ATC TRANSCRIPT APPENDIX A Doubtful words are indicated by a series of question marks. The time signal is shown in brackets as it occurs in the sequence. There was a slight difference between the time signals at LATCC and Southampton (SOTON) but it was of no significance and has not been adjusted. The co-pilot was unable to hear the transmissions from LATCC during the descent and before he had slowed the aircraft to 150 kt at FL 110, due to the noisy cockpit environment produced by airflow noise and the captain flailing on the outside of the aircraft. To LATCC BAW 5390 LATCC BAW 5390 LATCC BAW 5390, LATCC BAW 5390 BAW 5390 From BAW 5390 LATCC BAW 5390 LATCC BAW 5390 LATCC BAW 5390 LATCC BAW 5390 Recorded Intelligence Mayday mayday - - London this is the speedbird five three nine zero mayday mayday mayd- Speedbird five three nine zero Roger mayday acknowledged out --=-227 797777 Speedbir- (0733) Er Speedbird five three nine zero er confirm acknowledge mayday Mayday mayday Er Speedbird five three nine zero London Control one three two d- decimal eight mayday acknowledged Speedbird five 92? 92? zero mayday mayday mayday ‘emergency depressurisation on a radar heading of one nine five descending to flight level one hundred Speedbird five three nine zero mayday acknowledged understand er descending flight level one zero zero on heading one nine five degrees (0734) Speedbird five three nine zero is maintaining one one ze10- Speedbird five three nine zero understand maintaining one one zeroTo LATCC PAA 34 PAA 34 LATCC BAW 5390 LATCC BAW 218 LATCC BAW 5390 BAW 5390 BAW 5390 LATCC DAN 231 LATCC From PAA 34 LATCC LATCC PAA 34 LATCC BAW 218 BAW 218 LATCC LATCC LATCC DAN 231 LATCC DAN231 Recorded Intelligence London from thirty four would you like us to try to relay thirtytwo eight Er it's okay Sir I think he may be receiving 2 What's that Thirty four er thanks all the same Sir And Speedbird five three nine zero how do you read now Sir (0735) Er London Speedbird two one eight good morning er we're descending to flight level two seven zero Speedbird two one eight good morning Sir make your heading now one one five degrees and continue descent, down to flight level one one zero to be level abeam Kenet - Speedbird two one eight radar heading one one five descend flight level one one zero to be level abeam Kenet ‘Speedbird five three nine zero London Control how do you read Speedbird five three nine zero London Control how do you read (0736) ‘Speedbird five three nine zero er London Control how do you read now Sir London Dan' two three one good morning flight level two nine zero direct to Berry Head Dan’ two three one good morning Sir maintain flight level two nine zero Maintaining two nine zero two three one A2To LATCC BAL 224A, LATCC LATCC. BAL 224A BAW 5390 BAW 5390 LATCC LATCC BAW 5390 BAW 5390 BAW 5390 LATCC BAW 5390 LATCC BAW 5390 From BAL 224A LATCC BAL 224A BAL 224A LATCC EIN 522 BAW 5390 LATCC EIN 522 EIN 522 BAW 5390 LATCC BAW 5390 LATCC Recorded Intelligence "Morning London Britannia two two four alfa at three one eight climbing three three zero direct Berry Head Britannia two two four alfa good momning maintain flight level three three zero on reaching S- two two four alfa wilco (0737) Britannia two two four alfa's reaching three three zero ‘Two two four alfa roger ‘Speedbird five three nine zero London one three two eight (0738) Er sorry station calling try again Er London the speedbird five three nine zero's having problems 22? 27? 722 777 five three nine zero do you read ‘Speedbird five three nine zero read you strength five Sir go ahead now Five three nine zero go ahead Five three nine zero go ahead London reading you London this is speedbird five three nine zero this is er speedbird five three nine zero ‘Speedbird five three nine zero London Control one three two decimal eight I hear you strength five Sir go ahead now Roger Sir we have had an emergency depressurisation and er requesting radar assistance please for the nearest airfield (0739) Er speedbird five three nine zero roger can you accept landing at Southampton ASTo LATCC BAW 5390 LATCC BAW 5390 BAW 5390 LATCC BAW 5390 BAW 5390 LATCC LATCC BAW 5390 From BAW 5390 BAW 5390 LATCC BAW 5390 BAW 5390 RYR 506 LATCC RYR 506 BAW 5390 LATCC Recorded Intelligence Speedbird er five three nine zero I am familiar with Gatwick would appreciate Gatwick Er speedbird five three nine zero roger if you make a left tum now Sir direct to Mayfield - nine zero if you can er direct me into Southampton affirmative Okay Sir would you prefer Southampton or Gat- er Gatwick Er Speedbird five three nine zero confirm you wish to route now to Southampton Speedbird five three nine zero er we have (fuselage) sory (heads down) - speedbird five three nine