The Weekly Reflektion 10/2022

Introduction of foreign objects to a workplace may be acceptable, but this may cause unidentified hazards.

RAF A330 Voyager Aircraft

Do you have discipline around your work sites, and what is allowed?

On 9th February 2014 an RAF Airbus A330 Voyager aircraft was flying over the Black Sea towards Afghanistan with 198 passengers and crew. The aircraft suddenly, without warning,pitched down violently throwing unrestrained passengers to the ceiling of the aircraft, leaving 48 injured and unfit for duty. The aircraft lost 4400 foot (1340m) in 27 seconds before being brought back under control by the crew and diverted to a base in southern Turkey. If the event had occurred at a lower altitude, a catastrophe could have resulted.

Finding the cause quickly was important as a fleet of six Voyager aircraft used by the RAF were immediately grounded. An investigation, independent of the military arms in the UK, the Army, Royal Navy, and Royal Air Forcefocussed on the autopilot which appeared to have malfunctioned. The investigation found that 44 seconds before the event a noise had been registered on the cockpit recorderand simultaneously there was a small forward displacement of the stick. This movement was too small to disconnect the autopilot and resulted in no disturbance to the aircraft. The noise was heard again just before the pitch down event which indicated something had contacted the stick, but it was unclear what this could be.

Further investigation uncovered that the captain, an eager photographer, was taking photographs of other planes and stars in the night sky. Analysing the captain’s camera, it was found that 28 photos had been taken in the 8 minutes prior to the pitch down event. The casing of the camera was dented, and analysis of material in the dent revealed trace amounts of material from the stick. The reconstruction of the chain of events concluded that the camera had been taken into the flight deck, the captain had been taking several photos, put the camera down next to the stick, and the motorised seat had been moved trapping the camera between the stick and the seat. This moved the stick enough to disconnect the autopilot and put the plane into a dive. 

The introduction of foreign objects into the cockpit was not allowed, but discipline around this was lax. These foreign objects introduce unidentified hazards which could have hadmore serious consequences.

How is the discipline around introduction of foreign objects to your workplaces? How are you controlling that any potential hazards are under control?

Reflekt AS