Aircraft crashes

[Nev]

For a presentation at work I'm looking for a good example of an air crash that was caused by lots of little things going wrong, that all added up cause a major disaster. You know the kind of thing, 4 or 5 things that couldn't or shouldn't go wrong, all went wrong at the same time.

Thanks

[HOLMES]

In view of what is going on with the Malaysian airlines right now ( gone missing etc) I would say your phrase"looking for a good example of an air crash " might be a little inappropriate. ...

Have you Googled air crashes because you will find air crash reports from newspaper etc which will assist in your line of work for your presentation.

[PC12Driver]

<br />For a presentation at work I'm looking for a good example of an air crash that was caused by lots of little things going wrong, that all added up cause a major disaster.  You know the kind of thing, 4 or 5 things that couldn't or shouldn't go wrong, all went wrong at the same time.<br /><br />Thanks<br />

<br /><br /><br />

There have been several - but there was a crash of an Eastern Airlines L-1011 (I'm guessing) that crashed into the Everglades killing all aboard. The problem was one of the "gear down" indicator lights was not illuminated which would indicate an unsafe gear condition. The pilot, co-pilot and flight engineer were all looking down at the light and flipping through the manuals trying to solve the riddle. In the meantime, the aircraft was on autopilot (they thought - it wasn't) and "crunch". The problem was a burnt bulb which they could troubleshoot by swapping bulbs. But the MAIN problem is that nobody was flying the plane.

You'll have to google it. I think it occurred in the '80's. The recent Colgan Air disaster in Buffalo is well documented as to what was or wasn't going on in the cockpit. It was a tail-plane icing incident.

Hope thise help a little! Good luck!

Kevin

[Jim S]

Not to turn this in to an Airbus bash-a-thon but Air France 447 comes to mind.

Wikipedia page

Edited March 8, 2014 by Jim S

[spejic]

The television show "Air Crash Investigation" has lots of examples. You can try season 2 episode 5 (American Airlines Flight 965), season 9 episode 7 (Air Inter Flight 148), season 11 episode 1 (TAM Airlines Flight 3054), and season 13 episode 8 (XL Airways Germany Flight 888T)

[vince14]

Not to turn this in to an Airbus bash-a-thon but Air France 447 comes to mind.

Wikipedia page

For Nev's purposes, AF447 is probably too complex - you really need to understand how the Airbus systems work and have some understanding of crew psychology to make full sense of it. Reading Understanding Air France 447 is recommended.

As for the original question, I'd suggest Colgan 3407, Eastern 401 or Birgenair 301. There's also the Tenerife airport disaster, the world's worst aircrash, where small mistakes by both crews, ATC and weather factors resulted in two 747's colliding on the runway.

Vince

[White Wolf]

Two disasters which I think might answer the OP's question:

1. The mid-air collision near Zagreb in the late 70s between a British Airways flight and a Inex-Adria Airways flight.

2. The Mount Erebus disaster involving an Air New Zealand DC-10.

[Bonehammer73]

For a presentation at work I'm looking for a good example of an air crash that was caused by lots of little things going wrong, that all added up cause a major disaster. You know the kind of thing, 4 or 5 things that couldn't or shouldn't go wrong, all went wrong at the same time.

Thanks

I think most crashes are caused by this... the relevant ones that spring to mind are:

Air Midwest Flight 5481 crashed because of a combination of overload (due to the usage of official, but wrong, estimates of passenger and baggage weights), and an improper maintenance carried out on the elevators (the problem would've been spotted if the final check hadn't been skipped).

The crash of a sightseeing flight into Mt. Erebus in Antartica was caused by discrepancies between the flight plan, the coordinates entered into the flight computer, and the instructions received by the crew, compounded with weather conditions that didn't allow the crew to see the side of the mountain.

Korean Flight 801 crashed in bad weather after the pilot followed a spurious signal instead of the ILS. Other members of the creew remembered that the ILS was out of service and the plane couldn't be on the right glideslope, but couldn't make themselves heard by the tired captain. Other factors such as the use of outdated maps and warning settings at the airport also played a role in the accident.

Are you using the accident as a case history to promote defence-in-depth policies at work?

In my company we have a problematic foreman who, in spite of our customers introducing stricter and stricter safety rules, has an approach to work safety that would've been defined as 'lax' even fifteen years ago. No PPEs, hot work without permission, smoking wherever etc. This ultimately resulted in an accident that could've had serious consequences (we refer to it as "The Day We Almost Lost Venice"). While the management was debating about what to do with the guy, I asked for 20 minutes of their time and told them about the "Czar-52" crash and the events leading to it. It did a lot to help them make up their minds...

[streetstream]

To me the crash at Uberlingen comes to mind.

http://en.wikipedia.org/wiki/%C3%9Cberlingen_mid-air_collision

There are alot of small things that went wrong and if even one didn't happen, the collision could have been avoided.

1) The controller was working 2 stations instead of one.