zero - Iam maintaining one one zero I am at er one fifty knots requesting radar assistance into Southampton ‘Speedbird five three nine zero roger er standby Sir (0740) And speedbird five three nine zero if you er commence descent Sir down to flight level seven zero initially Descend seven zero five three nine zero ‘London the Ryanair five zero six standing by for descent Sir Five zero six roger cleared down to flight level one one zero level er by Kenet - leaving two one zero for one one zero to be level by Kenet five - five zero six Confirm height cleared to Er speedbird five three nine zero you're now cleared down to flight level seven zero if you make one left hand orbit in your present position please Sir be handing you off very shortly 0741) A4To LATCC BAW 5390 LATCC BAW 5390 BAW 218 LATCC EIN 602 LATCC EIN 522 LATCC RYR 506 LATCC BAW 5390 LATCC From BAW 5390 LATCC BAW 5390 BAW 218 EIN 522, LATCC BAW 5390 RYR 506 Recorded Intelligence Cleared to seven zero speedbird five three nine zero ‘Speedbird five three nine zero continue now with London Control frequency is one three four decimal four five they will see you into Southampton - four four five thanks very much Bye Speedbird two one eight report your heading now to London Control frequency is one three two decimal zero five good day One three two zero five with heading speedbird two one eight good day ‘Shamrock six zero two contact London Control one three three decimal four five good day - Three four five Shamrock five two two contact London one two seven decimal seven good day ‘One two seven seven five two two (0742) Ryanair five zero six make your heading now zero nine five degrees This is ?7? 22? 72? nine zero descending out of eight zero for seven zero - no if you could hold on if you could hold onto him Er speedbird five three nine zero roger remain on this, frequency then Sir and I will give you radar vectors into Southampton - Er London confirm radar heading zero nine zero for Ryanair five zero six ASTo RYR 506 LATCC LATCC BAW 5390 BAW 5390, LATCC BAW 5390 LATCC BAW 5390 LATCC BAW 5390 LATCC BAW 5390 BAW 5390 LATCC BAW 5390 LATCC From LATCC RYR 506 BAW 5390 LATCC. LATCC BAW 5390 LATCC BAW 5390 BAW 5390 LATCC BAW 5390 LATCC LATCC BAW 5390 LATCC OORDL Recorded Intelligence Five zero six make it zero nine five please Zero nine five for Ryanair five zero six Descending to seven zero Sir Five three nine zero roger confirm you wish to remain on this frequency ‘And speedbird five three nine zero continue descent now down to four thousand feet London it's speedbird five three nine zero Speedbird five three nine zero how do you read now sir Roger reading you er strength five I'm afraid er we have some er debris in the flight deck and er could you confirm. the frequency you changed me to (0743) (Okay sir if you remain on this frequency sir and continue descent down to four thousand feet please Four thousand feet on QFE confirm QNH confirm Affirmative sir What is the QNH five three nine zero Standby sir ‘And speedbird five three nine zero if you check that now on er frequency one three one decimal zero Southampton approach One three one decimal zero bye bye Bye London oscar oscar romeo delta lima good morning A6To OORDL OORDL SOTON BAW 5390 LATCC BAW 5390 SOTON BAW 5390 BAW 5390 LATCC BAL 224A, LATCC SOTON, BAW 5390 SOTON From LATCC LATCC BAW 5390 OORDL, LATCC BAW 5390 LATCC LATCC BAL 224A LATCC BAL 224A BAW 5390 SOTON, BAW 5390 Recorded Intelligence Oscar oscar romeo delta lima good morning sir maintain flight level eight zero and you can set course from your present position - ~ Direct for the bravo romeo india - Five three nine zero do you read Five three nine zero read you strength five sir Oscar delta lima maintaining eight zero and proceeding direct er bravo romeo india Er speedbird five three nine zero how do you read now sir (0744) ton it's speedbird five three nine Z - Speedbird five three nine zero read you strength five go ahead with your message Speedbird five three nine zero Er London it's britannia two two four alfa er speedbird five three nine zero's now talking to Southampton on er one three one zero Two two four alfa roger thanks a lot sir ‘Thank you (0745) Southampton this is speedbird five three nine zero do you read (0744) Speedbird five three nine zero good moming identified on hand over London radar six miles to the west of ‘Southampton airfield what is your passing level Roger sir presently leaving flight level six four could you confirm er your QNH please ATTo BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 BAW 5390 BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON From SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON SOTON SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 