick flight control. Quick action by the co-pilot, whose sidestick was not faulty, prevented a crash
  
Probable cause was failure of maintenance to install the correct hydraulic landing gear extension component and the failure of inspection to comply with post-maintenance test procedures. No injuries.
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:The investigation has focused on maintenance on the captain's controls carried out by Lufthansa Technik just before the flight. During the previous flight, a problem with one of the two elevator/aileron computers (ELAC) had occurred. An electrical pin in the connector was found to be damaged and was replaced. It has been confirmed that two pairs of pins inside the connector had accidentally been crossed during the repair. This changed the polarity in the sidestick and the respective control channels "bypassing" the control unit, which might have sensed the error and would have triggered a warning. Clues might have been seen on the electronic centralized aircraft monitor (ECAM) screen during the flight control checks, but often pilots only check for a deflection indication, not the direction. Before the aircraft left the hangar, a flight control check was performed by the mechanic, but only using the first officer's sidestick.
  
 
==Accidents==
 
==Accidents==
 
===American Airlines Flight 191===
 
===American Airlines Flight 191===
American airlines flight 191 (1979) is the worst aviation accident in the [[United States]]. Eight weeks before the disaster, the last repair of the plane damaged the overhead engine tower installed on the plane. When the plane took off from o'hare, the engine fell off the plane and landed on the runway, cutting off the electrical system and spilling hydraulic oil. It controlled some of the moving parts of the wing, and the pilots couldn't see the wing and didn't realize they were losing liquid oil. Damaged left, however, has stalled, the plane a dive, crashed into an open field, debris was thrown into a trailer park, near the destroyed several trailer and cars, there is an old aircraft hanger, and serious damage to a few people on the ground, killing two people, including staff of 273 people were on the plane of fire burned to death, not a survivor.
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:''Main wikipage: [[American Airlines Flight 191]]''
 
 
It was the fourth fatal crash on the dc-10 since its inception, with 622 people killed in all four dc-10 crashes. This has drawn harsh criticism from several media outlets. The report said the weather was good at the time of the incident and there were no bird flocks or other aircraft nearby at the time of the incident. After a few years later, in all aspects of conclusion is aa maintenance department in engine repair, in order to save more than 200 hours of maintenance time and money, the engine and the ""dragon"" (Pylon, suspended structure) between the engine and wings removed and put together all night just back, so that in the Pylon and cracks caused by the wing joint area. This is a violation of dc-10 design original McDonnell Douglas maintenance procedures, aircraft maintenance must be step-by-step, not to save time and money to take shortcuts.
 
  
The DC-10 left Chicago O'Hare on the Friday afternoon of Memorial Day weekend only for its left engine to detach from its wing and fall off, rolling the plane in the air and sending it crashing to earth just a mile from the runway.The plane ""burst into a pillar of flame and smoke that could be seen up to eight miles away,"" the Chicago Tribune reported at the time. All 271 people on board and two on the ground were killed in what remains America's worst aviation disaster.The plane ""burst into a pillar of flame and smoke that could be seen up to eight miles away,"" the Chicago Tribune reported at the time. All 271 people on board and two on the ground were killed in what remains America's worst aviation disaster.
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:The worst aviation accident in the [[United States]] happened on May 25, 1979. The American Airlines, Inc., Flight 191, a McDonnell-Douglas DC-10-10 aircraft, crashed into an open field about 4,600 ft northwest of the departure end of runway 32R at Chicago-O'Hare International Airport, Illinois.
  
The crash was found to be the result of a shortcut taken by removing the plane's engines for maintenance, cracking an aluminium component which held the engine to the wing.
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:Eight weeks before the disaster, the last repair of the plane damaged the overhead engine tower installed on the plane. The crash was found to be the result of a shortcut taken by removing the plane's engines for maintenance, cracking an aluminum component which held the engine to the wing.
  
A DC-10-10 aircraft took off due to a sudden loss of left engine caused the flap to lose control and the main instrument power failure, the pilot due to unknown posture to carry out the wrong handling procedures, resulting in many deaths.
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:In order to save more than 200 hours of maintenance time and money, the engine and the "dragon" (Pylon, suspended structure) between the engine and wings removed and put together all night just back, so that in the Pylon and cracks caused by the wing joint area. This was a violation of DC-10-10 design original McDonnell Douglas maintenance procedures.
  
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:When the American Airlines Flight 191 took off from O'Hare, the engine fell off the plane and landed on the runway, cutting off the electrical system and spilling hydraulic oil. Because of the airplane design, the pilots couldn't see the wing and didn't realize they were losing liquid oil. While being unaware of the real situation, the pilots carried out the wrong handling procedures. The damaged left has stalled, the plane dived and crashed, killing 273 people on the board and two people on the ground.
  
The complete report is published at https://www.ntsb.gov/investigations/accidentreports/pages/AAR7917.aspx
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:It was the fourth fatal crash on the DC-10 since its inception, with 622 people killed in all four DC-10 crashes. The complete report is published on [https://www.ntsb.gov/investigations/accidentreports/pages/AAR7917.aspx ntsb.gov/investigations]. The FAA report is published on [https://www.faa.gov/about/initiatives/maintenance_hf/library/documents/media/aviation_maintenance/american_airlines.pdf faa.gov/about/initiatives]
  
 
===Japan Airlines Flight 123===
 
===Japan Airlines Flight 123===
On August 12, 1985, the Japan Airlines Flight 123 suffered mechanical failures 12 minutes into the flight and 32 minutes later crashed.
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:''Main wikipage: [[Japan Airlines Flight 123]]''
 
 
The aircraft was involved in a tail strike incident on 2 June 1978, which damaged the bulkhead. However, the repair of the bulkhead didn't conform to Boeing's approved repair methods. So this reduced the part's resistance to metal fatigue by 70%.
 
 
 
In short, the bulkhead gave way leads to the failure of all 4 hydraulic systems then the aircraft's control disabled, the aircraft became uncontrollable, which leads to the disaster.
 
 
 
JAL123:After the tail damage, Boeing did not properly repair the damaged section. When replacing the damaged pressure wall plate, a whole joint plate should be used to connect the two panels to be connected and three rows of rivets should be used to fix them, but the maintenance personnel used two discontinuous joint plates, one with one row of rivets and the other with two rows of rivets. This results in a significant increase in stress on the metal skin near the joint and a reduction in resistance to metal fatigue of at least 70%. During the flight several years after maintenance, metal fatigue accumulated in the cabin due to repeated pressurization and decompression.The whole accident boils down to the maintenance man's irresponsibility.
 
 
 
The jal 123 disaster occurred in 1985, the second deadliest air crash after tenerife, which killed 583 people. The jal 123 disaster is still unforgettable.
 
