This document discusses a fatal aircraft accident and analyzes the chain of events and human factors that led to it. It describes how a doctor purchased a modified Mooney aircraft that experienced problems during several flights. Facing a looming insurance deadline, the doctor decided to ferry the aircraft himself. Despite continuing mechanical issues, especially with the propeller installation, the pre-flight checks were rushed. On takeoff, something fell off the aircraft and it crashed, killing the pilot. The summary identifies a series of thoughtless decisions and risky behaviors that ignored applicable human factors, ultimately leading to an undesirable accident that could have been prevented.
A simple fact of the aircraft resale market is that aircraft with missing documents usually sell for significantly less than those with continual chronological history. At best, expensive maintenance procedures may have to be reperformed and properly documented in order to return the aircraft to airworthy status. With a standardized Records Archive Management, you can control, collaborate, and safeguard the value of the aircraft records.
A simple fact of the aircraft resale market is that aircraft with missing documents usually sell for significantly less than those with continual chronological history. At best, expensive maintenance procedures may have to be reperformed and properly documented in order to return the aircraft to airworthy status. With a standardized Records Archive Management, you can control, collaborate, and safeguard the value of the aircraft records.
Aircraft Maintenance Manuals for Engineer's by Engr. Malay Kanti BalaMalay Kanti Bala
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Aircraft Maintenance Manual is an important document for the Aircraft Maintenance Personnel. For the airworthiness of any flight, we do an inspection, servicing, repair, removal, installation, etc activities by following the approved documents which in manual or AMM. Here the presentation will disclose and familiarise with different manuals
This is seminar report of ageing of aircraft.this useful for those student who want to give seminar on designing area of aircraft.In this report you will find brief introduction of ageing of aircraft.
This presentation is an examination of structural repair of aircraft. It details the goals, regulations and classification of repairs for different types of aircraft damage.
The paper that this presentation is based on was presented by Dr. Kishore Brahma of the AXISCADES Engineering Core Group at the International Conference & Exhibition on Fatigue, Durability & Fracture Mechanics (FatigueDurabilityIndia2015) in Bangalore from 28-30th May 2015.
Aircraft Maintenance Manuals for Engineer's by Engr. Malay Kanti BalaMalay Kanti Bala
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Aircraft Maintenance Manual is an important document for the Aircraft Maintenance Personnel. For the airworthiness of any flight, we do an inspection, servicing, repair, removal, installation, etc activities by following the approved documents which in manual or AMM. Here the presentation will disclose and familiarise with different manuals
This is seminar report of ageing of aircraft.this useful for those student who want to give seminar on designing area of aircraft.In this report you will find brief introduction of ageing of aircraft.
This presentation is an examination of structural repair of aircraft. It details the goals, regulations and classification of repairs for different types of aircraft damage.
The paper that this presentation is based on was presented by Dr. Kishore Brahma of the AXISCADES Engineering Core Group at the International Conference & Exhibition on Fatigue, Durability & Fracture Mechanics (FatigueDurabilityIndia2015) in Bangalore from 28-30th May 2015.
How can we prevent accidents caused by human error? This presentation deals with typical examples of severe accidents related to human errors, and shows methods to prevent them.
Human Factors Training: There's nothing that can't go wrong. This simple insight forms the foundation of human factors training for pilots. In special courses, pilots are prepared for any possible emergency situation and action strategies. Crews learn to analyze and evaluate their own behavior and that of those around them more effectively. Training leads to more efficient work processes, a functioning error management culture, and increased safety. This is a general prsentation and human factors management in aviation training.
NTSB Senior Air Safety Investigator, Kristi Dunks, talks about aeronautical decision making when a pilot plans a flight.
This presentation is part of the release of the NTSB General Aviation Safety Series at the FAA Safety forums during Sun 'N Fun 2012 in Lakeland FL.
NTSB Board Member, Earl Weener Ph. D, discusses why all pilots need to focus on their personal flying habits.