Recorded Intelligence Roger my QNH one zero one nine millibars the runway in use is runway zero two the wind is three five zero degrees at twelve knots Roger sir I am not familiar with er er Southampton I request ‘you shepherd me on to the runway please (0744:30) Roger that is copied roll out then on to a heading of one eight zer0 Radar heading of one eight zero speedbird five three nine zero Five three niner zero what is your passing level Passing level size zero for four zero sir ‘Thank you and what is your number of persons on board We have eighty four passengers sir and er I think that will be all until we're on the ground (0745) Roger that's copied And we've been advised that it's pressurization failure is that the only problem Speedbird five three nine zero turn left heading one one zero ‘Tuming left one one zero speedbird five three nine zero Five three nine zero we've been advised it's pressurization failure is that the only problem Er negative sir the er captain is half sucked out of the aeroplane I understand I believe he is dead (0745:30) Roger that is copied Er flight attendant's holding on to him but er requesting ‘emergency facilities for the captainI I I think he's dead ASTo BAW 5390 SOTON, BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON GBS From SOTON, BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON GBS SOTON Recorded Intelligence Roger that is copied continue your descent then at two thousand feet QNH one zero one niner make it a nice gentle ‘tum at the moment you're seven miles southwest of the airfield Five three niner er five three nine zero that’s affirm that’s er ro-radar heading one one zero descending to two thousand feet Affirm what is your passing level (0746) Tm leaving flight er five thousand five hundred feet on ten nineteen Roger that's copied give you a little bit more space then tum right on to a heading of one eight zero ‘Turing right onto one eight zero speedbird five three nine zero could you please confirm the er the length of your runway at Southampton is acceptable for er a One-Eleven (0746:30) Yes it is acceptable for a One-Eleven and I'll just give you the figures very shortly Eras long as we have er at least two and a half thousand metres Tam happy Er afraid we don't have two and a half thousand metres neither do Bournemouth we have a maximum of eighteen hundred metres Five three nine zero that is acceptable Roger that is copied Bravo sierra sorry to interrupt we're at Hurst Castle (0747) ‘Thank you bravo sierra contact Bournemouth frequency one one nine decimal six two ADTo SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON UKA 455 From G-BS SOTON, BAW 5390 SOTON, BAW 5390 SOTON BAW 5390 SOTON, BAW 5390 SOTON BAW 5390 SOTON, BAW 5390 SOTON BAW 5390 SOTON Recorded Intelligence ‘One one nine six two thank you Speedbird five three niner zero what is your passing level ‘Speedbird five three nine zero passing level er three eight fifty ‘Thankyou very much continue descent altitude one seven zero zero feet QNH one zero one niner if I turn you in now you will have fourteen miles is that sufficient Give me twenty miles speedbird five three nine zero descend to er confirm level clear to (0747:30) ‘One seven zero zero feet Cleared to seventeen hundred feet on QFE Er QEE one zero one seven now ‘QFE one zero one seven speedbird five three nine zero Five three nine zero commence a gentle left tum now then ‘onto a heading of three six zero Tl give you twenty track miles to run for touchdown (0748) Roger sir do you have an ILS frequency Er negative I have a VOR but it will be radar vectors onto the visual final Five three nine zero thank you very much we are three greens er and flaps forty five so I'm set up for an approach but make it please very gentle Yes I will do indeed you are number one in traffic Five three nine zero thank you Air Ukay four five five are you with me A-10To SOTON UKA 455 SOTON UKA 455 SOTON SOTON SOTON BAW 5390 SOTON UKA 455 SOTON MAQ422 SOTON MAQ 422 From MAQ422 SOTON UKA 455 SOTON UKA 455 MAQ422 BAW 5390 SOTON BAW 5390 SOTON, UKA 455 SOTON MAQ 422 SOTON, Recorded Intelligence Southampton er good morning this is Mac Air four two two er five zero level er holding over hotel romeo november (0748:30) Air Ukay four five five Southampton ‘Yeah we're finally levelling six zero on one two zero ‘Thank you very much turn right now own navigation for Ontac Ontac ukay four five five request level change one two zero Southampton er good morning mac air four two two five thousand and we're er hotel romeo november (0749) Speedbird er five three nine zero heading er turing er left onto a heading of due north and levelling er eighteen hundred feet ‘Thank you make that one seven zero zero feet on the QFE one zero er one