Myanmar National Embraer 190 NLG Jam: Maintenance Error? We’re Not Convinced!

Maintenance actions were not properly done as per the fault isolation manual in rectifying the intermittent Weight off Wheels System Fail fault and in addition, poor workmanship in performing the Nose Landing Gear Strut N2 servicing.

Our Observations and Warnings on WYLFIWYF and the FFP Fallacy

However, disappointingly, the investigators actually provided no evidence for their conclusions! They identify no omission or error by the first engineer.  They don’t comment on the dilemma the second engineer faced, namely the absence from the FIM of the oddly phrased problem reported nor do the investigators assess the adequacy of the maintenance instructions in general.  The investigators also do not identify why the N2 Chamber servicing was either incorrect or, indeed if correct, may have contributed to the jam on the 24th flight.  There are also no details of the inspection of the NLG.

The investigators may have fallen for the trap of looking for maintenance errors, as What You Look For is What You Find (WYLFIWYF). In other words concluding that as maintenance is meant to prevent failures, the outcome proves the maintenance was flawed, without needing to connect any actions or omissions with the outcome. Alternatively they may have made the assumption that the FIM and AMM were perfect and that any resulting failures are simply due to poor performance of the tasks. This is the most extreme variant of what we call the Failure to Follow Procedures Fallacy (FFP Fallacy), which can also feature when investigators assume any deviation from procedures must be significant and causal, without determining if the procedure was even appropriate.

We realise AAIBM is not a large and well funded safety investigation body and that, to their credit, they still managed to complete and publish their report over 10 times faster than a recently issued report on another regional jet landing gear jam: CRJ-200 Landing Incident Highlighted US Maintenance Competency Inadequacies! Indeed, they may have evidence to back up their conclusions and simply erred themselves by not documenting it (investigators are human too!).

However, it’s a reminder to air operators and maintenance organisations of the importance of completing their own internal safety reports by going through the stages of 1) gathering the facts, 2) analysing the facts, 3) drawing conclusions and 4) recommending actions. If each step is not supported by the former steps, the actions taken may well not prevent future actions and may well unfairly penalise individuals.

WYLFIWYF is especially prone to occur in safety department investigations when:

1. Investigators training has been orientated to ‘error investigation’.   Sometimes courses that are (re-)titled as ‘event investigation’ or ‘occurrence investigation’ are still primarily focused on interview of frontline staff and their behaviour with technical information simply being given by the instructor. Interview skills are important but just one of many skills investigators need.
2. Investigations are reviewed / approved by panels or review groups who work to a judgemental process that is primarily orientated around classifying errors and behaviour, determining culpability (or ‘accountability’) and whether disciplinary action should be instigated.
3. The motivation for investigations is simply to satisfy third parties (regulators, customers etc) and show the ‘system’ is OK.

In turn, such investigations can also fall for the FFP Fallacy too.  We’ve also seem statistical studies that have misleadingly classified any procedural issue as FFP.

Safety Resources

We have previously written:

