Incident: Boeing 737-200 Cargo Plane Engine Failure and Emergency Landing

Published Date: 2021-07-02

Postmortem Analysis
Timeline 1. The software failure incident involving the Boeing 737-200 cargo plane happened in early hours of Friday off the coast of Hawaii as reported on July 2, 2021 [Article 116431].
System unknown
Responsible Organization 1. The software failure incident involving the Boeing 737-200 cargo plane off the coast of Hawaii was not caused by a software issue. The incident was primarily due to the failure of both engines of the aircraft, leading to an emergency landing in the sea [116431].
Impacted Organization 1. Transair (Rhoades Aviation Inc) - The entity operating the Boeing 737-200 cargo plane that experienced the software failure incident [116431]. 2. Boeing - The manufacturer of the Boeing 737-200 cargo plane that experienced the software failure incident [116431].
Software Causes unknown
Non-software Causes 1. The failure incident was caused by both engines of the Boeing 737-200 cargo plane failing off the coast of Hawaii, leading to an emergency landing in the sea due to engine malfunctions [Article 116431]. 2. The engines appeared to be failing and running very hot, with the pilot reporting the loss of one engine and the potential loss of the second engine [Article 116431]. 3. It was mentioned that engines can fail due to factors like bird strikes or volcanic ash, but the specific cause of these engine malfunctions was unclear [Article 116431]. 4. The incident involved a 46-year-old Boeing 737-200 cargo plane operated by Rhoades Aviation Inc, doing business as Transair, which raises questions about the age and maintenance of the aircraft [Article 116431]. 5. The pilots reported trouble with both engines, leading to the emergency landing in the sea, and the aircraft was unable to return to Honolulu due to insufficient altitude [Article 116431].
Impacts 1. The software failure incident involving the Boeing 737-200 cargo plane led to both engines failing, forcing an emergency landing in the sea off the coast of Hawaii. This resulted in one pilot sustaining serious injuries and being airlifted to the hospital, while the other pilot was less severely harmed and transported back to land by boat [Article 116431]. 2. The incident raised worrying questions about the cause of the engine malfunction, as it was unclear what led to the failure of both engines in the 46-year-old plane [Article 116431]. 3. Following the emergency landing, shares of Boeing fell by three percent, indicating a negative impact on the company's stock value [Article 116431]. 4. The National Transportation Safety Board deployed seven investigators to look into the incident, highlighting the seriousness of the software failure and its implications for aviation safety [Article 116431].
Preventions 1. Regular maintenance and thorough inspections of the engines could have potentially prevented the software failure incident by detecting any issues before they escalated [116431]. 2. Implementation of advanced engine monitoring systems or sensors that could provide real-time data on engine performance and potential malfunctions could have helped in early detection of the engine issues [116431]. 3. Enhanced training for pilots on handling emergency situations and engine failures could have potentially mitigated the impact of the incident and improved the chances of a successful emergency landing [116431].
Fixes 1. Conduct a thorough investigation by the National Transportation Safety Board (NTSB) to determine the root cause of the software failure incident [116431]. 2. Implement necessary software updates or modifications based on the findings of the investigation to prevent similar incidents in the future [116431]. 3. Provide additional training to pilots on handling emergency situations and software-related issues to ensure they can effectively manage such scenarios [116431].
References 1. LiveATC [116431] 2. FlightAware.com [116431] 3. RadarBox.com [116431] 4. SimpleFlying.com [116431]

