ACTIVITY NO.

1 CASE STUDY ANALYSIS: AIRCRAFT DESIGN ERRORS

NAME: CHUA, DIMALIBOT, DIZON, J.M., PARULI, SUBMISSION DATE: FEB. 14, 2024
SANCHEZ, TORRES
INSTRUCTOR: ENGR. RAUL RAMIRO C. SILVA RATING:

1. INTRODUCTION AND SUMMARY

The case study will feature an aircraft incident or accident caused by an aircraft’s
design or a manufacturing error. It will then analyze the incident based on the
investigation findings and identify alternative solutions to the problem or cause. The
case study will help the students have an analytical view and proper application of
regulations when designing an aircraft to prevent repeating the same mistakes.

Figure 1.1 BOAC Flight 781

This case study will analyze the aircraft accident involving the BOAC (British
Overseas Airways Corporation) Flight 781 that departed from Singapore and bounded to
London with 35 on board, including the crew. This accident involves the de Havilland
Comet passenger jet aircraft, which is known to be the world’s first commercial jet
aircraft. As BOAC Flight 781 approached to finish its itinerary from Singapore and on its
last stretch, where it would fly from Rome to its final destination in London, all of the
necessary parts, fluids, and all other clearances that were needed to be confirmed
before commencing flight were conducted by engineers and were verified and approved
by the Captain, Alan Gibson.

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 ACTIVITY NO. 1 CASE STUDY ANALYSIS: AIRCRAFT DESIGN ERRORS

Figure 1.2. BOAC Flight 781 Simulation of the Accident

The aircraft commenced its flight to Rome at 10:31 CET (09:31 UTC) on 10 January
1954; it gained its altitude, all of which seemed normal. Around 10:50 CEST, another
BOAC operating aircraft came into contact with Captain Alan Gibson through radio
communication, and after a few minutes, Captain Alan Gibson could not be contacted as
well as from the airport tower of Rome. A few hours later, the report came in that BOAC
Flight 781, bound for London, had crashed into the Mediterranean Sea near the Island of
Elba. There were no survivors, and local residents of Elba stated they heard a loud sound
that was described as somewhat like thunder that had struck and was followed by
burning aircraft parts falling from the sky. At that time, there were no hints of what had
caused the BOAC Flight 781 accident.

Figure 1.3, & 1.4. De Havilland Comet Pressure Simulation

As there were no hints of knowing what happened to the accident, the British
Overseas Airways Corporation pushed through a rigorous investigation to objectively
describe and discover what led to the accident. Their investigation leads to various ways
of investigating an aircraft’s capacity throughout its design life cycle. One of which is the
aircraft pressurization simulation; the team came up to analyze and simulate this
scenario as they have learned most of the victims have ruptured lungs that had occurred
before their death. Another simulation test was to put an actual scale of the aircraft into
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 ACTIVITY NO. 1 CASE STUDY ANALYSIS: AIRCRAFT DESIGN ERRORS

a giant water tank that simulates the pressure happening throughout the aircraft’s flight
cycle. Research and innovative practices lead to new methods of investigating and
testing a plane, which sprouts new opportunities for various airlines for the years to
come to try their aircraft and design it to the full extent and, therefore, move aviation
safety forward and improve it to a much more complex system.

Figure 1.5. BOAC Flight 781 Structural Damage Illustration

With the water tank simulation, they learned that the design of the de Havilland jet
aircraft, recording only 3,000 flight hours, had already experienced a ruptured skin in the
fuselage. This further progress of the investigation led the team to learn more about the
aircraft structure's significance and how stresses and various loads act on the aircraft's
fuselage. They also understand more about metal fatigue through an aircraft life cycle.
This metal fatigue was emphasized during the investigation as jet aircraft runs through a
pressurized cabin and cockpit to ensure that the passenger and the crew have enough
oxygen to breathe and as well as for the pressure in the cabin, cockpit, and cargo
compartment to have an acceptable differential pressure with the ambient pressure
outside the aircraft to prevent structural damage. Only aluminum alloy metals were used
at that time, and building the aircraft's structure was simple. Learning how stresses and
loads act on an aircraft throughout its life cycle was a significant step in aviation and
aircraft design. To this day, the complexity of building aircraft parts has grown and is
more complex than ever to ensure the reliability of various aircraft.

1.1 Objectives

The report of this case aims to understand and learn about what happened
to the BOAC Flight 781 accident. It also aims to see what specific parts of the
aircraft have caused the accident and to know if it is an aircraft design or
manufacturing error. One of the objectives is to see what we can learn from this
kind of catastrophe to advance aviation safety further and also to recommend

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 ACTIVITY NO. 1 CASE STUDY ANALYSIS: AIRCRAFT DESIGN ERRORS

various types of actions that should be done to prevent this type of accident from
happening again.

1.2 Scope and limitations

This report will investigate the accident that occurred on January 10, 1954.
It will use available resources to fully understand what happened and what further
actions were taken from those years that led to the advancement of aircraft design
about the aircraft design error that will be discovered in this investigation. Although
a following accident has occurred that is similar to the BOAC Flight 781; this report
will only study the case of BOAC Flight 781 as in its final investigation, both aircraft
are correlated with the events that occurred.

1.3 Problem and Significance

One of the challenging tasks to fully understand and explain what happened
during the accident of BOAC Flight 781 is the evidence to explore, as in 1954, there
were no such black boxes or Flight Data recorders to refer to. Investigating this case
based on the British Overseas Airways Corporation was a daunting task as the
aircraft pieces were in the deep ocean of the Mediterranean.

