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Airworthiness: Doctoring maintenance

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Airworthiness: Doctoring maintenance by FAASTeam

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Airworthiness: Doctoring maintenance

  1. 1. Federal AviationAdministrationAirworthinessPositive Safety CultureDoctoring MaintenanceA Discussion of HumanFactors and Behavior
  2. 2. Federal AviationAdministration2Introduction• Review a fatal accident scenario• Analyze chain of events leading up to the fatalclimax• Discuss how poor safety culture, unsafebehavior, and ignoring Human Factors causeda pilot to perish.
  3. 3. Federal AviationAdministration3Objectives• Emphasize thoughtless decisions and riskybehavior lead to undesirable consequence.• Recognize Human Factors and not to ignorethem.• Encourage embracing a more positive safetyculture that inspires safe behavior.
  4. 4. Federal AviationAdministration4
  5. 5. Federal AviationAdministration5Ended up like this!!
  6. 6. Federal AviationAdministration6Mooney M20K• Original Configuration per Type Certificate DataSheet (TCDS) 2A3.• Engine: Continental TSIO-360 (210 HP)• Prop: McCauley 2A34C216
  7. 7. Federal AviationAdministration7Accident Mooney M20K• Modified by Supplemental Type Certificate(STC) No. STC5691NM• Engine: Continental TSIO 520 (305 hp)• Propeller: McCauley 3AF32C505
  8. 8. Federal AviationAdministration8Departure• Departure, under visual flight rules, cross-country.• Destination airport expected to be VisualMeteorological Conditions (VMC).
  9. 9. Federal AviationAdministration9Arrival• Destination airport weather not as anticipated.• Unsuccessful attempts to land.• Diverted to another airport.
  10. 10. Federal AviationAdministration10LANDING• The approach to diversion airport wassuccessful.• At touchdown events began to unfold.• Failed attempt to pull up.• Unexpected climax
  11. 11. Federal AviationAdministration11Non Injury Accident• The Mooney was damaged .• Doctor X did not follow procedures• Doctor realized “Other” factors were in effect
  12. 12. Federal AviationAdministration12Heading to the fatal accident• Doctor X needed a replacement aircraft rightaway• Purchased a another aircraft• Mooney would be repaired and used again.
  13. 13. Federal AviationAdministration13Heading to the fatal accident• The Mooney insurance policy close to expiring.• No local area repair available.• Need to move the aircraft.
  14. 14. Federal AviationAdministration14On course to fatal accident• Doctor X decides to get Ferry Permit.• The Doctor makes arrangements with homebased aircraft repair facility.• Ferry Permit has time limit.
  15. 15. Federal AviationAdministration15Still on course to fatal accident• Mooney propeller must be replaced• Doctor X owns another McCauley propeller• Spare propeller not correct for the Mooney
  16. 16. Federal AviationAdministration16Course to fatal accident not altered• Mechanics sent to prepare damaged Mooney.• Problems encountered with the landing gear.
  17. 17. Federal AviationAdministration17Course 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
  18. 18. Federal AviationAdministration18Accident Course Slightly Delayed• Tires and nose strut gets serviced• Test run-up performed
  19. 19. Federal AviationAdministration19Back on the course to accident• Doctor and Mechanic 2 return to Augusta, GA.• Mechanic 2 was also a pilot• Final Ferry preparation began
  20. 20. Federal AviationAdministration20The Day of the Crash• Mechanic 2 began operational check of engine• More Problems…….now with the propeller• Doctor X knows the problem exists!
  21. 21. Federal AviationAdministration21The Day of the Crash• Flight preparation continues• Doctor X advises Mechanic 2 of his flight plan
  22. 22. Federal AviationAdministration22Shortly 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
  23. 23. Federal AviationAdministration23Moments before crash• The Mooney lifts off• Witnesses observed the lift off.• Seconds before the crash
  24. 24. Federal AviationAdministration24The Crash:• Something fell off of the aircraft.• The aircraft continued a short distance more• Impacted the ground
  25. 25. Federal AviationAdministration25The Crash Scene
  26. 26. Federal AviationAdministration26Post Discussion Analysis:• What and why did things go wrong?• Human Factors (HF) were NOT recognized andWERE ignored.• Opportunities to prevent either/BOTHaccidents.
  27. 27. Federal AviationAdministration27Analysis:• HF1. The Doctor was very busy, used aircraftfor business and had logged more than 4000hours in his Mooney.• HF2: The Mooney insurance expiring.
  28. 28. Federal AviationAdministration28Analysis:• HF3: Acquaintance advice.• HF4: Ferry Permit expiration
  29. 29. Federal AviationAdministration29Analysis:• HF5: Landing gear problems.• HF6: The propeller problems
  30. 30. Federal AviationAdministration30Analysis:HF9: Propeller tips so close to the ground.HF10: Engine did not achieve powerHF11: Propeller control operates backwards.
  31. 31. Federal AviationAdministration31Summary• This scenario shows how thoughtless decisions andrisky behavior led to undesirable consequence.• We identified applicable Human Factors and why youshould not to ignore them.• Adopting a more positive safety culture will inspiressafe behavior in you as well as your associates.
  32. 32. Federal AviationAdministration32Before we close• Any questions or comments• www.FAAsafety.gov• AMT Awards Program

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