We’re Human: Follow Rules

By By Douglas Nelms | August 4, 2014

By Douglas Nelms

On Dec. 7, 2011, an AS350-B2 operated by Sundance Helicopters crashed just outside Las Vegas, Nev., killing the pilot and four passengers. NTSB cited probable cause to be “inadequate maintenance of the helicopter.”

Specifically, NTSB said the cause included (1) the improper reuse of a degraded self-locking nut, (2) the improper or lack of installation of a split pin, and (3) inadequate post-maintenance inspection. Contributing to that was fatigue and the lack of clearly delineated maintenance task steps to follow on the part of the mechanic, and fatigue and the lack of clearly delineated inspections to follow on the part of the inspector.


Or, to phrase that another way: complacency – inattention to detail. NTSB issued three recommendations (Report AAR-13/01-03) designed to eliminate the kind of human factor errors that caused the Sundance crash. FAA subsequently issued an Advisory Circular (AC 136-2) backing up the recommendations. However, the AC was only aimed at tour operators. I have no idea why. Complacency occurs in every type of aircraft operations – fixed and rotary wing – and evidently always has.

Rudy Quevedo, director of global programs for Flight Safety Foundation, told me that not much has really changed since the 1930s and ‘40s… that while the industry has “talked a lot about those things in recent years, the fact is that we keep having the same issues.” Promoting helicopter maintenance safety is a simple concept, ranging from “don’t drop a wench on your foot,” to “follow the procedures in the manual.” Very simple instructions. So why do accidents keep happening? Last year, NTSB reported 42 maintenance-related accidents, of which eight were rotary wing.

The OEMs are doing their part – using advanced technology equipment and computerization as well as improved training methods. Sikorsky said that it “continues to utilize HUMS data in new ways that are focused on helping the operator and the maintainer,” as well as an “extensive training program” for aircraft such as the new S-76D. In techno-speak, Sikorsky said that it has “developed tools that combine information from the aircraft with centralized knowledge base and sophisticated fault logic algorithms to give confidence-based maintenance action suggestions.” So as the aircraft are becoming more sophisticated, so are the programs designed to keep them safe. So why is there still a problem?

What it boils down to is safety management. There is even a safety management system (SMS) toolkit, issued by the U.S. Joint Helicopter Safety Implementation Team (US-JHSIT) designed “to help U.S.-based organizations understand the fundamentals of SMS. It serves as a guide to implement and manage an SMS, tailored to all size organizations.” This includes a guide to establishing safety management for the maintenance operations.

But apparently the problem of maintenance-related accidents is still there. Quevedo said that while FSF continues to take a serious look at the problem of human factors in maintenance safety, it’s now doing so with a different view, “approaching it a little bit differently, more on the psychological end, trying to understand why [current procedures] haven’t worked.”

He said that one of the biggest problems in aviation is simply communicating the need for awareness by maintenance personnel to follow procedures. A few years ago, FSF formed a committee to try and resolve issues involving maintenance safety, with a special working group looking at the problem of failure to follow procedures. This includes a worldwide group of 22 people from countries including the U.S., UAE, Australia and China.

One of the problem areas is a growing shortage of highly qualified mechanics, “especially with aviation booming in new parts of world, like Asia,” he said. This includes the mentoring of new mechanics by older, highly experienced individuals.

“There are a lot of things, soft skills, that are not really trained, things such as communicating clearly, writing clearly, reading blueprints. Long ago the people who were mentoring had 25 years of experience. They were true professionals in every sense of the word. Today young men come into aviation maintenance – and their mentors only have three or four years themselves because of high turnover.” In one of its recent newsletters, IHST stated that the industry should “encourage operators and maintainers to implement a robust Quality Assurance program that ensures the use of manufacturers maintenance manuals, service bulletins and procedures.”

Yes – we should do that.

Related: Maintenance News

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