The Fat Bird Hath a Fall!!

Part - 1
Preamble: Humans, howsoever educated or enlightened are bound to commit mistakes and errors. So should we expect machines, which are made by humans, to be perfect? The question itself is in perfect, and more critical for a machine, when it works in the sky, with complexity of sorts. Incidentally an air plane is the most complex machine build by humans. It beats rockets and manmade satellites by a fair margin. Hence, wouldnt it be appropriate to change the idiom, its not rocket science to its not aero science.

The bus In Air

Airbus is already on way to make sky traffic terribly congested, with all the fat birds like Airbus A380s being put up there. Although an A380 possesses state of the art technology and is considered to be environmentally friendly, even has far better fuel efficiency than any other air plane in the skies, also its aerodynamics are such that it creates very low sound. But by far the most important quality that it possesses is that it is the largest air plane ever built by man. It can carry more than 600 passengers. But herein lay the fear factor. Up till date, an accident which involved two boeing 747s killing 400 odd people, is considered to be the most fatal accident ever. Now imagine an Airbus going down. It is universally accepted that although probability of an air crash happening is very low at 11,000,000:1, nonetheless the

Bus
Passenger carrying capacity Accidents per year Deaths caused per year Cost 80-100 -- NA -4000

Train
600-1000 3000 1000

Air Plane
300-400 20 200 665 gallons/hour 10-20 1 in 10.46 million

61.5-2 miles/gallon 7miles/gallon Crew Members 2 50-60 Probability of dying 1 in 250 1 in 115,000

probability of someone surviving in an event of an air crash is a figure diametrically opposite, a dismal 1:10,000,0000. If its a goof it is a big poof. It would kill people in excess of 600 in a few seconds in an event of an A380 crash, which is more than the number of people dying in terrorist attacks world wide each year. This is a scary thought. So, why not learn from the mistakes fast? Hence the importance of this article where our objective is to learn from our mistakes of the pasts, apply them in future aviation projects and come up with a strategy with which we can achieve zero defects in the design of an air plane. That is we are aiming for the ideal. Ambitious, but certainly not impossible. Objective: To achieve a perfect flight with Zero Defects First off! Are We Safe In The Sky!

A Back Flight To History.

Back in the 1920s and 1930s, commercial air travel started its journey. With it came safety concerns as the passengers were common people rather than military. To enhance safety of the civilians traveling, there would have to be a drastic improvement in the air plane design. Technology was still in its nave stage. Crashes were common place. Commercial planes were only used by American mailing services, which crashed often. But increasing popularity of commercial air travel meant better safety standards. Design had to evolve. Hence a way to evolve must be found. And this way was found precisely in 1931. On 23rd may 1931, a plane carrying 8 passengers including one star football coach of America died in a plane crash. Due to the celebrity status of the victims, there was a thorough investigation done on the crash, a first of its kind. It was found that the wing which was designed and manufactured using wood as building

material was the culprit. After a thorough investigation it was found that on that fateful rainy day, the wing of the plane being made of wood swelled up on wetting and due to the additional pressure on the joints holding it in place, the wing collapsed and the plane crashed. Thus it was decided after the investigation that all planes made of wooden wings have to be immediately grounded and burnt. And that all the wings of future planes must be metallic. Due to a shortage of planes and high demand, there was a great need to design a plane for commercial travel. Douglas, one aeronautical scientist of America did just that. He designed one air plane which is till date considered the best designed plane. And the technology has evolved from that first to now. Once a perfect flying machine was designed it was difficult to design a drastically different design. Learning from the mistakes was one important way to improve design. Hence, NTSB (National Transport Safety Board) was set up in the United States of America to investigate in great detail any future air crashes. It is due to this effort on the part of the NTSB that air travel today is considered to be the safest way to travel. And the probabilities shown in the following figure demonstrate the same.

Close To Heaven Or Hell!!

Following is briefly about some air crashes that occurred due to various reasons: The approach used to describe the event is diagrammatically displayed in the flow diagram. The basics of the accident analysis are outlined. As our objective is to achieve zero defects, a look into the past will help us in not committing the mistakes again in the future. NTSB the leading body in the world is involved almost in most of the accidents. Local investigative agencies help in the investigation. The terror that the passengers of the air craft, which has become a death ship for them could be well imagined.

