Follow the manual

March 1, 1998

Follow the Manual!

A lesson that can't be stressed enough

By John Goglia

March 1998

John Goglia is a member of the National Transportation Safety Board (NTSB). He has been a technician for USAir for the past 30 years.

As I review FAR violations that occurred in the past, I am amazed by how many violations involve technicians who do not follow the manual either on their own or by asking their supervisor for instructions. If you chose either of these methods, sooner or later you will face a problem.

A pilot/technician who was employed by a FAR Part 135 air carrier was working under the verbal instructions given to him by the maintenance supervisor on how to install a used propeller governor onto another engine. The governor installation was accomplished without any problems; however, the oil supply line from the engine was difficult to connect to the governor as there is little clearance and the line is pre-bent so it did not line up. When this technician was unable to get the "B" nut to start on the threads, he called the maintenance supervisor who first checked the part number of the line to insure that it was the correct line. It was.

This technician was then told to bend the line so it would line up with the aluminum fitting on the governor. After some custom bending, the line was in the correct position and the "B" nut was tightened using an open-end wrench. The maintenance manual called for 110 inch-pounds of torque for this nut. In testimony, it was clear that a torque wrench was available to this technician; however, this installation requires a crowsfoot, which was not available. As a result, the line was tightened without the benefit of the torque wrench.

While this work was under way, the maintenance supervisor was nearby. When the work was completed, the supervisor inspected the completed task. After the maintenance was completed the pilot/technician proceeded to fly the aircraft on several flights without any problem. After approximately six hours of flying, another pilot, flying at 4,000 feet, experienced a severe oil leak which caused the engine to fail.

The FAA reviewed the accident, determined the technician had not used a torque wrench, and charged the technician who performed the work with violations of FAR 43.13a and b. This was appealed to a National Transportation Safety Board (NTSB) administrative law judge who heard testimony from experts on both sides. There is plenty of discussion, in the record, of the events that lead up to the accident and of conversations between the technician and the supervisor. The supervisor who inspected the work actually helped the FAA pin the responsibility for this accident on the technician.

The judge ruled that the technician was in fact wrong and the suspension of his A&P certificate was upheld. When you cut through all the testimony, one simple fact surfaces — the technician did not follow the manual. Even though the supervisor was more experienced than this technician, his experience could not cover for the fact that the technician did not follow the approved manual.

We have all been there before; just trying to get the job accomplished using the knowledge and experience of our coworkers as a resource in accomplishing the task. But even the best intentions and the most experienced advice is not a substitute for following the approved maintenance manuals.

Time and time again, I see violations of the FARs simply because technicians do not review and follow the appropriate maintenance manuals. We technicians have become very good at removing and replacing parts without ever looking at a maintenance manual.

However, our aviation system requires more from each of us. We are professionals and we need to act like professionals. That means we need to refer to and follow all the published procedures in the manual and accomplish our respective tasks. When we all do that, the pilots and passengers who rely on us will not be placed in unnecessary risk.