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crash aero (Event sequence (National Transportation Safety Board, 1999)…
Event sequence (National Transportation Safety Board, 1999)
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Flight 427 entered a 6 mile radius of the destination airport, this air space was uncrontrolled
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All crew and passengers died on impact (132 people). the aircraft was completely destroyed due to the impact and fire which erupted on the ground
Why it happened?
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Meteorological information clear and visibility 5 miles ahead (National Transportation Safety Board 1999)
Report was same at 1852,1932 and 1952 pm
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System Parts
Rudder Control System
The 737-300 has a single rudder panel actuated by a single hydraulic rudder PCU (National Transportation Safety Board 1999)
A standby rudder actuator is available to move the rudder if hydraulic systems A and/or B
fail.(National Transportation Safety Board 1999)
The 737 main rudder PCU is capable of producing about 5,900 pounds(National Transportation Safety Board 1999)
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Issues
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Findings
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Flight 427 was also flying in another aircraft's vortex just seconds before the rudder system failed
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Reference: List Gonzales, C 2015, Machine design: what are human-machine interfaces and why are they becoming more important, viewed 18 July 2018, http://www.machinedesign.com/iot/what-are-human-machine-interfaces-and-why-are-they-becoming-more-important National Transportation Safety Board, 1999. Probale cause of US Flight 427, Washington : NTSB.CASA, 2011. Aircraft Control Cable System , Canberra : CASA Cockpit Voice Recorder Database , 2018 USAir 427. [Online]
Available at: https://www.tailstrike.com/080994.htm
[Accessed 16 09 2018]Woods, DD& Hollnagel, E 2006, 'Prologue: resilience engineering concepts', in E Hollnagel, DD Woods & N leveson (eds), Resilience engineering: concepts and precepts, Ashgate, Aldershot
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(Gonzales C 2015) Discusses the human and machine relationships which highlights why humans and systems need to improve together
(CASA 2011) Identified that rudder control system have in the past been installed and maintained which led to a new airworthyness procedure for maintainers
(Partto, M & Saariluoma, P 2011) The members from aogra highlight the errors which occur within the design process
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(Zimmerman J, 2014) Identifies distractions to be the biggest failure within the testing of control systems on board an aircraft
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