质量是安全的先决条件.ppt

Quality Moment 质量意识 Presented by :- Liao Liming Monday 14th Sept 2009 Quality is a pre-requisite of Safety. 质量是安全保障的先决条件！ BAC One-Eleven, G-BJRT ?The Didcot Incident 10th June 1990 ?British Airways flight 5390, over Didcot in Oxfordshire en route to Malaga from Birmingham, experiences sudden decompression whilst climbing through 17,300 ft. The left front cockpit windshield of the BAC One-Eleven has blown out, the commander is blown through the windshield aperture by the force of the decompression (only his legs being tangled in the control column prevents him being completely blown out of the aircraft). Through quick action of the cabin crew in clinging on to the commander, and the co-pilot in making an emergency descent, the incident resulted in nothing more than broken bones, some frostbite and shock. Subsequent investigation found that the left windscreen had been recently replaced ?84 out of 90 of the securing bolts were of a smaller diameter than specified. BAC 1-11型客机，机身编号G-BJRT ?迪科特飞行事故 1990年6月10 日，英航5390次航班。在伯明翰飞往西班牙马略卡途中，途经津郡迪科特市时丆此时已爬升至17,300英尺的高度，遭遇突发事故，机身在高空忽然失压。 这导致位于驾驶室左方，即正机长位置的挡风玻璃脱落，机长立即被气流从座位扯出驾驶室外（只是因为他的脚被缠在控制盘上，才使得他没有被完全吹出窗外）。 机舱内工作人员迅速上前紧抓住机长双腿，同时副机长设法紧急迫降，幸运的是此次事故只导致正机长身体多处骨折、冻伤和昏迷。 调查发现该飞机的挡风玻璃出事前曾被更换，可是90颗安在挡风玻璃的螺丝钉中有84颗的直径比标准要求的小。 The BAC One-Eleven Cockpit BAC 1-11型客机-驾驶室 What went wrong? Friday 8th June ?Late shift - The Shift Maintenance Manager (SMM) at Birmingham was carrying out the replacement of the left windscreen which had been reported as showing symptoms of leaking pressure from the interior to atmosphere. The specified bolts for the windscreen was BS A 211 type 8D. When the old bolts were removed, rather than consulting the parts catalogue, the SMM simply took an old bolt to the stores for comparison. The bolts removed were type 7D ?the wrong bolts had been used before. Local stores did not have any of the 慶orrect?bolts to hand ?SMS has to travel to a remote stores for replacements. The remote stores are unatte