federal aviation administration airworthiness positive safety culture doctoring maintenance a...
Post on 16-Jan-2016
218 Views
Preview:
TRANSCRIPT
Federal AviationAdministrationAirworthiness
Positive Safety Culture
Doctoring Maintenance
A Discussion of Human Factors and Behavior
Federal AviationAdministration
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.
Federal AviationAdministration
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.
Federal AviationAdministration
4
Federal AviationAdministration
5
Ended up like this!!
Federal AviationAdministration
6
Mooney M20K
• Original Configuration per Type Certificate Data Sheet (TCDS) 2A3.
• Engine: Continental TSIO-360 (210 HP)
• Prop: McCauley 2A34C216
Federal AviationAdministration
7
Accident Mooney M20K
• Modified by Supplemental Type Certificate (STC) No. STC5691NM
• Engine: Continental TSIO 520 (305 hp)
• Propeller: McCauley 3AF32C505
Federal AviationAdministration
8
Departure
• Departure, under visual flight rules, cross-country.
• Destination airport expected to be Visual
Meteorological Conditions (VMC).
Federal AviationAdministration
9
Arrival
• Destination airport weather not as anticipated.
• Unsuccessful attempts to land.
• Diverted to another airport.
Federal AviationAdministration
10
LANDING
• The approach to diversion airport was successful.
• At touchdown events began to unfold.
• Failed attempt to pull up.
• Unexpected climax
Federal AviationAdministration
11
Non Injury Accident
• The Mooney was damaged .
• Doctor X did not follow procedures
• Doctor realized “Other” factors were in effect
Federal AviationAdministration
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.
Federal AviationAdministration
13
Heading to the fatal accident
• The Mooney insurance policy close to expiring.
• No local area repair available.
• Need to move the aircraft.
Federal AviationAdministration
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.
Federal AviationAdministration
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
Federal AviationAdministration
16
Course to fatal accident not altered
• Mechanics sent to prepare damaged Mooney.
• Problems encountered with the landing gear.
Federal AviationAdministration
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
Federal AviationAdministration
18
Accident Course Slightly Delayed
• Tires and nose strut gets serviced
• Test run-up performed
Federal AviationAdministration
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
Federal AviationAdministration
20
The Day of the Crash
• Mechanic 2 began operational check of engine
• More Problems…….now with the propeller
• Doctor X knows the problem exists!
Federal AviationAdministration
21
The Day of the Crash
• Flight preparation continues
• Doctor X advises Mechanic 2 of his flight plan
Federal AviationAdministration
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
Federal AviationAdministration
23
Moments before crash
• The Mooney lifts off
• Witnesses observed the lift off.
• Seconds before the crash
Federal AviationAdministration
24
The Crash:
• Something fell off of the aircraft.
• The aircraft continued a short distance more
• Impacted the ground
Federal AviationAdministration
25
The Crash Scene
Federal AviationAdministration
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.
Federal AviationAdministration
27
Analysis:
• HF1. The Doctor was very busy, used aircraft for business and had logged more than 4000 hours in his Mooney.
• HF2: The Mooney insurance expiring.
Federal AviationAdministration
28
Analysis:
• HF3: Acquaintance advice.
• HF4: Ferry Permit expiration
Federal AviationAdministration
29
Analysis:
• HF5: Landing gear problems.
• HF6: The propeller problems
Federal AviationAdministration
30
Analysis:
HF9: Propeller tips so close to the ground.
HF10: Engine did not achieve power
HF11: Propeller control operates backwards
.
Federal AviationAdministration
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.
Federal AviationAdministration
32
Before we close
• Any questions or comments
• www.FAAsafety.gov
• AMT Awards Program
top related