Page 1 of 12 Retrospective Investigation into the accident of BAC -One Eleven G -BJRT over Didcot

Page 1 of 12

Retrospective Investigation into the accident of
BAC -One Eleven G -BJRT over Didcot,
Oxfordshire

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26/10/2018
PROJECT PLAN AND FEASIBILITY STUDY
BSc Aerospace Technology with Management

Cleo De Guzman

Dr. Rachel Cunliffe

Report title in
Arial Bold 21/21pt
Report subtitle and date in Arial Bold 1 1/1 1pt
Date
www .herts.ac.uk

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Contents

1.0 PROJECT BACKGROUND ………………………….. ………………………….. ………………………….. …. 3
1.1 AIMS ………………………….. ………………………….. ………………………….. ………………………….. ……….. 3
1.2 OBJECTIVES ………………………….. ………………………….. ………………………….. ……………………… 4
1.3 MOTIVATION AND TARGET AUDIENCE ………………………….. ………………………….. ………. 4
2.0 PLANNING ………………………….. ………………………….. ………………………….. …………………………. 4
3.0 SOURCES OF INFORMATION ………………………….. ………………………….. ……………………….. 5
RISK AND THREAT ASSESSMENT ………………………….. ………………………….. …………………………. 7
APPENDIX B: Project Resources Checklist ………………………….. ………………………….. ……………. 7
APPENDIX C: Project Risk, Ethics and Threat Assessment Checklist ………………………….. 8
REFERENCES ………………………….. ………………………….. ………………………….. ………………………….. … 10

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1.0 PROJECT BACKGROUND
On June 10th 1990 in the UK, a BAC1 -11 (British Airways flight 5390) was climbing through
17,300 feet on departure from Birmingham International Airport when the left windscreen,
which had been replaced prior to flight, was blown out under the effects of cabin pressure
when it overcame the retention of the securing bolts, 84 of which, out of a total of 90, were
smaller than the specified diameter. The commander was sucked halfway out of the
windscreen aperture and was restrained by cabin crew whilst the co -pilot flew th e aircraft to a
safe landing at Southampton Airport. 1
The sole intention for executing this project is to develop a clear understanding of various
effects of air crash due to variables including, but not limited to, human error, maintenance
faults, poo r communication, management failures and financial restraints of aircraft
organisations, examining British Airways specifically. The aims of this study are to closely
investigate the incident of the British Airways BAC -One Eleven G -BJRT over Didcot
Oxford shire in 1990 and to understand the influence of human factors in the aviation industry.
According to the International Journal of Aviation Psychology; “General aviation accidents
represent 70% to 90% of all aviation accidents. Human error is implicated as a contributory
factor in 85% of these crashes.” 2 These statistics show that the aviation industry has
acknowledged that human error causes most aviation accidents.
The expected benefits of this study are wildly extensive. Harnessing the growing body of
human behaviours’ awareness will boost the performance of Civil Aviation Authority (CAA) to
minimise the number of incidents and accidents by reducing human error and refining worker
skills, through trainings and programs, and other personnel to avoid a ccidents related with
other causes. If the findings of this study are thoroughly understood and followed, the changes
in the way organisations handle design, training, adhere to policies and procedures will most
likely improve.
1.1 AIMS
The aims of this project are to successfully investigate the accident of British Airways BAC –
One Eleven G -BJRT over Didcot, Oxfordshire in 1990. In over a decade, technologies have
and will, inevitably, continue to improve and evolve so the question of wh ether the investigation
report, completed by Mr D F King – an Inspector of air accidents, on the accident of the BAC –
One Eleven G -BJRT was the best they could have concluded or if all aspects were covered
and thoroughly examined so if it were to happen in this day of age, how different would
circumstances be and severity of its impact – is the main reason why this study is conducted.
Furthermore, this study aims to understand human behaviours contribution in air accidents
and its effects on safety performan ce. This study aims to discover whether the incident was a

