CC150 Polaris - Epilogue
Report / August 25, 2013 / Project number: CC15001-C-Cat
Location: 8 Wing, Trenton, Ontario
Status: Investigation Complete
Date: 25 August 2013
A contractor technician was lockwiring the drainplug of the left no. 4 flap screwjack gearbox while another technician, who was concurrently working on the right main landing gear brake system, applied hydraulic power to the aircraft. When the hydraulic system was activated, the left no. 6 wing spoiler closed onto the lockwiring technician, seriously injuring him.
The preliminary investigation revealed deficiencies in aircraft maintenance safety procedures and equipment. These concerns were immediately brought to the attention of both the RCAF technical authority and the contracted air maintenance organization, which undertook numerous rectifying and prevent actions to ensure this accident would not reoccur.
The investigation then focussed on supervision and organizational factors that preceded the accident. Numerous organizational safety stressors were identified including contract, facilities, organization and personnel disruptions; training and supervision of apprentices with too few supervisors; and a mismatch between contractor resources and operational demands which cumulatively increased the safety risk being incurred to meet these demands. Additionally, the investigation determined that the contracting and accreditation mechanisms were insufficient to detect this situation and reliance on the contractor to self-identify the risk could create a potential conflict of interest within an incentivized performance contract. This highlights a safety assurance gap for contracted maintenance that should be addressed by the RCAF.
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