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The Human Component in a
Mechanical System
1
Kristi Dunks
Senior Air Safety Investigator
Overview
• The NTSB
• General aviation safety
• Identifying risks/hazards
• Case studies
2
Who is the NTSB?
• Promotes transportation safety
• Investigate for probable cause
• Issue safety recommendations
• Promotes safety improvements
• Multi-modal: Aviation, highway, marine, railroad, pipeline, HAZMAT
• Small federal agency
General Aviation Safety
• 1,466 GA accidents in 2011
• 271 fatal accidents resulting in 457
fatalities
• NTSB working with FAA, AOPA, EAA,
and others to improve GA accident rate
Risk/Hazard Identifier
• People
• Actions
• Resources
• Environment
Physical Size
Age
Strength
The Five Senses
Physiological Health
Nutrition
Lifestyle
Alertness/fatigue
Chemical dependency
Psychological Knowledge
Experience
Training
Attitude
Emotional state
Psychosocial Interpersonal relations
Ability to communicate
Empathy
Leadership
People
PhysicalWeather extremes
Location (in/out)
Workspace
Lighting
Sound levels
Housekeeping
Safety issues
Organizational Personnel
Supervision
Labor - management
Size of company
Profitability
Job security
Morale
Corporate culture
Safety culture
Environment
• What do you need to know?
• What skills are necessary?
• Steps to perform a task
• Sequence of actions
• Communication requirements
• Information requirements
• Inspection requirements
• Certification requirements
Actions
• Technical documentation systems
• Test equipment
• Enough time
• Enough people
• Lifts, ladders, stands, seats
• Materials
• Portable lighting, heating, cooling
• Training
Resources
Case Study
• Cirrus SR 22
• VMC prevailed
• March 19, 2010
History of Flight
• Buchanan
Field, Concord, California, to Renton
Municipal Airport, Renton, Washington
• Departed at 1540
• Accident occurred at 1910
History of Flight
• 1906:51 pilot transmitted
“Mayday, Mayday, Cirrus N4GS”
• “I’m west of Strom airport, trying to
make the field.”
• Wreckage located 2.5 west-northwest
of Strom Field Airport
History of Flight
Cirrus Airframe Parachute System
• Rocket motor and deployment bag remained
connected to parachute
• Activation handle found seated in the handle
holder
• Enclosure cover found 15 feet from
wreckage
• Consistent with activation due to impact
forces
Engine Examination
• Examined at Teledyne Continental
• Engine test run
• Fitting cap installed finger tight
• Engine operated normally
Fuel Line Caps
Last Annual Inspection Entry
Annual Work Order Entry
Fuel System Check
Inspection Checklist
Maintenance Personnel Interviews
• Three mechanics worked on airplane, two
IAs and one A&P
• Another Cirrus SR22 in facility
• Rushed to complete work
• Performed fuel pressure check
• Final checklist items incomplete
Findings
• Engine lost power during cruise
• Fitting cap for throttle and metering
assembly inlet found uninstalled
• Engine operated normally following accident
• Maintenance was performed that required
cap to be removed
• If cap had been properly torqued it would
have remained secure
Findings
• Director of Maintenance signed off annual
inspection on work order
• Assigned IA indicated he had not completed
the annual inspection
• Maintenance records incomplete
• If final checks completed, cap would have
likely been identified
Risks/Hazards:
People, Actions, Resources, and
Environment
How could this accident have been
prevented?
