Air Transport Safety : A school english presentation has been given in 2007. It also talks about the crash of Tuninter Flight 1153 occured in August 2005.

1. 1
This presentation has been given in 2007 when I was a
student at the National School of Computer Science.

2. 2
AIR TRANSPORT SAFETY
By
National School of Computer Studies
English Course Professor : Mr. DAKHLAOUI Faysel
Group : II 1 C

3. 3
http://www.youtube.com/watch?v=lksDISvCmNI

4. 4
 THE PLAN
1. Why do aircraft accidents happen ?
 Human factors
 Aircraft reliability
 Weather and flight conditions
A. Reasons
B. James Reason’s "Swiss Cheese" Model
 Companies
 The theory
AIR TRANSPORT SAFETY

5. 5
 THE PLAN
2. Example : TUNINTER Flight 1153
 Informations about the flight
A. Story Reconstruction
B. Investigation
 Design of the low level alarm
 Aircraft specifications : ATR-72
 Problem of interchangeability
 Crew qualification
AIR TRANSPORT SAFETY

6. 6
 THE PLAN
3. Other examples in Tunisia
 Sekorsky HH-3 helicopter : crash
A. Airforce accidents
 C-130 Hercules : take-off missing
 F-5 fighters : crashs
B. Civilian air transport accidents
 EGYPTAIR : crash of B-737
AIR TRANSPORT SAFETY

7. 7
 THE PLAN
4. Recommendations and conclusion
B. Conclusion
A. General recommendations
 The importance of air transport
 The low rate of accidents
 Studying air transport accidents
 Developing new systems
 Crew training
 Maintenance
AIR TRANSPORT SAFETY

8. 8AIR TRANSPORT SAFETY
 Introduction
 Nowadays, aircraft is the most important mean of
transport :
 Faster : higher speed and longer distance
 Efficient : hundreds of passengers and
tonnes of freight
 Safer : One accident for 1.000.000 flights
 Inspite of security mesures and defenses, accidents can take
place because of these following reasons :
1. Why do aircraft accidents happen ?

9. 9AIR TRANSPORT SAFETY
A. Reasons
 Human capabilities and limitations can influence
task performance and safety inside the aircraft cockpit
and within the maintenance environment.
A.1 Human factors
 Pilots, technicians and air traffic controllers are
often the principal actors of many tragedies because
of :
1. Why do aircraft accidents happen ?

10. 10AIR TRANSPORT SAFETY
A. Reasons
 Bad attitude towards work and colleagues
 Poor communication skills
 Etc …
A.1 Human factors
 Physical fatigue, tiredness …
 Insufficiency of technical knowledge
 Routine: same job, same tasks …
 Synchronization (time zone, date/night shifts)
1. Why do aircraft accidents happen ?

11. 11AIR TRANSPORT SAFETY
A. Reasons
 Systems failures : avionics, engines …
 Etc …
A.2 Aircraft reliability
 Problems of fuselage and structure
 Aircrafts not in accordance with regulations
 Problems of design and conception
1. Why do aircraft accidents happen ?

12. 12AIR TRANSPORT SAFETY
A. Reasons
 Problems with maintenance and spare parts
: Charter operators
 Etc …
A.3 companies
 High workload for pilots and technicians
 Incompetence of some directors : bad
decisions taken
1. Why do aircraft accidents happen ?

13. 13AIR TRANSPORT SAFETY
A. Reasons
 Precipitation, fog and ice
A.4 Weather and atmospheric conditions
 Engineers can never control the weather and
atmospheric parameters :
 Wind, wind shear, whirlwind : while take off,
approch or landing
 Problem of visibility and runway condition
1. Why do aircraft accidents happen ?

14. 14AIR TRANSPORT SAFETY
A. Reasons
A.5 Statistics
1. Why do aircraft accidents happen ?