seven millibars turn right heading zero two five final approach Descending on to seventeen hundred feet and tuning right onto zero two five er speedbird five three nine zero (0749:30) Ukay four four four five five contact London frequency one three four four five ‘One three four four five cheerio Mike alfa kilo four four two descend altitude two five zero zero QNH one zero one niner Leaving zero five zero to twenty five hundred feet one zero one niner mac four two two Four two two contact Bournemouth frequency one two five decimal six bye bye AllTo SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON, BAW 5390 BAW 5390 SOTON BAW 5390 SOTON From MAQ422 SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON SOTON BAW 5390 SOTON BAW 5390 Recorded Intelligence ‘Two two now to one two five point six so long Speedbird five three nine zero is nine miles from touchdown you are clear to land the wind indicates zero two zero degrees one four knots descend to height one five zero zero feet on the QFE one zero one seven Roger sir descending to fifteen hundred feet talk me me down all the way Ineed all the help I can get Roger that is copied ‘We're running on a heading of zero two five five five three nine zero Roger and er you will be able to stop on the runway to evacuate the aircraft on the runway you are number one you are clear to land (0750:30) Five three nine zero thank you very much ‘Your range now is seven miles from touchdown you're on the extended centreline Five three nine zero thank you very much guidance all the way please Of course ‘Your range now is at six and half miles you are clear to land you are on the final approach track Five three nine zero (0751) Five three nine zero turn left five degrees you are five miles from touchdown continue your descent at the recommended rate for a three degree glide path (0751:30) Roger sir if you can er understood AlTo BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON, BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON From SOTON, BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 SOTON BAW 5390 Recorded Intelligence ‘You need not acknowledge further instructions unless requested it will be an interrupted talk down but fee! free to interrupt if you need to you are clear to land four and half miles on the final approach track heading zero two zero Emergency facilities er facilities please er and the ambulance Everything is available for you Er five three nine zero thank you ‘Your range is four miles your height should be one two five zero feet and the wind is zero two zero degrees at one zero knots (0752) Five five five three nine zero thank you ‘Three and a half miles from touchdown turn right three degrees on the final approach track heading is good Five three nine zero thank you very much ‘You're lined up you are clear to land Five three nine zero ‘You are three miles from touchdown the height should be nine five er zero feet on a three degree glide path you are lined up you are clear to land (0752:30) Five three nine zero thank you er I have the runway in sight ‘Thank you and you are clear to land do you wish me to continue with further information Negative Roger remain on this frequency Five three nine zero Al3To From Recorded Intelligence BAW 5390 SOTON Speedbird five three nine zero fantastic approach you may shut down on the runway and leave the frequency SOTON BAW 5390 Five three nine zero thank you A-l4APPENDIX B BIRMINGHAM INTERNATIONAL AIRPORT - LAYOUTAPPENDIX C POR ag EE 35 DAY SHIFT PATTERN - Part 1 ClSa 35 DAY SHIFT PATTERN - Part 2 C2APPENDIX D QUALITY MONITORING SCHEDULE PRODUCT SAMPLE (AIRCRAFT ON-LINE AND MINOR CHECK) This Form is to be used when applying the Quality Monitor Schedule EDP-MON-01-01 Appendix B item 01. 1 2 21 2.2 2.3 24 25 2.6 27 2.8 2.9 2.10 Cleanliness: Check areas and assemblies Condition: check the following for general condition:- External airframe and attachments Wheel Bays and assemblies Service Centres/Equipment Bays Engines Interior Furnishing Flight Deck Galleys Toilets Emergency Equipment Decals/notices/documentation Rectification standards monitor: Select 3 defects actioned during this input and ‘monitor for recurrence and number of further rectifications required to effect a cure over a minimum of 7 days in service. Record the number of recurrences for each defect. Reference defects and highlight by SecvLog/Defect NO. (The information should be obtained from DISC) and attach to Product Sample. Functioning: Select specific systems for Test/Part Test to be conducted in accordance with the M.M and in conjunction with Authorised staff. ATP/Work shects: Manuals, worksheets and Technical Logs selected for check on amendment state, condition, location, accuracy, legibility, eligibility. Work