What Happens When Aviation Maintainers Are Under Stress?
They support commercial, military, or General Aviation (GA). In the aviation industry, they are largely unsung heroes. We call them “Aviation Maintainers.”
They work diligently and strive to keep the nation’s aircraft airworthy and mission capable. Aviation Maintainers are indispensable and a great tribute to the safest form of transportation in modern history.
ASRS (Aviation Safety Reporting System)* does, however, receive reports suggesting Maintainers are vulnerable to similar types of threats that plague aircrew. Distraction, fatigue, confusion, inexperience, lack of teamwork, communication, or procedural discipline, documentation errors, and understaffing are but a few. Others do exist, and in today’s environment, Maintainers face special challenges in preserving the many aircraft that have become temporarily grounded.
“…when you see mighty jet aircraft
as they mark their way through the air,
the grease-stained man with a wrench in his hand
is the man who put them there.” – Anonymous1
The eleventh hour
■ Shortly after the completion of a 100-hour inspection, this C172 pilot assumed that the aircraft was airworthy. Engine trouble and subsequent discoveries proved otherwise. I was flying to see a friend and lost power at 9,500 feet. I had intermittent power, but not enough to maintain altitude. I ran through my checklist with no luck and requested priority handling. [ATC]…gave me vectors to ZZZ.… I kept fiddling with the fuel and leaning combinations but had time to take down a phone number for ATC, so I could call after landing. Then I switched to UNICOM.… I checked the weather and made the airport with about 3,000 feet of altitude to spare. [I made a] spiral descent to downwind and landed without incident. There was a policeman waiting when we landed, and Mechanics [were] on duty.
I had eleven hours on the plane since a 100-hour inspection. The ignition harness had been replaced during that inspection. At the same time, a new electronic starter was installed. It was apparent to the Mechanic at ZZZ that the spark plugs had not been removed, cleaned, or replaced. One had ceased firing and was visibly oval-shaped from wear. Another had corroded through the ceramic liner and was not firing properly.… All twelve had not been cleaned. There was visible rust on the exterior of two of the other ten. I’m not a Mechanic, but I read the 100-hour [inspection] checklist that mandates a close look at any rusty parts. If the spark plugs were not removed, they didn’t do a compression test. The Cessna 100-hour [inspection] checklist calls for a compression test and an inspection of all engine systems.
According to the [Mechanic at ZZZ,], the ignition switch was replaced with a new ACS A-510-2K and matching door locks, and…an Annual Inspection, described under Title 14 CFR 43, Appendix D, was performed.… [The aircraft] was determined to be in an airworthy condition at this time.
Out with the old, in with the new
A procedure skirted and an assumption unverified produced a threat unnoticed to this Maintenance Technician. Serious consequences thoroughly reiterated the old lessons.
■ Last week, I was informed that the oil drum [containing unused oil] was running low. After asking Stores personnel more than once over the span of a couple of days to bring new barrels over from our remote storage facility, I went out…near our loading docks to find a barrel [containing unused oil] that we could use.… New barrels [of unused oil] are often stored alongside waste barrels before they are moved.… We found a barrel that appeared to be unused, and we brought it into the hangar. I was informed that a [servicing unit] was filled with waste oil, but that the Mechanics who identified it thought that [the only item]…serviced [by that servicing unit] was an Integrated Drive Generator (IDG), which was [then] flushed and ops-checked good. The [servicing unit] was then put out of service, and the barrel, [which we had brought in], removed.
ZZZ identified an aircraft that was serviced with waste oil.… The source of this waste oil may have been me moving the barrel from outside, and…several aircraft may have been serviced with waste oil. The Crew Chiefs then worked with Maintenance Control to identify all affected aircraft.
I failed to follow procedures, as I did not verify the barrel to see if it had a serviceable Part/Material Inspection (PMI) tag. Stores could have eliminated this issue by acting upon requests when they are made or by not storing waste and new oil next to each other. I also should have verified the PMI tag and issued it to the floor when moving the barrel.
Safety, integrity, & the bottom line
Once in a long while, professionalism suffers when judgment and integrity fade, and the bottom-line clouds the clear vision of safety. Kudos to this Aviation Maintenance Technician.
■ During troubleshooting of the [B777] D5L passenger entry door, the flight lock was not releasing, allowing the door to be opened and closed. The outbound Captain approached me and the assigned Mechanic, and asked several times for me, the certifying engineer, to make a false logbook entry stating that the door operated normally, and that he would endorse the fact that he witnessed the correct operation. Each time I refused to acknowledge his request. The driver for his request was…the number of passengers that would need to be offloaded due to an inoperative door.
[When] it was deemed that the door would have to be deferred as inoperative, I was in the flight deck reviewing the [maintenance procedure].… The Captain approached me again and said, “You know, you’re killing my company by doing this. If you won’t do what I had asked, maybe we can find another company that will do it for us.” My response was, “That’s not up to me. That’s up to the company.”
After that, there wasn’t any further dialog regarding the serviceable condition of the door.
We all should have . . .
When this Maintenance Technician helped move a CRJ700, the reduced manpower, relaxed procedural discipline, and lack of a clear plan all produced an undesirable result.
