Human Factors in Maintenance

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  • Topic: Landing, Takeoff, Task analysis
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  • Published : March 5, 2013
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Human Factors in Maintenance
Kevin Carr
Embry-Riddle University
Nigeria Airways Flight 2120
Nationair DC-8 Flight 2120 took the lives of 247 passengers and 14 crew members; 261 in all; during takeoff on July 11, 1991. The jet was owned by Canadian airline Nolisair, and was being operated by a Nigerian company to transport Nigerian pilgrims in and out of Mecca. The DC- 8 caught fire during take-off from Abdulaziz International Airport, Jeddah, Saudi Arabia. Pilots noticed problems during early stages of take-off and only made it 671 meters in elevation before attempting to turn around for a emergency landing. It was too late; the under inflated tires had overheated began to catch fire. The fire grew and blew out the hydraulics which made the emergency landing impossible. This was the worst wreck a DC-8 had ever experienced and has held the record for many years following. The NTSB concluded that the fire could have been handled by leaving the landing gear extended and away from the plane. Although the pilots failed to make the right decision, and added just one more human error to the equation, it was the obvious neglect by the maintenance team that caused this horrific accident. There are many human factors which played a vital role in the crash. The maintenance team failed to inflate the #2 and #4 main gear tires after recognizing the pressure during the pre-flight. An attempt to inflate the tires failed because there was no nitrogen available at the location. Further investigation shows later that the maintenance team recognized and had written up the tires during a previous "A" inspection but was signed off and overlooked more than twice before the incident.

Human Factors Involvement

There are many human factors that caused the Flight 2120 crash, and most of them are maintenance related. There was a Liveware-Liveware problem with the lack of communication between the lead mechanic and Director of Production. The...
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