Applications of Human Factor Concepts

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Case Study

The forgotten sleeve

In preparation for the scheduled flight of MH 468, from Hobart Airport to Perth Int. airport  ,

Section 1

On the night of 11th November 2020, there were two engineers- Hugh and Liam working on flight MH 468. Around 10:45 PM  Hugh, the apron engineer fitted the landing gear ground locks (LGGL) to the Airbus A320 before it was towed to its departure bay and he completed the pre departure check.Then he went to supervise the refuelling of another aircraft, with the intention of returning for the refuelling of the flight 468 and removing the LGGL.

Approximately 40 minutes later , Chris, the first officer of the flight 468, performed a preflight walk-around and identified the presence of the LGGL. Nicole, the captain of the flight acknowledged the First officer’s observation but anticipated that normal departure procedures would lead to the removal of the LGGL before flight.

Section 2

It is a practice of the airline engineers to do handovers with their colleagues  because of the high workload. As departure approached, Hugh realised he would be unable to return for refuelling due to complications that arose during the refueling of the other aircraft. So he contacted the engineering coordinator and  directed the refueling supervision and departure responsibilities to Liam, on top of the task he was already performing(supervising the rectification of the engine throttle stagger on the flight deck.)

Then Hugh did the handover over the radio to Liam, and informed that he already performed the departure checks and Liam just needed to supervise the refueling of the aircraft and remove the pins.

However, the handover between the engineers was not effective at communicating the requirement to remove the LGGL, as Liam was busy paying attention to the technician who was rectifying the defect. Liam, then supervised the refuelling and returned to the flight deck but failed to notice the LGGL as he did not carry a flashlight because he was supervising the onboard rectification and assumed that Hugh must’ve done a first walk around.

Section 3

The flight crew commenced their pre-flight procedures and checklists later than anticipated as the flight schedule was delayed by the rectification work . So the crew did not detect that the LGGL had not been stowed on board the aircraft as required, as they were rushing to be on schedule.

Section 4

The organisational procedure is that pushback is conducted by the towtug driver and a dispatcher without the presence of a technical officer.  While waiting for pushback to commence, Jason, the pushback tug driver and  Luke who was the dispatcher saw pins and associated red tags attached to the landing gear of the aircraft.

Margot,  the  aircraft movements co-ordinator was having trouble with her walkie talkie. Therefore Luke was unable to contact Margrot,  and with just seven minutes until the scheduled take-off, Jason removed the LGGL pins but unknowingly left the locking sleeves in place.

Regardless of someone’s specific role working around an aircraft, everyone has a responsibility to notify the operating crew of any concerns they may have with an aircraft and that any concerns are assessed and rectified by any qualified personnel before flight.

Section 5

Luke then entered the cockpit to have the load sheet signed by the flight crew. Neither him or Jason advised the flight crew of the presence and removal of the lock pins.

The aircraft subsequently taxied for departure with the LGGL sleeves attached. A sleeve fell unnoticed onto the taxiway and the other fell onto the runway shortly after take-off. Shortly after the DHL flight 284 on the takeoff roll, ingested the locking sleeve that was on the runaway leading to an engine failure and the crew performing an emergency stop.


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