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THE HUMAN ERROR


The Moral is to never use Tefl on tape on an aircraft component, and if you remove a fi tting that has the tape on it, use a pick to clean out the threads. For the pilots among us, simply pulling the power off on the overpowering engine would have enabled directional control. The MAP would have quickly come back to normal, at least until another piece of the tape blocked the orifi ce to the waste gate.


The Lazair had a very extended glide on one engine and a glide ratio of 12 to 1 with no engines. So, why was he observed in a near vertical descent to crash and burn just behind a barn in the country with fi elds suitable for landing everywhere? The wreckage was brought back to our workshop and examined for control continuity and missing parts. What wasn’t destroyed by fi re was complete. The left engine was not developing power at impact


about to do. If you are a rogue who just follows the rules that suit you, remember that most rules are developed to act as Safety nets and help protect you from harm. All too often they are written in blood. Sooner or later, you will very likely provide more blood to the rule not followed. The fi nal two accidents will involve helicopters with a maintenance cause and a maintenance contribution.


Gordon Dupont worked as a special programs coordinator for Transport Canada from March 1993 to August 1999. Prior to working


#10 NOW THIS IS PILOT ERROR The fatal accident aircraft was a Canadian designed ultralight called a Lazair. It was a twin engine aircraft that had an empty weight of only 210 lbs, yet, could lift 450 lbs using two 6.5 hp. 2 stroke chain saw motors. The pilot was described by his


girlfriend as a “free spirit” who would try anything. He had bought one of the 2,000 kits sold and self taught himself to fl y. He was going to experiment with bigger engines and possibly even a 3rd engine. There were some indications that he was a bit of a rogue that somehow exempted him from having to follow all the rules.


as evidenced by the propeller. Also, the seat belt was undone at impact. The lead to the left engine spark plug was detached and had burn marks from the cylinder head fi ns on it. These could only occur with the lead detached from the sparkplug. It is believed that the lead, vibrating in the slipstream, became detached in fl ight. Looking at the actual picture of the pilot starting the second engine with a pull start, you can see that he would have had to undo his seat belt and stand up in order to reattach the spark plug lead. In doing so he advanced the center of gravity forward and the aircraft nosed down. This likely caused him to fall forward more and the aircraft descended near vertical until impact with the ground. What made him decide to attempt reattaching the wire in fl ight when he could easily have made the airstrip on one engine or chose from many fi elds to make an emergency landing? The Moral. is to always take that


minute for Safety and think of all the possible outcomes for what you are


26 DOMmagazine.com | dec 2017 | jan 2018


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 fi rsthand 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 Pacifi c 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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