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Air Transport Safety

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Air Transport Safety : A school english presentation has been given in 2007. It also talks about the crash of Tuninter Flight 1153 occured in August 2005.

Publicada em: Engenharia, Tecnologia, Negócios
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Air Transport Safety

  1. 1. 1 This presentation has been given in 2007 when I was a student at the National School of Computer Science.
  2. 2. 2 AIR TRANSPORT SAFETY By National School of Computer Studies English Course Professor : Mr. DAKHLAOUI Faysel Group : II 1 C
  3. 3. 3 http://www.youtube.com/watch?v=lksDISvCmNI
  4. 4. 4  THE PLAN 1. Why do aircraft accidents happen ?  Human factors  Aircraft reliability  Weather and flight conditions A. Reasons B. James Reason’s "Swiss Cheese" Model  Companies  The theory AIR TRANSPORT SAFETY
  5. 5. 5  THE PLAN 2. Example : TUNINTER Flight 1153  Informations about the flight A. Story Reconstruction B. Investigation  Design of the low level alarm  Aircraft specifications : ATR-72  Problem of interchangeability  Crew qualification AIR TRANSPORT SAFETY
  6. 6. 6  THE PLAN 3. Other examples in Tunisia  Sekorsky HH-3 helicopter : crash A. Airforce accidents  C-130 Hercules : take-off missing  F-5 fighters : crashs B. Civilian air transport accidents  EGYPTAIR : crash of B-737 AIR TRANSPORT SAFETY
  7. 7. 7  THE PLAN 4. Recommendations and conclusion B. Conclusion A. General recommendations  The importance of air transport  The low rate of accidents  Studying air transport accidents  Developing new systems  Crew training  Maintenance AIR TRANSPORT SAFETY
  8. 8. 8AIR TRANSPORT SAFETY  Introduction  Nowadays, aircraft is the most important mean of transport :  Faster : higher speed and longer distance  Efficient : hundreds of passengers and tonnes of freight  Safer : One accident for 1.000.000 flights  Inspite of security mesures and defenses, accidents can take place because of these following reasons : 1. Why do aircraft accidents happen ?
  9. 9. 9AIR TRANSPORT SAFETY A. Reasons  Human capabilities and limitations can influence task performance and safety inside the aircraft cockpit and within the maintenance environment. A.1 Human factors  Pilots, technicians and air traffic controllers are often the principal actors of many tragedies because of : 1. Why do aircraft accidents happen ?
  10. 10. 10AIR TRANSPORT SAFETY A. Reasons  Bad attitude towards work and colleagues  Poor communication skills  Etc … A.1 Human factors  Physical fatigue, tiredness …  Insufficiency of technical knowledge  Routine: same job, same tasks …  Synchronization (time zone, date/night shifts) 1. Why do aircraft accidents happen ?
  11. 11. 11AIR TRANSPORT SAFETY A. Reasons  Systems failures : avionics, engines …  Etc … A.2 Aircraft reliability  Problems of fuselage and structure  Aircrafts not in accordance with regulations  Problems of design and conception 1. Why do aircraft accidents happen ?
  12. 12. 12AIR TRANSPORT SAFETY A. Reasons  Problems with maintenance and spare parts : Charter operators  Etc … A.3 companies  High workload for pilots and technicians  Incompetence of some directors : bad decisions taken 1. Why do aircraft accidents happen ?
  13. 13. 13AIR TRANSPORT SAFETY A. Reasons  Precipitation, fog and ice A.4 Weather and atmospheric conditions  Engineers can never control the weather and atmospheric parameters :  Wind, wind shear, whirlwind : while take off, approch or landing  Problem of visibility and runway condition 1. Why do aircraft accidents happen ?
  14. 14. 14AIR TRANSPORT SAFETY A. Reasons A.5 Statistics 1. Why do aircraft accidents happen ?
