Roles and Interactions Between Specific and Systemic Failings:

Leodis Airline, Boeing 737, LO 237, Leeds, July 31, 2017

Cheuk Man Sin (200929370)

The roles and interactions of this accident are shown in figure 1. In particular, Specific failings refer

to issues in this particular accident (i.e. Roles that directly involve operation of this flight) while

Systemic failings refer to the issues of management structure (i.e. latent error).

Figure 1. Roles (in circles) and interaction charts (in arrows) of LO 237 accident in specific
(Left) and systemic aspect (Right). The red arrows are representing an interaction failing for
the roles.

1. Roles and Interactions in Specific aspect

Captain, First Officer and cabin crew did not have communication issues, thus the accident is unlikely

caused by the failure of teamwork like Kegworth crash1. This is due to CVR expert, Mr Ingleby,

commented in the accident hearing on October 17, 20172, said that flight crew have worked in a

professional manner, followed SOP properly and had communication with cabin crew even in the

emergency, as shown in the CVR transcript. Also, despite the fact that mechanical engineer, Ms

Prodanova, failed to complete the C check on time due to working with an understaffed team and

feeling stressed, the captain did not have any issues on the delay and signing off the maintenance

certificate and related documents, as mentioned during the accident hearing3.

The major failing in this aspect is between Airline Director of Safety, Cabin crew and passengers in

the rival groups. Surviving cabin crew and Airline Director of Safety have spoken in the accident

Q&A Questions for Cabin Crew of Flight LO2374 and Questions for Airline Director of Safety5

thread respectively, which Airline Director of Safety has given the list of the members of the rival

group to the crew but cabin crew did not know who were the related passengers. Therefore, cabin

crew could only notify the flight crew and unable to implement any prevention measures (e.g.

separating the passengers if they sitting next to each other). This may have led to the riot to happen,

thus increased the difficulty in evacuation and indirectly contributing to injuries and fatalities.

2. Roles and Interactions in Systemic aspect

Airline Director of Operation and Maintenance, Director of Safety and Director of Training had

communication to ensure airline work properly, as shown in accident Q&A thread for their role

respectively. They have established crew training and operating procedure for both normal operation

and emergency, recurrent training6, aircraft safety equipment5 and maintenance checklist7 which fulfil

the Authoritys regulation. With the operating procedure without prevention of riot, this shows a

recommendation for the airline to change their operating procedure in response to this accident.

However, as stated in section 1, the cabin crew were unalarmed on the list of the related passengers

while Director of Safety said he has already passed it to the cabin crew and notified Airline Director

of Operation once received the list from LBA Security Officer5. It shows that there was a

miscommunication thus airline should improve communication with crew in unforeseen situations.

Secondly, there were lack of inspection of the third-party maintenance company7. Ms Prodanova

stated in the hearing that the understaffed maintenance team had worked 3 extra hours per day and

feeling stressful to complete C check. Fatigue reduces task-directed effort8, which human likely to

create mistakes and may indirectly led to the engine explosion. However, airline did not inspect the

maintenance company after outsourcing7, as stated in Director of Operation Q&A thread and did not

comment on the rostering issues and work quality. This shows a long term recommendation for airline

to implement regular inspection over outsourced company in response to the accident.

References

1. J. Ford, R. Hederson and D. OHare, Barriers to Intra-Aircraft Communication and Safety: The Perspective of
the Flight Attendants, The International Journal of Aviation Psychology, 23(4), 368-387, 2013.
2. L. Ingleby, CVR expert comment on flight crew performance in LO237 accident hearing on October 17, 2017.
3. S. Prodanova, Engine and APU mechanical engineer comment on maintenance team performance in LO237
accident hearing on October 17, 2017.
4. T. Edwards, Accident Q&A thread Questions for Cabin Crew of Flight LO237. October 17, 2017.
5. L. Ingleby, Accident Q&A thread Questions for Airline Director of Safety. October 18, 2017.
6. L. Ingleby, Accident Q&A thread Questions for Airline Director of Training. October 18, 2017.
7. S. Prodanova, Accident Q&A thread Questions for Airline Director of Operations and Maintenance. October
17, 2017.
8. A. Williamson, D. Lombardi, S. Folkard, J. Stutts, T. Courtney and J. Connor, The link between fatigue and
safety, Accident Analysis and Prevention, 43(2), 498-515, 2011.