Aloha Airlines Flight 243
Aloha Airlines Flight 243 was a scheduled Aloha Airlines flight between Hilo and Honolulu in Hawaii. On April 28, 1988 a Boeing 737-297 serving the flight suffered extensive damage after an explosive decompression in flight; caused by part of the fuselage breaking due to poor maintenance and metal fatigue. The plane was able to land safely at Kahului Airport on Maui. The one fatality, a flight attendant, was ejected from the plane. Another 65 passengers were injured. The substantial damage inflicted by the decompression, the loss of one cabin crew member, and the safe landing of the aircraft established the incident as a significant event in the history of aviation, with farreaching effects on aviation safety policies and procedures. Nothing unusual was noted during the pre-departure inspection of the aircraft. Routine fuselage examinations were conducted during the night which made carrying out adequate inspection of the aircraft’s outer skin more difficult. During an interview one passenger told investigators that she noticed a crack in the fuselage upon boarding, but did not notify anyone.
During each flight cycle (takeoff and landing) the fuselage reacts the same way that a balloon does when it is filled with air; high stress when inflated, no stress when deflated. The fatigue strength of Aluminum is much lower than that of steel, and becomes a problem after 30,000 to 50,000 flight cycles. The manufacturer and operators of the aircraft were aware of the situation and had maintenance procedures in place to avoid failures. While the airframe had accumulated 35,496 flight hours prior to the accident, those hours included nearly 90,000 flight cycles (takeoffs and landings) which amounted to more than twice the number of flight cycles for which it was designed.
NO COMMON SENSE!
ANALYZE THE EXAMPLE
* Which supports and barriers were in play?
* What were the dynamics?
* Who, or what, won the Tug-of-War?
* Discuss the outcome with your friends and family.
* Use Post #4 as a reference for the dynamics and the relationships between supports and barriers.