Failure to Follow Procedures

Editor's Notes

• #2: This Presentation speaks to 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). Author’s Name: Richard Mileham Date: 01/22/07 Phone No: 847-294-7623 email: richard.mileham@faa.gov Product No. - PP 07020101
• #3: This Presentation will also cover failure to follow procedures, causal factors, maintenance errors and introduction to faasafety.gov.
• #4: 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
• #5: 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.
• #6: 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.
• #7: 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.
• #8: Lets Get Started- But before we do!
• #9: Self Explanatory
• #10: 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.
• #11: 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).”
• #12: 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.
• #13: Regulations require you to use proper checklist for the type of inspections being performed. Must follow the procedures as indicated in the checklist. Procedures for additional performance requirements within the regulation.
• #14: The regulations require you to perform certain tasks in accordance with the manufacturer’s recommendation.
• #15: Correct response to question 1 of 3: Answer: All the above
• #16: Procedures may come from other sources such as: 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
• #17: This regulation requires any person performing work for an air carrier to follow the procedures as outlined in the certificate holder’s manual. FAR 121.367 requires each certificate holder to have an inspection program and a program covering other maintenance, preventive maintenance, and alterations that ensures that maintenance, preventive maintenance and alterations performed by it or by other persons are performed in accordance with the certificate holder’s manual.
• #18: Lets look at National Statistics and an NTSB investigated accident that has identified failing to follow procedures as a causal factor.
• #19: In general around 80% of accidents have human error as a major causal factor. Pilot errors are not the only human errors. 12% involved maintenance and inspection deficiencies.
• #20: National Aircraft Accidents Statistics indicate 12 % of all accidents are results of maintenance errors. Failure to follow procedures has been identified in the following applications.
• #21: Contributing factors in all maintenance related accidents by maintenance personnel causes relates to failure to follow procedures.
• #22: 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.
• #23: 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.
• #24: 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 to bang into things during flight. What is this called? (foreign object damage) All of these possible outcomes involved the same error.
• #25: 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. For instance if we usually add an O-ring, we might add one, even when it is not called for this time.
• #26: Any of these errors can have different consequences, from no effect to a major catastrophic event plays a role.
• #27: 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
• #28: DCA03MA022 The Safety Board's full report is available at http://www.ntsb.gov/publictn/publictn.htm . The Aircraft Accident Report number is NTSB/AAR-04/01. On January 8, 2003, about 0847:28 eastern standard time, Air Midwest (doing business as US Airways Express) flight 5481, a Raytheon (Beechcraft) 1900D, N233YV, crashed shortly after takeoff from runway 18R at Charlotte-Douglas International Airport (CLT), Charlotte, North Carolina. The 2 flight crewmembers and 19 passengers aboard the airplane were killed, 1 person on the ground received minor injuries, and the airplane was destroyed by impact forces and a postcrash fire. Flight 5481 was a regularly scheduled passenger flight to Greenville-Spartanburg International Airport (GSP), Greer, South Carolina, and was operating under the provisions of 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident. The accident airplane had been flown from the Tri-State/Milton J. Ferguson Field, Huntington, West Virginia (HTS), to CLT on January 7, 2003 (the day before the accident). Air Midwest records indicated that the accident pilots flew the accident airplane on six flight legs that day. The first officer (the nonflying pilot) of the flight from HTS to CLT told the accident first officer, when handing off the airplane, that "everything was normal" and "it was a good flying airplane." The accident pilots began their trip sequence about 1340 and ended their trip sequence at CLT about 2045. Another flight crew met the accident airplane for a trip that night from CLT to Lynchburg Regional Airport/Preston Glenn Field, Lynchburg, Virginia. That flight crew flew the accident airplane back to CLT the next morning (January 8th), arriving at 0715. According to post accident interviews, neither the captain nor the first officer of those two flight legs noticed anything unusual about the airplane. On January 8, 2003, the accident flight crew was scheduled to fly two flight legs on a 1-day trip sequence-CLT to GSP and GSP to Raleigh-Durham International Airport (RDU), Raleigh-Durham, North Carolina-and then to travel on duty as passengers from RDU to CLT. An Air Midwest pilot saw the captain in the gate area about 0745 