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simple software glitch that failed to alert the pilots on -board during safety checks or was it a
lack of safety awareness for the maintenance crew. In this report, all the findings and
conclusions will aim to cover these topics.
1.2 OBJECTIVES
To achieve the aims stated, the following will be necessary:
? Explore different departments that could have influenced the occurrence of the accident
? In-depth analysis on maintenance unit
? Examine problems within the management sector – analysis on company culture and
possible financial restraints
? Discuss the evolution of aircraft technologies – using a chart to show comparisons
? Analyse the fundamentals of human behaviours effect on safety performance
? Investigate the importance of human error by conducting an experiment
? Review the programs and required trainings British Airways provide for staff
1.3 MOTIVATION AND TARGET AUDIENCE
Despite the growth and evolution of technology and ch anges in organisations approach on
safety and management, humans are ultimately responsible for ensuring the success and
safety of the aviation industry. The results and findings from this study could possibly have
applications in the industry that could e ncourage organisations to consider implementation for
improved airworthiness of aircraft , decrease the severity of impacts, improved accessibility to
tools and equipment, an d even for an enhanced management. Organisations must continue
to be knowledgeable, adaptable , dedicated, effective and efficient while exercising good
judgment. This study will promote this while highlighting the importance of industry’s continuity
to invest in trainings, equipment, and systems that have long -term implications as techno logy
continues to advance rapidly than the capability to foresee how humans will interact with it.
This project is executed to deliver real -world recommendations founded from data found on
the investigation of BAC One – Eleven G -BJRT, supported by primary a nd secondary data
including published records, journals, articles, and a practical experiment to gather primary
data.
2.0 PLANNING
The Gantt chart (figure 1. 0 and 1.2 ) shows the key deadlines and task specifications for this
study. They are displayed in “summary” and the tasks required to complete the report follow
below. This effectively shows the workload distribution – helping put problems or tasks into
perspective and how to proceed with the project. It is critical for the tasks to be completed on
time as this could sl ow down the process of the study. E.g. getting in -touch with a maintenance

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crew in British Airways, if the allocated time is not adhered to and potentially exceeds time,
that delays the following tasks as findings for that particular study is needed to mak e progress.
In a similar way if there are delays in ordering parts, practical work cannot proceed with
incomplete parts. Therefore, the consistency of ensuring the tasks set in that certain time –
frame a re completed is important to meet the deadline for the final report submission date.
The Gantt chart aids as a visual guidance to assist with the distribution workload and ensuring
work is completed on time.
3.0 SOURCES OF INFORMATION
the books, journals and articles identified in the following are aids to this study’s completion.
It must be considered that these are potentially not as accurate as they are not up -to-date and
could be falling behind in information.
? Beyond Aviation Human Factors
Daniel E Maurino, James Reason, Neil Johnston and Rob B Lee – 1998

Daniel E Maurino et al, believes that a systematic organisational method of approach to flight
safety requires altering methods preferred in the past. Identical safety faults are becoming
recurring features in accident reports rather than displaying new varieties. This indicates the
necessity to analyse and study the tradition al accident prevention strategies, looking in -depth
on the activity or in -activity of operational personnel. The book has been adopted by ICAO,
IMO and many others. 3
? Investigating Human Error: incidents, accidents and complex systems
Barry Strauch – 200 2

Barry Strauch applies the modern error concept to appreciate why and how humans can make
critical errors . This bo ok appears beneficial as it shows references to both systematic research
and investigative studies in a widespread of applications.
? Mainte nance Resource Management: A key process initiative to reduce human factors in
aviation maintenance
Muhammad Habibullah Siddiqui, Assad Iqbal, Irfan Anjum Manarvi – 2012

MRM is a process for improving communication, effectiveness and safety in aircraft
maintenance operations. This study covers the different aspects of human factors and
how MRM training can reduce the human error coefficient from an aviation maintenance
setup. 4 Additional articles and journals include:
? Human factors in aviation maintenance: how we got to where we are?
By Anand K. Gramopadhyea

? Human Factors in Aviation Maintenance: Challenges for the Future.
By Anand K. Gramopadhye , Colin G. Drury et al.

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? ICAO: human factors, management and organization . By Jose D Perez Gonzalez.

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RISK AND THREAT ASSESSMENT
APPENDIX B: Project Resources Checklist
This appendix must be included with the Project Plan .
Student ‘s Name: Cleo De Guzman
SRN: 15043359
Project Title:
RETROSPECTIVE INVESTIGATION INTO THE
ACCIDENT OF BAC – ONE ELEVEN G -BJRT OVER
DIDCOT OXFORDSHIRE
Supervisor ‘s Name: Dr. Rachel Cunliffe
Date: 26/10/2018
Please enter below your BEST ESTIMATES for the information requested. You will
not be penalised for small errors and later genuine changes – only for not
bothering!
1 W ill materials or components be ordered? Yes No
2 W ill you be designing a PCB or drawing which will require
manufacture during the course of your project? (Note that this
should only be contemplated where absolutely necessary for the
success of the project!)
Yes No
3 W ill PCB or drawing assemblies already designed and
manufactured within the School be required? Please specify:
Yes No
4 W ill a PC be required for work other than for report writing? Yes No
5 If the answer to 4 is Yes, will you require any special hardware
installed/attached (f. e. PROM emulation, USB interface). Please
specify:
Yes No
6 W ill you require specific software, other than word processing?
(Please specify):
Yes No
7 W ill your project require technical staff to make items requiring
workshop facilities?
Yes No
8 If the answer to 7 is Yes, which of the following workshop
activities will be required (please circle):
Drilling Sheet metal forming Lathe work Milling Other (Please
specify)