Accident
Chronology of event The Event in Brief Investigation process

Lets study some actual mishaps and there root causes. In this Learning Experience first part we will enlist two crashes and there case studies. In the continued parts more case studies will be discussed.
Design changes

American Airlines Flight 191 DC 10

Aviation Safety The Event in brief The plane takes off from Chicago airport on a clear spring day, as the wheals leaves the runway it looses power on one of its engines suddenly it roles to left seconds later the plane hits the ground and disintegrates. Investigation Process In the investigation process it is found that on take off an engine fell off due to structural faults. The DC 10 has 3 engines each weighing more than 5 tons, one is on the tail and the other two hang from the wings each connected by the pile on. A pile on attaches to the wing at three points two at the front one at the rear, it has dozens of components. The air plane can fly normally even if it looses one of its engines. The flight data recorders are recovered and they reveal some facts. The pilot was able to stabilize the plane level just after it lost its engine. But, it started rolling to the left. After close scrutiny of the pile on assembly that holds the engines to the wings, investigators discover what they believe to be probable cause for the engine falling off, a fractured bolt. A senior metallurgist is called and he examines the bolt. The bolt reflected a fatigued fracture. But the metallurgist from his experience reveals that the bolt was damaged during the flight not before. He saw no fatigue in the bolt. The flange is another key piece of the pile on assembly. It is recovered and close inspection reveals it is damaged, a damage which is believed to be caused before the crash. The flange is on a bulk head bolted to a clevis, when during maintenance the bolt is removed to detach the pile on, for standard maintenance of the engines prior to the flight, the

flange can move up on the clevis, cracking it and bending it exactly matching the curve of the clevis. This is why the engine came off. But, the air craft does not crash just by one engine coming off. Then a piece of the left wing is found on the run way. The piece has been ripped away from the rest of the wing by the engine which swung out up and over the wing ripping it away. This crucial piece of the wing carries the hydraulic unit crucial to moving the flaps up and down to steer the plane. Without them the flaps would jam and the plane would be uncontrollable exactly what happened on this flight and this is why the plane crashed. Learning Experience The most important learning experience was for the maintenance people. Aviation safety depends on a large variety of people, from pilots flying the air plane, to designers designing them, to maintenance men maintaining them. Hence, every one of them must realize that they hold the lives of a number o people in there hands and hence must be responsible. Although there was irresponsibility and lack of realization of the importance of the jobs on the part of the maintenance people that led to this accident. Design Changes DC 10 air plane have a tarnished history. Although considered to be one of the most sophisticated planes of its time. DC 10 planes have had many accidents. This one although was not due to any major design flaw but due to negligence in maintenance. Hence no design changes were brought about after the crash although the aviation was made safer by changes in the maintenance procedures. Aviation Safety As the after math of the accident there were stricter measures in taking care of the air plane while in maintenance. This made the aviation safer, by regulating the maintenance procedures.

Air Transat 236 a fully loaded AirBus A330

The Event in Brief A fully loaded AirBus A330, with 306 people on board ran out of fuel mid way over the Atlantic. How can a state of art computerized air liner suffer such a catastrophic failure? It was a case of how pilots did not trust there equipment and believed that a faulty sensor must be to blame for the low fuel warnings that repeatedly alerted the pilots of a possible fuel leak. In reality there was a major fuel leak in the number

two engine of the plane. No one was killed in the accident and ultimately the skills of the pilots helped land the plane safely. Investigation Process From the flight data recorders and voice recorders the investigators found that the sensors repeatedly warned the pilots. But the pilots did not believe the sensors and opened the valve that shifts fuel from one engine to another to prevent engine two from running out of fuel and flaming out. This resulted in even faster fuel loss and ultimately fuel starvation to both the engines and both the engines flamed out over the sea. Due to the failing of both engines there was a loss of power on the plane and only a limited number of functionalities of the plane were functional. So now a sophisticated airbus 330 was nothing more than a glider although a controllable glider. By the help of experience the pilots were able to steer the plane to safety and land the plane on an island and save the lives of all on board. Now the question remained that how did the leak happen. On close inspection of the plane it was revealed that there was a major pipe that burst. It had a hole in it which was caused by friction. Another smaller hydraulic pipe was very close to the larger fuel pipe and was continuously rubbing with the larger fuel pipe. Due to this continuous rubbing action the larger tube finally developed a fracture allowing the fuel leak. Again it was not a case of faulty design but faulty repair by the maintenance people. For maintenance one of the engines of the plane was replaced recently and a replacement engine was placed for the time being but the engine came without the hydraulic pump assembly, to overcome this, the maintenance people fitted the pump assembly of an older engine but they did not fit properly. The pipes were rubbing together for 5 days and finally it gave way. Learning Experience Again this accident justifies the risk factor of 16 that we arrive at from our data in a preceding section. Maintenance plays a major role in air plane safety. This crash is another example of how maintenance lapse almost caused 300 odd lives. Design Changes After the accident the airbus modified the checklist in case of a fuel imbalance, from now on computer checks all fuel levels on board against the flight plan, which was earlier done by the first officer manually. And it now gives a clear warning if more fuel is being lost than the engines can consume. All in all this accident has made the flying safer. Aviation Safety