This presentation is part of the release of the NTSB General Aviation Safety Series at the FAA Safety forums during Sun 'N Fun 2012 in Lakeland FL.
Knuckledragger Disasters and What Engineers Can Do to Prevent Themwboelter
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Customers, both internal to
and external, want us to meet deadlines, keep
costs down, and provide superior products. It is
important that we carefully consider all of those
customers and include their input in the early design
phase of a product. Doing this improves safety, saves
a great deal of time and the expense of retrofits or
rework, and improves customer satisfaction and loyalty
by helping the customer to feel like they are part of the
design team.
A smart cockpit is available right now, and progress will accelerate as more manufacturers and aircraft owners adopt Automatic Dependent Surveillance-Broadcast (ADS-B) technology.
Smart Cockpit Technology: Industry to research and develop smart cockpit technology that helps identify emergency situations, prompts pilots (aurally/visually) through pertinent checklist items, and provides instructions based on aircraft position and condition of flight.
Having fun means flying safely! Hobby or recreational flying doesn't require FAA approval but you must follow safety guidelines. Any other use requires FAA authorization.
Avoid doing anything hazardous to other airplanes or people and property on the ground.
To reduce the risk of accidents due to weather related factors, pilots should rely upon accurate real-time weather
reporting and learn about weather reporting technologies currently available.
According to the Joseph T. Nall report (produced by AOPAâs Air Safety Institute), 89 accidents occurred in 2010 as a result of fuel exhaustion; 11 of them fatal. And despite a decline in fuel management accidents through 2008, more recently those numbers have been reversing, accounting for eight percent of all accidents in 2010
So what is single-pilot resource management? The FAA Risk Management Handbook notes that SRM is defined as the art of managing all the resources (both onboard the aircraft and from outside sources) available to a pilot prior to and during flight to ensure a successful flight
More than 25 percent of general aviation fatal accidents occur during the maneuvering phase of flight â turning, climbing, or descending close to the ground. The vast majority of these accidents involve stall/spin scenarios (half of which are while in the traffic pattern) and buzzing attempts.
Returning to flight operations after a period of inactivity has resulted in loss of control accidents. But with a solid plan and determination, you can get back to enjoying the freedom only flying can offer.
Runway incursions are a serious safety concern and significantly impact safe operations at any airport. Incursions, which also can occur on taxiways although not considered runway incursions, have involved air carrier aircraft, military planes, general aviation aircraft, air traffic controllers, ground vehicles and pedestrians.
The May/June 2014 issue of FAA Safety Briefing is all about Airworthiness Certification and Standards. In this issue we look at the hidden dangers of layering supplemental type certificates (STC), who to go to when your plane has an issue, and how to take care of an aging aircraft. In addition, you can learn more about the airworthiness directive process and how to apply for an STC.
Francesca Gottschalk - How can education support child empowerment.pptxEduSkills OECD
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Francesca Gottschalk from the OECDâs Centre for Educational Research and Innovation presents at the Ask an Expert Webinar: How can education support child empowerment?
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
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Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
⢠The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
⢠The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate âany matterâ at âany timeâ under House Rule X.
⢠The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
How to Make a Field invisible in Odoo 17Celine George
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It is possible to hide or invisible some fields in odoo. Commonly using âinvisibleâ attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
Acetabularia Information For Class 9 .docxvaibhavrinwa19
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Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
Introduction to AI for Nonprofits with Tapp NetworkTechSoup
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Dive into the world of AI! Experts Jon Hill and Tareq Monaur will guide you through AI's role in enhancing nonprofit websites and basic marketing strategies, making it easy to understand and apply.
2. Federal Aviation
Administration
2
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.
3. Federal Aviation
Administration
3
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.
12. Federal Aviation
Administration
12
Heading to the fatal accident
⢠Doctor X needed a replacement aircraft right
away
⢠Purchased a another aircraft
⢠Mooney would be repaired and used again.
13. Federal Aviation
Administration
13
Heading to the fatal accident
⢠The Mooney insurance policy close to expiring.
⢠No local area repair available.
