“Pull the throttle back!” Lenore, a flight instructor, ordered the learner, Jennifer, as the revolutions per minute (rpm) climbed past past 2,000 on engine start. “I did, I did!”
Both Jennifer and Lenore grabbed the mixture and pulled. The engine went from a deafening roar to silence. They looked at each other. “What happened?” asked Jennifer. “I don’t know. Let’s check the engine,” Lenore said.
Ten minutes later, they had removed the cowling from the airplane. A quick engine check gave them the answer. The throttle rod-end was not connected to the carburetor arm—no bolt, no nut, just air between the rod-end and the arm. Jennifer looked at Lenore. “What if this had happened in flight?”
“What I want to know,” Lenore said, “is how this happened at all. The annual inspection was signed off yesterday.”
The previous day, the annual inspection had been signed off after a lengthy inspection by a local facility. Several mechanics had been involved in the inspection, including the owner/learner who had installed a headliner. The mechanic with the Inspection Authorization (IA) who signed off the annual was supervising several annuals, so most of the maintenance was performed by other mechanics.
After the inspection, the engine had been run-up according to the usual post-inspection procedures. The learner and instructor had flown the airplane for a half-hour familiarization flight. The next day’s engine start resulted in a runaway engine with the apparent cause due to the lack of the throttle rod-end hardware being safetied.
Three deficient areas in this annual inspection were identified by a round-table discussion group of aircraft and powerplant (A&P) mechanics and the learner. These areas were:
- Lack of responsibility
- Checklist misuse
- Complacency
Lack of responsibility—no one took responsibility for the entire inspection. The chances of something being overlooked increase with an increase in the number of mechanics involved in an inspection. The responsible person is removed from the actual procedure. The learner remembers hearing the IA ask one of the engine mechanics about the throttle. However, the question was vague, the answer was vague, and the rod-end was not safetied.
Checklist misuse—Perhaps the throttle rod-end had been disconnected for maintenance after the IA had signed off the control inspection and marked that item as complete on the maintenance checklist. In that case, a discrepancy should have been entered onto the discrepancy sheet stating, “reconnect and safety throttle rod-end.”
Complacency—an insidious and hard-to-identify attitude. Each of the mechanics involved in the incident thought someone else had inspected the throttle rod-end. The IA signed off the annual inspection after asking the mechanics about the items on the checklist, making frequent visits to the airplane, inspecting some of the various items, and deciding that was good enough. Complacency crippled the mechanics’ quality of work by removing any thoughts of double-checking each other’s work.
While a definite answer to the question of what happened remains a matter of speculation, professional mechanics heed warning signs of potential problems. The combination of a lengthy inspection, numerous technicians, an overworked supervisor, a poor checklist, and vague communication raise a red flag of caution.
This scenario underscores the need for safety risk management at all levels of aviation. Safety risk management, a formal system of hazard identification, assessment, and mitigation, is essential in keeping risk at acceptable levels. Part of this process is selecting the appropriate controls to mitigate the risk of the identified hazard. The primary objective of risk management is accident prevention, which is achieved by proactively identifying, assessing, and eliminating or mitigating safety-related hazards to acceptable levels.
This section discusses safety risk management in the aviation community, looking at it as preemptive, rather than reactive. The principles of risk management and the tools for teaching risk management in the flight training environment are addressed in Techniques of Flight Instruction.