PTSD
BY GORDON DUPONT
but I suspect that would have mattered little to him. When interviewed he was what we called a “Dead
Man Walking.” He had that all too familiar haunted look in his eyes as the full realization of the small error he had made had resulted in the deaths of four people he knew. Today we would call that look PTSD but back then, having seen it too many times in the past, I knew there was a high likelihood that he would be dead within two years and that those two years would be painful for him as he subconsciously punished himself for what he had done. No human punishment could come near to what he was to endure. He likely would turn to alcohol or drugs to try to find relief, but every morning on waking up, his first thought would be, “I killed four people because of my carelessness.” One person described it as an 8-track in his head. For those who don’t know what an 8-track is, it was a music tape player popular in the 70’s, before cassettes took over, that would play the same music endlessly until the tape broke. He could never get it out of his head. For many, without professional help, they believe the only way to stop that tape is suicide. All too many will put the alcohol bottle to their head and pull the trigger. Looking at the small clamp accident, there were many
contributing factors that I call the Dirty Dozen that contributed to him making the error.
They are what I see as the following:
Leaving a small, seemingly insignificant, clamp off of a fuel injector line resulted in a crash that took four lives and severely injured three others. (See Helicopter Maintenance October/November 2019 article “Sweat the Small Stuff.”) The accident also resulted in the company’s loss of its Operating Certificate (OC) effectively shutting down the company. The AME responsible for leaving the clamp off never touched a wrench to an aircraft again but left the town to work at a lawnmower repair shop hundreds of miles away. It is likely that the regulatory body suspended his license,
FATIGUE has to be number one as he worked very long hours and did not have any days off for months. This would result in chronic fatigue with many negative consequences — the big one being the gradual development of a “Don’t Care” attitude. In my opinion, fatigue makes it easier for the other Dirty Dozen to occur. We need that break and the realization of just what fatigue can do to us. He had neither.
PRESSURE played a role as he was the only one who could keep the aircraft airworthy and flying. He took this responsibility very seriously, and this self-pressure would heavily influence his decision making.
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
20
HelicopterMaintenanceMagazine.com December 2019 | January 2020
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44
