Japan Airlines Flight123, Boeing 747-SR100, JA8119/FAA
Question
Japan Airlines Flight 123, Boeing 747-SR100, JA8119/FAA
https://lessonslearned.faa.gov/ll_main.cfm?TabID=1&LLID=16
Explore the aircraft maintenance, inspection, repair, or alteration flaws, often involving errors or faulty assumptions during the maintenance process. Be sensitive to discover what the flaws, errors and faulty assumptions were. Analyze this case study in terms of mechanical and structural factors and provide a technical report which analyzes this accident.
1. Title or Cover Page
2. Introduction or executive summary
3. Primary Causal Factor(s) of the Accident
4. Contributing Factors to the Accident
5. Structural and Mechanical Factors Related to the Accident
6. Relevant Human Factors and/or Organizational Factors Related to the Accident
7. Outcomes of the Accident
8. Risk Mitigation or Reduction Strategies
9. Conclusion or Summary
10. Reference Page


Solution
Japan
Airlines Flight123, Boeing 747-SR100, JA8119/FAA
On June 12, 1988, Japan Airlines
Flight 123 was a routine Japanese domestic flight from Tokyo International
Airport to Osaka International Airport that crashed shortly after take-off (Administration,
1985). The airplane’s pilot reported difficulties soon after departure and gave
his position 55 miles southwest of Tokyo (Jackson, 1985), which would put the
flight on course for Alaska. However, the flight lost control twelve minutes
after take-off from Tokyo airport on August 12, 1985, as it approached a
cruising height of 7,200m (Hideo & Hiroyuki, 1985). The plane experienced
an exploding decompression as a result of the aft bulkhead's rapture
(Administration, 1985). The aft bulkhead became fatigued, followed by the
vertical fin's structural failure (Administration, 1985). Finally, after
thirty-two minutes of irregular flight, the flight was crushed at Mt.
Takamaghara, Ueno, Gunna Prefecture (Hideo & Hiroyuki, 1985). The fuselage,
empennage, and much of the control surfaces were all destroyed (Hideo &
Hiroyuki, 1985). Five hundred twenty people were killed in the collision (15
crew and 505 passengers), accounting for almost half of the 524 individuals on
board, the most catastrophic single-aircraft accident in history (“Japan
airlines 123 CVR transcript,” n.d.).
Primary
Casual Factors of the accident
The accident’s causes revealed
numerous contributing factors that resulted in the tragedy, including several
concerns that caused it. The root cause of the crash was the improper repairs
made on the plane several years before the accident (Administration, 1985). In
June 1978, the aircraft received large-scale repairs at the maintenance field
at Haneda after experiencing a tail hit landing at the Osaka airport (Hideo
& Hiroyuki, 1985). The tail of the aircraft struck the runway, causing a
mechanical failure and vulnerable pressure points on the plane bulkhead
(Administration, 1985). The consistent repair of the damaged bulkhead was not
conducted following the company’s procedure, and two separate slice plates
instead of a single plate were used during the repair. As a result, the entire
load was transmitted through the center rivet row only, and multiple site
fatigue cracks were initiated from the rivet holes of the center row soon after
repair. The fatigue failure was due to a mistake made during the repairs at
that time. Over time, the airplane bulkhead was pushed and pulled by the
pressures on both sides. As a result, explosive decompression ruptured the
flight’s hydraulic systems. The damage to the hydraulic systems disabled the
flight controls, lending the plane uncontrollable.
Contributing
factors to the accident
Maintenance errors were made on the
aircraft over time, such as the bulkhead repair with the improper installation
of plates to strengthen it. This gave in to the force after a failed row rivets
implementation, which resulted in a reduced effect. In addition, the maintenance
engineers’ failure to understand the fundamental mechanism of load transmission
and preliminary inspection by the airline representatives are also contributing
factors to the crash.
Structural
& Mechanical factors related to the accident
Another consideration is the
structural failure during flight, which was a significant element in its status.
The failure was caused by the airplane's systems being repeatedly subjected to
high and low air pressure (“Japan Airlines 123 CVR transcript,” n.d.).
Furthermore, the falling of the bulkhead caused severe hydraulic failure due to
the catastrophic decompression initiated by the failure of the aircraft’s
control systems. As a result, while the pilot was able to keep the plane in the
air for approximately 32 minutes and avoid a mid-air explosion, the disabled
flight controls rendered the plane uncontrollable, leading to the fatal crash (“Japan
Airlines 123 CVR transcript,” n.d.).
