The document provides summaries of four case studies from aircraft accident investigations conducted by the NTSB. The first case study describes a Cirrus SR22 that lost engine power due to a fuel line cap not being properly installed during maintenance. The second case study describes an AS350 helicopter that crashed after its servo disconnected in flight due to improper maintenance of a lock nut. The third case study examines a Piper PA-22 that lost oil pressure due to an improperly modified breather tube. The fourth case study details a Diamond DA-40 that experienced a propeller malfunction caused by an improperly assembled governor during manufacturing.
This document summarizes key points from a presentation on Process Safety Management. It identifies several frequently cited PSM violations including issues with P&IDs, process safety information, compliance with recognized and generally accepted good engineering practices, process hazard analyses, operating procedures, mechanical integrity programs, management of change procedures, incident investigations, and compliance audits. It also discusses trends in PSM violations and comments from investigators about common deficiencies they observe.
Establishing exclusion zones • Personnel in area • Unauthorized access to test area;
• Workers struck by flying materials;
• Worker struck by High pressure water release;
Signage to test area • Personnel in area • Unauthorized access to test area;
• Inadequate signage to test area;
Pressure testing • High pressure to pipework; • Uncontrolled Stored Energy release;
• Rupture/failure in Pipe lines during testing;
• Valve/connection failure;
• Instrument failure resulting in system over-pressurization;
• End caps/plugs ejecting under high pressure;
• Weld/seal/fitting failure, flying objects;
• High pressure water/air injection.
Emergency procedures • High pressure to pipework; • Emergency procedures not briefed to task workers;
• Poor response in the event of an emergency;
Re-testing in the event of failure • Re-testing with high pressure • Injury due to uncontrolled testing;
• Worker injury due to working on pressurized system;
• Injury due to failure to ensure adequate pre-checks undertaken;
Work in confined spaces present a number of unseen risks & can be extremely hazardous. This presentation details all of the precautions required to reduce these risks to an acceptable level and allow work to be carried out safely.
The candidate is applying for a position requiring maintenance, engineering and coaching experience. They have extensive experience in the oil and gas industry holding various roles including as an instrument technician, engineer, and leader. They believe their interpersonal skills and experience working in teams and tackling challenges will make them a strong fit for the role.
Nfpa process safety and osha, seven keys to surviving a chem nep audivtsiri
This document discusses the OSHA National Emphasis Program (NEP) for process safety management (PSM) inspections at chemical facilities. It provides background on NEPs and compares the Refinery NEP and Chemical NEP. The Chemical NEP aims to conduct fewer but more targeted inspections. It focuses on PSM, lockout/tagout, and other standards. Common violations found include deficiencies in process safety information, process hazard analyses, mechanical integrity programs, operating procedures, and emergency response. The document lists some examples of typical violations cited under the PSM standard.
This is seminar report of ageing of aircraft.this useful for those student who want to give seminar on designing area of aircraft.In this report you will find brief introduction of ageing of aircraft.
NTSB Board Member, Earl Weener Ph. D, discusses why all pilots need to focus on their personal flying habits.
This presentation is part of the release of the NTSB General Aviation Safety Series at the FAA Safety forums during Sun 'N Fun 2012 in Lakeland FL.
PetroSync - Pre-Commissioning, Commissioning and Start-UpPetroSync
Successful commissioning new or starting-up revised equipment and systems requires meticulous planning, organizing and controlling. Careful methodical, detailed planning – early – is the key to the success of any commissioning.
This document summarizes key points from a presentation on Process Safety Management. It identifies several frequently cited PSM violations including issues with P&IDs, process safety information, compliance with recognized and generally accepted good engineering practices, process hazard analyses, operating procedures, mechanical integrity programs, management of change procedures, incident investigations, and compliance audits. It also discusses trends in PSM violations and comments from investigators about common deficiencies they observe.
Establishing exclusion zones • Personnel in area • Unauthorized access to test area;
• Workers struck by flying materials;
• Worker struck by High pressure water release;
Signage to test area • Personnel in area • Unauthorized access to test area;
• Inadequate signage to test area;
Pressure testing • High pressure to pipework; • Uncontrolled Stored Energy release;
• Rupture/failure in Pipe lines during testing;
• Valve/connection failure;
• Instrument failure resulting in system over-pressurization;
• End caps/plugs ejecting under high pressure;
• Weld/seal/fitting failure, flying objects;
• High pressure water/air injection.
Emergency procedures • High pressure to pipework; • Emergency procedures not briefed to task workers;
• Poor response in the event of an emergency;
Re-testing in the event of failure • Re-testing with high pressure • Injury due to uncontrolled testing;
• Worker injury due to working on pressurized system;
• Injury due to failure to ensure adequate pre-checks undertaken;
Work in confined spaces present a number of unseen risks & can be extremely hazardous. This presentation details all of the precautions required to reduce these risks to an acceptable level and allow work to be carried out safely.
The candidate is applying for a position requiring maintenance, engineering and coaching experience. They have extensive experience in the oil and gas industry holding various roles including as an instrument technician, engineer, and leader. They believe their interpersonal skills and experience working in teams and tackling challenges will make them a strong fit for the role.
Nfpa process safety and osha, seven keys to surviving a chem nep audivtsiri
This document discusses the OSHA National Emphasis Program (NEP) for process safety management (PSM) inspections at chemical facilities. It provides background on NEPs and compares the Refinery NEP and Chemical NEP. The Chemical NEP aims to conduct fewer but more targeted inspections. It focuses on PSM, lockout/tagout, and other standards. Common violations found include deficiencies in process safety information, process hazard analyses, mechanical integrity programs, operating procedures, and emergency response. The document lists some examples of typical violations cited under the PSM standard.
This is seminar report of ageing of aircraft.this useful for those student who want to give seminar on designing area of aircraft.In this report you will find brief introduction of ageing of aircraft.
NTSB Board Member, Earl Weener Ph. D, discusses why all pilots need to focus on their personal flying habits.
This presentation is part of the release of the NTSB General Aviation Safety Series at the FAA Safety forums during Sun 'N Fun 2012 in Lakeland FL.
PetroSync - Pre-Commissioning, Commissioning and Start-UpPetroSync
Successful commissioning new or starting-up revised equipment and systems requires meticulous planning, organizing and controlling. Careful methodical, detailed planning – early – is the key to the success of any commissioning.
World Class Manufacturing:Plant Start Up and Commissioning Procedure HIMADRI BANERJI
The document provides an overview of plant commissioning and start-up procedures. It discusses the commissioning process which includes preparation and planning, mechanical completion and integrity checking, pre-commissioning and operational testing, start-up and initial operation, performance and acceptance testing, and post-commissioning. It then goes into more detail on specific aspects of the commissioning process such as developing start-up procedures, commissioning utilities, pressure testing, cleaning and flushing, and pre-commissioning operational testing.
