Sometime later the aircraft was observed by another technician and it seemed to be down on one wing. He immediately called for help, but, by then it was too late. If another technician had been on hand for the job, chances are the accident could have been avoided or minimized.
Each technician must be aware of who is around him and what threat his surroundings present to him.
There were no gear lock pins in place on this aircraft. Perhaps the technician was not aware of them or had not been trained in this area. I doubt if anyone at this company will forget to check for gear downlock pins again. There has to be a standard operating procedure for such things as entering a dangerous place like a wheel well. Lock pins are mandatory items.
The accident described earlier where screws were left out of a tail leading edge boot retainer occurred as a result of shift change. You can't rely on simply having a conversation over coffee with one or two of the people on the previous shift. There must be a written shift turnover document in plain view at the work stations.
One of the best examples of a similar procedure is the "nurse's report." Anyone who has worked in a hospital will know that at shift change there is a formal meeting of the two shifts, including residents on staff, which gives the oncoming shift a clear statement of patient conditions, medication protocols, diagnostic tests to be completed, and a general outline of work in progress. This is a life and death meeting of the two work groups and the health of many people are in their hands. The similarity is uncanny. Our patient is the airplane in the hangar.
The aircraft maintenance record or paper notes are not the place for shift turnover instructions. A separate record should be present so there is no possibility of confusion. Furthermore, all members of both shifts should be present to review the written shift record and make appropriate notations and comments regarding work in progress. You must create a standard that can be followed by all of the technicians on the hangar or shop floor.
Clear and consistent guidelines or procedures for such things as gear retraction tests, high power turnups, testing of flight control movement, and hydraulic and electrical circuit testing are a must. Absent standard written procedures, that are rigidly followed, accidents will happen.
SAFETY AND REGULATION DIRECTOR
The Federal Aviation Regulations (FAR) spell out a safety management function for air carriers and the companion job at a repair stations is generally described in the op specs for the chief inspector.
The FAA's "one level of safety" for air carriers rulemaking in 1996 set forth a new management safety function under FAR 119.65 and described it as a "director of safety" which includes regulatory compliance. Suddenly, at least for air carriers, the FAA decided that safety should be elevated to the status and responsibility of a management person. Awareness of the safety function is now squarely and by force of regulation placed on a management person. Awareness of regulatory responsibility and more importantly the compliance standards are a necessary and fundamental requirement. Your company could be under the gun for FAA civil penalties and/or certificate action if there is no oversight in the safety area. In addition, civil liability outside the FAA could be applied, if the inspection process reveals a failure of compliance. You can rest assured litigation and lawyers will follow any safety oversight!
THE LEGAL ANGLE
Everyone should be aware of the litigation circus that has haunted and continues to haunt the aviation industry. Every time there is an aircraft accident you can count on lawyers representing injured parties attacking vigorously.
Accidents are always costly. When an employee is injured on the job he is provided workers compensation coverage for medical and lost wages and is generally precluded from suing his fellow employees or his employer for damages. However, you can be sure that the workers compensation insurance carrier will look around for some third party to blame and recover their payments from.
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