In order to prevent the mix-up from ever happening again, the Australia Civil Aviation Safety Bureau required Qantas to perform a “risk assessment” to determine the causal factors and install safeguards. While I am not privy to Qantas corrective actions, I am sure it would incorporate fixes like: painting the carts different colors, branding the cart with the name of the gas that is being carried, installing warning placards and servicing instructions on the cart itself, revising the task work cards to ensure the mechanic identifies the proper cart and gas to be used, and requiring initial and recurrent training on the servicing of oxygen bottles and aircraft tires.
So what is the lesson here? The lesson is that any time a new piece of equipment comes on line, management should perform a “risk assessment” to ensure that a situation similar to our Qantas case study will not happen.
Let’s not look only at new equipment! Look at old equipment and see if it is still serviceable. While checking APUs, jacks, oxygen and nitrogen carts, and hydraulic mules are important, may I suggest there is something in everybody’s hangar that is often overlooked but is vitally important to maintaining safety. Have you tested your hangar grounding points? Can those grounding rods you clip onto every day still offer a safe ground?
Imagine the damage an errant spark could do inside a hangar. Over the years, the ability to make a good ground might be affected by changes in the soil condition and water table. That is just one area you might want to check. You might want to take a look at other things around your home away from home and do a little “risk assessment” of your own. You might find a little more than bad air lurking there.