The document discusses several incidents involving software errors that led to accidents, including a dropped cable that killed a dockworker due to inconsistent speed readings by sensors, injuries caused by erratic behavior of elevators and bales from an outdated software patch, and a generator trip caused by an unofficial software change made by a vendor. It emphasizes the importance of software configuration management, requirements gathering, failure mode analysis, and change control to prevent such incidents.
Airside Observation Statement -24.12.2015.xlsx(A).xlsx01Andrew Louis
This document provides an airside observation statement from Andrew Louis, assessing safety compliance at various airport operations from December 9-24, 2015. Key findings include:
- Most departments scored satisfactory or above average in equipment positioning, servicing, and compliance with safety procedures. Ramp and traffic operations required attention regarding equipment usage.
- A total of 28 events were observed and assessed across departments, with most scoring satisfactorily in safety standards.
- For ramp/line base operations, most bays scored satisfactorily except for some issues with equipment positioning. Cargo apron required attention to equipment positioning.
- No incidents or accidents were reported, though continued compliance with safety reminders and best
Kathryn Rattigan - Cybersecurity & The Commercial Done IndustryARMA International
Drones are increasingly being used for commercial purposes but this brings cybersecurity risks as drones can be vulnerable to cyber attacks. The document discusses regulatory compliance requirements for commercial drone use including FAA's Part 107 rules. It also outlines potential drone uses and privacy/data concerns when collecting information. The document provides tips for mitigating cyber risks to drones such as keeping software updated, encrypting communications, and implementing network security practices.
NTSB Senior Air Safety Investigator, Kristi Dunks, talks about aeronautical decision making when a pilot plans a flight.
This presentation is part of the release of the NTSB General Aviation Safety Series at the FAA Safety forums during Sun 'N Fun 2012 in Lakeland FL.
High-Fidelity Operator Training Simulator for CCGT Implemented Before Plant C...GSE Systems, Inc.
This presentation highlights a project in which a high-fidelity operator training simulator was implemented in a North American combined cycle power plant prior to commissioning.
For more information, go to GSES.com, email info@gses, and follow us on Twitter @GSESystems and at Facebook.com/GSESystems. Thanks for viewing!
110921 commissioning of offshore installationslaithu2908
This document discusses the commissioning process for offshore installations built in yards. It covers the total commissioning activity and defines the key phases of mechanical completion, pre-commissioning and commissioning. Mechanical completion involves verifying construction work is complete according to design. Pre-commissioning verifies functionality and system integration. Commissioning verifies systems are ready for operation. The document provides details on planning, organization and activities for each phase. Estimates suggest 95-105 systems for an FPSO requiring around 135,000-145,000 hours for commissioning, taking around 6 months with a team of 90 people. Addressing issues can help improve estimates over time.
The document provides a resume for Matthew Omavowan Azanor, an Instrument & Control Engineer with over 13 years of experience working on various oil and gas projects in Nigeria, South Korea, the US and Houston for companies like Chevron and Nigeria Agip Oil Company. His experience includes roles in engineering design, construction, commissioning, start-up, and maintenance of electrical, instrumentation and control systems on offshore platforms and FPSOs. He also has qualifications in electrical/electronics engineering and instrumentation and control technologies.
This document provides guidance on field inspections, maintenance, and calibration for hydro-meteorological stations. It describes procedures for inspecting rain gauges, full climatic stations, and checking instrument exposure and observer training. Routine maintenance tasks are outlined for rain gauges, wind instruments, thermometers, evaporimeters, and other equipment. Spare part requirements are listed. Proper maintenance is important to ensure high quality comparable data from the field stations.
This presentation provides an overview of sport pilot flight instruction. It discusses the establishment of the light sport category and sport pilot certificate in 2004. It outlines the aircraft categories that fall under light sport aircraft and the certification processes. It covers the medical requirements, aeronautical experience requirements, privileges and limits of sport pilots compared to private pilots. It discusses who can provide instruction to sport pilots and requirements for flight instructors and sport pilot instructors. It also addresses considerations for transition training when pilots with prior experience move to light sport aircraft.
The 124th Fighter Wing Environmental Management System (EMS) conforms to ISO 14001 standards and manages all environmental programs at the installation. Aspects are activities that can interact with the environment, and impacts are changes to the environment from these aspects. A team identifies the aspects and impacts and determines which could cause significant environmental impact. Leadership annually reviews the aspects and impacts list to determine if any need to be added or reevaluated. The current list from June 2014 identifies various aspects such as air, cultural resources, energy use, hazardous materials and waste, integrated solid waste, toxics, water, and their associated impacts.
The final draft of the Environmental Assessment for the Proposed Temporary Relocation of the 366th Fighter Wing at Gowen Field for a portion of 2015 while runway construction ensues at Mountain Home AFB, Idaho.
NOTICE OF AVAILABILITY, Draft Focused Environmental Assessment (EA) and Draft Finding of No Significant Impact (FONSI) for the Proposed Temporary Relocation of the 366th Fighter Wing (FW), Mountain Home Air Force Base, United States Air Force.
The Idaho Air National Guard invites the public to review and comment on the Draft Focused EA for the Proposed Temporary Relocation of the 366 FW.
Regular inspections of safety critical equipment are needed to maximize safety, ensure reliability, optimize maintenance and provide compliance with standards. The document discusses the inspection services provided by Sparrows Group, including non-destructive testing techniques, lifting equipment examinations, rope access, underwater inspections and dropped object prevention. Sparrows Group has over 40 years of experience in inspection services and strategically placed inspection teams.
This document describes a software solution for sizing, selecting, and generating quotations for safety and pressure relief valves. The software provides guided configuration, integrated calculations, product selection, pricing, and proposal generation capabilities. It aims to streamline the sales process for valve manufacturers and provide a better customer experience.
SPX provides a wide range of aftermarket services for the oil and gas industry from its Aberdeen service center, including field service mobilization, repairs, overhauls, installations, inspections, maintenance, and more. It has experienced engineers available 24/7 to respond to emergencies and aims to support customers' needs to keep critical operations running with minimal downtime. The Aberdeen service center works to seamlessly support offshore field service mobilization from its location in Aberdeen.
This document outlines the requirements for pilots to carry passengers, act as pilot-in-command under instrument flight rules or in reduced visibility, and maintain instrument currency and ratings. It discusses the use of flight simulators, flight training devices, and aviation training devices for completing instrument training and experience requirements. It also provides summaries of various briefing, inspection, and pre-flight requirements for instrument flight.
This document provides an overview and table of contents for guidelines on Process Safety Management (PSM) for ammonia refrigeration facilities. It covers 14 chapters that address the key elements of OSHA's PSM standard, including employee participation, process safety information, process hazard analysis, operating procedures, training, management of change, mechanical integrity, compliance audits, and more. Each chapter provides regulatory context, required elements, explanations, procedures, forms, and customization guidelines for a specific facility.
