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Fixing the fixers

The Flight Safety Foundation, founded in 1947, is an international non-profit organisation whose purpose is to provide impartial, independent, expert safety guidance and resources for the aviation and aerospace industry. Today, membership includes more than 1,000 organisations, with individuals from 150 countries

In August 2012, the Flight Safety Foundation (FSF) established the Maintenance Advisory Committee (MAC). The committee developed a list of potential projects to examine, such as: training requirements in light of technological advancements; fatigue and the possible creation of a fatigue-risk management program specifically targeted to maintenance; or maintenance safety on the runway/taxiway. Rudy Quevedo, Director of Programs at the FSF, was joined on the committee by representatives from airlines, industry, unions, academia and the FAA.


He says an analysis of maintenance-related accidents shows that there are still some very common factors. In fact, these incidents are so closely matched it is sometimes difficult to tell when the report was actually written. Here are just three examples of similar incidents taken from the Aviation Safety Network database, a service of the FSF:


  • After completion of major overhaul, a routine test flight was made. The right wing dropped and struck the ground immediately after lifting off the runway. The right wing broke off and the aircraft cartwheeled to a stop. It appeared that the elevator control cables were reversed (1953). 
  • The improper (reverse) rigging of the elevator trim cables by company maintenance personnel, and their subsequent failure to discover the misrigging during required post-maintenance checks. Contributing to the accident was the captain’s inadequate post- maintenance preflight check (2003).
  • The improper replacement of the forward elevator trim cable, and subsequent inadequate functional check of the maintenance performed, which resulted in a reversal of the elevator trim system and a loss of control in-flight. Factors were the flightcrew’s failure to follow the checklist procedures, and the aircraft manufacturer’s erroneous depiction of the elevator trim drum in the maintenance manual (2008).


Of course, accidents are always a complex series of overlapping events and causes. It could be argued if one incident best summarises the FSF approach it is that of the Beech 1900 accident that took place at Charlotte-Douglas International Airport, NC, in 2003:


  • The loss of pitch control [during takeoff] resulted from the incorrect rigging of the elevator control system compounded by the airplane’s aft centre of gravity, which was substantially aft of the certified aft limit. Contributing to the cause of the accident was: (1) Air Midwest’s lack of oversight of the work being performed at the Huntington, West Virginia, maintenance station; (2) Air Midwest’s maintenance procedures and documentation; (3) Air Midwest’s weight and balance program at the time of the accident; (4) the Raytheon Aerospace quality assurance inspector’s failure to detect the incorrect rigging of the elevator system; (5) the FAA’s average weight assumptions in its weight and balance program guidance at the time of the accident; and (6) the FAA’s lack of oversight of Air Midwest’s maintenance program and its weight and balance program.


There are four main areas of concern, says Quevedo. The first is a failure to follow procedures, which seems to be a worldwide and perennial problem. Secondly, there is a need to ensure high levels of professionalism as the industry undergoes change. A possible remedy is closer working with schools and the increased use of mentoring for new employees. Unfortunately, he says, mentors in the US may now be less effective, given that many experienced technicians have now left the industry. This shortage of experience subsequently means upcoming technicians may not benefit from personal mentoring as much as they might have before.


Leading on from this, the third area of note is the leadership and safety culture. Again, there needs to be a rethink on training: promotion of personnel is generally based on technical ability, however management skills may be lacking, so it is best to incorporate these as part of the original curriculum. Education regarding safety in the workplace is also important for improved safety, but there are better ways of doing this than putting up posters in the hangar; to produce a thriving safety culture, Quevedo says, staff “have to live it”.


Lastly, there is oversight and quality. Quality standards are usually assessed against operator requirements – Quevedo argues that there needs to be a review in order to ensure these requirements are correct for each operational context.


In this instance, Europe is ahead of the US in training, he says. Quevedo strongly believes the Type Rating is a very useful qualification in comparison to the general A&P licence. However, he does concede that minimum training requirements are being looked at by the FAA, which should produce positive results.

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