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Evaluating Health, Safety and Security Challenges in Aviation Ground Operations: Insights from the MD81 Accident (1991) and Boeing 747-8F Incident (2017)

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Air traffic is a very wide-ranging technology. In contemporary years, significant technical and structural developments have taken place in this system as a result of globalisation. The new economic framework has altered customers' assumptions about the value of their service, and the level of their services that travellers anticipate differs from the value of their service. Ground handling businesses have to understand the causes and guarantee consumer happiness and strategic edge. This variation in perspective. The safe, effective, appropriate, creative, knowledgeable, inventive and productive operation of the system relies on its efficiency (Chen, 2019). Each service company and staff should execute their duties properly and in a timely way to ensure pleasure for their consumers in air transport. In this aspect, this study has selected an event that will demonstrate the information regarding the health and safety issue during the ground service management of the different organisations in the aviation industry.

1. MD81 Accident in 1991 to Evaluate the Health and Safety challenges faced

1.1 Brief Description of the Event

On 27 December 1991, an “MCDONNELL DOUGLAS MD-81” (OY-KHO) was being operated by “Scandinavian Airlines System” (SAS) on a scheduled worldwide tourist flight from “Stockholm Arlanda to Copenhagen” as SK751 encountered total engine issue in day IMC a few moments after take-off from Arlanda. After the start, the aircraft crew succeeded in crashing into the open terrain a little over 4 minutes afterwards they came out of the clouds at 900 metres above sea level. All the passengers remained. The aeroplane was wrecked. “Of the 129 passengers, 8 passengers suffered serious injuries”. “The remainder 37 were unhurt and 84 received minor injuries” (Jarnehammar, 2018). The “Swedish Board of Accident Investigation” conducted an enquiry (SHK). The debris was retrieved from “DFDR,” “QAR” and “30-minute CVR” and most of its data were retrieved with efficiency. CVR data might be synced and ATC transcripts were accessible. “A total of 8,020 total flight hours, including 590 type hours, was acquired by the 44-year old Captain”.

After 6 years as a “Fokker F27 pilot”, he accomplished a type change 16 months before the tragedy. “A total of 3,015 total flight hours of 34 years old”, 76 hours per type, were accrued by the First Officer. A year before the tragedy, he finished the type conversion and in the 90 days leading up to the accident almost every hour on the type. The operational crew was assisted throughout the trip by the Captain series “SAS MD80,” 47-year-old, with 920 hours on the flight. The aeroplane operated in air temperatures of about 0°C on the first day of the day after overnight stationery (Ruotsi, 2020). Nearly 2/3rd of gasoline needed to leave the following morning had been received in Arlanda in the following night. As the take-off times of the planes neared, the light snow and air tempo dropped very little to -0°C, which had before been just over zero.

To examine the airframe, the Captain depended on “SAS Line Maintenance” staff, who particularly includes the underneath of the front wings in the field de-icing operation with hot type 1 fluid. Before freezing, an expert who discovered slush but no ice on the surface of the top wing had been examined. The Captain and the technicians had no consideration regarding clear ice pre or post icing. With the take-off authorization granted, a rolled off with the Captain as a PF and the AT activated took approximately 21⁄2 minutes to the departing path (Plantinga, 2017). The Captain stated that he noticed an odd vibration that he could not detect after rotating the aircraft. This was captured on the CVR as a “low hum” and corresponded with claims from three passengers that ice was pouring out of the top surface.

When the aircraft climbed up by a reported “1.124 feet QNH after about 25 seconds with the AP still not in movement”, “little bangs, vibrations and jerks were felt inside the aircraft” which was characterised as “like hard braking.” The pilots acknowledged the right engine origin and believed a compressor stalled compression and said that vibration made the EFIS display of the engine indicator difficult to see. A modest (10 per cent) decrease of the right engine thrust has occurred at about 2000 feet QNH, although there have been vibrations (Newman and Wander, 2018). “DFDR/QAR data” revealed that the gasket control was transformed into an automated phase unbeknownst to the pilot's “Automatic Thrust Restoration”, where thrust has been raised, without the pilot notice, through approximately 7 per cent over the starting point.

