Airworthiness: Doctoring maintenance

Federal AviationAdministrationAirworthiness

Positive Safety Culture

Doctoring Maintenance

A Discussion of Human Factors and Behavior

Federal AviationAdministration

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Introduction

• Review a fatal accident scenario

• Analyze chain of events leading up to the fatal climax

• Discuss how poor safety culture, unsafe behavior, and ignoring Human Factors caused a pilot to perish.


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Objectives

• Emphasize thoughtless decisions and risky behavior lead to undesirable consequence.

• Recognize Human Factors and not to ignore them.

• Encourage embracing a more positive safety culture that inspires safe behavior.


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Ended up like this!!


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Mooney M20K

• Original Configuration per Type Certificate Data Sheet (TCDS) 2A3.

• Engine: Continental TSIO-360 (210 HP)

• Prop: McCauley 2A34C216


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Accident Mooney M20K

• Modified by Supplemental Type Certificate (STC) No. STC5691NM

• Engine: Continental TSIO 520 (305 hp)

• Propeller: McCauley 3AF32C505


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Departure

• Departure, under visual flight rules, cross-country.

• Destination airport expected to be Visual

Meteorological Conditions (VMC).


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Arrival

• Destination airport weather not as anticipated.

• Unsuccessful attempts to land.

• Diverted to another airport.


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LANDING

• The approach to diversion airport was successful.

• At touchdown events began to unfold.

• Failed attempt to pull up.

• Unexpected climax


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Non Injury Accident

• The Mooney was damaged .

• Doctor X did not follow procedures

• Doctor realized “Other” factors were in effect


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Heading to the fatal accident

• Doctor X needed a replacement aircraft right away

• Purchased a another aircraft

• Mooney would be repaired and used again.


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Heading to the fatal accident

• The Mooney insurance policy close to expiring.

• No local area repair available.

• Need to move the aircraft.


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On course to fatal accident

• Doctor X decides to get Ferry Permit.

• The Doctor makes arrangements with home based aircraft repair facility.

• Ferry Permit has time limit.


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Still on course to fatal accident

• Mooney propeller must be replaced

• Doctor X owns another McCauley propeller

• Spare propeller not correct for the Mooney


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Course to fatal accident not altered

• Mechanics sent to prepare damaged Mooney.

• Problems encountered with the landing gear.


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Course to fatal accident still not altered

• Mechanic 2 completes final repairs on fuselage

• Mechanic 1 works on the propeller

• Propeller installation problems

• Propeller is installed


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Accident Course Slightly Delayed

• Tires and nose strut gets serviced

• Test run-up performed


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Back on the course to accident

• Doctor and Mechanic 2 return to Augusta, GA.

• Mechanic 2 was also a pilot

• Final Ferry preparation began


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The Day of the Crash

• Mechanic 2 began operational check of engine

• More Problems…….now with the propeller

• Doctor X knows the problem exists!


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The Day of the Crash

• Flight preparation continues

• Doctor X advises Mechanic 2 of his flight plan


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Shortly before the Crash

• Doctor X taxies over to the FBO.

• Doctor X taxies to the runway.

• Mechanic 2 taxies Bonanza

• Mooney is cleared for take-off


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Moments before crash

• The Mooney lifts off

• Witnesses observed the lift off.

• Seconds before the crash


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The Crash:

• Something fell off of the aircraft.

• The aircraft continued a short distance more

• Impacted the ground


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The Crash Scene


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Post Discussion Analysis:

• What and why did things go wrong?

• Human Factors (HF) were NOT recognized and WERE ignored.

• Opportunities to prevent either/BOTH

accidents.


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Analysis:

• HF1. The Doctor was very busy, used aircraft for business and had logged more than 4000 hours in his Mooney.

• HF2: The Mooney insurance expiring.


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Analysis:

• HF3: Acquaintance advice.

• HF4: Ferry Permit expiration


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Analysis:

• HF5: Landing gear problems.

• HF6: The propeller problems


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Analysis:

HF9: Propeller tips so close to the ground.

HF10: Engine did not achieve power

HF11: Propeller control operates backwards

.


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Summary

• This scenario shows how thoughtless decisions and risky behavior led to undesirable consequence.

• We identified applicable Human Factors and why you should not to ignore them.

• Adopting a more positive safety culture will inspires safe behavior in you as well as your associates.


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Before we close

• Any questions or comments

• www.FAAsafety.gov

• AMT Awards Program

Airworthiness: Doctoring maintenance

Education

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