In 2001 an airline had recently changed out an aircraft engine on an Airbus 330 charter aircraft. Later, work on a hydraulic system required that a hydraulic line be replaced. The mechanic recognized that the replacement line was incorrect for the job because it did not fit properly, but he was ordered to use it anyway. Later, the replaced line rubbed against a fuel line while the aircraft was in flight. Fuel was lost and the pilots mis-interpreted the early indications of trouble, so they responded incorrectly. Eventually both engines flamed out with 306 people on-board. With the loss of both main engines, electrical power was lost - quite a predicament on a "fly by wire" design. Main hydraulic power for operating flaps and other flight control surfaces and for operating engine thrust reversers (a type of brake that works at high landing speeds) was lost. Fortunately the plane was close enough to a long runway in the Azores in the mid-Atlantic ocean and the pilots were skilled enough to carry out a glider landing of this jet aircraft. The emergency brakes were used, several tires burst on landing and the plane eventually slowed to a stop. Only 18 people suffered minor injuries but the potential for major loss of life had been high.
Pilot error combined with the maintenance crew using the wrong part led to the incident. Fortunately the pilots, although they had made mistakes on this flight, were skilled enough to land the disabled aircraft safely. The maintainers however, despite a comprehensive Management of Change program did not follow its rules. Management of change is about more than just the hardware. It's also about people and how they work.
Managing the change of engine and all related parts from the engineering of the change to the execution of all modifications necessary to complete the change was proven to be highly important here. Having the right parts available for future maintenance work is also critical. Using the wrong parts can be very dangerous. Regardless of external pressures to work quickly and get the job done employees need to know the significance of their choices at all times. Technical and process changes are not enough - don't forget the people.
Get help to ensure your people to make sure they too are full on-board with your programs.
The benefit of these programs is the avoidance of future failures that can cause lost production, avoidable repair costs and potentially unsafe or environmentally unsound situations to arise. If the investment of effort in making the changes is worth doing, then having your people follow up with all the needed changes and sustaining them is also important.
