A Study of Maintenance Awareness in Desi PDF

MAINTENANCE AWARENESS IN DESIGN
MAINTENANCE ENG. & ASSET MGMT.
ABSTRACT
This paper would narrate and analyse about the case study of Alaska Airline Flight
261 crashed disaster in year 2000. The case study shows how the impact of the current
economic situation in 1990’s forced the Alaska Airline top management making decision to
changed many of their policies as before that can consider as unacceptable. The management
decision, no safety procedure, and engineering aspects elements (maintenance and design)
contributed to the root causes of the Alaska Airline 261 crashed. The writer will start the
introduction chapter by explain the topic that have been selected generally and summarize
the objective for the second chapter Case Study: Alaska Airline 261 Crashed. In the second
chapter, discussion will be more to understand the case study deeply. It starts with
introduction to the case which a short brief about the history of the aircraft crashed and also
the short explanation about the failure of the horizontal stabilizer trim system that caused the
Alaska Airline Flight 216 had crashed. Then, writer will narrate the background of the
tragedy in summary based on the Cockpit Voice Recorder database (CVR Database), the
conversation between the Alaska Airline Flight 261 pilots with the people had contacted by
them. It will make the illustration of how serious the situation and both of the pilots struggled
to save the aircraft, all crew members and passengers until the end of this even where this
aircraft involved in crashed disaster. For next, this paper explained about the investigation
done by National Transportation Safety Board (NTSB) after the crashed, what they had
found, followed by recommendation for the jackscrew assembly design that not have fail-safe
feature. Based on the investigation section briefing, writer then analyse the causes of the
Alaska Airline Flight 261 that brings the aircraft into the worse disaster with all died in the
crashed. Then, with using the cause’s analysis, Fault Tree Diagram (FTA), Reliability Block
Diagram (RBD), Failure Mode and Effect Analysis will develop and discussed about the
strength and limitation each of the concept/tool. Lastly, discussion and conclusion will
discuss overall in the last chapter.
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M.KALAM AZAT ABU BAKAR
UNIVERSITY OF MANCHESTER (2012/13)
1. INTRODUCTION
In the world today, as modern era with sophisticated and complex technologies in
many items associated with engineering field such as equipment, machines and transportation
etc, high reliability on that items is very and always essential due to coping with safety
matter. Indeed in spite of that, sometimes designer have overlooked about the other aspects
especially design. It is because, in order to design equipment, machines, transportation etc, it
is not only must be have a nice look (design shape), easy to maintainability and of course
high reliability system but the design must have fail-safe features. Indeed, a fail-safe feature
is one element in safety aspect that should be given more concern by designers. Below are
examples of aircraft design shape and the elements in design aspect that needed to consider in
implementation of aircraft design.
Aircraft Design Shape: Different views of an aircraft by designers

(John P. Fielding, 1999)
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Design elements for aircraft (John P. Fielding, 1999)
In this paper, writer chooses the topic: How Designer Learn from Failure? and Why
the System Fail? Writer will explain about an event related to this topic. A case study:
Alaska Airline 261 Crashed has been selected. This paper will view this case deeply to
achieve several objectives related to the topic.
The objectives that to be achieved is to brief to reader about:
Case Study: Alaska Airline 261 Crashed

1) Introduction to the case
2) Horizontal stabilizer trim system
3) Background of the tragedy
4) Investigation the failure
5) Recommendation for the jackscrew assembly design
6) Causes analysis of the aircraft crashed
7) Concepts and tools for failure analysis: FTA, RBD and FMEA
8) Strength and limitation of the concepts and tools used
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2. CASE STUDY: ALASKA AIRLINE 261 CRASHED
Introduction to the Case

In 31th of January 2000, one of the Alaska Airlines aircraft (flight 261), a McDonnell
Douglas MD-83, N963AS from Diaz Ordaz International Airport (PVR), Puerto Vallarta,
Mexico to Seattle-Tacoma International Airport (SEA), Seattle, Washington was crashed
during the flight journey. The aircraft had crashed in Pacific Ocean which is approximately
2.7 miles North Anacapa Island, California. The flight has 2 pilots, brings 83 passengers and
3 crew members. Unfortunately, no one was survived in the aircraft crashed. The crashed
were killed all 88 life and the aircraft was totally destroyed by high impact forces in the
tragedy.
The crashed tragedy caused by technical failure of the horizontal stabilizer trim
system on the tail of the aircraft. Based on the National Transportation Safety Board (NSTB),
the horizontal stabilizer jackscrew was jammed during the flight journey and the problem is
because of inadequate lubrication or no lubrication on it. Below shows the timeline and
location illustration where the Alaska Airline Flight 261 was crashed:
Alaska Airline Flight 261 crashed map and timeline

(NTSB Report, 2002)
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Horizontal Stabilizer Trim System

The horizontal stabilizer trim system on the Alaska Airline Flight 216 tail functioning
to control or adjust the angle of aircraft during flight. Below shows the diagram of the
system:
Horizontal Stabilizer Trim System
This system works by using motor to move the horizontal stabilizer jackscrew to
move up and down. How the concept of the system can control the aircraft angle are:
 When the horizontal stabilizer jackscrew moves up, the aircraft will move down.
 When the horizontal stabilizer jackscrew moves down, the aircraft will move up.
Retaining Nut
Jackscrew structure on the Horizontal Stabilizer Trim System

