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هوافضا::
بوت ضد یخ (سیسیتم ضد یخ)
The investigation revealed that the accident occurred because the attaching screws on top of the left side leading edge of the horizontal stabilizer were removed and not reattached, leaving the leading edge/de-ice boot assembly secured to the horizontal stabilizer by only the bottom attachment screws.15
6.3.18 The investigation of the Continental Express Flight 2574 accident revealed that the attaching screws on the top of the left side leading edge of the horizontal stabilizer had been removed and had not been reattached, leaving the leading edge/de-ice boot assembly secured to the horizontal stabilizer by only the bottom attachment screws.
6.3.22 The investigation also discovered two previous maintenance actions on the accident aircraft, each of which departed from the approved procedures and involved employees different from those engaged in the de-icing boot replacement.
6.4.5 In the EMB-120 accident, the second shift supervisor who was responsible for the aircraft failed to solicit an end-of-shift verbal report (shift turnover) from the two technicians he assigned to remove both horizontal stabilizer de-ice boots.
It is probable that the accident could have been avoided if this supervisor had solicited a verbal shift turnover from the two technicians assigned to remove the de-ice boots, had passed that information to the third shift supervisor, had completed the maintenance shift turnover form and had ensured that the technicians who had worked on the de-ice boots had filled out the maintenance work cards so that the third shift supervisor could have reviewed them (latent failure and L-L mismatch).
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