Kenneth E. Bristow is a United States Navy Senior Chief with over 26 years of experience transitioning to civilian life. He has extensive experience in gas-turbine plants, steam plants, Landing Craft Air Cushions (LCACs), and nuclear steam plants. His qualifications include experience as an Engineering Officer of the Watch, Quality Assurance Supervisor, program manager, and facilities manager supervising over 125 personnel. He is proficient in Microsoft Office and has experience building websites. He is looking for a position utilizing his engineering and management experience in the Hampton Roads, Virginia area.
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.
This document provides an overview of a Safety Management System (SMS) as used by the Federal Aviation Administration (FAA). It discusses the four main components or "pillars" of an SMS: policy, safety risk management, safety assurance, and safety promotion. It also outlines the workflows for safety risk management and safety assurance. Key aspects of an SMS include identifying hazards, controlling risks, providing assurance that risk controls are effective, and promoting a positive safety culture. An SMS provides a systematic approach to these aspects of safety management.
The document discusses safety promotion, which involves training and knowledge sharing activities to support the implementation of a Safety Management System (SMS) in an organization. It emphasizes that personnel must receive initial and ongoing training to understand the SMS, learn from safety lessons, and foster open reporting of safety concerns. Organizations must also identify competency requirements, provide training, and evaluate personnel to ensure they have the proper skills to support the SMS. Management's commitment to and visible support of the SMS through their attitudes and actions is cited as the most important factor for developing a positive safety culture.
World Class Manufacturing:Plant Start Up and Commissioning Procedure HIMADRI BANERJI
The document provides an overview of plant commissioning and start-up procedures. It discusses the commissioning process which includes preparation and planning, mechanical completion and integrity checking, pre-commissioning and operational testing, start-up and initial operation, performance and acceptance testing, and post-commissioning. It then goes into more detail on specific aspects of the commissioning process such as developing start-up procedures, commissioning utilities, pressure testing, cleaning and flushing, and pre-commissioning operational testing.
The document discusses several incidents involving software errors that led to accidents, including a dropped cable that killed a dockworker due to inconsistent speed readings by sensors, injuries caused by erratic behavior of elevators and bales from an outdated software patch, and a generator trip caused by an unofficial software change made by a vendor. It emphasizes the importance of software configuration management, requirements gathering, failure mode analysis, and change control to prevent such incidents.
Airside Observation Statement -24.12.2015.xlsx(A).xlsx01Andrew Louis
This document provides an airside observation statement from Andrew Louis, assessing safety compliance at various airport operations from December 9-24, 2015. Key findings include:
- Most departments scored satisfactory or above average in equipment positioning, servicing, and compliance with safety procedures. Ramp and traffic operations required attention regarding equipment usage.
- A total of 28 events were observed and assessed across departments, with most scoring satisfactorily in safety standards.
- For ramp/line base operations, most bays scored satisfactorily except for some issues with equipment positioning. Cargo apron required attention to equipment positioning.
- No incidents or accidents were reported, though continued compliance with safety reminders and best
Kathryn Rattigan - Cybersecurity & The Commercial Done IndustryARMA International
Drones are increasingly being used for commercial purposes but this brings cybersecurity risks as drones can be vulnerable to cyber attacks. The document discusses regulatory compliance requirements for commercial drone use including FAA's Part 107 rules. It also outlines potential drone uses and privacy/data concerns when collecting information. The document provides tips for mitigating cyber risks to drones such as keeping software updated, encrypting communications, and implementing network security practices.
NTSB Senior Air Safety Investigator, Kristi Dunks, talks about aeronautical decision making when a pilot plans a flight.
This presentation is part of the release of the NTSB General Aviation Safety Series at the FAA Safety forums during Sun 'N Fun 2012 in Lakeland FL.
High-Fidelity Operator Training Simulator for CCGT Implemented Before Plant C...GSE Systems, Inc.
This presentation highlights a project in which a high-fidelity operator training simulator was implemented in a North American combined cycle power plant prior to commissioning.
For more information, go to GSES.com, email info@gses, and follow us on Twitter @GSESystems and at Facebook.com/GSESystems. Thanks for viewing!
110921 commissioning of offshore installationslaithu2908
This document discusses the commissioning process for offshore installations built in yards. It covers the total commissioning activity and defines the key phases of mechanical completion, pre-commissioning and commissioning. Mechanical completion involves verifying construction work is complete according to design. Pre-commissioning verifies functionality and system integration. Commissioning verifies systems are ready for operation. The document provides details on planning, organization and activities for each phase. Estimates suggest 95-105 systems for an FPSO requiring around 135,000-145,000 hours for commissioning, taking around 6 months with a team of 90 people. Addressing issues can help improve estimates over time.
The document provides a resume for Matthew Omavowan Azanor, an Instrument & Control Engineer with over 13 years of experience working on various oil and gas projects in Nigeria, South Korea, the US and Houston for companies like Chevron and Nigeria Agip Oil Company. His experience includes roles in engineering design, construction, commissioning, start-up, and maintenance of electrical, instrumentation and control systems on offshore platforms and FPSOs. He also has qualifications in electrical/electronics engineering and instrumentation and control technologies.
This document provides guidance on field inspections, maintenance, and calibration for hydro-meteorological stations. It describes procedures for inspecting rain gauges, full climatic stations, and checking instrument exposure and observer training. Routine maintenance tasks are outlined for rain gauges, wind instruments, thermometers, evaporimeters, and other equipment. Spare part requirements are listed. Proper maintenance is important to ensure high quality comparable data from the field stations.
This presentation provides an overview of sport pilot flight instruction. It discusses the establishment of the light sport category and sport pilot certificate in 2004. It outlines the aircraft categories that fall under light sport aircraft and the certification processes. It covers the medical requirements, aeronautical experience requirements, privileges and limits of sport pilots compared to private pilots. It discusses who can provide instruction to sport pilots and requirements for flight instructors and sport pilot instructors. It also addresses considerations for transition training when pilots with prior experience move to light sport aircraft.
The 124th Fighter Wing Environmental Management System (EMS) conforms to ISO 14001 standards and manages all environmental programs at the installation. Aspects are activities that can interact with the environment, and impacts are changes to the environment from these aspects. A team identifies the aspects and impacts and determines which could cause significant environmental impact. Leadership annually reviews the aspects and impacts list to determine if any need to be added or reevaluated. The current list from June 2014 identifies various aspects such as air, cultural resources, energy use, hazardous materials and waste, integrated solid waste, toxics, water, and their associated impacts.
The final draft of the Environmental Assessment for the Proposed Temporary Relocation of the 366th Fighter Wing at Gowen Field for a portion of 2015 while runway construction ensues at Mountain Home AFB, Idaho.
NOTICE OF AVAILABILITY, Draft Focused Environmental Assessment (EA) and Draft Finding of No Significant Impact (FONSI) for the Proposed Temporary Relocation of the 366th Fighter Wing (FW), Mountain Home Air Force Base, United States Air Force.
The Idaho Air National Guard invites the public to review and comment on the Draft Focused EA for the Proposed Temporary Relocation of the 366 FW.
