Conclusion and Recommendation The accidents reviewed above occurred fifteen to thirty years ago. Is there a current risk of the same causes of failure to follow procedures and the intent of the regulatory requirements for Required Inspection not being met? According to the press there is. In the summer of 2015, in the southwestern United States, a 158 seat passenger aircraft experienced an uncommanded rotation at 138 knots during takeoff roll. Full forward control input did not arrest the rotation and the takeoff was aborted without incident. The malfunction was caused by an unsecured bolt, which allowed the device that controls the elevators to become disconnected. It fell off and became jammed holding the elevator in one position. More than 200 flights were conducted since the major maintenance visit in which technicians failed to install a cotter pin in the nut connecting the input rod to an elevator hydraulic actuator. The maintenance performed should have been RII but did not get identified as such. [27, 28, 29 & 30] From the accidents reviewed above, I hope that the reader can conclude that in maintenance, the devil is not in the details. The danger is in the normalized deviation of not following procedures combined with, and the failure to meet the intent of RII regulations. The expression see the forest for “couldn't the trees” is used of someone who is too involved in the details of a problem to look at the situation as a whole. In maintenance caused accidents, each tree’s (accident’s) specific failure to follow procedures and its falling short of the intent of RII regulations, has not been expanded to see the blight in large areas of the forest itself. The theme of ISASI’s 2017 annual conference was "Investigations - Do They Well, investigation is what investigation does! Really Make a Difference?” If investigation of future maintenance caused accidents provides safety recommendations to correct the normalized deviation of failure to follow procedures in maintenance and to make RII regulation more effective, then the answer will be YES! The expressed in this paper do not necessarily represent the views of the United States (U.S), the U.S. Department of Transportation (DOT), the Federal Aviation Administration, or any other Federal agency.
Conclusion and Recommendation The accidents reviewed above occurred fifteen to thirty years ago. Is there a current risk of the same causes of failure to follow procedures and the intent of the regulatory requirements for Required Inspection not being met? According to the press there is. In the summer of 2015, in the southwestern United States, a 158 seat passenger aircraft experienced an uncommanded rotation at 138 knots during takeoff roll. Full forward control input did not arrest the rotation and the takeoff was aborted without incident. The malfunction was caused by an unsecured bolt, which allowed the device that controls the elevators to become disconnected. It fell off and became jammed holding the elevator in one position. More than 200 flights were conducted since the major maintenance visit in which technicians failed to install a cotter pin in the nut connecting the input rod to an elevator hydraulic actuator. The maintenance performed should have been RII but did not get identified as such. [27, 28, 29 & 30] From the accidents reviewed above, I hope that the reader can conclude that in maintenance, the devil is not in the details. The danger is in the normalized deviation of not following procedures combined with, and the failure to meet the intent of RII regulations. The expression “couldn't see the forest for the trees” is used of someone who is too involved in the details of a problem to look at the situation as a whole. In maintenance caused accidents, each tree’s (accident’s) specific failure to follow procedures and its falling short of the intent of RII regulations, has not been expanded to see the blight in large areas of the forest itself. The theme of ISASI’s 2017 annual conference was "Investigations - Do They Really Make a Difference?” Well, investigation is what investigation does! If investigation of future maintenance caused accidents provides safety recommendations to correct the normalized deviation of failure to follow procedures in maintenance and to make RII regulation more effective, then the answer will be YES! The expressed in this paper do not necessarily represent the views of the United States (U.S), the U.S. Department of Transportation (DOT), the Federal Aviation Administration, or any other Federal agency.
2.%20Forest%20Chump%20and%20the%20Trees.docx