RAAF F111 Digital Flight Control Computer Incident

1
RAAF F-111 Digital Flight Control Computer
Incident
2
Incident Details

• DFCC required to make Aircraft A serviceable
• DFCC cannibalised from Aircraft B a normal
  practise
• Unknown to the avionics technicians, Aircraft A
  had recently undergone an avionics upgrade

3
Incident Details

• CMO inspections were not visually carried out by
  the Trade Supervisor or Independent Inspector
• Tradesperson performing checks missed visual cue
  of problem
• Aircraft paperwork and documentation (CAMM2 and
  ASIs) had not been amended to indicate aircrafts
  modification status
• Aircrew noted a problem with RDR ALT LOW lamp but
  decided to proceed with mission
• Aircraft flew without incident and was placed
  unserviceable on return to base

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Breeches
Accident or incident
Defences
Parts Configuration Control
Aircrew Pre-flight Checks
Aircraft Documentation
Supervision
5
Breeches
Accident or incident
Defences
Parts Configuration Control
Aircrew Pre-flight Checks
Aircraft Documentation
Supervision
6
Breeches
Accident or incident
Defences
Parts Configuration Control
Aircrew Pre-flight Checks
Aircraft Documentation
Supervision
7
Breeches
Accident or incident
Defences
Parts Configuration Control
Aircrew Pre-flight Checks
Aircraft Documentation
Supervision
8
Maintenance Error Defences

• Aircraft Documentation
• Maintenance Publications
• Independent Inspections
• Pre-flight Checks

Think AMIP!