HUMAN FACTORS: WHOSE FAULT, REALLY?
African Pilot|January 2023
It was a pretty little thing, the Cherokee. Liquidly gloss white, with two-toned red stripes on the wings, fuselage and tail its gear wrapped in wheel pants. It had been owned by one man for the previous 20 years without incident and yet, nine months after its sale to a new owner, the Cherokee was a crumpled pile of junk lying in a ditch off the end of Runway 24 at Oswego County Airport (KFZY) in Fulton, New York.
WILLIAM E. DUBOIS
HUMAN FACTORS: WHOSE FAULT, REALLY?

The NTSB placed the blame for the wreck solely on the shoulders of the A&P / IA who completed the plane’s first annual under the new owner a mere three days before the crash. However, a closer look at the details surrounding the destruction of the airplane shows that there could well be more than enough fault to spread around.

The flight

We do not have a record of how long the plane was in for its annual inspection, but as any owner can tell you, all annuals are too long and, in this case, there was quite a bit of additional work undertaken, so it probably was not a fast turnaround. But after the annual, the owner picked up his plane at Cortland County Chase Field (N03) in Courtland, New York and started a ferry flight to his home base of KFZY some 46 nautical miles away. On take-off, he noted a film of oil starting to form on the windshield. It started at the bottom of the glass near the cowl, mainly on the copilot side and rapidly migrated five of six inches up the glass. But then it seems to stop, so rather than turn back and return to the maintenance shop, which is still the closest airport he decided to continue the flight home instead.

You thought this was when the crash was going to happen, didn’t you? No. Not yet. The gods of flight smile upon our hero and he makes it home safely. The next day, he calls his IA, who tells the pilot not to fly the airplane and that he will come over and check it out. But the pilot decides to check it out himself. He opens the cowl and sees no oil. He cleans the windshield and does a run-up. Then, according to his cursive handwritten statement to the NTSB, “I saw a few specks of oil, so I decided to do a take-off and landing.”

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