• James Reason’s 12 Principles of Error Management
• Back to the Future: Error Management
• Airworthiness Matters: Next Generation Maintenance Human Factors
• Rockets Sleds, Steamships and Human Factors: Murphy’s Law or Holt’s Law?
• Safety Performance Listening and Learning – AEROSPACE March 2017
• B1900D Emergency Landing: Maintenance Standards & Practices
• B747 Landing Gear Failure Due to Omission of Rig Pin During Maintenance
• When Down Is Up: 747 Actuator Installation Incident
• Lost in Translation: Misrigged Main Landing Gear
• Maintenance Human Factors in Finnish F406 Landing Gear Collapse
• ERJ-190 Flying Control Rigging Error (UPDATED 25 June 2020 with Final Report – very different levels of detail and analytical rigour evident)
• NTSB Confirms United Airlines Maintenance Error After 12 Years
• Fire After O-Ring Nipped on Installation
• A Lufthansa MD-11F Nose Wheel Detached after Maintenance Error
• B767 Fire and Uncommanded Evacuation After Lockwire Omitted
• What Leaks in Vegas Stays in Vegas – A320 Hydraulic Failure
• A319 Double Cowling Loss and Fire – AAIB Report
• CFM56-7 HPC Titanium Fire Due to VSV Maintenance Assembly Error (United Boeing 737-924)
• Uncontained CF6-80 Failure: American B767-300 28 Oct 2016
• Inadequate Maintenance, An Engine Failure and Mishandling: Crash of a USAF WC-130H
• Crazy’ KC-10 Boom Loss: Informal Maintenance Shift Handovers and Skipped Tasks
• Hoist Assembly Errors: SAR Personnel Dropped Into Sea
• Contaminated Oxygen on ‘Air Force One’
• Meeting Your Waterloo: Competence Assessment and Remembering the Lessons of Past Accidents
• UPDATE 25 June 2020: Japanese Jetstar Boeing 787 GEnx-1B Engine Biocide Serious Incident
• UPDATE 28 June 2020: Maintenance Issues in Fire-Fighting S-61A Accident
• UPDATE 22 July 2020: NDI Process Failures Preceded B777 PW4077 Engine FBO
• UPDATE 12 October 2020: Frozen Dash 8-100 Landing Gear After ‘Improper Maintenance Practices’ Say NTSB
• UPDATE 18 November 2020: Embraer ERJ-190 EWIS Production Quality a Factor in Fire
• Also see our review of The Field Guide to Understanding Human Error by Sidney Dekker presented to the Royal Aeronautical Society (RAeS): The Field Guide to Understanding Human Error – A Review

UPDATE 24 June 2020: The Chartered Institute of Ergonomics and Human Factors (CIEHF) has issued a white paper called Learning from Adverse Events.

UPDATE 1 July 2020: The National Transportation Safety Board (NTSB) discuss a Leonardo AW119 MkII Kola accident:

The pilot and the flight test engineer were completing a production test flight of the helicopter. A review of a surveillance video showed that, as they were preparing to land, the lower section of the left side of the engine cowling folded back and struck all four main rotor blades, which resulted in substantial damage to the blades. According to the operator/manufacturer, postaccident examination of the helicopter revealed that none of the fasteners on the left side of the cowling remained attached and that three of the fasteners were missing. No evidence of any preaccident discrepancies with the fasteners, the cowling, or the design and conformity of the helicopter structure was found.

According to the manufacturer/operator, before the flight, the pilot reported to maintenance personnel that he had seen that the fasteners attaching the generator duct to the right side of the same cowling appeared long. Maintenance personnel then removed the one-piece engine cowling, and a mechanic then replaced the generator duct fasteners and reinstalled the cowling with the help of another mechanic. The mechanic said he specifically fastened each of the fasteners on the cowling himself and checked all the fasteners after the cowling was reinstalled. Once the cowling was reinstalled, a quality inspector visually inspected the engine cowling fasteners. He did not see any anomalies and signed off that the work had been completed. The flight test engineer performed another preflight inspection of the helicopter and did not note any issues with any of the cowling fasteners. It is likely that the mechanic did not properly install the cowling fasteners before the flight, which resulted in the cowling coming loose and striking the main rotor blades.

The NTSB determined the probable cause of this accident to be:

The in-flight failure of the lower left side of the engine cowling due to the mechanic’s improper installation of the fasteners, which resulted in the cowling impacting all four main rotor blades.

The specific maintenance error is however not identified.

Aerossurance’s experienced investigators can help coach your investigation team, so they don’t make the mistake WYLFIWYF and or fall for the FFP Fallacy.

Aerossurance also worked with the Flight Safety Foundation (FSF) to create a Maintenance Observation Program (MOP) requirement for their contractible BARSOHO offshore helicopter Safety Performance Requirements to help learning about routine maintenance and then to initiate safety improvements:

Aerossurance can provide practice guidance and specialist support to successfully implement a MOP, which fills a gap in maintenance that in operations is filled by FDM and LOSA.