just plane maintenance! - alpa
TRANSCRIPT
Just Plane Maintenance!But … it’s what you don’t know that just might hurt you!
ByCaptain Bob Aaron
Central Air Safety ChairmanNWA
Gross errors are very visible …
But … it’s the little, unseen errors that are the “gotcha’s!”
So … where do we go from here?
What should we expect every time we strap a plane to our backs?
Pilots EXPECT their plane to be ready to fly … but is it?
AA 191DC-10May 25, 1979ORDLeft engine tore off AA process -remove pylon in one piece (CAL and UAL also)Hydraulic lines gone - aircraft bled to death
AL 261MD-80January 31, 2000Crash off Pt Mugu, CAMaintenance
Jack screw issuesLubrication issues
Impossible for crew to see prior
JAL 123
B747 ClassicAugust 12, 1985Tail scrape on landingBoeing AOG team
Aft pressure bulkhead repairExplosive decompressionLost 15 foot section of tail
Hydraulics also lost509 SOB, 505 killed
Air Midwest 5481Beech 1900DJanuary 8, 2003
Several possible causes …Elevator cable adjustmentWork done incorrectlyElevator travelCG issue as well Deadly combination w/ elevator
What sort of “unseen” errors occur?They cover the gamut …
Outsourced maintenanceOversight Troubleshoot or just MEL it?Airline and FAA oversight
MEL / DDG applicationsPaperwork errorsWrong items deferredMEL expirations
What sort of “unseen” errors occur?
Wrong parts installedWrong size screws used – wing panels and windshieldsIncomplete repairs to aircraft … but signed off anyway“Pilot pushing” to fly aircraft
How can pilots reverse the erosion of solid maintenance?
Your mitigation strategy will vary …Size of airline dependent Percentage of outsourcing being done
Training and qualifications of workers hiredOversight by both airline and the FAA
How can pilots reverse theerosion of solid maintenance?
Pilot involvement with management –key piece!Usage of ASAP, FOQA, ASIAS and NASA ASRS!Use their data to force a safety changeWillingness to refuse to fly that aircraft, if necessary
Thank you for your time!
54th Annual Air Safety & Security Week54th Annual Air Safety & Security Week
Air Carrier Maintenance Standards“What We Don’t Know Will Hurt Us!”
Air Carrier Maintenance Standards“What We Don’t Know Will Hurt Us!”
Mr. John GogliaFormer NTSB Board Member
Mr. John GogliaFormer NTSB Board Member
Presentation ByPresentation By
Mr. Gregory FeithFormer NTSB SeniorAir Safety Investigator
Mr. Gregory FeithFormer NTSB SeniorAir Safety Investigator
PERCEPTIONPERCEPTION
Is the EROSION of Air Carrier Maintenance?Is the EROSION of Air Carrier Maintenance?
or REALITY?or REALITY?
“SAFE”
Free from harm or risk;Secure from threat ofdanger, harm or loss;Affording safety andsecurity from danger or risk
Dictionary Definition:
How Do We Communicate?
Spoken WordsSounds or Noises
Verbal Non-VerbalSign LanguageHand GesturesWritten WordsPicturesSmoke Signal
Miscommunicationor
Misinterpretation
Poor information sharingbetween crewmembers, maintenance tech/control
andmanagement!
IN THE HANGARor
ON THE LINE
IS THERE A COMMON LANGUAGE THAT CAN BE UNDERSTOOD BY ALL GROUPS?
The Language!
Pilots Talk Problems
Mechanics Talk Solutions
Engineers Talk Data
Management Talks Money
FAA Talks Compliance
American Airlines Flight 191American Airlines Flight 191
Probable Cause: The asymmetrical stall and ensuing roll of the aircraftbecause of the uncommanded retraction of the left wing outboard leading edgeslats and loss of stall warning…resulting from maintenance-induced damageleading to the separation of the No. 1 engine and pylon assembly at a criticalpoint in the takeoff.
Contributing to the cause of the accident were…deficiencies in the FAA oversightwhich failed to detect and prevent the use of improper maintenance procedures;deficiencies in the practices and communications among operators….
Emery Worldwide AirlinesDouglas DC-8; Cargo Configuration
February 2000
Probable Cause: The loss of pitch control resulting fromthe disconnection of the right elevator control tab. Thedisconnection was caused by the failure [of maintenancepersonnel] to properly secure and inspect the attachment bolt.
January 8, 2003Air Midwest Flight 5481Beech 1900D
Probable Cause: Loss of pitch controlduring takeoff due toincorrect rigging of the elevator control system
Alaska Air Flight 261
The probable cause of this accident was a loss of airplane pitch control resulting from the in-flight failure of the horizontal stabilizer trim system jackscrew assembly’s acme nut threads. The thread failure was caused by excessive wear resulting from Alaska Airlines’ insufficient lubrication of the jackscrew assembly. Contributing to the accident were Alaska Airlines’ extended lubrication interval and the Federal Aviation Administration’s (FAA) approval of that extension, which increased the likelihood that a missed or inadequate lubrication would result in excessive wear of the acme nut threads, and Alaska Airlines’ extended end play check interval and the FAA’s approval of that extension, which allowed the excessive wear of the acme nut threads to progress to failure without the opportunity for detection. Also contributing to the accident was the absence on the McDonnell Douglas MD-80 of a fail-safe mechanism to prevent the catastrophic effects of total acme nut thread loss.
Valujet Flight 593Florida EvergladesValujet Flight 593Florida Everglades
There is NO Competition in Aviation Safety!!!
DISCUSSION&
QUESTIONS
Gregory A. FeithGregory A. Feith, LLC.Copyright@2008