LACK OF RESOURCES. With parts being available only on a cash basis, the lack of a small clamp played a key role in the accident. Had that resource been available, the accident would not have happened. Lack of Resources – manpower. There was a desperate need for a second licensed AME to share the workload.
LACK OF ASSERTIVENESS. As DOM he had the responsibility to insist on more manpower and parts. Money was being diverted to build a second lodge that should have been used to acquire needed parts as well as relief help. By failing to do that his lack of assertiveness contributed to the accident.
COMPLACENCY. He had done this type of work many times before and failed to realize the danger of doing what he was in the habit of doing. He failed to see the missing clamps on his run up inspection, but instead saw what he expected to see. He only realized it when he saw one of the missing clamps in his toolbox. These are not making excuses for the person but to help us
understand how this could possibly happen even to us given the same circumstances.
CITATION | LEARJET
Human factors training could have given him the
knowledge on how to avoid that deadly error he never intended to make. He would be the fi fth victim in the tragic accident due to PTSD. In my years as an accident investigator I saw it many times after a fatal accident. Sometimes the person may not have even been in any way responsible for the accident such as a dispatcher with tears running down her face and that haunted look who told me, “If only I hadn’t dispatched them this morning, they would still be alive.” That is not true because if she hadn’t, someone else would have and it had nothing to do with the accident. We were trained to not get emotionally entangled with any of the persons you came in contact with and were discouraged from doing any follow up after the report was released but I would hope that she and others were provided some support to understand what was happening to them. I believe that today they would. I recall a brush with PTSD back in my New Guinea days when I went to the scene of a fatal accident that had taken the lives of seven people. Go to our website at
www.system-
safety.com click on “Safety Videos” and read the storyline of “The Price of a Mistake.”
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