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NOVEMBER-DECEMBER 1996

F L I G H T S A F E T Y F O U N D A T I O N

Aviation Mechanics Bulletin

Team of MaintenanceInspectors and HumanFactors Researchers

Improves Shift-turnover Log

Aircraft number: Date: Shift (Please Circle): Day Afternoon Night

Inspectors Assigned: Projected A/C Departure Date:

Problem Workcards

Card number Problem

General Problems

Inspection Shift-turnover Log

F L I G H T S A F E T Y F O U N D A T I O N

Aviation Mechanics BulletinDedicated to the aviation mechanic whose knowledge,craftsmanship and integrity form the core of air safety.

Robert A. Feeler, editorial coordinator

Team of Maintenance Inspectors and Human FactorsResearchers Improves Shift-turnover Log ....................................................1

News & Tips ............................................................................................... 17

Maintenance Alerts ..................................................................................... 18

New Products ............................................................................................. 20

November–December 1996 Vol. 44 No. 6

AVIATION MECHANICS BULLETINCopyright © 1996 FLIGHT SAFETY FOUNDATION INC. ISSN 0005-2140

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FLIGHT SAFETY FOUNDATION • AVIATION MECHANICS BULLETIN • NOVEMBER–DECEMBER 1996 1

Team of MaintenanceInspectors and Human Factors

Researchers ImprovesShift-turnover Log

A maintenance technician was rein-stalling a turbine’s plugs and coverswhen a colleague offered to help. Thefirst maintenance technician told thesecond to go ahead and install theignitors. “I saw him install the out-board ignitor,” the maintenance tech-nician recalled later, adding that hiscolleague had then moved under theengine as if he were also installingthe inboard ignitor. “I did not go backand check his work because I trust thework he does.” The first techniciansigned off on the paperwork, only tolearn later that his colleague had notinstalled the inboard ignitor.

This is one example of the manykinds of human factors, ranging

from chronic overwork to poor work-place organization, that can causeproblems in aircraft-maintenancefacilities.

A research report, “Human FactorsProgram Development and Imple-mentation,” by Colin G. Drury, Ph.D.,Caren Levine and Jacqueline L. Rey-nolds, of the State University of NewYork (SUNY) at Buffalo, New York,U.S., explains how a human factorsprogram was developed and imple-mented at one U.S. airline.

The report outlines lessons learnedfrom the program — that, at this fa-cility, accomplishing program goalsrequired focusing on one specific

Robert L. KoenigAviation Writer

2 FLIGHT SAFETY FOUNDATION • AVIATION MECHANICS BULLETIN • NOVEMBER–DECEMBER 1996

problem that the maintenance depart-ment could control, and that distrustof management’s motives was an im-pediment to the program.

When human factors researchershelped develop the human factorsprogram, they found that their initialapproach — using a small workforce–management team to targetimprovements related to specific jobs— did not work as well as it had inother industries.

“Our airline partner’s specific needsrequired a different approach, basedon involving the maximum numberof people, instead of a small taskforce, and limiting the scope toone issue, such as communication,rather than searching broadly for[human factors] mismatches,” thereport concluded. “Focusing oncommunication brought potentialsolutions under direct control ofemployees at the site, while stilldemonstrating potential for im-proved human-error rates.”

If an aircraft maintenance technicianforgets to report a rag dropped acci-dentally into an engine or a mainte-nance technician has trouble stayingawake because of shift changes, thoseare human factors that can causemaintenance problems. The goal ofhuman factors, also known as ergo-nomics, research is to find ways toimprove employee productivity, max-imize the consistent quality of their

work and improve the long-termhealth and safety of workers.

To reach that goal, researchers mea-sure the job demands imposed by theworkplace, environment and sched-ule. Then they compare those demandswith the employees’ capabilities tocomplete the tasks consistently andthoroughly. “Where task demandsexceed human capabilities, perfor-mance will break down, leading tohuman errors, which can manifest assafety-compromising incidents and/or on-the-job injuries,” the reportsaid.

To improve safety and reduce thenumber of injuries, employersshould develop “a better (safer)match between task demandsand human capabilities,” either bychanging the demands — the work-place, the environment or the orga-nization of the work — or bychanging the workers’ capabilitiesthrough better training or placement,the report said.

The airline established a human fac-tors program to redesign its aircraftmaintenance technicians’ work envi-ronments and to prevent on-the-jobinjuries, the report said. The initial fo-cus of the program was on the air-line’s maintenance-base inspectionsdepartment.

The company formed a human fac-tors task force including both


management and hangar workers andgave each task-force member a jobtitle, such as inspector or safety man-ager. Human factors researchers fromSUNY-Buffalo were assigned as ad-visers to the task force. The reportsaid that the initial decision to use atask force as recommended by Burke1

was made because “a team approachgives the organization maximum in-put from various people who will beaffected by any changes.”

The researchers also felt that includ-ing “work force representatives inthe analysis and redesign of theirown jobs makes them more inclinedto accept [human factors] solutions”suggested by the task force. “This isbecause they actively contributed tothe solution-development process.”

In addition, the university research-ers contended that including inspec-tors on the task force “was criticalto its potential for success. Inspec-tors have unparalleled expertise ...that leads to an understanding ofwhat changes are most necessary andwhat solutions may or may notwork.”

