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!
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
Airworthiness: Failure to follow procedures
Presented to:By:Date:Federal AviationAdministrationAIRWORTHINESSPositive Safety CultureFailure to FollowProcedures 1R1
Federal AviationAdministrationFailure to Follow ProceduresFT-2Introduction• Failure to Follow Procedures• Causal Factors• Maintenance Errors
Federal AviationAdministrationFailure to Follow ProceduresFT-3Overview• Regulation Overview• Accident Scenario• Maintenance Error Findings• Chain of Events• Safety Nets• Safety Motivation• Safety Tools
Federal AviationAdministrationFailure to Follow ProceduresFT-4ObjectiveProvide awareness of risk associated withfailing to follow procedures and prevention ofcontributing or causal factors so as to reducemaintenance errors.
Federal AviationAdministrationFailure to Follow ProceduresFT-5
Federal AviationAdministrationFailure to Follow ProceduresFT-6Mental Limits: DisassemblyThere is only one way to disassemble the nuts, but over 40,000 wrongways to reassemble.Your task here is to remove these nuts from the bolt. Now reassemblethem back into alphabetical order.
Federal AviationAdministrationFailure to Follow ProceduresFT-7Lets Get StartedBut before we do!
Federal AviationAdministrationFailure to Follow ProceduresFT-8First – Let us read from the goodbook of regulationsFAARegulatory Overview
Federal AviationAdministrationFailure to Follow ProceduresFT-9PERFORMANCE STANDARDS• 14 CFR Part 43.13(a) requires all maintenanceto be performed using the methods,techniques and practices prescribed in thecurrent manufacturer’s maintenance manual.• Tools and equipment and test apparatus inaccordance with accepted industry practiceand the manufacturer.
Federal AviationAdministrationFailure to Follow ProceduresFT-1043.13 (continued)• 14 CFR Part FAR 43.13(b) Each personmaintaining an aircraft shall do that work insuch a manner and use the materials ofsuch a quality, that the condition of theaircraft, airframe, aircraft engine, propeller,or appliance worked on will be at least equalto it’s original or properly alteredcondition…
Federal AviationAdministrationFailure to Follow ProceduresFT-1143.13 (continued)14 CFR Part FAR.43.13(c) A Part 121,127,129,or 135 Air Carriers operating manual andoperation specifications are considered anacceptable means of complying with thissection.
Federal AviationAdministrationFailure to Follow Procedures(c) ANNUAL AND 100 HOUR INSPECTIONS.(1) EACH PERSON PERFORMING AN ANNUAL OR 100 HOURINSPECTION SHALL USE A CHECKLIST… THAT INCLUDES THESCOPE AND DETAIL OF APPENDIX D OF (FAR PART 43).(2) BEFORE APPROVING A RECIPROCATING ENGINE POWEREDAIRCRAFT FOR RETURN TO SERVICE AFTER AN ANNUAL OR 100HOUR, EACH PERSON SHALL RUN THE ENGINE(S) TODETERMINE SATISFACTORY PERFORMANCE OF:(i) POWER OUTPUT (STATIC AND IDLE R.P.M.)(ii) MAGNETOS(iii) FUEL AND OIL PRESSURE(iv) CYLINDER AND OIL TEMPERATUREADDITIONAL PERFORMANCE RULES FOR INSPECTIONS14 CFR Part 43.15
Federal AviationAdministrationFailure to Follow Procedures(3) BEFORE APPROVING A TURBINE ENGINE POWERED AIRCRAFTFOR RETURN TO SERVICE AFTER AN ANNUAL OR 100 HOUR,EACH PERSON SHALL RUN THE ENGINE(S) TO CHECKSATISFACTORY PERFORMANCE IAW THE MANUFACTURER’SRECOMMENDATIONS.ADDITIONAL PERFORMANCE RULES FOR INSPECTIONS14 CFR Part 43.15 (cont)
Federal AviationAdministrationFailure to Follow ProceduresFT-1414 CFR Part 43.13 addresses?1. Industry approved tools and when wehave to use them.2. Methods, techniques and practices.3. Performance standards.Question
Federal AviationAdministrationFailure to Follow ProceduresFT-15Additional 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
Federal AviationAdministrationFailure to Follow ProceduresFT-16Some Statistics to Ponder• The Number one reason for FAA violationsbeing filed on AMTs is “Failure to FollowProcedures”• The NTSB has identified “Failure to FollowProcedures” as a leading factor in aviationaccidents where maintenance was involved.
Federal AviationAdministrationFailure to Follow ProceduresFT-17National Aircraft Accidents Statistics• The number of all accidents wheremaintenance errors were thecause or a contributing factor areincreasing each year.
Federal AviationAdministrationFailure to Follow ProceduresFT-18Maintenance Related AccidentsMaintenance Related AccidentsMaintenance related accidents are aresult of causal factors that includefailure to follow procedures.The failure to follow procedures can resultin the death, injury, occupational illness ofpersons or damage to or loss of equipment,property or damage to the environment
Federal AviationAdministrationFailure to Follow ProceduresFT-19Aviation AccidentsAviation AccidentsHuman CausesHuman CausesMachine CausesMachine Causes1903 TodayTIME10%20%30%40%50%60%70%80%90%100%0%
Federal AviationAdministrationFailure to Follow ProceduresFT-20Human ErrorHuman ErrorHuman error is the unintentional act ofperforming a task incorrectly whichcan potentially degrade the system.
