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A Small Mistake That Could Have Been a Real Issue

By George Fisher, gaf1998@yahoo.com


Last month I had the pleasure of performing my first annual inspection on my F1 Rocket. What a milestone. Build and fly my own high-performance aircraft, receive my repairman certificate from the FAA, and now perform my own annual condition inspections. My dream had finally come true. What a year!

But with that dream comes responsibility. As I inspected my new aircraft, even though I knew the ship better than anyone else, I had an important responsibility to be thorough and complete with my inspection. Let me tell you, doing an annual is a lot of work! There are times when I thought, “I know that bearing behind that panel is brand new; do I really need to remove that panel to take a look?” The answer is most certainly yes. Before I started the work I approached it with a strict discipline to not take shortcuts and to look at everything and make sure that when I was finished, I felt confident and safe in not only flying it myself but also in taking along my friends and family.

Well, as clichés go, “The best laid schemes o’ mice an’ men…” falls into place. Or, you might just call it Murphy’s Law. I learned that something can go wrong even with the best of intentions. In fact, it could have been catastrophic. The mistake was honest, but in the world of aviation, a mistake, honest or not, can kill you.
The scenario is simple. I was at the end of my annual. I was reassembling parts to the engine, just after performing a compression test on all the cylinders. The only thing left to do was reinstall the spark plugs, connect the plug wires, reinstall the top of the pressure plenum, and reinstall the top of the cowling. “Great,” I thought, “the end is near, and soon I will be back flying.” Well, at airports part of the allure is that friends are always hanging out, curious of what you are doing and interested in helping out.

A friend, knowledgeable about the aircraft industry, offered to help out, and I was glad to have him assist. As we were reinstalling the top set of spark plugs, my friend Dale was installing the left ones as I installed the right. Dale screwed the plugs in hand tight, and I was to torque them when I finished with the left side. In walked two friends, and the conversation (distraction) started. I finished with the right-hand plugs and was ready to install the pressure plenum. On it went with the top of the cowling after that. Did you catch that? I hope so.
The next day, I pulled the aircraft out of the hangar, excited, since I have not flown in my Rocket for a while. The ship started as easily as always and roared with energy as if it were also anxious to fly. I taxied down to the runway for a preflight run-up, checking systems as I went, making sure all systems were in order. I performed my normal run-up, checking the left and right ignitions, and when I shut down the left side, the engine ran really rough. I thought that maybe some junk fell into one of the plugs during the annual, so I tried to clear the plugs; no luck.

Back to the hangar I went. I immediately pulled the ship back into the hangar and pulled the top cowl and pressure plenum; no small task I might add. Did I see anything? I sure did.

Here is what I believe happened.

As mentioned, Dale and I were installing the top spark plugs when two friends walked in. That innocent distraction caused me to fall short of my responsibility. I did not finish installing the left-side top spark plugs and plug wires. The plugs were left finger-tight and the wires were off of those three plugs. I caught the mistake during the run-up, and that is a good thing; that’s what run-ups are for. But to not install three plugs and wires on an aircraft engine is a mistake of great significance. Needless to say, since I take great pride in being thorough and meticulous when it comes to aircraft, this really hit me pretty hard. I was embarrassed, but at least I am not dead.

So what should I do differently next time? What did I do correctly? What went wrong? I believe my philosophy of being thorough is a good one. But I let myself get distracted when curious friends walked in the door. At that point, it seemed that I placed a higher priority in being social rather than being thorough. I think that was the greatest mistake. I’ll tell you that it will never happen again. When anyone walks into the hangar and I am working on my ship or any plane for that matter, I may not appear to be my friendly self until I have finished what I am doing. I guess I will have to fight my human nature and delay enjoying the good company of my friends and keep my priorities in place when working on an airplane. This sounds like a simple discipline, but as I found out, it is an important one and easy to overlook.

I hope this embarrassing mistake and root-cause analysis is helpful to others. There are a lot of distractions out there. We all need to keep our priorities in mind and resist temptation to deviate from those priorities when working on our pride and joys. As friends of those who work on aircraft, we need to be understanding of the mindset that is employed to ensure thoroughness and respect the fact that we may not get the social response we are looking for when we arrive in the hangar environment. Since the friendships are a great component of allure of aviation, maintaining focus can be more of a challenge than you might think.

I certainly expect all of my friends and associates will be giving me a “ration of $%#*” for this mistake. I would be disappointed if it did not happen. Stay focused.

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