(source from TailStrike web)
The diagram above shows acme nut does not have any supporting follower nuts such
as redundancy system to ensure the safety even the mechanism has failure. The system was
jammed because of wear on acme nut thread. The pilots cannot control the system to move up
when their tried. When the acme nut already had totally moved down, it cannot to move up
again. The sequences from the problem at the time before the horizontal stabilizer trim
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system totally failure, the system only supporting by the retaining nut while the nut capability
is too low for supporting too much load. Consequences, the aircraft lastly crashed after the
retaining nut loose and disconnected from the acme screw. For the details about the
mechanism system, refer attachment [APPENDIX A: SCHEMATIC DIAGRAM OF
TRIM ACTUATING MECHANISM on page 26].
Background of the Tragedy
Time: 15.49.49 - 16.10.33

The pilots (Captain Ted Thompson and First Officer William Tansky) start realized the
horizontal stabilizer on the tail of the aircraft does not want to move. They tried to checking
standard checklist to free the horizontal stabilizer but did not work. At the time, they think the
problem is about faulty of electric motors that control the system. The pilot then activated the
primary electric motor but the system still does not moved. The captain considered the
system was jammed. Then, the captain decided to not use auto pilot. They start to control the
aircraft by manual. Then, the captain makes contact their airline maintenance department
asking about the system. The maintenance personnel in-charge said no history in past 30 days
and there is no advice from him to the pilots after 7 minutes. The pilots then tried switch on
the both of electric motor to control the horizontal stabilizer system. Suddenly, the aircraft
had turned down (first dive), both the pilot had struggled to control their aircraft and they
successful to stable the aircraft.
Time: 16.10.33 - 16.17.57

After that, the captain had contact Los Angeles Control Centre asking coordinate position to
find another space for troubleshooting the aircraft. The horizontal stabilizer totally jammed at
the time. The pilots just tried with fully effort anything they can do to save the flight. Then,
the captain contact back the maintenance personnel in-charge ask for helps, asking what they
should do because the pilots already tried everything. The already fully pull down the
horizontal stabilizer system but it does not want to going up again. The captain worried what
going to be happens if they try pulling down more the horizontal stabilizer system.
Unfortunately, feedback from the maintenance personnel in-charge was very bad, he just said
“if you wanna to try that ok for me, if not that find.” That is the last actions from pilots
struggle to save the flight. The maintenance personnel in-charge really does not concern
about the situation coping by both of the pilots.
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Time: 16.17.57- 16.19.43

Then, pilots tried to fix the aircraft even they did not know what going to be happens. It is
like crashed waiting to happen. Suddenly, the flaps tail broken and the final dive occurred.
The Alaska Airline Flight 261 crashed.
Sequence of Failure
(M05 In-Module-Assignment, 2013)
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Alaska Airline Flight 216 aircraft and flight info (source from SFGate web)
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Investigation the Failure

After the crashed tragedy, investigation had been implemented by NTSB. The
investigation implemented by NTSB collaborate with Federal Aviation Administration
(FAA) starting with listening to the Cockpit Voice Recorder Database (CVR Database),
finding the technical failure root cause (the failure of horizontal stabilizer trim system) and
finding all matters that relating which brings to the causes for the system became failed.
Many factors found from the investigation as the clues for the cause that brings the Alaska
Airline Flight 261 into the crashed disaster on 31th of January 2000. The findings from the
NTSB investigation are:
 The problem or failure during the crashed is on tail of the aircraft (horizontal
stabilizer trim system). The jackscrew was jammed.
 Not have SOP for coping failure of jackscrew in quick reference book in the aircraft
that the pilots have.
 No training for the pilots to coping on that problem and situation. Moreover, the
situation never occurs before the tragedy.
 There is no lubrication (no grease visible) on the working area of the jackscrew. That
is very surprising them because that is the only way or reason to make the acme nut
wearing then the functioning of the jackscrew failure.
 Then, FAA immediately checked on all MD-80 aircraft in USA at the time during the
Alaska Airline Flight 216 crashed, FAA have shocking discovery the 6 fleet of 34
aircraft should be replace by new jackscrew assembly after failing on the inspection.
 From the maintenance records, some of the work had been altered done, even the
work does not performed by them. This is because the pressure to keep their aircrafts
flying more intensively.
 In early 1990, economic had down, the Alaska Airline top management making
decision to cutting cost to revise their company fortune. Furthermore, Alaska Airline
at the time well known as one of the most successful American airline company. The
worst things are the decisions influence them to change their maintenance
program/procedure.
 In 1999, one year before the crashed FAA also had checked the company; Alaska
Airline did violation many FAA rules and regulations. They changed company
maintenance safety procedure. The result from that, two supervisors had been
suspended caused by falsifying records.
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 John Leo teams had important clue why the Alaska Airline Flight 216 crashed. He
was the Lead Mechanic at the Alaska Airline and works over eight years. Over the
two years before at the aircraft last overhaul, he had order new jackscrew assembly
on the particular aircraft under his responsible but then he was off shift from works.
From the investigation found:
 Alaska Airline had overruled the recommendation by John Leo teams by the
next shift teams. The worse thing is they put back the aircraft into flying
service.
 It was two and half years before the next overhaul on the jackscrew.
 Unfortunately, two months before the next overhaul, the Alaska Airline Flight
216 was crashed.
 Besides, the decision about cutting cost by top management makes them extend the
interval time for the jackscrew assembly service.
 Every parts design including jackscrew assembly was stated when it should
be service or replace.
 In 1996, Alaska Airline extended the interval service time for lubrication for
the MD-80 aircrafts by 40%.
 From the 1600 hours after flying, the jackscrew must be service with new
lubrication before, but starting on 1996 Alaska Airline changed to the 2550
hours after flying without notifying FAA. Below shows the changed had
made by Alaska Airline and comparison as suggested by manufacturer:
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Comparison between manufacturer recommended and Alaska Airline for jackscrew

