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Analysing Operator Error


Having not done a 750 hour Borescope Inspections
for about a year, it is surprising that the
Controller did not feel it necessary to use the 
Task Card to remind himself of the complete
procedure.   A possible for him not having done
this before going to the remote T2 hanger, may
have been that he expected Task Cards and AMM to
be part of the normal workpack.

(Section 2.10.1 from UK Air Accident Investigation 
Branch report into near loss of Boeing 737-400, 
G-OBMM near Daventry on 25 February 1995)


forall t: 
 not consult(controller, task_cards, t) <=
   K_controller(at(task_cards, hangar_t2), t), 
   before(t, 21_40_00)


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