  15. 15. 15AIR TRANSPORT SAFETY B. James Reason’s "Swiss Cheese" Model  A series of Human Factor problems form an error chain. If any one of the links in this chain had been broken the incident may have been prevented. It might be done by building in measures/defenses, which may not permit an error at one or more of the stages. A good example is J.Reason’s ‘Swiss Cheese’ Model. 1. Why do aircraft accidents happen ? B.1 The theory
  16. 16. 16AIR TRANSPORT SAFETY 1. Why do aircraft accidents happen ? B. James Reason’s "Swiss Cheese" Model B.2 J.Reason’s ‘Swiss Cheese’ Model – fig -
  17. 17. 17AIR TRANSPORT SAFETY A. Story Reconstruction 2. Example : TUNINTER Flight 1153 A.1 Aircraft specifications : ATR-72 Capacity………………….....68 Length…………………27,17m Wingspan……….…….27,05m Height…………….……..7,65m Maximum weight………..21,5t Freight………………….….7,3t Flight range…………. 2222km Maximum speed…….516km/h
  18. 18. 18AIR TRANSPORT SAFETY A. Story Reconstruction 2. Example : TUNINTER Flight 1153 A.2 Informations about the flight  Saturday, 6th of August, near Palermo:  During daily flight from Bari to Djerba, at 15:24 (local time) the crew of the flight 1153 (TUINTER) contacted Palermo for an emergency landing.
  19. 19. 19AIR TRANSPORT SAFETY A. Story Reconstruction 2. Example : TUNINTER Flight 1153 A.2 Informations about the flight  The aircraft (ATR-72) had lost both engines.  The crew tries to reach the nearest airoport. But They did not make it to Palermo and ditched in the sea around 15:40.
  20. 20. 20AIR TRANSPORT SAFETY A. Story Reconstruction 2. Example : TUNINTER Flight 1153 A.3 Cockpit voice recorder CVR  Captain: Please confirm the distance...  Palermo ATC: 20…  Captain: Please confirm the distance..  Palermo ATC: The distance is 20 miles  Captain: I think…we are not able, we are not able to reach the terrain. We are 4.000ft and we are not able, we lose both engines. Can you send us helicopters or something like that? Quick, quick, quick… http://www.youtube.com/watch?v=6OnwwE1s1hg
  21. 21. 21AIR TRANSPORT SAFETY A. Story Reconstruction 2. Example : TUNINTER Flight 1153 A.4 Casuality Crew (total 4)……….victimes: 2 Pax (total 35)……..victimes: 14 Total on bord 39….victimes: 16  Aircraft: during the ditshing, the fuselage had been broken in several parts.  Only the wings remains on the sea surface.The rest falls in 12 meter depth.
  22. 22. 22AIR TRANSPORT SAFETY B. Investigation 2. Example : TUNINTER Flight 1153 B.1 Friday 5th of august (end of the day)  The crew noted on the LogBook that the FQI (Fuel Quantity Indicator) had three dispaly-bars misfunctionning.
  23. 23. 23AIR TRANSPORT SAFETY B. Investigation 2. Example : TUNINTER Flight 1153 B.2 The maintenance  The technician asked the warehouse for ATR-72 FQI using a special management software: AMASIS system.  He didn’t find the right FQI but AMASIS system told him that an ATR-42 FQI can be installed in place of the ATR-72 one
  24. 24. 24AIR TRANSPORT SAFETY B. Investigation 2. Example : TUNINTER Flight 1153 B.2 The maintenance  The technician did not check the compatibility of the ATR-42 FQI in the ATR-72 documentation. << AMASIS program
  25. 25. 25AIR TRANSPORT SAFETY B. Investigation 2. Example : TUNINTER Flight 1153 B.3 First error : Maintenance error FQI of ATR72 & ATR 42 ARE NOT INTERCHANGEABLE.
  26. 26. 26AIR TRANSPORT SAFETY B. Investigation 2. Example : TUNINTER Flight 1153 B.3 First error : Maintenance error  After replacement of the FQI, the quantity of fuel indicated is 3050 kg, instead of 790 kg.
  27. 27. 27AIR TRANSPORT SAFETY B. Investigation 2. Example : TUNINTER Flight 1153 B.4 Second error : Pilot error  During preparion for flight 152F to Bari. An amount of 465 kg fuel was added for the flight. 3800 Kg is indecated (real quantity is 1255 Kg).  After landing in Bari, the FQI shows 2300 Kg. 1500Kg of fuel had been consumed in stead of 1050Kg . The crew noticed this but does not react.  The A/C took off Bari with only 305 kg. 26Km north of Palermo the fuel tanks are empty ( the indicator shows 1800Kg). The Captain tries to joint the airport, but the A/C ditched near the coast.