It is true what the NTSB investigators say, every crash makes flying safer. Certainly this crash served its purpose.

Exploration Into The Future Safety.

Quantitative Analysis
*reference for using the following analysis and table: Grades Points A 1 B 2 C 3 D 4 E 5 Rating Ultimate Disaster Crash Probable Crash Crash Landing Land safely Sr. No. Value 5 4 3 2 1

1. 2. 3. 4. 5. 6.

Causes of an Probability Grade for Risk factor air crash of crash due Rating probable of the to the cause prevention cause Human error 9/10 5 A 5 Cargo door 5/10 3 A 3 Hydraulic 5/10 3 D 12 Failure Bird Strike 2/10 2 E 10 Both engine fail mid 4/10 4 C 12 flight Fuel Finished 4/10 4 B 8 (leak etc.)

7. On-board Computer problem 8. Faulty sensors 9. Maintenance Insufficiency 10. Air plane too old

2/10 8/10 7/10 3/10

1 3 4 2

B C B A

2 9 16 10

How we arrived at the above results?

Causes: Various air crash investigations undertaken by the NTSB (national transport safety board) of the USA were taken as reference and it was found that the above mentioned ten causes represent the 80% range and was sufficient to arrive at acceptable average results necessary for this article. Probability of Crash Due to any of the causes: There were 100 investigations taken *at random, from the various studied and a general probability was arrived at. It is entirely the authors own versions and may not be taken as official and final. Rating: The probability is the basis of the ratings and takes into considerations the number of people died in the crashes that had any of the above mentioned causes. Again it is purely the authors awn version targeted entirely to bring home a point and is only meant for this article and may not be used for arriving at any other conclusions. Grade for probable Disaster: The grade is given entirely on the basis of the probability data. Risk Factor of a Crash: The multiplication of the rating and grade is the risk factor, the higher the number more is the risk of a crash.

Visual Aid to the above analysis.

16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0

Human error Cargo door Hydraulic Failure Bird Strike Both engine fail mid flight Fuel Finished (leak etc.) On-board Computer problem Faulty sensors Maintenance Insufficiency Air plane too old
Rating Grade Risk Factor

Conclusion and Inference

Analyzing the above table we infer that in the case of a maintenance insufficiency the risk of disaster is the steepest, which in perfect harmony with the various plane crashes investigated. There were a number of crashes that took place due to the shear insufficiencies on the part of the maintenance. Interestingly the risk factor in the case of a human error is the least. It is because the risk factor takes into account two factors. One is the risk of an accident and another is the scope of prevention. And it is clear that the risk of prevention of human error is most likely hence the risk factor is lowest in that case. Although these are just some of the causes of most air crashes, we can never predict how the next plane is going to crash. But there

are some precautions that we might take. For example pray to God whenever we board an air craft or for my non-spiritual friends I have some piece of advice. Following statistics show two ways in which you can be saved in an event of an air crash: 1. Mostly there are high risk months and low risk months. Following figure demonstrate the same. Well, if you are not spiritual then you may see that traveling in the month of April or May is the safest.

2. And in case you happen to board in one of the high risk months, do not worry too much. We have another way to improve your probability of living in case of an air crash. Just take the back seats.

Leonardo Da Vinci said, Learning never exhausts the mind. Hence we must continue the Endeavour of a perfect flight. There is a law in mathematics. The law of limits. Similar to what Heisenberg pointed out in his theory of uncertainty that speed and distance cannot be measured precisely together, the law of limit might point out that we can only go thus far to a perfect flight. But we must keep getting closer and closer to the ideal. We must not get fatigued from the thought that we will never achieve the perfection. God made us humans and kept the perfection to himself. He is the only perfect thing. Nonetheless, the closer the better.

Jai Hind!