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HUMAN PERFORMANCE IN MAINTENANCE                 

 

CASE  STUDY #4

"Careless, Stupid, Dumb and Lazy"

 


This video is not based on an actual event but serves to illustrate how all of the "Dirty Dozen" plus "Early Life Decisions" (ELDs) contribute to an error in judgment that leads to an accident.  There are also a number of "System" errors that are not recognized.

 

Read how a simple maintenance error was the “active” failure at the end of a series of “latent” failures.  Safety nets, which are the last defense, were not in place or had holes in them, the end result was a terrible accident.

 

As a review of the causes of a person to make an unintentional error in judgment, watch the video, follow in this workbook and mark down the error causes in the left-hand column as you review them.

 

Choose the best of the possible responses and realize that some are quite close.  I.e., Pressure and Stress are closely related so read carefully.

 

Also, what Safety Nets can we put in place to help ensure this kind of accident is not repeated?

 

 

This video was sponsored by the following companies in an ongoing effort to advance Aviation Safety

                     

Produced by  System Safety Services

“We must learn from the mistakes of others

because we will never live long enough

to make them all ourselves”

 

To purchase, or for more information regarding this case study contact

Gordon Dupont

System Safety Services

Website: www.system-safety.com

Email: dupontg@system-safety.com

Phone/Fax: 604 526-3993

  This case study may be reproduced for use with the training video

 

Scene: The office of Low Cost Airline 's Ramp Manager, Mr. Rodney Dontknow (RD), In the office with Mr. Dontknow is Johnny Workhard (jw), a newer member, still on probation, of their Morning Ramp Crew.

Johnny Workhard (jw) You wanted to see me?

Rodney Dontknow(RD): You bet I wanted to see you. You were extremely CARELESS out there. What happened?

Johnny Workhard (jw): I'm sorry Mr. Dontknow. I guess I messed up!

RD: You guess you messed up! You bet you really did mess up.. It says here that 603 has got two formers and belly skin damage, and it's going to have to be replaced. Its going to be down for 5 days. How could you be so STUPID?

jw: I really didn't mean to do it.

RD: What do you mean you didn't really mean to do it. Ramp Policy 442-C specifically says that you should not drive under that kind of airplane for just this very reason.

jw: But they didn't teach us anything about that in our initial training.

RD: They didn't teach you? That's part of your job, to read these Ramp Policies.

jw: Well, I guess so, but I just never got around to it and besides everyone does it.

RD: Everyone does it! How DUMB can you get. If I catch them, I'm going to have their brains for breakfast. ( a Unisex version of an often used quote)

jw: But I always do it that way and I've been doing it that way ever since I started without any problem. I just don't understand! I took the first load out not 10 minutes before the same way with no problem

RD: Well you sure have one now; and we expected better of you. Your final probation report says: "Johnny Workhard is the best person I got on my crew.I "He is a hard worker." "He's the most dependable person on the ramp." "He's always willing to help." I see you work a lot of overtime.

jw: Yes sir! I have a beautiful baby daughter at home. But lately she has been sick a lot. It has been worrying us sick. My wife worries about the money. You know how expensive kids are these days. She kind of wishes I had a better paying job.

RD: Yeah, well you should not bring your personal problems to work.

jw: Yes sir.

RD: What shift are you on anyway?

jw: I start at 6am sir.

RD: At 6 am? It's now 8. We've been paying you overtime since 2 oclock this afternoon.

jw: Yes sir. We are short one on the crew. Plus Mary is on holidays and Joe is off sick again so they asked me to stay on..

RD: They ask you to stay on a lot don't they!

jw: We are very short handed. I don't mind except when the baby is sick. She cries a lot at night and its hard to sleep sometimes.

RD: Well you might get some time to rest soon. You must have had that tug floored to put a dent in the aircraft like that. What do you think the ramp is? The Indianapolis speedway?

jw: Oh no sir. I was kind of rushing a bit because Larry, our crew chief wanted me to hurry up so I could help another crew unload the Hawaii 47 that came in late: But its just that Tug 13 stalls on you when you go to start off so you have to rev it up good and drop it into gear.

RD: Well you just too LAZY to go get another tug.

jw: We are short of tugs, but I was using Tug 15 until Pete went and swapped on me when I was unloading Flight 1355.

RD: Well why did you let him do that?

jw: Well he has more seniority then me and I am on probation and don't like to make waves. Besides we were running behind schedule and I didn't have time to argue.

RD: How long have you had this problem with Tug 13?

jw: Its been like that for a couple of months.

RD: Couple of months! Why the heck didn't you report it?

jw: Well, I though some of the others had.

RD: Well they haven't. Why didn't you talk to them and find that out?

jw: I guess we just talk about other things and it never sort of came up.

RD: Jack was with you unloading . Why didn't you have him watch where you were going?

jw: Well I guess he could have but we just didn't plan it that way.

RD: Why can't we have somebody do some thinking around here! Why didn't you at least look back and see if you were clear?

jw: Oh I always do that but this time I had to look out for a fuel truck that had just finished refuelling and was getting ready to back up.

MD: So... the airplane had just been refuelled? Did you know that the aircraft struts would compress up to 9 inches from an empty aircraft to a full fuel load?

jw: No, I wasn't aware of that.

RD: Well you should be. It's just common sense. Everybody knows that for heavens sake. You've been CARELESS, STUPID, DUMB just too LAZY to do it right.

jw: My Dad always used to tell me I had nothing between my ears.

RD: Well I think he was right. We have invested a lot of money in your training. This is the sixth time that this has happened this year. I just don't know what else to do. I'm sorry Johnny but I'm going to have to make an example of you. You're fired.

jw: I understand. It seems I've managed to screw up just about everything I've done in my life but I really liked working for Low Cost Airlines and I hoped things would be different.

RD: Well I'm sorry too. I'll make sure that you get all of the company benefits......

Thus a company loses another good worker and will likely go on to hire another who will repeat the same mistake because they all lack the knowledge to understand what makes them make that error in judgment that results in an expensive incident.