August 16, 2019

sasadmin

Every Picture Tells a Story!

Sure, but sometimes there is a story behind the story.

Turns out the Captain had a very hairy landing (maybe wake turbulence from a departing aircraft) but in any event, he believed it was normal.

Basically the Cowl of this huge 55,000 pounds thrust engine “kissed” the ground.

Unfortunately, the Engineer missed this during his walk around!

It was found by the Captain doing a final PDI (by which time the aircraft was loaded with Fuel/PAX/Cargo/Baggage and Catering).

Clearly, it was not going anywhere but now it is a huge story as the aircraft had to be swapped.

So what happened?

The Engineer missed it because he redesigned his walkaround to avoid going outboard of the No 1 Engine (No need right! Came in ok will go out ok) he had become lazy in fact – believing the walkaround was essentially a chore!

Which Human Factor?

Well amongst several, for sure we are looking at complacency – bottom line the Engineer had been doing this job for years and never a problem!

There are other issues and an obvious question becomes “Is this a unique behaviour or a manifestation of the local culture?” – Where is the oversight – How is the effectiveness of the Competence Management System (yes competence to perform a “real” walkaround in fact) being managed?

Where is the Cheese?

Unfortunately for all the positions, this aircraft could have been parked at this particular airport, it was on the “outermost” stand – means there was no traffic passing by – no one to say WTF happened their mate!

Any other day it would not have mattered – but this aircraft & this day it mattered – tough luck!

What happened to the Engineer?

So he lost his approval and shortly after left the company to seek his fortune elsewhere.

And the message – Yes there is one – it is this!

Imagine in your whole career of 40 years working on Aircraft – one event like this will be waiting for you. It could be today, tomorrow, or in 34 years and 2 months time!

Treat every inspection as if  “today is the day” and that is all anyone can ask of you –

Skip and you are rolling the dice of fortune.

Tags:

Complacency, HF, Human Factors, Maintenance Error