Jump to content
Sign in to follow this  
Seeker

Fatigue-Related Maintenance Error Identified As Cause Of 2011 Sundance Helicopters Crash

Recommended Posts

"As a result of its investigation, the NTSB proposed three new safety recommendations to the Federal Aviation Administration. One is to establish duty time regulations for maintenance personnel to take into consideration such factors as workload, shift changes and circadian rhythms."

  • Like 3

Share this post


Link to post
Share on other sites

It has been a long time coming and I am sure is yet to be some time. It will however bring a higher level of safety which I think we can all agree is a good thing. I find the older I get the more fatigue impacts me. By about 2am I'm not sure of anything I am doing.

  • Like 1

Share this post


Link to post
Share on other sites

The system is flawed that's for sure. I can't count the number of times over the years that i have found loose items on a machine after an "all nighter" inspection. The Wrench starts off on a "day" schedule and is "switched" to a graveyard without any adjustment. I am talking about good men and women who do a conscientious job but they are just zombies by the morning. It's a completely ridiculous system and sadly until a few more people are killed things will not change.

 

I am so tired of the older generation of owners and managers still living in the 60's and 70's, telling stories about going into the bush with one shirt and a pair of coveralls and staying out all summer with no contact, etc. and wearing it like a badge of honor, oh the good old days... The bugs were bigger, the beds were harder, it was colder and rainier but by God we got it done! And no complaining about long shifts/deployment, working free overtime, no outside contact and a 5 month deployment. I remember one guy boasting that he stayed up over 48 hours to complete an in bush overhaul. Hey who was the lucky bast ard who got to climb into that one? Oh %&*$#, it was probably ME! not so much LOL

  • Like 8

Share this post


Link to post
Share on other sites

I think there's a good argument to be made that the human factor at work here was not so much fatigue, as it was both complacency and norms.

 

As mentioned, it is the norm for engineers to push - trying to get the machine out the door for those owners/managers who... well, you know the ones I mean. Yep, it's normal... but is it right? Nope. One of the most basic employee rights is the right to refuse unsafe work, but it's very rare to meet anyone in aviation who will actually say "no I'm sorry, it would be dangerous for me to do that because I'm tired".

Sure Whitestone, you've found loose items after an all nighter... but that's because you've looked. As a function of work carried out - mistakes happen, and you haven't become complacent enough to assume that the guy who put the servo together actually put the cotter pin in it. That, or your engineer stopped you before you jumped into the seat and said "hey man, you're not going anywhere until you double check my work".

 

I'm not saying that everyone should work the night through, and then rely on the system to catch what their mental prowess failed to... What I'm saying is that maybe (just maybe) instead of pushing the new regulatory buzz-word - FMS, we should actually follow the safety management mindset and find the root of the problem. Complacent pilots and engineers are complacent regardless of their state of alertness. We can regulate duty time and maybe stop a few people from falling asleep at the controls or into a running lathe - but why? What is motivating those individuals (and we've all done it) to push the limits?

 

As much as we all disdain having SMS shoved down our throats, its core concepts are sound. A safety culture involves everyone. If you run a company that rewards people who beat the risks to get the job done, or subtly penalizes people who say "no, that's not safe", YOU, my friend, are part of the problem . If you refuse to pay an apprentice or low-time pilot a fair wage, thereby precluding anyone with intelligence or without out a trust-fund from entering the business, again, part of the problem.

 

Duty times can be regulated, rest periods can be legislated, but until such reasons as "I'm sorry, my son has figure skating practice so I need to leave at five" or "I'm sorry, I'm having marital issues and need a family day" are accepted as valid, nothing will change. If we can't attract and keep positive, engaged, intelligent staff - and enough of them so that there's someone to take over when your shift is done, or cover for you when your mom is sick and needs you to take her to the hospital - nothing is going to change. That's the norm.

 

/rant

  • Like 11

Share this post


Link to post
Share on other sites
What I'm saying is that maybe (just maybe) instead of pushing the new regulatory buzz-word - FMS, we should actually follow the safety management mindset and find the root of the problem. Complacent pilots and engineers are complacent regardless of their state of alertness.