lubrication service interval time (NTSB Report, 2002)
Extend the maintenance service interval time is the significant contribution and the
main reason behind the Alaska Airline Flight 261 was crashed. It is because that is the only
way (follow the maintenance on jackscrew assembly as scheduled) to ensure safety of the
aircraft. Other than that, the original maintenance also stated the inspection must be
performing after 600 flight hours and replace every 2000 flight hours. With following all of
the original maintenance scheduled and rules will ensure the jackscrew assembly working
properly without fail. So, that is the reason why the designer did not add additional
redundancy nuts to support acme nut on jackscrew assembly.
Recommendations for the Jackscrew Assembly Design

After all the investigation, many causes had been discovered by NTSB that brings to
the failure of the jackscrew assembly acme nut on the horizontal stabilizer trim system on
Alaska Airline flight 261 on 31th January 2000. This is the root cause (technical root cause –
acme nut thread wear) for the crashed disaster. The jackscrew acme nut does not have other
redundancy nuts or follower to supporting it if the failure like this case happens. So, even the
jackscrew assembly was failed (jammed), the aircraft crashed can be avoided if the design of
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the jackscrew assembly had redundancy nuts or follower to supporting it. Therefore, the
design considered as not fail-safe. After the Alaska Airline Flight 261 crashed tragedy, the
new design of the jackscrew assembly was proposed. The new design shown below:
Old and new proposed design of the jackscrew assembly
Actually, the design proposed was already made by NASA two years prior to the
crashed tragedy. In 1998, engineers at NASA’s Kennedy Space Center (KSC) were made
aware of the consequences of possible jackscrew failures during an incident involving the
gaseous oxygen (GOX) vent arm (C.G.W. Schnedler, Daniel Murphy, S.J. Stumpp,
Frantz St. Phar, 2007). Even though it had already been prepared for the next launch,
technicians at KSC decided to perform an additional test to verity proper arm alignment with
the external tank (ET) (C.G.W. Schnedler, Daniel Murphy, S.J. Stumpp, Frantz St. Phar,
2007). During the test, the jackscrew nut threads sheared and the GOX hood fell from its
position (C.G.W. Schnedler, Daniel Murphy, S.J. Stumpp, Frantz St. Phar, 2007). If the
failure had occurred on the next planned cycle, severe damage would have been sustained by
the shuttle vehicle (KSC Support) (C.G.W. Schnedler, Daniel Murphy, S.J. Stumpp,
Frantz St. Phar, 2007).
But this is weird matter and raises doubt, why the manufacturer did not want to produce
the design for the aircraft industry. It is because the design already had since 1998 after
NASA’s Space Kennedy Centre developed it. Several reasons had been answered why the
manufacturer of jackscrew assembly did not change and produce the design:
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1) After devising the new assembly, this same task force was charged with determining
whether a commercial market existed for the improved design. They quickly found
that the pressures for economic performance constantly at work in commercial
industries led only one of the manufacturers contacted to indicate a desire to consider
licensing the improved design (C.G.W. Schnedler, Daniel Murphy, S.J. Stumpp,
Frantz St. Phar, 2007).
2) The majority of companies producing jackscrews and ballscrews were not interested
in safety technologies for jackscrews… No market drivers are apparent…” (KSC
Assessment, 2001).
3) The major jackscrew manufacturers… (did not solve) the problem because they did
not recognize it as their problem… Sentiments (were heard) that (the manufacturers)
produce the jackscrew and the user must maintain it, and if the recommended
maintenance procedures are followed then failure is unlikely” (KSC Assessment,
2001).
For details and other fully recommendations by NTSB, refer attachment [APPENDIX B:
NTSB RECOMMENDATIONS on page 27].
Causes Analysis of the Aircraft Crashed

After the writer had been reviewed from many sources such as reports, articles,
websites, etc on this case study, based on that and the investigation evidence as explained in
the section before (Investigation), writer will make summarization about the causes or factors
by sequentially which brings the Alaska into the crashed disaster.
From the investigation evidence, the causes of this Alaska Airline Flight 216 crashed are:
1) Management Decision
In 1990, economic was decline at the time and the top management of the Alaska
Airline company starts making decision for cutting cost to revise their fortune. At
the same time the maintenance department had been pressed to keep flight flying
more intensively. This is all about money and profits due to coping with the
economic situation on that time. The worst thing is, both of these matters caused the
management change their maintenance program (extend service interval time on
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jackscrew) without notifying FAA. They neglected about the important maintenance
aspect that can ensure the safety of their aircrafts and passengers.
2) Safety Procedure
During the tragedy, the pilots did not know exactly what they should do. They just
struggle tried the best with their knowledge and experienced to save the flight. There
is no Safety/Standard Operation Procedure for horizontal stabilizer trim system
failure in their quick reference book in the aircraft. The pilot also had contact the
maintenance department asking what they must do in the critical condition but the
personnel in-charge did not give good feedback and answer. Besides, there is also no
training provided by the company to their pilots to coping the failure of the
system. Even they did not receive any training to cope on that situation, they still can
save the flight if the SOP provided in the pilot quick reference book to handle the
aircraft during the failure of the system.
3) Engineering
Engineering causes can be divided into two categories which is:
 Maintenance
The failure of the Alaska Airline Flight 261 jackscrew assembly during the
travel was considered inadequate lubrication or no lubrication by the
investigation teams. During the discovery of the aircraft’s wreckage after the
crashed, there is like no grease on the jackscrew. The investigation team
conclude it is because improper lubrication on jackscrew. The other reason
why the aircraft crashed is due to the schedule maintenance not
implemented as recommended by manufacturer of the jackscrew. Both of this
causes is related to the management decision where can concluded sequences
as below:
1) Management Decision: (1)Cutting cost to revise fortune and
(1)keep flight flying more intensively make them (3)extend
service interval time on jackscrew.
2) Management Decision: (3)Extend service interval time on
jackscrew creating situation which the (7)schedule maintenance
not implemented as recommended by manufacturer and thereby
creating possibilities the implementation of improper lubrication
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on jackscrew. This is the reason why the aircraft had crashed. It is

