Dirty Dozen Case

From this report, I learnt that human error is the main contributing factor for most aircraft disasters, and that it is due to the Dirty Dozen, such as complacency, lack of knowledge and lack of awareness, that such incidents occur.

The fact that the cracks on the fuselage were unable to be detected over a period of six years, even though they are able to be seen by visual inspection, was astonishing to me as with so many people doing various checks on the aircraft and it still went undetected after such a long time, one would have thought that it was impossible to occur, and yet it did.

This shows that companies, in this case aerospace related industries, should have even more safety nets and redundancies to prevent similar incidents from occurring again, reducing the chances of such events happening to as close to zero as possible. Some examples include more stringent inspection of aircrafts, with two or even three inspectors so that defects can be more easily spotted, or always expect a fault and not assume anything so that one will not be complacent and thus not spotting the mistakes.

I also learnt that everything has to be done by the book as not doing so may result in dire consequences. In the case of this report, the technicians did not comply with the repair scheme and made minor adjustments so as to complete the job, however, even a little change from what the repair should actually be resulted in a small defect which snowballed into a much more significant problem over time.

Finally, this report also taught me that it is important to understand how human factors affect the working environment so that potential problems and mistakes can be eliminated by reducing or preventing them from occurring in the first place, which is done by studying other cases and adopting safety nets which will greatly help in preventing mistakes and thus chances of incident occurring will be reduced.