THE HUMAN ERROR
tag the spoilers and they never thought to check the spoiler’s other wing mate. SAFETY IS HARD. If either of us had taken a “Minute for Safety,” this very near chance of multiple fatalities might have been avoided. In that minute simply ask yourself just two questions: 1. What can possibility go wrong? 2. What can I do to mitigate the possibilities of something going wrong to ALARP? (As Low As Reasonability Possible) Having “dodged the 8 ball” that time, the work sheet was changed to include tagging the ground spoilers any time we were working on the wing and no flight control was to be moved until BOTH were checked as clear and the person yelled “Clear whatever the control was.” As I’ve said many times, rules and regulations are all too often written in blood. Thank goodness this one wasn’t one of them. Always keep in mind that SAFETY IS HARD.
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 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. Visit
www.system-safety. com for more information.
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