■ I was trying to be helpful by staying on overtime to help the dayshift wing-walk the aircraft into the hangar because they didn’t have enough people.
The plane arrived back from the gate to the hangar. We hooked up the towbar to the tug to start moving the aircraft inside. Person 2 and I were the only wing-walkers, and Person 3 was on the tug. Person 3 didn’t have a tail-walker but started [pulling] the plane inside the hangar, nose in.… Person 3…angled the plane to me so he cleared Person 2’s side because the hangar doors were not opened all the way.
After Person 3 cleared the wingtip on Person 2’s side, he cut the wheel so the wingtip on my side would clear.… When he cut the wheel, he could no longer see me, and if I went in his line of sight, I would no longer be able to see if the wingtip cleared.… Person 2 was walking to my side so he could tell how much clearance we had.… That’s when I crossed my arms and said, “Cut it, stop,” because the wingtip was going to hit the hangar door.… Person 3 kept moving with the tug and hit the hangar door with the right-hand wingtip.… Person 2 even saw me cross my arms and…did not say anything to the tug driver.
The tug driver should have had a tail-walker before tugging the aircraft, and the hangar doors should have been more open, but Person 3 said it was enough room.… Person 2 should have told the tug driver that I had my arms crossed.
The nuts and bolts of maintenance
A B767 engine had been repaired. Training was being accomplished during the engine run test, and an apparent oversight resulted in significant damage to the engine.
■ [We three] Mechanics removed and replaced three fan blades and three opposites for weight purposes. Other blades underwent Non-Destructive Testing (NDT) for damage. After the blade replacement, I was asked to train for engine run qualification. [Two of us] were being trained. We did an engine run for vibration per the Airplane Maintenance Manual (AMM), test number six.… [Ground Operations] pushed us into location, and they were out front with communications with us and Tower.
The vibrations for the fan were out of limits high: We couldn’t go above 76 percent. We then returned to the gate, and [the Trainer] called Maintenance Control. [The Trainer] said that they instructed him to have [the team of three] remove the spinner and run the engine again.
We pushed back for more engine run training.… The Trainer was in the First Observer’s seat.… Another Mechanic was in the doorway. Ground Operations was in front of the aircraft in a car, and all were in communications with Tower. We ran both engines up, and the vibrations were lower than before and closer to within limits. We taxied back to the gate and shut down. When we got out, the Mechanics on the ground informed us that, when we started to go to full power, they heard a noise. Neither Ground Operations nor Tower…informed us of this. We then looked at the engine and noticed the damage to the blades and cowling. We called Maintenance Control and informed them.
The barrel nuts for holding the spinner on came out of their respective mounts and flew into the blades and engine [inlet] acoustic [liner], creating the damage.
*From CALLBACK, NASA’s Aviation Safety System Reporting, Issue 484, May 2020.
1Remembering the Forgotten Mechanic, Anonymous.
Equipment reliability professionals—such as mechanics or “maintainers”—need great troubleshooting and root cause analysis skills
What are the biggest problems finding the root causes of equipment failures and equipment reliability issues? First, if you don’t do good troubleshooting to start with, you will lose the evidence you need to identify the failure’s root causes. That’s why we worked with equipment reliability expert Heinz Bloch to develop the Equifactor® Troubleshooting Tables. They can help your equipment experts or mechanics do a great job troubleshooting equipment problems and collecting the information you need for root cause analysis. To that regard, the tables can be customized to your unique problem. Learn more about Equifactor® here and take a look at how the Equifactor® courses can help you and your team.
Second, equipment reliability experts know a lot about the equipment, but they don’t usually know about human factors. The TapRooT® Root Cause Analysis System will help guide equipment reliability experts to the root causes of equipment failures whether they are caused by mechanical failures or human errors.
Founded in 1988, the TapRooT® Root Cause Analysis System solves hurdles every investigator faces
TapRooT® Root Cause Analysis Training System takes an investigator beyond his or her knowledge to think outside the box. Backed with extensive research in human performance, incident investigation, and root cause analysis, TapRooT® is a global leader in improved investigation effectiveness and productivity, stopping finger-pointing and blame, improving equipment reliability, and fixing operating problems.
System Improvements, the creator of the TapRooT® System, has a team of investigators and instructors with years of extensive training ready to offer assistance worldwide.
TapRooT® Root Cause Analysis Training courses are taught all over the world
If you are interested in learning how to stop repeat incidents, find a 2-Day or 5-Day course; or view the complete selection of TapRooT® courses. We are available to train you and your staff on-site at your workplace; Contact us to discuss your needs. You may also call us at 865.539.2139 to discuss any questions you may have.
Keep in touch to improve your problem-solving skills
We’re continually training, helping you improve your professional root cause analysis skills. Stay current with your TapRooT® Root Cause Analysis skills and training through:
- Following our blog;
- Free newsletters;
- Tuning in to TapRooT® TV Video Sessions or our podcasts;
- Connecting with us on Facebook, Twitter, Instagram, Pinterest, LinkedIn, and YouTube;
- And our annual Global TapRooT® Summit.