Thursday, April 21, 2011

What is NOT Said!

The TV was on this morning, coffee time.  The programme was ‘Air Accident Investigation’.  Seemed good enough to spend an hour watching.  Us aviation type people will watch anything that’s got aeroplanes in it even if it is a little traumatic.

This was a lot traumatic.  This was the story of how two pilots fought a B747 for over thirty minutes, not knowing their efforts were useless.  It was Japan Air Lines (JAL) Flight Number 123.
Dreadful accident.  Just dreadful.
Miraculously there were survivors.  A few.  There might have been more but rescue was late and the mountaintop was cold.

The programme detailed the events that led up to the accident.  It was both enthralling and horrific.
At the end they reported on the cause.  In some detail.  They stopped there.
They did say that there was to have been a prosecution against Boeing but it never came about.  They did say that there were lots of conspiracy-mongers who said that the blame lay with JAL and not Boeing, that JAL was being ‘protected’ by the Japanese Government and Boeing.
Still, JAL very nearly went under because of it.
JAL was entirely innocent.  As innocent as all those victims.
The cause?  A repair to the rear pressure bulkhead had blown apart and removed, in so doing, the fin of the aircraft.  Thus the aircraft had become uncontrollable with the inevitable consequences.

I remember, many years ago, that there was talk about the engineer who had come out to Japan from Boeing to effect this repair.  That it was his fault.  The finger of blame descended upon him and his team.
But let’s just think about that for a moment.
This is a skilled engineer and his colleagues.  They are all experienced and know the B747 well.  They know their job well.  These are good people at the top of their profession or they would not have been sent out to Japan to do this work.

Shall we go back to the beginning?  This B747 made an appalling landing, for reasons best known at the time to the pilot alone.  He managed to skid the empennage along the ground causing damage to the under-skin and the pressure bulkhead.  Structural checks, carried out at the time by JAL engineers, revealed no problems anywhere else (top skin, wing retaining bolts, engine pylons, etc.).
What is the next step?
Telephone Boeing.  “I’m sorry, Mr. Boeing-san, but we feel that this repair is beyond our expertise.  Please help.”
Boeing looked at the damage and produced a ‘Repair Plan’.
Got that?  A ‘Repair Plan’.  This is a normal procedure for manufacturers of all aircraft.  Your aircraft is broken and there is nothing in the Structural Repair Manual (SRM) to cover it?  Call the manufacturers and get a ‘Repair Plan’ from them.
Boeing produced the plan and sent engineers, at the request of JAL, out to do the job.

A note about engineers.  And American practices.
Thirty years ago we worked with the United States Air Forces in Europe (USAFE).  They were good and conscientious lads—and girls, too.  If they received an amendment to one of their manuals (TO—Technical Orders, they called them) they would not just insert the amendment as we did.  No, no!  They checked EVERY page in EVERY book!  Very, very time consuming and a task that would bore any living engineer or mechanic to tears.
Similarly, when they went out to do a maintenance check on an aeroplane, they would follow the book precisely:
Page 1, Paragraph 1—Check ‘item’ in left undercarriage bay.  (Tick—done.)
Page 1, Paragraph 2—Check ‘item’ in right undercarriage bay.  (Tick—done.)
Page 2, Paragraph 3—Check ‘item’ in left undercarriage bay.  (Tick—done.)
Page 2, Paragraph 4—Check ‘item’ in right undercarriage bay.  (Tick—done.)
....and so on.
We did a circular route around the aircraft rather than hop from one side to the other and back again.  But their rules said ‘follow the book’.

But we still ‘follow the book’ when it comes to what to check, when to check it and how to check it.

Back to Japan.
The engineer from Boeing has arrived in Japan with his favourite tools and gets out the ‘Repair Plan’.
He follows the ‘Repair Plan’ because he knows that if he gets creative with it there could be very nasty repercussions.  The words ‘Big Black Smoking Hole in the Ground’ spring very readily to mind at such times.
He does as he is told.  The supervisor checks ‘The Plan’ and the repair.  The Quality Assurance manager checks ‘The Plan’ and the repair.
Everything matches.  All is well.
But it wasn’t.
The person, or team, that drew up the ‘Repair Plan’ got it horribly wrong.  The Manager who approved the ‘Repair Plan’ got it horribly wrong.
And then....
The engineer, his supervisor and the QAM should have thought “Hello!  Something odd about this.”  They should have queried Headquarters.
These are experienced people.  They didn’t ask.

Never be afraid to ask.


We are so drilled into ‘following the book’ that we forget that, sometimes, it is right to ask.  Sometimes your duty is to ask.

It can save lives.