The document discusses potential issues with incomplete, misleading, or unclear aircraft maintenance procedures. It notes that one misleading procedure led to five aircraft accidents. It advises maintenance technicians to carefully review current procedures and compare them to related documents like the Illustrated Parts Catalog, Service Instructions, and Special Airworthiness Information Bulletins to validate procedures before performing maintenance. It also provides guidance on what technicians should do if they find any conflicts or issues with procedures.
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Objective
• Caution you that maintenance procedures
may be incomplete, misleading, or unclear.
• How to minimize using incomplete,
misleading, or unclear procedures.
• What to do if you become aware of
incomplete, misleading, or unclear
procedures
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Sometimes Following Procedures
Leads To Improper Installation
• One Misleading Procedure Leads To Five
Aircraft Accidents
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Scenario Summary
• Prop Governor Installed In Accordance With:
– Maintenance Manual “ONLY”
– Read related documents to affirm procedure
• Illustrated Parts Catalog (IPC)
• Service Instruction (SI)
• Special Airworthiness Information Bulletin (SAIB)
Prior to Performing Maintenance ---- Carefully review
the current applicable maintenance instructions.
Then compare to related information.
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Regulatory Requirement
• Sec. 43.13
Performance rules (general).
(a) Each person performing maintenance, alteration, or preventive
maintenance on an aircraft, engine, propeller, or appliance shall use
the methods, techniques, and practices prescribed in the current
manufacturer's maintenance manual or Instructions for Continued
Airworthiness prepared by its manufacturer, or other methods,
techniques, and practices acceptable to the Administrator, except as
noted in Sec. 43.16. He shall use the tools, equipment, and test
apparatus necessary to assure completion of the work in accordance
with accepted industry practices. If special equipment or test
apparatus is recommended by the manufacturer involved, he must
use that equipment or apparatus or its equivalent acceptable to the
Administrator.
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What should I…the AMT… do?
• Carefully read maintenance procedures.
• Determine if procedures are complete
• Research available data to validate the
procedure.
– IPC, SAIB, Service Letters, Overhaul Manual etc.
• www.faasafety.gov has links to many resources
• If conflicts noted-Stop, Report, and Discuss
– Contact local FAASTeam FPM or FSDO ASI
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Summary
• Be wary maintenance procedures may be
incomplete or misleading.
• Know there is related maintenance
information that can be used to verify
maintenance procedures
• There are actions you can pursue to remedy
Editor's Notes
2012/7/26-013 (I) PP T Organizational Culture – Confusing & Unclear Procedures. Author: Roy Hutto, Western Pacific FAASTeam Program Manager; POC: AFS-850, Phil Randall, Greensboro FSDO, Office 336-369-3948; Revision 1, dated 11-8-2012 by Pete Wilhelmson, AFS-850.
Emphasize the objectives.
A recent accident investigation (NTSB WPR12LA108) of a Mooney M20J concluded the accident was due to engine failure caused by a leaking propeller governor gasket. The installation of a single gasket on the propeller governor pad allowed oil to leak. This condition was attributed to at least 5 accidents due in flight engine failures. Interestingly, it was determined that the manufacture’s installation procedures were followed……………….so what when wrong!?
It was affirmed a single gasket was installed in accordance with the Mooney M20J maintenance manual, paragraph 61-20-10. Read Step 3. Then discuss what it implies (i.e. installation of a single gasket). A person could easily assume only one gasket is required. Using these instructions alone could result in improper installation. Suppose you had removed the propeller governor for some maintenance issue in the field. You observe only one gasket upon removal. You check the maintenance instructions and read “install new gasket”. This infers only one gasket. WOW! They match! It would be very easy for any AMT to feel confident the previous installation and the instructions are correct. Consequently, you all should be wary of assuming a previous installation has been done correctly. Ask participants if they have experienced/detected misleading or vague instructions during their careers. If some respond, ask them what they did to elevate or rectify the problem. Advise that some helpful suggestions will be provided later in this presentation.
Recall the procedure described in step three of the M20J maintenance manual. It states “install new gasket”. Note here, the Illustrated Parts Catalog shows a disparity from what Step 3 is instructing. This illustration depicts three components between the governor and mounting pad (i.e. a plate between two gaskets). Checking the Illustrated Parts Catalog (IPC) can help validate an installation procedure. Emphasize that the IPC is not installation instructions and should not be used in that capacity. It may, however, as a reference, identify disparities which should cause AMT’s to STOP!! REPORT and/or PERFORM further investigation of the disparity. The point to emphasize here is that AMT’s won’t detect disparities unless they routinely start cross checking the maintenance procedures with other related information such as the IPC, Manufacturer Service Letters, Bulletins, FAA sources etc.
Going beyond the IPC, further investigation should take the AMT to other available sources. Interestingly, the FAA issued a Special Airworthiness Information Bulletin (SAIB) addressing this specific maintenance procedure. The SAIB was issued in November 2005. It describes proper installation as well as suggests (see red bordered area) more than one document may be necessary to affirm a more complete installation process. The SAIB not only refers to the Illustrated Parts Catalog but also the Lycoming Overhaul Manual and Lycoming Service Instruction No. 1438A. Ask participants if they readily research SAIB’s as other sources of information when performing maintenance. Ask if they know where or how to retrieve an SAIB. Ask them to share. Advise that some research avenues will be provided later.
Here is a view of the Lycoming Engine Overhaul parts catalog. It clearly shows a plate is sandwiched between two gaskets offering more important information regarding gasket installation. Of course, doing routine field maintenance would not normally prompt you to review an engine overhaul manual. However, it is brought up here to inform that it can provide a valuable cross reference during your research. You now should clearly be alert to thoroughly do your “homework” before performing maintenance. Verify and validate maintenance instructions and remember never trust that a previous installation was done correctly.
In this scenario, following the maintenance instructions only, without researching additional related documents, led to an undesirable outcome. We all know the maintenance instructions must be followed when performing maintenance. We are taught this in maintenance school, it is re-emphasized in subsequent recurrent training, and it is required by regulation. Ask if anyone knows which regulation addresses this. It is 14 CFR Part 43.
More specifically, Section 43.13 (a) directs the use of current manufacturer’s manuals or Instructions for Continued Airworthiness (ICA). Review the regulation with the participants. Note the rule states the “methods, techniques, or practices” prescribed by manufacturer….but doesn’t affirm how rudimentary or comprehensive the methods, techniques, or practices may be. So what should you do? Ask for comments then go to next slide. Be familiar with 43.16 in case someone asks.
Although current manufacturers procedures must be followed, you can see that the procedures may not provide complete comprehensive instructions. If in doubt, you should consult some or all of the recommended resources listed. How do you access these additional documents. How many here know about www.faasafety.gov? How many are registered on the site? Discuss the website, the “Maintenance Hanger”, and available resource links. Recommend they also seek assistance from local FPM or ASI for further guidance or means to elevate the problem. Discuss some FAA avenues, Malfunction & Defect Report, Safety Recommendations, etc.
Reiterate briefly each of the bullet items……………….add information if desired.