4.0 Shift /Task Turnover Presented by: Dave Supplee, USAirways/IAM Terry Kleiser, FedEx Express Introduction of The Operator’s Manual for Human Factors

4.0 Shift /Task Turnover

Presented by:

Dave Supplee, USAirways/IAM

Terry Kleiser, FedEx Express

Introduction of The Operator’s Manual for Human Factors in Aviation Maintenance

jetBlue Airways New York25-26 October2005

Federal AviationAdministration

FAA/Industry Maintenance Human Factors Workgroup

2

The Operator’s Manual for Human Factors in Aviation Maintenance

FAA/Industry Maintenance Human Factors Workgroup 25-26 October 2005jetBlue Airways New York


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

3




Agenda




Key References


4




Shift/Task Turnover – Why is it Important

• 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.

Use bullets an pictures

DO NOT READ THEM THE BOOK!

5




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

6




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 AMT’s 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”

7




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 AMT’s failed to document (short sign) the loosening of 38 of the 42 flange bolts that held the assembly to the core

8




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 AMT’s 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.

9




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/O’s airspeed still was at 0 kts, T/O aborted.

• AC returned to the gate where ADC lines were reconnected.

10




Agenda




Key References


11




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

12




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.

13





• 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.

14





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.

15




Agenda




Key References


16




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

17




Agenda




Key References


18




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.

19




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.

20




Agenda




Key References


21





“You can’t be careful enough, work turnover is a time technicians are at greatest risk”

Documents

4.0 Shift /Task Turnover Presented by: Dave Supplee, USAirways/IAM Terry Kleiser, FedEx Express Introduction of The Operator’s Manual for Human Factors