November 5, 2007 | Mark Paradies

Monday Accident & Lessons Learned – Sometimes a Repeat Failure IS NOT a Repeat Failure…

Last Monday I published an article titled:

Monday Accidents & Lessons Learned: Third Accident in 2 Months – When is an Accident a Repeat Failure?

The Danish Accident Investigation Board has published a report that suggests that this third Dash-8 Q400 accident was NOT a Repeat Failure but rather a failure of the landing gear from a totally separate cause.

To see the Danish Accident Investigation Report go to:

http://www.hcl.dk/graphics/Synkron-Library/hcl/dokumenter/Redegorelser/2007/510-000449%20LN-RDI%20Preliminary%20Report%20UK_03112007.pdf

The investigation shows that this accident could have been caused by an o-ring failure and prior landing gear replacements (although the investigation is not complete).

Lesson Learned: You can’t assume that a failure is a Repeat Failure until the investigation is complete and you are sure that the cause is indeed the same.

One more note: The o-ring failure might be a Repeat Failure. The difference is that this time they moved a component from one system to another that allowed the failed o-ring to enter the landing gear system. (See the report for more info.)

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Drawing from Report

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