An experienced and qualified aircraft maintenance technician (AMT) with a tight deadline discovered that he needed a special jig to drill a new door torque tube on a Boeing 747. The jig was not available, so he decided to drill the holes by hand with a pillar drill — a fixed workshop drill and an unapproved procedure.
Subsequently, the door came open in flight and the flight crew had to make an emergency landing. The AMT, being a “company man” and trying to get the aircraft out on time, committed what is known as a situational violation. A situational violation occurs when an AMT, typically with good intentions, deviates from a procedure to get the job done.
The reason for a procedural deviation may stem from time pressure, working conditions or a lack of resources. This example is not only a classic maintenance human factors error, but also speaks to the issue of professionalism and integrity conflicting with efficiency.
The European Aviation Safety Agency (EASA), in it…
