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MAINTENANCE ERROR ACCIDENTS

MAINTENANCE ERROR ACCIDENTS. By Wg Cdr (Retd) M U Khan, VSM Deputy General Manager (Flight Testing) Hindustan Aeronautics Ltd. Maintenance Error Accidents. Maintenance is : Essential & Integral part of aviation industry. Thus

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MAINTENANCE ERROR ACCIDENTS

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  1. MAINTENANCE ERROR ACCIDENTS By Wg Cdr (Retd) M U Khan, VSM Deputy General Manager (Flight Testing) Hindustan Aeronautics Ltd

  2. Maintenance Error Accidents Maintenance is : • Essential & Integral part of aviation industry. Thus • Maintenance errors are likely to occur just like the flight crew related errors. Aim is to: • Minimise the risk of maintenance related accidents / incidents

  3. Content • Statistics of Indian Civil Helicopter Accidents due to Maintenance reasons • Contributory factors towards maintenance errors • Man • Machine • Environment • New Safety Requirements • Preventive and Predictive Maintenance • Future Trends

  4. TotalMaintenance Year Wise Statistics of Accidents (1990-2005)

  5. OTHERS 5% GROUND ACCIDENT 10% PILOT ERROR 57% MAINTENANCE 28% Statistics of Accidents (1990-2005)

  6. Technical Defects 60% Improper Maintenance 40% Fatal : 2 Injury : 1 Substantial Damage : 8 Total Loss : 3 Breakdown of Maintenance Related Accidents (1990-2005)

  7. IMPROPER MAINTENANCE Incorrect Attachment Incorrect Connection Omission Wrong part Reversed Installation Wrong Judgement Improper tool/equipment TECHNICAL DEFECTS Fatigue Failure Improper Manufacture Incorrect Assembly Internal Failures Faulty Design Faulty Mfg Process Maintenance Issues

  8. Maintenance Errors - Factors MAN MACHINEENVIRONMENT

  9. ERRORS Oversight Attention lapses VIOLATIONS Non-compliance of laid down instructions or regulations Maintenance Errors - Someone in most maintenance departments make life or death decisions everyday. - They determine if an aircraft is safe for flight or not. - Most component technical issues in helicopters fall into shades of gray category thus

  10. The maintenance personnel have a tough task to perform to keep the fleet airborne. • Their decision is easy if it’s a major safety of flight issue – ‘The aircraft is down’. • It is more difficult if it’s a minor discrepancy like metal chips in a transmission, a leaky actuator or minor cracks in secondary / tertiary structures. • All military & commercial aircraft fly with minor discrepancies. THE INDIVIDUAL WHO MAKES SAFETY OF FLIGHT DECISION CAN’T MAKE MISTAKES

  11. However, • Not all errors lead to incidents / accidents. • Individuals usually realise their mistakes and rectify them. • Research has shown that people involved in critical professions routinely make small mistakes, which they detect and correct themselves.

  12. Other Human Factors • Lack of Communication • Complacency • Distraction • Lack of Knowledge • Lack of Teamwork • Fatigue • Lack of Assertiveness • Stress • Lack of Resources • Pressure

  13. Environmental Aspects • Mostly all maintenance activities take place by night in artificial lighting conditions. • Hangars & Tarmac may not be always available at all times for maintenance operations. • Heat, Dust, Rain etc can be source of initiation of maintenance related incidents / accidents.

  14. Errors due to the Machine • The helicopter is a very complex machine as compared to its fixed wing counterpart. • It operates in adverse environment such as dusty and salt laden atmosphere as well as close to ground. Thus making it maintenance intensive. • Present concept is to make the design for near Zero routine maintenance for short terms and ‘inspect & replace’ for the longer term maintenance cycles.

  15. Design features known to be a source of human errors are eliminated Software logic to prevent errors H U M S (Health & Usage Monitoring system) I E T M S (Interactive Electronic Technical Manuals) Onboard Diagnostics Avoid Maintenance Errors thru Design

  16. Preventive Vs Predictive Maintenance • Maintenance professionals emphasize prevention as an inexpensive method of controlling maintenance costs and ensuring safety. • Technology has now advanced to such a point that a new trend has emerged – Predictive Maintenance. • But the two are not mutually exclusive. • An operator who has adopted both approaches is unlikely to get an unwelcome surprise from maintenance problems. • However the future is towards predictive maintenance.

  17. Future Trends in Maintenance • Onboard diagnostic systems to not only record but also to analyse the data during the flight. • Possibly relay the same to the maintenance agency to ensure ‘just in time’ deliveries of replacement parts rather than stockpiling them. • Nanotechnology. • Smart materials. • Virtual Retinal Display.

  18. Conclusion • The human aspect of the maintenance personnel is the most important area and needs careful attention by both – the operator and the regulator. • The environment plays a major role in ensuring proper maintenance of our helicopters and thus requires careful attention. • Modern technologies can aid reduction in maintenance error accidents.

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