THE HUMAN ERROR
I realized that it could have just as easily been me who made the error. That was one of the defi ning points in my life and Safety took on a whole new meaning. You can and I urge you to go to our website (Address above) and read the case study of the Safety video “The Price of a Mistake.” The man who made the mistake is dead as I believe he never forgave himself for the deaths of his best friends. Read the case study carefully. Even though he may have been responsible for the engine fi re, the FAA and manufacturer bear the full responsibility for the deaths. So what can we do to avoid becoming one of the 15%? You likely already have devised some personal Safety nets such as:
An interesting study was conducted to illustrate the power of distraction.
1. A group of teenage students were each given a task to build something diff erent using building blocks. (Teenagers are ideal as they still think that they know it all and have not yet entered the “school of hard knocks”)
2. They were each given a sheet with numbered step by step instructions on how to build the object. (Their curiosity would encourage them to wonder what it would be when completed)
3. They were called away for a coff ee break before any of them had completed their project. (The distraction)
4. After coff ee they were asked to write down what step they had stopped at before the coff ee break. (The answers shouldn’t be too much of a surprise)
EVERYONE wrote they were ONE to THREE steps further ahead than they were. Always remember: The brain can
work faster than the hands and it does.
A simple distraction almost caused me to leave aviation a lot of years ago while working in New Guinea. At times it haunts me to this day. If you look at the small picture in the top cartoon, it says 8 fatal below and gives a one sentence explanation for the accident. “A conscious licensed Aircraft Maintenance Engineer was distracted when asked to help another at the critical moment of tightening a fuel line and later thought that he had completed the task.” The result was an engine fi re in fl ight and a fi ery crash that I responded to. A child was thrown out of the aircraft at impact and lay dead near the burning wreckage. That child was about the same age as my son and when I found out why the accident occurred
• NEVER start fastening a B nut or any other component without either completing the task or completely undoing it. Make it “all the way on or all the way off ” always.
• Tag the task with a bright ribbon at the last point of completion. A warning tag can be installed but they often take too long to fi ll out and consequently are seldom used.
• Some companies have issued each person with a roll of fl agging tape to tear off and tie to the part as a reminder of where you are.
• Torqueseal, better known in World War II. as “anti-sabotage paint”, if used properly, will act as a last chance Safety net to catch the unexpected. To be used correctly, the B nut must be torqued and have the Torqueseal applied before the wrench is removed. Many a B nut in a cluster has been accidentally tightened twice leaving one loose in its place.
26 |
DOMmagazine.com | august 2016
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70
