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LaunchDetected
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Manufacturing-related accident or incident

Fri Mar 01, 2019 9:25 am

Hi everybody,

I would like to have examples of manufacturing-related accident or incident. I would say that the main part of those events are due to maintenance fault or even design mistakes. But how many are caused by faulty manufacturing process?

Recently i remember the wiring-related incident that occured on an Etihad 777 and several others.
https://www.mro-network.com/airlines/et ... nspections

Four years in service caused the mis-routed wire bundle to chafe on a nearby screw, generating smoke and activating the forward cargo fire detection system. It led to production-line Wiring Inspections. Here is the report by the Australian Transport Safety Bureau: https://www.atsb.gov.au/media/5774692/a ... _final.pdf

Do you have any other examples?
Caravelle lover
 
Dalmd88
Posts: 3159
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Re: Manufacturing-related accident or incident

Fri Mar 01, 2019 1:21 pm

This one comes to mind. Cause is manufacturing defect that was undetected by follow up maintenance inspections.

https://en.wikipedia.org/wiki/Delta_Air ... light_1288

If I recall it was how the machining process was carried out when the hub was made. I think it overheated and allowed micro cracks to form which after time failed.
 
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Erebus
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Re: Manufacturing-related accident or incident

Fri Mar 01, 2019 2:34 pm

QF 32 is probably one of the more high profile ones in recent times, the cause being a misaligned counter bore within a stub oil pipe leading to a fatigue fracture.

Do the 787 battery-related issues count? And the ET 787 that burned at LHR was attributed to a miswiring as well AFAIK but it didn't have anyone on it at that time, so not sure if you'd call that an accident or incident.
 
PSAatSAN4Ever
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Re: Manufacturing-related accident or incident

Fri Mar 01, 2019 7:16 pm

https://aviation-safety.net/database/record.php?id=19890719-1

The flaw in the casting process of the number two engine that would go on N1819U in 1973 was not discovered until late 1989, after the Sioux City incident.

https://aviation-safety.net/database/record.php?id=19820628-1

Not sure if the grounding of all Yak-42's counts, but the design of the jackscrew proved insufficient over the long term. All -42's were grounded for more than two years until a solution was found.
 
SteelChair
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Re: Manufacturing-related accident or incident

Fri Mar 01, 2019 7:26 pm

DL37, November 7, 1996. MD11 stabilizer jam due to no lubricant in the jackscrews.

I seem to remember a whole series of Boeing twins that had the cables for the T handles reversed in the 1990s.
 
BravoOne
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Re: Manufacturing-related accident or incident

Fri Mar 01, 2019 7:38 pm

How about the Lockheed Electra. Loss of 2 aircraft.
 
stephanwintner
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Re: Manufacturing-related accident or incident

Fri Mar 01, 2019 7:50 pm

Erebus wrote:
QF 32 is probably one of the more high profile ones in recent times, the cause being a misaligned counter bore within a stub oil pipe leading to a fatigue fracture.



If I recall, it was either that the blueprint did not specify a concentricity between the two relevant diameters, so the thin wall was not detected, or that the blueprint tolerance was met, but that specified tolerance was too much, and permitted a very thin wall, which cracked. Either way, I think the part met the blueprint.... kinda scary.
 
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klm617
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Re: Manufacturing-related accident or incident

Fri Mar 01, 2019 7:52 pm

Turkish 981, American 191 and American 96
the truth does matter, guys. too bad it's often quite subjective. the truth is beyond the mere facts and figures. it's beyond good and bad, right and wrong...
 
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klm617
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Re: Manufacturing-related accident or incident

Fri Mar 01, 2019 7:53 pm

Japan Airlines 123
the truth does matter, guys. too bad it's often quite subjective. the truth is beyond the mere facts and figures. it's beyond good and bad, right and wrong...
 
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klm617
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Re: Manufacturing-related accident or incident

Fri Mar 01, 2019 7:54 pm

The Comet
the truth does matter, guys. too bad it's often quite subjective. the truth is beyond the mere facts and figures. it's beyond good and bad, right and wrong...
 
kalvado
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Re: Manufacturing-related accident or incident

Fri Mar 01, 2019 7:57 pm

Not sure if this fits the definition:
AA383 engine fire in Chicago. Root cause - undetected (and undetectable with methods used) defect in metal used for turbine disk, disk rupture, fire, writeoff. Fortunately no casualties...
 