because that is the only way to prevent the failure of the acme nut
on jackscrew is with following the schedule maintenance as
recommended by manufacturer.
Discovery of the aircraft’s wreckage after the crashed:

almost no visible grease (NTSB Report, 2002)
 Design
The jackscrew design is not fail-safe. There is no the features in the design
on the jackscrew. It is because the manufacturer producing the jackscrew
including with the recommended maintenance schedule for their customers
such as service interval time for the jackscrew (inspection, lubrication and
replacement). Maintenance recommended by the manufacturer also stated the
inspection must be performing after 600 flight hours and replace every 2000
flight hours. The jackscrew will not fail if all the recommendations followed
by them. Unfortunately, Alaska Airline extended the lubrication service
interval time and also did not follow the recommended inspection and
replacement interval time on the jackscrew by the manufacturer. This is the
way for the acme nut jackscrew becoming to fail and when it had failed there
is no redundant/follower nuts to support it. Consequently, the Alaska Airline
Flight 261 was lost of aircraft pitch control and then crashed.
Therefore, the both questions related to this paper topic which is How Designer
Learn from Failure? and Why the System Fail? have been answered in this section. The
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designer must design their product including fail-safe feature and must always allocating the
feature as the main and first element on their design. The system of the horizontal stabilizer
trim failed caused by the wear of the jackscrew acme nut because of many factors
(Management Decision, Safety Procedure and Engineering; Maintenance and Design) that
brings the Alaska Airline Flight 261 crashed which is had been discussed above.
Based on analysis and summarization about the causes of Alaska Airline Flight 261
crashed in this section, the Fault Tree Diagram (FTA), Reliability Block Diagram (RBD) and
Failure Mode and Effect Analysis (FMEA) will develop and shown on the next section
(Concept and Tools for Failure Analysis).
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Concept and Tools for Failure Analysis

Fault Tree Analysis
1 2 3 4 5 6 7 8
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Reliability Block Diagram
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Failure Mode and Effect Analysis
Potential Failure Potential Failure Potential Effects Existing Conditions

Mode Causes of Failure Current Controls O S D RPN
(Mode) (Causes) (Effect)
A. Management
Decision
1.Cutting cost Economic impact Reduce budget on No, caused by economic 1 10 5 50

maintenance etc impact
Neglected safety aspect in

maintenance
2.Keep flight service Economic impact + desire Pressure on maintenance No, caused by economic 1 8 5 40
intensively to get profits department/personnel impact and the decision had
made by top management
Improper maintenance on
aircraft
3.Extend service Cutting cost + to keep Improper maintenance No, caused by economic 5 10 5 250
interval time on flight service intensively service for aircraft (e.g.: impact and the decision had
jackscrew decision jackscrew assembly made by top management
improper inspection,
lubrication, replacement)
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B. Safety Procedure
1. No SOP Not provide by company Pilot will not know exactly No, company not providing 1 10 10 100
how to cope with failure any SOP for coping on
situation + aircraft crashed horizontal stabilizer trim
if fail to cope. system fail situation.
2. No training Not provide by company Pilot will not know exactly No, company not providing 1 10 10 100
how to cope with failure any training for coping on
situation + aircraft crashed horizontal stabilizer trim
if fail to cope. system fail situation.
C. Engineering
Maintenance:
1.Improper lubrication Pressure to keep flight Jackscrew assembly fail + Yes, with follow 9 10 3 270
service intensively + stabilizer system fail maintenance procedures and
extended service interval schedule as recommended
time on jackscrew Aircraft crashed for inspection, lubrication
and replacement services by
manufacturer
2.Maintenance Cutting cost + to keep Jackscrew assembly fail + Yes, the only way to ensure 9 10 5 450
scheduled not flight service intensively stabilizer system fail the jackscrew assembly
followed decision by top working properly is must
management = extended Aircraft crashed follow the schedule
service interval time on maintenance as
jackscrew recommended by
manufacturer
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Design:
1.Not fail-safe Manufacturer did not Aircraft crashed Yes, with proper lubrication. 1 10 10 100
produce the jackscrew + So, must perform
safe-fail feature at the time maintenance service as
schedule as recommended by
Manufacturer provide manufacturer
maintenance service
recommendation for the
jackscrew
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Strength and Limitation of the Concepts and Tools Used
Concept Strength Limitation
FTA  The structure makes easily for the  This concept is quite hard to classify
reader understanding the causes each of the causes into main
that brings to the failure event (top categories (first event level before
event). the top event and other sub-event)
 It uses logic gate principle to respectively in-case too much main
determine the failure of system. causes and sub-causes. It is become
Easy, simple but very meaningful. too much difficult for complex cases.
 It acts as a knowledge-base of how The causes needed to determine first,
a system fails, hence can be used categorize, and then develop the
for diagnostics or fault finding FTA.
(Labib and Ramesh, 2012).  Cannot determine which one causes
 The correlation between causes is more critical than others, means
could know easily based on the criticality for prioritization purpose
logic symbol used. did not capture.
 FTA can used to determine the
probability of failure from the
minimal cut sets.
 It provides ways of analysing
human, software, procedure and
other factors in addition to the
traditional physical parts of the
system (Labib and Ramesh, 2013).
 FTA can be used to develop RBD
easily from top event.
RBD  It helps to highlight vulnerable or  It possible to develop RBD based on

