Fatigue and Poor Practice – a Bad Combination

This week the National Transportation Safety Board (NTSB) issued a statement regarding the December 2011 air tour helicopter crash near Las Vegas, Nevada. The findings of the NTSB hit very close to home for all aircraft maintenance professionals.

The NTSB press release states the crash was the result of the operator’s “improper reuse of a degraded self-locking nut in the servo control input rod and the improper or non-use of a split pin to secure the degraded nut, in addition to an inadequate post-maintenance inspection. Contributing to the improper (or lack of) split pin installation was the mechanic's fatigue and lack of clearly delineated steps to follow on a "work card" or "checklist." The inspector's fatigue and lack of a work card or checklist clearly laying out the inspection steps to follow contributed to an inadequate post-maintenance inspection.”

Decisions regarding aircraft hardware and the importance of following procedures and checklists are core tasks that we as aircraft maintenance technicians learn early in our careers and many make on a daily basis. Over the years most aircraft maintenance technicians have attended maintenance human factors awareness training, read articles in AMT and other publications on human factors, technician fatigue, and the consequences of failure to follow procedures. Here’s a tragic reminder why this is important.

The findings in this report are very alarming and unfortunately can cast a dark shadow on the integrity of our profession. I encourage everyone to read the report, try to relate to the circumstances, and then determine what steps you will personally take to prevent any similarity of this happening to you.

http://www.aviationpros.com/news/10860840/ntsb-finds-improper-maintenance-led-to-air-tour-helicopter-crash-near-las-vegas