The recent run of aviation accidents starting off the year has focused a spotlight on aviation safety. Gregory Feith, a former senior accident investigator with the National Transportation Safety Board (NTSB), as well as a private pilot and a highly respected expert on aviation safety, addressed the role that maintenance has to play in his keynote address on Tuesday at NBAA’s Maintenance Conference in Columbus, Ohio.
“We don’t want those accidents and the people that are involved in those accidents and incidents to have either perished or at least sustained any kind of injury in vain,” said Feith, who spearheaded a number of high-profile accident investigations during his more than two decades with the agency. “We have to take those lessons, we have to bring them back into aviation.”
Now a consultant, media aviation commentator, and one of the hosts of the Flight Safety Detectives podcast, Feith told the audience, “As a pilot, when that airplane comes out of maintenance, I have a tacit trust in my mechanic that that airplane has been returned to service properly…and that aircraft has been maintained properly by procedure.”
He cited a quote by Wilbur Wright, one of the fathers of powered aviation. “Carelessness and overconfidence are usually more dangerous than deliberately accepted risk.” Indeed, it was his brother, Orville Wright, that was involved in the first fatal aircraft accident in September 1908, killing the passenger.
Feith described how the pioneering brothers, in search of a government contract, changed the propellers on their Military Flyer to an untested version before they demonstrated the machine in front of U.S. Army officials. Passenger Lt. Thomas Selfridge was mortally wounded in the accident, while Orville—who was piloting the spindly biplane when one of the new propellers broke in flight—was hospitalized for nearly two months.
Feith identifies that incident as the birth of aviation risk management. “We do what we need to do to mitigate that risk to as close to zero,” he said, explaining that it can never be eliminated entirely. “As long as you have interaction between humans and machines, there is always going to be that possibility of failure in some way, shape, or form."
One of the key accident factors Feith examined during his tenure with the NTSB was the organizational safety culture of aircraft operators. While he acknowledged that even the best organizations can have accidents, complacency can set in. For example, due to employee turnover, maintenance staff may not have the necessary training, experience, or focus, or there may not be any supervisory oversight of the maintenance work.
Feith cited the fatal crash of a DC-8 freighter in February 2000. The NTSB investigation determined that an inexperienced mechanic attempted a shortcut in control surface maintenance, and the failure to insert a cotter pin resulted in the detachment of the right elevator control tab soon after takeoff. “The nut backed off, the bolt slid out, that control got jammed, and the rest is history,” Feith said, adding that little things can have disastrous consequences. “It’s not tails falling off, it’s not wings coming off: a bolt, a nut, a cotter pin. That’s the difference between success and failure.”
He explained that when it comes to procedures and regulations, there are two forms of noncompliance. Procedural intentional noncompliance is premeditated and can become very pervasive. The person knew the proper procedures and, for some reason, chose not to follow them. Maybe they had done it that way before, and it didn’t have an adverse impact; it may have even earned them praise in the past and made them complacent.
Cases of unintentional noncompliance are where the person got distracted, misunderstood the procedure, or was rushing to complete the task, allowing errors to creep in. In a field as unforgiving as aircraft maintenance, they can be equally devastating.
“It is all about integrity,” said Feith. “You have to take accountability if you’ve done something wrong…because lives depend on it. You can’t shortcut the process.”