fault tree - kegworth
TRANSCRIPT
FAULT TREE ANALYSIS OF THE KEGWORTH AIR DISASTERROSS APTED
Engine failure
High power
setting in flight
Fan blade fracture
Heavy vibrationsMetal fatigue
Heavy vibrations Flawed engine design
In adequate testing in
high
Engine vibrations sensor failure
Wrong engine shutdown (right engine)
No protocols in
place to deal with
simultaneous symptom of vibration and smoke.
Equipment failureJudgment error
Insufficient protocols Poor aircraft design
No way to get visual
conformation from cockpit
Inadequate
maintenance
Inadequate training
Pilots did not know that the aircraft had a different air-
condition
system
Other tasks
Pilots did no re-evaluate engine
switch of decision due to high cabin work
load.
British Midland Flight BD 92 crash landing
Engine failure
High power setting in
flight
Fan blade fracture
Heavy vibrationsMetal fatigue
Heavy vibrations Flawed engine design
In adequate testing in
high
Engine vibrations sensor failure
Wrong engine shutdown (right engine)
No protocols in place to deal
with simultaneous symptom of vibration and
smoke.
Equipment failureJudgment error
Insufficient protocols Poor aircraft design
No way to get visual
conformation from cockpit
Inadequate maintenance
Inadequate training
Pilots did not know that the aircraft had a different air-
condition system
Other tasks
Pilots did no re-evaluate
engine switch of decision due to high cabin work load.
Engine vibrations sensor failure
Wrong engine shutdown (right engine)
No protocols in place to deal
with simultaneous symptom of vibration and
smoke.
Equipment failureJudgment error
Insufficient protocols Poor aircraft design
No way to get visual
conformation from cockpit
Inadequate maintenance
Inadequate training
Pilots did not know that the aircraft had a different air-
condition system
Other tasks
Pilots did no re-evaluate
engine switch of decision due to high cabin work load.