Software Taxonomy of Faults

Category Option Rationale
Recurring multiple_organization (a) The software failure incident having happened again at one_organization: - The article does not mention any specific software failure incident happening again within the same organization or with its products and services. (b) The software failure incident having happened again at multiple_organization: - The article mentions a previous incident involving the Boeing 737 MAX, where two accidents occurred due to software issues that led to the grounding of the aircraft for 20 months [116431].
Phase (Design/Operation) unknown (a) The software failure incident related to the design phase: - The incident involving the Boeing 737-200 cargo plane's dual engine failure off the coast of Hawaii was not attributed to a software failure related to the design phase. The focus of the incident was on the mechanical failure of the engines, leading to the emergency landing in the sea [116431]. (b) The software failure incident related to the operation phase: - The article does not mention any software failure incident related to the operation phase. The primary focus of the incident was on the mechanical failure of the engines of the Boeing 737-200 cargo plane, leading to the emergency landing in the sea [116431].
Boundary (Internal/External) within_system (a) The software failure incident related to the Boeing 737-200 cargo plane crash off the coast of Hawaii appears to be within_system. The incident involved both engines of the plane failing, leading to an emergency landing in the sea. The pilots reported losing one engine and the second one running very hot before failing as well. The software failure in this case seems to be related to the malfunction or failure of the engines within the aircraft system itself, rather than being caused by external factors [116431].
Nature (Human/Non-human) unknown (a) The software failure incident in the Boeing 737-200 cargo plane off the coast of Hawaii was not directly attributed to non-human actions such as a software glitch, bug, or fault. The incident was primarily related to the failure of both engines, leading to an emergency landing in the sea. The cause of the engine malfunction was not specified in the articles [116431]. (b) The software failure incident in the Boeing 737-200 cargo plane off the coast of Hawaii was not directly attributed to human actions introducing contributing factors that led to the failure. The incident was primarily related to the failure of both engines, which prompted the emergency landing in the sea. The cause of the engine failure was not explicitly linked to human actions [116431].
Dimension (Hardware/Software) unknown (a) The software failure incident in the Boeing 737-200 cargo plane off the coast of Hawaii was not directly attributed to hardware failure. The incident involved both engines failing, leading to an emergency landing in the sea. The cause of the engine malfunction was not specified in the articles, and it was mentioned that it was unclear what caused the engines to malfunction [116431]. (b) The software failure incident did not have contributing factors originating in software as the primary cause. The incident was primarily focused on the failure of both engines of the Boeing 737-200 cargo plane, leading to the emergency landing in the sea. The articles did not mention any software-related issues as a contributing factor to the incident [116431].
Objective (Malicious/Non-malicious) non-malicious (a) The software failure incident in the Boeing 737-200 cargo plane off the coast of Hawaii was non-malicious. The incident involved both engines of the plane failing, leading to an emergency landing in the sea. The pilots reported losing one engine and the second engine running very hot, indicating a technical malfunction rather than a malicious act. The National Transportation Safety Board sent investigators to determine the cause of the engine failures [Article 116431]. (b) The incident did not involve any indication of malicious intent or sabotage related to the software failure. The focus was on the technical aspects of the engine failures and the emergency landing that followed, with no mention of intentional harm introduced by humans [Article 116431].
Intent (Poor/Accidental Decisions) unknown The software failure incident reported in the articles does not directly relate to either poor decisions or accidental decisions. The incident primarily involved the failure of both engines of a Boeing 737-200 cargo plane off the coast of Hawaii, leading to an emergency landing in the sea. The focus was on the mechanical failure of the engines rather than software-related issues.
Capability (Incompetence/Accidental) accidental (a) The software failure incident does not seem to be related to development incompetence. The incident was primarily due to the failure of both engines of a Boeing 737-200 cargo plane, leading to an emergency landing in the sea off the coast of Hawaii. The cause of the engine malfunction was not specified in the articles [Article 116431]. (b) The software failure incident appears to be accidental rather than intentional. The incident was described as the loss of both engines of the Boeing 737-200 cargo plane, which forced the emergency landing in the sea. The pilots reported engine troubles and were attempting to return to Honolulu before losing the second engine and having to ditch the aircraft into the ocean. The exact cause of the engine failures was not explicitly mentioned in the articles, indicating an accidental nature of the incident [Article 116431].
Duration unknown The software failure incident reported in the news articles does not directly relate to a software failure in terms of a bug, fault, error, or glitch. Instead, the incident primarily involves the failure of both engines of a Boeing 737-200 cargo plane, leading to an emergency landing in the sea off the coast of Hawaii. The focus is on the mechanical failure of the engines rather than a software-related issue. Therefore, the articles do not provide information on the duration of the software failure incident as it is not applicable in this context.
Behaviour crash (a) crash: The software failure incident in the news article resulted in a crash as the Boeing 737-200 cargo plane experienced engine failures and had to make an emergency landing in the sea off the coast of Hawaii [116431]. (b) omission: There is no specific mention of the software omitting to perform its intended functions in the incident reported in the news article. (c) timing: The incident did not involve a failure related to the timing of the system performing its intended functions. (d) value: The software failure incident did not involve the system performing its intended functions incorrectly. (e) byzantine: The incident did not exhibit behavior related to the system behaving erroneously with inconsistent responses and interactions. (f) other: The software failure incident in the news article involved a crash due to engine failures on the Boeing 737-200 cargo plane, leading to an emergency landing in the sea off the coast of Hawaii. The incident raised questions about the cause of the engine malfunctions, but there was no specific mention of the software itself malfunctioning in a way not covered by the other options.

IoT System Layer

Layer Option Rationale
Perception None None
Communication None None
Application None None

Other Details

Category Option Rationale
Consequence harm (a) death: People lost their lives due to the software failure - The incident involving the Boeing 737-200 cargo plane off the coast of Hawaii resulted in both pilots being rescued from the sea, with one sustaining serious injuries and being airlifted to the hospital. It was reported that one of the pilots was in critical condition, and the other was in serious condition with a head injury and multiple lacerations [Article 116431]. (b) harm: People were physically harmed due to the software failure - One of the pilots rescued from the crashed Boeing 737 cargo plane was in critical condition with a head injury and the other was in serious condition with multiple lacerations [Article 116431].
Domain transportation, health (a) The failed system was intended to support the transportation industry, specifically in the context of air cargo transportation. The incident involved a Boeing 737-200 cargo plane operated by Rhoades Aviation Inc, which does business as Transair, one of Hawaii's largest air cargo carriers [Article 116431]. (j) The failed system was also related to the health industry indirectly as it involved the transportation of cargo, which could include medical supplies, equipment, or pharmaceuticals that are essential for healthcare operations [Article 116431]. (m) The incident did not directly relate to any other industry mentioned in the options provided.

Sources

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