Regular inspections of safety critical equipment are needed to maximize safety, ensure reliability, optimize maintenance and provide compliance with standards. The document discusses the inspection services provided by Sparrows Group, including non-destructive testing techniques, lifting equipment examinations, rope access, underwater inspections and dropped object prevention. Sparrows Group has over 40 years of experience in inspection services and strategically placed inspection teams.
This document describes a software solution for sizing, selecting, and generating quotations for safety and pressure relief valves. The software provides guided configuration, integrated calculations, product selection, pricing, and proposal generation capabilities. It aims to streamline the sales process for valve manufacturers and provide a better customer experience.
SPX provides a wide range of aftermarket services for the oil and gas industry from its Aberdeen service center, including field service mobilization, repairs, overhauls, installations, inspections, maintenance, and more. It has experienced engineers available 24/7 to respond to emergencies and aims to support customers' needs to keep critical operations running with minimal downtime. The Aberdeen service center works to seamlessly support offshore field service mobilization from its location in Aberdeen.
This document outlines the requirements for pilots to carry passengers, act as pilot-in-command under instrument flight rules or in reduced visibility, and maintain instrument currency and ratings. It discusses the use of flight simulators, flight training devices, and aviation training devices for completing instrument training and experience requirements. It also provides summaries of various briefing, inspection, and pre-flight requirements for instrument flight.
This document provides an overview and table of contents for guidelines on Process Safety Management (PSM) for ammonia refrigeration facilities. It covers 14 chapters that address the key elements of OSHA's PSM standard, including employee participation, process safety information, process hazard analysis, operating procedures, training, management of change, mechanical integrity, compliance audits, and more. Each chapter provides regulatory context, required elements, explanations, procedures, forms, and customization guidelines for a specific facility.
Kenneth E. Bristow is a United States Navy Senior Chief with over 26 years of experience transitioning to civilian life. He has extensive experience in gas-turbine plants, steam plants, Landing Craft Air Cushions (LCACs), and nuclear steam plants. His qualifications include experience as an Engineering Officer of the Watch, Quality Assurance Supervisor, program manager, and facilities manager supervising over 125 personnel. He is proficient in Microsoft Office and has experience building websites. He is looking for a position utilizing his engineering and management experience in the Hampton Roads, Virginia area.
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.
This document provides an overview of a Safety Management System (SMS) as used by the Federal Aviation Administration (FAA). It discusses the four main components or "pillars" of an SMS: policy, safety risk management, safety assurance, and safety promotion. It also outlines the workflows for safety risk management and safety assurance. Key aspects of an SMS include identifying hazards, controlling risks, providing assurance that risk controls are effective, and promoting a positive safety culture. An SMS provides a systematic approach to these aspects of safety management.
The document discusses safety promotion, which involves training and knowledge sharing activities to support the implementation of a Safety Management System (SMS) in an organization. It emphasizes that personnel must receive initial and ongoing training to understand the SMS, learn from safety lessons, and foster open reporting of safety concerns. Organizations must also identify competency requirements, provide training, and evaluate personnel to ensure they have the proper skills to support the SMS. Management's commitment to and visible support of the SMS through their attitudes and actions is cited as the most important factor for developing a positive safety culture.
The document outlines the Federal Aviation Administration's (FAA) Safety Management System (SMS) framework. It includes four key components of an SMS: safety policy and objectives, safety risk management, safety assurance, and safety promotion. Each component contains various processes to identify hazards, assess and mitigate risks, monitor safety performance, promote a positive safety culture, and continuously improve the system. The FAA is implementing SMS in phases to help organizations progressively develop and mature their safety management processes.
This example was contributed by Capt. Robert Sumwalt, U.S. Airways (retired), Member and former Vice Chair of the NTSB.
It is based on an actual operation from a corporate flight department.
Human Activity System (HAS) Maps visually illustrate and capture the “flow” of causes and outcomes in a problem situation.
In HAS Mapping a problem situation is viewed as occurring within a “system”, a Human Activity System (HAS), where the “system” allows a problem situation’s causes and effects to be identified and shaped into a causal relationship flow map, so underlying issues and their interrelationships can be better recognised and addressed.
The flow of causes to outcomes within a problem situation can be developed, for example, based on using, for example, “but-for” analysis (i.e. “but for an act or omission of X, Y would not have occurred”), and “Why- Because” analysis.
HAS Maps are versatile and can be applied to investigating, assessing, and addressing a wide range of problem situations.
The document discusses safety assurance, which involves collecting information to ensure that safety risk controls are effective and continuously meeting objectives. It describes safety assurance functions like monitoring operations, conducting audits, analyzing data from sources like reports and investigations, assessing system performance, and implementing corrective actions. The goal is to give confidence that risk controls are working as intended and safety is being maintained. Continuous monitoring, audits, data analysis, and corrective actions form a process circle to ensure safety.
This document outlines the key components and requirements of a Safety Management System (SMS) as defined by CAR Section 1 Series C Part 1. An SMS is a management system for organizing safety practices through defined processes. It includes establishing a safety policy, identifying hazards, managing risk, training personnel, reporting/analyzing incidents, auditing the system, and monitoring safety performance. The Accountable Executive has overall responsibility for the SMS, and a Safety Manager is responsible for implementing and maintaining the SMS processes. An SMS Manual documents all SMS processes and personnel responsibilities.
The document provides an overview of a safety management system (SMS) used by the Federal Aviation Administration (FAA). It describes the four components of an SMS - safety policy, safety risk management, safety assurance, and safety promotion. It focuses on the safety risk management component, outlining the processes of system description, hazard identification, risk analysis, risk assessment, and risk control. It provides examples of how these processes would be applied to identifying and mitigating risks associated with aircraft deicing activities.
- Income from other sources is a residual head of income that covers any income that does not fall under the other four heads of income (salary, house property, business/profession, capital gains).
- Some examples included under this head are dividend income, interest income, rental income from machinery/furniture, winnings from lotteries, gifts received without consideration.
- Standard deductions are available for repairs, insurance, depreciation of assets let out on rent. Interest received on securities and specific exempt categories are not taxed under this head.
Human Resource Management Practices in japan Rahat ul Aain
Japan has traditionally emphasized long-term employment and seniority-based promotion and compensation. However, it is now converging towards more Western-style human resource management practices. Issues include an aging population, lack of gender diversity and equality in the workplace, and increasing "karoshi" or death from overwork. Reform efforts aim to introduce more flexibility and performance-based approaches to address business needs in a changing environment.
This presentation summarizes the key aspects of value-added tax (VAT) in India. It introduces VAT and explains how it differs from other sales tax systems by being levied at multiple points of a product's production and distribution chain. The presentation outlines the history of taxation systems in India, the reasons for changing to VAT, how VAT affects the Indian economy, and compares the advantages and disadvantages of VAT to other systems. Real-world examples of calculating VAT are provided.
