Module 1 Discussion
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School
Embry-Riddle Aeronautical University *
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Course
240
Subject
Industrial Engineering
Date
Dec 6, 2023
Type
docx
Pages
2
Uploaded by AmbassadorFogZebra6
Previously, you completed the Aviation Certification Resources reading
activity which included the
FAA Operator's Manual: Human Factors Aviation
Maintenance (FAA/PDF).
Now, read the
NTSB Report ATL02FA175 (NTSB:
National Transportation Safety Board)
Links to an external site.
and the "The
PEAR Model: A Case Study" fact list below about an actual accident that took
place in Milton, Florida.
P: People who do the job.
E: Environment in which they work.
A: Actions they perform.
R: Resources necessary to complete the job.
Now you will apply what you learned from your research in this discussion. In
your post, select an element of the PEAR Model that can assist with
understanding the human failures in this real-world case study. Explain
possible human factors that may have led to the corroded cable being
overlooked during the annual inspection.
Your post must focus on explaining the maintenance and safety issues,
consider aviation and industrial safety requirements, what documentation is
required, and why.
Use these questions to guide your work:
Explain possible human factors that affect safety that may have led
to the corroded cable being overlooked during the annual
inspection.
Review and connect this using the government regulation
Code of
Federal Aviation Regulations (FAR) Part 43 Appendix D (eCFR)
Links
to an external site.
for the inspection process and related
requirements. What inspection elements did they overlook?
Could the PEAR Model have prevented the cable failure, engine
power loss, and the resulting death of the pilot?
What other factors can you think of that would help prevent
something like this from occurring again?
A handful of the typical human factors could have played a role in the cable failure,
engine power loss, and ultimately crash and fatality of a young pilot, the most likely being
complacency, stress, lack of knowledge, lack of resources, and pressure. Complacency comes
from comfortability when performing something that a person has done repeatedly and they
feel as if they could “do it with their eyes closed,” for lack of better terms. This can become
dangerous as a person may forget part of the inspection requirements or those requirements
might have changed without the maintainer knowing it. In Naval aviation maintenance, we
stress the importance of always referring to the publication any time any maintenance is
performed, no matter how many times you may have performed it before. Stress and pressure
could be overlapping issues in this situation. The experimental program that the pilot was
involved in seems to be an expedited type of training. In turn, the operational tempo is probably
accelerated as well which can put a lot of pressure on the maintenance crew to release an
aircraft in a short amount of time to meet the demands of the training environment. Lack of
knowledge could have played a part in this event, but is highly unlikely given the training
required to be an airframe and powerplant mechanic. Lastly, due to the fact that a fuel pump
that clearly stated “Not Recommended for Use in Aircraft Application” was installed on the
aircraft, I think that it would be fair to assume that a lack of resources was probably an issue, as
well. Luckily, it doesn’t seem that the incorrect fuel pump played a role in the accident.
The Code of Federal Aviation Regulations states in Part 43, Appendix D, Subparagraph (d)
(6), the engine controls shall be inspected “for defects, improper travel, and improper
safetying.” While this is just a vague inspection criterion, it serves as just a baseline standard for
aircraft inspection. A checklist that is actually being used should be more specific to the aircraft.
In the Navy, as well as other branches, I’m sure, we are taught to not only inspect by the
checklist, but also to use the “36 inch rule,” which means that we also inspect within a 18 inch
radius around the component. In personal experience, I feel that I’ve found more discrepancies
employing this concept than if I was just following the checklist due to the tunnel vision one can
get when focusing on something.
In some way, all four pillars of the PEAR model could have prevented this mishap. If the
people who did the job caught the corroded cable, they could have repaired or replaced it so
that it wouldn’t have sheared off during flight or they could have switched to a different aircraft
and downed the original one for maintenance. Considering the flight school was in Pensacola,
Florida, which is right on the Gulf of Mexico, the environment most likely caused corrosion to
occur at a faster rate than if it had been somewhere inland. If the Action of overlooking to
corroded cable didn’t occur, then it could have been corrected before the aircraft was
incorrectly deemed safe to fly. Lastly, a lack of Resources could have played a part in the mishap
due to the unapproved fuel pump that was found installed on the aircraft. Even though it was
proven that the fuel pump didn’t cause any issues, if there was a lack of resources that would
cause that part to be installed, I think it’s safe to assume that resources were lacking when it
came to other parts of the aircraft, as well.
In the future, I think that more in depth training on proper corrosion identification,
cleaning, and prevention would be beneficial, as well as a continued emphasis on procedural
compliance and completing inspections thoroughly and completely.
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