1.2 Gap Observed in Regulations, Technology, or Organisational Elements

During the consideration of the incident, the existence of prominent regulations within the industry significantly helps to mitigate the possibility of the occurrence of hazardous circumstances. The regulations those have imposed by the “Swedish Civil Aviation Administration” and “National Police Board” was playing the most significant role in the occurrence of this incident. Moreover, the training team of the organisation, the pilots and co-pilots of aircraft, the executive team and the air hostess are the prime elements of the organisation, which have the contribution within the incident (Komljenovic, Loiselle and Kumral, 2017). These employees, the organisational culture are prominently responsible for efficiently managing the health and safety of the passengers. Generally, concerning aircraft from the “DC-9-80 series”, the “Swedish Civil Aviation Administration” shall guarantee that airlines do not take off clean ice from the wings of the aeroplane for which they are technologically liable. Moreover, in the case of aircraft of the “DC-9-80 series,” “The Swedish Civil Aviation Administration” shall attempt to provide “Automatic Thrust Restoration” (ATR) methods of deactivation.

In addition to this, the “National Police Board” improves registering procedures and training in case of incidents. The “Swedish Civil Aviation Administration” must aim to enhance the existing design rules concerning the danger of “FOD damages” to rear-mounted motors due to aircraft ice cream through worldwide cooperation among civil aviation authorities. In this aspect, the case of undetected presence of clear ice on the wings of the aircraft grabs this regulation as a potential contributory factor. However, throughout the year 1991, there are no sufficiency regarding the utilisation of technological features within the passenger transporting aircraft (Hulme et al., 2021). Therefore, the issue regarding the undetected clean ice on the wings of the aircraft leads to the crash landing. In case there was the existence of AI or VR technological features within the system of the aircraft, then the pilots would be able to significantly reduce the possibility of the crash landing. But, due to the inexistence of sufficient and appropriate technological features within the system of the aircraft, the pilots had been unable to take essential steps during their landing.

Furthermore, FDR data indicate that, if indeed the motor force is currently at “Go Around”, it had switched off immediately when the right engine started to emerge 25 seconds after lifting, when the “Automatic Thrust Restoration” (ATR), mechanically equipped once the elevation after take-off reaches “350 feet agl”. After 10 seconds, the ATR was triggered according to the software architecture, which negated the A/T start-out and raised both motor thrust configurations to “Go Around”. That would have pushed active way thrust controls, which would have been confirmed by changing the “FMA” (“from CLMP to EPR G/A”) and “EPR selector panel” (“from T/O to GA”). This increment has been achieved “It has helped to make the surge continue and intensify,” till following 51 seconds of surgery the engine burned down completely (Moura et al., 2017). “The additional thrust led to a surge 12 seconds before the right motor broke and since the thrust was greater, after a surge of just 14 seconds the engine failed” there was a mistake. Due to this, the staff of this aircraft company had been unable to sufficiently manage the health safety of the passengers.

1.3 Ideas to Trap, Avoid or Mitigate the Event

The investigation concluded that the piles of the “MD80” were thus not instructed in the field or referenced in their “Operations Manual” at the time of the accident: “there wasn't any ATR expertise inside SAS”. Yet both the AFM and the “McDonnell Douglas FCOM” included the concept. They were regarded to be “handbooks that every operator must know”. If the pilots had known about the ATR system, the automated rise in engine pressure that hastened the damage of both engines would have been easier recognised and the effort by the commander to decrease the right-hand engine power would have been reversible (Nnaji and Karakhan, 2020). This breach through SAS was judged a “Severe Flight Security Defect”. No element of this method has been recognised as a memory recall, even though the “Engine Surging Emergency Checklist” process may conclude with engine failure.

There was no indication that either engine was affected by any further destruction beyond minor breakage in the fan phases when the aircraft came off. The damage “was probably not so extensive as to prevent surging in the right engine from stopping if the power had been reduced sufficiently” and then could be utilised at a decreased speed. It would have been deemed to have been the case. It was also believed that rushing certainly would have been impossible at all if the start-up force was not immediately boosted through activating the ATR mechanism in the left engine (Anjum et al., 2021). It was thus determined that “with sufficiently reduced thrust on the right engine and maintained thrust on the left, the engines would probably not have failed (and) the aircraft would then have been able to return (to Arlanda) for a landing”.

