as much as I would myself. How does one live knowing that their action took the lives of 261 people?
THREE TYPES OF VIOLATIONS A violation is simply intentional rule breaking for whatever reason with a positive consequence foreseen or expected to occur. These violations are generally placed into three classifi ca- tions: situational, routine and excep- tional. See if you recognize which category my violation fi ts into. Situational violation occurs when
the person sees that the end goal cannot be met without a violation. They are usually time pressured and not often repeated. The situation appears to justify the violation. For example: The last remaining item on the task card calls for the 45 nuts to be torqued to 25 foot pounds, but the only calibrated torque wrench available is being used by another crew and the aircraft is scheduled to depart in 20 minutes. The “Armstrong” wrench is used and only you know about the violation. Routine violation occurs when
there appears to be a better way to do a task and no one recognizes any negative consequences. This is what we often call a norm and sometimes comes from what started once as a situational violation. If the organization knows and condones or at least tolerates the violation, they can be further broken down into “organizational’ violations. The classic routine (organizational) violation can be seen on the maintenance No. 12 “Norm” Dirty Dozen” safety poster. The norm of using a forklift to remove and replace the wing engines on their DC10s led 273 people to pay the ultimate price. Interestingly, they all would have survived if the captain had not adhered to the rule of lowering their airspeed to the best two engine rate of climb speed in the event of loss of engine power. That speed was below the stalling speed of a wing with the leading edge slots retracted, which is what had occurred on the left wing that lost the engine, severing the hydraulic lines that kept the slots
PT6A Simplex Flow Divider
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PT6@HeritageTurbines.com 1-888-669-9531 (toll free, US) | 508-778-7788 | FAX 508 775-4489
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