 

Bang on. An honest and genuine root cause analysis will reveal exactly what's going on. Saying he's fatigued or overworked is merely a half-hearted answer. But WHY is he fatigued or overworked? Chances are that it's not simply the lack of a well-developed regulatory FMS that's missing. Individual and/or company complacency and industry norms are more than likely involved.

  • Like 2

Share this post


Link to post
Share on other sites

Sad story. A few happy couples sign up for a helicopter tour and it ends like this. I think I remember something about this story when the accident first happened. Wasn't the pilot described as a bit of a barnstormer in the media and we were left to think he'd caused the accident. Now we find a gross maintenance error the cause and according to some posts the evils of management are to blame. With all the current safety nets in place it's hard to imagine what sort of "rule" might have prevented a tragedy like this. Every day it's us brothers and sisters that fix and fly these machines and US that need to put the cotter pin in and check that it's been done correctly.

 

Don't get me wrong, I see maintenance fatigue management as looming large over this industry and it'll shake things up good when it comes. In the mean time I guess we just manage ourselves. I'll tell an engineer not to work all night if I think it's in the best interest of safety. Just sayin'

 

sb

  • Like 1

Share this post


Link to post
Share on other sites

I think there's a good argument to be made that the human factor at work here was not so much fatigue, as it was both complacency and norms.

 

As mentioned, it is the norm for engineers to push - trying to get the machine out the door for those owners/managers who... well, you know the ones I mean. Yep, it's normal... but is it right? Nope. One of the most basic employee rights is the right to refuse unsafe work, but it's very rare to meet anyone in aviation who will actually say "no I'm sorry, it would be dangerous for me to do that because I'm tired".

Sure Whitestone, you've found loose items after an all nighter... but that's because you've looked. As a function of work carried out - mistakes happen, and you haven't become complacent enough to assume that the guy who put the servo together actually put the cotter pin in it. That, or your engineer stopped you before you jumped into the seat and said "hey man, you're not going anywhere until you double check my work".

 

I'm not saying that everyone should work the night through, and then rely on the system to catch what their mental prowess failed to... What I'm saying is that maybe (just maybe) instead of pushing the new regulatory buzz-word - FMS, we should actually follow the safety management mindset and find the root of the problem. Complacent pilots and engineers are complacent regardless of their state of alertness. We can regulate duty time and maybe stop a few people from falling asleep at the controls or into a running lathe - but why? What is motivating those individuals (and we've all done it) to push the limits?

 

As much as we all disdain having SMS shoved down our throats, its core concepts are sound. A safety culture involves everyone. If you run a company that rewards people who beat the risks to get the job done, or subtly penalizes people who say "no, that's not safe", YOU, my friend, are part of the problem . If you refuse to pay an apprentice or low-time pilot a fair wage, thereby precluding anyone with intelligence or without out a trust-fund from entering the business, again, part of the problem.

 

Duty times can be regulated, rest periods can be legislated, but until such reasons as "I'm sorry, my son has figure skating practice so I need to leave at five" or "I'm sorry, I'm having marital issues and need a family day" are accepted as valid, nothing will change. If we can't attract and keep positive, engaged, intelligent staff - and enough of them so that there's someone to take over when your shift is done, or cover for you when your mom is sick and needs you to take her to the hospital - nothing is going to change. That's the norm.

 

/rant

 

Very well said. I know there are operators/employees who fudge numbers and have other workarounds for pilot duty-day limits, so what's to stop these same offenders from continuing this MO when it comes to AME duty times.

 

Clichéd as it sounds, true change must come from within...

  • Like 2

Share this post


Link to post
Share on other sites

Join the conversation

You can post now and register later. If you have an account, sign in now to post with your account.

Guest
Reply to this topic...

×   Pasted as rich text.   Paste as plain text instead

  Only 75 emoji are allowed.

×   Your link has been automatically embedded.   Display as a link instead

×   Your previous content has been restored.   Clear editor

×   You cannot paste images directly. Upload or insert images from URL.

Loading...
Sign in to follow this  

×
×
  • Create New...