The 787 document is only a Special Bulletin not a final report. It does confirm Buffers suspicion that they put the locking pin into the middle of a pivot (apex) pin. I don't think the final report will say much else. I thought it odd that the locking pin would fit snugly but from the illustrtions in the SB the apex pin bore tapers so it probably felt OK as it went home. Classic 3 bits of cheese (google Reason swiss cheese accident) incident.
1/ Design constrains and poor hazard assesment left apex pin open in middle close to locking pin location.
2/ SB not embodied and (presumably mechanics had not read technical information letter).
3/ Mechanics did not get a step ladder so they could see what they were doing properly rather the reaching at arms length and feeing for a hole with the end of pin.
There would have been a lot more injuries if they had been loadng Pax at the time.
It annoys me somewhat when discussing mitigation for safety issues and someone tries to use "it will only be done by skilled trained personell" that is not a reasonable defence.
Robert G8RPI
This is my personal opinion and may not reflect that of my employer.
Edited By Robert Atkinson 2 on 16/07/2021 12:02:07