ats:
Things I've learned from accident reports today: fuel antifreeze and runway de-icer are not the same stuff.
Apparently RAF Mount Pleasant managed to order a container of each and get the labels the wrong way round...
... meaning they mixed the runway de-icer with their fuel supply, and sprayed the fuel antifreeze all over the runway.
I suspect the "did not seek to apportion blame" requirement was a bit strained with this investigation...
... as evidenced by the ten pages of explanation of what a mistake is.
There's a fantastic diagram showing that of five containers they checked during the investigation, only one was found to have the right label on it...
... and that's because people had made two mistakes, changing it to the wrong label then changing it by accident to the right one.
Also, the report includes Photoshopped pictures of cheese.
ats: Things I've learned from accident reports today: fuel antifreeze and runway de-icer are not the same stuff.
Apparently RAF Mount Pleasant managed to order a container of each and get the labels the wrong way round...
... meaning they mixed the runway de-icer with their fuel supply, and sprayed the fuel antifreeze all over the runway.
I suspect the "did not seek to apportion blame" requirement was a bit strained with this investigation...
... as evidenced by the ten pages of explanation of what a mistake is.
There's a fantastic diagram showing that of five containers they checked during the investigation, only one was found to have the right label on it...
... and that's because people had made two mistakes, changing it to the wrong label then changing it by accident to the right one.
Also, the report includes Photoshopped pictures of cheese.