and the first officer about 0800. The dispatch release for flight 5481 showed that a maximum of 32 bags was allowed on the flight. One of the two ramp agents working flight 5481 stated, in a post accident interview, that 23 bags had been checked and that 8 bags were carried on the airplane. The ramp agent stated that two of the checked bags were heavy, with an estimated weight of between 70 and 80 pounds. The ramp agent also stated that he told the captain that some of the bags were heavy, although they were not marked as such. According to the ramp agent, the captain indicated that the bags were fine because a child would be on board, which would allow for the extra baggage weight. The ramp agent estimated that the forward cargo compartment was about 98 percent full by volume. Cockpit voice recorder (CVR) information early in the recording indicated that the flight crew was completing the preflight paperwork regarding the airplane's weight and balance. Air Midwest records indicated that flight 5481 departed the gate on time about 0830. The captain was the flying pilot, and the first officer was the nonflying pilot. Flight data recorder (FDR) data indicated that, beginning about 0835:16, the flight crew performed a control check of the elevators. The pitch control position parameter, which measures the position of the control column, recorded values from 15º airplane nose up (ANU) to 16.5º airplane nose down (AND). These values corresponded to elevator positions from full ANU to 7º AND. About 0837:20, the CVR recorded the first officer contacting the CLT Air Traffic Control Tower (ATCT) ground controller and informing him that flight 5481 was ready to taxi. The ground controller instructed the flight crew to taxi to runway 18R. About 0846:18, the tower (local) controller cleared flight 5481 for takeoff and instructed the flight crew to turn right to a heading of 230º after takeoff. About 0846:35, the captain asked the first officer to set the takeoff power, and the first officer stated that the power had been set. About 0846:48, the airplane's airspeed was above 102 knots, and the elevator position was 7º AND. About 3 seconds later, the elevator position was 1º AND, and the pitch attitude of the airplane began to increase. After 0846:53, the pitch trim started moving AND, and, about 3 seconds later, the captain called for the landing gear to be retracted. About 0846:57, the elevator position returned to 7º AND, and, about 2 seconds later, the CVR recorded the sound of the landing gear retracting. About 0847:02, the first officer stated, "wuh," and the captain stated, "oh." About 0847:03, the captain stated, "help me." At that point, the airplane was about 90 feet above ground level, and FDR data showed that the airplane's pitch attitude was 20º ANU and airspeed was 139 knots. About 0847:04, the CVR recorded the captain asking, "you got it?" and FDR data indicated that the flight crew was forcefully commanding AND. During the next 8 seconds, the CVR recorded multiple statements and sounds from both flight crewmembers associated with their efforts to push the airplane's nose down. Also, about 0847:09, the CVR recorded a change in engine/propeller noise and, about 1 second later, the beginning of a sound similar to the stall warning horn. About 0847:13, the FDR recorded a maximum pitch attitude of 54º ANU. About 0847:16, the captain radioed the ATCT and stated, "we have an emergency for Air [Midwest] fifty four eighty one," and the CVR recorded the end of the sound similar to the stall warning horn. About 0847:18, the airplane's pitch attitude decreased through 0º, and the elevator position began to move ANU. By 0847:19, the airplane was about 1,150 feet above ground level, and the FDR recorded a maximum left roll of 127º and a minimum airspeed of 31 knots. About 1 second later, the FDR recorded a pitch attitude of 42º AND. About 0847:21, the captain stated, "pull the power back," the elevator position reached full ANU, and the airplane's pitch attitude was 39º AND. At 0847:21.7, the CVR recorded the beginning of a sound similar to the stall warning horn, which continued to the end of the recording. About 0847:22, the airplane's roll attitude stabilized at about 20º left wing down; the pitch attitude began to increase; and the elevator position moved in the AND direction, reaching about 8º ANU. About 1 second later, the elevator position began moving in the ANU direction. About 0847:24 the airplane rolled right through wings level, and the pitch attitude increased to about 5º AND. About 0847:26, the FDR recorded a maximum right roll of 68º and a maximum vertical acceleration of 1.9 Gs. About the same time, the captain stated, "oh my god ahh," and the first officer stated something similar to, "uh uh god ahh [expletive]." The CVR recording ended at 0847:28.1. The FDR's last recorded pitch attitude was 47º AND; roll attitude was 66º to the right; and pitch control position was 19.2º ANU, which corresponded to an elevator position of full ANU. The airplane struck a US Airways maintenance hangar on CLT property and came to rest about 1,650 feet east of the runway 18R centerline and about 7,600 feet beyond the runway 18R threshold. ATCT controllers heard an emergency locator transmitter signal beginning about 0847:29. The accident occurred at 35º 12' 25" north latitude and 80º 56' 46.85" west longitude during daylight hours.