carried forward: Current record of ADD and DDA.APPENDIX E New 10 UNF Comparison of bolt heads in countersinks (shown approximately 1.9 life-size)APPENDIX F PSYCHOLOGIST'S COMMENTS ‘The human factors issues raised by the fitting of incorrectly sized bolts to the windscreen of this aircraft may be roughly categorised into those directly associated with the individual who carried out the work, and those associated with the system or environment within which he operated. These factors are considered in tum. Factors Associated with the Individual ‘The errors made by the Shift Maintenance Manager in fitting the windscreen may be listed as follows: a, _ He failed to adopt the ideal procedure of identifying the type of bolt required by reference to the illustrated parts catalogue (IPC), and its location by reference to the stores computer. Instead he simply made a match that relied on his own perception of identity between a used bolt removed from the old windscreen and a new one from the parts carousel drawer. b. He failed to heed the storeman who told him words to the effect "They're 8Ds in that windscreen", and continued to make a perceptual match. c. _Inmaking the perceptual match, he accepted as identical two bolts that are different. d. He failed either to notice or to question the significance of the fact that the incorrectly fitted bolts left an abnormally large amount of countersink showing once they had been fitted. €. He noticed, when fitting a windscreen the following night that 8D bolts were being used to fit it, believed himself to have used 7D bolts the previous night, but, even so, failed to question the acceptability of his previous night's work. Perceptual Problems The above factors may be split into those in which he made what could be termed poor judgements or work practices and those that involve perceptual errors. Item c, the failure to identify the difference between the used 7D bolt and the new 8C bolt may reasonably be judged a perceptual error. ‘The Shift Maintenance Manager claims that he made this perceptual match accurately in the well lit stores area of the hangar, and noted that the used bolt matched with a new size 7D bolt. When he came to make the match in the poorly lit stores of the international pier area, however, he was content that the used bolt matched a new size 8C bolt. He claims that he made the discrimination in terms of both sight and touch. He held both bolts between the forefinger and ‘thumb of one hand while rolling them between the forefinger and thumb of the other. Fl“The subjective similarity of these bolts may not be defined without some form of experiment: it is fair to suggest, however, that they are similar, but not so similar that they cannot be distinguished with reasonable care. The Shift Maintenance Manager does make limited use of reading glasses, which appear to be of a fairly weak prescription, but does not habitually use them at work and was not wearing them on this occasion. Given the poor quality of lighting in the pier area stores, he cannot be regarded as having been in the best visual environment or possessing the best visual equipment for making a visual discrimination that required some degree of acuity. Item d above may also be regarded as a perceptual error if he failed to perceive that there was more countersink than normal showing around the heads of the 8C bolts. It is possible, however, that he did notice this, but made what might be termed a poor judgement in not acting upon his awareness that the heads looked too far down the countersink. The latter possibility may be regarded as the more likely since, when one of his colleagues spoke with him after the accident, he claims that he remembered that the countersinks had appeared too big - ie, he had noticed extra countersink showing, but interpreted this in terms of an oversize countersink and not in terms of an undersize bolt. Although such an interpretation may seem extraordinary, it is well documented that individuals who generate an internal model of the world with which they are content often require overwhelming contradictory evidence before they are prepared to reassess their model. This tendency may well be exacerbated when the mental resources required for such reassessment are limited by, for example, sleep deprivation or circadian (time of day) effects. The effects of time of day on many physiological and psychological variables are heavily researched, the results indicating that the period between 0300 and 0600 is that during which human performance is at its lowest ebb. Itis likely that such time of day effects were important both in enabling the Shift Maintenance Manager to fail to make accurate perceptual discriminations, and in terms