Aloha Airlines Flight 243 Case Study & Report
COURSE CODE AERO2486
COURSE TITLE Aircraft Maintenance Management
ASSESSMENT TITLE Aloha Airlines Flight 243 Case Study & Report
STUDENT NAME / ID R Thanasrubhen / S3917592
NUMBER
SUBMISSION DATE 2 April 2023
WORD COUNT 1974 words
Content Page
1. Abbreviation Table………………………………………………………………...........2
2. Introduction & Summary……….……………...………...……………………….….…3
3. Human Factors at AQ…….…………………………………………...……………..4-5
3.1. Inadequate maintenance & inspection procedures and training…………………………..4
3.2. AQ management’s lack of attention to safety issues……………………………………….4
3.3. Maintenance department’s complacency culture & inadequate supervisory oversight…5
3.4. Lack of strong safety culture within AQ………………………………………………………5
4. AQ Compliance with Regulatory & Manufacture Recommendations..……….…...6
5. AQ Maintenance Program………………………..……………………………………7
6. Conclusion…………………..……..…………………………………..………………..8
7. References..………………………………………………………………………….....9
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Assignment 1: Case Study
1. Abbreviation Table
AD Airworthiness Directive
AQ Aloha Airlines
AQMP Aloha Airlines Maintenance Programme
AQ243 Aloha Airlines Flight 243
B Boeing
BMPD Boeing’s Maintenance Planning Document
FAA Federal Aviation Authority
HARTCC Honolulu Air Route Traffic Control Centre
HNL Daniel K. Inouye International Airport
HST Hawaii Standard Time
ILO Hilo International Airport
OGG Kahului Airport
SB Service Bulletin
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2. Introduction & Summary
AQ243 was a regular short-haul commuter flight between ILO and HNL. On April 28 1988,
AQ243 tagged under N73711, a B737-200 aircraft to fly the route, departed ILO at 1325HST as
its 7th flight for the day to HNL, with a constant rattling emanating from the ageing airframe as it
reached 24,000ft cruising height.
At 1346HST, a sudden explosive decompression with 18ft of cabin skin and structure after the
cabin entrance door and above the passenger floorline separated from the aircraft. The flight
crew along with the observer, donned their oxygen masks while activating the passenger
oxygen masks and the captain performed an emergency descent. The first officer dialled 7700
transponder emergency code and attempted to notify HARTCC of the OGG diversion. At
1348HST, AQ243 informed OGG Tower of the rapid decompression emergency and requested
emergency vehicles. With Engine 1 failing, AQ243 landed safely on OGG Runway 02 at 1358
HST, followed by a successful emergency evacuation of 94 souls onboard and 1 missing cabin
crew member (NTSB 1989).
This incident resulted in more safety and regulatory aviation procedures and enhanced
maintenance checks and programmes conducted by aircraft owners internationally. Thus, this
report aims to address the human factors and possible actions taken by AQ maintenance
department to avoid the incident occurrence, AQ’s compliance with incident-relevant SBs and
ADs, AQMP shortcomings and recommendations and comparison of contemporary requirement
and practices to AQMP.
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3. Human Factors at AQ
Prior to the AQ243 incident, there were several human factors issues related to the conduct of
AQ’s maintenance and general staff attitudes that contributed to the incident:
3.1 Inadequate maintenance and inspection procedures and training
The aircraft's fuselage is made of aluminium, which is prone to fatigue and corrosion over time.
However, the maintenance procedures did not adequately account for these risks nor were the
staff formally trained and certified in corrosion identification, prevention and control, which
resulted in their inability to identify the aircraft’s metal fatigue (NTSB 1989).
AQ could have implemented more robust maintenance and inspection procedures that
accounted for the risks of aircraft fuselage fatigue and corrosion, such as regular inspections of
the aircraft's structure using non-destructive and efficient testing methods (i.e. ultrasound or X-
ray technology and drones to perform maintenance checks and tasks in hard-to-reach areas).
Moreover, involving maintenance personnel in any near misses or incident investigation and
analysis could help identify the root cause and areas for improvement in the maintenance
programme.
3.2 AQ management’s lack of attention to safety issues
The management was prioritizing profits and pushing out aircrafts to perform scheduled flights
on time and not in safety and investing adequately in maintenance and inspection programs.
They also did not respond to the concerns raised by their employees regarding maintenance
issues and continued to operate the aircraft despite evidence of serious safety concerns.
Moreover, maintenance staff were working long hours and experienced fatigue due to
understaffing, which increased the likelihood of errors (Laura A. 2016).
AQ's management could have prioritised safety over cost-cutting measures and invested in
maintenance and inspection programmes to ensure the safety of their aircrafts. Additionally,
they could have responded to the concerns raised by their employees and taken appropriate
action to address any safety issues. Frequent through audits and inspections can be conducted
to identify and correct any deficiencies in procedures, supervision or training before they
contribute to an incident.