  
The original crash had damaged the tail seven years earlier, but the damage had not been properly repaired. The metal used in the repairs can only withstand about 10, 000 flights, and the crash was the 12, 000th such flight. So as the plane climbed and flew, the metal that had been repaired in the tail broke under pressure, leading to a series of tragedies.
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:On August 12, 1985, the Japan Airlines Flight 123 suffered mechanical failures 12 minutes into the flight and 32 minutes later crashed into a mountain while killing 15 crew members and 509 passengers on board. Till now, this is the second deadliest disaster in the history of aviation.
  
===Alaska Airlines Flight 261===
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:The aircraft was involved in a tail strike incident seven years earlier, on 2 June 1978, which damaged the rear bulkhead. However, the repair of the damaged section had not been properly repaired. When replacing the damaged pressure wall plate, a whole joint plate should be used to connect the two panels to be connected and three rows of rivets should be used to fix them, but the maintenance personnel used two discontinuous joint plates, one with one row of rivets and the other with two rows of rivets. This results in a significant increase in stress on the metal skin near the joint and a reduction in resistance to metal fatigue of at least 70%.  
Alaska Airlines Flight 261, a McDonnell Douglas MD-83 aircraft, experienced a fatal accident on January 31, 2000, in the Pacific Ocean. The two pilots, three cabin crewmembers, and 83 passengers on board were killed and the aircraft was destroyed.
 
  
The subsequent investigation by the National Transportation Safety Board (NTSB) determined that inadequate maintenance led to excessive wear and catastrophic failure of a critical flight control system during flight. The probable cause was stated to be “a loss of airplane pitch control resulting from the in-flight failure of the horizontal stabilizer trim system jackscrew assembly’s acme nut threads. The thread failure was caused by excessive wear resulting from Alaska Airlines insufficient lubrication of the jackscrew assembly.
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:The metal used in the repairs can only withstand about 10,000 flights, and the Flight 123 was the 12319th flight after the crash. During the flight several years after maintenance, metal fatigue accumulated in the cabin due to repeated pressurization and decompression. Eventually, the rear bulkhead gave way leads to the failure of all 4 hydraulic systems, which disabled the aircraft's control disabled and, when the aircraft became uncontrollable, led to the disaster.
  
The stuck horizontal tail hinders operation of the balancing system. Investigators found that the maintenance took only about an hour to complete. In fact, the plane's manufacturer expected the maintenance work to take about four hours to complete, suggesting the mechanic wasn't up to the job.
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:When the aircraft climbed to about 7,000 meters, the accumulated metal fatigue of the pressure wall panel reached the limit, and it could no longer bear the pressure difference and break. As a result, explosion and decompression occurred in the engine room. High pressure air rushed into the tail, blowing down the vertical tail directly and tearing off the main hydraulic pipeline, which made the pilot unable to control the aircraft normally.
That led to a crash that killed all 88 people on board.
 
  
===China Airlines Flight 611===
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:The pilots and engineers on the wrecked plane struggled with the plane for half an hour under the condition of nearly completely out of control, showing great efforts. Instead of failed hydraulic systems, the pilots heroically used the engine accelerations and de-accelerations to direct the plane. However, the huge size of the plane and continuous mountain terrain made their task impossible. After the accident, no investigators and pilots who simulated the situation at that time could fly for half an hour under the same circumstances.
:On May 25, 2002, China Airlines Flight 611 Boeing 747 broke into pieces in mid-air and crashed, killing all 225 people on board. The accident was the result of metal fatigue caused by inadequate maintenance after a previous incident.
 
  
:During the permanent maintenance of China Airlines, the maintenance personnel discovered the severe metal fatigue skin and, instead of replacing the whole skin according to the structural maintenance manual prescribed by Boeing, just covered the area with an aluminum plate similar in size to the damaged skin. However, the maintenance personnel indicated on the maintenance record that the maintenance was carried out in accordance with the Boeing maintenance guidelines. Follow-up maintenance personnel believed his maintenance record and were not checked.
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===Aloha Airlines Flight 243===
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:''Main wikipage: [[Aloha Airlines Flight 243]]''
  
A passenger plane from Taiwan's Zhongzheng International Airport to Hong Kong International Airport disintegrated and crashed. A Boeing 747-200, b-18255 (old b-1866) airliner carrying 206 passengers and 19 crew members (including the first and second pilots and Flight Engineers) broke up and crashed at a high altitude of 34900 feet (10640 meters) 23 nautical miles northeast of Magong City, Penghu County on the same day, killing all the people on board, which is the worst casualty in Taiwan A heavy air crash.
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:On April 28, 1988, at 1346, a Boeing 737-200, N73711, operated by Aloha Airlines Inc., as flight 243, experienced an explosive decompression and structural failure at 24,000 feet, while en route from Hilo, to Honolulu, Hawaii. Approximately 18 feet of the cabin skin and structure aft of the cabin entrance door and above the passenger floorline separated from the airplane during flight. There were 89 passengers and 6 crewmembers on board.  One flight attendant was swept overboard during the decompression and died; 7 passengers and 1 flight attendant received serious injuries. The flightcrew performed an emergency descent and landing at Kahului Airport on the Island of Maui.
  
In fact, after investigation, it was found that the aircraft had maintenance records before the accident and the tail skin was damaged, but the maintenance personnel did not replace the whole skin according to the requirements of the maintenance manual. But only the damaged part was repaired. After the aircraft climbed, the accumulated metal fatigue here led to the falling off of the whole tail, which eventually led to the crash of the aircraft. This is very similar to the original Aloha accident in the United States, which is caused by the accumulated metal fatigue caused by long-term rain erosion.
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:Failure of the Aloha Airlines maintenance program to detect the presence of significant disbonding and fatigue damage ultimately led to failure of the lap joint at S-10L and the separation of the fuselage upper lobe, which is believed to be the probable cause of the accident.
  
On May 25, 2002, Taiwan China Airlines Flight CI611 crashed in the waters near Penghu, killing all 225 passengers and crew on board, making it the most shocking air crash in Taiwan in recent years.
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:The cited contributing causes include:
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:#The failure of Aloha Airlines management to supervise properly its maintenance force;
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:#The failure of the FAA to evaluate properly the Aloha Airlines maintenance program and to assess the airline's inspection and quality control deficiencies;
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:#The failure of the FAA to require Airworthiness Directive 87-21-08 inspection of all the lap joints proposed by Boeing Alert Service Bulletin SB 737-53A1039; and
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:#The lack of a complete terminating action (neither generated by Boeing nor required by the FAA) after the discovery of early production difficulties in the B-737 cold bond lap joint which resulted in low bond durability, corrosion, and premature fatigue cracking.
  
