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FSD Episode 133

Via the FSD podcast:

Human Factors Ignored on the Maintenance Floor – Episode 133

September 21, 2022/in Episodes /

An accident involving a Hughes 269C helicopter demonstrates the lack of depth in accidents attributed to maintenance errors. Once again, there is no analysis on the human factors involved among maintenance personnel.

The NTSB probable cause for this air crash points to an improperly installed mounting bracket on the engine. The supporting details and aviation insights are lacking.

“My frustration is that they go no further than to say this is a maintenance issue,” John Goglia says. “No human factors are explored although that is as important in maintenance as it is in the cockpit.”

John, Greg and Todd find many questions unanswered. They discuss the value in going deeper than “maintenance screwed up.”

They explore the many questions not investigated that could lead to information that people can learn from. They talk about why even the most benign accidents can result in aviation safety benefits. This accident report is among many that are a disservice to the aviation community because it is superficial.

Also in this episode, Greg retracts a Episode 131 statement that 50% of NTSB probably causes are wrong. He does not have sufficient documentation to support the statement. However, he stands by his statement that he is confident that at least half of NTSB reports are incomplete.

Helpful links:

• NTSB Public Docket, NTSB Number WPR14LA340
  
• NTSB Final Report (PDF)
  
• USA Today article, “Unchecked carnage: NTSB probes are skimpy for small-aircraft crashes”
  June 14 2014
  
• RAND Report, “Safety in the Skies” (PDF)
  

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