THE HUMAN ERROR
them to look almost directly at the crack location, but that stand was in another hangar and would have involved pushing aircraft out to obtain and position the stand. Being ingenious AMTs, they connected themselves in harnesses attached to the rafters Should they slip off, it would stop them before hitting the hangar floor. (See drawing above) I suspect they did a great job inspecting the rivets on the top of the aircraft, but as their head got below their butt, the odds are very high they sped up the inspection of that area as the prospect of sliding down headfirst loomed. All of this was occurring in the circadian rhythm low of 3 to 5 a.m. when one’s “don’t care” attitude would be at its highest along with other negative fatigue symptoms. The links in the chain of events towards
an accident were forming and they didn’t have a clue. Special tools make the job easier and in some cases, possible, but who hasn’t made a tool to do a particular job? The question has to be: Am I 100-percent sure this tool will do the job? If not, don’t use it. A LAME (Australia) was servicing a Beechcraft model with an electric actuated landing gear that used a spring to provide the tension to keep the gear over-center lock locked. The inspection called for a special tool with a gauge to be used to push against the over-center lock until a 020” feeler gauge could be inserted into the unlocking gear. The gauge showed the acceptable range for this to occur. Not having this tool, he took a fish scale and attached a piece of angle metal to it and pulled on
the scale until the feeler gauge fit it. Now, any fisherman will attest to the accuracy of these gauges that enable them to have bigger bragging rights than they are entitled to regarding fish weight. Not too long after, the left gear collapsed on a rough gravel strip. Fortunately, there was no fire from the leaking fuel, but you can be sure you could have bought an awful lot of the “special tool” with the cost of the repair. The Safety net is the same as the materials one. Think how many people thanked him for keeping the aircraft flying with his “Mickey Mouse” tool. Our next article will cover a
contributing factor that I’m sure we have all experienced.
Gordon Dupont worked as a special programs coordinator for Transport Canada from March 1993 to August 1999. Prior to working
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for Transport, Dupont worked for seven years as a technical investigator for the Canadian Aviation Safety Board (later to become the Canadian Transportation Safety Board). He saw firsthand the tragic results of maintenance and human error. Dupont has been an aircraft maintenance engineer and commercial pilot in Canada, the United States and Australia. He is the past president and founding member of the Pacific Aircraft Maintenance Engineers Association. He is a founding member and a board member of the Maintenance and Ramp Safety Society (MARSS). Dupont, who is often called “The Father of the Dirty Dozen,” has provided human factors training around the world. He retired from Transport Canada in 1999 and is now a private consultant. He is interested in any work that will serve to make our industry safer. Visit
www.system-safety.com for more information.
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