Human Factors Training – Where do we go from here?

It came oh so close to happening again.

If not for some truly great piloting, yet another example of technician-error could have lead to a serious, if not fatal, aircraft accident. Because it’s still under “investigation”
I can’t share any of the details, but in a nutshell here’s what happened:

A technician was working on the elevator trim tab on a popular business jet, then for some reason, the technician was interrupted before he finished the job. Fast-forward to later that morning when the crew arrived to take delivery of the airplane. And after a pretty thorough inspection, (that unfortunately did not include climbing up on a ladder to look at the elevator), they fired-up and off they went. That’s when things literally came unglued.
Right after gear-up the aircraft started shaking and bucking. The crew then declared an emergency and was, according to the captain, “real lucky to wrestle it back to the runway…” After being escorted back to the maintenance center by the crash trucks, the crew and the DOM saw the problem.

The elevator trim tab was just hanging there. Obviously, technician had not finished attaching it to the elevator.

The unanswered question is why? Why did the technician get called away from the airplane at this critical time? Why was the work signed-off as completed? Was it a critical issue or just a lapse in judgment? (In all too many cases it’s proven to be the latter).

“I think to some the mindset is that it’s (being an aircraft technician) just a paycheck. It’s not. And you have to understand what you are doing and the importance of it,” explained Richard Komarniski, president, Grey Owl Aviation Consultants ( “It is easy for some people, in some situations, to lose sight of that fact.”

Just how serious is what technicians do on a daily basis? When you stop and look at it, it’s pretty darn serious. So much so that Komarniski likens it to being a surgeon. And rightfully so.

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