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leleko747
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Re: Manufacturing-related accident or incident

Fri Mar 01, 2019 8:11 pm

klm617 wrote:
Japan Airlines 123


Wasn't that caused by improper maintenance by JAL? Therefore, not related to manufacturing?
I wonder when people will understand:
Embraer 190 or simply E190, not ERJ-190. E-Jets are NOT ERJs!
Boeing 747-8, not Boeing 747-800. Same goes for 787.
Airbus A320, not Airbus 320.
Airbii does not exist.
 
MileHFL400
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Re: Manufacturing-related accident or incident

Fri Mar 01, 2019 8:44 pm

klm617 wrote:
Japan Airlines 123


I think that was repair related.
Thanks and best Regards
AA
 
MileHFL400
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Re: Manufacturing-related accident or incident

Fri Mar 01, 2019 8:45 pm

klm617 wrote:
The Comet


Design related, not the manufacture process.
Thanks and best Regards
AA
 
WayexTDI
Posts: 1953
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Re: Manufacturing-related accident or incident

Fri Mar 01, 2019 8:45 pm

klm617 wrote:
Turkish 981, American 191 and American 96

American 191 was improper maintenance procedure (replacement of the engine using a forklift instead of a crane, resulting in damage to the pylon).

Turkish 981 & American 96 were primarily design defect, which were later corrected.
 
WayexTDI
Posts: 1953
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Re: Manufacturing-related accident or incident

Fri Mar 01, 2019 8:46 pm

klm617 wrote:
Japan Airlines 123

Improper repair
 
WayexTDI
Posts: 1953
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Re: Manufacturing-related accident or incident

Fri Mar 01, 2019 8:47 pm

klm617 wrote:
The Comet

Design defect.

You cited 5+ accidents, none primarily due to manufacturing... Good job!
 
fabian9
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Re: Manufacturing-related accident or incident

Fri Mar 01, 2019 8:58 pm

Erebus wrote:
QF 32 is probably one of the more high profile ones in recent times, the cause being a misaligned counter bore within a stub oil pipe leading to a fatigue fracture.


I don’t remember if the engineering drawing of the part was missing a concentricity tolerance berween the pipe and the counterbore? If it did, then this would be considered an engineering drop off rather than manufacturing?

stephanwintner wrote:
Erebus wrote:
QF 32 is probably one of the more high profile ones in recent times, the cause being a misaligned counter bore within a stub oil pipe leading to a fatigue fracture.



If I recall, it was either that the blueprint did not specify a concentricity between the two relevant diameters, so the thin wall was not detected, or that the blueprint tolerance was met, but that specified tolerance was too much, and permitted a very thin wall, which cracked. Either way, I think the part met the blueprint.... kinda scary.


Beat me to it.
 
kalvado
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Re: Manufacturing-related accident or incident

Fri Mar 01, 2019 9:43 pm

fabian9 wrote:
Erebus wrote:
QF 32 is probably one of the more high profile ones in recent times, the cause being a misaligned counter bore within a stub oil pipe leading to a fatigue fracture.


I don’t remember if the engineering drawing of the part was missing a concentricity tolerance berween the pipe and the counterbore? If it did, then this would be considered an engineering drop off rather than manufacturing?

stephanwintner wrote:
Erebus wrote:
QF 32 is probably one of the more high profile ones in recent times, the cause being a misaligned counter bore within a stub oil pipe leading to a fatigue fracture.



If I recall, it was either that the blueprint did not specify a concentricity between the two relevant diameters, so the thin wall was not detected, or that the blueprint tolerance was met, but that specified tolerance was too much, and permitted a very thin wall, which cracked. Either way, I think the part met the blueprint.... kinda scary.


Beat me to it.

As far as I remember, it was about technology, not design. How dimensions were measured. It was a systematic problem - but not due to design, rather implementation of the design.
 
Noshow
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Re: Manufacturing-related accident or incident

Fri Mar 01, 2019 9:59 pm

Swissair MD-11 at Halifax.
Not original MDD manufacturing related but happened during heavy maintenance later:
Had received some aftermarket IFE that accidentally got hooked up to the hot battery bus. Crew had no chance to pull the circuit breakers when facing some electrical fire and crashed.
 
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CALTECH
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Re: Manufacturing-related accident or incident

Sat Mar 02, 2019 12:36 am

SteelChair wrote:
I seem to remember a whole series of Boeing twins that had the cables for the T handles reversed in the 1990s.


Nope. Pilot error. British Midland. They shut down the good engine. Though IIRC, there was vibrations in the upgraded engines which were not accounted for, could be called a manufacturing defect or testing defect. Fan blade broke. Precautionary inspections were carried out in Fleet Campaign Directives to inspect T-Handles and Fire Bottles, which turned up nothing. And T Handles have no cables, wires, but not cables.
You are here.
 