of enabling him to fail to appreciate the significance of cues with which he was presented. Direct circadian effects are compounded in this instance with some sleep deprivation. As is common among those on a first night shift, he had slept normally the night before his shift, but slept little during the afternoon before going on shift. Thus, at 0300- 0500 he would have had a significant requirement for sleep as well as being at his circadian low. These factors may reasonably be regarded as combining to exacerbate the effects described above, Problems of Judgement and Work Practice Items a, b, and e above may be regarded as problems of poor judgement or work practice. The Shift Maintenance Manager's failure to use the IPC and stores computer to their best effect, his failure to heed the storeman's identification of the bolts, and his failure to take any retrospective action when he realised the following day that he was using bolts of a different size from those he had used on the same job the previous day, lead to the conclusion that he was not working F2with the degree of care that the job demanded, What is less clear, however, is whether he was doing the job in a way that he regarded as being of a standard acceptable to the system within which he was working, or whether he knew that his work practices left a good deal to be desired, but chose to ignore this knowledge in the interests of expediency. ‘A.clue to the solution may be found in the Shift Maintenance Manager's other behaviour and in the opinions of his colleagues. A consistent picture emerges from such considerations. He appears to be regarded as solid and careful by others, and this assessment seems substantiated by his behaviour on the night in question. Although his shift did not start until 1030, he was at work 45 minutes early in order to prepare himself and to get the work of his shift organised. He also continued to work through his meal break. At interview he does not give the impression of one who would take his responsibilities lightly, or behave in a way that he would consciously appreciate as derelict. One is left with the impression that the Shift Maintenance ‘Manager behaved in a way that he felt was appropriate to the circumstances in which he found himself. Overall, his approach to the job could be summarised as conscientious but pragmatic, rather than conscientious and meticulous. A good example of this approach concerns his decision to torque the windscreen bolts to 20 Ibf in instead of the specified 15 Ibf in. He plainly did not do this as a matter of expediency, but because he felt that this was a better way to do the job. What was missing was an appreciation that such individual work practices are completely out of place in aircraft servicing. This impression is reinforced by conversation with other shift supervisors. At informal interview, these individuals gave the general impression of being free to tackle jobs in idiosyncratic ways, and when informed of the manner in which the Shift Maintenance Manager behaved on the night in question they did not (except one individual) regard this as unreasonable or demanding of censure. It does not seem unreasonable to suggest that the general climate in the maintenance facility at Birmingham was not one in which the care and safety awareness exhibited by the staff matched the criticality of the task. The nature of the maintenance operation at Birmingham and the setting and checking of operational standards is therefore examined below. ‘The Operating Environment Inspection A procedure included in many industrial operations that have safety implications is that of independent inspection of work. It is possible that independent inspection would have prevented this accident since the poor fit of the bolt heads in the countersinks was potentially observable. There are some more important general points that may be made about the utility of inspection in safety critical systems: a. _ Independent inspection does not have a small effect on the possibility of a maintenance error going undetected, but reduces it dramatically. If an individual operator has, say, a 01 F3chance of not noticing a fault, then the combined probability of two such individuals failing to notice the fault becomes only .0001. b. If an individual has made an error in work that he has carried out, then (because he has developed a perceptual "set") he is less likely to detect that error than an individual who comes to the task both afresh and in a "checking" frame of mind. c. The knowledge that work is to be inspected may change the approach of an operator to his task. It could be argued that the operator would become less careful if he felt that inspection would pick up his errors, and would