The initial objectives of the task forceincluded:

• Developing a process for iden-tifying and addressing humanfactors issues in the inspectiondepartment that would later beused in other departments;

• Reducing the number of on-the-job injuries;

• Finding solutions to human fac-tors problems that could beimplemented and whose resultscould be measured; and,

• Teaching employees about hu-man factors.

The task force followed a number ofguidelines concerning the focus (“in-spection jobs and tasks in the han-gar area”), the time span (one year)and other criteria. The researchersconducted a one-day training semi-nar for the task force. Then the taskforce selected the five inspectiontasks to be analyzed at the mainte-nance base: electrical and equip-ment-compartment inspection; keelinspection; fuel-tank inspection;combustion-chamber inspection;and nose- and forward accessory–compartment inspections.

Using an electronic-audit inspectionprogram developed by SUNY-Buffalo, the task force audited fourof the jobs listed above to determinethe human factors risks facing theemployees.

In each of the following six areas, thetask force listed three risk factors thatwere the greatest concerns:

• Work cards (card content inac-curate; breaks between cardsinappropriate; and card contrastvaried);


• Lighting (fixtures dirty; lightinginadequate at the back ofthe hangar; no preventive-maintenance program forlighting);

• Keel inspection (body position-ing; cleaning; lighting);

• Drain-box inspection (body po-sition; nondestructive testing[NDT] equipment; cleaning);

• Electrical and equipment-compartment inspection (light-ing, temperature and equip-ment); and,

• Forward access-compartmentinspection (ladder design, lad-der control and work planning).

Task-force members decided to con-centrate on finding potential improve-ments for ladder purchase andcontrol, cleaning, task lighting andwork-card design.

Despite the clear definition of taskforce goals, the researchers soonfound that the group “was not pro-gressing on developing solutions.”After discussing the problems withtask-force members, the researchersconcluded that the team’s work hadbeen hampered by factors such as:

• Work mandate. Some task-force members felt that they“had no mandate to pursue their[task-force] assignments as partof their busy schedules”;

• Jurisdiction. Some solutions,such as redesigning work cards,were functions of another partof the company;

• Costs. Solutions such as im-proving lighting would be ex-pensive; and,

• Support. Even though a seniormanager had championed thehuman factors effort, “neithermanagement nor the work forcefelt a ground swell of support forthe task force’s activities.”

Therefore, the report said, “the taskforce was disbanded, and the [humanfactors] efforts were refocused on adifferent problem that could havebroad-based support and be entirelyunder the control at the maintenancebase.”

The new focus was on communica-tion because “many task-force mem-bers recognized communicationbetween shifts as one area in need ofimprovement.” In addition, that prob-lem could be addressed without in-volving other parts of the airline.

To determine the extent of commu-nication problems, the human factorsadvisers developed a user-needsanalysis questionnaire that was sentto inspectors on all three shifts. In-spectors play a key role because theyare the first to examine an aircraftto identify its problems. Inspectorsdecide which problems maintenance


technicians must fix before the air-craft leaves the hangar and whichmaintenance tasks can be delayeduntil the next regular maintenancecheck. Also, inspectors must ensurethat maintenance technicians’ workwas performed properly.

“An inspector must be able to shareinformation with management andother employees so that everyoneunderstands an aircraft’s current sta-tus,” the report said. Depending onthe situation, inspectors might haveto communicate with other inspec-tors (on the same shift or on othershifts), maintenance technicians, thelead inspector, the inspection man-ager, the maintenance manager, en-gineers, other company managementor flight crews. “The inspector musthave the communication tools andskills to share information with oth-er members of the organization,” thereport said.

The SUNY-Buffalo advisers also ex-amined data from outside sources. Tofind examples of breakdowns in com-munication, the researchers reviewed28 maintenance technician’s reportsfrom the U.S. National Aeronauticsand Space Administration (NASA)Aviation Safety Reporting System(ASRS) data base. Those incidentswere reported voluntarily by mainte-nance technicians at many airlinesduring a seven-year period, and thereport emphasized that they were notincidents from the airline for which

the human factors program was be-ing developed and implemented.

[Aviation maintenance technicianssubmit only about 1 percent of thetotal number of ASRS reports,2

and because the reports are volun-tary they do not represent a statisti-cally valid sample of all aviationmaintenance incidents. The num-bers, types and percentages ofincidents in ASRS records do notrepresent the numbers, types andpercentages of incidents actuallyoccurring, reported or not.

[The only reasonable inference is thatthe number of incidents of a particu-lar type reported to ASRS is the min-imum number that actually occurred.Although the unknowable actual to-tal might be much greater, the num-ber of ASRS reports is often all thatdecision makers need to determinethat a problem exists and requiresattention.]

The review of ASRS reports foundseveral typical types of communica-tion problems involving maintenancetechnicians or inspectors:

• Many incidents were caused bymaintenance technicians be-coming distracted while per-forming a task;

• Maintenance technicians oftendid not write exactly what theydid or what parts of a task wereuncompleted;


• When a maintenance techni-cian had to allow anothermaintenance technician tocomplete a task, it could “leadto difficulties when the second[maintenance technician did]not understand the situation orrealize specifically what [re-mained] to be done”;

• Because one maintenance tech-nician had to sign off on thecompletion of a task even ifothers also worked on it, “it[was] difficult to pinpoint whoactually worked on the task,”other than the maintenancetechnician who signed;

• Maintenance technicians weresometimes given false verbaldescriptions of discrepancies,or verbal descriptions that dif-fered from the information thatwas in the logbook; and,

• At times, maintenance techni-cians were assigned to a taskwithout being given all the ac-companying paperwork. “Thiscan lead to the [maintenancetechnician] making an incor-rect diagnosis of the problemand, consequently, taking in-correct action to correct theproblem.”