The reason is that on February 7,1980, the aircraft damaged the machine tail skin at the time of flying, and was transported back to Taiwan for temporary maintenance on the same day. However, it only covers the area with an aluminum plate with an area that is similar to the damaged skin, and does not replace the one-piece skin with the maintenance guidelines prescribed by Boeing, which thus accumulates the metal fatigue. After the crack, the aircraft tail fell off and out of control, and finally crashed through the loss of pressure and control.
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:The FAA report is published on [https://www.faa.gov/about/initiatives/maintenance_hf/library/documents/media/aviation_maintenance/aloha.pdf faa.gov/about/initiatives]
  
===Colgan Air Beech 1900D===
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===Air Ontario Flight 1363===
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:''Main wikipage: [[Air Ontario Flight 1363]]''
  
On August 26, 2003, a Colgan Air Beech 1900D crashed just after takeoff from Hyannis, Massachusetts. Both pilots were killed.
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:Air Ontario Flight 1363, a Fokker F-28 jet, crashed during takeoff from Dryden Municipal Airport, Ontario, Canada on March 10, 1989. Of the 69 persons on board, 24 suffered fatal injuries.
  
The improper replacement of the forward elevator trim cable and subsequent inadequate functional check of the maintenance performed that resulted in a reversal of the elevator trim system and a loss of control in flight. Factors were the flight crew’s failure to follow the checklist procedures and the aircraft manufacturer’s erroneous depiction of the elevator trim drum in the maintenance manual.
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:The aircraft had suffered from a malfunctioning auxiliary power unit (APU) for the five days preceding the accident. Throughout the week preceding March 10, Air Ontario maintenance attempted, with limited success, to cure the APU problems. On March 9 it was decided to defer the repair of the APU until the aircraft returned to Toronto on the night of March 10. This meant that the aircraft was dispatched with the APU inoperable.
  
===American Airlines Flight 1400===
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:On the morning of March 10, the jet departed Winnipeg on a round trip flight to Dryden, Thunder Bay and back. Since no external power unit was available at Dryden, the engines couldn't be restarted in case of engine shutdown on the ground.
  
On September 28, 2007, American Airlines Flight 1400 DC-9 experienced an in-flight engine fire during departure climb from Lambert St. Louis International Airport (STL).  During the return to STL, the nose landing gear failed to extend, and the flight crew executed a go-around, during which the crew extended the nose gear using the emergency procedure. The flight crew conducted an emergency landing, and the 2 flight crewmembers, 3 flight attendants, and 138 passengers deplaned on the runway. No occupant injuries were reported, but the airplane sustained substantial damage from the fire.
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:The flight to Thunder Bay was unentful apart from a slight delay due to poor weather at Thunder Bay. As the aircraft was prepared for the return flight, it appeared that the aircraft was overweight as a result of ten additional passengers having transferred to the flight due to an earlier cancellation. The Air Ontario duty manager decided to off-load fuel and to arrange refuelling at Dryden. This caused an additional delay of 35 minutes.
  
American Airlines' maintenance personnel's use of an inappropriate manual engine-start procedure, which led to the uncommanded opening of the left engine air turbine starter valve, and a subsequent left engine fire.
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:The Fokker F-28 departed Thunder Bay at 11:55 hours EST, about one hour behind schedule. The aircraft landed at Dryden at 11:39 hours CST. It began to snow lightly when the aircraft landed.
  
The complete report is published at https://www.ntsb.gov/investigations/accidentreports/pages/AAR0903.aspx
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:Between 11:40 and 12:01, Air Ontario 1363 was refuelled with the right engine operating and with the passengers remaining on board the aircraft. This so called 'hot refuelling' procedure was followed because the APU was unserviceable. Eight passengers deplaned in Dryden and seven passengers boarded the aircraft.
  
==Other failures==
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:Meanwhile, snow was accumulating on the wings, forming a layer of 1/8-1/4 inch. No de-icing was done because de-icing with either engine running was prohibited by both Fokker and Air Ontario.
  
===Draft story===
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:The aircraft then taxied to runway 29 for departure, but was instructed to hold as there was a Cessna 150 on approach. The snow was continuing to fall heavily, becoming increasingly thick on the wings.
Long voyage air crash in 1981 and ""China airlines air crash"" in 2002
 
  
Cause: the plane lost pressure in the air and crashed
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:At 12:09 the aircraft started it's takeoff roll on the slush-covered runway 29. There was an accumulation of at least one-half inch of wet, layered snow on the wings of the F-28 as it began its takeoff roll.
  
The disappearance of the Malaysia airlines passenger plane, some people have been analyzed as the plane had a collision in Shanghai pudong airport, resulting in wing damage caused by metal fatigue, leading to the disintegration of the aircraft. This is not uncommon in the history of air accidents, including two in Taiwan.
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:After a longer than normal takeoff roll, the aircraft was rotated near taxiway Alpha, at approximately the 3500 foot mark. The aircraft lifted off slightly, began to shudder, and then settled back down onto the runway. The takeoff roll then continued and the aircraft was rotated a second time, finally lifting off at approximately the 5700 mark of the 6000 foot runway. It flew over the end of the runway approximately 15 feet above the ground. It thereafter failed to gain altitude and mushed through the air in a nose-high attitude, before commencing to strike trees.
  
On August 22, 1981, a Boeing 737 operated by Taiwan's far east airlines crashed over miaoli county while flying from Taipei to kaohsiung. All 104 passengers and six crew members were killed.
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:The aircraft crashed and came to rest in a wooded area, 3156 feet past the runway end and caught fire.
  
An investigation later found that the plane also lost cabin pressure on August 5, when it was flying from Taipei to kaohsiung."
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:After a 20-month investigation, it was concluded that "Captain [-], as the pilot-in-command, must bear responsibility for the decision to land and take off in Dryden on the day in question. However, it is equally clear that the air transportation system failed him by allowing him to be placed in a situation where he did not have all the necessary tools that should have supported him in making the proper decision."
  
===Draft story===
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===British Airways Flight 5390===
1. Errors caused by maintenance:
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:''Main wikipage: [[British Airways Flight 5390]]''
  
a) In 2005, an accident occurred when an amphibious airplane operated by Chalk’s Ocean Airline crashed into a shipping channel near the Port of Miami, Florida. Once crash investigators concluded their analysis, the NTSB reported their findings: that the crash had been caused by the separation of the plane’s right wing during flight, and that this had occurred due to dual failures in the airline’s aircraft maintenance program.
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:On 10 June 1990, British Airways Flight 5390 took off from Birmingham Airport in England and headed towards Málaga Airport in Spain. Shortly after takeoff, its windscreen panel separated from its frame, causing the explosive decompression of the cockpit. The plane's captain was sucked out of the cockpit and was blown partially out of the aircraft. The flight attendant succeeded to keep the captain's legs in the cockpit.
  