weak, areas in the model that need FTA if the RBD was developing
attention in form of adding, for first.
example built-in-testing,  RBD did not show to the reader
redundancy or more preventive about the sequences of failure or
maintenance (Labib and Ramesh, causes that brings to the failure
2012). event.
 Reliability of the system can be
determined if the availability of the
each block/box are provided or
known. Therefore, engineer or
designer would know how reliable
their system (for engineer) and
design (for designer).
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FMEA  The prioritization of criticality can  Not too suitable to analysis the
be determined using this concept factors (causes; in FMEA table is on
based on RPN. failure mode, in FTA is causes) other
 From FMEA table, engineer or than technical failure such as human
designer easily know the failure (e.g.: human error, human decision
mode, causes, effect, current etc), environment (e.g.: weather,
controls (existing controls) and economic impact etc) etc.
RPN, means they could  In-case the failure/causes of human
understanding the current problem or environmental, the occurrence
situation clearly of equipment, number is not reliable that can affect
machine etc. the result for RPN. It is because for
 Easy for engineer or designer to instance in the case study Alaska
make steps or decision for new Airline Flight 216 Crashed, the
controls based on existing controls cutting on cost decision had made by
especially and all others management (human decision) just
information on the FMEA table. only once but the effects and impact
 Strength and very suitable to find is huge and ongoing for a long time
the RPN for technical problems until year 2000. Another example is
(technical failure) on equipment, case for such as car had accident
machine etc. caused by trees fallen-[failure mode
in FMEA,] on road because of bad
weather-[environment] (e.g.: heavy
rain and windstorm), the occurrence
for this case is low and can consider
the rating as 1, but the impact is the
car had accident and broken, the
passenger maybe could get injured or
more worse than that which is death.
 The RPN digits sometimes have

doubt in term of its accuracy. It is
because the effecting from human
judgment to allocate the rating for
occurrence, severity and detection.
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FMEA  It needs details on specification

explanation about the rating (level)
for the occurrence, severity and
detection for each different systems
specifically in order to get the
accuracy on the number of
occurrence, severity, detection and
thus for the accuracy of the RPN
result.
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3. DISCUSSION AND CONCLUSION
The economic impact and desire need to get profits make the Alaska Airline’s top
management decided to cutting cost and keep flights flying more intensively. These decision
overall making their neglected the important engineering aspect which is the most important
procedure in the maintenance their aircrafts especially for Alaska Airline Flight 261 in this
case where the only way can guarantee the safety of the aircraft. The lesson is any decision
decided must not compromise with safety aspect or other aspect than can affect safety aspect.
Besides, the management decision must not overrule engineering decision such as changing
to extend the interval time service for the jackscrew assembly without approval.
The safety procedure to coping with any aircraft system failure situation also must be
given to every pilot and provided in quick reference book in each of aircrafts. Besides, all
pilots must be trained using the procedures as training. So, if the failures situation occurs,
pilots clearly and exactly know what they should do and it’s would making they could taking
fast action to prevent aircraft from danger and crashed. The most important is to prevent
human from death.
For the design element, any design must have fail-safe features. In this Alaska Airline
Flight 261 case, the crashed disaster would not occur if the design of the jackscrew assembly
has redundancy or follower nuts to support the acme nut. Therefore, the lesson from this
accident is designer or manufacturer must produce their product with have this essential
feature. They could deny it just because of they provide such as recommended lubrication
service interval time etc for customers because people always or sometimes overlooked or
neglect the important matters that they must follow to do to confirm with safety.
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APPENDIX A: SCHEMATIC DIAGRAM OF TRIM ACTUATING MECHANISM
Source: National Transportation Safety Board Report, 2002 (page 16)
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APPENDIX B: NTSB RECOMMENDATIONS
NEW RECOMMENDATIONS
As a result of the investigation of the Alaska Airlines flight 261 accident, the National
Transportation Safety Board makes the following recommendations to the Federal
Aviation Administration:
Issue a flight standards information bulletin directing air carriers to instruct pilots that in
the event of an inoperative or malfunctioning flight control system, if the airplane is
controllable they should complete only the applicable checklist procedures and should not
attempt any corrective actions beyond those specified. In particular, in the event of an
inoperative or malfunctioning horizontal stabilizer trim control system, after a final
determination has been made in accordance with the applicable checklist that both the
primary and alternate trim systems are inoperative, neither the primary nor the alternate
trim motor should be activated, either by engaging the autopilot or using any other trim
control switch or handle. Pilots should further be instructed that if checklist procedures are
not effective, they should land at the nearest suitable airport. (A-02-36)
Direct all certificate management offices to instruct inspectors to conduct surveillance of

airline dispatch and maintenance control personnel to ensure that their training and
operations directives provide appropriate dispatch support to pilots who are experiencing a
malfunction threatening safety of flight and instruct them to refrain from suggesting
continued flight in the interest of airline flight scheduling. (A-02-37)
As part of the response to Safety Recommendation A-01-41, require operators of Douglas