15. 15AIR TRANSPORT SAFETY
B. James Reason’s "Swiss Cheese" Model
 A series of Human Factor problems form an error
chain. If any one of the links in this chain had been
broken the incident may have been prevented. It might
be done by building in measures/defenses, which may
not permit an error at one or more of the stages. A
good example is J.Reason’s ‘Swiss Cheese’ Model.
1. Why do aircraft accidents happen ?
B.1 The theory

16. 16AIR TRANSPORT SAFETY
1. Why do aircraft accidents happen ?
B. James Reason’s "Swiss Cheese" Model
B.2 J.Reason’s ‘Swiss Cheese’ Model – fig -

17. 17AIR TRANSPORT SAFETY
A. Story Reconstruction
2. Example : TUNINTER Flight 1153
A.1 Aircraft specifications : ATR-72
Capacity………………….....68
Length…………………27,17m
Wingspan……….…….27,05m
Height…………….……..7,65m
Maximum weight………..21,5t
Freight………………….….7,3t
Flight range…………. 2222km
Maximum speed…….516km/h

18. 18AIR TRANSPORT SAFETY
A. Story Reconstruction
2. Example : TUNINTER Flight 1153
A.2 Informations about the flight
 Saturday, 6th of August, near Palermo:
 During daily flight from Bari to Djerba, at
15:24 (local time) the crew of the flight 1153
(TUINTER) contacted Palermo for an
emergency landing.

19. 19AIR TRANSPORT SAFETY
A. Story Reconstruction
2. Example : TUNINTER Flight 1153
A.2 Informations about the flight
 The aircraft (ATR-72) had lost both engines.
 The crew tries to reach the nearest airoport.
But They did not make it to Palermo and ditched
in the sea around 15:40.

20. 20AIR TRANSPORT SAFETY
A. Story Reconstruction
2. Example : TUNINTER Flight 1153
A.3 Cockpit voice recorder CVR
 Captain: Please confirm the distance...
 Palermo ATC: 20…
 Captain: Please confirm the distance..
 Palermo ATC: The distance is 20 miles
 Captain: I think…we are not able, we
are not able to reach the terrain. We are
4.000ft and we are not able, we lose
both engines. Can you send us
helicopters or something like that?
Quick, quick, quick…
http://www.youtube.com/watch?v=6OnwwE1s1hg

21. 21AIR TRANSPORT SAFETY
A. Story Reconstruction
2. Example : TUNINTER Flight 1153
A.4 Casuality
Crew (total 4)……….victimes: 2
Pax (total 35)……..victimes: 14
Total on bord 39….victimes: 16
 Aircraft: during the ditshing, the
fuselage had been broken in several parts.
 Only the wings remains on the sea
surface.The rest falls in 12 meter depth.

22. 22AIR TRANSPORT SAFETY
B. Investigation
2. Example : TUNINTER Flight 1153
B.1 Friday 5th of august (end of the day)
 The crew noted on the LogBook that the FQI (Fuel Quantity
Indicator) had three dispaly-bars misfunctionning.

23. 23AIR TRANSPORT SAFETY
B. Investigation
2. Example : TUNINTER Flight 1153
B.2 The maintenance
 The technician asked the warehouse for ATR-72 FQI using a
special management software: AMASIS system.
 He didn’t find the right FQI but AMASIS system told him that an
ATR-42 FQI can be installed in place of the ATR-72 one

24. 24AIR TRANSPORT SAFETY
B. Investigation
2. Example : TUNINTER Flight 1153
B.2 The maintenance
 The technician did not check the compatibility of the ATR-42 FQI
in the ATR-72 documentation.
<< AMASIS program

25. 25AIR TRANSPORT SAFETY
B. Investigation
2. Example : TUNINTER Flight 1153
B.3 First error : Maintenance error
FQI of ATR72 & ATR 42
ARE NOT INTERCHANGEABLE.

26. 26AIR TRANSPORT SAFETY
B. Investigation
2. Example : TUNINTER Flight 1153
B.3 First error : Maintenance error
 After replacement of the FQI, the quantity of fuel indicated is
3050 kg, instead of 790 kg.

27. 27AIR TRANSPORT SAFETY
B. Investigation
2. Example : TUNINTER Flight 1153
B.4 Second error : Pilot error
 During preparion for flight 152F to Bari. An amount of 465 kg fuel
was added for the flight. 3800 Kg is indecated (real quantity is 1255
Kg).
 After landing in Bari, the FQI shows 2300 Kg. 1500Kg of fuel had
been consumed in stead of 1050Kg . The crew noticed this but does
not react.
 The A/C took off Bari with only 305 kg. 26Km north of Palermo the
fuel tanks are empty ( the indicator shows 1800Kg). The Captain tries
to joint the airport, but the A/C ditched near the coast.