Certain communication failure typeswere associated with different com-munication needs in the 28 ASRS re-ports that the researchers analyzed;

and although the ASRS data do notprovide a random sample of commu-nication failures, they can be used toidentify the different types of failuresexperienced in the aircraft mainte-nance environment.

A maintenance technician communi-cating with himself or herself canhave a memory failure. This hap-pened when a mechanic relied onmemory rather than a written note orother job aid, such as a checklist.

Maintenance technicians communi-cating with flight crew were subjectto failures of both written andverbal communication. Communica-tion problems from flight crew tomaintenance were either failures tocommunicate at all or a breakdown ofthe written process. The researcherssuggested that this might result “fromthe widely different background train-ing of flight operations [personnel] andtechnical operations [personnel] andthe lack of opportunities for verbalcommunication between these groups.Clearly, methods of improving com-munications between these groups areneeded, [for example], extensions ofCRM [crew resource management]and MRM [maintenance resourcemanagement] to joint training.”

Communication failures betweenmaintenance technicians, and betweenmaintenance technicians and supervi-sors, resulted from either a failure to


communicate at all or a failure of ver-bal communication. This also includ-ed shift-change communication.

The report said, “Clearly, writtencommunication does not fail; if peo-ple use written communication, thenthis is adequate. The main emphasisfor addressing these problems shouldbe ensuring that [maintenance tech-nicians] and supervisors use writtencommunication. Thus, the new focusof this project became redesigningcommunication forms so [mainte-nance technicians] and supervisorscan use them more easily.”

Based on these findings, the research-ers concluded that written communi-cation is extremely important inairline maintenance and inspection.“Verbal communication, althoughoften more convenient, is more error-prone, especially when informationmust be remembered for long peri-ods of time or must be passed sequen-tially through a number of people,”the report said.

Because of the critical importance ofcommunication, the researchers inter-viewed inspectors at the maintenancebase to determine how communica-tion there might be improved. A ma-jor focus of the communicationuser-needs analysis questionnairewas on the shift-turnover log, a boundbook with numbered pages. Lead in-spectors make entries in the log ev-ery day, with information such as who

called in sick, who worked overtimeand a quick summary of each air-craft’s status.

“It is difficult to identify who madean entry in the log, and few entries areever followed up with another entrydescribing how the problem was re-solved,” the report said. “The existingshift-turnover log does not serve as acommunication tool, showing thetasks with multishift implications, nordoes it provide the information neces-sary for subsequent shifts to ‘pick up’where a previous shift left off.”

The researchers questioned inspec-tors and management in detail. Theresponses to the user-needs analysisquestionnaire revealed that many in-spectors did not understand how theirtasks fit into the larger picture of air-line maintenance. “For example, jobsare often assigned to inspectors inwhat they perceive as a random man-ner ... ,” the report said. “Many times,there seems to be little considerationof how job scheduling affects themaintenance department.”

Follow-up personal interviews withinspectors “generally support[ed] theresults from the user-needs analysis,”the researchers found, and also pro-vided insight into how to improvecommunication for inspectors. Someexamples follow:

• Inspectors said that they nearlyalways communicated verbally


with their lead inspector andwith other airline employees.But most inspectors had notconsidered the consequences ofdoing a job correctly but notdetailing it in writing. “Even ifan inspector did everything cor-rectly, there would be no wayto prove this in an investiga-tion,” the report said;

• Information resources werebetter on the weekday-dayshift and in the early part of theweekday-afternoon shift,when each department wasfully staffed with engineers,management officials andplanners. “During the secondhalf of the afternoon shift, onthe night shift and on week-ends, it [was] difficult andtime-consuming to get infor-mation from those resources,”the report said;

• Inspectors tended to receiveonly the information from theprevious shift that the previousshift’s lead inspector passedalong. The report warned ofa “danger in filtering criticalinformation through the leadinspectors” without commun-ication from others on theshift;

• When inspectors were busy, theytended to fall behind in readingupdates to maintenance manuals.Inspectors were supposed to read

the updates daily and sign offon any new entries. But no su-pervisor ever seemed to questioninspectors if inspectors fellbehind in that task; and,

• Inspectors received a lot of in-formation from maintenanceupdates and other sources that“they [saw] as irrelevant to theircurrent responsibilities,” andwasted time that might havebeen spent keeping up-to-dateon material that did apply totheir operations. Thus, if a baseserviced only McDonnell Dou-glas DC-9s but was flooded withinformation about Boeing 727sand McDonnell Douglas DC-10s, some inspectors feared thatthey might overlook a relevantupdate.

In their meetings with airlinemanagement officials, the research-ers said that communicationproblems existed and made severalrecommendations:

• Improve inspectors’ communi-cation skills by training them.“Inspectors must learn what isexpected, so they understandwhat information must be com-municated and why it isimportant,” the report said;

• Explain the benefits of bettercommunication, to motivateinspectors to improve and toreassure them that the new


requirements would not in-crease their work loads; and,

• Develop better communicationtools for passing along infor-mation such as managementmemos and aircraft alerts andfor recording detailed problemsand necessary follow-up ac-tions at shift turnovers.

