The thing is workarounds are insidious. They are subject to “tolerance creep.”
Tolerance creep is the gradual deterioration of a standard or limit by the assumption that previous experience shows that limits are flexible. As each evaluation of the limit is made for the same item or similar items on aircraft elsewhere, further “judgment calls” allow the limits to be exceeded based on logical sounding assumptions that promote general consensus.
A good sample of tolerance creep is fuel prices. Once gas got to $4 a gallon, there was a public outcry. But as the price became the norm, people stopped protesting and have by and large accepted higher fuel prices.
In any organization once personnel have established that something works, even if it violates a standard, it becomes an accepted norm over time. Complacency has set in.
To that end latent hazards are not often detectable until an event reveals their presence. These latent “states” will wait for the right set of circumstances to reveal themselves.
Aircraft accidents are rare events and the least likely outcome of workarounds, but their severity greatly magnifies the outcome of such violations.
For example: In January 2003 a Beech 1900D crashed on takeoff from Charlotte, NC. The findings from the report:
- The accident airplane’s elevator control system was incorrectly rigged during the detail six maintenance check, and the incorrect rigging restricted the airplane’s elevator travel to 7 degrees airplane nose down, or about one-half of the downward travel specified by the airplane manufacturer.
- The changes in the elevator control system resulting from the incorrect rigging were not conspicuous to the flight crew.
- The QA inspector did not provide adequate on-the-job training and supervision to the mechanic who examined and incorrectly adjusted the system.
- Because the repair station’s inspector and the mechanic did not follow the procedure as written, they missed a critical step that would have likely detected and thus prevented the accident.
In creating a progressive organization based on best practices, management must lead the way in ruthlessly examining internal processes for compliance, currency, and safety. Internal self-audit or evaluation methods are the most effective way of examining operations and challenging complacency. In using all the tools at our disposal we drive the risk posed by procedural deviations way down, to levels that assure every flight remains an uneventful journey.
It may be that some people’s sole purpose in life is to be an example of what not to do in this world. Don’t become the poster child for what not to do when fixing an airplane. Take the long way home . . . no workarounds.
Vern Berry began his aviation career as an A&P mechanic in 1979. His experience within the aviation industry includes key management roles in quality and safety for both MRO and air carrier operations. He currently resides in upper state New York where he writes and manages a consultant firm at www.blowntireaviation.com.
Checklists are an effective production and control tool.
The FAA has zero tolerance for workarounds when an Airworthiness Directive is involved.
Don't just work around it, push the manufacturers to get it fixed.