4. Federal Aviation
Administration
Failure to Follow Procedures
FT-4
Objective
Provide awareness of risk associated with
failing to follow procedures and prevention of
contributing or causal factors so as to reduce
maintenance errors.
6. Federal Aviation
Administration
Failure to Follow Procedures
FT-6
Mental Limits: Disassembly
There is only one way to disassemble the nuts, but over 40,000 wrong
ways to reassemble.
Your task here is to remove these nuts from the bolt. Now reassemble
them back into alphabetical order.
9. Federal Aviation
Administration
Failure to Follow Procedures
FT-9
PERFORMANCE STANDARDS
• 14 CFR Part 43.13(a) requires all maintenance
to be performed using the methods,
techniques and practices prescribed in the
current manufacturer’s maintenance manual.
• Tools and equipment and test apparatus in
accordance with accepted industry practice
and the manufacturer.
10. Federal Aviation
Administration
Failure to Follow Procedures
FT-10
43.13 (continued)
• 14 CFR Part FAR 43.13(b) Each person
maintaining an aircraft shall do that work in
such a manner and use the materials of
such a quality, that the condition of the
aircraft, airframe, aircraft engine, propeller,
or appliance worked on will be at least equal
to it’s original or properly altered
condition…
11. Federal Aviation
Administration
Failure to Follow Procedures
FT-11
43.13 (continued)
14 CFR Part FAR.43.13(c) A Part 121,127,129,
or 135 Air Carriers operating manual and
operation specifications are considered an
acceptable means of complying with this
section.
12. Federal Aviation
Administration
Failure to Follow Procedures
(c) ANNUAL AND 100 HOUR INSPECTIONS.
(1) EACH PERSON PERFORMING AN ANNUAL OR 100 HOUR
INSPECTION SHALL USE A CHECKLIST… THAT INCLUDES THE
SCOPE AND DETAIL OF APPENDIX D OF (FAR PART 43).
(2) BEFORE APPROVING A RECIPROCATING ENGINE POWERED
AIRCRAFT FOR RETURN TO SERVICE AFTER AN ANNUAL OR 100
HOUR, EACH PERSON SHALL RUN THE ENGINE(S) TO
DETERMINE SATISFACTORY PERFORMANCE OF:
(i) POWER OUTPUT (STATIC AND IDLE R.P.M.)
(ii) MAGNETOS
(iii) FUEL AND OIL PRESSURE
(iv) CYLINDER AND OIL TEMPERATURE
ADDITIONAL PERFORMANCE RULES FOR INSPECTIONS
14 CFR Part 43.15
13. Federal Aviation
Administration
Failure to Follow Procedures
(3) BEFORE APPROVING A TURBINE ENGINE POWERED AIRCRAFT
FOR RETURN TO SERVICE AFTER AN ANNUAL OR 100 HOUR,
EACH PERSON SHALL RUN THE ENGINE(S) TO CHECK
SATISFACTORY PERFORMANCE IAW THE MANUFACTURER’S
RECOMMENDATIONS.
ADDITIONAL PERFORMANCE RULES FOR INSPECTIONS
14 CFR Part 43.15 (cont)
14. Federal Aviation
Administration
Failure to Follow Procedures
FT-14
14 CFR Part 43.13 addresses?
1. Industry approved tools and when we
have to use them.
2. Methods, techniques and practices.
3. Performance standards.
Question
15. Federal Aviation
Administration
Failure to Follow Procedures
FT-15
Additional procedures may include:
• Service Bulletins
• Service Instructions
• Airworthiness Directives
• Type Certificate Data Sheets
• Supplemental Type Certificates
• Instructions for Continued Airworthiness
• Advisory Circulars (AC 43.13-1B etc.)
• Inspection procedures (Appendix D, Part 43)
• Air Carrier Procedures
16. Federal Aviation
Administration
Failure to Follow Procedures
FT-16
Some Statistics to Ponder
• The Number one reason for FAA violations
being filed on AMTs is “Failure to Follow
Procedures”
• The NTSB has identified “Failure to Follow
Procedures” as a leading factor in aviation
accidents where maintenance was involved.
17. Federal Aviation
Administration
Failure to Follow Procedures
FT-17
National Aircraft Accidents Statistics
• The number of all accidents where
maintenance errors were the
cause or a contributing factor are
increasing each year.