2. cause by violation, slip, and lapse
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:This flight attendant believed that the captain is dead, but the crew was afraid that the captain's body can destroy the engine if released.
a) 28 December 2014 - Indonesia AirAsia Flight 8501 crashed into the Java Sea as a result of an aerodynamic stall due to pilot error. The aircraft exceeded the climb rate, way beyond its operational limits. All 155 passengers and 7 crew members on board were killed.
 
b) 3 January 1961 – Aero Flight 311 crashed near Kvevlax, Finland. All twenty-five occupants were killed in the accident, which was the deadliest in Finnish history. An investigation later determined that both pilots were intoxicated during the flight, and may have been interrupted by a passenger at the time of the crash.
 
  
c) 6 February 2015 – TransAsia Airways Flight 235: one of the ATR 72's engines experienced a flameout. As airplanes are able to fly on one engine alone, the pilot then shut down one of the engines. However, he accidentally shut off the engine that was functioning correctly and left the plane powerless, at which point he unsuccessfully tried to restart both engines. The plane then clipped a bridge and plummeted into the Keelung river as the pilot tried to avoid city terrain, killing 37 of the 53 on board."
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:With the captain pinned against the window frame for twenty minutes, the first officer managed to land at Southampton Airport. Although the captain was seriously injured, he survived. No loss of life occurred.
===Draft story===
 
According to the information analysis provided by the flight data recorder (FDR) and cockpit voice recorder (CVR), before and after the bolt falling off, the flight is normal. After the bolt falling off, the control of the elevator by the joystick is abnormal no matter in the state of automatic driving or manual control of the flight. Then the pilot feels that the pitch control of the aircraft is abnormal. Because the center of gravity of the aircraft changes little at this time, the crew is taking After moving passengers forward and releasing the choke plate, the aircraft can barely maintain the descent state. As the landing gear is released, the aircraft will generate pitching moment, and the pilot pull rod tries to keep the aircraft in a state. However, due to the abnormal control of the elevator, the aircraft continues to pitching. The pilot increased the amount of pull rod. At this time, as shown in the ground test, the elevator suddenly deviated upward due to the contact between π 3 pull rod and 135 rocker arm, and the aircraft tilted up violently. In order to overcome the trend of strong pitch up, the pilot quickly put the rod, because the pitch control has lost the linear change rule, the elevator rapidly deflects downward to the maximum, the aircraft pitch down to the ground. Finally, although the pilot tried to pull the rod, there was no corresponding change in the rudder surface, and the aircraft failed to change out of the dive state.
 
===Draft story===
 
  
At guangzhou airport, China civil aviation IL18 1982 final approach, smoke in the cabin, unit judgment for electrical fire, cut off the total power, aircraft landing using the emergency brake, at the contact point successfully stopped, the plane passengers once doors down the work of the ladder began to evacuate, but to an 11 passengers, thicken cabin smoke, then into a flame, the fire finally put out after 1 hour, the plane completely destroyed.
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:The investigation determined that the windscreen panel was not properly installed on the airplane one day before the accident.
  
The possible reason is that the passenger smoking on the plane, accidentally dropped the cigarette butt into the floor, causing fire; The captain handled and coordinated improperly, did not identify the source of the fire, handled correctly, and reported to the tower."
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===Alaska Airlines Flight 261===
===Draft story===
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:''Main wikipage: [[Alaska Airlines Flight 261]]''
  
From the data recorded by the flight data recorder, it can be seen that: after takeoff and departure from the ground, all the transverse and lateral parameters of the aircraft have a significant change of low frequency. This clearly shows that the aircraft appears to have a divergent transverse pendulum. Debris collected from the scene of the accident confirmed that there were two plugs on the autopilot mounting seat, namely the plug for the control aileron (green) in the socket for the control course rudder (yellow) and the plug for the control course rudder (yellow) in the socket for the control course aileron (green).
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:Alaska Airlines Flight 261, a McDonnell Douglas MD-83 aircraft, experienced a fatal accident on January 31, 2000, in the Pacific Ocean. The two pilots, three cabin crewmembers, and 83 passengers on board were killed and the aircraft was destroyed.
===Draft story===
 
In 1994, when a Chinese aircraft was carrying out a flight mission, the ground maintenance personnel misinserted the inclined damping plug and heading damping plug in each other during the replacement and installation, which eventually led to the abnormal handling of the aircraft and then disintegrated and crashed. I think these mistakes can be avoided before employees start work. Employees need thorough and rigorous training and testing before starting their jobs. 
 
In 1994, when an aircraft was carrying out a flight mission in China, because the maintenance personnel on the ground inserted the tilt damping plug and the heading damping plug wrongly when they were replacing and installing them, the maneuverability of the aircraft was abnormal, and then the aircraft was disintegrated and crashed
 
  
===Draft story===
+
:The subsequent investigation by the [[National Transportation Safety Board]] ([[NTSB]]) determined that inadequate maintenance led to excessive wear and catastrophic failure of a critical flight control system during flight. The probable cause was stated to be “a loss of airplane pitch control resulting from the in-flight failure of the horizontal stabilizer trim system jackscrew assembly’s acme nut threads. The thread failure was caused by excessive wear resulting from Alaska Airlines insufficient lubrication of the jackscrew assembly.
Japan air self-defense force (jasdf) released an investigation report on June 10, which initially concluded that the f-35a fighter jet that crashed into the sea did not have mechanical problems, but that the crash was caused by human factors. Although the pilot did not have serious operational errors, his loss of space orientation during flight was the direct cause of the crash.
 
===Draft story===
 
Korean air flight 801 (KAL801, KE801) is a Korean air flight from Seoul (now Seoul) to Guam. On August 6, 1997, the flight crashed just before landing at Guam's Antonio wangpat international airport.
 
  
The plane was a Boeing 747-300, with the fuselage registration number HL7468. The flight departed Seoul kimpo international airport at 2053 local time (2153 Guam time) on 5 August with a total of 17 crew members and 237 passengers on board.
+
:The stuck horizontal tail hinders operation of the balancing system. Investigators found that the maintenance took only about an hour to complete. In fact, the plane's manufacturer expected the maintenance work to take about four hours to complete, suggesting the mechanic wasn't up to the job.
  
At 1am local time on August 6, flight 801 made preparations for landing. Due to heavy rain and poor visibility in Guam airspace, the pilot decided to make a manual landing. At about 1.40 am, the aircrew was cleared to land runway 6L. At 1:42 PM, the plane misjudged the location of the airport during the landing process. The crew mistakenly thought that the passenger plane had passed the head or could not see the location of the airport. They planned to lift and fly again. But the plane was five kilometers short of the 78-meter runway and crashed into the side of nimitz mountain at 201 meters.
+
===China Airlines Flight 611===
 +
:''Main wikipage: [[China Airlines Flight 611]]''
  
(NTSB) indicated in its subsequent report that the main causes of the accident were as follows:
+
:On May 25, 2002, China Airlines Flight 611, Boeing 747-200, took off Taiwan's Zhongzheng International Airport while heading to Hong Kong International Airport, but broke into pieces in mid-air and crashed in the waters near Penghu, killing all 206 passengers and 19 crew members on board. The accident was the result of metal fatigue caused by inadequate maintenance after a previous incident.
  
