Trust Your Own Judgment

Nov. 1, 2002

Prevent accidents by following instincts

My mistake took place sometime in the mid 1980s when I was employed by a helicopter operator that specialized in Emergency Medical Services contracts. I was a lead mechanic/project manager in charge of a crew of three A&Ps. We were performing a major inspection on a BK117, a project that lasted several weeks.

The No.1 engine had previously been removed for heavy maintenance and was ready to be reinstalled. The homemade, swedged cable sling we had used to remove the engine had become visibly worn. But we used it anyway, because it was the only means we had of lifting the engine from the aircraft. As my crew prepared the engine for reinstallation, I shared my concerns with the shop foreman and field maintenance supervisor about the deteriorated condition of the engine sling. Their response was something like "That sling’s fine. Go ahead and use it. Nothing wrong with it."

As we proceeded to lift the engine to the height of the engine mounts (at least 6 feet above floor level), my suspicion about the integrity of the engine sling proved to be correct. When the engine reached a height of about 4 feet, the sling failed. The LTS101 engine landed on its oil pump, shattering it, in addition to causing unknown internal damage. Luckily, no one was directly under the engine when it fell. It only slightly grazed the leg of one of my crew as it came crashing down. As you would imagine, it made a rather loud thud as it hit the hangar floor.

I strolled into the hangar office to inform the shop foreman and field maintenance supervisor about the "accident" that just took place. With a large "I told you so" grin on my face, I asked, "You remember the engine sling I told you about? Well, guess what that loud crash was from." They both raced out to the hangar floor in disbelief to see the dead engine for themselves.

As I look back on that incident with the benefit of nearly 20 years of hindsight, I partially blame myself for what happened. Management should have taken my warning seriously and replaced the defective support equipment. And I should have refused to use that sling that I no longer trusted to do the job safely. An "I’ll show you" attitude endangered both myself and my crew.

Editors Note: This story which was submitted by one of our readers is an example of our new column in AMT – Lessons Learned.

As I mentioned in my August 2002 editorial column, one of the ways that many of us learn safe maintenance practices is through the lessons learned from someone’s mistakes or oversights. If we can learn from others mistakes or share our own with others, everyone is more knowledgeable, and safety is enhanced.

So send us your story of an incident that happened to you or someone you know. Tell us the specifics of the incident such as the type of aircraft being worked on and the mistake(s) made. If possible, include any contributing factors that led to the incident like stress, distraction, or lack of resources. Then share what lesson was learned from this event.

I want to stress that company names will not be printed nor will personal names. We don’t want to point any fingers, only provide the opportunity to learn from mistakes. You can send in your story to:

AMT

"Lessons Learned"

1233 Janesville Avenue

Fort Atkinson, WI 53538

or e-mail to [email protected]

Thanks to all of those that sent in their stories. To those that haven’t, why don’t you share your story so that others may learn. AMT