DC-9, McDonnell Douglas MD-80/90, and Boeing 717 series airplanes to remove
degraded grease from the jackscrew assembly acme screw and flush degraded grease and
particulates from the acme nut before applying fresh grease. (A-02-38)
As part of the response to Safety Recommendation A-01-41, require operators of Douglas

DC-9, McDonnell Douglas MD-80/90, and Boeing 17 series airplanes, in coordination
with Boeing, to increase the size of the access panels that are used to accomplish the
jackscrew assembly lubrication procedure. (A-02-39)
Establish the jackscrew assembly lubrication procedure as a required inspection item that
must have an inspector's signoff before the task can be considered complete. (A-02-40)
Review all existing maintenance intervals for tasks that could affect critical aircraft
components and identify those that have been extended without adequate engineering
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justification in the form of technical data and analysis demonstrating that the extended
interval will not present any increased risk and require modifications of those intervals to
ensure that they (1) take into account assumptions made by the original designers, (2) are
supported by adequate technical data and analysis, and (3) include an appropriate safety
margin that takes into account the possibility of missed or inadequate accomplishment of
the maintenance task. In conducting this review, the Federal Aviation Administration
should also consider original intervals recommended or established for new aircraft models
that are derivatives of earlier models and, if the aircraft component and the task are
substantially the same and the recommended interval for the new model is greater than that
recommended for the earlier model, treat such original intervals for the derivative model as
"extended" intervals. (A-02-41)
Conduct a systematic industrywide evaluation and issue a report on the process by which
manufacturers recommend and airlines establish and revise maintenance task intervals and
make changes to the process to ensure that, in the future, intervals for each task (1) take
into account assumptions made by the original designers, (2) are supported by adequate
technical data and analysis, and (3) include an appropriate safety margin that takes into
account the possibility of missed or inadequate accomplishment of the maintenance task.
(A-02-42)
Require operators to supply the Federal Aviation Administration (FAA), before the
implementation of any changes in maintenance tasks intervals that could affect critical
aircraft components, technical data and analysis for each task demonstrating that none of
the proposed changes will present any potential hazards, and obtain written approval of the
proposed changes from the principal maintenance inspector and written concurrence from
the appropriate FAA aircraft certification office. (A-02-43)
Pending the incorporation of a fail-safe mechanism in the design of the Douglas DC-9,
McDonnell Douglas MD-80/90, and Boeing 717 horizontal stabilizer jackscrew assembly,
as recommended in Safety Recommendation A-02-49, establish an end play check interval
that (1) accounts for the possibility of higher-than-expected wear rates and measurement
error in estimating acme nut thread wear and (2) provides for at least two opportunities to
detect excessive wear before a potentially catastrophic wear condition becomes possible.
(A-02-44)
Require operators to permanently (1) track end play measures according to airplane
registration number and jackscrew assembly serial number, (2) calculate and record
average wear rates for each airplane based on end play measurements and flight times, and
Page | 28
(3) develop and implement a program to analyze these data to identify and determine the
cause of excessive or unexpected wear rates, trends, or anomalies. The Federal Aviation
Administration (FAA) should also require operators to report this information to the FAA
for use in determining and evaluating an appropriate end play check interval. (A-02-45)
Require that maintenance facilities that overhaul jackscrew assemblies record and inform
customers of an overhauled jackscrew assembly's end play measurement. (A-02-46)
Require operators to measure and record the on-wing end play measurement whenever a
jackscrew assembly is replaced. (A-02-47)
Require that maintenance facilities that overhaul Douglas DC-9, McDonnell Douglas MD-
80/90, and Boeing 717 series airplanes' jackscrew assemblies obtain specific authorization
to perform such overhauls, predicated on demonstrating that they possess the necessary
capability, documentation, and equipment for the task and that they have procedures in
place to (1) perform and document the detailed steps that must be followed to properly
accomplish the end play check procedure and lubrication of the jackscrew assembly,
including specification of appropriate tools and grease types; (2) perform and document
the appropriate steps for verifying that the proper acme screw thread surface finish has
been applied; and (3) ensure that appropriate packing procedures are followed for all
returned overhauled jackscrew assemblies, regardless of whether the assembly has been
designated for storage or shipping. (A-02-48)
Conduct a systematic engineering review to (1) identify means to eliminate the

catastrophic effects of total acme nut thread failure in the horizontal stabilizer trim system
jackscrew assembly in Douglas DC-9 (DC-9), McDonnel Douglas MD-80/90 (MD-80/90),
and Boeing 717 (717) series airplanes and require, if practicable, that such fail-safe
mechanisms be incorporated in the design of all existing and future DC-9, MD-80/90, and
717 series airplanes and their derivatives; (2) evaluate the horizontal stabilizer trim
systems of all other transport-category airplanes to identify any designs that have a
catastrophic single-point failure mode and, for any such system; (3) identify means to
eliminate the catastrophic effects of that single-point failure mode and, if practicable,
require that such fail-safe mechanisms be incorporated in the design of all existing and
future airplanes that are equipped with such horizontal stabilizer trim systems (A-02-49)
Modify the certification regulations, policies, or procedures to ensure that new horizontal
stabilizer trim control system designs are not certified if they have a single-point
catastrophic failure mode, regardless of whether any element of that system is considered
Page | 29
structure rather than system or is otherwise considered exempt from certification standards
for systems. (A-02-50)
Review and revise aircraft certification regulations and associated guidance applicable to
the certification of transport-category airplanes to ensure that wear-related failures are fully
considered and addressed so that, to the maximum extent possible, they will not be
catastrophic. (A-02-51)
PREVIOUSLY ISSUED RECOMMENDATIONS RESULTING FROM THIS ACCIDENT INVESTIGATION

