 Welcome. In today's world of shortcuts, we've discovered that in aircraft accidents and incidents, what can sometimes happen is when you fail to follow procedures, bad things happen. Today's presenter, John Toy, is a Fast Team Program Manager for Kentucky and Tennessee and has a vast background in maintenance. Please welcome Mr. John Toy. Thank you, Kathleen. As Kathleen said, I'm John Toy out of Nashville, Tennessee, and I'm glad to be here to talk to you about maintenance procedures. I'm a failure to follow the maintenance procedures. What I'd like to explain to you to begin with is John Toy's philosophy about presentations. If I stand up here and give my complete presentation and you don't understand it, then I haven't given you a good presentation. If we only do 50% of it and you get 50% of it, then we've done a good job. And if you have any questions along the way, I want you to make sure that you understand what I'm trying to explain to you. And if we can do that, then we've got it made. We're going to talk about failure to follow procedures, the causal factors of failure to follow procedures, some of the maintenance errors that we have, and how you can get registered at www.fasafety.gov. The overview is going to be the Fast Team Introduction. We're going to work with that. Registration, how to do that. Regulation overview. An accident scenario that we've gotten from the NTSB. Maintenance error findings. How the chain of events affects everything. Some of the safety nets that you can use to keep the errors from happening are to at least minimize them. Safety motivation and some of the safety tools that we're going to be presenting and I have available for you. What we'd like to do in this presentation is provide the awareness of the risk that's associated with failing to follow procedures when you're doing maintenance on aircraft. And the prevention of contributing or causal factors so that we can reduce maintenance errors. As a member of the FAA Safety Team, which we are called the Fast Team, it's a new concept. We're happy to be able to present this to you. On FAA Safety.gov, we have the website when we're going to be talking about education. You can see the different things that we have for you. And over here, I get this to work, we have where you can get registered. Go in there and register on this website. We want to have the information from you about your geographic location so that we can send out, when we send out emails, that they will get to the right people in the right place at the right time. Some of the resources that we have are listed here and you'll find those on the website. This is an example of one of them, the art of aeronautical decision making. It's one of them. We have the details on the registration and put on my eyes so I can see a little better. So if you have any questions about getting on to www.faisafety.gov, we have a booth out front and you should be able to find out how to do this there. And if you're not, then you'll find people all over the place that can help you. One of the things that we've found is that there's a cognitive responsibility for everyone who operates in the aviation industry. And sometimes there's different things that affect that. What we have here is a bolt with several nuts on it. There's only one way to get all those nuts off of that bolt but there's supposed to be 40,000 ways that you can put them back on their wrong. So your task when I get finished here is to remove the nuts from the bolt then reassemble them back in alphabetical order. So let's get started. As we're starting, we want to talk about the regulations, do an overview, regulatory overview. So we're going to look from the good book of regulations. Where do we find performance standards? FAR, not FAR, 14 CFR part 4313. And there it requires all maintenance to be performed using the methods, techniques, and practices prescribed in the current manufacturer's maintenance manual. We're also required to use the tools and equipment, the test apparatus, and everything that is associated with it in accordance with accepted industry practice and the manufacturer. 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, or the appliance that's being worked on, it's returned to its original or properly altered condition. This is the regulation that I use when I want to tell people that are out there in a maintenance field that are not involved with an air carrier or repair station where they need to go and get the, this is what lets you know that you have to have your torque wrenches calibrated. To me, that's what it says. How are you going to return an aircraft to its properly, its original or properly altered condition if you don't have calibrated tools in order to do that? So this is the regulation that will guide you right back to that. Part C is one for 121, 127, 129, or 135. These are air carriers operating manual and operation specifications. And these are considered an acceptable means of complying with this section. There are additional performance rules for inspection. This is found in 43.15, annual and 100-hour inspections on the aircraft, that general aviation aircraft. And what does it say in there? It says that each person that is doing this shall use a checklist that includes the scope and detail of appendix D about FAR part 43. So before approving a reciprocating engine powered aircraft will return to service an annual, after an annual or 100-hour each person shall run the engine to determine the satisfactory performance of the following items. The power output, the magnetos, fuel on oil pressure, cylinder, and oil temperature. Some additional performance inspections under an item three. So before approving a turbine engine powered aircraft will return to service after an annual or 100-hour, shall run the engine to check the satisfactory