In developing such new tools,the medium of communica-tion — logbooks, verbal mes-sages or blackboards — mustbe chosen carefully “to pro-vide only the information thatinspectors need and not tooverload them with unneces-sary information,” the reportsaid. “Information should bepresented in a form that is easyto use and that allows inspec-tors easily to elicit specificdetails, as necessary”;

• Arrange for input from every-one in the inspection depart-ment — including managers,the lead maintenance techni-cian and inspectors — into re-designing the communicationssystem;

• Standardize communicationsystems so that they can beused by all the inspectiongroups, such as support shops,engine shops and major main-tenance shops. “Such standard-ization would make it easier forinspectors to move among

groups, effectively obtainingnecessary information ... ,” thereport said; and,

• Make it standard practice to usethe shift-turnover log to com-municate information from themaintenance department’s dai-ly morning meeting to othershifts.

To solve communication problems,the researchers considered a numberof options, including the following:

• A formal written log (the shift-turnover log), which would bea permanent written record ofactivities in the inspectiondepartment;

• Informal written notes, ad-dressed to either an individualor an entire crew, whichwould be preferable to verbalcommunication;

• Tape recordings, which offer aquick way to replace writtennotes. Some tapes might laterbe transcribed into a writtenlog;

• Computer software tools, suchas e-mail, electronic bulletinboards and electronic turnoverlogs, which allow morethan one person to have accessto the same informationsimultaneously;

• Blackboards or whiteboards,which are useful in displaying


information that needs to beseen for only a short time. Thiscan be a good way of commu-nicating with an entire crew;

• Formal crew meetings, whichare useful in reaching all in-spectors, who then have theopportunity to discuss the in-formation presented;

• Informal verbal communica-tion, a quick but short-livedway to transmit information.During busy times, however,such communications can over-tax inspectors’ memories; and,

• Nonroutine work cards, whichcan be used to identify parts ofthe aircraft that require main-tenance and can later bechecked to verify that the workwas done properly.

In the end, the researchers proposeddeveloping a revised version of theexisting shift-turnover log that couldimprove communication among in-spectors on different work shifts.“The present shift-turnover log isused mainly by the lead inspectorsand does not contain much informa-tion that inspectors can utilize,” thereport said. “It does not record activ-ities that took place during a shift orhelp the next shift know what theyneed to accomplish.”

Researchers developed versions of anew log that “is intended for use by

all inspectors,” the report said. “It al-lows an inspector to record activitiesduring a shift, leaving a written ac-count of what needs to be accom-plished and helping prevent rework,”or more than one inspection of thesame area of the aircraft. Rework isoften caused by miscommunicationbetween two inspectors, especiallywhen an inspection is carried overfrom one shift to the next shift.

The first draft of the new shift-turnover log was organized into fivebound logbooks, each with numberedpages. The first logbook (Figure 1,page 11) was the “general shift-turnover log,” which could be used topass information between shift leads.Information that could be entered intothe general shift-turnover log includ-ed general problems and personnelinformation, such as assigned over-time and call-ins of workers.

The other four logbooks were color-coded, each colored logbook corre-sponding to a color assigned to oneof the four hangar bays. A new log-book was used for each aircraft, sum-marizing the inspection history of theaircraft (Figure 2, page 12). Inspec-tors assigned to that aircraft wereasked to complete the log, whichcould be filed when the aircraft leftthe hangar.

A sample group of 17 inspectorswas asked to evaluate the proposedshift-turnover log. The inspectors


General Shift Information

Date: To Be Read By: Morning Afternoon Night Shift

Filled in By: on the Morning Afternoon Night Shift

Lead Inspector: Manager:

Personnel InformationCall-Ins

Name Reason Time

Name Reason Number of Hours

Overtime

Field Trips

Special Instructions/General Problems

Departure ReturnName Destination Time Time

Problem Needed Action/Alert Resolution Date Time

Inspection Shift-turnover Log (First Draft)

Figure 1

were asked to rate the log on a scaleof 0 (lowest) to 8 (highest) for 18aspects of usefulness and ease of use.

Researchers analyzed the inspectors’responses to determine whether the

median response for each questionwas significantly different from thelow point (0), midpoint (4) or highpoint of the rating scale (8). [The me-dian is the midpoint value in a range;that is, the value above which half

Source: Colin G. Drury, Ph.D., et al.



Insp. Project/Problem Needed Action/Alert Resolution Date TimeOther Projects/Problems

Project Status Needed Action/Alert InspectorLong Term Projects

General Information/Notes:

Aircraft Status (Please Circle): Line Initial Shakedown Buyback

Inspectors Assigned:

Aircraft number: Day: Shift (Please circle): Morning Afternoon Night

the responses fall and below whichthe other half falls.]

The report said that the analysisshowed the following significantfindings:

• “Inspectors felt that theuse of a separate log forrecording personnel issuesand general problems wassignificantly better than‘useful’;

Figure 2

Inspection Log: Blue Bay (First Draft)


• “[Inspectors] ... indicated thatthey would read the turnoverlog for the aircraft to whichthey were assigned more thanthree times per week;

• “Inspectors ... felt that the pro-posed turnover log was moreuseful than the current turnoverlog; [and],

• Inspectors [indicated] thatthey would use the proposedturnover log more often thanthey [used] the current turnoverlog.”

