Reader Feedback: Chain of Events

I read your editorial in the February Aviation Maintenance You need to read the whole accident report, not just the headline grabbing stuff.

The mechanics and inspector had been working in excess of 14/16 hours per day, they were critically understaffed, the aircraft was over 500 pounds over loaded and center of gravity was 5 percent aft of the aft limit.

Further, I believe the load data sheet they were using was incorrect, and the cockpit voice recorder shows the pilots were rather flippant in their comments. I read transcripts and it goes something like, "Look at those people pointing to the tail sitting so low, must be all that baggage we put there."

It seems they may have been less than 100 percent professional on the flight deck. Even noting people pointing to the tail should have alerted them to a problem.

It was not a simple, easily blamed error of a mechanic. It was a human factors disaster waiting to happen.

So please don’t simplistically blame the mechanic, look at all the factors:

• Insufficient staff,

• Over worked staff who were very tired

• Inadequate training of staff

• Faulty weight balance data

• Overloaded and out of C of G

• Pilots who appeared to be less than 100% committed to operating safely

If the aircraft had been properly loaded and pilots switched on the crash may not have occurred with the severity it did. Why not ask why did the pilots not cut power when the first noted a problem, which was noted at less than 75 feet above the runway...zero power would have probably meant a survivable accident from that height.

Why does the U.S. still not require a duplicate, independent inspection of all flight controls following maintenance?

This is a law in Australia and has been so since at least 1962.

I can see some merit in your argument however, two days later, I still believe the most basic, over riding procedural error, was the maintenance provider being so understaffed as to require people to average 16 hour days.

Also, we have a law, Civil Aviation Regulation 42G, which states:

42G Flight control system: additional requirements (1) This regulation sets out the additional requirements to be complied with if any part of the flight control system of an Australian aircraft is assembled, adjusted, repaired, modified or replaced in the course of carrying out maintenance on the aircraft. (2) Subject to subregulation (4), the system must: (a) be inspected by the person who carried out the assembly, adjustment, repair, modification or replacement; and (b) be independently inspected by another person who is an appropriate person within the meaning of subregulation (5). (3) A person carrying out an inspection must: (a) check that the assembly, adjustment, repair, modification or replacement was carried out in accordance with the aircraft’s approved maintenance data; and (b) check that the system functions correctly.

This can be a life saver. The NTSB recommended the FAA introduce such a check, but that has not happened as yet.

Overall, though, the procedural error in not having sufficient maintenance staff should mean aircraft are grounded until sufficient staff are employed.

Arnold Long

Aircraft Maintenance Engineer and Inspector

Brisbane Australia