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25/03/2009

6 août 2005 : crash d’un avion de TUNINTER

tuninter.jpg

 

Puisqu’on reparle de cet accident qui a fait 16 victimes, lire attentivement cet extrait du rapport d’enquête technique. En résumé, un accident était prévisible dans cette compagnie à cause de multiples conditions dangereuses latentes.

 

 

BannerIndex.jpg2.13.2 Accident origin and analysis.

 

The accident originated from the incorrect replacement of the fuel quantity indicator (FQI) performed the day before. However, this should not be considered the main cause.

 

The event has been analysed not only as a human error performed

·             by mechanics/technicians who replaced the FQI not searching for the correct item

·             by the aircraft’s crew who, although they had the possibility of notice the incorrect replacement, did not perform any corrective action

but also as a series of organizational errors.

 

All people involved in the event did not received sufficient aid from the system in which they were operating to avoid the so-called fatal error.

 

The error that caused the accident has been determined by errors carried out by so-called “front-line” operators, but such errors occurred in a critical operational situation which, if it has not been so, maybe would have prevented the accident itself.

 

The aetiology of the event shows in fact the presence of multiple factors:

·             errors committed by ground mechanics when searching for and correctly identifying the fuel indicator

·             errors committed by the flight crew

·             non respect of various operational procedures

·             lack of adequate control by responsible persons of various sectors of the operator’s organization

·             lack of an adequate quality control system

·             lack of accuracy of data entered in the spares management system database

·             mechanics not adequately trained on use and procedures for spares search with the spares management system

·             deficiencies in maintenance and configuration control for the fleet’s aircraft

·             procedural deficiencies in technical management and maintenance of the aircraft

·             low qualitative standard for maintenance operations

·             inadequate surveillance of the operator by the competent Tunisian authority

·             lack of Flight Data Monitoring system

·             lack of adequate Safety Management System

 

From the above mentioned considerations, it is possible to affirm that in the event two types of errors (failures) occurred: active and latent failures.

22:36 Écrit par HMC | Commentaires (0)

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