Procedural Noncompliance: The number one Causation of Aviation Mishaps by Maintenance by AMCS (AW/SW) Anthony Abraham
“IF YOU DON’T HAVE TIME TO DO IT RIGHT, WHEN WILL YOU HAVE TIME TO DO IT OVER?”
T
QUOTE BY COACH JOHN WOODEN his is a quote of a few words, but it shares a strategy to the achievement of any measurable success. In the world of aviation maintenance, there is only one way of doing things the right way and that is by doing it strictly by the book.
As part of the Naval Safety Center’s assessment team, responsible for comprehensive safety centric looks of all the aviation squadrons across the fleet for both the Navy and Marine Corps alike, I have observed the consequences when maintainers do not adhere to this mandated requirement. It is no coincidence that procedural noncompliance is the number one causation of aviation mishaps by maintenance personnel.
While there are a plethora of noncompliance examples I have observed that give credence to the consequences of not performing maintenance actions strictly by the book, one that immediately comes to mind that best highlights this was in a recent mishap that grabbed my attention. The mishap resulted in an inadvertent and unplanned discharge of an engine fire bottle due to a series of noncompliance lapses by personnel within the maintenance department.
IT IS NO COINCIDENCE THAT PROCEDURAL NONCOMPLIANCE IS THE NUMBER ONE CAUSATION OF AVIATION MISHAPS BY MAINTENANCE PERSONNEL.
THIS MISHAP resulted in an inadvertent and unplanned discharge of an engine fire bottle...
6
MECH
In this case, it started with identifying a maintenance discrepancy by a squadron pilot who was conducting a pre-flight ground check for a Functional Check Flight (FCF) and noted that the left main landing gear light did not illuminate. The pilot called for a troubleshooter to replace the broken lamp. As soon as the light was replaced, all of the gear lights extinguished while the HOOK light, Spin Recovery light, and the Fire Bottle DISCH light all illuminated. Unable to get the erroneous lights to extinguish and the gear lights to return, the pilot declared the aircraft down for the flight. When the squadron pilot asked Maintenance Control if a Maintenance Action Form (MAF) had been written, he was informed that it was. Later on, you will see where this becomes critical in its contribution to this mishap.