This document discusses various indirect taxes in India including central sales tax, value added tax, central excise duty, and customs duty. It defines key terms related to these taxes such as incidence and impact of direct vs indirect taxes. It also covers the classification of taxes, authorities that levy different taxes, taxable events, and calculation of taxes. The key highlights are that indirect taxes are imposed on goods and services while direct taxes are imposed on individuals, and indirect tax burden can be shifted to consumers.
Welcome to the SMS Fundamentals presentation.
The core processes, elements and components that comprise a functional and robust Safety Management System will be explained.
These lessons will provide you a general understanding of the principles of a Safety Management System (SMS). Also it will provide you an understanding of the components, elements, and core processes that comprise a functional SMS.
Each organization must determine their safety needs and scale their SMS to meet those needs.
The document discusses various direct taxes levied in India including income tax, corporation tax, dividend tax, capital gains tax, wealth tax, gift tax, estate duty, land revenue, agricultural income tax, and professional tax. It outlines the introduction and key aspects of each tax. It also discusses direct taxes at the state and local government levels. The document notes both the merits and demerits of direct taxes, such as equity and economy but also possibilities of evasion, complexity, and unsuitability for underdeveloped countries.
Art is a creative expression that stimulates the senses or imagination according to Felicity Hampel. Picasso believed that every child is an artist but growing up can stop that creativity. Aristotle defined art as anything requiring a maker and not being able to create itself.
The NTSB investigates drone accidents and incidents to determine probable causes and make safety recommendations. The speaker, an NTSB investigator, discussed how investigations are conducted with input from operators, manufacturers, and regulators. Two case studies were presented: a police drone that crashed due to an inappropriate platform and mission, and a hobbyist drone that crashed with a low battery after the pilot overrode safety systems. The presentation emphasized principles for safe drone operation and preparation for potential investigations.
This document provides an overview of aircraft inspection, documentation, ground handling, and maintenance training. It discusses safety procedures for aircraft inspection, ground handling, towing, taxiing, parking, marshalling, fueling, jacking, and servicing. Precautions are outlined for propeller safety, towing and taxiing rules, control surface locking, tie-downs, jack points, and fuel identification. Ground support equipment for electrical and hydraulic power is also summarized. The goal is to train students on aircraft inspection and ground operations according to proper procedures.
This document discusses drill rig safety and provides guidance on various topics:
- Personal protective equipment (PPE) like hard hats and safety boots should be worn at all times. Drug and alcohol policies and operator training are also important.
- Common safety accidents involve electrocution, rig rollovers, fires, falling objects, and moving parts. Proper rig setup, cribbing, and maintenance can prevent rollovers.
- Drill rig operation should follow safe procedures for setup, operation, transportation, maintenance, and repair. Inspections and preventative maintenance are critical for safety.
Peter Zaidel from KPA presented on regulations for transporting hazardous materials. KPA is a nationwide compliance expert that provides services to over 3000 clients. The presentation covered which government agencies regulate hazmat, why inspections occur, hazard classes, penalties for noncompliance, and the inspection process. Key points included how the DOT and FAA ensure safety, past incidents that prompted regulations, inspection focus areas, and importance of being prepared and following protocols to avoid penalties.
HUMAN FACTOR CONSIDERATIONS IN MILITARY AIRCRAFT MAINTENANCE AND INSPECTIONSLahiru Dilshan
study of how humans behave physically and psychologically in relation to particular environments, products, or services. application of psychological and physiological principles to the engineering and design of products, processes, and systems.
This document discusses lockout/tagout procedures and regulations. It provides examples of workplace incidents where lack of proper lockout/tagout resulted in injuries. The main points are:
- OSHA's lockout/tagout standard (1910.147) requires controlling hazardous energy sources during maintenance and servicing to prevent injuries.
- Case studies show failures to properly lockout energy sources have led to amputations and deaths from machines starting unexpectedly.
- Authorized employees must be trained to apply lockout devices and verify isolation of all energy sources before starting work. Affected employees must also be trained.
- Procedures must be documented in writing and include energy control steps and machine-specific lock
1. The document discusses maintenance aspects of owning your own aircraft, including authorized preventive maintenance tasks a pilot can perform and how to properly document them.
2. It provides examples of common preventive maintenance items like replacing spark plugs, cleaning the engine, and lubricating parts.
3. Checklists are included for conducting preflight inspections of various aircraft systems and components like the propeller, engine, cabin, wings, landing gear, and a functional check flight.
Heavy Equipment Inspection Report 03.01.2024.pptxAdeniranIdris
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The ability to identify and control hazardous energy is a critical point for any industrial safety program. This webinar will provide background on the applicable OSHA and ANSI standards and help attendees to better understand the importance and application of lockout/tagout procedures as they relate to pneumatic safety.
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Chapter wise All Notes of First year Basic Civil Engineering.pptxDenish Jangid
Chapter wise All Notes of First year Basic Civil Engineering
Syllabus
Chapter-1
Introduction to objective, scope and outcome the subject
Chapter 2
Introduction: Scope and Specialization of Civil Engineering, Role of civil Engineer in Society, Impact of infrastructural development on economy of country.
Chapter 3
Surveying: Object Principles & Types of Surveying; Site Plans, Plans & Maps; Scales & Unit of different Measurements.
Linear Measurements: Instruments used. Linear Measurement by Tape, Ranging out Survey Lines and overcoming Obstructions; Measurements on sloping ground; Tape corrections, conventional symbols. Angular Measurements: Instruments used; Introduction to Compass Surveying, Bearings and Longitude & Latitude of a Line, Introduction to total station.
Levelling: Instrument used Object of levelling, Methods of levelling in brief, and Contour maps.
Chapter 4
Buildings: Selection of site for Buildings, Layout of Building Plan, Types of buildings, Plinth area, carpet area, floor space index, Introduction to building byelaws, concept of sun light & ventilation. Components of Buildings & their functions, Basic concept of R.C.C., Introduction to types of foundation
Chapter 5
Transportation: Introduction to Transportation Engineering; Traffic and Road Safety: Types and Characteristics of Various Modes of Transportation; Various Road Traffic Signs, Causes of Accidents and Road Safety Measures.
Chapter 6
Environmental Engineering: Environmental Pollution, Environmental Acts and Regulations, Functional Concepts of Ecology, Basics of Species, Biodiversity, Ecosystem, Hydrological Cycle; Chemical Cycles: Carbon, Nitrogen & Phosphorus; Energy Flow in Ecosystems.
