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Aeronautics Study - Safety Threats Term Paper

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Aircraft Maintenance Drunk Driving Root Cause Analysis Accident Investigation
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For an additional 14 occurrences, the outcome could not be determined. A a) Figures are rounded to nearest percentage.

Errors

Perceptual error

Example: After being on duty for 18 hr on a long overtime shift, the worker was carrying out a general inspection on an engine at around 22:00. He missed obvious damage to the internals of the cold stream duct area. The damage was found later, when another defect was being investigated.

Memory lapse

Example: Just prior to the departure of the aircraft, I remembered I had left a blanking plug within the engine inlet area. I advised the pilot that I needed to check that area again and retrieved the blank.

Slip

Example: Without thinking, I moved to wipe oil with a rag. The rag was ingested in the engine intake causing FOD [Foreign Object Damage].

Rule-based error

Example: A mechanic did not check the position of the flap lever before he pushed in a cockpit circuit breaker that provided electrical power to a hydraulic pump. When the pump started, the flaps began to retract automatically. This could have caused damage to the aircraft or injured other workers.

Violation

Example: At the end of a shift we realized that an engine hadn't been run to check for oil leaks when the aircraft was to be placed online. Under pressure to avoid a delay due to this oversight,...

I was unfamiliar with the aircraft, so I asked an airframe tradesman who was working on the aircraft and he pointed to a red rocker switch. I queried him and he said that must be it. I pushed the switch and the right engine turned over, with the propeller narrowly missing a tradesman who was inspecting the engine. There is no radio master in this aircraft. I immediately marked the "start" and some other switches and learned a valuable lesson.
Mischance

Example: A service procedure was carried out in accordance with the aircraft maintenance manual. The manual however, contained an error, which resulted in an aircraft system failing to operate correctly during a functional test at the end of the maintenance procedure.

Factor n or Fatigue 1-0.2

Pressure 8-1.9

Coordination 6-1.4

Training 1-0.2

Supervision 5-1.9

Procedure 16 9.0 **

Equipment 1-0.3 deviation 4-4.3 *

Environment 1-0.8 chi square](9, N = 805) 46.68

Wald test significant at p

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References

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Dismukes, Key, Berman, Benjamin a. And Loukopoulos, Loukia D. (2007). The Limits of Expertise: Rethinking Pilot Error and the Causes of Airline.... Ashgate Publishing, Ltd. Retrieved November 23, 2007, at http://books.google.com/books?id=mMxaYxhu0l0C&dq=runway+excrusions+causes

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Mcfadden, K.L. (2002). DWI Convictions Linked to a Higher Risk of Alcohol-Related Aircraft Accidents. Human Factors, 44(4), 522+. Retrieved November 23, 2007, from Questia database: http://www.questia.com/PM.qst?a=o&d=5001910855
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Olson, W.A., & Sarter, N.B. (2001). Management by Consent in Human-Machine Systems: When and Why it Breaks Down. Human Factors, 43(2), 255. Retrieved November 19, 2007, from Questia database: http://www.questia.com/PM.qst?a=o&d=5001043608
Runway Safety. (2007, October 10). Federal Aviation Administration. Retrieved November 23, 2007, at http://www.faa.gov/runwaysafety/
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Runway Safety the Human Element. (2007). Retrieved November 23, 2007, at http://www.faa.gov/runwaysafety/human.cfm
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