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