• #29: Abstract: On January 8, 2003, about 0847:28 EST, Air Midwest flight 5481, a Raytheon (Beechcraft) 1900D, N233YV, crashed shortly after takeoff from runway 18R at Charlotte-Douglas International Airport, Charlotte, North Carolina. The 2 flight crew members and 19 passengers aboard the airplane were killed, 1 person on the ground received minor injuries, and the airplane was destroyed by impact forces and a post crash fire. Flight 5481 was a regularly scheduled passenger flight to Greenville-Spartanburg International Airport, Greer, South Carolina, and was operating under the provisions of 14 "Code of Federal Regulations" Part 121 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident. The National Transportation Safety Board determines that the probable cause of this accident was the airplane's loss of pitch control during takeoff. The loss of pitch control resulted from the incorrect rigging of the elevator control system compounded by the airplane's aft center of gravity, which was substantially aft of the certified aft limit. Contributing to the cause of the accident were the following: (1) Air Midwest's lack of oversight of the work being performed at the Huntington, West Virginia, maintenance station; (2) Air Midwest's maintenance procedures and documentation; (3) Air Midwest's weight and balance program at the time of the accident; (4) the Raytheon Aerospace quality assurance inspector's failure to detect the incorrect rigging of the elevator control system; (5) the FAA's average weight assumptions in its weight and balance program guidance at the time of the accident; and (6) the FAA's lack of oversight of Air Midwest's maintenance program and its weight and balance program. The safety issues in this report focus on maintenance work practices, oversight, and quality assurance; aircraft weight and balance programs; maintenance training; FAA oversight; and Beech 1900 cockpit voice recorder problems.
• #30: The mechanic who adjusted the flight-control cables on the Beech 1900 turboprop was doing the job on that type of airplane for the first time, sources said. He expected an inspection by his supervisor. Whether the inspection ever occurred is part of the investigation. "(The mechanic) was told to do the job," the source said. "The inspector/supervisor told him some steps to follow and said he would watch him. But that guy was busy, inspecting and managing (and) trying to hold the operation together." At bigger maintenance bases, including some third-party shops, there is typically more support for a mechanic, including inspectors, more supervisors and experienced co-workers
• #31: Even the inspection card and the aircraft Maintenance Manual had inadequate instructions.
• #32: Cable Mis-rigged Altered Relation Between FDR Sensor and Elevator. This was caused by the failure to follow the correct rigging procedure.
• #33: Additional NTSB findings included: Failure to follow procedures Company Manufacturer Failure to document actions Failure to communicate Turnover process Supervisory oversight Regulatory oversight “Safety Culture”
• #34: NTSB 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. .
• #35: In every accident there are a series of events that link together to form a chain. We call this a chain of events.
• #36: 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.
• #37: Break the chain of events by complying with the performance standards set forth by regulatory, manufacturer’s and operator’s procedures.
• #38: Safety nets are mechanisms that you can put into place to help break the chain and insure an error doesn’t go on to create an accident. All of the factors in the SHELL model 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?
• #39: 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
• #40: Safety Nets continued: 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
• #41: Reasons to follow procedures motivation will be to Do the job to the best of your ability Complying with the required regulations Be safety minded Take pride in ownership Be a professional Its good for the company Its just good business
• #42: Review Checklist. Before the Task KEEP THIS IN YOUR TOOLBOX!!
• #43: Review Checklist. After the Task
• #44: 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, providing answers to specific questions related to regulatory overview, Accident scenario, Maintenance error, Chain of events, Safety nets, Safety motivation and Safety tools.
• #45: The first nut on the bolt (Nut A) represents the minimum standard of performance that maintenance personnel are accountable for when performing maintenance. ( 15 seconds to write your answer) The correct answer is FAR 43.13
• #46: The second nut on the bolt (Nut B) represents the functions or tasks that FAR 43.13 applies to. ( 15 seconds to write your 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.
• #47: (This is a two part question) The third nut on the bolt (Nut C) 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 & Inspection
• #48: (This is a two part question) The fourth nut on the bolt (Nut D) represents the national statistics of aircraft accidents resulting from maintenance error. What is the most prevalent maintenance error and statistical percentage (%) ? ( 20 seconds to write your answer)
• #49: The fifth nut on the bolt (Nut E) is a rhetorical question where the instructor simply provides the answers.
• #50: There are at least 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 See Slides 47 & 48 for additional answers
• #51: The seventh nut on the bolt (Nut F), 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)
• #52: The eighth nut on the bolt (Nut H), represents a safety tool designed to prevent failure to follow procedure events. The safety tool outlines steps to use before and after a maintenance or inspection task that we have discussed today. Name that tool ( 15 seconds to write your answer)
• #53: Congratulations on your successful and safe reassembly of the nuts and bolt in preventing a failure to follow procedures!
• #54: 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.