Routine Maintenance Gone Wrong
“It was very, very hard for me. I saw my hand come off - I could see my hand on the ground and other parts all over the place.” German aircraft engineer, Hendrik Donkers
Tire charging is a routine task in aircraft maintenance. However, if proper precaution is not observed, it can cause severe injury and even death. We will review two case studies where this routine task had gone wrong. We will discuss the possible causes of the errors and how we can prevent a similar incident in the Republic of Singapore Air Force (RSAF).
Case Study 1 - Civil Airliner Incident
In 2008, the nose tire of a 50-seater passenger aircraft exploded during inflation. The German aircraft engineer performing the task was standing less …show more content…
Before the accident, a sergeant and a specialist were assigned to change the tire. The sergeant had informed the phase team supervisor that the nitrogen cart’s low-pressure side was unserviceable and that there was no tire inflation kit available. The phase team supervisor asked if he had ever inflated a tire using the nitrogen cart’s high pressure side without using a tire inflation kit. Apparently, the sergeant had done it many times in the past. So the supervisor instructed him to charge a small quantity at a time and then check the tire pressure. The high pressure hose was connected to the tire and the pressure valve was opened, and then closed. As the sergeant leaned over for the tire pressure check, the tire exploded. He lost both his …show more content…
The RSAF Human Factor Analysis Model [See Figure 2] was formulated to address both active and latent failures. It was is revised from Reason’s9 Swiss Cheese Model with the 4Ls factors: Individual Factors, Team Factors, Unit/ Section/ Flight Management factors and RSAF/Command/Group Management Factors. It is designed to ensure that we can identify and plug any gaps in each of the four layers when carrying out activities. There is a comprehensive list of 64 factors to enable a thorough post-incident analysis. It recognises that HF accident is not caused by a singular error. It is a failure of all the layers of protection that allowed the holes to be aligned in the cheese
“It was very, very hard for me. I saw my hand come off - I could see my hand on the ground and other parts all over the place.” German aircraft engineer, Hendrik Donkers
Tire charging is a routine task in aircraft maintenance. However, if proper precaution is not observed, it can cause severe injury and even death. We will review two case studies where this routine task had gone wrong. We will discuss the possible causes of the errors and how we can prevent a similar incident in the Republic of Singapore Air Force (RSAF).
Case Study 1 - Civil Airliner Incident
In 2008, the nose tire of a 50-seater passenger aircraft exploded during inflation. The German aircraft engineer performing the task was standing less …show more content…
Before the accident, a sergeant and a specialist were assigned to change the tire. The sergeant had informed the phase team supervisor that the nitrogen cart’s low-pressure side was unserviceable and that there was no tire inflation kit available. The phase team supervisor asked if he had ever inflated a tire using the nitrogen cart’s high pressure side without using a tire inflation kit. Apparently, the sergeant had done it many times in the past. So the supervisor instructed him to charge a small quantity at a time and then check the tire pressure. The high pressure hose was connected to the tire and the pressure valve was opened, and then closed. As the sergeant leaned over for the tire pressure check, the tire exploded. He lost both his …show more content…
The RSAF Human Factor Analysis Model [See Figure 2] was formulated to address both active and latent failures. It was is revised from Reason’s9 Swiss Cheese Model with the 4Ls factors: Individual Factors, Team Factors, Unit/ Section/ Flight Management factors and RSAF/Command/Group Management Factors. It is designed to ensure that we can identify and plug any gaps in each of the four layers when carrying out activities. There is a comprehensive list of 64 factors to enable a thorough post-incident analysis. It recognises that HF accident is not caused by a singular error. It is a failure of all the layers of protection that allowed the holes to be aligned in the cheese