The Human Error

Hi Gordon,

I am looking forward to reading your human error articles in D.O.M. magazine.

I have not heard of the Dirty Dozen in human error contributing factors, so I am going to spend some time researching them. (Google to the rescue.)

My career was mainly military aircraft maintenance (10 years Army, UH-60, AH-64, OH-58, UH-1H, OV-1D), then contract maintenance in Kuwait, Iraq for 5 years, 5 years at Mooney and now a sales manager at AmSafe. I am a school-trained avionics technician that earned my A&P the hard way, years and years of work.

I might be a little old fashioned on safety, but my mantra has always been “break the chain of events.” In every accident report I have ever read or wrote (unfortunately), there was always the “ah ha” moment that shined a light on where the accident chain could have been broken thus preventing the accident from ever occurring.

In military jargon, the Technical Inspector was the brick wall that stood between errors (almost daily) and the safe operation of the aircraft. I remember the first day I was given my TI stamp (avionics) then full TI stamp later on. I was scared to death! How could they (those very dumb people) give me authorization to release an aircraft for flight? Now all that responsibility rested on my shoulders and let me tell you, that was a very heavy burden to hold up.

I was shocked at all the mistakes I found – some life threatening, some potentially catastrophic and some just plain stupid mechanic errors. There were nights that I woke up from a sound sleep, got dressed and went back to the flight line to check on a specific item that I didn’t recall looking at.

In all my years working on aircraft, I never had one go down, not even for a precautionary, on any aircraft that I had worked on or signed off for return to service. I contribute this to the fact that I never released an aircraft until I was 100% confident that it was ready to go, and many times I was climbing on the aircraft to fly with the crew on the post maintenance test flight.

Rushed work, distracted mechanics jumping from job to job, changing priorities and novice mechanics were the most contributing factors in the errors that I saw the most.

Well I am old(er) and fat(er) now and spend more time at my desk and less time on the aircraft but I still remember all those days and that heavy, heavy weight of that stamp.

With Kindest Regards,
Richard Heitzman