Water Pollution: Water Quality standards, Introduction to Treatment & Disposal of Waste Water. Reuse and Saving of Water, Rain Water Harvesting. Solid Waste Management: Classification of Solid Waste, Collection, Transportation and Disposal of Solid. Recycling of Solid Waste: Energy Recovery, Sanitary Landfill, On-Site Sanitation. Air & Noise Pollution: Primary and Secondary air pollutants, Harmful effects of Air Pollution, Control of Air Pollution. . Noise Pollution Harmful Effects of noise pollution, control of noise pollution, Global warming & Climate Change, Ozone depletion, Greenhouse effect
Text Books:
1. Palancharmy, Basic Civil Engineering, McGraw Hill publishers.
2. Satheesh Gopi, Basic Civil Engineering, Pearson Publishers.
3. Ketki Rangwala Dalal, Essentials of Civil Engineering, Charotar Publishing House.
4. BCP, Surveying volume 1
Film vocab for eal 3 students: Australia the movie
Safety Alert: The Human Component in a Mechanical System
1. The Human Component in a
Mechanical System
1
Kristi Dunks
Senior Air Safety Investigator
2. Overview
• The NTSB
• General aviation safety
• Identifying risks/hazards
• Case studies
2
3. Who is the NTSB?
• Promotes transportation safety
• Investigate for probable cause
• Issue safety recommendations
• Promotes safety improvements
• Multi-modal:
Aviation, highway, marine, railroad, pip
eline, HAZMAT
• Small federal agency
4. General Aviation Safety
• 1,466 GA accidents in 2011
• 271 fatal accidents resulting in 457
fatalities
• NTSB working with FAA, AOPA, EAA,
and others to improve GA accident rate
8. • What do you need to know?
• What skills are necessary?
• Steps to perform a task
• Sequence of actions
• Communication requirements
• Information requirements
• Inspection requirements
• Certification requirements
Actions
9. • Technical documentation systems
• Test equipment
• Enough time
• Enough people
• Lifts, ladders, stands, seats
• Materials
• Portable lighting, heating, cooling
• Training
Resources
11. History of Flight
• Buchanan
Field, Concord, California, to Renton
Municipal Airport, Renton, Washington
• Departed at 1540
• Accident occurred at 1910
12. History of Flight
• 1906:51 pilot transmitted
“Mayday, Mayday, Cirrus N4GS”
• “I’m west of Strom airport, trying to
make the field.”
• Wreckage located 2.5 west-northwest
of Strom Field Airport
17. Cirrus Airframe Parachute System
• Rocket motor and deployment bag remained
connected to parachute
• Activation handle found seated in the handle
holder
• Enclosure cover found 15 feet from
wreckage
• Consistent with activation due to impact
forces
18.
19.
20. Engine Examination
• Examined at Teledyne Continental
• Engine test run
• Fitting cap installed finger tight
• Engine operated normally
28. Maintenance Personnel Interviews
• Three mechanics worked on airplane, two
IAs and one A&P
• Another Cirrus SR22 in facility
• Rushed to complete work
• Performed fuel pressure check
• Final checklist items incomplete
29. Findings
• Engine lost power during cruise
• Fitting cap for throttle and metering
assembly inlet found uninstalled
• Engine operated normally following accident
• Maintenance was performed that required
cap to be removed
• If cap had been properly torqued it would
have remained secure
30. Findings
• Director of Maintenance signed off annual
inspection on work order
• Assigned IA indicated he had not completed
the annual inspection
• Maintenance records incomplete
• If final checks completed, cap would have
likely been identified
33. Initial Information
• Sightseeing tour from Las Vegas
to Hoover Dam
• Normal departure - VFR
• Calm wind, good visibility
• Standardized route
33
34. Flight Path
Las Vegas Airport
To Hoover Dam
Accident site
Sudden climb and turn
Path approximate
and not to scale, for
visualization only
Flightpath
Tour route
Flightpath
35. Sequence of Events
35
Hoover Dam
Sudden climb and turn
3100
feet, 90° off
course
Path approximate
and not to scale, for
visualization only
Steep descent and
crash site
45. Hardware Reuse
• Fleet inspection of 13 helicopters, half
of nuts did not meet requirements
• Manufacturer’s guidance: “If a nut can
be easily tightened, it is to be
discarded”
• FAA guidance: “DO NOT reuse a fiber
or nylon lock nut if the nut cannot meet
the minimum prevailing torque values”
45
46. Bolt Loss Scenario
46
• Two locking devices
• Self-locking nut
• Split pin
• Self-locking nut most likely became
separated from bolt
47. Postmaintenance Inspection and
Check Flight
• Mechanic and inspector
completed inspection
• Helicopter check flight conducted
• Hydraulic belt tension
• No flight discrepancies
47
48. Maintenance Errors
• Improper securing of the fore/aft
servo
• Improper tension of the hydraulic
belt
• Incomplete maintenance inspection
48
51. Maintenance Personnel Fatigue
51
Personnel Normal Shift
Shift
Originally
Scheduled for
December 6
Actual Schedule
on December 6
Mechanic Noon to 11:00 pm Off duty 5:50 am to 6:46 pm
Inspector Noon to 11:00 pm Off duty 5:31 am to 6:55 pm
52. Maintenance Personnel Fatigue
• Effects of fatigue
• Difficulty sustaining attention
• Memory errors
• Lapses in performance
52
53. Human Factors Training
• Causes of fatigue, its effects, and
countermeasures
• Fatigue education as part of a
training curriculum
• No human factors training
requirement in United States
53
54. Work Cards With Delineated Steps
54
• Paperwork for 100-hour inspection
• Inspector signoff for overall fore/aft
servo installation
• No specific signoffs for critical
steps within task
58. GA Maintenance Alert
• Independent inspections of work
• Safety and security of
components disconnected
• Look for the obvious; if there is a
castellated nut, there is generally
an associated cotter pin
58
59. GA Maintenance Alert
• Review and adhere to guidance
regarding self-locking nuts
• When a component or system is
in the work process, mark it
• Cell phone policies
59
60. GA Maintenance Alert
• Turnover briefings
• Pilot check flights/review are last
opportunity to detect potential
safety hazards
• Review FAA HF guidance and
“Personal Minimums” Checklist
60
61. Safety recommendations
• Duty time limitations for
maintenance personnel
• Work cards for maintenance tasks
• Human factors training for
maintenance personnel
• Review issue of human fatigue in
aviation maintenance
61
63. • Pilot recently purchased airplane
• Lost oil pressure during flight and
landed in a field
• Post accident examination showed
that the main crankshaft seal was
extruded and oil had been pumped
out during the flight
• Breather tube modified to drain oil
and moisture away from airplane
Overview
64.