Other general trends, which were notstatistically significant, included thefollowing:

• Inspectors found the proposedlog easy to understand;

• Inspectors found that the gen-eral and aircraft sections con-tained the right amount ofinformation;

• Inspectors indicated that theywould be likely to make an en-try in the log only three timesper week, not every day, as thelog would require;

• Inspectors indicated that theproposed shift-turnover log didnot meet their needs for infor-mation; and,

• Inspectors did not find the pro-posed shift-turnover log layoutparticularly easy to use.

Using a team approach, the re-searchers met with each inspectionshift to discuss ways to improve thelog’s design. But “only a few” ofthe 10 inspectors to 15 inspectorsat each meeting gave suggestionsfor redesigning the log. In general,they recommended simplifying thelog so that it would require less timeto complete.

In contrast to their responses to the“user-needs” questionnaires, manyinspectors at the meetings said thatthey did not like the idea of a newlog because it “would require toomuch time and would place toomany additional requirements on theinspectors.”

Although many inspectors said thatthey liked the idea of a dedicated logfor the aircraft to which they wereassigned, they suggested that thelogs be designed for the lead inspec-tors rather than the inspection crews.The researchers described thatattitude as “troubling” because theASRS reports indicated that “it iscritical for inspectors working on anaircraft to have a good understand-ing of the problems the previousshifts encountered.”

In probing the inspectors’ preferenc-es concerning the logbook, theresearchers said that there was “alarge mismatch between the inspec-tors’ needs for information and theeffort they are willing to make to


obtain it. ... Inspectors seem to wantto receive information from the pre-vious shifts, but not to provide in-formation to the next shift.”

The roots of communication prob-lems went deeper than proceduralquestions, the report suggested.More fundamentally, they resultedfrom an atmosphere of distrust be-tween inspectors and management.Responses by 17 inspectors to theuser-needs analysis questionnaireidentified “a general problem withinspectors’ job satisfaction,” the re-port said. “Many inspectors reporthaving difficulty obtaining informa-tion they need to perform the job. ...The shift-turnover log is seen asa managerial tool, not as a way tocommunicate.”

The report added that “this reluctanceto communicate is a serious problemand must be addressed if inspectionproductivity is to be improved.”

Even though written communicationis far more accurate, it also madesome inspectors or maintenance tech-nicians uncomfortable because theyfeared that it would be used as an in-vestigative tool to examine actionstaken or not taken by maintenancecrews, the report said.

“There is an understandable reluc-tance in all branches of the airlineindustry to write anything not specif-ically required to be committed to

paper,” the report said. “[Inspectors]do not want to record additional in-formation in a log which could beused against them in an investigation;they do not realize that informationin a written log could protect them inan investigation ... .

“Many inspectors seem unwillingto make an effort to improve the com-munication process. They are unhap-py with how management treats themand, thus, have little motivation toimprove the situation. Most simplywant to perform their jobs and takeon as little responsibility as possible.Inspectors are distrustful of manage-ment and do not believe that manage-ment wants to aid the inspectors bytrying to improve communication. ...Even individual inspectors who wantto improve their jobs do not want toappear sympathetic to management’sneeds or wants.”

The researchers contended thatproblems between management andinspectors “must be resolved beforeany proposed shift-turnover log canmeet information needs of bothgroups. As is true of many humanfactors issues in aircraft mainte-nance and inspection, searching fora consensus solution to a technicalproblem reveals broad social issueswhen it is time for implementation.”

Beyond attitudinal issues, the com-munication systems had problems,and the report said: “Inspectors do not


use the shift-turnover log regularly,almost always need to search formore information after being as-signed a job, have experiencedon-the-job problems caused by mis-communication and deal with eachother almost always verbally.”

Concluding, nevertheless, that “in-spectors approve of the idea ofdeveloping a new format for the shift-turnover log and will utilize an

improved log,” the researchers devel-oped a simplified color-coded shift-turnover log in which inspectorswould record information about indi-vidual aircraft, considerably reducingthe detail required (Figure 3).

The researchers found that “inspec-tors rated the second draft signifi-cantly higher in both informationcontent and format,” and many in-dicated that it was more useful. In

Aircraft number: Date: Shift (Please Circle): Day Afternoon Night

Inspectors Assigned: Projected A/C Departure Date:

Problem Workcards

Card number Problem

General Problems

Inspection Shift-turnover Log (Second Draft)

Figure 3



the end, the new shift-turnover logmet more communication needs thanthe original log and was generallyaccepted by inspectors. “The specif-ic choice of the shift-turnover logshowed how involvement of bothhuman factors professionals and theinspection work force can producea practical, refined job aid,” thereport said.

In an effort to improve communica-tions, the airline introduced a bulletinboard for posting company news andannouncements at the maintenance-base inspections department, andscheduled more meetings betweenmanagement and inspectors.

Like the researchers, inspectors sug-gested allowing each inspector tocarry a small tape recorder and us-ing a blackboard or whiteboard torecord information that might beuseful on a short-term basis to allinspectors.

