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Man...this coulda' been ugly

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There's an AD coming out with a fix, but it's not here yet. The two losses involving uncommanded rudder involved different causes, and neither one is definite. In the meantime, reports of uncommanded rudder deflection have continued to occur.

Boeing has proposed a fix which involves replacing the entire rudder control system with an entirely different design system, and that will likely be the thrust of the new AD.
Forgotten brush may have caused 737 rudder glitch

Seattle Times -- A wire brush left under the cockpit floor of a United Airlines Boeing 737 may have led to a rudder problem the pilots encountered last week as the plane was descending into Chicago. The discovery of the brush is part of the National Transportation Safety Board's investigation into the occurrence, said Paul Schlamm, a board spokesman. Several years ago, an
upgraded rudder servo valve was installed on 737s to
prevent rudder malfunctions.

AirlineBiz.com Newswire
Hi Guys,
If (and only if) the incident was primarily caused by FOD. UAL should FIRE every single A&P, IA and maintenance supervisor that was responsible for the last job that had the cockpit floor unbuttoned. Does this sound harsh? Going to the extreme? Not knowing all the facts? Perhaps it does...BUT it's IMHO
What is the most basic item that you check for when you preflight YOUR airplane? Well, in the military (Navy, specifically) I was trained to look for FOD, condition, security and corrosion of all components. When I was a PC trainee (Plane Captain, or what the USAF calls a Crew Chief), we were trained to ALWAYS do a tool inventory AND FOD check PRIOR to signing that aircraft off as safe for flight. There are a lot of ways to ensure this is to the maximum extent. The best way is training folks to ALWAYS be thinking FOD. Hell, I think FOD walking up my driveway! Guess I was in the service too long is what my wife jokes. However, it's the mindset that prevents DUMBASS mistakes like leaving a 10 cent acid brush in the bowels of the cockpit of a 737.
You want to know why I sound so harsh? Because someone's lack of attention to detail caused myself and another three young men to nearly get killed in the crash of an SH-60F helicopter in 91'.
No excuses, terminate them all and let them work on go-karts, but never again on airplanes.


Could FOD have caused USAIR 733 crashes, kind of makes you wonder a little doesn't it?
Unfortunately, as long as there are people are in the equation, mistakes will be made. It's up to the engineers to try and make things "idiot-proof" and up to the flight and maintenance crews to do their best in order to maximize safety. Even when everyone has apparently done their job correctly we will have the occasional tail fall off an airplane!!!
Before we hang, condemn, and fire, lets' get the facts. Then make a decsion. I believe that's still taught in the military, too.

You wouldn't have time to read the number of experiences I can list from memory right here concerning things I've found following post maintenance walk-throughs that required attention. Forgotton tools, loose items, misrigged controls (once), capped fuel lines, incorrect safety wire, abandoned roles of safety wire, a generator hanging loose following installation, fuel and oil manually shut off, bleeds disconnected, missing covers and panels, missing fasteners, and a host of other items. I once asked a returning pilot how his electrical had been behaving in flight and the output from XXX generator, and he said fine. I showed him that it wasn't attached, and was incapable of outputting anything. He was surprised, but he hadn't caught it, and had flown it on several missions. Go figure.

The fact is that things happen. In this case, an article in a newspaper has given a possible definite maybe. We all know that the media prints only the accurate truth, and that when a story reaches the papers, no further investigation is necessary or warranted, because that's the bottom line. However, my instinct as a pilot, mechanic, inspector, instructor, flight engineer, and practiced airport bum tell me that it's probably worth waiting to get the facts before sharpening the guillotine.

Regardless, I've found that in virtually all cases (expect intentional neglect, and that is very rare indeed), re-education and training is far better than rashly firing someone or ruining their career. We don't make mistakes. We just learn great lessons. What lessons can be learned here?
Great comments, Avbug, but I must disagree with one comment. To say that "we don't make mistakes. We just learn great lessons." is an oversimplification.

First, a caveat. There are no firm answers to this flight upset episode, so we are all taking positions before the truth emerges. As such, I am just making a comment on how we should handle those responsible during a problem resolution.

