Photo: British Airways 5390, BAC-111, G-BJRT, from Donato Bolelli

Eddie Sez:

Mechanics are just as likely as pilots to become complacent as they grow with experience and earn the respect of their peers. In fact, in many ways they are at greater risk. They are not subected to the same regimen of training and evaluation; they can go longer without a "course correction" to bring them back into the standards they were initially trained to. Mechanics can often be relied upon to work alone, even in large shops, and they may find themselves inspecting their own work. In some cases, the first test of a mechanic's work is the next time the airplane flies with a load of passengers. This is a case study of just such a mechanic.

The mechanic in question exhibited all four aspects of what I call "Maintenance Malpractice." He took several short cuts, bypassed the chance for a second set of eyes to perform quality assurance, may have not been recently trained to relearn lessons he had forgotten, and he wasn't properly rested. He is very lucky nobody died.

So this is a flight mishap but we won't be discussing the flight other than to say the pilot's windshield blew out passing 17,300' because it was installed improperly. The captain was blown mostly out of the cockpit and would have died hadn't it been for the efforts of the cabin crew holding onto him and of the first officer for getting the airplane on the ground quickly. We pilots can learn from this exercise, however. Look your airplanes over carefully after maintenance. If you have a one mechanic shop, develop a raport and volunteer to be that second set of eyes. The life this effort saves could be yours.

What follows comes from the references shown below and my comments shown in blue.


Accident Report


Narrative

The Flight

[AAR 1/92, ¶1.1]

The Windshield Replacement

[AAR 1/92, ¶1.6.3]

[AAR 1/92, ¶1.12.1]

[AAR 1/92, ¶1.16]

[AAR 1/92, ¶1.17.4]

[AAR 1/92, ¶1.17]


Analysis

[AAR 1/92, ¶2.2


Probable Cause

[AAR 1/92, ¶3 (b)


See Also:

Abnormal Procedures / Maintenance Malpractice

Pilot Psychology / Complacency

Technical / Fault Tolerance


References

Aircraft Accident Report 1/92, Report on the accident to BAC One-Eleven, G-BJRT over Didcot, Oxfordshire on 10 June 1990, Air Accidents Investigation Branch, Department of Transport, London, February 1992