Other possibilities suggested by in-spectors to improve communicationincluded a shift-turnover log in theform of a simple checklist, allow-ing for quick completion, and us-ing one-on-one shift turnovers inwhich incoming inspectors walkthrough the hangar with outgoing

inspectors to discuss important in-formation.♦

Editorial note: This article was adapt-ed from “Human Factors ProgramDevelopment and Implementation,”by Colin G. Drury, Ph.D., Caren Le-vine and Jacqueline L. Reynolds, ofthe State University of New York atBuffalo. The report was included asChapter 6 in Human Factors in Avia-tion Maintenance — Phase FiveProgress Report, U.S. Federal Avia-tion Administration (FAA) Report no.DOT/FAA/AM-96/2. The 35-pagereport includes tables, figures, refer-ences and an appendix that details“Ergonomic Audits of InspectionsTasks,” “Ergonomic Risk Factors”and “General Communication UserNeeds Analysis.”

References1. Burke, M. Applied Ergonomics

Handbook. Boca Raton, Florida,United States: Lewis Publishers,1992.

2. U.S. National Aeronautics andSpace Administration (NASA)Aviation Safety Reporting System(ASRS). “ASRS Database Statistics.”ASRS Directline Issue no. 8 (June1996).


Get AirworthinessAlerts on the Internet

Advisory Circular (AC) 43-16, Gen-eral Aviation Airworthiness Alerts,issued periodically by the U.S.Federal Aviation Administration, isnow available on the Internet. To ac-cess AC 43-16, use the following ad-dress: http://www.fedworld.gov/ftp.htm.

Keying in that address will open theFedWorld File Transfer ProtocolSearch and Retrieve Service screen.Select the heading “Federal AviationAdministration” followed by “FAA-ASI.” The AC 43-16 file names beginwith ALT, followed by three letters forthe month, followed by two digits forthe year. Files can be viewed onscreenor downloaded.

PAMA ReschedulesAnnual Meeting

The Professional Aviation Mainte-nance Association (PAMA) has an-nounced that its Annual Symposiumand Trade Show, originally plannedfor May 14–16, 1997, has been re-scheduled. To avoid a conflict withanother association’s convention,PAMA has changed the dates of theAnnual Symposium and Trade Show

to May 20–22, 1997. The locationwill be the Fort Worth/Tarrant Coun-ty (Texas, U.S.) Convention Center.

Advisory CircularDescribes Distributor

Accreditation Program

The U.S. Federal Aviation Adminis-tration (FAA) has issued an Adviso-ry Circular (AC) that describes avoluntary system, which is based onindustry oversight, for the accredita-tion of civil aircraft parts distributors.The FAA believes that “such pro-grams will assist in alleviating lackof documentation and will improvetraceability,” according to the AC.

AC 00-56, Voluntary Industry Dis-tributor Accreditation Program, lists“quality systems” to ensure thatdocumentation provided by distrib-utors along with parts shipmentscontains the information necessaryto determine whether the parts areacceptable; lists organizations thathave existing quality standards con-sidered appropriate for distributors;describes procedures for auditingdistributors; describes accreditationprocedures; and includes sample cer-tification statement language.

There are about 2,500 civil aviationparts distributors in the United

NEWS & TIPS


States, the AC says, and they are notdirectly regulated by the FAA. “Partsfrom ... ‘accredited distributors’ willconvey an assurance to the purchas-er that the [parts are of] the qualitystated and that the appropriate doc-umentation is on file at the distribu-tor’s place of business.”

Gas Turbine ExpositionScheduled

Commercial and military aircraft en-gines will be among the applicationsfor gas turbines to be featured in theTurbo Expo ’97 Congress, spon-sored by the American Society ofMechanical Engineers (ASME) In-ternational. The exposition will take

place June 2–5, 1997, in Orlando,Florida, U.S.

The Congress will include four fulldays of technical sessions featuringmore than 500 presentations. The1997 Gas Turbine Users Symposium,which will run concurrently with theCongress, will include a “feature ses-sion” on important issues in aircraftengine applications, among otherareas.

For more information, contact: Inter-national Gas Turbine Institute, ASMEInternational, P.O. Box 422029,Atlanta, GA 30342 U.S. Telephone:(404) 847-0072; Fax: (404) 847-0151or (404) 843-2517.♦

MAINTENANCE ALERTS

New CorrosionInspection Requirements

Issued for DHC-6

A de Havilland Canada DHC-6 TwinOtter floatplane experienced a fail-ure of the down elevator control ca-ble while climbing after takeoff fromPort Hardy, British Columbia, Can-ada, on Sept. 17, 1994. The aircraftstalled and impacted the water, kill-ing the first officer and the two pas-sengers and seriously injuring thecaptain.

The cable failure, caused by corro-sion, occurred at station 376. It wasthe fifth reported DHC-6 cable fail-ure, all at station 376.

The maintenance required by the deHavilland Equal Maintenance forMaximum Availability (EMMA)work card directs: “ ... [Inspect] con-trol cables for fraying, brokenstrands, flattening, corrosion andsecurity of turnbuckles and cableends; plastic sheathing, where appli-cable, for cracking and deterioration.NOTE: It is important to operate


controls through the full range sothat cables move away from pulleysand all portions of cables are ex-posed for inspection.”

The Transportation Safety Board ofCanada (TSB) determined that theelevator control cable failure result-ed from gradual deterioration in anarea that contacted the lowermostpulley of the pulley cluster. It ap-peared that individual wires andstrands had failed before the com-plete failure.

EMMA requires the DHC-6 elevatorcontrol cable to be inspected every800 hours for an aircraft in normalservice and every 400 hours for anaircraft that regularly transports live-stock or corrosive materials. The PortHardy accident occurred 68 servicehours after the last inspection.