⢠Need to move the aircraft.
14. Federal Aviation
Administration
14
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.
15. Federal Aviation
Administration
15
Still on course to fatal accident
⢠Mooney propeller must be replaced
⢠Doctor X owns another McCauley propeller
⢠Spare propeller not correct for the Mooney
17. Federal Aviation
Administration
17
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
19. Federal Aviation
Administration
19
Back on the course to accident
⢠Doctor and Mechanic 2 return to Augusta, GA.
⢠Mechanic 2 was also a pilot
⢠Final Ferry preparation began
20. Federal Aviation
Administration
20
The Day of the Crash
⢠Mechanic 2 began operational check of engine
⢠More ProblemsâŚâŚ.now with the propeller
⢠Doctor X knows the problem exists!
22. Federal Aviation
Administration
22
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
26. Federal Aviation
Administration
26
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.
31. Federal Aviation
Administration
31
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.
Author: Stephen DaCosta, ASI, Charlotte FSDO; POC: AFS-850, Phil Randall, Greensboro FSDO, NC, Office Phone: 336-369-3948; Revision 1, 11/08/2012 by Pete Wilhelmson, AFS-850 2012/12/5-023 (I) PP
This presentation is based on an actual aviation accident which resulted in the fatality of a prominent doctor. We will see that many actions in the chain of events, any of which if handled differently, may have prevented the tragic ending. Our intent is to getâŚâŚâŚ.. YOUâŚâŚâŚâŚ.. engaged in the discussion regarding positive safety thinking, safe behavior and of course recognizing the presence of Human Factors and effects on our performance. Finally to realize how a lack of a positive safety culture, poor behavior and how ignoring Human Factors can led to fatal results. Two options for this presentation: 1. Discuss culture, behavior and Human Factors throughout the scenario presentation 2. Present the raw scenario then conduct discussion of culture, behavior and Human Factors at the end.
Read Objectives: Presenter may add more supportive discussion if desired
This is a Mooney M20K. It is similar to the Mooney aircraft owned and operated by a prominent Doctor who had more than 4000 hours flying experience. We are going to tell you a tale about how procedures, maintenance and operational, were not followed and an experienced pilot, in a beautiful aircraft, similar to the one in this photo âŚâŚâŚâŚâŚâŚ(go next slide)
JULY 18, 2011, a tragic fatality that could have âŚâŚâŚâŚ and should have been prevented!!!
This is the engine prop configuration approved for Mooney M20K by the Type Certificate Data Sheet more commonly referred to as TCDS. The TCDS is issued upon FAA certification of aircraft, engines and propellers. The TCDS for an aircraft lists approved engine and propeller configurations as well as many other parameters, limitations, and equipment necessary to meet/retain airworthiness requirements. This McCauley propeller is two bladed model.
The accident Mooney was modified per a Supplemental Type Certificate commonly referred to as STC. An STC is issued by the FAA that allows an approved modification to be performed. This engine and prop combination were approved to be used on this particular aircraft by STC 5691NM. Note the HP increase from 210 hp to 305 and this propeller is a three bladed McCauley, feathering prop found on a lot of twin engine Cessna aircraft.
This tale begins at take-off âŚâŚâŚâŚ... at 2 a.m., (Yes! âŚ.wee hours of the morning!), on April 11, 2011, when Doctor X departed Shreveport, Louisiana in his (legally modified) Mooney M20, on a 600 mile trip to a small airport close to Augusta, GA. The weather at his destination was expected to be clear. Question? Do you think the Doctor was tired BEFORE he started his trip? Any other possible Human Factors having an effect on the trip?
When Doctor X arrived shortly after daybreak there was considerable morning fog. The Doctor X performed three missed approaches and was not able to land. Doctor X then decided to divert to Augusta Bush Field. Question: Do you think he should have tried to land three times BEFORE deciding to divert to another airport? Discuss the possible Human Factors i.e. pressure, complacency, lack of assertivenessâŚâŚ..Others??
