Human Factor- Aircraft Incident

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This assignment will be discuss, analyse and critical evaluate on the incident of aircraft Boeing 737-400 with flight registration number G-OBMM near Daventry on 23 February 1995. This assignment will be base on the report of Air Accident Investigation Branch (AAIB), Department of Transport with report number 3/96 (EW/C95/2/3). This aircraft incident has been choose because of the report provided by AAIB was clear with the sequences of incident, information of the aircraft operator and the Authority, complete with clear finding and factors that lead to incident also provide with 15 safety recommendations to prevent this type of incident occur again in the future. In this assignment also, the SHELL Model which is a conceptual framework proposed in International Civil Aviation Organization (ICAO) Circular 216-AN31 (Tzvetomir Blajev, 2009) will be used to analyse and explain the causes of the incident and describe how these factors fit into the SHELL Model. The chosen of this error module because it was conceptual framework proposed by ICAO in Circular 216-AN31 to be used in Human Factors subject (Tzvetomir Blajev, 2009). 2)SYNOPSIS OF THE INCIDENT

A flight G-OBMM (B737-400) was charted to fly from East Mid Land Airport to Lanzarote in the Canary Island. Before departing, during commencing normal pre-flight check, flight crews noticed that the hydraulics power circuit breakers (CB’s) had been left open. The flight officer went down to the apron and asked the dispatching engineer about the open of hydraulics power CB’s. The dispatching engineer check the aircraft logbook to look for any G-OBMM maintenance history related with the open of hydraulics power CB’s. The dispatching engineer just found the borescope inspection that was carried out at both engine during previous night and that task was signed off by the in charged engineer who indicated that task was completed and satisfied successfully. As far as the engineer concern, the bore scope inspection at the engines did not involve with the hydraulics power system and there is no point left the hydraulics power CB’s remain open so the dispatching engineer allowed the flight first officer to close that CB’s. Flight G-OBMM took off from East Midland Airport at 1157 hrs on Runway 27. As flight G-OBMM climbing approximately at flight climbing level 140, the flight commander noted that the both engines oil quantity gauges were indicate about 15% oil left and it continuously decrease. At the same this, the oil pressure gauge also indicate the oil pressure eventually decrease. At 1204 hrs, flight commander contact the London airspace control to ask the permission of return back to East Midland Airport. The London airspace control gave the clearance to the G-OBMM to return back to the East Midland Airport at the flight level 180. At this time, the oil pressure and quantity gauges indicated zero. Flight first officer and commander felt that they cannot return to the east Midland Airport and ask the permission from London airspace controller to landing at the nearest airport. At the same time the flight officer declared ‘Mayday’ which indicates the aircraft in emergency condition. The London Airspace Controller gave the permission to the flight G-OBMM to landing at the London Luton Airport at the flight level 120. Flight G-OBMM successfully touched down at London Luton Airport at 1214 hrs on Runway 26 at the speed of 170 knots. There are no injury to all flight crews and passengers. Also there is no damage to the aircraft but both engines were removed to further investigation. 3)CAUSES OF THE G-OBMM INCIDENT

According to the report Aircraft Accident Report 3/96 which was provided and presented by Air Accidents Investigation Branch, Department of Transport, under the report title of “Report on the Incident to Boeing 737-400, G-OBMM near Davontry on 23 February 1995”, there are several cause factors that lead to the incident. There are: 3.1)...
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