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Kegworth Air disaster

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

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Kegworth Air disaster

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

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

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

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

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

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

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

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

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

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

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

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

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

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