However, having to explore the roots of the accident would bring back the
reliability of the British Overseas Airways Corporation in conducting flights and the
reliability of the design of the De Havilland Comet Jet Aircraft. But most importantly,
to learn and improve the structural or overall design of the aircraft.

2. FINDINGS

The failure resulted from metal fatigue caused by the repeated pressurization and
de-pressurization of the aircraft cabin. However, it was only if the aircraft's structural
integrity had been maintained.

This is because the supports around the windows were riveted, not glued, as the
original specifications for the aircraft had called for. The problem was exacerbated by the
punch rivet construction technique employed. Unlike drill riveting, the imperfect nature
of the hole created by punch riveting caused manufacturing defect cracks, which may
have caused fatigue cracks to start around the rivet.

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 ACTIVITY NO. 1 CASE STUDY ANALYSIS: AIRCRAFT DESIGN ERRORS

Figure 2.1. BOAC Flight 781 recovered fuselage part

With the aircraft handling the pressure around it and experiencing a lot of stress,
simple holes like rivets in the attachment of the window may cause a lot of downfalls in
its structural integrity. As stated, the windows in the fuselage of the De Havilland Comet
were supposed to be glued instead of riveted in the skin. Therefore, it is a manufacturing
error, as it needs to follow the designed assembly process.

Considering that the accident occurred due to metal fatigue experienced forward of
the fuselage wherein a 2-centimeter crack appeared in a riveted area as the aircraft
pressurized as it moved at a high altitude for it to cruise efficiently. Although it may lead
to further understanding of the aircraft structure and safety precautions in
manufacturing the aircraft, sadly, 35 victims lost their lives.

3. DISCUSSIONS

The primary issue was metal fatigue in the fuselage skin around the square
windows of BOAC Flight 781’s. These windows created stress concentrations,
exacerbated by the design and manufacturing techniques used. Repeated pressurization
cycles caused the microscopic cracks to propagate, ultimately leading to catastrophic
failure.

Evaluation of Identified Alternatives:

1. Using Stronger Material and Design

• Advantages: Stronger materials make planes more durable and resistant to

damage. Better design can distribute stress more evenly, making the plane safer.

• Disadvantages: Developing new materials and designs can be expensive and

take time. Testing new designs thoroughly is crucial for safety.

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 ACTIVITY NO. 1 CASE STUDY ANALYSIS: AIRCRAFT DESIGN ERRORS

2. Regular Maintenance Checks:

• Advantages: Regular checks can catch problems early, preventing disasters.

They ensure the plane is safe to fly.

• Disadvantages: Maintenance can be costly and cause delays. Sometimes,

problems may be missed during checks.

3. Predictive Maintenance:

• Advantages: Early detection and address of potential issues before they

become critical.

• Disadvantages: Requires advanced sensor technology and data analysis,

potential for false positives and maintenance costs.

4. Better Training:

• Advantages: Improves crew response and increases survival chances.

• Disadvantages: Requires ongoing training and practice.

4. CONCLUSIONS

In conclusion, the investigation into the event involving BOAC Flight 781 on January
10, 1954, provided important insights into the accident's core causes and benefits. The
main issue discovered was structural fatigue in the fuselage, worsened by installing
square windows, which focused stress on fracture propagation. The forensic inspection
of wreckage, flight data analysis, and review of maintenance records all confirmed this
finding.

The findings highlighted the significance of repairing design defects, improving

maintenance methods, and increasing regulatory control in commercial aviation safety.
Several recommendations have been made to reduce the likelihood of similar incidents,
including redesigning windows to reduce stress concentration, implementing rigorous
inspection procedures, developing lifecycle management strategies, improving
maintenance staff training programs, and revising regulatory requirements for aircraft
design and maintenance.

By collaborating with business organizations and regulatory authorities to

implement these recommendations, the aviation sector may work to improve safety
standards and prevent structural fatigue-related accidents in the future. This complete
strategy aims to enhance structural integrity, strengthen safety standards, and protect
the well-being of passengers and crew.

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5. RECOMMENDATIONS

Here is a list of specific recommendations that have been suggested in response to

the inquiry of the aircraft accident to reduce the likelihood of failures caused by
structural fatigue. By working together, these suggestions seek to increase commercial
aviation safety and reduce the possibility of future occurrences of this kind of mishap.

a. Improvements to Windows to lessen stress concentration areas; think about

remodeling the windows of airplanes. Switching to rounded or oval-shaped
windows might reduce the likelihood of fatigue-related breakdowns by more
uniformly distributing load throughout the fuselage.

b. Improved Inspection Procedures to increase the frequency and intensity of

inspection procedures, paying particular attention to locations where stress
concentration is likely to occur.

c. Lifecycle Management of Aircraft provides a thorough lifecycle management

strategy for aircraft that addresses structural fatigue concerns proactively. Consider
putting routine structural health monitoring systems in place to keep tabs on the
state of essential parts over time.

d. Training and Awareness improve maintenance staff training programs to

guarantee a deeper comprehension of the possible repercussions of structural
fatigue. Stress the value of conducting in-depth inspections and promptly reporting
any irregularities.

e. Regulatory Monitoring works with aviation authorities to revise rules concerning

aircraft design and maintenance requirements. Promote the use of better design
techniques and materials to increase structural integrity.

6. REFERENCES

cros. (2016, January 19). Air crash investigation BOAC flight 781 [48:40] [Video].
YouTube. https://www.youtube.com/watch?v=n9ePyQjT6io

BOAC flight 781. (n.d.). YouTube.

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watch%3Fv%3DWWjaeFnE0pM&psig=AOvVaw1r7bBshvLMBj_fx1OZYI8r&ust=17
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com%2Ftag%2Fflight-
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