When flight 801 was preparing to land on runway 6L, the tower staff told the Korean airlines crew that the Glide slope beacon in the instrument landing system had been shut down due to a fault. But at one point in the recording, possibly due to interference from other sources, the captain said he saw the glide path gauge move and asked the co-pilot if the glide path was really malfunctioning. As for the Minimum Safe Altitude Warning system (m-saw), it was frequently misreported by the wrong signals in the vicinity of the airport. As a result, it was repeatedly corrected by the engineers, which resulted in the effective range of the system being further away from the airport and unable to cover the surrounding area near the airport. The pilot of flight 801 did not strictly follow the manual landing procedure when it happened, and he lowered the flight altitude too early, relying too much on automatic operation. The crew of flight 801 was tired."
+
:During the permanent maintenance of China Airlines, the maintenance personnel discovered the severe metal fatigue skin and, instead of replacing the whole skin according to the structural maintenance manual prescribed by Boeing, just covered the area with an aluminum plate similar in size to the damaged skin. However, the maintenance personnel indicated on the maintenance record that the maintenance was carried out in accordance with the Boeing maintenance guidelines. Follow-up maintenance personnel believed his maintenance record and were not checked.
===Draft story===
 
On August 22, 1981, a Boeing 737 passenger plane from Taiwan's ""Far East Airline"" flew from Taipei to Kaohsiung and crashed in the vicinity of Miaoli County. 104 passengers and 6 crew members on board were all killed.
 
  
After the incident, the investigation found that the aircraft crashed from Taipei to Kaohsiung on August 5 of that year, and there was a situation of pressure loss in the cabin. The rear body was severely corroded, causing the fuselage skin to rupture and disintegration.
+
:In fact, after investigation, it was found that the aircraft had maintenance records before the accident and the tail skin was damaged, but the maintenance personnel did not replace the whole skin according to the requirements of the maintenance manual. But only the damaged part was repaired. After the aircraft climbed, the accumulated metal fatigue here led to the falling off of the whole tail, which eventually led to the crash of the aircraft. This is very similar to the original [[Aloha Airlines Flight 243|Aloha accident in the United States]], which is caused by the accumulated metal fatigue caused by long-term rain erosion.
  
Like the Malaysia Airlines lost passenger plane, the CI611 flight accident occurred very suddenly. The contact between the pilot and the ground tower before the accident was normal. There was no precursor. The radar record showed that the CI611 split into four large structures before crashing. Sea. The investigators found that one of the tail skins had been repaired and had a strong fuel smell, which confirmed that the skin had severe metal fatigue. After checking the maintenance records of the aircraft, the entire air crash was discovered. Beginning and ending:
+
:The reason is that on February 7, 1980, the aircraft damaged the machine tail skin at the time of flying, and was transported back to Taiwan for temporary maintenance on the same day. However, it only covers the area with an aluminum plate with an area that is similar to the damaged skin, and does not replace the one-piece skin with the maintenance guidelines prescribed by Boeing, which thus accumulates the metal fatigue. After the crack, the aircraft tail fell off and out of control, and finally crashed through the loss of pressure and control.
  
On February 7, 1980, the aircraft was damaged by the tail of the aircraft during the flight, and was transported back to Taiwan for temporary maintenance. However, China Airlines only covered the area with an aluminum plate of the same size as the damaged skin, and did not replace the entire skin with the maintenance instructions set by Boeing. This repaired part accumulated metal fatigue.
+
===Colgan Air Beech 1900D===
 
+
:''Main wikipage: [[Colgan Air Beech 1900D]]''
After the split, the aircraft tail fell off and lost control, and finally crashed due to loss of pressure and loss of control."
+
:On August 26, 2003, a Colgan Air Beech 1900D crashed just after takeoff from Hyannis, Massachusetts. Both pilots were killed.
===Draft story===
 
On August 24, 2010, Henan Airlines Co., Ltd. B3130 ERJ-190 regional passenger plane carried out the VD8387 Harbin-Yichun flight mission, took off at Harbin airport at 20:51, this plan landed at Yichun Lindu airport at 21:40, but crashed ahead of time at about 22:10 outside the runway 690 meters from Yichun Lindu airport. 42 people were killed and 54 survived.
 
===Draft story===
 
On August 31, 1983, Korean air flight 007 flew from Alaska to Seoul, Korea. On September 1, the plane was shot down by a Soviet air force su-15 interceptor in international waters southwest of sakhalin island after it strayed into Soviet airspace due to a pilot error. The interceptor had not flown in front of the plane before shooting it down. It had not reported that it was a Boeing with a portholes, not an rc-135, nor had it fired tracer bullets. Even later, the pilot who was ordered to shoot down the plane claimed that he shot it down decisively, even though he knew he was dealing with a passenger plane, because "western fighters often pretend to be passenger planes..." All 240 passengers and 29 crew members died.
 
===Draft story===
 
On June 2, 1978, the aircraft had damaged the tail of jal115 when it landed at IDAN airport.Boeing did not properly repair the damaged area after the tail was damaged. When replacing the damaged pressure wall panel, a whole joint plate should be used to connect the two panels to be connected, and three rows of rivets should be used to fix them. However, the maintenance personnel used two discontinuous joint plates, one with one row of rivets and the other with two rows of rivets. This makes the stress of the metal skin near the joint increase significantly, and the resistance to metal fatigue decreases by at least 70%. During the flight several years after the maintenance, the metal fatigue in the cabin is accumulating because of the multiple pressurization and decompression in the cabin. According to the calculation of the ex post investigators, the repair can only take about 10000 flights, and the flight is the 12319th flight after the crash.When the aircraft climbs to about 7000 meters, the accumulated metal fatigue of the pressure wall panel reaches the limit, and it can no longer bear the pressure difference and break. As a result, explosion and decompression occurred in the engine room. High pressure air rushed into the tail, blowing down the vertical tail directly and tearing off the main hydraulic pipeline, which made the pilot unable to control the aircraft normally.The pilots and engineers on the wrecked plane struggled with the plane for half an hour under the condition of nearly completely out of control, and tried to avoid the continuous mountain terrain before the crash, showing great efforts and Technology (after the accident, no investigators and pilots who simulated the situation at that time could fly for half an hour under the same circumstances). However, at that time, the captain showed sluggish response (failed to respond to colleagues' requests and tower calls for many times) and operational errors (did not choose to descend to the respirable state under high altitude hypoxia; the flight engineer proposed to use the oxygen mask to answer the permission but did not implement it; after losing control of the aircraft, he still insisted on returning to Yutian airport rather than going to the nearest airport Nagoya landing) has also been criticized, but given that the crew has always been in a state of high tension and hard handling of the joystick, these mistakes are not hard to understand.
 