28. 28AIR TRANSPORT SAFETY
B. Investigation
2. Example : TUNINTER Flight 1153
B.5 Third error : Design and conception error
 On the ATR Family, The Fuel Level Alarm : « LO LVL » is
depending on the FQI.
 The quantity of fuel computed by the FQI is erroneus
and the alarm had never been triggered.
TANK
WARNING

29. 29AIR TRANSPORT SAFETY
B. Investigation
2. Example : TUNINTER Flight 1153
B.6 Application of J Reason’s Model
Maintenance
Crew qualification
Design and conception

30. 30AIR TRANSPORT SAFETY
http://www.youtube.com/watch?v=tnRKp8d_0OQ

31. 31AIR TRANSPORT SAFETY
A. Airforce accidents
3. Other examples in Tunisia
A.1 C-130 Hercules : take-off missing
Date…..………..……….…April 1994
Location…….…Gafsa Airforce base
Accident…..………Take-off missing
Cause…………..…3rd engine failure
………………..…Pilot incompetence
..…Unit commander irresponsability
Damages…….Aircraft out of action

32. 32AIR TRANSPORT SAFETY
http://www.youtube.com/watch?v=fhxGn_MsDQo

33. 33AIR TRANSPORT SAFETY
A. Airforce accidents
3. Other examples in Tunisia
A.2 Sekorsky HH-3 helicopter : crash
Date…..………..……….…April 2002
Location……….…….…Mejez el Beb
Accident….…………………….Crash
Cause………………………Unknown
Damages…………+20 officers killed
…...Helicopter completely destroyed

34. 34AIR TRANSPORT SAFETY
A. Airforce accidents
3. Other examples in Tunisia
A.3 F-5 fighter : crashs
Date…..………..between 1990-2003
Location……….………Training zone
Accident….…………………...Crashs
Cause………………Engines failures
……………………..Hard manœuvre
………………………Pilots limtations
Damages…………+6 officers killed
…...Fighters completely destroyed

35. 35AIR TRANSPORT SAFETY
A. Airforce accidents
3. Other examples in Tunisia

36. 36AIR TRANSPORT SAFETY
B. Civilian air transport accidents
3. Other examples in Tunisia
 EGYPTAIR : crash of B-737
 7th of mai 2002, Tunis, while
starting the landing to Tunis
Cathage airport, the B-737
of EGYPTAIR hit the hill of Nahli
park.
 The visibility was very bad
and the pilot has forgetten to
adjust his altimeter.

37. 37AIR TRANSPORT SAFETY
B. Civilian air transport accidents
3. Other examples in Tunisia
 EGYPTAIR : crash of B-737
 14/62 passengers killed

38. 38AIR TRANSPORT SAFETY
A. Recommendations
4. Recommendations and conclusion
 Technology and new systems can improve the aircraft performance and
help pilots to take the right decision.
 companies should review its maintenace system and procedures.
 companies should review its monitoring procedures and training exercises.
 Aircraft crashs must be studied and analysed to correct anomalies in order
to avoid any futur accident.

39. 39AIR TRANSPORT SAFETY
A. Recommendations
4. Recommendations and conclusion
B-737 simulator>>

40. 40AIR TRANSPORT SAFETY
B. Conclusion
4. Recommendations and conclusion
 Inspite of accidents, the international air traffic is still growing and new
machines: powerful, larger, faster, more modern and sophisticated are under
production to transport passengers safely and smoothly : A-380, B-787
 If we believe in a future without accidents, we will be able to make the
air transport more popular, less expensive and more reliable.
 Aircraft crashs are not the result of one error but of several errors done
by the different actors of the accident.

41. 41AIR TRANSPORT SAFETY
4. Bibliography
 Documentary : « pourquoi les avions tombent? » arte
 Internet: www.airdisaster.com
 Documentary : FATAL DITCHING T-BRO production :
Part 1 : http://www.youtube.com/watch?v=Xvkdwnr1Anc
Part2 : http://www.youtube.com/watch?v=IIXKDUQHILM
Part3 : http://www.youtube.com/watch?v=aO_-GiJyJys

42. 42AIR TRANSPORT SAFETY
Thank You !