National

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2.0 Documentation
Barbara Kanki 650 604-5785 Barbara.g.kanki_at_nasa.go
v Ernie Kiss 678 898-3422 kissgatr_at_juno.com
National Aeronautics and Space Administration
Introduction of The Operators Manual for Human
Factors in Aviation Maintenance jetBlue Airways
New York 25-26 October2005
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Agenda
Why is Documentation Important
How to Implement a Documentation Program
How to know the Documentation program is working
Key References
Discussion as Time Permits
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Agenda
Why is Documentation Important
How to Implement a Documentation Program
How to know the Documentation program is working
Key References
Discussion
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Mechanics would benefit from using Airliner
Maintenance Manuals with more specific
instructions for critical flight system
procedures.
NTSB/AAR-04/01

• Flight 2574, September 11, 1991
• Flight 5481, January 8, 2003

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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 airplanes 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.

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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. . .

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Flight 5481, January 8, 2003

• Beechcraft 1900D with 19 passengers/2 crew,
  lost pitch control during takeoff and crashed
  killing all onboard
• Probable Cause Airplanes loss of pitch
  control during takeoff resulting from the
  incorrect rigging of the elevator control system
  compounded by the airplanes aft center of
  gravity
• Contributing Factors Operators lack of
  oversight of the work being performed at
  the maintenance station, maintenance procedures
  and documentation, and weight and
  balance
• program. . .

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Flight 5481 NTSB Boardroom Meeting S. Carbone,
Aircraft Maintenance and Records Investigator
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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. .

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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

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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 users

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Agenda
Why is Documentation Important
How to Implement a Documentation Program
How to know the Documentation program is working
Key References
Discussion
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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?

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Agenda
Why is Documentation Important
How to Implement a Documentation Program
How to know the Documentation program is working
Key References
Discussion
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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/practices

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Agenda
Why is Documentation Important
How to Implement a Documentation Program
How to know the Documentation program is working
Key References
Discussion
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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.

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Agenda
Why is Documentation Important
How to Implement a Documentation Program
How to know the Documentation program is working
Key References
Further Discussion
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Discussion Topics

• What are your most important documentation
  issues?
• Lessons Learned in Solving Documentation Problems
• 121, 135, 145

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Summary
Why is Documentation Important
How to Implement a Documentation Program
How to know the Documentation Program is working
Key References
Further Discussion
The 5th Annual CIS, Central Eastern Europe
Airline Engineering Maintenance
Conference 14-15 September 2005 - Warsaw