===Draft story===
 
  
On March 27, 1977, a Dutch Boeing 747 and an American Boeing 747 collided on the runway at los lodes airport in Spain. Because both of the planes were large passenger jets full of fuel and crew, in a flash, 583 passengers and crew members died, with only 61 surviving. The incident was the deadliest in a plane-related disaster and the deadliest plane crash to date. Confused instructions and jammed radio communication were the main causes of the accident.
+
:The improper replacement of the forward elevator trim cable and subsequent inadequate functional check of the maintenance performed that resulted in a reversal of the elevator trim system and a loss of control in flight. Factors were the flight crew's failure to follow the checklist procedures and the aircraft manufacturer's erroneous depiction of the elevator trim drum in the maintenance manual.
===Draft story===
 
On May 8, 1997, the Boeing 737-300 b-2925 of China southern airlines crashed during the landing of flight CZ3456 from chongqing to shenzhen. 65 passengers were on board, 33 of them dead, 9 of them in the flight crew, 2 of them dead.
 
  
Due to the heavy rain in the night flight, poor visibility, water on the runway, light effect is not good, see the ground is not clear. In this case, the aircrew did not take the go-around measures decisively and continued to approach and descend in violation of the regulations, delaying the opportunity. This is the main reason for the abnormal landing and the final cause of the accident.
+
===Chalk's Ocean Airways Flight 101===
 +
:''Main wikipage: [[Chalk's Ocean Airways Flight 101]]''
 +
:On December 19, 2005, a Grumman Turbo Mallard (G-73T) amphibious airplane, N2969, operated by Flying Boat, Inc., doing business as Chalk’s Ocean Airways flight 101, crashed into a shipping channel adjacent to the Port of Miami, Florida, shortly after takeoff from the Miami Seaplane Base. Flight 101 was a regularly scheduled passenger flight to Bimini, Bahamas, with 2 flight crewmembers and 18 passengers on board. The airplane’s right wing separated during flight. All 20 people aboard the airplane were killed, and the airplane was destroyed by impact forces. Flight 101 was operating under the provisions of 14 Code of Federal Regulations Part 121 on a visual flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.
  
When the plane approached the platform at an altitude of 170 feet, a ""glide path low"" warning appeared in the cockpit. Subsequently, the crew corrected the plane to return to the normal glide track, but did not reduce the throttle. The plane was able to see the plane face for 2 to 3 seconds before the plane grounded."
+
:​The [[National Transportation Safety Board]] determines that the probable cause of this accident was the in-flight failure and separation of the right wing during normal flight, which resulted from (1) the failure of the Chalk's Ocean Airways maintenance program to identify and properly repair fatigue cracks in the right wing and (2) the failure of the [[Federal Aviation Administration]] ([[FAA]]) to detect and correct deficiencies in the company's maintenance program.
===Draft story===
 
There is a famous air crash accident in 1994 which happened in Xian.It was caused by the auto-guiding machine which was done by people incorrectly.To our pity ,there are no one surviving in this horrible accident.
 
  
And the result of the research is people should be stricted with the rules of plane and take whole charge of their responsibility to ensure passengers’safety."
+
:The complete report is published on [https://www.ntsb.gov/investigations/AccidentReports/Pages/AAR0704.aspx ntsb.gov/investigations]
  
 
==See also==
 
==See also==
 
*https://www.faa.gov/data_research/accident_incident/
 
*https://www.faa.gov/data_research/accident_incident/

Latest revision as of 15:35, 20 March 2023

This list of maintenance-related failures is a listing of incidents and accidents that have been, partially or completely, caused by human errors in aircraft maintenance.


Incidents

Eastern Air Lines Flight 855

Main wikipage: Eastern Air Lines Flight 855
At 08:56 on May 5, 1983, Eastern Air Lines, Inc., Flight 855, a Lockheed L-1011, with 10 crewmembers and 162 passengers on board, departed Miami International Airport en route to Nassau, Bahamas.
About 09:15, while descending through 15,000 feet, the low oil pressure light on the No. 2 engine illuminated. The No. 2 engine was shut down, and the captain decided to return to Miami to land. The airplane was cleared to Miami and began a climb to FL 200. While en route to Miami, the low oil pressure lights for engines Nos. 1 and 3 illuminated.
At 09:28, while at 16,000 feet, the No. 3 engine flamed out. At 0933:20, the No. 1 engine flamed out while the flightcrew was attempting to restart the No. 2 engine. The airplane descended without power from about 13,000 feet to about 4,000 feet, at which time the No. 2 engine was restarted.
The airplane made a one-engine landing at Miami International Airport at 09:46. There were no injuries to the occupants.
The National Transportation Safety Board determines that the probable cause of the accident was the omission of all the O-ring seals on the master chip detector assemblies leading to the loss of lubrication and damage to the airplane's three engines as a result of the failure of mechanics to follow the established and proper procedures for the installation of master chip detectors in the engine lubrication system, the repeated failure of supervisory personnel to require mechanics to comply strictly with the prescribed installation procedures, and the failure of Eastern Air Lines management to assess adequately the significance of similar previous occurrences and to act effectively to institute corrective action.
Contributing to the cause of the accident was the failure of Federal Aviation Administration maintenance inspectors to assess the significance of the incidents involving master chip detectors and to take effective surveillance and enforcement measures to prevent the recurrence of the incidents.
The FAA report is published on faa.gov/about/initiatives

Excalibur Airways Airbus 320

Main wikipage: Excalibur Airways Airbus 320
On August 26, 1993, an Excalibur Airways Airbus 320 took off from London-Gatwick Airport (LGW) and exhibited an undemanded roll to the right on takeoff, a condition which persisted until the aircraft landed back at LGW 37 minutes later. Control of the aircraft required significant left sidestick at all times and the flight control system was degraded by the loss of spoiler control.
Technicians familiar with Boeing 757 flap change procedures lacked the knowledge required to correctly lock out the spoilers on the Airbus during the flap change work that was done the day before the flight. Turnover to technicians on the next shift compounded the problem. No mention of incorrect spoiler lockout procedure was given since it was assumed that the 320 was like the 757. The flap change was operationally checked, but the spoiler remained locked out incorrectly and was not detected by the flight crew during standard functional checks.

Lufthansa Airbus A320

Main wikipage: Lufthansa Airbus A320
On March 20, 2001 a Lufthansa Airbus A320 almost crashed shortly after takeoff because of reversed wiring in the captain's sidestick flight control. Quick action by the co-pilot, whose sidestick was not faulty, prevented a crash
The investigation has focused on maintenance on the captain's controls carried out by Lufthansa Technik just before the flight. During the previous flight, a problem with one of the two elevator/aileron computers (ELAC) had occurred. An electrical pin in the connector was found to be damaged and was replaced. It has been confirmed that two pairs of pins inside the connector had accidentally been crossed during the repair. This changed the polarity in the sidestick and the respective control channels "bypassing" the control unit, which might have sensed the error and would have triggered a warning. Clues might have been seen on the electronic centralized aircraft monitor (ECAM) screen during the flight control checks, but often pilots only check for a deflection indication, not the direction. Before the aircraft left the hangar, a flight control check was performed by the mechanic, but only using the first officer's sidestick.

