In closing, I want to recognize the NTSB staff for their excellent and thorough work bringing this report to the Board, in particular, the staff from the Office of Aviation Safety and from the Office of Research and Engineering. Bill English, Investigator-in-Charge, and his team did an outstanding job.
At the beginning of today's meeting, I mentioned the work of James Reason and Alan Hobbs. Their research also revealed that the largest category of maintenance errors can be characterized as "failing to carry out necessary actions."
And, that is our finding from this investigation. Inserting a small pin, smaller than a paper clip, and just one small step in a routine maintenance procedure, was the necessary action. The omission of this action was the difference between an uneventful flight and tragedy.
But, there are lines of defense, necessary lines, when dealing with complex machinery that travels high and fast with souls on board. This is why we issue recommendations today, recommendations to address maintenance fatigue and human factors. One of the critical lines of defense is straightforward: improved maintenance documentation through delineated work cards.
Work cards are commonsense - just like checklists.
Raise your hand if you've ever used a checklist - as a pilot, as an office worker or even as a parent. They help us know what to do and in what order or priority. And, checklists can be crucial reminders and especially helpful when we are tired, or distracted, or new to a job or any number of situations so common to the human condition. They are a backstop to human error.
Checklists are not rocket science, but they can have astronomical benefits.
Look at what checklists have done for safety in the cockpit. They can make similar, lifesaving contributions on the hangar floor, both during maintenance and in the important inspections that follow.
Here's one last thought from the men who wrote the book on maintenance error. The authors say, "The maintenance error problem can be managed in the same way that any well-defined business risk can be managed."
And, most importantly, it is time to respect the importance of maintenance professionals when it comes to assuring safety in aviation. They deserve the same support and recognition shown to pilots when it comes to human factors.
That is the point of the recommendations we issue today. There are best practices available. They should be followed by everyone concerned about aviation safety and about saving lives.
We stand adjourned.