The approach to runway 35, at Augusta Bush Field, was uneventful. Aircraft was lined up to land. When Doctor X flared at touchdown he felt a vibration and heard loud noise. As the aircraft was settling on the runway, Doctor X realized that the landing gear was NOT down. He attempted to pull up and applied full power and selected the landing gear down. By this time too much energy was dissipated and the aircraft settled and skidded approximately 700 feet. The engine stopped and the gear remained up.
First Bullet : On April 11, 2011, The aircraft received âsubstantial damageâ to lower structure causing it to be an accident. The propeller blades were also curled from rotating contact with pavement resulting in sudden stoppage of the engine. Second Bullet : Doctor X did not follow procedures. He admitted that he did NOT use the checklist. He demonstrated poor safety culture by Failing to Follow the very basic procedures. HF1 Complacency Question: Do you think the Doctorâs more than 4000 hours in this aircraft made him a bit complacent in not using the checklist? Third Bullet: Doctor X also stated he was fatigued and weather and diversion distracted him. Do you think the Doctorâs own assessment regarding other human factors were pretty darn accurate!? We know fatigue is a Human Factor but what human factors are associated with weather and diversion? weather=âStressâ, any others? diversion=âDistractionâ, âStressâ, any others? Do you think this accident should have changed his safety culture and behavior as well as his awareness of human factors? The aircraft and propeller display obvious physical damageâŚbut what about the engine, it looks just fine? Continental Service Bulletin SB96-11 addresses PROPELLER STRIKE INSPECTIONS and says âFollowing any propeller strike, complete disassembly and inspection of all rotating engine components is mandatory and must be accomplished prior to further flight. Inspect all engine driven accessories in accordance with the manufacturerâs maintenance instructions. Remember this lead to Doctor Xâs SECOND accident, just three months later! The FATAL accident on July18, 2011!
The Doctorâs business required he had to have an aircraft right away. Consequently, he purchased a Bonanza V tail 35. Nonetheless, his intention was to get the Mooney repaired and use it again. Reliance on an aircraft for business can result in âPressureâ that tend to push the envelop of safety to satisfy an immediate needâŚ..especially in the General Aviation arena. Go to Next Slide:
As time passes, the Doctor realizes the insurance policy on the Mooney will soon expire. Although he tried, he could not find any local maintenance that wanted to repair the aircraft . So new âPressureâ is added. He has to move the aircraft. He decided to relocate the aircraft back home to Lake Norman, NC to have the repairs done. Now more âPressureâ to get this done. Recall the immediate need to get another aircraft for his business? This gives you a clue that this guy does not have lotâs of spare time. Now the movement of his damaged aircraft is in the chain of events and we could conclude he wants âŚor has to get this done quickly.
Recall the damaged aircraft is in Augusta, GA. Itâs now the week of July 2011 and the Doctor could not obtain a local repair facility to fix his Mooney. He decides to relocate his aircraft on a Special Flight Permit commonly known as âferry permitâ. He makes arrangements with a local repair facility, at his home base, in Lake Norman, NC to repair aircraft and also to begin process to obtain a Ferry Permit for the Mooney for relocation flight back home. The Ferry Permit is received but it will expire July 18 th âŚâŚâŚâŚâŚ.not much time to prep aircraftâŚâŚ..more âPressureâ. So preparation begins.
Recall the Mooney, approved three bladed propeller, is severely damaged! It must be replaced for the ferry flight. BUT WAIT!!.....Doctor X owns a 2 bladed McCauley propeller . It was being stored by an acquaintance in Virginia. He contacted his acquaintance and asked if this propeller would work on the Mooney. The individual told Doctor X that the engine would start and run but was not the correct propeller for his engine per his STC . Nonetheless the doctor had the propeller shipped to Aircraft Repair Facility in Lake Norman, NC. What do you think the Doctor has in mind? One could question his safety culture at this time. The spare propeller 2AC34C50 is typically installed on Cessna 182. What would you have done if YOU were the acquaintance? The acquaintance displayed lack of assertiveness by not discouraging the Doctor from using the propeller!