  28. 28. 28AIR TRANSPORT SAFETY B. Investigation 2. Example : TUNINTER Flight 1153 B.5 Third error : Design and conception error  On the ATR Family, The Fuel Level Alarm : « LO LVL » is depending on the FQI.  The quantity of fuel computed by the FQI is erroneus and the alarm had never been triggered. TANK WARNING
  29. 29. 29AIR TRANSPORT SAFETY B. Investigation 2. Example : TUNINTER Flight 1153 B.6 Application of J Reason’s Model Maintenance Crew qualification Design and conception
  30. 30. 30AIR TRANSPORT SAFETY http://www.youtube.com/watch?v=tnRKp8d_0OQ
  31. 31. 31AIR TRANSPORT SAFETY A. Airforce accidents 3. Other examples in Tunisia A.1 C-130 Hercules : take-off missing Date…..………..……….…April 1994 Location…….…Gafsa Airforce base Accident…..………Take-off missing Cause…………..…3rd engine failure ………………..…Pilot incompetence ..…Unit commander irresponsability Damages…….Aircraft out of action
  32. 32. 32AIR TRANSPORT SAFETY http://www.youtube.com/watch?v=fhxGn_MsDQo
  33. 33. 33AIR TRANSPORT SAFETY A. Airforce accidents 3. Other examples in Tunisia A.2 Sekorsky HH-3 helicopter : crash Date…..………..……….…April 2002 Location……….…….…Mejez el Beb Accident….…………………….Crash Cause………………………Unknown Damages…………+20 officers killed …...Helicopter completely destroyed
  34. 34. 34AIR TRANSPORT SAFETY A. Airforce accidents 3. Other examples in Tunisia A.3 F-5 fighter : crashs Date…..………..between 1990-2003 Location……….………Training zone Accident….…………………...Crashs Cause………………Engines failures ……………………..Hard manœuvre ………………………Pilots limtations Damages…………+6 officers killed …...Fighters completely destroyed
  35. 35. 35AIR TRANSPORT SAFETY A. Airforce accidents 3. Other examples in Tunisia
  36. 36. 36AIR TRANSPORT SAFETY B. Civilian air transport accidents 3. Other examples in Tunisia  EGYPTAIR : crash of B-737  7th of mai 2002, Tunis, while starting the landing to Tunis Cathage airport, the B-737 of EGYPTAIR hit the hill of Nahli park.  The visibility was very bad and the pilot has forgetten to adjust his altimeter.
  37. 37. 37AIR TRANSPORT SAFETY B. Civilian air transport accidents 3. Other examples in Tunisia  EGYPTAIR : crash of B-737  14/62 passengers killed
  38. 38. 38AIR TRANSPORT SAFETY A. Recommendations 4. Recommendations and conclusion  Technology and new systems can improve the aircraft performance and help pilots to take the right decision.  companies should review its maintenace system and procedures.  companies should review its monitoring procedures and training exercises.  Aircraft crashs must be studied and analysed to correct anomalies in order to avoid any futur accident.
  39. 39. 39AIR TRANSPORT SAFETY A. Recommendations 4. Recommendations and conclusion B-737 simulator>>
  40. 40. 40AIR TRANSPORT SAFETY B. Conclusion 4. Recommendations and conclusion  Inspite of accidents, the international air traffic is still growing and new machines: powerful, larger, faster, more modern and sophisticated are under production to transport passengers safely and smoothly : A-380, B-787  If we believe in a future without accidents, we will be able to make the air transport more popular, less expensive and more reliable.  Aircraft crashs are not the result of one error but of several errors done by the different actors of the accident.
  41. 41. 41AIR TRANSPORT SAFETY 4. Bibliography  Documentary : « pourquoi les avions tombent? » arte  Internet: www.airdisaster.com  Documentary : FATAL DITCHING T-BRO production : Part 1 : http://www.youtube.com/watch?v=Xvkdwnr1Anc Part2 : http://www.youtube.com/watch?v=IIXKDUQHILM Part3 : http://www.youtube.com/watch?v=aO_-GiJyJys
  42. 42. 42AIR TRANSPORT SAFETY Thank You !

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