Three of the cable failures occurredon aircraft operating in a salt waterenvironment. Bombardier RegionalAircraft Division, which supports theDHC-6, has accelerated the requiredmaintenance schedule for aircraftoperating in marine areas or wherethere is a high salt concentration. For-merly, cables were required to be re-placed only as necessary. Now, thecontrol cables must be replaced ev-ery 12 months.

In another occurrence, the corrosionfailure was believed to be caused bycorrosive cargos leaking onto the

pulley area. Bombardier now re-quires the replacement of the eleva-tor and rudder control cables belowthe cargo compartment if there isspillage.

Bulkhead StructuralCracks Found in

Beechcraft Bonanza

During a scheduled inspection of aBeechcraft A36 Bonanza, a crackwas found in a bulkhead doubler(part number 002-440000-29), in anarea that is part of the reinforcementfor the attachment point of the rearspar for the vertical stabilizer.

The operator inspected the remain-der of its fleet and found five simi-lar defects. The total times for thedefective parts ranged from 2,300hours to 2,600 hours.

The crack that first alerted the oper-ator originated in the radius cutoutarea of the bulkhead doubler on theleft side. This is a difficult locationto inspect, requiring a mirror andflashlight. Access to the area isthrough the inspection panel on theleft rear of the fuselage.

Piper Aztec Heater FuelLeak Reported

The pilot of a Piper PA-23 Aztecreported fuel fumes in the cockpit


NEW PRODUCTS

Microprocessor-basedConductivity TesterPerforms with NewLevel of Accuracy

A microprocessor-based conductiv-ity tester that is said to offer up tofour times greater accuracy thanconventional testers has been intro-duced by Centurion NDT. The FM-140XL Digital Conductivity Testermeasures the conductivity of mostnonferrous metals and alloys,including aluminum, copper andbrass. As the operator scans a testpiece with the FM-140XL’s probetip, conductivity readings are dis-played on a seven-segment light-emitting diode (LED) screen.Although conventional testers are

typically accurate within plus orminus 2 percent, the FM-140XL isaccurate to within 0.5 percent, ac-cording to the company. A multiad-justable handle enables the operatorto lock the unit into position toachieve the easiest viewing angle.

For quick sorting applications, thetester allows the operator to pre-seta range of acceptable readings. Agreen light flashes when a readingis within the acceptable range; a redlight signals a reading that is outsidethe selected range. The FM-140XLis also useful for measuring smallchanges in conductivity that can takeplace during engineering processessuch as hardening, annealing andheat treating, or that can occur natu-rally with age or from corrosion.

after the engines and heater wereturned on. An investigation foundthat fuel was leaking from the heat-er’s fuel-strainer assembly (partnumber 460-755), which is mount-ed above the heater in the airplanenose.

Corrosion and a crack were found inthe fuel-strainer assembly sedimentbowl. According to maintenancerecords, the fuel screen had been

cleaned during the last annual in-spection. The corrosion in the bowlhad apparently contributed to thebowl being crushed during theinspection.

Maintenance technicians working onthe Piper PA-23 should check thecondition of the fuel-strainer assem-bly sediment bowl when the fuelscreen is cleaned during annualinspections.♦


Measuring seven centimeters highby 22 centimeters wide by 23 centi-meters deep (2.75 inches by 8.5 inch-es by nine inches), and weighingonly two kilograms (five pounds),the FM-140XL is portable, yet itsrugged build enables it to withstanda rough shop environment, the man-ufacturer claims. The unit is poweredby a rechargeable nickel-cadmiumbattery pack that provides up to 10hours of continuous operation on asingle charge. Custom probes and acarrying case are also available. Formore information, contact: Centuri-on NDT Inc., 707 Remington Road,Suite 9, Schaumburg, IL 60173 U.S.Telephone: (847) 884-4949; Fax:(847) 884-8772.

Laser-aimed PortableInfrared ThermometerHelps Troubleshooting

Leaks in pneumatic systems or refrig-erant systems, electrical problems as-sociated with overheating, or bearing

problems resulting in a temperatureincrease are detectable with a sensi-tive temperature-measuring device.With the advent of portable infrared(IR) measurement devices, relative-ly small temperature differencescan be accurately pinpointed anddocumented.

The new PT-3 Series pocket-size non-contact IR thermometer from CAP-INTEC Inc. is intended for use inmaintenance and troubleshooting.This ultracompact portable instru-ment features a built-in laser to pin-point targets of interest.

FM-140XL Digital ConductivityTester from Centurion NDT

The PT-3 operates in the eight-micrometer (µm) to 14-µm spectralband and covers a temperature rangefrom -20 degrees C to 400 degrees C(-4 degrees F to 752 degrees F). Theliquid crystal display (LCD) offersone-degree resolution and includesautomatic backlighting for takingmeasurements in dark areas. Re-

PT-3 Series IR thermometerfrom CAPINTEC Inc.


sponse time is one second. The unitis operated by two AA batteries,which are said to yield 100 hours ofoperation. The device weighs 198grams (seven ounces) and comes in asoft carrying pouch.

For more information, contact: CAP-INTEC Inc., 6 Arrow Road, Ramsey,NJ 07446 U.S. Telephone: (800) 631-3826 (United States and Canada);Fax: (201) 825-1336.