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3.3 Maintenance department’s complacency culture and inadequate supervisory
oversight
The staff had become accustomed to flying older aircraft but were not following proper
maintenance procedures and were not adequately trained to identify and report potential safety
risks, leading to a lack of communication and collaboration between maintenance personnel and
superiors. Additionally, maintenance supervisors were not providing adequate oversight and
monitoring of the work performed by mechanics, resulting in the falsification of repair orders to
meet next-day operations requirements (Laura A. 2016).
AQ could have invested in formal and refresher training and certification programmes for
maintenance personnel, including aircraft corrosion identification, prevention and control. This
would equip maintenance staff and supervisors with the necessary skills and knowledge to
perform their jobs effectively and identify potential safety risks actively while not experiencing
fatigue with better resources and maximum staff duty time implemented.
3.4 Lack of strong safety culture within AQ
There was a general attitude among the staff that maintenance and safety procedures were
burdensome and time-consuming, and shortcuts were often taken to reduce costs and meet
daily operational requirements. This attitude was compounded by a lack of effective
communication between maintenance personnel and management to report any safety
concerns (Laura A. 2016).
The airline could have promoted a culture of safety by encouraging open communication and
collaboration between maintenance personnel and management. AQ could implement an open
reporting system for safety concerns through awareness programs and provide incentives for
employees to report any issues they identify.
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4. AQ Compliance with Regulatory and Manufacture
Recommendations
SBs are instructions issued by the aircraft manufacturer to address maintenance requirements,
modifications or inspections to maintain the airworthiness of an aircraft, while ADs are
mandatory instructions issued by a country’s aviation authority to address and fix any safety
issues. The responsibility lies with the aircraft operator to comply with both SBs and ADs to
ensure the safety of its passengers and crew.
AQ did not comply with 4 out of 9 SBs provided by Boeing targeted at B737 fuselage structures,
as these SBs (i.e., SB 737-53-1076, -1078, -1085 and -1089) were not found in their
maintenance records. However, AD 87-21-08 issued affecting N73711 under SB 737-53A1039
was found to have not been fully complied with as the two repair areas on lap joint S-4R were
performed, but there was no non-destructive testing report record of the required eddy current
inspection done, despite N73711 maintenance log mentioned a visual inspection was performed
as per the AD (Nauman H. 2011). Moreover, lap joints S-10, S-14, S-19, S-20 and S-24
recommended by SB 737-53A1039 were not performed, along with the S-4 lap joint with
protruding head rivets in the upper row remaining fasteners replacement . When the AD
inspection and repair were performed, N73711 was well over the requirement of 30,000
cumulative or 250 landings criteria of the AD effective date, it had 87,056 accumulated cycles
(NTSB 1989).
After AQ132 incident, all AQ B737 aircrafts went through compliance checks concerning AD 87-
21-08 and through corrosion and structural inspections with N73713 and N73712 deemed
beyond economical repair and N73717 had all outstanding SBs and permanent structural
repairs done as per ADs addressing it (NTSB 1989).
AQ aircrafts operated in a corrosive marine environment due to their frequent exposure to
saltwater and moisture which increased the likelihood of corrosion, as they primarily flew inter-
island routes within Hawaii. The airline's flight schedule also operated under high-frequency,
daily short-haul flights with quick turnarounds, which may have put additional stress and fatigue
on the aircraft structure and lap joints, due to multiple take-offs and landings and cabin
pressurisation cycles (Faisal B. 2021). Thus, it may have been challenging to perform all the
necessary inspections and repairs within the recommended time frames for SB 737-53A1039.
While the SBs provided detailed instructions for inspecting and repairing fatigue cracks, their
time frames and flight cycle limits may not have been adequate for an airline with AQ’s' unique
operating environment and flight schedule.
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5. AQ Maintenance Program (AQMP)
The major shortcomings in AQMP that led to the incident where the separation of the fuselage
upper lobe and the failing of the lap joint at S-10L occurred were due to the failure to discover
the presence of significant metal disbanding, fatigue and corrosion damage, along with repairing
them under the severe corrosive operating environment that AQ’s fleet operated in.
AQMP had allowed 1.5 times the number of flight cycles that could be clocked in on a normal
airplane, due to AQ’s flight-hour-based structural maintenance program intention. Moreover, its
fleet’s D checks were split into 52 independent work packages across 8 years, which were
approved by the FAA, whereas BMPD has a 6-8 year interval (NTSB 1989). This resulted in
hurried checks, limited areas inspection and insufficient time for early detection of corrosion and
damage repair and control, but would enable the aircraft to adhere to its flight schedule.