It is now Friday (end of a work week!??) July 15 th , two mechanics, with prop âunder armâ, are sent to Augusta do interim repairs for Ferry Flight. What kind of shape are the two mechanics in? (When does the ferry permit expire? July 18 th !...........not much time..right?). Quick Question: Does aircraft have to be airworthy for ferry flight? No! but it must be SAFE for the flight! One could question how much research was done by the repair facility to validate condition /applicability of propeller. Do you think this a human factor in the chain of events? The left landing gear would not lock in the down position so the gear was secured and physically locked down by mechanics and the circuit breaker was pulled. Do you think this might affect climb performance? Considering the Doctorâs safety culture or risky behavior do you think the Doctor even give this a second thought?
At some point, both mechanics were advised that Doctor X had spoken to an individual in Virginia and said the two bladed propeller would work BUT it was not the right one. (Should have been an alarm?). Mechanic 2 finishes final preparation to airframe. Mechanic 1 removes the 3 bladed propeller and attempts to install the 2 bladed McCauley but something is amiss!! The propeller bolts are too short! Question: What would you do at this point if you were the mechanic installing the propeller? Have discussion of behavior, safety culture, and human factors in effect. Well mechanic one presses on and removes the bulkhead, installs the propeller but must leave spinner off because that mounts to the bulkhead which is now removed! Propeller now installed. Mechanic 1, in subsequent interview, stated the propeller was installed using the Mooney Maintenance Manual . Discussion of facts: The replacement propeller is not approved for this aircraft per TCDS and remember this aircraft was modified with a different engine and propeller per STC! So use of Mooney manual is suspicious at bestâŚâŚâŚâŚ..do you agree?
A local maintenance facility support was sought to provide the Doctorâs mechanics with nitrogen service equipment to service the tires and nose strut. The local mechanic from the facility thought it was odd that the propeller tip was only 8 inches from the ground ( HF9 )âŚâŚâŚâŚâŚ.but nevertheless the servicing was completed. Why was the propeller tip clearance not further questioned or addressed? Anyone care to speculate on this? Afterwards, mechanic 1 and 2 attempted to run the engine. The engine started but power could not be obtained. Finally, it was late and the Doctor with both mechanics departed back to Lake Norman, NC.
Itâs Monday July 18, 2011, the day the Ferry Permit will expire. Any Human Factors here? Mechanic 2 flew back with Doctor X in his Bonanza. The âplanâ was that Mechanic 2, who was also a pilot, would fly the Bonanza back to Lake Norman, while the doctor flew the Mooney. Upon arrival Mechanic 2 began final preparation of the Mooney. He connected the battery then prepared to run the engineâŚâŚâŚâŚâŚâŚ.again. Recall when they left on Friday the engine was started and ran but full power couldnât be obtained.
The Mechanic 2 started the engine and ran it up. During the run up he noticed something was not quite right. The propeller control operated BACKWARDS! The correct propeller control is when the control is pulled out the engine RPM will decrease. However now the prop control INCREASED engine RPM when pulled out. What do you think Mechanic 2 did to remedy this? He advised Doctor X of this condition. It is not known how the Doctor reacted to this advisementâŚâŚBUT is fully aware of the condition! What was the only thing on his mind? What HF influences were in effect?
Doctor X asked Mechanic 2 to service the spongy brakes. This is so bizarre âŚâŚâŚâŚ.the Doc has a propeller control that operates backwards yet he is concerned over spongy brakes!! NonethelessâŚ..the Doctor presses on. The doctor told Mechanic 2 that he was going to take off and climb to 8000 feet over Bush Field and if everything was good he would proceed to Lake Norman. Well at this point we know that everything is NOT goodâŚâŚâŚâŚâŚâŚ.. mechanic 2 knows everything is not good. But the Doctorâs behavior, decisions, and actions are contrary to any that an experienced, safety conscious pilot should display.