18. Federal Aviation
Administration
Failure to Follow Procedures
FT-18
Maintenance Related AccidentsMaintenance Related Accidents
Maintenance related accidents are a
result of causal factors that include
failure to follow procedures.
The failure to follow procedures can result
in the death, injury, occupational illness of
persons or damage to or loss of equipment,
property or damage to the environment
19. Federal Aviation
Administration
Failure to Follow Procedures
FT-19
Aviation AccidentsAviation Accidents
Human CausesHuman Causes
Machine CausesMachine Causes
1903 Today
TIME
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0%
20. Federal Aviation
Administration
Failure to Follow Procedures
FT-20
Human ErrorHuman Error
Human error is the unintentional act of
performing a task incorrectly which
can potentially degrade the system.
21. Federal Aviation
Administration
Failure to Follow Procedures
FT-21
Human ErrorHuman Error
Three types of human error:
– Error of omission
• Not performing an act or behavior — just didn’t do it
– Error of commission
• Performing a different act or behavior - not the norm
– Extraneous error
• Performing an additional action - change from the norm
22. Federal Aviation
Administration
Failure to Follow Procedures
FT-22
Human ErrorHuman Error
Levels of consequence of human error
– Little or no effect
– Physical damage to equipment
– Personal injury
– Catastrophic event
23. Federal Aviation
Administration
Failure to Follow Procedures
FT-23
Failure to Follow procedures are results of
human errors related to:
• Lack of Knowledge
• Lack of Current Technical Data
• Lack of Experience
• Lack of Proper tools and equipment
• Lack of Training
• Lack of Proper preparation
• Lack of Resources
• Failure to take Safety Precautions
• Failure to research FAR’s
24. Federal Aviation
Administration
Failure to Follow Procedures
FT-24
Chain of EventsChain of Events
Chain of Events
– Multiple contributing factors can lead to an
accident.
Accident
Training
Current Data
Supervision
Failure to follow
procedures
25. Federal Aviation
Administration
Failure to Follow Procedures
FT-25
Break the Chain of EventsBreak the Chain of Events
If we can break the chain,
the accident doesn’t happen
Preventing any event could prevent the accidentPreventing any event could prevent the accident
management
maintenance
crew
26. Federal Aviation
Administration
Failure to Follow Procedures
FT-26
Preventive MeasurePreventive Measure
Break the chain of events by
employing the performance
standards set forth by regulatory,
manufacturer’s and operator’s
procedures.
27. Federal Aviation
Administration
Failure to Follow Procedures
FT-27
Safety NetsSafety Nets
Employing the mechanism of
performance standards to
break the chain of events.
What Safety Nets Can we put in
place to prevent a failure to follow
procedures?
28. Federal Aviation
Administration
Failure to Follow Procedures
FT-28
Safety Nets
• Perform the task to best of your abilities
• Perform the task to be equal to it’s original
condition
• Perform the task in accordance with
appropriate data
• Perform the task using methods,
techniques and practices acceptable to
industry and the administrator
• Perform the task without pressure, stress,
and distractions
29. Federal Aviation
Administration
Failure to Follow Procedures
FT-29
Safety Nets (cont.)
• Re-inspect or have someone inspect your
work before return to service
• Make the proper record entries for the work
performed
• Perform the operational checks in
accordance with the manufacturer’s or air
carrier’s approved procedures
30. Federal Aviation
Administration
Failure to Follow Procedures
FT-30
Motivation
• Your motivation is to do the job to the best
of your ability
• Self Regulation - Integrity
• Lower your risk - liability
• Pride in ownership – your character
• Professionalism - Responsibility
• Good for the company - profit and loss
• It’s just good business - Public Confidence
• Bottom line - Safety
33. Federal Aviation
Administration
Failure to Follow Procedures
FT-33
Mental Limits: Reassembly
Prevention of Failure to Follow Procedures - Recognizing and managing
contributing factors - Breaking the Chain of Events – Mitigating
maintenance related accidents in aviation
Your task is to reinstall these nuts on the bolt, placing them back into
alphabetical order based on the elements of this presentation.
34. Federal Aviation
Administration
Failure to Follow Procedures
FT-34
Question Number 1 (Nut A)
• What Federal Aviation Regulation identifies
the Performance Rules for persons
performing maintenance?
