CASE STUDY

"Dedicated to assisting companies to operate Safer by reducing human error"

HUMAN PERFORMANCE IN MAINTENANCE

CASE STUDY #5

"And a Merry Christmas to You"

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

This case study is not based on any actual single event but is made up from experiences I have had that for this study, have been amplified. No one should think that such a scenario could not happen.

Look at the chain of events as they build up and look at some ways we can prevent it from happening.

Note also how the system contributed to the error.

So what happened? Look carefully at all the circumstances, figure out the links in the chain that added up to an error and look carefully at the safety nets that were not in place or could have been in place to prevent the accident.

“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

Synopsis

It was Christmas Eve and the corporation's maintenance department was shutting down for the Christmas holidays. Joe was looking forward to this Christmas because his parents were coming to spent it with him and the children were old enough to enjoy the full excitement of present opening. It was going to be like old times. He was explaining this to Abdul, his friend, when he was asked to go see the Director of Maintenance.

Aircraft 402 had called in with a governor problem but failed to inform the Director of Maintenance of the seriousness of the problem or the fact they were running late.

The Director of Maintenance asked Joe if he would mind staying back a few minutes to clear a small snag on 402 when it arrived. It was needed for an personal flight with the boss and his family, early the next morning, and Joe was the company’s best AME. "D__", thought Joe, "but OK, I guess a few minutes won’t hurt."

As the hangar emptied Joe felt the anger welling up inside him. "Why always me?" Dispatch wished him a Merry Christmas when he finally went up to find out why 402 was late and he found it difficult to respond in kind. Two hours late, Joe finally got 402 into the hangar: "About the same time everyone is sitting down to dinner without me" he thought. "Small job my A__! The only way to do this right is to replace the governor. It’s the fifth one I’ve changed in the last two months so I sure won’t need the manual. D__! The special tools are locked away: Can’t anything go right? Oh ___, there’s no gaskets left in stock but the old one should be ok. Double D__! That last stud broke off and now I’ve got to pull the whole thing off again. I’ll bet they’re opening up their presents by now. There, the d__ thing is in and all I have to do is run it up. Gosh I’m tired but it’s almost finished. Look at that, its snowing and there’s only me to get this thing out of the hangar. To h___ with it! I’ll just sign the logbooks and just maybe, someone will still be up when I get home. Why is it always me? Why?"

It was 0130 by the time Joe finished the installation and he had not eaten since lunch but was surviving on multiple cups of black coffee.

At 0630 the next morning the bedside phone rang in Joe’s ear. The morning shift had loaded the plane with the boss and his family and he was not amused when the right engine covered the aircraft with oil on start-up. The used gasket had a crack in it. "I just don’t understand. How could that have happened?" thought Joe in bewilderment.

Post script:

On his first day back to work, Joe was fired for his carelessness, because as the Director of Maintenance explained:

"In this company, safety is our number one concern."