performance in accordance with the manufacturer's recommendation. For the reciprocating engine we have a list that you follow. For the turbine engine we have the manufacturer's recommendations that you follow. So I have a question for you. Under 14 CFR part 43.13, what does it discuss? This could be a rhetorical question. It discusses industry-approved tools when we have to use them, methods, techniques, and practices, and performance standards. So those are the three things that we discussed in 43.13 which are performance standards. Industry-approved tools, methods, techniques, and practices, and performance standards. We have some additional procedures that you can use when you're doing these. These come from other items such as service bulletins, service instructions, awareness directives, type certificate data sheets. There's a whole list of them, such as advisory circulars, and then the following is air carrier procedures. Now we're talking on the failure to follow maintenance procedures involved both general aviation and air carrier. So we have the air carrier procedures which are found in 14 CFR part 121.367. And the thing that you need to remember there, you go through this whole regulation and you get down at the bottom and this is done in accordance with the certificate holder's manual. The air carrier procedures or the air carrier has a manual system and the certificate holder's manual is where they find the procedures for doing that. So let's take a look right now. We've gone through the regulations and now we have accidents that are happening, accidents and incidents. There's some statistics, it's easy for me to say. There are some statistics and scenarios that we want to look at. National statistics and an NTSB-investigated accident. And this accident has identified several causal factors for failure to follow procedures. Let me talk about the FAS team for just a second. We used to have a safety program manager that went out and gave presentations and these worked really well. We did a lot of work, we visited a lot of places and we made a lot of presentations. But one of the things that the FAS team, the FAA safety team is doing is that we're going into the programs that we have, the computers and things of that nature, the programs that are out there that are being input from the field and we're finding that there are certain causal factors involved and we've come up with several of them that are maintenance related. And we find that 12% of the accidents that are out there are caused by maintenance procedures and some inspection deficiencies. You can see the whole list there of everything that is involved. And this is the point where I want to say that we have the safest mode of transportation of anything that exists today. We're down to a municipal causal factor, an accident factor. We're just not having any accidents based on the amount of flying that's done, the amount of people that are being carried from place to place. But we do want to stop and make it lower as we go along. But 12% of those are maintenance and inspection deficiencies and that's where that we drill down and found out certain items that were, fell into that category. NTSB, aviation, accident and incident data system. This is up through 205. You can see that we have maintenance installation on the left up there all the way down to taxi speed that's involved in this. We've gone in and drilled down and everything that we can think of and this is what we come up with. We're getting better. We're getting more detailed as we get people trained and educated in the fact that we need to get better information put into the system and this is where a lot of you come in. If you know things that are not presented right, then you need to let us know and we will take care of that. But these are the places that we've gone into and found out that they're the figure to follow maintenance procedures is one of the main causes and that's where we're going to start out. This particular presentation is part one. We're going to have a part two that comes out and it will be following right along after this one but that's at another time, another year. Main is related accidents. Main is related accidents are a result of causal factors that include failure to follow procedures and that's a term that if you haven't been hearing it already you're going to be hearing it throughout the rest of the year. This one I particularly want to read that I don't like reading all of them but that this one I particularly would like to. The failure to follow procedures can result in the death, injury, occupational illness of persons or damage to or loss of equipment, property or damage to the environment and we all know how that affects us. We don't like it because this is our bread and butter and we want to stay away from it. The first accident was pretty much 90% of the machine caused that accident and 10% was human causes, the first accident. As we've gone through the years and our equipment has gotten a lot better and our maintenance training has gotten a lot better we see that the human causes have increased and the machine causes have decreased because usually on the machine accidents you don't have human factors involved in there. It's when you get into the human causes that we have the human factors involved. So what a segue to get into the next part about human error. Human error is the unintentional act of performing a task incorrectly which can potentially degrade the system. We're talking about an unintentional act. An intentional act is called sabotage and that's a different story altogether. I've been around this business in the FAA for 22 years. I've been in aviation for a little longer than that. It started in 1959 so I've been around in that a little while and I've worked with a lot of people, a lot of