Following Safety Procedures

During regular maintenance, the procedure for cleaning a small component of the automatic engine starter on an MD-80 was not followed. This eventually caused the starter to quit working. Unable to start the engine, the pilots called for assistance. Maintenance personnel then did not follow the procedure for manually starting the engine. Instead of opening the engine cowl and using a specialized wrench, they slid in a pry bar because it was quicker. This further damaged the starter, resulting in an in-flight engine fire.

The fire was prolonged because the pilots did not follow the engine fire procedure. In addition to that, the flight attendants failed to communicate their observations to the pilots, which they should have done according to company procedure. The accident investigators concluded that the airline’s maintenance personnel had ignored the manual start procedure on other occasions. The airline asked the manufacturer to modify the starter so that the pry bar would no longer work. They already had a process for auditing conformance to procedures, so the accident investigators instructed them to make that process work.

Operating procedures are a mandatory component of a safety program.

What can you do if workers decide not to follow them? It’s not like everybody involved didn’t appreciate the gravity of the situation – they all knew they were dealing with the safe operation of a large passenger aircraft. The airline chose to change a piece of equipment to eliminate one non-compliance, but you can’t build a practical fool-proof system. Even if they improve their audits, they’ll only be able to evaluate whether or not procedures have been followed after the fact.

Safety is an attitude.

If you are unable to establish a corporate culture that values safety, all the procedures and audits in the world are not going to prevent accidents. “During post-accident interviews, maintenance personnel indicated that the approved procedure was very time consuming and could take about 20 to 40 minutes to perform….” The next time your flight is delayed 20 to 40 minutes for maintenance, thank them, because it could be they were taking the time to follow procedures! The following are some examples of  procedures to adopt and comply with to enhance what is already in place in the work place:

Job Safe Practice (JSP)

Relevant JSPs must be reviewed before a job commences. It is important that all employees do jobs as outlined in the JSPs.

Job Safety Analysis (JSA)

JSA must be completed for all non-routine tasks or when a job condition changes. Documentation and understanding of this JSA is absolutely necessary.

Permits

All applicable permits must be in place before a job commences. Work permits are required for high risk jobs in an area that will be conducted by personnel from another area.

Personal Protective Equipment (PPE)

All required PPE must be worn in designated areas. This is required whether or not a task is being done or a hazard is recognizable. The PPE procedure requires all personnel to wear basic PPE (hats, goggles (glasses in Mines, powerhouse and shops) and boots) in all operating areas and additional PPE for specific purposes.

Speed Limit

The speed limit when operating mobile equipment must be adhered to. Operating and Driving to conditions is of paramount importance.

Seat Belt

Seatbelt use for all operators and passengers is mandatory.

Cell Phone Use

Operators of equipment are not permitted to  use cell/mobile phone while operating any moving vehicle within the facility and in moving company vehicle anywhere.

And a bonus quote:

“To admit you were wrong is to declare you are wiser now than before.” -Unknown

Thanks for the share, TO!