As a result of the Alaska Airlines flight 261 accident investigation, the Safety Board
issued the following safety recommendations to the FAA on October 1, 2001:
Require the Boeing Commercial Airplane Group to revise the lubrication procedure for the
horizontal stabilizer trim system of Douglas DC-9, McDonnell Douglas MD-80/90, and
Boeing 717 series airplanes to minimize the probability of inadequate lubrication. (A-01-
41)
On June 14, 2002, the Safety Board classified Safety Recommendation A-01-41 "Open-
Acceptable Response."
Require the Boeing Commercial Airplane Group to revise the end play check procedure
for the horizontal stabilizer trim system of Douglas DC-9, McDonnell Douglas MD-80/90,
and Boeing 717 series airplanes to minimize the probability of measurement error and
conduct a study to empirically validate the revised procedure against an appropriate
physical standard of actual acme screw and acme nut wear. This study should also
establish that the procedure produces a measurement that is reliable when conducted on-
wing. (A-01-42)
Require maintenance personnel who lubricate the horizontal stabilizer trim system of
Douglas DC-9, McDonnell Douglas MD-80/90, and Boeing 717 series airplanes to
undergo specialized training for this task. (A-01-43)
Unacceptable Response." system of Douglas DC-9, McDonnell Douglas MD-80/90, and
Boeing 717 series airplanes to undergo specialized training for this task. This training
Page | 30
should include familiarization with the selection, inspection, and proper use of the tooling
to perform the end play check. (A-01-44)
Unacceptable Response."
Before the implementation of any proposed changes in allowable lubrication applications

for critical aircraft systems, require operators to supply to the FAA technical data
(including performance information and test results) demonstrating that the proposed
changes will not present any potential hazards and obtain approval of the proposed
changes from the principal maintenance inspector and concurrence from the FAA
applicable aircraft certification office. (A-01-45)
On July 29, 2002, the Safety Board classified Safety Recommendation A-01-45 "Closed-
Acceptable Action."
Issue guidance to principal maintenance inspectors to notify all operators about the
potential hazards of using inappropriate grease types and mixing incompatible grease
types. (A-01-46)
On July 29, 2002, the Safety Board classified Safety Recommendation A-01-46 "Closed-
Acceptable Action."
Survey all operators to identify any lubrication practices that deviate from those specified
in the manufacturer's airplane maintenance manual, determine whether any of those
deviations involve the current use of inappropriate grease types or incompatible grease
mixtures on critical aircraft systems and, if so, eliminate the use of any such inappropriate
grease types or incompatible mixtures. (A-01-47)
Within the next 120 days, convene an industrywide forum to disseminate information
about and discuss issues pertaining to the lubrication of aircraft components, including the
qualification, selection, application methods, performance, inspection, testing, and
incompatibility of grease types used on aircraft components. (A-01-48)
Page | 31
Source: National Transportation Safety Board Report, 2002 (page 181-185) or;
Source: Alaska 216 Aircraft Accident Report – Summary, available at
https://www.ntsb.gov/investigations/summary/AAR0201.html
Page | 32
REFERENCES
 Lecture Note:
1. Ashraf Labib (2013). Maintenance Awareness in Design. University of Manchester,
George Begg Building on 4–8th of February 2013.
 Journals:
1. Ashraf Labib, Ramesh Champaneri (2012). The Bhopal Disaster – Learning From
Failures and Evaluating Risk. Journal of Maintenance and Asset Management,
(May/June), pp. 41-47.
2. Ashraf Labib, Martin Read (2013). Not Just Rearranging the Deckchairs on the
Titatic – Learning From Failures through Risk and Reliability Analysis. Journal of
Safety Science, (None), pp. 397-413.
3. Christian G.W. Schnedler, Daniel Murphy, Steven J. Stumpp, Frantz St. Phar (2007).
Alaska Airlines Flight 261: Understanding the Systemic Contributors to
Organizational Accidents. Journal of System Research, (None), pp. 42-51.
4. Ashraf Labib, G.G Davidson (2003). Learning from Failures: Design Improvements
Using a Multiple Criteria Decision-Making Process. Journal of Aerospace
Engineering, (None), pp. 201-216.
 Articles:
1. John P. Fielding, College of Aeronautics, Cranfield University (1999). Introduction to
Aircraft Design. Published by Cambridge University Press.
2. Source: http://enpub.fulton.asu.edu/, Fulton School of Engineering (None). Aircraft
Conceptual Design. Links: http://enpub.fulton.asu.edu/aero/mae444/sizingchapter.pdf
3. Source: http://www.fmeainfocentre.com, Quality Associated International
Incorporated (None). Severity, Occurrence, and Detection Criteria for Process
FMEA. Links: http://www.fmeainfocentre.com/guides/ProcessPktNewRatings.pdf
 Reports:
1. Aircraft Accident Report (2002). Loss of Control and Impact with Pacific Ocean,
Alaska Airlines Flight 261, McDonnell Douglas MD-83, N963AS, About 2.7 Miles
North of Anacapa Island, California January 31, 2000. By National Transportation
Safety Board, Washington, USA.
Page | 33
2. Cockpit Voice Recorder Report (2000). Factual Report of Investigation: Cockpit