Accidents

American Airlines Flight 191

Main wikipage: American Airlines Flight 191
The worst aviation accident in the United States happened on May 25, 1979. The American Airlines, Inc., Flight 191, a McDonnell-Douglas DC-10-10 aircraft, crashed into an open field about 4,600 ft northwest of the departure end of runway 32R at Chicago-O'Hare International Airport, Illinois.
Eight weeks before the disaster, the last repair of the plane damaged the overhead engine tower installed on the plane. The crash was found to be the result of a shortcut taken by removing the plane's engines for maintenance, cracking an aluminum component which held the engine to the wing.
In order to save more than 200 hours of maintenance time and money, the engine and the "dragon" (Pylon, suspended structure) between the engine and wings removed and put together all night just back, so that in the Pylon and cracks caused by the wing joint area. This was a violation of DC-10-10 design original McDonnell Douglas maintenance procedures.
When the American Airlines Flight 191 took off from O'Hare, the engine fell off the plane and landed on the runway, cutting off the electrical system and spilling hydraulic oil. Because of the airplane design, the pilots couldn't see the wing and didn't realize they were losing liquid oil. While being unaware of the real situation, the pilots carried out the wrong handling procedures. The damaged left has stalled, the plane dived and crashed, killing 273 people on the board and two people on the ground.
It was the fourth fatal crash on the DC-10 since its inception, with 622 people killed in all four DC-10 crashes. The complete report is published on ntsb.gov/investigations. The FAA report is published on faa.gov/about/initiatives

Japan Airlines Flight 123

Main wikipage: Japan Airlines Flight 123
On August 12, 1985, the Japan Airlines Flight 123 suffered mechanical failures 12 minutes into the flight and 32 minutes later crashed into a mountain while killing 15 crew members and 509 passengers on board. Till now, this is the second deadliest disaster in the history of aviation.
The aircraft was involved in a tail strike incident seven years earlier, on 2 June 1978, which damaged the rear bulkhead. However, the repair of the damaged section had not been properly repaired. When replacing the damaged pressure wall plate, a whole joint plate should be used to connect the two panels to be connected and three rows of rivets should be used to fix them, but the maintenance personnel used two discontinuous joint plates, one with one row of rivets and the other with two rows of rivets. This results in a significant increase in stress on the metal skin near the joint and a reduction in resistance to metal fatigue of at least 70%.
The metal used in the repairs can only withstand about 10,000 flights, and the Flight 123 was the 12319th flight after the crash. During the flight several years after maintenance, metal fatigue accumulated in the cabin due to repeated pressurization and decompression. Eventually, the rear bulkhead gave way leads to the failure of all 4 hydraulic systems, which disabled the aircraft's control disabled and, when the aircraft became uncontrollable, led to the disaster.
When the aircraft climbed to about 7,000 meters, the accumulated metal fatigue of the pressure wall panel reached the limit, and it could no longer bear the pressure difference and break. As a result, explosion and decompression occurred in the engine room. High pressure air rushed into the tail, blowing down the vertical tail directly and tearing off the main hydraulic pipeline, which made the pilot unable to control the aircraft normally.
The pilots and engineers on the wrecked plane struggled with the plane for half an hour under the condition of nearly completely out of control, showing great efforts. Instead of failed hydraulic systems, the pilots heroically used the engine accelerations and de-accelerations to direct the plane. However, the huge size of the plane and continuous mountain terrain made their task impossible. After the accident, no investigators and pilots who simulated the situation at that time could fly for half an hour under the same circumstances.

Aloha Airlines Flight 243

Main wikipage: Aloha Airlines Flight 243
On April 28, 1988, at 1346, a Boeing 737-200, N73711, operated by Aloha Airlines Inc., as flight 243, experienced an explosive decompression and structural failure at 24,000 feet, while en route from Hilo, to Honolulu, Hawaii. Approximately 18 feet of the cabin skin and structure aft of the cabin entrance door and above the passenger floorline separated from the airplane during flight. There were 89 passengers and 6 crewmembers on board. One flight attendant was swept overboard during the decompression and died; 7 passengers and 1 flight attendant received serious injuries. The flightcrew performed an emergency descent and landing at Kahului Airport on the Island of Maui.
Failure of the Aloha Airlines maintenance program to detect the presence of significant disbonding and fatigue damage ultimately led to failure of the lap joint at S-10L and the separation of the fuselage upper lobe, which is believed to be the probable cause of the accident.
The cited contributing causes include:
  1. The failure of Aloha Airlines management to supervise properly its maintenance force;
  2. The failure of the FAA to evaluate properly the Aloha Airlines maintenance program and to assess the airline's inspection and quality control deficiencies;
  3. The failure of the FAA to require Airworthiness Directive 87-21-08 inspection of all the lap joints proposed by Boeing Alert Service Bulletin SB 737-53A1039; and
  4. The lack of a complete terminating action (neither generated by Boeing nor required by the FAA) after the discovery of early production difficulties in the B-737 cold bond lap joint which resulted in low bond durability, corrosion, and premature fatigue cracking.
The FAA report is published on faa.gov/about/initiatives

