THE HUMAN ERROR
SWEAT THE SMALL STUFF!
If you sweat the small stuff (hazards), you will never need to sweat the big stuff (accidents). Hazards are all around us, but we often fail to see them as such after we have lived with them for a time. One little fuel injector clamp on a Piper Navajo was accidently left off resulting in four people dying while three would be severely injured. One tire on a DC8 aircraft had low air pressure resulting in 261 people dying. The airline would cease to exist less than a year later (Read case study of “Death of an Airline” training video at
www.system-safety.com). Let’s look at the small clamp accident and see if we can determine why this fatal accident occurred.
THE COMPANY The company was owned by an ex-airline pilot who still held a pilot’s license. It was a small charter company that operated a Piper Navajo servicing small towns and companies in the North. The company was in fi nancial diffi culties. The owner also owned a profi table fi shing lodge and was building a second one. He was putting all possible spare money into the lodge. The company also owned a deHavilland Beaver and two Cessna 180s on fl oats. The primary purpose of all aircraft were to service the lodge. Parts for the aircraft were on a “cash only” basis with the owner needing to pay for all parts when ordering before they would be shipped.
THE AIRCRAFT The Piper Navajo is a twin reciprocating engine, 10 passenger aircraft. The high-time accident aircraft had “seen better days” and was in constant need of repair. Parts could only be obtained with the owner’s approval
THE DOM The AME was nearing the end of his career and loved the wilderness and the challenge of keeping the tired aircraft fl ying. His only assistance to keep four aircraft fl ying was two apprentices who lacked knowledge but not enthusiasm. He had been promised experienced help but to date that had not been forthcoming. Thus, in the busy summer season, he was forced to work long hours with no days off .
THE PILOT The pilot was a young man who was only there to build up his hours for bigger things. He was a cheerful happy go lucky person who fl ew well, having worked his way up from the fl oat planes to gain twin time. He had received
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minimal training on the twin from the company owner and was left to learn on his own with minimal supervision. With no guidance he was known to treat the aircraft more like a fi ghter plane than a passenger aircraft.
THE FINAL FLIGHT The aircraft landed at the small logging town airstrip where the pilot picked up the town store owner, his wife and their 13-year old son. The store owner asked if his son could sit up front in the co-pilot’s seat which had all controls removed. The pilot happily agreed, and the wife sat behind the son with the father in the seat behind the pilot. Two other passengers sat right behind them. The father suddenly realized that he had forgotten to tell his oldest son, who would be running the store, about something so he left the aircraft as they were struggling to load a large outboard engine into the aircraft. On returning, he discovered that a late-arriving passenger had taken his seat so he sat in the back as they completed loading the baggage and parcels into the aircraft. The pilot decided not to bother tying the cargo down as
it was a short fl ight and he had experienced no turbulence on the fl ight in. Without a weight and balance, he knew that the aircraft was likely over gross and could even be a little out of CG, but the aircraft had plenty of power and he had successfully fl own worse loads before without a problem.
THE FLIGHT He didn’t bother with the prefi ght check as he glanced at the gauges and took off . Just as he retracted the gear the left engine started to backfi re and lose power. His possible thoughts may have been as follows: “What the %&*# is going on? The left engine has lost power, but it is still turning 1200 rpm and making a lot of noise, so I’ll let it continue to run
BY GORDON DUPONT
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