Federal AviationAdministrationFailure to Follow ProceduresFT-21Human ErrorHuman ErrorThree 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
Federal AviationAdministrationFailure to Follow ProceduresFT-22Human ErrorHuman ErrorLevels of consequence of human error– Little or no effect– Physical damage to equipment– Personal injury– Catastrophic event
Federal AviationAdministrationFailure to Follow ProceduresFT-23Failure to Follow procedures are results ofhuman 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
Federal AviationAdministrationFailure to Follow ProceduresFT-24Chain of EventsChain of EventsChain of Events– Multiple contributing factors can lead to anaccident.AccidentTrainingCurrent DataSupervisionFailure to followprocedures
Federal AviationAdministrationFailure to Follow ProceduresFT-25Break the Chain of EventsBreak the Chain of EventsIf we can break the chain,the accident doesn’t happenPreventing any event could prevent the accidentPreventing any event could prevent the accidentmanagementmaintenancecrew
Federal AviationAdministrationFailure to Follow ProceduresFT-26Preventive MeasurePreventive MeasureBreak the chain of events byemploying the performancestandards set forth by regulatory,manufacturer’s and operator’sprocedures.
Federal AviationAdministrationFailure to Follow ProceduresFT-27Safety NetsSafety NetsEmploying the mechanism ofperformance standards tobreak the chain of events.What Safety Nets Can we put inplace to prevent a failure to followprocedures?
Federal AviationAdministrationFailure to Follow ProceduresFT-28Safety Nets• Perform the task to best of your abilities• Perform the task to be equal to it’s originalcondition• Perform the task in accordance withappropriate data• Perform the task using methods,techniques and practices acceptable toindustry and the administrator• Perform the task without pressure, stress,and distractions
Federal AviationAdministrationFailure to Follow ProceduresFT-29Safety Nets (cont.)• Re-inspect or have someone inspect yourwork before return to service• Make the proper record entries for the workperformed• Perform the operational checks inaccordance with the manufacturer’s or aircarrier’s approved procedures
Federal AviationAdministrationFailure to Follow ProceduresFT-30Motivation• Your motivation is to do the job to the bestof 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
Federal AviationAdministrationFailure to Follow ProceduresFT-31SAFETY TOOL
Federal AviationAdministrationFailure to Follow ProceduresFT-32SAFETY TOOL
Federal AviationAdministrationFailure to Follow ProceduresFT-33Mental Limits: ReassemblyPrevention of Failure to Follow Procedures - Recognizing and managingcontributing factors - Breaking the Chain of Events – Mitigatingmaintenance related accidents in aviationYour task is to reinstall these nuts on the bolt, placing them back intoalphabetical order based on the elements of this presentation.
Federal AviationAdministrationFailure to Follow ProceduresFT-34Question Number 1 (Nut A)• What Federal Aviation Regulation identifiesthe Performance Rules for personsperforming maintenance?• 14 CFR Part 43.13
Federal AviationAdministrationFailure to Follow ProceduresFT-35Question Number 2 (Nut B)• Performance Rules contained in 14 CFRPart 43.13 apply to what functions or tasks?• Maintenance, Alteration, or PreventiveMaintenance
Federal AviationAdministrationFailure to Follow ProceduresFT-36Question Number 3 (Nut C)• Additional Performance Rules are found inwhat Federal Aviation Regulation?• Answer: 14 CFR Part 43.15• Additional Performance Rules apply to whattasks or functions?• Answer: Inspection
Federal AviationAdministrationFailure to Follow ProceduresFT-37Question # 4 (Nut D)• What is the number 1 maintenance errorthat results in or contributes to aircraftaccidents?• Answer: Failure to Follow Procedures• National aircraft accident statisticsindicate that maintenance error causedaccident are increasing, True or False?• Answer: True
Federal AviationAdministrationFailure to Follow ProceduresFT-38Question number 5 (Nut E)• The Chain of events that can lead to anaccident . What four examples of thosecontributing factors have we looked attoday?1.Training2.Current Data3.Supervision4.Failure to Follow Procedures
Federal AviationAdministrationFailure to Follow ProceduresFT-39Question 6 (Nut F)• What Safety Nets can we put in place toprevent a failure to follow procedures?1. Perform the task to the best of my abilities2. Perform the task to be equal to its originalcondition3. Perform the task IAW appropriate data4. Perform the task using acceptabletechniques, methods and practices
Federal AviationAdministrationFailure to Follow ProceduresFT-40Question number 7 (Nut G)• Safety Motivation to perform your job tothe best of you ability must include whatpractices and or traits?1. Self regulation – Integrity2. Lower your risk – Liability3. Pride in ownership – Your character4. Professionalism – Responsibility5. Bottom line - Safety
Federal AviationAdministrationFailure to Follow ProceduresFT-41Final Question – Number 8 (Nut H)• What safety tool canyou employ to preventor mitigate thelikelihood of a failureto follow procedures?
Federal AviationAdministrationFailure to Follow ProceduresFT-42Prevention of Failure to FollowProceduresPerformanceRules43.1343.13MaintenanceAlterationpreventiveMaintenance43.15AdditionalPerformance RulesInspection12%ofAccidentsChain ofEventsSafetyNetsSafetyMotivationSafety Tools
Federal AviationAdministrationFailure to Follow ProceduresFT-43Summary:• Regulation Overview• Chain of Events• Safety Nets• Safety Motivation• Safety Tools
Federal AviationAdministrationFailure to Follow ProceduresFT-44Conclusion• Any Questions?• www.FAASafety.gov• GA Awards Program• AMT Awards Program• Give us your Feedback
Federal AviationAdministrationFailure to Follow ProceduresFT-45The End