Air Ontario Flight 1363

Main wikipage: Air Ontario Flight 1363
Air Ontario Flight 1363, a Fokker F-28 jet, crashed during takeoff from Dryden Municipal Airport, Ontario, Canada on March 10, 1989. Of the 69 persons on board, 24 suffered fatal injuries.
The aircraft had suffered from a malfunctioning auxiliary power unit (APU) for the five days preceding the accident. Throughout the week preceding March 10, Air Ontario maintenance attempted, with limited success, to cure the APU problems. On March 9 it was decided to defer the repair of the APU until the aircraft returned to Toronto on the night of March 10. This meant that the aircraft was dispatched with the APU inoperable.
On the morning of March 10, the jet departed Winnipeg on a round trip flight to Dryden, Thunder Bay and back. Since no external power unit was available at Dryden, the engines couldn't be restarted in case of engine shutdown on the ground.
The flight to Thunder Bay was unentful apart from a slight delay due to poor weather at Thunder Bay. As the aircraft was prepared for the return flight, it appeared that the aircraft was overweight as a result of ten additional passengers having transferred to the flight due to an earlier cancellation. The Air Ontario duty manager decided to off-load fuel and to arrange refuelling at Dryden. This caused an additional delay of 35 minutes.
The Fokker F-28 departed Thunder Bay at 11:55 hours EST, about one hour behind schedule. The aircraft landed at Dryden at 11:39 hours CST. It began to snow lightly when the aircraft landed.
Between 11:40 and 12:01, Air Ontario 1363 was refuelled with the right engine operating and with the passengers remaining on board the aircraft. This so called 'hot refuelling' procedure was followed because the APU was unserviceable. Eight passengers deplaned in Dryden and seven passengers boarded the aircraft.
Meanwhile, snow was accumulating on the wings, forming a layer of 1/8-1/4 inch. No de-icing was done because de-icing with either engine running was prohibited by both Fokker and Air Ontario.
The aircraft then taxied to runway 29 for departure, but was instructed to hold as there was a Cessna 150 on approach. The snow was continuing to fall heavily, becoming increasingly thick on the wings.
At 12:09 the aircraft started it's takeoff roll on the slush-covered runway 29. There was an accumulation of at least one-half inch of wet, layered snow on the wings of the F-28 as it began its takeoff roll.
After a longer than normal takeoff roll, the aircraft was rotated near taxiway Alpha, at approximately the 3500 foot mark. The aircraft lifted off slightly, began to shudder, and then settled back down onto the runway. The takeoff roll then continued and the aircraft was rotated a second time, finally lifting off at approximately the 5700 mark of the 6000 foot runway. It flew over the end of the runway approximately 15 feet above the ground. It thereafter failed to gain altitude and mushed through the air in a nose-high attitude, before commencing to strike trees.
The aircraft crashed and came to rest in a wooded area, 3156 feet past the runway end and caught fire.
After a 20-month investigation, it was concluded that "Captain [-], as the pilot-in-command, must bear responsibility for the decision to land and take off in Dryden on the day in question. However, it is equally clear that the air transportation system failed him by allowing him to be placed in a situation where he did not have all the necessary tools that should have supported him in making the proper decision."

British Airways Flight 5390

Main wikipage: British Airways Flight 5390
On 10 June 1990, British Airways Flight 5390 took off from Birmingham Airport in England and headed towards Málaga Airport in Spain. Shortly after takeoff, its windscreen panel separated from its frame, causing the explosive decompression of the cockpit. The plane's captain was sucked out of the cockpit and was blown partially out of the aircraft. The flight attendant succeeded to keep the captain's legs in the cockpit.
This flight attendant believed that the captain is dead, but the crew was afraid that the captain's body can destroy the engine if released.
With the captain pinned against the window frame for twenty minutes, the first officer managed to land at Southampton Airport. Although the captain was seriously injured, he survived. No loss of life occurred.
The investigation determined that the windscreen panel was not properly installed on the airplane one day before the accident.

Alaska Airlines Flight 261

Main wikipage: Alaska Airlines Flight 261
Alaska Airlines Flight 261, a McDonnell Douglas MD-83 aircraft, experienced a fatal accident on January 31, 2000, in the Pacific Ocean. The two pilots, three cabin crewmembers, and 83 passengers on board were killed and the aircraft was destroyed.
The subsequent investigation by the National Transportation Safety Board (NTSB) determined that inadequate maintenance led to excessive wear and catastrophic failure of a critical flight control system during flight. The probable cause was stated to be “a loss of airplane pitch control resulting from the in-flight failure of the horizontal stabilizer trim system jackscrew assembly’s acme nut threads. The thread failure was caused by excessive wear resulting from Alaska Airlines insufficient lubrication of the jackscrew assembly.
The stuck horizontal tail hinders operation of the balancing system. Investigators found that the maintenance took only about an hour to complete. In fact, the plane's manufacturer expected the maintenance work to take about four hours to complete, suggesting the mechanic wasn't up to the job.

China Airlines Flight 611

Main wikipage: China Airlines Flight 611
On May 25, 2002, China Airlines Flight 611, Boeing 747-200, took off Taiwan's Zhongzheng International Airport while heading to Hong Kong International Airport, but broke into pieces in mid-air and crashed in the waters near Penghu, killing all 206 passengers and 19 crew members on board. The accident was the result of metal fatigue caused by inadequate maintenance after a previous incident.
During the permanent maintenance of China Airlines, the maintenance personnel discovered the severe metal fatigue skin and, instead of replacing the whole skin according to the structural maintenance manual prescribed by Boeing, just covered the area with an aluminum plate similar in size to the damaged skin. However, the maintenance personnel indicated on the maintenance record that the maintenance was carried out in accordance with the Boeing maintenance guidelines. Follow-up maintenance personnel believed his maintenance record and were not checked.
In fact, after investigation, it was found that the aircraft had maintenance records before the accident and the tail skin was damaged, but the maintenance personnel did not replace the whole skin according to the requirements of the maintenance manual. But only the damaged part was repaired. After the aircraft climbed, the accumulated metal fatigue here led to the falling off of the whole tail, which eventually led to the crash of the aircraft. This is very similar to the original Aloha accident in the United States, which is caused by the accumulated metal fatigue caused by long-term rain erosion.
The reason is that on February 7, 1980, the aircraft damaged the machine tail skin at the time of flying, and was transported back to Taiwan for temporary maintenance on the same day. However, it only covers the area with an aluminum plate with an area that is similar to the damaged skin, and does not replace the one-piece skin with the maintenance guidelines prescribed by Boeing, which thus accumulates the metal fatigue. After the crack, the aircraft tail fell off and out of control, and finally crashed through the loss of pressure and control.

Colgan Air Beech 1900D

Main wikipage: Colgan Air Beech 1900D
On August 26, 2003, a Colgan Air Beech 1900D crashed just after takeoff from Hyannis, Massachusetts. Both pilots were killed.
The improper replacement of the forward elevator trim cable and subsequent inadequate functional check of the maintenance performed that resulted in a reversal of the elevator trim system and a loss of control in flight. Factors were the flight crew's failure to follow the checklist procedures and the aircraft manufacturer's erroneous depiction of the elevator trim drum in the maintenance manual.

Chalk's Ocean Airways Flight 101

Main wikipage: Chalk's Ocean Airways Flight 101
On December 19, 2005, a Grumman Turbo Mallard (G-73T) amphibious airplane, N2969, operated by Flying Boat, Inc., doing business as Chalk’s Ocean Airways flight 101, crashed into a shipping channel adjacent to the Port of Miami, Florida, shortly after takeoff from the Miami Seaplane Base. Flight 101 was a regularly scheduled passenger flight to Bimini, Bahamas, with 2 flight crewmembers and 18 passengers on board. The airplane’s right wing separated during flight. All 20 people aboard the airplane were killed, and the airplane was destroyed by impact forces. Flight 101 was operating under the provisions of 14 Code of Federal Regulations Part 121 on a visual flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.
​The National Transportation Safety Board determines that the probable cause of this accident was the in-flight failure and separation of the right wing during normal flight, which resulted from (1) the failure of the Chalk's Ocean Airways maintenance program to identify and properly repair fatigue cracks in the right wing and (2) the failure of the Federal Aviation Administration (FAA) to detect and correct deficiencies in the company's maintenance program.
The complete report is published on ntsb.gov/investigations

See also