1. Federal Aviation Administration Airworthiness Positive Safety Culture Doctoring Maintenance A Discussion of Human Factors and Behavior

2. Federal Aviation Administration 2 Introduction Review a fatal accident scenario Analyze chain of events leading up to the fatal climax Discuss how poor safety culture, unsafe behavior, and ignoring Human Factors caused a pilot to perish.

3. Federal Aviation Administration 3 Objectives Emphasize thoughtless decisions and risky behavior lead to undesirable consequence. Recognize Human Factors and not to ignore them. Encourage embracing a more positive safety culture that inspires safe behavior.

4. Federal Aviation Administration 4

5. Federal Aviation Administration 5 Ended up like this!!

6. Federal Aviation Administration 6 Mooney M20K Original Configuration per Type Certificate Data Sheet (TCDS) 2A3. Engine: Continental TSIO-360 (210 HP) Prop: McCauley 2A34C216

7. Federal Aviation Administration 7 Accident Mooney M20K Modified by Supplemental Type Certificate (STC) No. STC5691NM Engine: Continental TSIO 520 (305 hp) Propeller: McCauley 3AF32C505

8. Federal Aviation Administration 8 Departure Departure, under visual flight rules, cross- country. Destination airport expected to be Visual Meteorological Conditions (VMC).

9. Federal Aviation Administration 9 Arrival Destination airport weather not as anticipated. Unsuccessful attempts to land. Diverted to another airport.

10. Federal Aviation Administration 10 LANDING The approach to diversion airport was successful. At touchdown events began to unfold. Failed attempt to pull up. Unexpected climax

11. Federal Aviation Administration 11 Non Injury Accident The Mooney was damaged. Doctor X did not follow procedures Doctor realized “Other” factors were in effect

12. Federal Aviation Administration 12 Heading to the fatal accident Doctor X needed a replacement aircraft right away Purchased a another aircraft Mooney would be repaired and used again.

13. Federal Aviation Administration 13 Heading to the fatal accident The Mooney insurance policy close to expiring. No local area repair available. Need to move the aircraft.

14. Federal Aviation Administration 14 On course to fatal accident Doctor X decides to get Ferry Permit. The Doctor makes arrangements with home based aircraft repair facility. Ferry Permit has time limit.

15. Federal Aviation Administration 15 Still on course to fatal accident Mooney propeller must be replaced Doctor X owns another McCauley propeller Spare propeller not correct for the Mooney

16. Federal Aviation Administration 16 Course to fatal accident not altered Mechanics sent to prepare damaged Mooney. Problems encountered with the landing gear.

17. Federal Aviation Administration 17 Course to fatal accident still not altered Mechanic 2 completes final repairs on fuselage Mechanic 1 works on the propeller Propeller installation problems Propeller is installed

18. Federal Aviation Administration 18 Accident Course Slightly Delayed Tires and nose strut gets serviced Test run-up performed

19. Federal Aviation Administration 19 Back on the course to accident Doctor and Mechanic 2 return to Augusta, GA. Mechanic 2 was also a pilot Final Ferry preparation began

20. Federal Aviation Administration 20 The Day of the Crash Mechanic 2 began operational check of engine More Problems…….now with the propeller Doctor X knows the problem exists!

21. Federal Aviation Administration 21 The Day of the Crash Flight preparation continues Doctor X advises Mechanic 2 of his flight plan

22. Federal Aviation Administration 22 Shortly before the Crash Doctor X taxies over to the FBO. Doctor X taxies to the runway. Mechanic 2 taxies Bonanza Mooney is cleared for take-off

23. Federal Aviation Administration 23 Moments before crash The Mooney lifts off Witnesses observed the lift off. Seconds before the crash

24. Federal Aviation Administration 24 The Crash: Something fell off of the aircraft. The aircraft continued a short distance more Impacted the ground

25. Federal Aviation Administration 25 The Crash Scene

26. Federal Aviation Administration 26 Post Discussion Analysis: What and why did things go wrong? Human Factors (HF) were NOT recognized and WERE ignored. Opportunities to prevent either/BOTH accidents.

27. Federal Aviation Administration 27 Analysis: HF1. The Doctor was very busy, used aircraft for business and had logged more than 4000 hours in his Mooney. HF2: The Mooney insurance expiring.

28. Federal Aviation Administration 28 Analysis: HF3: Acquaintance advice. HF4: Ferry Permit expiration

29. Federal Aviation Administration 29 Analysis: HF5: Landing gear problems. HF6: The propeller problems

30. Federal Aviation Administration 30 Analysis: HF9: Propeller tips so close to the ground. HF10: Engine did not achieve power HF11: Propeller control operates backwards.

31. Federal Aviation Administration 31 Summary This scenario shows how thoughtless decisions and risky behavior led to undesirable consequence. We identified applicable Human Factors and why you should not to ignore them. Adopting a more positive safety culture will inspires safe behavior in you as well as your associates.

32. Federal Aviation Administration 32 Before we close Any questions or comments www.FAAsafety.gov AMT Awards Program