HUMAN PERFORMANCE IN MAINTENANCE
"The Price of a Mistake"
Released . 2004
Produced by System
“We must learn from
the mistakes of others
because we will never live long enough
to make them
To purchase, or for more information regarding this case study contact
I was a young AME, there was a terrible plane crash that I'll never forget.
The following is the true story as told by the AME who made the one
I'm a happy go lucky person but that day my world turned upside down.
Grief washed over me in suffocating waves.
The sight of those seven caskets in a grimly accusing row was almost
more than I could bear. I didn't
think I could stand it. I was
responsible. They were dead because of my error. I was a failure.
never forget the moment I first heard the news. It was almost suppertime.
Nearly everyone was beginning to unwind after another busy day.
We were wrapping things up at the hangar where I'm an aircraft
maintenance engineer. Two planes were still out but would be back before dark.
The flight dispatcher was standing by for their radio calls and heard
the call. He hit me with it cold,
when over the phone he said: “The Aztec is on fire.”
I raced to the dispatch room in time to hear them desperately dive for
safety at Bobqic and crash just short of the runway. Dave was on his way to Goodhope and saw it from the air.
He said it looked bad. I
couldn’t believe it! It
couldn’t be! Not our plane!
told us no one survived while I listened in numbed silence.
He was near Bobqic, an abandoned WWII airfield about halfway on the 40
minute run to Goodhope when he heard Don call our dispatcher:
"Mayday, Mayday, Mayday! I
have a fire in my starboard engine and am now feathering.
I'll try for a landing at Bobqic."
Dave spotted the Aztec, streaming frightful orange and white flames
from the right engine and a long trail of ugly black smoke traced Don's
desperate dive for safety. The
Aztec passed over the runway and was turning to land when suddenly there was a
brilliant flash of fire and the right wing folded upward.
The plane rolled violently to the right and crashed inverted.
There were no survivors. Seven
people perished instantly in a ball of flame and twisted metal.
stupefied to feel emotion, I sat in a daze.
My thoughts raced around in tortured circles. Did I do something wrong?
I was one of the aircraft mechanics maintaining the Aztec.
I tried to think, but my mind was numb.
The events of the preceding day were routine.
I had performed a hundred hour inspection as I had done so many times
before. I had inspected the right
engine at the end of the day! The
one that caught fire! That had to
be the key. Was there something I
had or hadn't done?
Kyle, a new apprentice had
helped me on the inspection. He
was changing the right magneto while I was underneath the engine replacing the
carburetor fuel finger screen. I
had just hooked up the fuel line again and twisted the B nut finger tight when
he asked for a hand with the mags. I
got out from under the engine to help and.... That had to be it!!
I never finished tightening that nut with a wrench!
I was stunned. My practice
of always making a final visual inspection of everything I do had failed me.
How could I have missed that nut?
The thought was agonizing. The
simple lack of a final twist of the wrench on that fuel line meant a fine
spray of gasoline could escape. It
went unnoticed on the post-inspection run-up I'd done late that evening, but
after several hours of flying, the nut must have loosened more and
I turned to Keith, our
Chief Pilot, and in the midst of tears and grief, told him it was my fault.
Sure enough, a subsequent investigation by the Dept. of Civil Aviation
proved it. The nut on the fuel
line was only finger tight. My
failure to tighten that nut cost seven people, my close friends and
co-workers, their lives. I had killed them.
The funeral was a ghastly
ordeal. The sight of those
caskets lined up hit me like a blow to the stomach.
I wanted nothing but to get out of there. At the gravesite the same terrible anguish gnawed at my
vitals. Oblivious to anything but
my grief, I was absolutely, totally wretched.
How could I face my friends? How
could I face myself? I was
overwhelmed with guilt. I was a
failure. The tyranny of that
failure made the next few days the worst I've ever lived.
I was responsible for a hundred hourly on one of our other planes.
It was the last thing I wanted to do but there was no choice.
I remember going from the hangar into the parts store to get a new fuel
line. I started to pick it up but
couldn't. I was literally
repulsed. Tears flooded my
cheeks; I leaned on the bench and sobbed.
I couldn't do it. I
couldn’t work on planes. Look
what I had just done - sent seven people to their deaths.
Love had got me through that week; the love of Kyle assigned to help with the work. He sensed the tumult in my mind and encouraged me. I'm sure that everyone knew something of the cause of the accident but I never sensed rejection by anyone. But it was not over yet. The emotional wringer squeezing me dry of everything but guilt and grief still had one more twist before spitting me out. I wanted to talk with Don's wife but I was afraid. What would she say? I couldn't face her so I put it off and the longer I put it off the harder it got.
On the day Don's family was scheduled to return to
live with her parents, I was working at the hangar as usual.
They were waiting for the 206 to return from the milk run in the
pilot's lounge. I had to talk to
them. I hesitantly pushed the
door open and asked everyone but Angela to leave.
No one spoke; they just got up and left; left me with the wife of the
man I had killed. I closed the
door and opened my broken heart. I wept and wept. My
voice choked with sobs as I asked her for forgiveness. "That hand there", I said, "took
Don's life". With
almost incoherent, sobs shaking my whole body, I sat wrapped in misery. Angela reached out and took my hand into hers, the hand that
had taken her husband's life. The
warmth of her forgiveness flowed over me like a balm.
Time has gone on and the healing continues.
I HOPE THAT NONE OF US EVER
HAS TO LIVE THROUGH THE AGONY OF HAVING MADE A MISTAKE.
While Charlie, the AME, may be held responsible for the loose B nut and the resulting engine fire, I feel that he was not responsible for the seven deaths, as all aircraft are required to have a safety net in the event of engine fires called a firewall. This firewall safety net had a large hole in it in the form of an aluminum turbocharger oil tank that had been installed after-market as an approved modification. This approved mod went right through the firewall. It is believed that it was the oil from this tank that continued to burn even after the pilot had shut off the fuel to the engine.
Sadly, Charlie died about 5 years
later of cancer. I believe that
he never forgave himself for the simple error he committed.
That also can be the terrible price of a mistake.