Torqued: Work continues for a future free of fatalities

 - April 14, 2011, 6:52 AM

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!

However, I can't resist a note of caution: 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.

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 analysis, problem identification and correction cycle that the best safety management systems embrace. In the meantime, the work needed to eliminate known problems must continue.

Mx Manuals Need Attention
One area that constantly vexes me is the maintenance manuals issued by manufacturers without the kind of sturdy review needed to prevent errors that maintenance workers are then left to deal with, often without any management guidance. Inadequacies in the maintenance manuals have led to U.S. airline passenger fatalities.

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 airline's 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 were killed. Finally, the 2003 crash of an Air MidWest Beech 1900D in Charlotte, N.C., 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.

Unless maintenance manuals are subjected to the same stringent verification requirements as the aircraft flight manual, the problem will not go away.

Another Duty for Mechanics
After years of raising this manual problem, I was 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 working to resolve this problem. My optimism was short lived. After I read the bulletin, I was fuming.

The bulletin 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! It instructs mechanics to contact the manufacturer directly. But nowhere does it say whom to contact or where. Most manufacturers are huge global entities with thousands of employees. Where exactly and to whom are these concerns supposed to be sent?

Most maintenance operations are so short-staffed that 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? The FAA is asking line workers not only to identify problems in the manuals but then to find their way through a manufacturer's bureaucracy and follow up to get the problem corrected. How realistic is that?

So, kudos to the FAA for stating that incorrect maintenance manuals are a problem. But zero points 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.

The opinions expressed in this column are those of the author and not necessarily endorsed by AIN.