The Price of a Mistake (2004) Series #6
Video length - 36 minutes.
This video is the sixth of the series produced by System Safety Services and like the previous in the series, challenges the viewer to recognize the links that form to cause the accident. The video then demonstrates the links and finally the safety nets that can help prevent a repeat of the accident.
This video is sadly based on an actual accident. A well meaning and conscientious AME is distracted at a critical moment and the resulting human error leads to the deaths of seven of his close friends. He also, will die as a result of this accident. However a human error before his, can be traced to the true cause of the unnecessary deaths. (See case study below)
This video illustrates the worse nightmare of anyone who works on aircraft.
The video is used in System Safety Services, Human Performance in Maintenance Part 1, workshop.
Copies of this video, the training booklet and the facilitator notes that accompany it, may be obtained directly from System Safety Services on DVD with appropriate chapters.
Cost of this video or others in the series is $175.00 Canadian funds plus shipping and handling.
A selection of any six (6) training videos may be obtained for $900.00 Canadian plus shipping and handling. This is a savings of $275 over individual ordering.
Funds from the videos are used to produce further training videos in the series.
Warning: This video has very strong emotional content and may not be suitable for everyone.
Unfortunately the same accident occurred again over twenty years later when maintenance AGAIN made an error.
The docket is stored in the Docket Management System (DMS). Please contact Public Inquiries
14 CFR Part 91: General Aviation
Accident occurred Sunday, October 23, 1994 in NEWVILLE, AL
Probable Cause Approval Date: 7/31/1995
Aircraft: PIPER PA-23-250, registration: N999BW
Injuries: 2 Fatal.
MAINTENANCE HAD BEEN PERFORMED ON THE ENGINE TURBO-CHARGERS & EXHAUST SYSTEMS SEVERAL DAYS BEFORE THE ACCIDENT FLIGHT. AFTER DEPARTURE, THE PILOT REPORTED THAT THE LEFT ENGINE LOST POWER & HE ELECTED TO RETURN TO THE AIRPORT. A WITNESS REPORTED SEEING THE AIRPLANE HEADING TOWARD THE AIRPORT WITH AN ORANGE GLOW UNDER THE LEFT WING ABOUT FOUR FEET OUTBOARD OF THE FUSELAGE. THE WITNESS SAID THERE WAS A LOUD POP, THE LEFT WING SEPARATED FROM THE AIRPLANE, & THE PLANE FELL TO THE GROUND. INSPECTION REVEALED EXTENSIVE FIRE DAMAGE IN THE AREA OF THE LEFT WHEEL WELL & SPAR, BEHIND THE FIREWALL, IMMEDIATELY AFT OF THE TURBO-CHARGER EXHAUST. FUEL LINES IN THE WHEEL WELL AREA HAD BURNED AWAY. THE LEFT ENGINE TURBOCHARGER TAIL PIPE & MARMON CONNECTOR CLAMP WERE MISSING. THE ENGINES HAD BEEN EQUIPPED WITH AIRESEARCH TURBOCHARGERS IN ACCORDANCE WITH STC SA909WE.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:FAILURE OF MAINTENANCE PERSONNEL TO PROPERLY INSTALL THE MARMON CLAMP ON THE DISCHARGE SIDE OF THE TURBOCHARGER.