As the two Rolls-Royce Dart engines that pulled the Hawker 748-2A into the wide-open winter Canadian sky suddenly stopped running in a cloud of black smoke then unnerving silence, Richard Komarniski watched, heart in throat, as the passenger-full twin turboprop airliner-turned heavy glider slipped under a line of trees and disappeared.
Being the chief engineer for the airline's maintenance base, Komarniski knew that whatever was happening--had happened--to the 748 was his responsibility. Something had unaccountably caused both engines to fail, and it was highly unlikely that the cause was not maintenance-related.
When Komarniski and the rest of the hangar team and the airport rescue squad found the 748, their heavy-hearted concern about what had caused the double engine failure was somewhat tempered by what they saw: an intact airliner sitting safely on the frozen Churchill River, gear still retracted, propeller blades bent, and relieved yet quizzical passengers carefully climbing out of the damaged airplane.
It wasn't until the investigation was complete that Komarniski and crew discovered the source of the engine failures: a simple, but potentially fatal mistake by a temporary replacement mechanic, exacerbated by a process that wasn't the least bit rigorous, a process where brief lack of attention led to a critical error that thankfully didn't turn out tragically.
It is this kind of error that Richard Komarniski has dedicated his life to eliminating, through the teaching of human factors issues to aircraft technicians. Komarniski is no armchair professor lecturing on theory; he has indeed been there and done that, and he is here in West Palm Beach, Florida to try to hammer some of the lessons into our thick brains in an attempt to prevent the kinds of accidents he has observed, both from afar and in the case of the 748, from way too close.
I attended the Grey Owl Aviation Consultants Human Factors for Aviation Technicians and Managers class at West Palm to experience first-hand Komarniski's teaching and hopefully learn more about human factors issues. Interestingly, the class consisted not only of technicians and managers from nearby Jet Aviation, which sends people every year to the Grey Owl course, but also two managers from drug distributor Medco Health Solutions. They were attending the class because quality problems in the drug distribution business are just as critical as in the aircraft maintenance industry.
Komarniski spent 30 years working as an aircraft maintenance technician and five years with Transport Canada as an airworthiness inspector. He has been teaching for the past ten years, not just human factors but also regulatory training and company maintenance and quality manual development, which is another service that Grey Owl offers.
The Grey Owl human factors course comes in four different flavors. The first, recommended for any technician and manager, is the Phase I Two-Day Awareness course. This class is an excellent introduction to human factors issues and covers behavioral characteristics, pressure on maintainers, stress, fatigue, communication, and other factors that affect the performance of aviation technicians and managers.
After completing the two-day course, Grey Owl recommends periodic refresher courses, including a one-day refresher that can be done each year and a one-day refresher course designed for aviation mentors.
Komarniski is an engaging presenter and keeps the audience busy and constantly learning as he weaves tales of his own maintenance background with classic maintenance-caused accidents to show how human factors play a huge role in safety. During the second day, the most interesting activity was a survival exercise that tested not only each classmember's survival skills but also their ability to work as a team to solve challenging survival problems. My team, for example, did a much better job than I would have done individually.
The accident that really brought home the necessity of the human factors training endeavor was that of the HS748 in Churchill, Manitoba. Both engines quit shortly after takeoff because someone filled the aircraft's water-injection tank with aviation gasoline. When the pilots selected water/methanol during takeoff for added power, the engines overtemped and disintegrated. The reason for gasoline having been placed in the water-injection tank was mundane, but underscored how critical it is to have formal processes in place that everyone adheres to. That Komarniski was not only standing there and watching the accident happen and also was responsible for the work being done brought home his lessons in a powerful fashion.
Or, as Komarniski himself said during the class: "It takes an accident sometimes to shake things up."
Grey Owl Aviation Consultants
Phone: 204-848-7353
www.greyowl.com.
Sidebar
The primary human factors categories that can lead to an accident are:
Stress -- This human body response to demands made upon it can be influenced by a combination of stressors including life events, job events, and coping stress.
Communication -- The exchange of ideas, feelings, or attitudes between two or more people. Includes both verbal and non-verbal methods.
Fatigue -- The body's normal reaction to a physical or mental stress.
Complacency -- A conscious or unconscious relaxation of one's usual standards in making decisions
Distraction -- Psychologists say they are the number one cause of forgetting.
Lack of Resources -- Absence of necessary items to complete the task.
Lack of Knowledge -- Not understanding each step of what you are doing and not discussing with someone who does.
Lack of Awareness -- Even technicians who are very knowledgeable can fail to consider possible consequences to what is normally a good maintenance practice.
Pressure -- Too much pressure is a negative, but some pressure is what motivates workers to do the job.
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