make him feel less trusted and responsible. For individuals with some pride in their work, however, the knowledge that their work was to be inspected might well make them more careful since they would not wish to be found to have made a mistake. ¢. _ Inspection is likely to have a general effect on the individual operator's perception of the standards and care expected of him by the system. Inspection of work may serve as a regular reminder to operators that the work they carry out has safety importance, and must be carried out meticulously. It is likely that an operator will perceive the absence of inspection as an indication that the managers of the system regard the cost saving involved as more important than the safety benefit, and this may well influence the Shift Maintenance Manager's general approach to his task, tis thus suggested that inspection represents an important addition to the maintenance work practices evident in this accident, and that it is especially important for work carried out at night, when errors are more likely to be made, and less likely to be detected by their perpetrators. Lastly, it is interesting to note in this context that had this windscreen been changed in the Royal Air Force, not only would the work have been inspected, but the aircraft would have been pressure tested on the ground before flight. Maintenance of Standards in Working Practices ‘There appears to be a stark contrast between the procedures adopted to ensure that pilots adhere to standard operating procedures and to ensure that they are familiar with good working practice and those adopted for maintenance personnel. Although the maintenance environment is checked periodically to ensure, for example, the calibration of equipment and currency of technical information, there does not appear to be any checking of the knowledge of, or techniques used by, the engineers. In the absence of such checks, and in the apparent absence of any courses, instruction, or training designed to ensure that aircraft engineers appreciate the importance of standardised procedures, a meticulous approach to the job, and the consequences of error, it should not perhaps be regarded as surprising that experience and familiarity tend to dull the engineer's conscious appreciation of the critical nature of his task. F4It seems that the system operated at Birmingham relied entirely on the "professionalism" of individual shift supervisors to ensure that working practices were appropriate. Whereas it is zntirely right to expect a professional approach from such individuals, the wisdom of leaving the safety of aircraft entirely to individual judgement without having any systems for maintaining consistency or for checking that high standards are maintained must be questionable. Design Safety Itis obviously highly undesirable that this windscreen assembly should have been designed such that it could be fitted with bolts that were very similar to the correct ones, that could be inserted and engage with the anchor nuts, and yet which failed as soon as they were loaded. It is not asking too much for considerations such as this to be made during design, but the awareness that this type of problem is best obviated at the design stage was not widespread when this aircraft was conceived. It could also be argued that this windscreen should have been designed to be fitted as a plug from the inside of the aircraft - an obviously safe practice in a pressurised hull. Poor design is further evidenced by the fact that this aircraft was already fitted with the wrong bolts (7Ds instead of 8Ds) in the old windscreen. This is probably because the No 1 and No 3 windscreens are fitted with bolts of slightly different lengths, yet only the shorter bolt is actually illustrated in the IPC. It is difficult to believe that it would not have been easily possible for these windscreens to have been designed so that they were both fitted with the same size of bolt. “Vhen a new windscreen is fitted, it is customary for the engineers to fit new bolts only if those removed were damaged or paint clogged. The relative cost of bolts and windscreen might suggest, however, that it would not be unreasonable for new bolts to be fitted whenever a windscreen was changed. If this were so, the windscreen could be supplied as a kit with a set of correct bolts included. Tr may also be observed that, once the type of bolt used on this windscreen is removed from its packet, it carries no identifier, compelling it to be identified by its physical characteristics. It is possible that if its head were stamped with such an identifier (eg 8D), then the Shift ‘Maintenance Manager may have used this instead of relying on a physical comparison. Pia ine Ute King fo HMSO FS