65. • Moisture is expelled from the engine crankcase
through the breather tube which often extends
through the bottom of the engine cowling into the
air stream
• This moisture may freeze and continue a buildup
of ice until the tube is completely blocked
• To prevent freeze-up, the breather tube may be
insulated, it may be designed so the end is
located in a hot area, it may be equipped with an
electric heater, or it may incorporate a hole, notch
or slot which is often called a "whistle slot"
Whistle Slot Guidance- Lycoming
Flyer
66. • The operator of any aircraft should know which
method is used for preventing freezing of the
breather tube, and should insure that the
configuration is maintained as specified by the
airframe manufacturer
• Because of its simplicity, the "whistle slot" is often
used, and a notch or hole in the tube is located in
a warm area near the engine where freezing is
extremely unlikely
• When a breather tube with whistle slot is
changed, the new tube must be of the same
design
Whistle Slot Guidance- Lycoming
Flyer
69. • The run up was without incident and the pilot
noted that the RPMs dropped slower than normal
when he cycled the propeller
• During climb out, he noticed that the engine
RPMs climbed to 2,800 so he leveled off his climb
and pulled the propeller control back with no
reduction in RPM noted
• Attempted to cycle the propeller twice but noticed
no change in RPMs
• Decided to return to the departure airport and
then he heard and felt a thump forward of the
cockpit
• Engine continued to run smoothly, while
developing adequate power, and the pilot landed
uneventfully
Overview
70. Engine examination
• Post incident engine examination showed
a blister in the engine casing and
fragments of metal in the oil
• Engine then disassembled and ball
bearings from the propeller governor were
located in the engine
• Further disassembly of the engine
identified one ball bearing within the oil
sump, as well as damage to the case and
two camshaft lifters
• The ball bearings from the governor were
able to pass through the oil drain hole of
the governor
72. • Follow up examinations of the propeller
governor showed that the governor bearing race
and plunger were assembled with the bearing
race set screw and plunger hole misaligned
• When the bearing race set screw was torqued
down, the set screw tip flattened against the
harder plunger surface
• During operation, the set screw/plunger race
separated
Governor examinations
73.
74. • Review of the governor manufacturer’s
reports showed two service difficulty
reports (SDRs) had been reported for
similar events
• The two events, as well as the governor
assembly from the accident, were from a
single batch of 74 assemblies
Service difficulty reports
76. • As a result of this incident, the governor
manufacturer issued a mandatory service
bulletin (SB) DES-353, on December 18, 2008,
for the affected assemblies. The SB required
that the units be returned to Ontic for inspection
and, if necessary, repair.
• The FAA issued an Airworthiness Directive
requiring examination of the affected
assemblies.
77.
78. Probable Cause
The failure of maintenance personnel to
properly secure a fitting cap on the throttle
and metering assembly inlet after
conducting a fuel system pressure check,
which resulted in a loss of engine power due
to fuel starvation.
79. Contributing Factor
Contributing to the accident was the decision
by the Director of Maintenance to return the
airplane to service without verifying with the
assigned inspector that all annual inspection
items had been completed.
80. Probable cause
• Sundance Helicopters’ inadequate maintenance
of the helicopter, 8 including (1) the improper
reuse of a degraded self-locking nut, (2) the
improper or lack of installation of a split pin, and
(3) inadequate postmaintenance
inspections, which resulted in the in-flight
separation of the pilot servo control input rod
from the fore/aft servo and rendered the
helicopter uncontrollable.
80
81. Probable cause
• Contributing to the improper or lack of installation
of the split pin was the mechanic’s fatigue and
the lack of clearly delineated maintenance task
steps to follow. Contributing to the inadequate
postmaintenance inspection was the inspector’s
fatigue and the lack of clearly delineated
inspection steps to follow.
81
82. Probable Cause
The National Transportation Safety
Board determined the probable cause
of this accident to be:
• oil exhaustion due to an improper oil
breather tube installation, which became
plugged in flight due to frozen moisture
build-up. The blocked breather tube then
created a crankcase over pressure that
caused a failure of the crankshaft seal.
The rough, uneven terrain and strong
crosswind were factors in the accident.
83. Probable Cause
The National Transportation Safety
Board determined the probable
cause of this accident as follows:
• The improper assembly of the
governor during manufacture.
Editor's Notes
Good morning. I will discuss maintenance issues identified during the investigation.
This is a view looking northeast at the wreckage site, in rugged terrain on National Park Service land. The wreckage was consistent with a steep descent into the narrow ravine. Impact forces were high and the site was in a very contained area. The wreckage was fragmented and consumed by fire.[CLICK] The red circle indicates the tail boom and skids, [CLICK] the fuselage impacted just to the left of the circle. All of the main and tail rotor blades were found in the area.[CLICK]
The day prior to the flight,Sundance maintenance personnel performed a routine 100 hour inspection, which among other tasks, included the replacement of the main rotor fore-aft servo. After the maintenance was completed a short check flight was performed, followed by two tour flights – one flown by the same pilot who performed the check flight and one by the accident pilot. The next tour flight was the accident flight, which occurred about 3.5 flight hours after the maintenance.Ms. Dunks will go into more detail on this work in her presentation and Dr. Alley-R will discuss human factors and fatigue in maintenance.[CLICK]
This is a view with the engine cowl open, of the area where the servos and other components are located, under the main rotor assembly, between the cabin and engine. The fore-aft servo is one of three that transfer pilot control inputs to the main rotor, allowing the pilot to change the pitch of the blades, in order to control the helicopter.[CLICK]
However, examination of the wreckage, found the fore-aft servo and the associated flight control input rod were not connected, and there was no evidence of a connecting bolt.[CLICK] This is a view of the input rod, and the servo [CLICK] at top right, the lugs [CLICK] indicated by the arrow are where the rod end should be fastened [CLICK] with a bolt, locknut, washer, and safety cotter or split pinA disconnected input rod to the fore-aft servo is considered catastrophic, the pilot would not be able to control main rotor pitch and other inputs would result in unexpected response. The input rod and servo therefore likely disconnected in flight, just prior to the unexpected climb and turn. [CLICK]
The day before the accident, the helicopter underwent a routine 100-hour inspection. Three mechanics and a company-designated quality control inspector participated in the maintenance activity. The helicopter also had its engine and fore aft and tail rotor servos replaced. As noted by Mr. English, the fore/aft servo was found disconnected from the input rod at the accident site.
The fore aft servo that wasinstalledon the accident helicopter was an overhauled unit. During the replacement of the fore/aft servo, the mechanic is required to assess the hardware condition and then to connect the fore aft servo to the input rod, torque the nut, and install the split pin. A company-designated quality control inspector then inspects the installation.
The schematic on the left shows a close-upview of the hardware for the fore aft servo and input rod connection. As shown, the bolt is inserted through the fore aft servo and servo control input rod, the washer is installed, and then the nut is installed. The nut is torqued and the split pin is inserted through the nut and bolt. Once the split pin is in place, the tangs are bent back to secure the connection.The image on the right shows a close-up view of the fore aft servo and input rod connection. In accordance with Sundance’s procedures, when inspecting the fore/aft servo installation, the inspector is required to mark all safeties with a torque pen. In the case of the accident helicopter, the inspector reported verifying and marking the security of the installation.
Here are images of self-locking nuts. The image on the left shows the full-circle nylon locking element of a new or “acceptable” nut. The image on the right shows a degraded nut with the nylon locking element worn. During the hardware assessment, the mechanic verifies the condition of the self-locking nut to ensure that it meets the minimum torque value. That is, it cannot be tightened by hand to the base of the bolt threads. NTSB tests showed that torque values degraded with each on-off cycle.In this case, the mechanic reported that the original hardware met the requirements and it was not replaced.
