Maintenance Error Causes $3.9 Million Damage to Air Force MQ-9 Reaper
According to a news release about an Air Force accident report, an incorrectly assembled valve caused a severe oil flow imbalance that resulted in the failure of the engine of the MQ-9 Reaper during a training flight. The remote pilot attempted to land the malfunctioning aircraft on a remote dessert landing strip and the resultant hard landing and overshooting the strip caused $3.9 Million in damage to the Reaper. I have not seen the report but a cause in the press release –
“improperly assembled oil system temperature control valve“
Doesn’t sound like a root cause. Rather, it seems like a causal factor that would be the result of an Equifactor® equipment troubleshooting evaluation.
To find the root cause, the causal factor of “technician incorrectly assembles valve” would need to be analyzed using the Root Cause Tree®.
I would bet that this would turn out to be a Human Performance Difficulty and the 15 Questions on the front side of the tree would help the investigator dig into the reasons for the maintenance error. A sample of the questions that would need to be looked into would include:
- Was the technician fatigued?
- Was the procedure used?
- Was the procedure difficult to use?
- What were the human factors involved in the work?
- Was the training adequate?
- Were their any communication issues?
This would lead to more in-depth analysis of the apoplicable seven Basic Cause categories (Procedures, Training, Quality Control, Communications, Management Systems, Human Engineering, and Work Direction).
This in-depth analysis would probably lead to several root cause – all of which, if corrected, are potential opportunities to apply best practices to improve performance and prevent a future maintenance error (saving millions of dollars).
I’ll try to find out more about this investigation and post any new information here.
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