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March 16, 2011

Where there is a human, there will be an error!

A report in the Hindustan Times about the investigation of a fire in Air India flight on September 4,2009 points out the following:
"A probe by the aviation regulator has found several safety lapses by Air India staff while evacuating 213 passengers from a Mumbai-Riyadh flight after a fire broke out in the aircraft on September 4, 2009. The Directorate General of Civil Aviation (DGCA) concluded that the AI's aircraft maintenance engineer failed to notice a fuel leak from the left side of aircraft before clearing it for take-off. "The engineer had left the bay without giving the final take-off clearance because it was raining," the report said.
Second, the airline ground staff were unable to report the fire to the pilots because the cockpit crew had switched off the radio communication equipment, violating the airline's operation manual. Worse, both the pilots left the aircraft before the evacuation process was complete and not a single cabin crew member was deployed at the end of the inflated emergency slides to assist passengers.
The report also blamed the airline engineers for failing to check the aircraft's fuel channel during routine inspection. "Constant wear and tear caused massive fuel leakage and fire," said the report.
An airport follow-me vehicle informed the air traffic controller on duty about the fuel leak but he wasted significant time in alerting the pilots, the report stated. "As per rules, the controller should have called the aircraft crew by its registration number but it kept calling the flight number," read the report.
The cockpit crew switched off the aircraft engine but was late to start the evacuation process. The cabin crew also overlooked hand signals about the fire from the ground staff."


It always takes a series of human errors to trigger an incident. In the chemical industry also, a similar situation exists. Pressure on production, lack of rest, overloading of equipment, communication gaps and top management disconnects are often common cause reasons for incidents.

Read the news report in this link.

1 comment:

  1. Good Near Miss but could easily be the worst hit

    ReplyDelete