Air Crash Investigation: Flight 191

1099 Words Nov 27th, 2012 5 Pages


Air Travel
Most effective and safest forms of transport
< 1 for every 2 x 109 personmiles flown

Air crash – One of worst situation
Team Members: Seran Karikalan 1002764 Sivaguru S/O Sivagnanam 1003260 Ng Aiting 1067138 DARE 3B 24

Number of lives it takes with it

Human Error
Manufacturers to Engineers
No one wishes for air crashes

On 25th May 1979, 15:00Hrs
A McDonnell Douglas (MD) DC-10 American Airlines Took-off from Chicago O’Hare Int. airport

Yet, 70% is caused by Human errors “That wouldn’t happen to me”
Is main cause for such errors

Just before lift off
Lost power from No.1 engine

Suddenly rolled heavily to left
Smoke gushing out

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Rules & Regulations
Aircraft Maintenance Manual (AMM) should be followed closely
• Unless there is no procedure

for a certain job

Risk assessment of new procedure should be evaluated

Improve on DC-10 Design
Introduce slat-locking mechanism on DC-10
• Prevent unintended slat

Improve on Communication
Error report to reach authority effectively Top management monitor the performance of engineers closely Improve training quality for engineers


Improve on accessibility of the emergency power supply
• Located somewhere within the

reach or be made automatic

• •

Series of errors caused the accident Continental Airlines not informing FAA about damage flange Altering Procedures



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Communication Human factor is a success only when a there is a top level commitment Consequence of Everyone 's actions Cutting corners and company norms

Top management must ensure AMM are followed Communication Human factor is a success only when a there is a top level commitment

Bibliography and References
Earl L. Wiener and David C. Nagel, 1988. Human
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