mechanics, done a lot of things in that time and I don't know of anyone. I've never heard of anyone and you can't make me believe that there's anyone out there that work in our industry that would intentionally do an act that would cause a problem with that airplane. Nothing that would cause safety flight. You just can't make me believe it. I thought about this for a long time and maybe I just refused to believe that there's someone out there that would do an intentional act to cause a problem with an aircraft performing incorrectly on purpose. I just can't believe it. There are three types of human error. The era of emission, era of commission and the extraneous era. The era of omission is when you don't perform an act or behavior, you just didn't do the job. The era of commission is performing a different act or behavior than what's supposed to be done and this is not the norm thing to do but you were performing the act of repairing the problem and it just didn't do it exactly the way it was supposed to be done. And then there's the extraneous era which is performing an additional action or not performing, I mean performing an additional action that caused the problem such as removing a clamp from an area to help you work better and then later on not putting the clamp back in place. The levels of consequence of human error, they range from little or no effect to physical damage to the equipment, personal injury and a catastrophic event. We want to keep the level of consequence at the top one, little or no effect. Most of them we want to catch. That's why we have two sets of eyes in our maintenance field that or two sets of eyes go out after a maintenance item has been done that either somebody helps you look at it or an inspection item is required to be performed. Some of the things that failure to follow procedures result from are the human errors that are related to what we're talking about human factors here, a lack of knowledge, lack of current technical data and that's a requirement. You're supposed to have the current technical data from whatever item you're working on that you're going to return to service, you're required to have that technical data current. A lack of experience and a lot of times this comes with working with a group and having the supervisor put you on a job and you've never done it before and but it's something that's similar to something you've done before but so you go ahead and do it. You don't have the experience to do it, you should not be doing it. In our regulations you're required to have experience within a certain parameters that follow their lack of proper tools and equipment. The mechanic when I worked on the farm and we had the disc behind there a big screwdriver and a hammer was the normal tool but on an airplane the big hammer and a large screwdriver is not your normal tool so experience and training run together, a lack of proper preparation. That's thinking about things other than the job that you're going to be doing. If you're not prepared to make that repair or do that inspection then that's where you have a lack of proper preparation. Lack of resources, we find this out there in small operations in general aviation mainly but in other places just a lack of resources maybe that you don't have what you need on hand, you want to fly that aircraft so you make do with what you've got. That is a human error that's an accident waiting to happen. Hopefully it doesn't, hopefully it just keeps on waiting. Failure to take safety precautions and failure to research the FARs to understand your responsibilities. We want to talk about one incident, accident this came from the NTSB flight 5481 happened on January the 8th 2003. This aircraft had been in maintenance, it came out of maintenance and it had flown several flights and there were several legs where the aircraft was handed off to the other crew and in that period of time they would say that the aircraft was flying good it had flown well. In this particular flight they had loaded a couple of larger bags into the cargo compartment they made up for the difference in the weight of the total weight of the aircraft by having people in the front of lesser weight and they went ahead and put the aircraft out on this leg. It was a Beatscraft 1900D, 19 passengers, two crew. It lost pitch control during takeoff and it crashed killing all of those that were on board. The probable cause was airplanes lost the pitch control during takeoff resulting from the incorrect rigging of the elevator control system compounded by the airplane's aft center of gravity. They looked at the weight of the two larger bags that were going into the cargo compartment and the weight of the passengers in the front and noticed that there were smaller people in the front so the total weight was less but what this did was cause an aft center of gravity and this was another problem. For the contributing factor was the operator's lack of oversight of the work that was being performed, the maintenance procedures, the documentation of such and the weight and balance program as we found out with this. Let y'all read some of that and what I want to do is just say that the mechanic who adjusted the controls was inexperienced. He was expecting an inspection and according to the investigation we don't know if that inspection ever or the secondary inspection ever occurred or not and it's still part of the ongoing investigation. He was told to do the job. Inspector told him some steps to follow and said he would watch him but he was busy. It was a smaller operation, it was busy time, it was a turnaround time and they got real busy and they just didn't get in there and do what they were supposed to be doing. So he needed more inspectors, needed some more experienced people working with him. Somebody, someone to help him out and