• 14 CFR Part 43.13
35. Federal Aviation
Administration
Failure to Follow Procedures
FT-35
Question Number 2 (Nut B)
• Performance Rules contained in 14 CFR
Part 43.13 apply to what functions or tasks?
• Maintenance, Alteration, or Preventive
Maintenance
36. Federal Aviation
Administration
Failure to Follow Procedures
FT-36
Question Number 3 (Nut C)
• Additional Performance Rules are found in
what Federal Aviation Regulation?
• Answer: 14 CFR Part 43.15
• Additional Performance Rules apply to what
tasks or functions?
• Answer: Inspection
37. Federal Aviation
Administration
Failure to Follow Procedures
FT-37
Question # 4 (Nut D)
• What is the number 1 maintenance error
that results in or contributes to aircraft
accidents?
• Answer: Failure to Follow Procedures
• National aircraft accident statistics
indicate that maintenance error caused
accident are increasing, True or False?
• Answer: True
38. Federal Aviation
Administration
Failure to Follow Procedures
FT-38
Question number 5 (Nut E)
• The Chain of events that can lead to an
accident . What four examples of those
contributing factors have we looked at
today?
1.Training
2.Current Data
3.Supervision
4.Failure to Follow Procedures
39. Federal Aviation
Administration
Failure to Follow Procedures
FT-39
Question 6 (Nut F)
• What Safety Nets can we put in place to
prevent a failure to follow procedures?
1. Perform the task to the best of my abilities
2. Perform the task to be equal to its original
condition
3. Perform the task IAW appropriate data
4. Perform the task using acceptable
techniques, methods and practices
40. Federal Aviation
Administration
Failure to Follow Procedures
FT-40
Question number 7 (Nut G)
• Safety Motivation to perform your job to
the best of you ability must include what
practices and or traits?
1. Self regulation – Integrity
2. Lower your risk – Liability
3. Pride in ownership – Your character
4. Professionalism – Responsibility
5. Bottom line - Safety
41. Federal Aviation
Administration
Failure to Follow Procedures
FT-41
Final Question – Number 8 (Nut H)
• What safety tool can
you employ to prevent
or mitigate the
likelihood of a failure
to follow procedures?
42. Federal Aviation
Administration
Failure to Follow Procedures
FT-42
Prevention of Failure to Follow
Procedures
Performance
Rules
43.1343.13
Maintenance
Alterationpreventive
Maintenance
43.15
Additional
Performance Rules
Inspection
12%ofAccidents
Chain of
Events
Safety
Nets
Safety
Motivation
Safety Tools
44. Federal Aviation
Administration
Failure to Follow Procedures
FT-44
Conclusion
• Any Questions?
• www.FAASafety.gov
• GA Awards Program
• AMT Awards Program
• Give us your Feedback
Number 2013/03/15-033 (l) PP Presentation Information: Original Author: Richard Mileham, Great Lakes FAASTeam; POC Phil Randall, AFS-850, Office 366-369,3948; Revision 1, 03/15/2013, by Ali Ispahany, AFS-850.
This Presentation emphasizes the number 1 national maintenance related error causal/contributing factor in aviation accidents, " Failure to Follow Procedures”. This presentation is directed toward all maintenance personnel ( Certificated and Non -Certificated). This Presentation will cover: failure to follow procedures; causal factors; maintenance errors and introduction to faasafety.gov.
Review bullets and let them know what will be expected in this block. FAASTeam introduction FAASafety.gov registration Regulation Overview Accident Scenario Maintenance Error Findings Chain of Events Safety Nets Safety Motivation Safety Tools
The objective of this presentation is to provide a basic awareness of risk factors associated with failing to follow procedures. Additionally we will discuss prevention of contributing or causal factors so as to reduce maintenance errors as well ultimately reducing aviation accidents and incidents.
On behalf of the FAASTeam we hope you will take the opportunity to register at FAASAFETY.GOV and take advantage of the resources available to you.
Human beings have mental or cognitive limits. Many tasks can push those limits. As an example, your task here is to remove these nuts from the bolt. Now reassemble them back into alphabetical order. There is only one way to disassemble the nuts, but over 40,000 wrong ways to reassemble them.
Lets Get Started- But before we do!