Following the accident, Sundance inspected its helicopter fleet to determine the condition of the servo hardware and to ensure that all items were safetied. Although no unsafetied items were found, about half of the nuts associated with the bolts that had beenexamined at the time of the NTSB’s visit did not meet the minimum locking capability.The manufacturer’s guidance states that if a nut can be easily tightened, it is to be discarded. FAA guidance states that nut torque must be verified and notes “DO NOT reuse a fiber or nylon lock nut if the nut cannot meet the minimum prevailing torque values.”Sundance now requires that all nuts be replaced with new nuts when servos are removed.
During the investigation, several nut and split pin installation scenarios were evaluated. By design, a properly installed input rod to the fore/aft servo has a secure connection because it has two locking devices, the self-locking nut and split pin. If an improperly installed or degraded nut is installed without a split pin, the nut can vibrate off of the bolt due to normal in-flight vibratory forces and a disconnect of the control input rod from the fore/aft servo can occur. Therefore, the self-locking nut most likely became separated from the bolt.
Once the maintenance was completed, the inspector, with assistance from the mechanic that installed the fore/aft servo, completed the final overall checks on the helicopter. No problems were identified.The following morning, the day of the accident, a check pilot completed the post maintenance checks. This included a before first flight check, a check of the maintenance items performed, and a check flight. During the before first flight check, the check pilot noted that the hydraulic belt tension was too loose. The belt tension had been set by the same mechanic that completed the installation of the fore aft servo. After the tension was reset, the check flight was completed. According to the check pilot, no discrepancies were identified during the flight.
As discussed earlier, the day before the accident, the accident helicopter underwent a 100-hour inspection, including the fore aft servo replacement. Errors made during this maintenance were: improper securing of the fore /aft servo connection hardware, improper tension of the hydraulic belt, and incomplete maintenance inspection of the accident helicopter. [click]
The mechanic was contacted on his off duty day, to report to work about 6 hours earlier than his normal shift and on a day he was previously scheduled to be off duty. He stated that he went to bed earlier than normal, about 10:00 pm; however, he had difficulty falling asleep. Heawoke at 5:00 am on the morning of December 6, after obtaining only about 5 hours of sleep and reported to work about 5:50 am. He completed his shift about 6:45 pm. He had been awake for over 13 ½ hours. [Click]
The inspector was also contacted on his off duty day, to report to work about 6½ hours earlier than his normal shift and also on a day when he was previously scheduled to be off duty.He went to bed about 9:00 pm on December 5 and awoke at 4:00 am on December 6, obtaining approximately 7 hours of sleep. He reported to work about 5:30 am and completed his final inspection and ground run of the accident helicopter around 6:00 pm, at the end of a 12-hour shift. The inspector had been awake for over 14 hours at the end of his shift. [Click]
Here is a table summarizing the mechanic’s and inspector’s normal shift schedule, the shift they were originally scheduled for on December 6, and actual shifts they worked.For the Mechanic, the insufficient time to adjust to working an earlier shift than normal and inadequate amount of sleep the night prior to the scheduled maintenance contributed to the development of fatigue. For the inspector, the insufficient time to adjust to working an earlier shift than normal and a long duty day contributed to the development of fatigue. [Click]
Fatigue associated with sleep loss, shift work, and long duty cycles can lead to increased difficulty in sustaining and directing attention, memory errors, and lapses in performance. Available evidence indicates that both the mechanic and inspector were experiencing fatigue and the known effects of fatigue can lead to the type of errors that they made. Staff concludes that both the mechanic’s and inspector’s degraded performance due to fatigue contributed to the improper securing of the fore/aft servo connection hardware, the improper tension of the hydraulic belt, and the incomplete maintenance inspection of the accident helicopter, respectively. [Click]
Education and training is another important approach to mitigating the risks of fatigue-related errors in maintenance. Educating maintenance personnel on the causes of fatigue, its effect on performance, and appropriate countermeasures promotes a safer maintenance culture. This type of training can be done as part of a human factors training curriculum which would provide benefits to reducing human errors in maintenance beyond fatigue awareness. Current federal regulations do not require maintenance personnel to receive human factors training, however, other international regulatory authorities such as the European Aviation Safety Agency do. The circumstances of this accident illustrate that the reliability of inspections of critical flight control system components can be affected by a number of inherent human factors. Therefore, staff concludes that all maintenance personnel would benefit from receiving human factors training, including fatigue education, which would help reduce the likelihood of human errors in aviation maintenance. Staff has proposed recommendations in these areas. [click]
Documentation used by Sundance Helicopters’ maintenance personnel for the fore/aft servo replacement listed the servo replacement task as an item on a discrepancy list to be accomplished with a reference to the Aircraft Maintenance Manual. The Aircraft Maintenance Manual listed the tools, parts, and sequential steps required to accomplish the task. According to Sundance’s General Maintenance Manual, maintenance functions requiring a safety, such as the fore/aft servo replacement, required an inspector sign off to approve the helicopter for return for service. However, the company’s 100-hour inspection paperwork provided only a single location for the inspector to signoff for the overall fore/aft servo installation rather than including individual areas for the inspector to sign off to note inspection of critical steps within this task. [Click]
This picture depicts a page from the 100-hour inspection paperwork showing the single sign off location for the overall fore/aft servo. [Click]It is likely that the maintenance personnel’s performance was also affected by human factors such as failure in systematic visual inspections, complacency and expectations, overreliance on memory for performing tasks or identifying critical areas for inspection, and interruptions (which are common in the maintenance environment). [Click]
Using documentation that clearly delineates the steps to be performed and critical areas to be inspected to support the maintenance and inspection task is one way to mitigate these factors.This picture depicts a section of a sample work card where the mechanic [Click] and the inspector [Click] have separate columns to sign off delineated steps for a task such as installation of the nut, applying torque, and installation of the split pin. Work cards, which are used much like checklists in the cockpit, can help to ensure that critical steps in a maintenance task have been performed and protected against some of the human factors errors. Staff has proposed a recommendation in this area.[Click]
As a result of concerns regarding the reuse of hardware and other helicopter maintenance items, the FAA issued a GA Maintenance Alert in November 2012. This alert notice was distributed via the FAA’s safety and outreach FAAST Team email database to 239,000 users including pilots and mechanics.Similar information will also be published by the FAA in an Aviation Maintenance Alert in early 2013.Additionally, the NTSB provided accident case study data related to maintenance errors to FAAST for inclusion in its inspection authorization renewal training, and this information will be included in renewal training clinics throughout the United States in 2013.
As a result of concerns regarding the reuse of hardware and other helicopter maintenance items, the FAA issued a GA Maintenance Alert in November 2012. This alert notice was distributed via the FAA’s safety and outreach FAAST Team email database to 239,000 users including pilots and mechanics.Similar information will also be published by the FAA in an Aviation Maintenance Alert in early 2013.Additionally, the NTSB provided accident case study data related to maintenance errors to FAAST for inclusion in its inspection authorization renewal training, and this information will be included in renewal training clinics throughout the United States in 2013.