THE HUMAN ERROR
He ran the engine, signed off the paperwork and headed home for some much-needed sleep.
THE SMALL CLAMP The next day he noticed a small clamp on his toolbox and won- dered where it had come from. He threw it in a toolbox drawer and vowed to take a close look at the engine on the next inspection. After all, “IT”S JUST A SMALL CLAMP”
The second look revealed that he needed two clamps but could fi nd only one in his tool box. He contacted the owner to order a clamp but since it was such an insignifi cant part the owner decided to wait until they needed more parts.
The engine went through two 100-hour inspections before the accident. What’s the big deal about a small clamp?
That little clamp was one of DOM-half-page-nov-issue-handshake.pdf 1 10/25/2019 4:11:09 PM
two that secured the fuel injection line for the number 1 cylinder. Without it, the fuel line vibrated and broke at the worse possible time. When it broke, the engine lost all power and would backfi re from the super lean mixture in the other cylinders. It was impossible for the aircraft to continue fl ying with the drag from this unfeathered engine. What were the causes of this maintenance error and how can it be prevented in the future? Watch for next month’s edition for the answers.
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.
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www.asibrake.com 16
DOMmagazine.com | nov 2019
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