2. Boeing 747-8F Incident in 2017 to Evaluate the Security Challenges

2.1 Brief Description of the Event

On 30 March of 2017, immediately after Boeing747-8F reached a standing position after landing in Prestwick, a large amount of fuel was detected to exit from the aircraft and the fire services were attentive to control and handle the accompanying fire and explosion risks (aviationsafetywiki.org, 2018). The UK AAIB conducted a field investigation. This investigation showed that the fuel came from a Bell 412 helicopter which belonged to the main deck cargo, and also that it was certified as fuel drained though it was not. These procedures of the shipper were deemed to be inadequate, especially as regards their representatives in the field. While investigating the helicopter, the shrink wrapping was damaged in the forward right fuel ventilation and fuel had flowed from it, previous to extraction from the shrink wrapping in which it was delivered.

It was observed that the 52-year-old captain of the Boeing747-8F had amassed 12,900 hours, of which 9,200 hours were on the type. This was concluded that a fuel smell observed by the crew during the closure of the engines was the first sign of everything being wrong. There is a comparative weight difference of 255 kg between the reported cargo weight when dispatched and the cargo weight after leakage. The amount of fuel in the helicopter was reported as 1,440 lb while electrically propelled, and a 467-litre uplift identical to about 369 kg was afterwards used to achieve the complete indicators for the tanks (aviationsafetywiki.org, 2018). After the refuelling had occurred, no fuel escaped from the helicopter. The RFFS of the Airport was named and comprised a fuel drainage system and the accompanying fire and explosion hazard was addressed. It was found during the investigation that the fuel could have leaked from the helicopter through the sump valves, refuelling valves, fuel ventilation lines or a loosely linked line of the fuel system.

2.2 Gap Observed in Regulations, Technology, or Organisational Elements

In the course of investigations, a substantial set of administrative irregularities and inaccurate statements was found concerning the shipment of an aircraft as airfreight and uncertainty appeared between the seller and buyer as to who was accountable for the helicopter dismantling and preparing the helicopter for air transport on consideration. The NOTOC (Notification to the Captain) of Dangerous Goods submitted to the captain of the aeroplane failed to include the helicopter at the ending of the process (Crown, 2018). Irrespective of the precise mechanism through which the helicopter fuel was escaping, the IATA Dangerous Goods Regulations (DGR) are in power to stop dangerous cargo from being transported as a hazard to aviation safety. There have been no sufficient efforts to arrange the helicopter properly for shipment and such problem has not been recognised before it has been offered for air transport.

In compliance with ICAO documents 9284 about technical directions on the safe transport of hazardous products by air, ICAO Annex 18 provides that dangerous goods should be transportable following the applicable criteria. The helicopter had been class 9 Dangerous Goods and flammable-liquid driven in vehicles category “UN3166”, and had been required to recognise it as hazardous goods with particular preparation, packing and labelling (aviationsafetywiki.org, 2018). Under special Provisions A70, however, it could have been granted conditional dispensation from the Dangerous Goods Regulations (DGR), which would have permitted the helicopter to be carried by air without having been announced to be consisting of a dangerous battery and other hazardous goods, and the fuel tank and fuel system being washed out and purged of any fuel or fuel fumes. Correspondence and documents related to a helicopter transaction suggested that, under the supervision of the purchasers' agents, the seller would support the purchaser in disassembling and preparing the helicopter for transit. The buyer thought that the defence of the helicopter was included in such preparations. On the other hand, the seller assumed that the buyer's responsibility was with all transport issues and that they knew the plan to carry the helicopter as an aviation cargo ship.

