THE HUMAN ERROR
DISTRACTIONS ARE AN EVERYDAY OCCURRENCE IN OUR WORK AND IN OUR LIFE. IT CAN BE AN UNUSUAL NOISE, A COFFEE BREAK, A STRIKING PERSON OF THE OPPOSITE SEX WALKING PAST OR HUNDREDS OF OTHER THINGS THAT “DRAW OUR ATTENTION AWAY FROM THE TASK AT HAND.”
DISTRACTION
Distraction is responsible for about 15% of all known maintenance errors. So why does it occur so often? When we are working on any task, our mind has a natural tendency to think ahead. This is normal and not a bad trait until we are distracted from the task at hand. If the distraction is sufficiently long and/or strong enough we will come back to the task thinking we are farther along than we actually are. If there are no visual clues as to the actual point of completion, and we don’t have any precautions (Safety nets) to counteract the distraction, then there is a very good chance that an error will occur. The error could be a loose B nut or something not completed. After the error, the victim of this factor will likely, in all honesty, swear that he or she had completed the task correctly because in his or her mind heor she had. The following is a case in point: The Bell 206 was in for a regular 100 hourly inspection and the task was almost complete. One of the snags that the pilot had complained about was an annoying N1 rpm fluctuation. Thus, the AME/AMT decided to change the N1 tach generator to determine if it was the cause of the fluctuation. As he was in the process of fastening the
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DOMmagazine.com | august 2016
BY GORDON DUPONT
cannon plug to the newly installed tach generator, the phone rang. He rushed to answer it as he was the only person in the hangar and it could be a customer. It wasn’t. It was his wife who was angry because he was supposed to be home getting ready for a long ago scheduled dinner date. After promising to be there shortly, he went back to the task, glanced to see everything was completed, signed the paperwork and hurried home. The next day, while at 3,000 feet
over water with five people on board, the pilot suddenly had the engine-out warning horn blaring in his ear and noticed his N1 indication dropping to zero. As trained, he quickly lowered the collective and made a perfect autorotation into the salt water. He experienced a difficult time in getting the rotor blades to stop before they all exited the sinking aircraft with their lifejackets. They and the upside down rapidly-sinking helicopter were picked out of the water just in time by a heli-logging helicopter with a long line that conveniently connected to the sinking helicopter’s belly cargo hook. All escaped injury by clinging
to the helicopter as it was lifted to shore (see photo on page 26), but the helicopter, after its soaking in the salt water, was almost a write off. The cause was easy to find when
the engine cowls were opened, for there on the deck lay the N1 cannon plug. The AME/AMT was absolutely sure he had tightened the plug on the tach generator but had no explanation for how it could have come loose. (You can read the complete case study by going to our website at
www.system-safety.com, click on “Safety Videos” and click on “Too Many Cooks.” If you read the case study you’ll find that more than just distraction was working against him) The AME/AMT had been caught with the biggest distraction creator known to man — the telephone. Use of the device while driving increases your odds of an accident by 25%. Throw in texting while driving and the odds at least double. There is a valid reason why it is illegal in many states and countries in the world. In 2014, over 2600 people died in the USA while “their attention was drawn away from the task at hand” by a phone.
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