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Printed page 2. PDF page 9.
contributed to the loss of the windscreen:- A safety critical task, not identified as a 'Vital Point', was undertaken by one individual who also carried total responsibility for the quality achieved and the installation was not tested until the aircraftOpen official document at PDF page 9Aircraft Accident Report 1/92: BAC One-Eleven G-BJRT, 10 June 1990
Printed page 17. PDF page 24.
adjustment. In September 1985 BCARs introduced a requirement for duplicate inspections of "Vital Points', which are defined as any point on an aircraft at which a single mal-assembly could lead to catastrophe, i.e. result in loss of the aircraft and/orOpen official document at PDF page 24Aircraft Accident Report 1/92: BAC One-Eleven G-BJRT, 10 June 1990
Printed page 42. PDF page 49.
but was fitted from the outside. e. The windscreen replacement was not designated a "Vital Point' task, therefore no duplicate inspection was required. f. The Shift Maintenance Manager was the only person whose work on the night shift was notOpen official document at PDF page 49Aircraft Accident Report 1/92: BAC One-Eleven G-BJRT, 10 June 1990
Printed page 43. PDF page 50.
2.2.4 2.2.4.1 2.2.4.2 "Vital Point' and consequently no duplicate inspection was called for and none took place, nor was the work of the Shift Maintenance Manager subject to review by another manager. Thus thOpen official document at PDF page 50Aircraft Accident Report 1/92: BAC One-Eleven G-BJRT, 10 June 1990
Printed page 49. PDF page 56.
processes detailed in it are complex, apart from work on flying and engine controls, and ‘Vital Points' (if defined) an authorised engineer may work on an aircraft unsupervised and unchecked. In spite of the itemised nature of the procedures detailedOpen official document at PDF page 56Aircraft Accident Report 1/92: BAC One-Eleven G-BJRT, 10 June 1990
Printed page 53. PDF page 60.
of detecting the error, the task of the windscreen installation was not designated a ‘Vital Point' and consequently no duplicate inspection was called for and none took place. The work of the Shift Maintenance Manager was not subject to reviewOpen official document at PDF page 60Aircraft Accident Report 1/92: BAC One-Eleven G-BJRT, 10 June 1990