Voice Recorder. By Douglass P. Brazy, Mechanical Engineer, Vehicles Recorders
Division, National Transportation Safety Board, Washington, USA.
 Presentation Slide:
1. M.Kalam Azat, Amafabia Daerefa-a M., Suhaimi Rashid, Anas Abas, Faiza Alzatjali,
University of Manchester, UMIST (2013). Alaska Airline 261 Disaster. School of
Mechanical Engineering, Manchester, England, UK.
 Media:
1. Air Crash Investigation - S01E06 Cutting Corners, Alaska Airlines Flight 261 (None)
Documentary. National Geographic. Cineflix Productions. Available at:
http://watchdocumentary.org/watch/air-crash-investigation-s01e06-cutting-corners-
alaska-airlines-flight-261-video_39d9f1fa7.html
 Websites:
1. National Transportation Safety Board (2002). Aircraft Accident Report: Alaska
Airline 261 (online). Available at:
https://www.ntsb.gov/investigations/summary/AAR0201.html
2. Chris Goodman, Priscilla Long (2001). Alaska Flight 261 bound for Seattle crashes
into the Pacific Ocean on January 31, 2000 (online). Available at:
http://www.historylink.org/index.cfm?DisplayPage=output.cfm&File_Id=2958
3. PBS NewsHour (2000). Alaska Airline Flight 261 Crash (online). Available at:
http://www.pbs.org/newshour/bb/transportation/jan-june00/alaskaair_2-1.html
4. Jet Aviator7 (2011). Alaska Airline 261 Accident (online). Available at: http://all-
things-aviation.com/aircraft-accidents/alaska-air-261-accident/
5. TailStrike.com (None). Alaska Airline Cockpit Voice Recorder Database (online).
Available at: http://www.tailstrike.com/310100.htm
6. Jerry White (2000). The Alaska Airlines Crash: Signs Point to a Wider Crisis in Air
Safety (online). Available at: http://www.wsws.org/en/articles/2000/02/alas-f19.html
7. Iasa.com.au (None). How It Would Have Prevented Alaska 261 (online). Available at:
http://www.iasa.com.au/folders/Safety_Issues/FAA_Inaction/fsjackscrew-1.html
8. Henry K. Lee (2000). Transcripts of Doomed Alaska Flight / Voices of Doom on
Alaska Air / Transcripts Depict Pilots' Frantic Struggle in Final Minutes of Flight
Page | 34
261 (online). Available at: http://www.sfgate.com/news/article/Transcripts-of-

Doomed-Alaska-Flight-Voices-of-3238003.php
 Pictures/Images:
1. SFGate.com (2000). Alaska Airline Flight 216 aircraft and flight info [Online image].
Available from: http://www.sfgate.com/news/article/SFO-Bound-Alaska-Airlines-Jet-
Crashes-2807300.php#photo-2211490. [Accessed 01/05/13].
2. TailStrike.com (None). Jackscrew structure on the Horizontal Stabilizer Trim System
[Online image]. Available from: http://www.tailstrike.com/310100.htm.
[Accessed 30/04/13].
Page | 35

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MAINTENANCE AWARENESS IN DESIGN

MAINTENANCE ENG. & ASSET MGMT.

Aircraft Design Shape: Different views of an aircraft by designers

Design elements for aircraft (John P. Fielding, 1999)

The objectives that to be achieved is to brief to reader about:

Case Study: Alaska Airline 261 Crashed

2. CASE STUDY: ALASKA AIRLINE 261 CRASHED

Introduction to the Case

Alaska Airline Flight 261 crashed map and timeline

Horizontal Stabilizer Trim System

Horizontal Stabilizer Trim System

Jackscrew structure on the Horizontal Stabilizer Trim System

Background of the Tragedy

Time: 15.49.49 - 16.10.33

Time: 16.10.33 - 16.17.57

Time: 16.17.57- 16.19.43

Investigation the Failure

Comparison between manufacturer recommended and Alaska Airline for jackscrew

Recommendations for the Jackscrew Assembly Design

Old and new proposed design of the jackscrew assembly

Causes Analysis of the Aircraft Crashed

on jackscrew. This is the reason why the aircraft had crashed. It is

Discovery of the aircraft’s wreckage after the crashed:

Concept and Tools for Failure Analysis

Reliability Block Diagram

Failure Mode and Effect Analysis

Potential Failure Potential Failure Potential Effects Existing Conditions

1.Cutting cost Economic impact Reduce budget on No, caused by economic 1 10 5 50

Neglected safety aspect in

Strength and Limitation of the Concepts and Tools Used

Concept Strength Limitation

RBD  It helps to highlight vulnerable or  It possible to develop RBD based on

 The RPN digits sometimes have

FMEA  It needs details on specification

3. DISCUSSION AND CONCLUSION

APPENDIX A: SCHEMATIC DIAGRAM OF TRIM ACTUATING MECHANISM

Source: National Transportation Safety Board Report, 2002 (page 16)

APPENDIX B: NTSB RECOMMENDATIONS

Direct all certificate management offices to instruct inspectors to conduct surveillance of

As part of the response to Safety Recommendation A-01-41, require operators of Douglas

As part of the response to Safety Recommendation A-01-41, require operators of Douglas

Conduct a systematic engineering review to (1) identify means to eliminate the

PREVIOUSLY ISSUED RECOMMENDATIONS RESULTING FROM THIS ACCIDENT INVESTIGATION

Before the implementation of any proposed changes in allowable lubrication applications

2. Cockpit Voice Recorder Report (2000). Factual Report of Investigation: Cockpit

261 (online). Available at: http://www.sfgate.com/news/article/Transcripts-of-

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