MAINTENANCE ERROR ACCIDENTS维修差错事故.pptVIP

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 Maintenance errors are likely to occur just like the flight crew related errors. Aim is to: Minimise the risk of maintenance related accidents / incidents 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 Year Wise Statistics of Accidents (1990-2005) Statistics of Accidents (1990-2005) Breakdown of Maintenance Related Accidents (1990-2005) Maintenance Issues 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 Errors - Factors MAN MACHINE ENVIRONMENT Maintenance Errors ERRORS Oversight Attention lapses VIOLATIONS Non-compliance of laid down instructions or regulations 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. 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. Other Human Factors Lack of Communication Complacency Distraction Lack of Knowledge Lack of Teamwork Fatigue Lack of Asser