NonflammableCleaner/Degreaser for

Electronic andEnergized Equipment

Contains no CFCs

Since the international phaseout ofchlorofluorocarbons (CFCs), produc-tion, repair and rework shops havebeen faced with trade-offs amongcleaning performance, plastics com-patibility, flammability and dryingtime in selecting cleaning and degreas-ing agents. To solve this problem,Chemtronics® has introduced Electro-Wash® PSN Cleaner Degreaser, aspray-on detergent that removes en-crusted dirt, oils, grease, oxides, fluxresidues and acrylic conformal coat-ings from generators, motors, ma-chines and precision devices.

The product has a low-odor formulathat is nonflammable, contains noCFCs, does contain hydrochlorofluo-rcarbons (HCFCs) and is specifically

engineered to clean and degrease en-ergized equipment and electronicswithout damaging surrounding plas-tics, the manufacturer says.

Electro-Wash PSN Cleaner Degreas-er is said to dry quickly and have ex-cellent wetting and penetrating actionthat flushes even tight-tolerance ar-eas clean. The product is available ina 340-gram (12-ounce) aerosol con-tainer that sprays at any angle, evenupside down. For more information,contact: Chemtronics, 8125 CobbCenter Drive, Kennesaw, GA 30152-3486 U.S. Telephone: (770) 423-0748; Fax: (770) 423-0748.

Cushioning ProtectsWires, Hoses AgainstAbrasion by Metal

Device Technologies Inc. has intro-duced a line of soft polymer cushionmaterials to protect cables, wires and

Electro-Wash® PSN CleanerDegreaser from Chemtronics®


hoses from abrasion caused by roughedges in sheet metal or other installa-tions. Originally developed for sensi-tive fiber-optic cable telecommun-ications applications, the Spring-Fast

Cushion Grommets are said to be ide-al for airframe installations as well.

The cushion grommets are made ofnylon-coated stainless steel, with asoft polymer cushion to provide max-imum protection from abrasion orcutting. The manufacturer says thatthe material is durable, strong andflexible and has the ability to conformto any two-axis contour. The grom-met edging snaps on, and the uniquespring gripping fingers hold it inplace. No tooling is required for theinstallation, and no adhesive is need-ed to hold it securely.

The Spring-Fast grommet edging isavailable in several sizes to accommo-date sheet metal thicknesses from 0.06centimeter to 0.6 centimeter (0.025inch to 0.250 inch). The material isavailable in precut lengths and in7.625-meter (25-foot) and 61-meter(200-foot) rolls. To request a free sam-ple or for more information, contact:Device Technologies Inc., 3 BrighamStreet, Marlborough, MA 01752-3140U.S. Telephone: (800) 669-9682(United States and Canada) or (508)229-2000; Fax: (508) 229-2622.

Convertible FlashlightCan Be Hand Held

Or Worn

Streamlight Inc. has developed a con-vertible flashlight that can be held inthe hands or worn, as the occasiondemands. Called WOW™, the lightis said to offer the advantages of arugged hand-held light combinedwith those of a hands-free lamp thatcan be worn around the head, hungaround the neck or suspended abovea work area.

As a hand-held flashlight, WOW is acompact unit weighing 159 grams(5.6 ounces). When hands-free oper-ation is required, the unit’s handlesrotate open and the adjustable elasticstrap can be used to fasten the lightaround a maintenance technician’shead or suspend it around the neckor from a nearby fixture.

Spring-Fast Cushion Grommetsfrom Device Technologies Inc.


For more information, contact:Streamlight Inc., 1030 West German-town Pike, Norristown, PA 19403U.S. Telephone: (215) 631-0600;Fax: (215) 631-0712.

Plain styles are available in sizes rang-ing from 0.25 millimeter to 32 milli-meters (0.01 inch to 1.25 inches)internal diameter, with varying wallthicknesses. Corrugated and convolut-ed (screw-thread) styles come in sizesfrom six millimeters to 25 millimeters(0.25 inch to one inch) internal diam-eter.

Priced according to type, size andquantity, the tubing is supplied in ran-dom-length coils or cut to length. Formore information, contact: M.M.Newman Corp., 24 Tioga Way, Mar-blehead, MA 01945 U.S. Telephone:(617) 631-7100; Fax: (617) 631-8887.♦

Teflon® tubing fromM.M. Newman Corp.WOW™ from Streamlight Inc.

Flexible TubingImproves Safety of

Handling Hot Liquidsand Gases

M.M. Newman Corp. has introduceda full line of Teflon® tubing for han-dling very hot liquids and gases. Thetubing, which is nonflammable andchemically inert, is said to be capableof operating at continuous tempera-tures of up to 232 degrees C (450 de-grees F). In addition, the tubing isunaffected by acids, alkalis and othercorrosive media, making it suitable fora wide range of fluid-transfer applica-tions, according to the manufacturer.

BLANKINSIDEBACK

COVER

Visit our World Wide Web site at: http://www.flightsafety.org

Flight Safety Foundationpresents the

9th annualEuropean Aviation Safety Seminar (EASS)

“Safety —The GlobalChallenge”March 3–5, 1997

Amsterdam, Netherlands

For more information contact Flight Safety Foundation.Telephone: (703) 739-6700 Fax: (703) 739-6708

aviation mechanics bulletin november-december 1996 · factors researchers ... mentation,” by...

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