4'0 Shift Task Turnover

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4.0 Shift /Task Turnover
Presented by Dave Supplee, USAirways/IAM Terry
Kleiser, FedEx Express
FAA/Industry Maintenance Human Factors Workgroup
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 Shift/Task Turnover Important
How to Implement a Shift/Task Turnover Process
How to know the Shift/Task Turnover process is
working
Key References
Final Thought/Discussion
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Agenda
Why is Shift/Task Turnover Important
How to Implement a Shift/Task Turnover Process
How to know the Shift/Task Turnover process is
working
Key References
Final Thought/Discussion
4
Shift/Task Turnover Why is it Important
Use bullets an pictures DO NOT READ THEM THE
BOOK!

• Shift and task turnover are critical periods in
  aircraft maintenance activities because workers
  relay crucial information for ending a shift and
  starting another as well as turning over a task
  within the shift.
• Events have shown us that inadequate information
  exchange during shift and task turnovers can have
  serious consequences.

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EMB-120RT, In-Flight Structural Breakup

• Departures from approved procedures included
  failures to solicit and give proper shift-change
  turnover reports, failures to use maintenance
  work cards as approved, failures to complete
  required maintenance/inspection shift/turnover
  forms, and a breach in the integrity of the
  quality control.
• NTSB /AAR-92/04 Eagle Lake

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EMB-120RT, In-Flight Structural Breakup

• Outgoing AMT failed to provide a written task
  turnover to supervisor, only a verbal task
  turnover was provided
• The Supervisor failed to pass on the verbal
  turnover to the next shift
• Oncoming AMTs looked at the L/E from below and
  it appeared the installation was complete
• Aircraft departed with the L/E only partially
  installed (upper screws missing), resulting in an
  catastrophic accident
• The Safety Board concludes that the GMM
  contained clear procedures, which, if followed
  could have prevented the accident

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B737-200, 1 Eng. Thrust Reverser Incident

• Due to an oil leak at the oil filter housing, a
  decision was made to remove and replace the
  engine
• Replacement engine was delivered without the
  tailpipe and T/R assembly
• 1st shift began swapping the tailpipe/thrust
  reverser assembly from the old engine to new
  engine
• 1st shift AMTs failed to document (short sign)
  the loosening of 38 of the 42 flange bolts that
  held the assembly to the core

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B737-200, On-Landing 1 Eng. Tailpipe/Thrust
Reverser Departed the Aircraft

• No verbal or written task turnover took place
  between shifts.
• 2nd shift decided they could fix the oil leak
  rather than removing and replacing the engine.
• 2nd shift AMTs repaired the leak. They did not
  know or recognize only 4 of the 42 bolts holding
  the tail pipe assembly were tight.
• The aircraft flew without incident for one day.
  The first landing of the next day the
  tailpipe/thrust reverser departed the aircraft,
  causing substantial damage to the pylon and
  engine.

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B737-300 ADC Lines Left Off After IRU Replacement

• IRU replaced on 2nd shift.
• ADC lines needed to be removed to provide
  clearance to remove IRU.
• AMT on 2nd shift did provide written turnover,
  but failed to mention ADC lines needed to be
  reconnected.
• AMT on 3rd shift was given written turnover and
  was told by supervisor that a functional check
  was all that was needed of the IRU.
• On originating flight of the day, at 80 kts,
  F/Os airspeed still was at 0 kts, T/O aborted.
• AC returned to the gate where ADC lines were
  reconnected.

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Agenda
Why is Shift/Task Turnover Important
How to Implement a Shift/Task Turnover Process
How to know the Shift/Task Turnover process is
working
Key References
Final Thought/Discussion
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Shift /Task Turnover - How to implement

• Development and implement policies, procedures
  and protocol
• Provide time and place for formal shift/task
  turnover
• Provide documentation that allows space for
  proper turnovers
• Accomplish initial and recurrent training on
  shift/task turnover policy/procedures
• Challenges
• Policy/Procedure compliance
• Consistent application

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Shift /Task Turnover Documentation Tools

• This turnover form has a running list of items
  needing completion or the completion of an item.
• In this example, a carrier had a task scheduled,
  but the open item was missed which required the
  left side control rods to be rigged, safetied
  close-up accomplished.
• Fortunately, this item was caught by the
  inspection crew when they performed the
  post-check inspection.

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Shift /Task Turnover Documentation Tools

• Another form of turn-over, but easier to track
  each item
• Had this form been used in the previous example,
  it would have been obvious that an item was not
  completed.

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Shift /Task Turnover Documentation Tools
These are shift turnover reports, where the
status of on-going work can be passed to the
on-coming shift. Also any incoming items can be
passed on with this form.
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Agenda
Why is Shift/Task Turnover Important
How to Implement a Shift/Task Turnover Process
How to know the Shift/Task Turnover process is
working
Key References
Final Thought/Discussion
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Shift/Task Turnover - How to know it is working

• Fewer incidents/accidents related to lack of
  verbal or written turnovers
• Fewer tasks starting over from the beginning of
  one shift to the other i.e. flight control
  rigging
• Decrease in Internal/FAA documentation audit
  findings

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Agenda
Why is Shift/Task Turnover Important
How to Implement a Shift/Task Turnover Process
How to know the Shift/Task Turnover process is
working
Key References
Final Thought/Discussion
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Shift/Task Turnover - Key References

• Shift work and Scheduling
• This document not only looks at the process of
  shift turn-over, but also the physical effects
  shift work has on the actual production during
  the shift. It gives valuable information on how
  to address some of the effects of shift work and
  on what an effective turn-over process should
  include.
• Task Analysis of Shift Change Activity in
  Aviation Maintenance Environment
• This document outlines the task analytic
  methodology used to analyze the shift change
  process at representative aircraft maintenance
  sites, the taxonomy of errors developed and the
  human factors interventions to prevent errors.
  Finally, the paper documents a standardized shift
  change process detailing the shift change
  protocol.

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Shift/Task Turnover - Key References (continued)

• CAP 716, Appendix T
• This document was drafted for EASA/JAR 145
  organizations and uses accident and incident
  findings to support the need for effective shift
  and task turn-overs. It gives examples of
  processes and documents to improve the shift/task
  turn-over communication.

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Agenda
Why is Shift/Task Turnover Important
How to Implement a Shift/Task Turnover Process
How to know the Shift/Task Turnover process is
working
Key References
Final Thought/Discussion
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Final Thought/Discussion

• You cant be careful enough, work turnover is a
  time technicians are at greatest risk