SteelChair
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Re: Manufacturing-related accident or incident

Sat Mar 02, 2019 1:16 am

CALTECH wrote:
SteelChair wrote:
I seem to remember a whole series of Boeing twins that had the cables for the T handles reversed in the 1990s.


Nope. Pilot error. British Midland. They shut down the good engine. Though IIRC, there was vibrations in the upgraded engines which were not accounted for, could be called a manufacturing defect or testing defect. Fan blade broke. Precautionary inspections were carried out in Fleet Campaign Directives to inspect T-Handles and Fire Bottles, which turned up nothing. And T Handles have no cables, wires, but not cables.


That is not the incident to which I was referring.

And many airplanes have cables to the firewall valves (fuel and hydraulic) though on every airplane that I am aware of the squibs are fired electrically.
 
wetpantsmcgee
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Re: Manufacturing-related accident or incident

Sat Mar 02, 2019 1:52 am

United 232 was a defect in the fan disk manufacturing, was it not?
 
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CALTECH
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Re: Manufacturing-related accident or incident

Wed Mar 06, 2019 7:18 pm

SteelChair wrote:
CALTECH wrote:
SteelChair wrote:
I seem to remember a whole series of Boeing twins that had the cables for the T handles reversed in the 1990s.


Nope. Pilot error. British Midland. They shut down the good engine. Though IIRC, there was vibrations in the upgraded engines which were not accounted for, could be called a manufacturing defect or testing defect. Fan blade broke. Precautionary inspections were carried out in Fleet Campaign Directives to inspect T-Handles and Fire Bottles, which turned up nothing. And T Handles have no cables, wires, but not cables.


That is not the incident to which I was referring.

And many airplanes have cables to the firewall valves (fuel and hydraulic) though on every airplane that I am aware of the squibs are fired electrically.


So, which one were you referring to ?
Which Boeing twin has cables for the 'T-Handles' ? 737 no. 757 no, 767 no, 777 no. Boeing 787 wasn't around back then, but it too is a no.
Do not remember any Boeing Twins having "cables for T-Handles reversed in the 1990s", except for the speculation around British Midland, where it was thought according to the accounts, the crew wanted to shut down the bad engine but the good one ended up shutting down. After the investigation and FCDs being performed it was found that the British Midland Crew shut down the wrong engine, the 'good one', that was and would have gotten them to the runway.
You are here.
 
WayexTDI
Posts: 1953
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Re: Manufacturing-related accident or incident

Wed Mar 06, 2019 9:14 pm

Noshow wrote:
Swissair MD-11 at Halifax.
Not original MDD manufacturing related but happened during heavy maintenance later:
Had received some aftermarket IFE that accidentally got hooked up to the hot battery bus. Crew had no chance to pull the circuit breakers when facing some electrical fire and crashed.

Isn't that more a design or installation defect?
 
diverted
Posts: 1296
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Re: Manufacturing-related accident or incident

Wed Mar 06, 2019 9:16 pm

ASA 529
The probable cause of the accident was determined to be the failure of the propeller due to undiscovered metal fatigue in one blade resulting from corrosion from chlorine.[1]:v There had been two previous failures of the same type of propeller, but those aircraft had been able to land safely.[1]:26–27 The failed propeller blade had undergone scheduled ultrasonic testing on May 19, 1994, which resulted in its rejection and removal from the propeller.[1]:37 The blade was sent to a Hamilton Standard facility, where it was subject to refurbishing work that was incorrectly performed.[1]:v The propeller blade was then installed on the propeller fitted to the aircraft on September 30, 1994.[1]:39

The National Transportation Safety Board (NTSB) criticized Hamilton Standard, who had maintained the propellers, for "inadequate and ineffective corporate inspection and repair techniques, training, documentation and communication", and both Hamilton and the Federal Aviation Administration for "failure to require recurrent on-wing ultrasonic inspections for the affected propellers".[1]:v The overcast skies and low cloud ceiling at the crash site also contributed to the severity of the crash.[1]:v
 
Gangurru
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Re: Manufacturing-related accident or incident

Wed Mar 06, 2019 10:15 pm

March 3rd was the 45th anniversary of the Turkish DC10 crash. This was a manufacturing related accident.

The THY DC10 was delivered on December 1972, which was 6 months after the first cargo door accident on AA96. There were design changes made in response to AA96, namely the installation of a support plate on the door’s locking mechanism.

The THY DC10 was on the manufacturing line when the response to AA96 was finalised. The support plate was signed off as being installed. Tragically it wasn’t.

Because of such an massive oversight when the risks to flight safety were know, many of the victims families have expressed regret that no one was ever charged with criminal negligence.

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