Self Explanatory
Whether you are a certificated mechanic or not you still have to perform to the same standards. You MUST have CURRENT technical data, and tools and equipment as specified by the manufacturer. If the manufacturer states in the maintenance manual that you need a tool P/N 746385 you must have it to perform that task.
You must perform your work to the same industry and FAA standards as the next person. FAR 43.13(b) states that “Each person maintaining an aircraft shall do that work in such a manner and use the materials of such a quality, that the condition of the aircraft, airframe, aircraft engine, propeller, or appliance worked on will be at least equal to it’s original or properly altered condition (with regard to aerodynamic function, structural strength, resistance to vibration and deterioration, and other qualities affecting airworthiness).”
This means that all persons complying with FAR Part 43 must also comply with the operator’s operating manual or procedures outlined in the operations specifications. FAR.43.13(c) A Part 121, 127, 129, or 135 Air Carriers operating manual and operation specifications are considered an acceptable means of complying with this section.
Here we see the regulation that specifies the “Additional” performance rules for “INSPECTIONS”. This rule requires you use a checklist for the type of inspections being performed. Not only should you use the checklist but be very thorough as well. Go beyond the item your inspecting and use every tactic and tool to complete the evaluation.
The regulations require you to perform certain tasks in accordance with the manufacturer’s recommendation. Each manufacturer’s specifications vary and may further vary for that particular engine as per the serial number of the engine you are running. Ensure you have the documents for the job/task at hand. Verify you have and current revision as well as understand all the steps in the procedure you are about to do.
Read the question and answers. Ask for correct response. Answer: All the above Discuss further is necessary
You should be aware of these other sources of information which may affect the performance of your work or procedures you are following. All of these may contain information, whether mandatory or not, about the task you are doing on a particular aircraft. Our strong recommendation is to check them out before the task rather than after “approving for return to service”. Service bulletins Service instructions Airworthiness Directives Type Certificated Data Sheets Supplemental Type Certificates Instructions for Continued Airworthiness Advisory Circulars (AC43.13.1B) ect. Inspection procedures (Appendix D, Part 43) Air Carrier Procedures
Lets look at two specific Statistics. The first from the FAA regarding violations. Read and discuss Then look at what the NTSB investigations reveal. Note: The presenter may want to add additional comments on local statistics!
The slide content says it all!
Any of these factors add up to create an accident. Sometimes all it takes is one, but most frequently many factors will contribute to an error and several errors may be involved in the accident. Time permitting elaborate on any one of these factors.
If we look at aviation then and now, we can see that systems are much safer than they were for Orville & Wilbur Wright. As the reliability of the equipment has improved in the last century, the human element assumed a larger role in the causes of aviation accidents. Due to advancements made in technology and manufacturing the shift has been from mechanical failures to human errors.
So lets take a closer look at what we mean by human error. Human error involves usually unintentional acts (intentional acts are called sabotage - that’s completely different) some task or action is performed incorrectly. Usually, we are concerned about those that can degrade the system. Many errors may not result in any bad consequence. But they may increase the probability of a bad consequence. For example, you may drop a wrench and it hits the ground (no bad consequence), but there was a chance that it could have: - hit someone’s foot. What is this called? (on-the-job injury) - hit the plane. What is this called? (ground damage), or - been left in the aircraft only to jam up pulleys, control arms etc.
There are different types of human error. We may forget to do a task. Frequently this happens when we are interrupted or distracted by a new task or problem that comes up. We may do something incorrectly. For example hitting the up-button instead of the down-button. We may do something extra even when it is not called for this time.
Any of these errors can have different consequences, from no effect to a major catastrophic event. For example, rotating the propeller while working on the aircraft when the magneto is live could surely cause injury or even kill.
Failure to Follow procedures are results of human errors related to: Lack of Knowledge Lack of Current Technical Data Lack of Experience Lack of Proper tools and equipment Lack of Training Lack of Proper preparation Lack of Resources Failure to take Safety Precautions Failure to research FAR’s Discuss how each of these can effect the outcome of our assigned task
In every accident there are a series of events that link together to form a chain. We call this a chain of events. Discuss the four contributing factors in the chain. Note: There is a very good video that Boeing Aircraft produced that addresses this.