The gap precisely found in this process lies in terms of sincere and systematic shipment process for the aircraft. The intention was that the sales agent of the buyer would monitor the dismantling and preparation of the helicopter for transportation; however, he could not attend and sent two assistants on his behalf to supervise preparedness and ensuring no harm was caused to the helicopter. One helper was there at the seller's premises when the helicopter shrink-wrapped, but was dismantled before his arrival. There was a second assistant to watch the helicopter cargo being loaded on delivery vehicles (Crown, 2018). In spite of a significant amount of fuel aboard the aircraft, the dismantling of the helicopter and preparations for its transportation took place at the seller's premises and were carried out by its staff notwithstanding the contractual responsibility for preparing and defueling the helicopter. On the other hand, the buyer anticipated the helicopter would be assembled following the instructions issued by the manufacture of the helicopter recommending defueling in transport preparation. In addition to the preparations, the helicopter was packaged with an open flame, which was a major health and safety concern to the involved parties. Nothing was noted either by the disassembling workers of the seller or by the agents of the buyer, who were thereafter present and recognised that a considerable amount of fuel remaining on the helicopter before it was packaged for transportation.

The investigation found that the diffusion of liability among the numerous different agencies and people concerned meant that no single agency or person could ensure that the shipping documents represent the helicopter's real condition and were following the DGR. The helicopter was filed for shipment to Cargolux within an invalid A70 exemption (aviationsafetywiki.org, 2018). This has been emphasised that the shipper is more responsible than the manufacturer or buyer for complying with the DGR. Bristow U.S. has indicated that the buyer is fully responsible for examining and carrying the helicopter under the terms of the sales agreement. Before travel, a basic inspection of the helicopter had been carried out and although there were no attempts to check the helicopter's current fuel level, it was wrongly found that the helicopter had been de-fuelled.

2.3 Ideas to Trap, Avoid or Mitigate the Event

The situation of the fuel leaking from the Boeing747-8F is one of the incidents that rarely occur in terms of failure to security in the ground operations. Hence, it is extremely unlikely that the behaviour of the fuel system of the helicopter in these situations could have been predicted or thought about previously, based on the opinion of Ploch, D?kan and Zýka (2018). However, some sincere steps should have been taken by the various entities engaged in the process to trap, avoid or mitigate the incident, which could be led to a serious accident and invite severe damage to humans and materials involved.

Shipping and Shipping Documentation

First, the shipper’s documentation that included that no hazardous materials were being exported should have been prepared with more cautiousness, according to what has been stated by Hlavatý and Kraus (2017). There was no reflective mention of the fuel onboard inside the helicopter. While implementing the Special Provision A70 of the IATA DGR, the shipper is responsible for ensuring the shipment to be aligned with the requirements of the regulations. The opinion from TAHA (2016) suggests that the shipper should have made appropriate declaration and documentation of dangerous products to ensure that every party engaged in the transportation process are aware of what kind of product is being transported, how to load and manage them, as well as which measures are to take in terms of the circumstances like this.

Detection of the Presence of Dangerous Goods

There should have been a process of detecting the presence of dangerous items in the aircraft, as Kim et al (2020) have opined. The event of fuel leakage and the succeeding investigation of the helicopter being carried by a shipping agent and a mechanic raised a concern about detection whether the helicopter was defueled before the transport or not. In this process, the mechanic who cleaned the fuel residue from the coating of shrink-wrap followed by interesting absorbent pads should have determined that there is no fuel remaining in the helicopter and report the actual fuel state of the vehicle to his/her supervisor.

Conclusion

The portfolio has focused on evaluating two incidents of ground operation in the aviation industry to assess two significant challenges faced by the industry, such as health and safety and security. Each incident has been explained with a brief description, followed by finding a gap in the regulation, technology or organisational elements to be further addressed by ideas to avoid, trap or mitigate the event. Both the incidents, including the MD81 accident in 1991 and the Boeing 747-8F fuel leakage incident in 2017, has indicated that there was a lack of maintenance in the regulations related to passenger health and safety and aircraft security, respectively. While proper engine maintenance could have avoided the situation of the MD81 accident, proper shipping and shipping documentation along with detecting the presence of dangerous goods would have been useful to prevent the fuel leakage incident of Boeing 747-8F.

References

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