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THE HUMAN ERROR


Tuk” at www.system-safety.com Safety Videos)


The Safety net that I thought about later was to simply spread a rag out under the component you are installing in order to catch anything that might be dropped. Just a minute of time to think what could go wrong would have saved me a lot of stress that night. I call that time, “a minute for Safety.” If not for the watch and the


two-cent coin, I might have been persuaded to forget about it. I’m glad I didn’t. If you are ever tempted to think, “it’s probably ok,” please remember the two-cent coin and the watch. “Probably” is NEVER good enough.


A word that comes to mind with all of these happenings is impossible. The watch surviving the fi re seems impossible, but I saw it with my own eyes. A small coin jamming controls of an open cockpit biplane seems impossible as well, but it happened. That small nut somehow travelling on the accessory gear case until it stopped on a generator lead like a ball in a pinball machine seems impossible but it happened. Thus if you ever think something threatening Safety is impossible, change that thought to improbable, add Murphy’s law and you have possible. Take a minute for Safety and do what you know you have to do.


Gordon Dupont worked as a special programs coordinator for Transport Canada from March 1993 to August 1999. Prior to working 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. Visit www.system-safety.com for more information.


ACX-1 Digital Aircraft Cable Tension Meter


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PREMIUM Tension Measurement Visit: Info.Tensitron.com/DOM_June for a discount coupon | sales@tensitron.com | 303.702.1980 26 DOMmagazine.com | june 2019


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