Relevant
human and organizational factors related to the accident
The maintenance engineers responsible
for the repairs made on the flight did not understand the fundamental mechanism
of load transmission and conducted faulty repairs. Additionally, the airline
representatives and air transportation authorities who should have identified
the mistakes during the inspection were unreliable. The site of the repair
mistake was covered with sealant (Hideo & Hiroyuki, 1985). However, with a
thorough inspection, the mistake would have been identified.
The
outcome of the accident
Japan airline flight 123 crash
involved the largest loss of life for any single air crash worldwide, where 520
lives were lost. The pilot sent out a distress signal that was picked up by
United States Air Force controllers at the Yokota Air Base, and transmission
with the flight was lost (Hood, 2013). The U.S. air force discovered the flight
90 minutes after the accident, but rescue was not attempted due to the
conflicts between the U.S. and Japanese air forces. Rescuers had great
difficulty reaching the crash site (Jackson, 1985) because of the harsh
conditions. The harsh conditions and lack of emergency medical assistance may
have caused the death of more passengers. According to (Jimbo, 1991), the
compensation amount to the affected families was not disclosed. Also, following
the accident, the company president resigned.
Risk
mitigation or Reduction strategies
Removing human factors in systems is
difficult. Accidents such as this are caused solely by human errors. Maintenance
operations and inspections are complex in the aviation industry and require
accuracy. To avoid such catastrophes and assure the public’s safety, rigorous
inspections should be done after major repairs have been completed to ensure
that the plane is in excellent operating order. Fundamental training and
education in areas such as mechanics of materials should be offered in detail,
even for the engineers on the site. Moreover, the authorities signing the
approval documents after repair should carefully check that all repairs are
correctly done. Also, operators should be supplied with tools to perform
experiments and test hypotheses to make acceptable performance limits visible.
Furthermore, minor and major plane
mistakes must be taken seriously regarding repair, upkeep, and upgrading. Also,
the rules and regulations of airline manufacturing businesses should be taken
into account while performing maintenance on an aircraft. It is essential to
hire a professional who can handle the installation and fabrication of parts
and ensure that all components are approved in case of the need to replace
airplane components.
Conclusion
The leading cause of the accident was
the mistake made during the repair of the bulkhead after the plane scraped the
runway. However, the direct cause of the airplane losing control is the loss of
the hydraulic control unit and the vertical fin. The repair work’s final check,
conducted by the airline’s representatives and air transport authority, was also
insufficient. In addition, maintenance engineers did not understand the
fundamental mechanism of load transmission. Many families suffered the loss of
their loved ones since most passengers were Japanese traveling to celebrate the
religious festivals of Obon. Being a fatal single plane crash worldwide, it
remained historical and a sore topic for everyone. The japan airline flight 123
was a jumbo jet used and trusted by many people, and concerns were raised after
the tragedy about whether the problem was common to the fleet. As a result, the
airline lost its credibility and took a long time to recover from the incident.
It is difficult to eliminate the
human factor in some systems. However, errors that can lead to considerable
loss of lives can be controlled differently; for instance, hypothetical
analysis by operators to determine the performance and safety of a system. Inspections
in aviation can be crucial but achievable. Inspections regularly and every time
a plane undergoes repairs can make it easier for the authorities to detect any
fault. Before signing off a plane as viable for take-off, the authorities
should double-check to ensure no errors were made. In addition, thorough
inspections should be conducted on the planes before take-off to ensure the
safety of passengers. Large systems are often prone to fault and can cause huge
damages, but proper repairs, testing, and thorough inspections can minimize
casualties.
References
Administration, F. A.
(1985, August 12). Boeing 747-SR100 Japan Airlines Flight 123, JA8119.
Federal Aviation Administration. https://lessonslearned.faa.gov/ll_main.cfm?TabID=1&LLID=16&LLTypeID=0
Hood, C. P.
(2013). Dealing with disaster in Japan: Responses to the flight JL123 crash
(1st ed.). Routledge.
Jackson, H.
(1985, August 13). 524 killed in worst single air disaster. News,
sport and opinion from the Guardian’s U.S. edition | The Guardian. https://www.theguardian.com/fromthearchive/story/0,,1017027,00.html
Japan airlines
123 CVR transcript. (n.d.). Cockpit Voice Recorder Database. https://tailstrike.com/database/12-august-1985-japan-airlines-123/
Jimbo, T.
(1991, March 26). Boeing and JAL crash victims’ families settle
compensation suit. AP NEWS. https://apnews.com/article/90247f31aff0e8a4c8fb99eb7e90f77f
Kobayash,
H., & Terada, H. (2008). Crash of Japan Airlines B-747 at Mt. Osutaka




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