THE HUMAN ERROR
LACK OF RESOURCES
BY GORDON DUPONT
We AMT/AMEs are proud of being able to keep aircraft flying, and rightfully so. There is the old adage that an AMT/AME is a person who can do more and more with less and less until he or she is fully qualified to do everything with absolutely nothing — and he or she is damn proud of it as well. While this might sound commendable, lack of resources has led to all too many accidents. With the cost of aircraft parts what
they are today, the lack of resources cause of maintenance error is always in the background and sometimes, unfortunately, in the forefront. Lack of resources is not just the lack of spare parts you would like to see in your stores. It is also the lack of that manual for a propeller you work on, that special tool for torqueing the wing attach bolts, proper lighting in the work area (a flashlight stuck between tubing is not proper lighting), shelter when the wind is blowing 40 kts. in a sleet-like rain, a hangar with heat when the outside and inside temperature is 40 below either scale, personnel for the work on hand and technical support when it’s needed. If you don’t have the answers, there should be someone you can turn to, be it the chief engineer, a wise peer you know or a tech rep. Let’s look at a case study that will illustrate the point. The Piper Navajo was one of the more high time aircraft in the fleet, but was generally well maintained. The crew had been complaining about a door “not closed” light coming on in flight, but it always appeared to function fine when maintenance
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tried it on the ground. As the latches were worn it was decided to order new parts for the next 100 hourly and even though they were AOGed (Aircraft on Ground), Piper was in Chapter 11 (a polite name for bankruptcy protection) and they had not arrived when the 100-hour rolled around. The aircraft was signed out as airworthy, but the door light was coming on more regularly and now could be made to illuminate on the ground if you pushed on the door. Still without the parts, the AME decided to remove the latches and file the securing screw holes so that the latches could be moved inward more. This “fix” appeared to work as pushing on the door would not cause the warning light to come on. The aircraft departed with a full load of passengers and had just reached cruise altitude over the mountains when the warning light flickered a few times and stayed on. The captain told the copilot to go back and check the handle to ensure that the door was fully closed. Fortunately, just before the copilot got there, the upper latching door flew open and the heavier lower door with the stairs and a leather- covered steel cable to pull it up to close, tore off at the hinge and was swinging at the end of the steel cable in the slipstream. It was striking
the empennage as it swung around, making a sound that amplified up into the cabin. A lady sitting near the door became hysterical as the banging sound plus a 200 mph wind in her face led her to believe that the end was near. The captain swung the aircraft around as he declared an emergency and pushed both throttles as far forward as they would go. The accelerated speed increased the slipstream and thus, the thundering noise of the door striking the metal skin. From the ever-increasing dent in the empennage, cracks began that slowly started to circle the battered airframe. By the time the landing was made with the aircraft still dragging the very-much-worse-for-wear-door down the runway, the cracks had progressed along almost 20 percent of the empennage circumference. Had the incident occurred 15 minutes later or perhaps even less, there would have been a fatal accident somewhere in the mountains with burning wreckage, minus its empennage. There were no physical injuries to
anyone, but plenty of adrenaline was flowing in that aircraft that day and one can be sure that multiple lawsuits likely followed. A pilot who was flying single pilot cargo in the same type of aircraft on autopilot wasn’t as lucky when he went back to check the door
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