this event the bolt was installed, in the field about 30 days prior to the accident, without the necessary washer to ensure that it stayed in place. The maintenance crew had failed to install the washer. See Figure 5. When the downstop assembly fell out of place it was pushed to the back of the track can and punctured a hole in the fuel tank. This failure to follow procedures error, for a small washer, lead to the aircraft loss.
CONCLUSIONS
Accident reports present many learning opportunities. The three examples described here are but many that show multiple human factors issues not only in maintenance but also with other crew members. Example 1 and 2 were from the accident reports. Example 3 came from the FAA website: Lessonslearned.faa.gov. That FAA site includes accidents from airlines, general aviation, and rotorcraft.
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FIGURE 5. Leading edge slat track and downstop assembly.
The figure shows the condition when
the nut comes through the downstop.
Main Track
These were not separated.
These parts may come off if washer
is not installed next to the nut.
Measured value
(Unit : inch)
Not to Scale
Stop Location
Nut
Nut
Sleeve
Downstop
Washer
Washer
Bolt
Downstop
0.408
0.256
0.414
0.433