Kaman has a valid point. There must be a reasonable demarcation between retraining and punishment in these instances. I do not believe that a maintenance tech. who forgets to re-install a low threat screw along the edge of an internal panel needs to be sent to Alcatraz (yeah, I know...it's closed).

Likewise, I do not believe any of us think that the SabreTech folks who packaged and shipped those indicted oxygen generators aboard the ValueJet DC-9 should have been retrained and allowed to continue their profession.

An interesting parallel is the criteria commonly used in the military. In short, they latch onto the concept of "mistake vs. criminal action" theory. Specifically, if there is a true mistake--an untrained individual taking some action of seemingly innocuous consequence that subsequently goes wrong--then you take corrective action to resolve the problem (retrain, educate, evaluate) and move on.

If, however, someone makes an decision or takes willful action contrary to written guidance or with ill-intent, then harsher penalties are necessary. The kid who decided to shortcut the tire change procedure and decided to loosen the rim bolts before releasing the pressure in the tire found out the hard way that his actions were wrong. When the entire assembly blew apart, he lost his abdomen, bleeding out on the shop floor.

His supervisor, however, found out that failure to follow the rules resulted in much more severe disciplinary action than a simple mistake would have.

IF, and that's a big if, this wire brush was the cause of the 737 flight upset, I would venture that the culprit that left this item in the cockpit will not be found. If he/she were located, however, I would hope that they'd be fined/fired for a criminal failure to follow existing procedure.

Our parents told us that we are accountable for our actions. Must we wait for a fatal accident to take strong steps to ensure those actions are correct?

My two cents.
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Hey Kaman,

Have you ever flown a LOC Back Course and set the inbound course for the ILS, or trying to capture a radial, but have the wrong frequency in the VOR. Here is a good one, have you ever busted an altitude/airspeed/heading. These all could be life threatning actions, but also honest mistakes. I have done every single one of these things, and will probally do them multiple more times in my career of flying. The only thing that I can promise is that I will be diligent in my work, and that I can do the best job that I can.

Do not throw rocks from a glass house. The fact that you had an experience with FOD does not mean you need to crucify Mechanics.

Think about this. You dont know how many times a mechanic has saved your life by being diligent in his work and found something that could lead to a seriouse accident.
Hey Simon,
Recognizing that this is a public forum you are entitled to your opinion. However, I will also add that I stand by my original post. Secondly, I was not and did not "crucify" any mechanics. My experience that I was refering to was not a FOD related incident. I've also been involved in one of those too. If memory serves a certain rigging pin was left in the flight controls. This made it past the tech. doing the job, the CDI/QAR (Collateral Duty Inspector/Quality Assurance Representative), the Plane Captain and last but not least, the pilots. Us aircrew types preflight the bottom, nose, cabin and tail. While the pilots do the top and the rotor system.
I agree that everyone in this business, both military and civilian makes mistakes. Your's truly humbly included. Where the distinction MUST be drawn is the difference between an honest mistake and negligent. Were those Navy folks negligent? Hell, yes! Was adminstrative (loss of CDI/QAR letter) action and punishment (Art. 15 Non-jdicial punishment) taken? Hell, yes! and it was indeed warranted.
In the case of the United Airlines 733 incident similar actions should also be taken. If and as I stated earlier. ONLY if proper maintenance procedures were NOT followed. If there was a breakdown in communication between maintenance control and the hangar floor than the airline itself is and should be subject to scrutiny by the FAA for it's maintenance procedures. Specifically, FOD and tool control.
Finally, my friend I spent a good amount of my time not only flying in Naval aircraft as a crewmember, but also turned many a wrench on them too. Did I keep an eagle eye on the other technicans? Hell, yes! Why? Because only my young ass was going flying off the boat in that helicopter and I had a vested interest in the airworthiness of that aircraft. There is an old saying in aviation, "In God We Trust, Everyone Else We Check". Think about that and it just might keep you or your buddies alive someday. Out of 6 young men in my initial training class, 3 were killed in aircraft mishaps and the remaining three, including myself were all involved in a Class "A" mishap (loss of aircraft or strike damage).


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