Additionally, corrosion control through corrective action was not present in AQMP, despite lap
joints corrosion being recorded in AQ’s maintenance records, as the maintenance and general
staff took corrosion as a daily operational norm condition (Faisal B. 2021).
The presence of saltwater, humidity and volcanic activity in the highly corrosive Hawaiian
region, could cause significant damage to aircraft components over time. AQMP did not
adequately account for and address these issues, resulting in N73711 being exposed to
excessive corrosion, which weakened the structure of its fuselage and went undetected.
N73711 was over 19 years old with 89,680 flight cycles at the time of the accident and had been
operating on frequent short-distance flights within Hawaii. The issues related to ageing aircraft
are the aircraft’s structural integrity and an increase in structural issue developments as it
continues to operate (Nauman H. 2011). The AQMP did not adequately address the ageing
aircraft issues.
High cycle-to-flight hour ratio, which refers to the number of takeoffs and landings per flight
hour, contributed to the accelerated ageing of the aircraft. AQ operated its aircraft on short-haul
routes, resulting in a high number of takeoffs and landings, which put additional stress on the
aircraft structure and increased the likelihood of fatigue cracks.
Contemporary practices and requirements have significantly evolved since the incident. Today,
regulatory agencies such as the FAA require airlines to implement more comprehensive
maintenance programs that account for ageing aircraft issues and components through the
Ageing Aircraft Program initiative, including fatigue cracking and corrosion (Nauman H. 2011).
Additionally, aircraft operators must conduct frequent inspections on aircraft skins and structural
reinforcements, and they must regularly evaluate their maintenance programs' effectiveness to
ensure continued aircraft safety and airworthiness by including the operating environment and
flight cycles and hours. Moreover, these programs incorporate advanced inspection techniques,
such as non-destructive testing, to detect corrosion and fatigue damage, and they prioritize the
replacement of components susceptible to corrosion or cracking and critical components before
they reach the end of their service lives.
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6. Conclusion
AQ’s maintenance and general staff had inadequate maintenance and inspection procedures
and training, safety issues were played down by management, being understaffed and
overworked, inadequate supervisory oversight, a complacent culture and the absence of a
strong organisational safety culture were the human factors that contributed to the AQ243
incident. Moreover, AQ did not comply with 4 out of 9 Boeing’s SBs, critical lap joint repair
segments stated in SB 737-53A1039 were not performed and FAA’s AD87-21-08 was partially
complied and performed far off from the indicated requirement criteria, despite its daily multiple
short-haul inter-island Hawaii routes being exposed to moisture, saltwater, humidity, volcanic
activity and corrosive operating environment. AQMP failed to include discover the significant
metal disbanding, fatigue and corrosion damage, corrosion control, aircraft’s old age structural
issues, flight schedules resulting in high cycle-to-flight ratio and repair works with regards to the
corrosive environment that its fleet operated in.
These resulted in and contributed to the AQ243 incident, but it could have been avoided with
maintenance and inspection procedures accounting for fuselage fatigue and corrosion control
and prevention. Additionally, training and certifying all maintenance staff regularly, prioritising
safety through audits and receptively responding to safety concerns highlighted by staff through
an open organisational safety culture and reporting system. Furthermore, maintenance in AQ
can be done easily with the use of drones to conduct inspections quickly and in hard-to-reach
areas to meet operational requirements, outsourcing its maintenance to an accredited
maintenance and repair organisation to reduce lapses and using electronic tablets to have a
step-by-step guide for all maintenance tasks and having it officially signed off by a superior.
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7. References
Faisal B. (2021) The Unfateful Aloha Airlines Flight 243, Aviation Geeks website, accessed 31
March 2023.
https://aviationgeeks1.com/the-unfateful-aloha-airlines-flight-243/
Laura A. (2016) Lessons learned from Aloha flight 243, aircraft registration N73711, Live Safely
with Human Error website, accessed 01 April 2023.
https://livingsafelywithhumanerror.wordpress.com/2016/04/29/lessons-learned-from-aloha-flight-
243-aircraft-registration-n73711/
National Transportation Safety Board (NTSB) (1989) Aircraft Accident Report--Aloha Airlines,
Flight 243, Boeing 737-200, N73711, near Maui, Hawaii, April 28, 1988, NTSB/AAR-89/03,
NTSB, United States Government, accessed 31 March 2023.
https://www.faa.gov/about/initiatives/maintenance_hf/library/documents/media/
human_factors_maintenance/aloha_airlines.pdf
Nauman H. (2011) Revisiting Aloha Airline Flight 243: Corrosion Engineer’s Stand Point, ROSA
P 39419, Bureau of Transportation Statistics, United States Government, accessed 01 April
2023.
https://rosap.ntl.bts.gov/view/dot/39419
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