Mechanic 2 recalls that he saw the doctor taxi the Mooney over to local fixed base operator (FBO) to be sure that he had the necessary fuel for the flight. About 2 PM, service is completed and Doctor X begins taxi to runway 17. Mechanic 2 is in the Bonanza and begins his taxi out. At 2:19, the Doctor receives clearance for take off and begins roll down the runway.
At this point one could ask what operating characteristics was the Doctor experiencing. Recall the engine power was an issue. Approximately one third down runway the aircraft lifted off. A ccording to witnesses, the engine was extremely loud and the aircraft was not climbing too fast . At the departure end of runway the aircraft began a shallow left turn and leveled off with the noise getting louderâŚâŚâŚâŚâŚâŚ.then about 2:21 a loud POP was heard.
Can you guess what fell off the aircraft? The object was the propeller! The aircraft travelled another 200 yards. Entered into a steep left spiral! Then impacted the ground and exploded!
The Doctor perished in post fire impact!
The subsequent slides is post accident analysis and are optional to the presenter. Discuss the Human Factors that may have contributed this accident. Use the Dirty Dozen âŚâŚâŚâŚ..or others that may have been in effect. Discuss the numerous opportunities that could have prevented not only the first accident but the fatal accident as well.
Complacency, Pressure, Others? How could/should they have been handled
Discuss acquaintanceâs advice about propeller and how should the Doctor have reactedâŚâŚâŚâŚ.and possible reasons why he did not. What about the effects of the looming expiring ferry permit? Discuss the important fact about ferry permits. Although the aircraft does not meet certain airworthiness requirement it must be safe for flight and there must be a log entry stating this. A ferry permit is not permission to do what ever it takes. . Maybe if the mechanics had expressed some assertiveness and concerns with the owner and refused to sign off the aircraft, the accident could have been avoided. Or a call to the FSDO. Human Factors: Lack of Knowledge, Lack of Communication, Lack of Assertiveness, Pressure,âŚâŚâŚâŚâŚâŚâŚâŚâŚ Others??
Although it is common to ferry aircraft with gears locked down, do you think the increased drag and effects on performance was taken in consideration? Not necessarily by the mechanics but most definitely should have been by the Doctor? Discuss possible HF and mitigating actions The propeller did not fit properly! Bolts too short. Bulkhead and spinner left off to allow bolts to fit. This is absolutely mind boggling!! Notwithstanding all previous opportunities, this is where the everything should have come to a halt! Discuss the possible reasons it did notâŚâŚâŚâŚâŚâŚ.i.e. culture, behavior, HFâs Lack of Knowledge, Lack of Assertiveness, PressureâŚâŚâŚâŚ..all others.
A local mechanic saw the propeller tips close to the groundâŚâŚâŚ..âŚthought it was oddâŚâŚâŚâŚâŚbut did not express his concern. Lack of Communication Lack of Assertiveness Engine did not achieve full powerâŚâŚâŚâŚâŚâŚaccepted by mechanic and/or Doctor. Discuss possible reasons why . Propeller controlâŚ..operates backwardsâŚâŚâŚ.accepted by mechanic and/or Doctor. Discuss possible reasons why.
Review the summary bullets; Ask for any final thoughts from the attendeeâs. Then ask the question to all in attendance â What, if anything would you have done different? Explain that the Number One Causal Factor of Fatal Accidents where maintenance is involved is âFailure to Follow the Proper Procedures.â Ask them: Do you follow procedures all the time? Give each attendee a copy of the âMaintenance Personal Minimum Checklistâ and encourage them to use it. This means not just reading it but routinely and honestly reacting to each one of the checklist items.
Provide last chance for questions Promote faasafety.govâŚâŚâŚâŚâŚbriefly discuss features, resources and location. Suggest hand out promotional business cards. Promote On-line AMT ProgramâŚâŚâŚ..emphasize where, howâŚâŚâŚâŚâŚâŚâŚâŚ. and benefits (increased training, expand knowledge, obtain an award and finally enhancing a resume of self improvementâŚâŚâŚ..i.e. a competitive edge.