Printed headline: The Buck Stops Here
Last September, a Jetstar Airways Airbus A320 utilized normal braking when thrust reversers were found inoperable during landing roll. A post-flight inspection revealed lockout pins still installed in the hydraulic control units. Investigation of the incident concluded that maintenance personnel failed to remove the pins after a three-day maintenance check.
Contrary to operator task cards prescribing sequential functional checks, engineers signed off on required tests based on checks completed earlier in the day. To save the time required to check out a lockout pin from the tool crib, a substitute pin—designed for in-service use and without an attached warning flag—was used.
The report describes a series of contributing factors leading to the failure to follow procedures (FFP). Unanticipated maintenance needs and an expedited departure schedule put added pressure on maintenance personnel, who worked extra hours and through breaks to return the aircraft to service on time. And generic cockpit notices were used in lieu of specific warning labels for thrust reverser de-activation, reportedly a common practice.
The incident is one a new FAA initiative aims to prevent. William Johnson, FAA chief scientific and technical advisor for human factors in aircraft maintenance systems, says the story is all too familiar. “Despite the common understanding of the importance to use written technical procedures, failure to follow instructions continues to be among the largest safety issues in aviation maintenance,” says Johnson. “FFP is not a technical issue; it is about attitude and commitment.”
Johnson is leading a new project focused on increasing attention on procedural compliance and educating and empowering MRO leadership and personnel. “There’s often lots of blame that goes around for failure to follow procedures. Mechanics are the obvious scapegoat, but blame could also lie with inspectors who overlook procedures, or managers that rush a task to meet a production schedule or flight departure time,” he says.
A new FAA online training resource focuses on corporate culture and individual accountability. Trainees who complete the course pledge to become champions of the procedural compliance culture and not to blame others for their own failure to follow procedures.
FAA officials say around 4,000 individuals have taken the online course since it was released in October. Anyone can access it for free at followprocedures.com.