Certainly the news that there were no U.S. airline passenger fatalities in 2010 is cause for reflection and, yes, some self-congratulation by all those who made it possible. From airline and manufacturers’ boardrooms to the 10th floor of 800 Independence Avenue, congratulations are in order. And most important, thanks to all who toil in often thankless jobs in the cockpits, cabins, hangar floors and ATC facilities where front-line aviation workers made safe flight a reality day after day. Jobs well done indeed!
But–you all know I canπt resist a note of caution–while congratulations are in order for all the hard work it takes to get to this point, accident prevention can never rest on yesteryear’s statistics. A fatality-free year can never be an excuse to let down our guards or discontinue the kinds of things that got us to zero fatalities. The work of identifying precursors to accidents and incidents needs to continue without pause not only because those precursors can change over time but also because some of the same old problems exist today and maybe we were just plain lucky that they didn’t provide a causal link in a fatal accident chain.
While luck or fate are dismissed in some aviation circles, for me there is always an element of happenstance when all the wrong things line up and a fatal accident results. And, no, I’m not suggesting that we shrug our safety responsibilities and leave it to luck to determine what we do. Just the opposite, really. Because anything can happen, the only way to minimize the impact of bad luck is to implement the kind of rigorous program that takes luck out of the equation as much as possible. This is the kind of rigorous analysis, problem identification and correction cycle that the best safety management systems embrace.
Maintenance Manuals Need FAA Attention
In the meantime, the work needed to eliminate known problems must continue. Just because these known problems didn’t result in an accident with fatalities in 2010 is no guarantee that they won’t in 2011 or subsequent years. One area that constantly vexes me, as my frequent readers will surely know, is the maintenance manuals issued by manufacturers without the kind of rigorous review needed to prevent errors that maintenance workers are then left to deal with, often without any management guidance but with the constant pressure of on-time departures. Inadequacies in the maintenance manuals have led to U.S. airline passenger fatalities in the past.
Off the top of my head, three accidents come to mind. First, the February 2000 crash of an Emery Air DC-8 on takeoff from Sacramento, Calif., was related in part to differences between the airlineπs maintenance manual and the original manufacturer’s manual. All three crewmembers were killed. In August 2003 a Colgan Beech 1900D crashed off the coast of Yarmouth, Mass., an event caused at least in part by faulty information in the maintenance manual regarding the elevator trim drum and the orientation of the cable around the drum. Both crewmembers, the only occupants, were killed. Finally, the 2003 crash of an Air MidWest Beech 1900D in Charlotte also involved problems stemming from the maintenance manual. The aircraft was misrigged because of poorly written maintenance instructions. All 21 people aboard the aircraft perished.
Since the problem of incorrect or poorly written maintenance manuals has not been addressed, the right combination of factors could combine again in the future to cause a fatal crash. Unless maintenance manuals are subjected to the same stringent verification requirements as the aircraft flight manual, the problem will not go away. (Imagine an aircraft flight manual being issued with its adequacy tested on passenger-carrying flights? That’s what manufacturers do with maintenance manuals.) The problem needs to be tackled–by the FAA and the manufacturers, with pressure from the airlines, the unions and others interested in air safety.
Another Duty for Mechanics
After all these years of raising this manual problem, I was momentarily heartened to receive an airworthiness bulletin from the FAA on this subject. Since the FAA approves the manufacturer’s maintenance manual when it certifies aircraft and each airline’s maintenance manual similarly requires FAA approval as part of the airline’s certification requirements, I thought the agency was finally stepping up to the plate, calling attention to this problem and working to resolve it. My optimism was short lived. After I read the bulletin, I was fuming.
The bulletin alerts mechanics to the well known problem of maintenance manuals being incorrect. It reads:
“How many times have you done a job and realized the maintenance manual was incomplete or incorrect? Do you just put a note in the margin or in the sleeve of the DVD? Do you just know how to perform the task correctly? What happens to the mechanic who may not be as familiar with the product or may be fatigued and/or pressured? Will he or she also recognize this maintenance manual error and come to the proper conclusion? The answer is, not always.”
The bulletin then places the responsibility for getting the manuals corrected solely on the mechanics! Incredibly, the bulletin instructs mechanics to contact the manufacturer directly. But nowhere does it even say whom to contact or where. Most manufacturers are huge global entities with offices around the world and thousands of employees. Where exactly and to whom are these critical concerns supposed to be sent? And does the FAA care? Not so much, apparently. The FAA wants to know only if there is no adequate (in the eyes of the mechanic) response from the manufacturer. However, it does not provide names or addresses, street or e-mail, of anyone at the FAA to contact.
Most maintenance operations are so short-staffed, performing all the maintenance tasks required can be a challenge for the most hard-working mechanics. Now the FAA wants to add another duty to already over-burdened workers? Am I the only one who finds this dismaying, even cynical? The FAA is asking line workers not only to identify problems in the manuals but then find their way through a manufacturerπs bureaucracy and follow up to get the problem corrected. How realistic is that?
So, kudos to the FAA for stating in writing that incorrect maintenance manuals are a problem. And for stating the obvious: everyone has a role to play in safety, which includes mechanics discovering errors in the maintenance manuals and reporting them. But zero points to the FAA for placing the responsibility for their correction solely in the laps of maintenance workers, instead of with manufacturers, airlines and the FAA itself. This is a certification issue the agency has the power and responsibility to address. Tomorrow’s zero fatality rate may well depend on it.