Precursors - Continued

One salient instance where a precursor impacted a flight was the 1979 American Airlines DC-10 crash, which was preceded by a 1978 pylon flange failure during maintenance. This incident was essentially masked in trivia in a report circulated to other airlines. It did not specifically identify that the failure was related to the method used to remove the engine/pylon assembly from the wing in order to expedite a maintenance inspection. This failure to recognize the precursor led to the same failure occurring, for the same reason, on an American Airlines DC-10, and the crash of American Airlines Flight 191 in May of 1979 was the result.

Precursors need not be just technical in nature. The DC-10 example also shows how precursors can be related to procedures, human factors, political events, and decisions. Accident precursor recognition is a vital part of a proactive intervention strategy and needs to be an important part of any safety management program.

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