Such was the case of a jackscrew assembly failure caused by excessive wear resulting from insufficient lubrication. Contributing factors included extended lubrication and end-play check intervals, lack of available parts, organizational norms, and regulatory oversight issues. (NTSB ALASKA 261 FINAL REPORT, The Operator’s Manual for Human Factors in Aviation Maintenance 03, NTSB AAR-O2/01 Final Report, Event Investigation.)
The jackscrew operates the stabilator on the DC-9. This was an example of organizational norms causing the maintenance to be rushed and the jackscrew assembly did not get the proper lubrication. Over a third of the passengers on this ill-fated flight were employees or family members of employees working for Alaska Airlines. This is only one example of a totally avoidable accident that all started with maintenance. Obviously this is an investigation that would be carried out by the NTSB.
On a smaller scale, let’s look within our own organizations. How many incidences and accidents occur within our own walls that have costly consequences to us or our company? And more importantly how many of them are avoidable by identifying the common denominators and human factors that cause them, and placing renewed focus and training in these areas. Event investigations help organizations identify and understand multiple contributing factors to errors and violations.
When events are investigated, we are able to understand the contributing factors, and corrective actions that must be developed to reduce the likelihood of future occurrences. Deviations from existing procedures are uncovered during the investigations, and they are corrected. Ultimately, the number of events caused by human performance decreases. The operator saves both time and money by decreasing interruptions to revenue flights, rework, personal injuries, and equipment damage.
Over time, cultural changes occur within the maintenance organization as personnel are discussing events, contributing factors, and corrective actions. Positive results from internal audits, employees acceptance of voluntary reporting systems, and adherence to regulatory guidelines evidences itself not just an important focus, but a recognizable one, as the organization morphs to an overall safety conscious community.
Numerous post-event investigations have clearly demonstrated that failure to use documentation appropriately was a major contributing factor. Keep in mind paperwork is to maintenance as location is to real estate! Location, location, location … document, document, and document! Have you ever had to sit on a witness stand and explain your paperwork?
Challenge yourself by going back to your log entries, whether it be for maintenance, fueling activities, or other tasks, and notice if they are clear, concise, and understandable as you once thought when you wrote them. Many times when we do this, we can find we are indeed confused by our own entries after some time has passed.
n A 2001 FAA study found that documentation is the leading contributing factor to maintenance events. In most cases organizational issues resulted in failure to use documentation that was available.
n In 2002 a study of procedural issues from a NASA Aviation Safety Reporting System incident report showed that the following factors contributed to documentation-related errors: procedural design flaws, user errors, currency, accessibility of documents, and organizational practices.
None of us work in a vacuum or bubble and we will never be able to totally eliminate human error. However, we can employ processes in combination with training and maintaining a safety conscious culture to eliminate avoidable errors that lead to avoidable accidents. And we can live by the Mechanic’s Creed, in the words of Author - Jerome F. "Jerry" Lederer:
“Upon my honor I swear that I shall hold in sacred trust the rights and privileges conferred upon me as a certified aircraft mechanic. Knowing full well that the safety and lives of others are dependent upon my skill and judgment. I shall never knowingly subject others to risks which I would not be willing to assume for myself, or those dear to me."
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