Accident Research Alaska Airlines Flight 261
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Case Study Analysis: Accident Research Alaska Airlines Flight 261
Mae Murch
Embry-Riddle Aeronautical University
BSAS 335
Mark Scharf
October 1, 2023
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Case Study Analysis: Accident Research Alaska Airlines Flight 261
On January 31, 2000, the Alaska Airlines Flight 261, scheduled to fly from Puerto Vallarta, Mexico, to Seattle Washington, crashed into the Pacific Ocean only 2.7 miles north of Anacapa Island California (Federal Aviation Administration, n.d.). None of the 88 people on board survived. The National Transportation Safety Board (NTSB) identified the primary causal factor of the accident as a loss of airplane pitch control due to the in-flight failure of the horizontal stabilizer trim system jackscrew assembly's Acme nut threads. This thread failure was attributed to excessive wear resulting from insufficient lubrication by the Alaska Airlines Maintenance department. Essentially, the inadequate maintenance and lubrication of this crucial component led to a catastrophic failure that resulted in the crash.
Some of the contributing factors to the accident were maintenance oversight. The failure to adequately maintain and lubricate the jackscrew assembly allowed for excessive wear to develop, which lead to the failure of the assembly.
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https://admiralcloudberg.medium.com/the-price-of-an-hour-the-crash-of-alaska-airlines-flight-
261-c797a7c3d90d
The airline's organizational culture and practices may have played a role in the maintenance oversight. Performing maintenance on a less frequent basis saves on labor cost and can keep the airplanes in the air longer. This increases overall revenue. Therefore, the interval between the jackscrew lubrication was increased from every 500 flight hours to approximately every eight months, which equated to about 2250 flight hours at the time. Theocratically the interval term would have been enough; however, this would only work if enough grease was applied in the correct way, every single time (Cloudberg, 2021). Some regulatory oversight was also at play. The NTSB investigation raised questions about the Federal Aviation Administration's (FAA) oversight of Alaska Airlines' maintenance practices. The FAA's failure to
identify and address maintenance deficiencies could be seen as a contributing factor. Another factor was the crew’s response. Once the aircraft was in a stable landing configuration, an emergency landing at LAX should have been made. However, the crew decided to use the autopilot and trim motors to troubleshoot the issue instead (Federal Aviation Administration, n.d.).
The key structural and mechanical factor in this accident was the jackscrew assembly's Acme nut threads, which were subject to excessive wear due to insufficient lubrication. This component was critical for maintaining pitch control of the MD-83 aircraft. The insufficient lubrication and wear on these threads ultimately led to their failure, causing the loss of pitch control and the subsequent crash. The accident raised several questions about the safety culture within Alaska Airlines and whether it prioritized maintenance and safety over operational considerations (Cloudberg, 2021).
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Following the accident, the NTSB made several recommendations aimed at preventing similar incidents. These included improvements in maintenance procedures, enhanced regulatory
oversight, and changes in aircraft design to prevent single-point failures. Additionally, Alaska Airlines implemented changes to its maintenance practices.
To mitigate the risk of similar accidents enhanced maintenance procedures are required, including regular inspections and lubrication schedules for critical components like the jackscrew assembly. The FAA also needs to strengthen its oversight of airline maintenance practices, ensuring compliance with safety standards and protocols. Alaskan Airlines also needs to start fostering a culture that prioritizes safety over operational considerations, encouraging employees to report safety concerns without fear of retribution and not use the cheapest, most competitive route.
Overall, the Alaska Airlines Flight 261 accident serves as a sad reminder of the critical importance of proper maintenance, safety culture, and regulatory oversight in aviation. Inadequate maintenance procedures, organizational culture issues, and regulatory shortcomings contributed to this tragic event. By implementing improved maintenance practices, strengthening
safety cultures, and enhancing regulatory oversight, the aviation industry can work to prevent similar accidents and ensure the safety of passengers and crew.
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References
Cloudberg, A. (2021, July 22). The price of an hour: The crash of Alaska Airlines Flight 261
. Medium. https://admiralcloudberg.medium.com/the-price-of-an-hour-the-crash-of-alaska-
airlines-flight-261-c797a7c3d90d McDonnell Douglas MD-83
. Federal Aviation Administration. (n.d.). https://www.faa.gov/lessons_learned/transport_airplane/accidents/N963AS