January 25, 2024 | Justin Clark

F-35 Eats a Torch: Human Error Isn’t the Root Cause

human error isn't the root cause

Equipment symptom is caused by human error. Read,

Flashlight left inside Air Force F-35 engine causes $4 million in damage.

This was a VERY simple human error that any equipment tech could make, especially the fast-moving and proficient ones. An F-35 aircraft maintenance tech left a flashlight near one engine, and it got “ingested” on startup. With FIFTEEN different complex procedures in progress or completed, it’s not surprising.

Good job to the Air Force for doing the drug and alcohol test as the first step, which is also part of the first of 15 questions in the TapRooT® Human Performance Troubleshooting Guide:

But how many other questions are there in that block above that would you want to ask about the causal factor “Maintenance Tech 1 left flashlight on intake lip?”

Human Error Isn’t the Root Cause

While human error isn’t a root cause, it’s a step on the critical path to failure, a causal factor. While equipment failures happen all the time, most of the root causes fall under the Human Performance Difficulty category. If you don’t know what questions to ask to find those root causes, you’ll probably

  • Stick with “HUMAN ERROR” as the end of your investigation;
  • Recommend training, procedures, and discipline as corrective actions;
  • See the same event happen over and over again.

To learn more about both the human and technical sides of equipment failure troubleshooting, check out the Maintenance and Reliability track of the TapRooT® Global Summit on Root Cause Analysis!

Categories
Equipment Reliability / Equifactor®
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