9 Are there other resources required, not covered above? (Please
specify):
Yes No

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APPENDIX C: Project Risk, Ethics and Threat Assessment Checklist
This appendix must be included with the Project Plan .
In addition, it is important that a university Risk Assessment Form is also
completed and submitted as a separate item on StudyNet.
Please PRINT all information CLEARLY
Student ‘s Name: Cleo De Guzman
SRN: 15043359
Project Title:
RETROSPECTIVE INVESTIGATION INTO THE
ACCIDENT OF BAC – ONE ELEVEN G -BJRT OVER
DIDCOT OXFORDSHIRE
Supervisor ‘s Name: Dr. Rachel Cunliffe
Date: 26/10/2018
Please enter below your BEST ESTIMATES for the information requested .
1
Is your project likely to involve either deliberate, or possible
accidental use or contact with:
Voltages above 30V
High currents at low voltage (f.e. lead acid batteries)
Rotating machines
High temperatures
Hazardous fluids or gases
Yes No
2
W ill your project involve attaching electrodes to yourself or
someone else In such a way as to produce low impedance
contact?

Yes No
3 If the answer to 2 is Yes, has an assessment of the risk in the
planned procedure been carried out? Yes No
4 If the answer to 2 or 3 is Yes, does the analysis show an
acceptable level of risk? Yes No
5 Are any substances classified as being ‘Hazardous to Health’
likely to be used in the course of your work? Yes No
6 Are any flammable substances likely to be used in the course
of your work? (eg volatile cleaning agents, paint, etc.) Yes No
7
Are there any other aspects of your projected work which
might impose a danger to yourself or to others? (Please
specify):
Yes No
• Notes: If the answer to any of these questions is YES, it is the responsibility of
the Supervisor to ensure that the risk established is evaluated and brought to
the attention of the Head of School before work proceeds.

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Ethical Issues
8 W ill your work involve measurements on human subjects or their
behaviour? Yes No
9 W ill your work involve asking human subjects to answer
questions of a personal nature? Yes No
10
Could any aspect of your work cause distress to human
subjects participating in your work either knowingly or
unknowingly?
Yes No
• Notes: If the answers to any of questions 2, 8, 9, or 10 are YES, the proposed
work must be submitted for approval to the Ethics Committee before work
proceeds. If you are in any doubt, please consult a member of technical and/or
academic staff.
Please provide a critical assessment in identifying events or situations that may pose
a threat to the successful completion of your project. Examples include loss of a
memory stick containing vital data, delays in obtaining materials, etc. Please extend
the table if you need more space.
Other Risks /
Threats
Severit
y
(H/M/L)
Mitigation
11
Misplacing memory
stick that contains all
findings for the
project

H
Delays making progress for the study – causes
hassle as the findings will have to be conducted
again
12
Unorganised time
and scheduling

H
Failure to allocate time correctly to each task
delays in making progress for the study. W hen
changes are needed to be made – it will be
rushed
13
Ordering materials
incorrectly

M
Failure to plan the quantity of materials needed
delays work from being completed
14
Failing to meet with
Supervisor for
updates on progress
of report

M
This could delay progress of report as feedbacks
are essential to ensure project is being
conducted correctly or going the correct path.
15

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REFERENCES

1 Harro Ranter, Aviation Safety Network. 2018. Aviation Safety Network ; . ONLINE
Available at: aviation -safety.net/database/record.php?id=19900610 -1
Accessed 20 October 2018.
2 Michael G. Lenné , Karen Ashby ; Michael Fitzharris. 2008. Analysis of General Aviation
Crashes in Australia Using the Human Factors Analysis and Classification System.
ARTICLE Accessed 20 October 2018.
3 Daniel E Maurino, James Reason, Neil Johnston and Rob B Lee. 1998. Beyond Aviation
Hu man Factors ARTICLE Accessed 20 October 2018.

4 Maintenance Resource Management. 2012. A key process initiative to reduce human
factors in aviation maintenance ONLINE Available at: https://ieeexplore -ieee –
org.ezproxy.herts.ac.uk/document/6187379/authors#authors . Accessed 20 October 2018.

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Figure 1.0 A Gantt Chart showing workload distribution and allocated time and date for each task

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Figure 1.2 shows a continuation of a Gantt Chart being used in this study to display workload distribution and the allocated time and date set
for each task until the final submission of this project.

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