IF we can break the chain at any link, the accident doesn’t happen. Harry Truman had a sign on his desk that said “the buck stops here”. In maintenance we need the same philosophy. If we can break the chain at the maintenance level, the accident doesn’t happen.
Break the chain of events by complying with the performance standards set forth by regulatory, manufacturer’s and operator’s procedures.
Safety nets are mechanisms that you can put into place to help break the chain and insure an error doesn’t result in an accident. All of the factors that we talked about can be designed to prevent errors, just as they can help create errors if they aren’t conducive to human performance. What are some safety nets that you can put into place to prevent the errors we’ve talked about?
Safety Nets Perform task to best of your abilities Perform the task to be equal to it’s original condition Perform the task in accordance with appropriate data Perform the task using methods, techniques and practices acceptable to industry and the administrator Perform the task without pressures, stress and distractions
Re-inspect or have someone inspect your work before return to service Make the proper record entries for the work performed Perform the operational checks in accordance with the manufacturer’s or air carrier’s approved procedures
Motivation to follow procedures will be to: Do the job to the best of your ability Complywith the required regulations Be safety conscious Take pride in ownership Be a professional Its good for the company Its just good business
This is probably the least expensive but most useful tool you can use in your profession! It is the Personal Minimums Checklist. This is the “Before the Task” actions. Discuss the steps DON”T JUST KEEP THIS IN YOUR TOOLBOX!!...............USE IT!
This is “After the Task” actions. Discuss the steps Again………………….DON’T JUST KEEP IT IN YOUR TOOLBOX………………. USE IT!
This is an opportunity to evaluate the effectiveness of your training. You will be mentally challenged over the next several slides to correctly reassemble the nuts, by providing answers to specific questions. Each nut relates to the following topics we discussed in this presentation: regulatory overview, accident scenario, maintenance error, chain of events, safety nets, safety motivation and safety tools. Keep this bolt image in your mind as we proceed.
Nut A on the bolt represents the “ minimum standard of performance ” that maintenance personnel are responsible and accountable for when performing maintenance. ( 15 seconds to write your answer). The correct answer is FAR 43.13
Nut B on the bolt represents the functions or tasks that FAR 43.13 applies to. ( 15 seconds to write your answer) Answer: 43.13 (a), (b) and (c) speak directly to the performance of Maintenance, Alteration and Preventive Maintenance and the methods techniques and practices that must be used during any of the associated tasks.
(This is a two part question). Nut 3 on the bolt represents the minimum standard of performance that maintenance personnel are accountable for when performing what function or task. ( 15 seconds to write your answer) The correct answers are FAR 43.15 and Inspection
(This is a two part question) Nut D on the bolt represents the national statistics of aircraft accidents resulting from maintenance error. Maintenance caused accidents are increasing ? ( 20 seconds to write your answer)
This is a rhetorical question where the instructor simply reads the question and provides the answers. Nut E on the bolt represents “Chain of Events”
Ask the question to stimulate answer and discussion. Slides 28-29 for all the Safety Nets Nut F on the bolt represents eight safety nets that can be employed to prevent a failure to follow procedures including employing the mechanisms of performance rules to break the chain of events
Nut F on the bolt represents at least eight practices and or traits of motivations for reducing failure to follow procedure maintenance errors. Name at least three that we have discussed today. (30 seconds to write your answer)
Nut H on the bolt represents a safety tool designed to prevent failure to follow procedure events. Name that tool. ( 15 seconds to write your answer). The Personal Minimums Checklist outlines steps to use before and after a maintenance or inspection task that will, if it is used, reduce maintenance errors.
Congratulations on your successful and correct reassembly of the nuts on the bolt. You are on a path to preventing a failure to follow procedures!
Review the summary. The FAA Safety Team (FAASTeam) is available for information and your training needs. Please take the opportunity to register at FAASafety.gov Familiarize yourself with the regulations and understand your performance standards associated to them. Break the chain of events when you see or know something is not correct. Establish Safety nets to assure the same errors do not happen again. Realize the safety motivation is be a part of the “Safety Culture” to prevent accidents. Use the safety tools as memory joggers to prevent failure to follow procedures.
Address questions. Promote and express the benefits and features of FAASafety.gov. Encourage them to register Mention the GA Awards Program Promote AMT Awards Program Feedback acceptable via verbal, phone, e-mail or our QMS Feedback link: Provide current link