31
Case Study
32
• Eurocopter AS350 B2
• December 7, 2011
Initial Information
• Sightseeing tour from Las Vegas
to Hoover Dam
• Normal departure - VFR
• Calm wind, good visibility
• Standardized route
33
Flight Path
Las Vegas Airport
To Hoover Dam
Accident site
Sudden climb and turn
Path approximate
and not to scale, for
visualization only
Flightpath
Tour route
Flightpath
Sequence of Events
35
Hoover Dam
Sudden climb and turn
3100
feet, 90° off
course
Path approximate
and not to scale, for
visualization only
Steep descent and
crash site
Fuselage
and engine
Preflight Sequence
37
• 100-hour maintenance inspection
• Replaced fore/aft servo
• Flew check flight
• 2 tour flights
• Accident on third tour flight
• 3.5 flight hours after maintenance
View of helicopter components
38
Main rotor assembly
Cockpit and cabin
Input rod and
fore/aft servo
Initial Findings
• No evidence of non-standard flight
• No evidence of bird strike
• Altitude clear of terrain/obstacles
• Weather not a factor
39
Input rod and servo
40
Servo body
Lugs
Input rod
Maintenance
• 100-hour inspection
• Replacement of the following:
• Engine
• Fore/aft and tail rotor servos
41
Fore/Aft Servo Installation
• Fore/aft servo replaced
• Fore/aft servo installation procedures:• Assess hardware
• Connect servo to input rod
• Torque nut
• Install split pin
• Inspect installation
42
Hardware
Input rod hardware Hardware installed
43
Fore/Aft servo with Ice Shield
Input Rod
Self-Locking Nut
Acceptable Nut Degraded Nut
44
Hardware Reuse
• Fleet inspection of 13 helicopters, half of nuts did not meet requirements
• Manufacturer’s guidance: “If a nut can be easily tightened, it is to be discarded”
• FAA guidance: “DO NOT reuse a fiber or nylon lock nut if the nut cannot meet the minimum prevailing torque values”
45
Bolt Loss Scenario
46
• Two locking devices
• Self-locking nut
• Split pin
• Self-locking nut most likely became
separated from bolt
Postmaintenance Inspection and
Check Flight
• Mechanic and inspector
completed inspection
• Helicopter check flight conducted
• Hydraulic belt tension
• No flight discrepancies
47
Maintenance Errors
• Improper securing of the fore/aft
servo
• Improper tension of the hydraulic
belt
• Incomplete maintenance inspection
48
Maintenance Personnel Fatigue
• The mechanic
• Recent sleep and wake activity
• Shift change
• Inadequate sleep
49
50
Maintenance Personnel Fatigue
• The inspector
• Recent sleep and wake activity
• Shift change
• Long duty day
Maintenance Personnel Fatigue
51
Personnel Normal Shift
Shift
Originally
Scheduled for
December 6
Actual Schedule
on December 6
Mechanic Noon to 11:00 pm Off duty 5:50 am to 6:46 pm
Inspector Noon to 11:00 pm Off duty 5:31 am to 6:55 pm
Maintenance Personnel Fatigue
• Effects of fatigue
• Difficulty sustaining attention
• Memory errors
• Lapses in performance
52
Human Factors Training
• Causes of fatigue, its effects, and
countermeasures
• Fatigue education as part of a
training curriculum
• No human factors training
requirement in United States
53
Work Cards With Delineated Steps
54
• Paperwork for 100-hour inspection
• Inspector signoff for overall fore/aft
servo installation
• No specific signoffs for critical
steps within task
100-Hour Inspection Paperwork
55
sign off
Work Cards With Delineated Steps
56
Sample work card
Risks/Hazards:
People, Actions, Resources, and
Environment
How could this accident have been
prevented?
57
GA Maintenance Alert
• Independent inspections of work
• Safety and security of
components disconnected
• Look for the obvious; if there is a
castellated nut, there is generally
an associated cotter pin
58
GA Maintenance Alert
• Review and adhere to guidance
regarding self-locking nuts
• When a component or system is
in the work process, mark it
• Cell phone policies
59
GA Maintenance Alert
• Turnover briefings
• Pilot check flights/review are last
opportunity to detect potential
safety hazards
• Review FAA HF guidance and
“Personal Minimums” Checklist
60
Safety recommendations
• Duty time limitations for
maintenance personnel
• Work cards for maintenance tasks
• Human factors training for
maintenance personnel
• Review issue of human fatigue in
aviation maintenance
61
• Piper PA-22-108
• No injuries
Case Study
• Pilot recently purchased airplane
• Lost oil pressure during flight and landed in a field
• Post accident examination showed that the main crankshaft seal was extruded and oil had been pumped out during the flight
• Breather tube modified to drain oil and moisture away from airplane
Overview
• Moisture is expelled from the engine crankcase through the breather tube which often extends through the bottom of the engine cowling into the air stream
• This moisture may freeze and continue a buildup of ice until the tube is completely blocked
• To prevent freeze-up, the breather tube may be insulated, it may be designed so the end is located in a hot area, it may be equipped with an electric heater, or it may incorporate a hole, notch or slot which is often called a "whistle slot"
Whistle Slot Guidance- Lycoming
Flyer
• The operator of any aircraft should know which method is used for preventing freezing of the breather tube, and should insure that the configuration is maintained as specified by the airframe manufacturer
• Because of its simplicity, the "whistle slot" is often used, and a notch or hole in the tube is located in a warm area near the engine where freezing is extremely unlikely
• When a breather tube with whistle slot is changed, the new tube must be of the same design
Whistle Slot Guidance- Lycoming
Flyer
Risks/Hazards:
People, Actions, Resources, and
Environment
How could this accident have been
prevented?