we'll get into how to stop that later. On the inspection work card there were nonspecific references, inadequate instructions. So we say it wasn't just the mechanic, it wasn't just the supervisor, they've got the instructions here that weren't sufficient to completely do the job. On the other side we have an aircraft that says aircraft equipped with a flight data recorder that you've got to calibrate the pitch position potentiometer. That's an important part here. Aircraft maintenance manual had in applicable steps and it had inadequate instructions. Failure to follow procedures includes not just the person not doing the job but it can also include the operator not having the proper up-to-date information or the manufacturer not having the information right there for the operator to take care of his problems. The cable was misrigged, altered the relation between the FDR sensor and the elevator. As you can see there's the rig pin holds the elevator in one position up here. You've got turnbuckles which alter the overall length of the cable and then you have the flight data recorder sensor up here which senses the shift in the column position. That's all right up in here when the column shifts the flight data recorder senses that so that it can hopefully we won't ever use them again but we did on this particular one to show that there was a problem. So what did the NTSB find? They found failure to follow procedures on the company and some on the manufacturer because of the inapplicable and sometimes not lack of detailed instruction. Failure to document the actions that were on there the turnover of process with the failure to communicate supervisory oversight and regulatory oversight. This ran the whole gamut of blame on what was going wrong with this aircraft. Somebody along the way should have seen something in here that was wrong but in retrospect looking at it and in my experience is the mechanics have a habit sometimes a good habit sometimes a bad habit of you take you do what you have to do and you do it safely but you can do things that you have an idea what's supposed to be there and then you do it that way. You've done it before in another instance but you need to follow the instructions for that particular aircraft at that particular time and the one of the things that they found that was missing was a safety culture and that's you've got to have the safety culture throughout the entire program entire operation. The NTSB recommendations the manufacturers of the part 21 aircraft and this is talking about a functional check of each critical flight system and determine which maintenance procedures should be followed by such functional checks. The manufacturers and the part 121 air carriers modify existing maintenance manuals to contain procedure procedures at the end of the maintenance for a complete functional check of each critical flight system. We have that right there in our regulations. If the aircraft is modified in such a way that it affects the flight characteristics of the aircraft then you have to have a test flight. On this one they had to have a functional check is all on each critical flight system. Part 21 air carriers implement a program where the manufacturers review all of the work cards, ensure the accuracy and usability of the instructions and write down to the level of training the mechanics on all of these. On most every accident that I've ever been involved in there has been a chain of events that led up to the accident not just one cause but several things that happened along the way. From the beginning it could have been a rush to get some place it could have been a decision based on the fact that we don't know about get home items and things of that nature. But if you have in here that the multiple contributing factors in this one was the training the current data supervision and then the failure to follow procedures resulted in an accident. So how do we stop that? You've got a chain of events here so how can the how can you know that you're not going to have an accident? How can this chain of events how can we do things in there that will keep that accident from happening? Well you have management that is there they're taking care of the oversight of the operation, maintenance and then the crew. If maintenance had have gone in and checked that sensor adjusted that sensor the way that it should have been done where the flight data recorder was then this accident with the chain of events would have been broken and this particular accident could not have happened. We see that it's a hindsight the 2020 you know the perfect hindsight is 2020 and we see that in every accident. We know that somewhere along the line that if someone had just taken the time to either looked at it twice or to have said you know that doesn't look right or gone back through it and said okay there's something here that's just not right let's change this they break the chain of events and that could have prevented an accident so we break the the preventing measure breaking the chain of events by doing the performance standards set forth by the regulatory the manufacturer and the operators procedures. So no one of the things that we have that will help us is a safety net that you can use to help you break the chain of events so which ones can we put into place to help prevent the failure to follow procedures? There's several of them I think in total there are eight that we came up with that even one of them could break the chain so we go over and meets one individually perform the task to the best of your abilities everyone should be doing that okay now what is the best of your ability which is the best of your ability at your peak is the best of your ability when you've been working for 16 hours straight it's the best of your ability when you are thinking about