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Premium member Presentation Transcript PowerPoint Presentation: National Aeronautics and Space Administration 2.0 Documentation Barbara Kanki 650 604-5785 Barbara.firstname.lastname@example.org Ernie Kiss 678 898-3422 email@example.com Introduction of The Operator’s Manual for Human Factors in Aviation Maintenance jetBlue Airways New York 25-26 October2005 Federal Aviation AdministrationAgenda : Agenda Why is Documentation Important How to Implement a Documentation Program How to know the Documentation program is working K ey R eferences Discussion as Time PermitsAgenda : Agenda Why is Documentation Important How to Implement a Documentation Program How to know the Documentation program is working K ey R eferences DiscussionPowerPoint Presentation: Flight 2574, September 11, 1991 Flight 5481, January 8, 2003 “Mechanics would benefit from using Airliner Maintenance Manuals with more specific instructions for critical flight system procedures.” NTSB/AAR-04/01Flight 2574, September 11, 1991 : 4 Flight 2574, September 11, 1991 Sudden in-flight loss of the partially secured left horizontal stabilizer leading edge and the immediate severe nose-down pitchover and breakup of the airplane Probable Cause: Failure of operator maintenance and inspection personnel to adhere to proper maintenance and quality assurance procedures for the airplane’s horizontal stabilizer deice boots Contributing Factors: Failure of the operator management to ensure compliance with the approved maintenance procedures Failure of regulator to detect and verify compliance with approved procedures.Recommendations: Flight 2574: 5 Recommendations: Flight 2574 Recommend FAA to: Enhance . . . surveillance of the operator to include . . . actual maintenance shop practices, to ensure that such practices conform to the operator General Maintenance Manual and applicable Federal Aviation Regulations. Enhance . . . the National Aviation Safety Inspection Program to emphasize hands-on inspection of equipment and procedures , unannounced spot inspections and the observation of quality assurance and internal audit functions, in order to evaluate the effectiveness of air carrier maintenance programs related to aircraft condition, the adherence to approval and prescribed procedures. . .Flight 5481, January 8, 2003 : 6 Flight 5481, January 8, 2003 Beechcraft 1900D with 19 passengers/2 crew, lost pitch control during takeoff and crashed killing all onboard Probable Cause : Airplane’s loss of pitch control during takeoff resulting from the incorrect rigging of the elevator control system compounded by the airplane’s aft center of gravity Contributing Factors: Operator’s lack of oversight of the work being performed at the maintenance station, maintenance procedures and documentation, and weight and balance program. . .PowerPoint Presentation: 7 Detail 6 Inspection Work Card (Aft fuselage/empennage) Nonspecific references Inadequate instructions Aircraft Maintenance Manual Inapplicable steps Inadequate instructions Flight 5481 NTSB Boardroom Meeting S. Carbone, Aircraft Maintenance and Records InvestigatorRecommendations: Flight 5481: 8 Recommendations: Flight 5481 Manufacturers of Part 121 Aircraft: identify appropriate procedures for a complete functional check of each critical flight system; determine which maintenance procedures should be followed by such functional checks. Manufacturers & Part 121 Air Carriers: modify existing maintenance manuals. . . to contain procedures at the end of maintenance for a complete functional check of each critical flight system Part 121 Air Carriers: implement a program in which air carriers and aircraft manufacturers review all work card and maintenance manual instructions for critical flight systems. . .ensure the accuracy and usability of these instructions . . . to the level of training of the mechanics. .Documentation issues and more: 9 Documentation issues and more Failure to follow procedures Company Manufacturer Failure to document actions Failure to communicate Turnover process Supervisory oversight Regulatory oversight “Safety Culture”Documentation – Why is it Important: Documentation – Why is it Important Accidents and Incidents US and International studies: Major Findings Documentation-related errors: procedural design flaws, currency and accessibility of documents User errors Failure to follow published technical documentation Using an unauthorized procedure not referenced in the technical documentation Supervisory personnel accepting non-use of technical documentation or failure to follow maintenance instructions. Other Organizational Issues Manufacturer – Operator Within Company – Multiple usersAgenda : Agenda Why is Documentation Important How to Implement a Documentation Program How to know the Documentation program is working K ey R eferences DiscussionHow to implement a Documentation Program: How to implement a Documentation Program Are Documentation issues captured in your event reporting system? (ex: Key Behaviors) Are you preserving standardization and best practices? Are you taking the opportunity to address documentation issues when introducing new technology or procedural changes? (ex: seat installation) Are there industry working groups that can help develop guidelines/ standards for addressing cross fleet/manufacturer issues? (ex: MEL working group) What is the process for submitting changes? What about multi-user documents?Agenda : Agenda Why is Documentation Important How to Implement a Documentation Program How to know the Documentation program is working K ey R eferences DiscussionHow to know the Documentation Program is working : How to know the Documentation Program is working Event reports and investigation Documentation use “normative behaviors,” accessibility, current How recommended changes are handled User feedback: positive, negative Authoring groups standards/practicesAgenda : Agenda Why is Documentation Important How to Implement a Documentation Program How to know the Documentation program is working K ey R eferences DiscussionDocumentation - Key References: Documentation - Key References ASD Simplified Technical English (2005). AeroSpace and Defense Industries Association of Europe Specification ASD-STE100(tm) Inaba, K., Parsons, S.O., and Smillie, R. Guidelines for Developing Instructions. Boca Raton, FL; CRC Press (ISBN 0-415-32209) United Kingdom Civil Aviation Publication (CAP) 716: Aviation Maintenance Human Factors (EASA Part-145), Chapter 6 and Appendices N and O.Agenda : Agenda Why is Documentation Important How to Implement a Documentation Program How to know the Documentation program is working K ey R eferences Further DiscussionDiscussion Topics: Discussion Topics What are your most important documentation issues? Lessons Learned in Solving Documentation Problems 121, 135, 145PowerPoint Presentation: The 5 th Annual CIS, Central & Eastern Europe Airline Engineering & Maintenance Conference 14-15 September 2005 - Warsaw Summary Why is Documentation Important How to Implement a Documentation Program How to know the Documentation Program is working K ey R eferences Federal Aviation Administration Further Discussion You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.