2) He had no working phones available to alert a nearby airport that a plane was making a late landing this occupied alot of his time).

3) Due to the phones not working a controller at another location couldn't Phone in a warning.

4) The cultural differences in handeling orders (Russian crews are taught to listen to controllers and use TCAS as a aid. Western crews are taught to give priority to TCAS)

These were some of the factors to led to the collision.

[TheFlyingDutchman]

All (unintentional) crashes happen because of multiple factors happening at the wrong time. An airliner doesn't crash for one reason, as there should always be a redundant system, extra check or other safety net that avoids the whole thing happening. It's called the 'Swiss cheese cake model':

[Nev]

Thanks for the replies guys, I'll have a read of them later. My presentation is around the handling of road tankers carrying bulk solvents at the chemical factory where I work. The presentation I was given starts with the swiss cheese example but explains it really badly so I want an example everyone can understand.

[11bee]

Not sure this is of interest:

http://www.crm-devel.org/resources/paper/darkblue/darkblue.htm

On the surface, it was simply a case of a reckless pilot flying his B-52 into the ground. When looked at in detail, it's a fascinating (and tragic) case study of what happens when management permits a toxic atmosphere regarding Health & Safety to exist.

My industry has nothing to do with aviation and I've forwarded this document to my own H&S dept for use in management training.

[Don]

I will second the suggestion of watching "Air Crash Investigation". There is a list of examples featured in this program that will easily meet your needs/requirements. I know my cable package has the series (or various episodes) in the "On Demand" section, Netflix had the series not that long ago, and baring that, I am sure that YouTube would yield some results. Good luck with the project.

Happy modeling all!

Don.

[gonzalo]

The Pan Am and KLM 747 crash at Tenerife Islands is a good example. I think Air Florida crash into the Patomac river that had ice on the wings. The Avianca flight that rainout of fuel going to JFK.

[Jennings]

For a presentation at work I'm looking for a good example of an air crash that was caused by lots of little things going wrong, that all added up cause a major disaster. You know the kind of thing, 4 or 5 things that couldn't or shouldn't go wrong, all went wrong at the same time.

Almost any aviation accident fits your description. Unless it were a bomb (in which case you could still make the argument), it's always a bunch of small things that add up to disaster. Possibly the single best example recently was Air France 447 that crashed in the mid-Atlantic on the way from Rio to Paris. A comedy of errors. Another is the Asiana 777 crash at San Francisco last year.

[Johnopfor]

There have been several - but there was a crash of an Eastern Airlines L-1011 (I'm guessing) that crashed into the Everglades killing all aboard. The problem was one of the "gear down" indicator lights was not illuminated which would indicate an unsafe gear condition. The pilot, co-pilot and flight engineer were all looking down at the light and flipping through the manuals trying to solve the riddle. In the meantime, the aircraft was on autopilot (they thought - it wasn't) and "crunch". The problem was a burnt bulb which they could troubleshoot by swapping bulbs. But the MAIN problem is that nobody was flying the plane.

Kevin

The crash of flight 401 on Dec. 29, 1972. The interesting stories about the flight are not just the crash itself, the legends that grew out of it. The reported ghost sightings of two of the flight officers on other L1011's that reportedly received salvaged parts from Flight 401 and the reactions of Eastern Airlines are interesting tales on their own. It resulted in a popular book, and a rather bad TV movie, true or not.

[hawkwrench]

Try studying the comair crash at Lexington airport. Human factor, unsafe cockpit procedures, lights out because of runway construction. It was a culmination of different factors that led to the crash.

[Jinxter13]

Rather bad timing with relation to the Air Malaysia tragedy, but google the PAN AM Flight 103 747 that went down in Lockerbie, Scotland. No, aircraft crash is ever good, the locations however; can be. Such as it going down in a open field rather than in a city or town's residential or business area.

Edited March 9, 2014 by #1 Greywolf

[vvac201]

The cause of the DC-10 crash in Sioux City can be traced all the way back to the manufacturing of the fan disc.

[Bonehammer73]

My presentation is around the handling of road tankers carrying bulk solvents

First thing first, tell them to make sure the vent valves are open when they empty them... after that they should be fine.

[majortomski]

Pull up the NTSB report on John Denver's Long EZE crash. One of the most detailed light aircraft reports on file. But, speaking as a USAF trained mishap investigator, there is usually only ONE reason the airplane crashed or the accident happened.

Many of the things cited as "holes" in the swiss cheese example are contributing factors, not the actual cause of the crash.

I lost my favorite ROTC instructor on a KC-135 crash outside of KI Sawyer AFB:

http://www3.gendisasters.com/michigan/5019/alpena,-mi-military-air-tanker-crashes,-sep-1976

Contributing factors

SAC HQ team on the plane

Late departure

Problem with the heating system

Reason for crash Crew forgot to fly the plane. They were all working on getting the aircraft comfortable for the SAC team in the back.

First name on the list Maj. (F)rederic Wrinkle.