Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
FC5304
Initial Report
This report is published in précis in order to disidentify those involved.
Whilst conducting a pre-flight system check at [Base], it became apparent there was an issue with the aircraft similar to one that I had experienced with it before. Due to the engineers on my previous event in this aircraft being concerned by it I was equally concerned and decided to return to stand.
We were met by an engineer who I feel was putting undue commercial pressure on us to accept the aircraft. He was extremely rude and told us we were basically wrong and that there was no standby aircraft so we were cancelling a service because the aircraft was perfectly serviceable – all this whilst he was outside the aircraft on the headset. I told the engineer to come up and stairs were attached. He came into the flight deck and I demonstrated what I had experienced. Again, significant pressure was put on us to accept the aircraft but we AOG’d it, refused to accept it, and were moved to a standby aircraft which was available all morning. I was quite flustered by the whole event and it took a lot of effort to put it behind me. Several SOP slips were subsequently made and, although not unsafe, there was a noticeable impact on the efficient running of the flight due to the pressure being put on us by the engineer. I felt berated for doing my job as a ‘guardian of safety’ and ‘last line in the defence’ and I feel this individual had no thoughts of flight safety or of his actions.
CHIRP Comment
Firstly, CHIRP commends the reporter for doing the right thing; it is for the aircraft commander to decide whether or not they are happy with the state of the aircraft before they fly it and so they were absolutely right to reject pressure from the engineer to ignore their concerns: the old aviation maxim of ‘If there’s any doubt, there’s no doubt’ applies. Although the engineer may have considered that their professional abilities were being questioned and were probably under pressure themselves to meet scheduling requirements, advocating that the crew take the aircraft without any real investigation being conducted to determine whether or not there was an issue seems unwise at best. That the Captain had rejected the aircraft before for a similar issue should have raised red flags to everyone so it’s disappointing that more caution wasn’t exercised. Repetitive defects are a real cause for concern but, that being said, we should also be cautious about confirmation bias in potentially rejecting aircraft simply because we may have experienced problems with that airframe before.
On a Human Factors note, the fact that the crew were then flustered and made mistakes in the subsequent flight should be a warning to all of the negative results that confrontational engagements can have. Ground Handling and Maintenance personnel need to ensure that aircraft crews are not agitated by their interactions (and vice-versa) and, although it’s easier said than done, if unsettled and flustered by any event such as this, everyone needs to take a moment to recover their composure before carrying on with their tasks so that they are in the right frame of mind to avoid errors and mistakes.
As a matter of detail, when CHIRP spoke with the company concerned they said that subsequent investigations by the engineering team did result in a component change. Acknowledging this, they agreed that the main lesson from the report was to highlight the Human Factors connotations rather than dwell on the technical aspects.