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Archive / FAA Aviation Maintenance References / Aviation Maintenance Technician Handbook: General - Chapter 14

Chapter 14 - pages 14-32 to 14-32

Human Factors Resources

FAA-H-8083-30B, Chapter 14 (2023)

Text-only reference. Published from the recorded official FAA General Chapter 14 PDF. Diagrams, photographs, and figure artwork are not reproduced here; use the official FAA PDF for those materials.

14-32 August 26, 1993, an Excalibur Airways Airbus 320 took off from London-Gatwick Airport (LGW) and exhibited an undemanded roll to the right on takeoff, a condition which persisted until the aircraft landed back at LGW 37 minutes later. Control of the aircraft required significant left sidestick at all times and the flight control system was degraded by the loss of spoiler control. Technicians familiar with Boeing 757 flap change procedures lacked the knowledge required to correctly lock out the spoilers on the Airbus during the flap change work that was done the day before the flight. Turnover to technicians on the next shift compounded the problem. No mention of incorrect spoiler lockout procedure was given since it was assumed that the 320 was like the 757. The flap change was operationally checked, but the spoiler remained locked out incorrectly and was not detected by the flight crew during standard functional checks. The lack of knowledge on Airbus procedures was considered a primary cause of this incident.

April 26, 2001, an Emery Worldwide Airlines DC-8-71F left main landing gear would not extend for landing. Probable cause was failure of maintenance to install the correct hydraulic landing gear extension component and the failure of inspection to comply with post-maintenance test procedures. No injuries. On May 25, 2002, China Airlines Flight 611 Boeing 747 broke into pieces in mid-air and crashed, killing all 225 people on board. The accident was the result of metal fatigue caused by inadequate maintenance after a previous incident. On August 26, 2003, a Colgan Air Beech 1900D crashed just after takeoff from Hyannis, Massachusetts. Both pilots were killed.

The improper replacement of the forward elevator trim cable and subsequent inadequate functional check of the maintenance performed resulted in a reversal of the elevator trim system and a loss of control in flight. Factors were the flight crew’s failure to follow the checklist procedures and the aircraft manufacturer’s erroneous depiction of the elevator trim drum in the maintenance manual. On September 28, 2007, American Airlines Flight 1400 DC-9 experienced an in-flight engine fire during departure climb from Lambert St. Louis International Airport (STL). During the return to STL, the nose landing gear failed to extend, and the flight crew executed a go-around, during which the crew extended the nose gear using the emergency procedure. The flight crew conducted an emergency landing, and the 2 flight crewmembers, 3 flight attendants, and 138 passengers deplaned on the runway. No occupant injuries were reported, but the airplane sustained substantial damage from the fire.

American Airlines’ maintenance personnel’s use of an inappropriate manual engine-start procedure, which led to the uncom- manded opening of the left engine air turbine starter valve, and a subsequent left engine fire. INCIDENT CAUSE INCIDENT CAUSE ACCIDENT CAUSE ACCIDENT CAUSE ACCIDENT CAUSE

Original source PDFPublished from pages 32 of the recorded source PDF.
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