THE HUMAN ERROR
SEVEN YEARS WITH THE TRANSPORTATION SAFETY BOARD, PART 1
In my 56 years in aviation, I have been privileged to meet a lot of people in our business. Sadly, in my seven years as a Transportation Safety Board of Canada accident investigator, some of them were dead. However, even in death they had a story to tell and we can learn from some of their stories. I’d like to share a few of them. In my seven years I investigated 146 accidents. Of those, three were undetermined. Although I had a pretty good idea of what likely happened, unless you can prove it, it must be recorded as undetermined. 35 (24 percent) were fatal, and 36 (24 percent) were maintenance related. Remember that my background is maintenance, so I received more of the suspected maintenance accidents to investigate. I would say that about 10 percent were directly maintenance related and about 25 percent had a maintenance contribution. I have 12 accidents with stories that I hope you will find interesting and useful.
Each will have a picture or two so
they will be divided into a series over the next four issues.
#1 THE REPORT THAT WAS
NEVER PUBLISHED Not long after the Challenger disaster in 1986, the office received a call that a DC8 was on fire at an airport about 60 miles away. An aircraft of that size emptied the office in two vehicles like keystone cops racing to the scene of the disaster. On arriving, we found a derrick aircraft with windows and doors missing and in the process of being scrapped. As I had just
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joined, they told me to gather some information and left. I dug out the report guide and began interviewing witnesses. I photographed it from all angles and, having got the names of the persons working on it, went to the hospital and interviewed the AME who was on top of the wing when it blew. He was fairly badly burned and under medication, but here was the story. They were under a two-week contract to strip the aircraft of as many useful parts before it was to be
BY GORDON DUPONT
reduced to scrap. It was slow going so they rented two big gas-powered cutting wheels to speed their entry into places that were difficult to access.
The burned one was on top of the wing, cutting aluminum over one of the fuel tanks that turned out to be about ¼ full. Murphy was waiting for that as the wheel found a steel screw and the sparks made an ideal source of ignition. He and the saw were blown up into the air and missed the concrete taxiway by about five feet to land in wet grass. That explained the picture of the cutting wheel that I thought belonged to the firemen. The guy on the other side had not found a screw yet.
The moral of the story is when under pressure, take a moment for Safety, perhaps your life and try
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