67
• Diamond DA-40
• No injuries
Case Study
• The run up was without incident and the pilot noted that the RPMs dropped slower than normal when he cycled the propeller
• During climb out, he noticed that the engine RPMs climbed to 2,800 so he leveled off his climb and pulled the propeller control back with no reduction in RPM noted
• Attempted to cycle the propeller twice but noticed no change in RPMs
• Decided to return to the departure airport and then he heard and felt a thump forward of the cockpit
• Engine continued to run smoothly, while developing adequate power, and the pilot landed uneventfully
Overview
Engine examination
• Post incident engine examination showed a blister in the engine casing and fragments of metal in the oil
• Engine then disassembled and ball bearings from the propeller governor were located in the engine
• Further disassembly of the engine identified one ball bearing within the oil sump, as well as damage to the case and two camshaft lifters
• The ball bearings from the governor were able to pass through the oil drain hole of the governor
Assembly
• Follow up examinations of the propeller
governor showed that the governor bearing race
and plunger were assembled with the bearing
race set screw and plunger hole misaligned
• When the bearing race set screw was torqued
down, the set screw tip flattened against the
harder plunger surface
• During operation, the set screw/plunger race
separated
Governor examinations
• Review of the governor manufacturer’s
reports showed two service difficulty
reports (SDRs) had been reported for
similar events
• The two events, as well as the governor
assembly from the accident, were from a
single batch of 74 assemblies
Service difficulty reports
Risks/Hazards:
People, Actions, Resources, and
Environment
How could this incident have been
prevented?
75
• As a result of this incident, the governor
manufacturer issued a mandatory service
bulletin (SB) DES-353, on December 18, 2008,
for the affected assemblies. The SB required
that the units be returned to Ontic for inspection
and, if necessary, repair.
• The FAA issued an Airworthiness Directive
requiring examination of the affected
assemblies.
Probable Cause
The failure of maintenance personnel to
properly secure a fitting cap on the throttle
and metering assembly inlet after
conducting a fuel system pressure check,
which resulted in a loss of engine power due
to fuel starvation.
Contributing Factor
Contributing to the accident was the decision
by the Director of Maintenance to return the
airplane to service without verifying with the
assigned inspector that all annual inspection
items had been completed.
Probable cause
• Sundance Helicopters’ inadequate maintenance
of the helicopter, 8 including (1) the improper
reuse of a degraded self-locking nut, (2) the
improper or lack of installation of a split pin, and
(3) inadequate postmaintenance
inspections, which resulted in the in-flight
separation of the pilot servo control input rod
from the fore/aft servo and rendered the
helicopter uncontrollable.
80
Probable cause
• Contributing to the improper or lack of installation
of the split pin was the mechanic’s fatigue and
the lack of clearly delineated maintenance task
steps to follow. Contributing to the inadequate
postmaintenance inspection was the inspector’s
fatigue and the lack of clearly delineated
inspection steps to follow.
81
Probable Cause
The National Transportation Safety Board determined the probable cause of this accident to be:• oil exhaustion due to an improper oil
breather tube installation, which became plugged in flight due to frozen moisture build-up. The blocked breather tube then created a crankcase over pressure that caused a failure of the crankshaft seal. The rough, uneven terrain and strong crosswind were factors in the accident.
Probable Cause
The National Transportation Safety
Board determined the probable
cause of this accident as follows:
• The improper assembly of the
governor during manufacture.