something else what is the best of your ability and that's the thing that we get involved in in human factors and some of the things that we're trying to present and you're going to hear a lot more about human factors on the maintenance side along the way for it's coming anyway you've got to perform the task to be equal to its original or properly altered condition properly altered condition means it's done in an approved manner perform the task in accordance with the appropriate approved data like I just covered that using the methods techniques and practice acceptable to the industry and the administrator and the industry out there we have the safest industry in the world and there's no doubt in my mind about that there's stop gaps in place all over the place and usually when these chain of events do not get broken it's because a stop gap is ignored it's either ignored or it's overridden because that most all the time we find that there is something there that should have keyed the factor that this is going to happen there's something going to be a problem you perform the task without pressure stress or distractions yeah right huh form the task without pressure stress or distractions if any of you ever worked in a small operation that has a lot of flights a few airplanes very few parts a lack of resources you know you can go on and on so you don't have pressure you don't have stress and you don't have distractions in this kind of operation another thing that you can do is reinspect two sets of eyes you make the proper entry for the work that's being performed and the reason that this is in there the safety net is so that if you repair this thing the same thing three or four times in a row you know there's something there it may not be the same thing that you're repairing it may not be the thing that you're repairing that's causing the problem it could be something else down the line that's coming back into this then to make it a problem so maybe what you need to do is to look at this and say we have more than just this one problem is we've tried it three times we tried everything that the manufacturer has discussed we tried everything that we know and this is not working so how do we go about making this thing work so you make the proper record entries and people can go back and look and see what was wrong and what you did to repair it and it worked at that time but later on down in a few days it went bad again perform operational checks in accordance with the manufacturer or the air cares approved procedures so what's your motivation for doing this well you're professional for one thing you want to do the job to the best of your ability and that's some of one of the things that I found all throughout the aviation industry when I was there when I first started we had we took pride in what we were doing we took pride in the individual job that we did we took pride in the fact that we made this aircraft that was not flying that we can do what make it do what it needed to be doing so I do it the best of your ability and even out there now I go out and I see the young guys the young people that are out there doing the work on the aircraft it's the same thing they're doing it to the best of their ability and they take pride in their workmanship and that comes along with self-regulation your integrity you're going to do it well and you're going to do it right you lower your risk when you do this which is lowering your liability and it's a liability for physical and mentally the liability and the accountability that comes along with that take pride in ownership which makes you a strong a stronger character rating that you have there the professionalism which shows that you take responsibility for what you do you enjoy what you're doing you do it to the best of your ability and on down the line and you take responsibility for that when you do these things it's good for the company this is where the bottom line comes in because it's good for the company it's good for the profit and loss column in that company just good business when you have public confidence when the public knows that you're flying safe aircraft when they know that your mechanics are doing safe maintenance then your your confidence level goes up the bottom line on this all of this is safety do we have any questions about anything that i've covered so far one of the tools that we put out is the FAA safety the fast team it was this came out with a safety program but it's your personal minimum checklist and in that you have the the before the task tool and then if you look go down through that and it asks you different questions the questions that you're looking at are all related to you and what you're doing do i have the knowledge to perform the task do i have the technical data have i performed the task previously do i have the proper tools and equipment to perform that task am i mentally prepared to perform the job task that's one of the things that we've talked about in human factors am i physically prepared to perform the task physically have you had any sleep are you tired did you go out the night before get in at three o'clock in the morning and up at four o'clock to come to work have i taken the proper safety precautions to perform the task do i have the resources available to perform it do you have the proper tools do you have the proper parts are they there are they on order or what exactly how are you going to get doing get busy doing this and have i researched the far is to ensure compliance and then once you've done the job how do you know that you've finished how do you take your personal responsibility for doing that you go to your safety tool and you look at it again and you ask yourself these questions did i perform the task to the best of my abilities was a job task performed to be equal to the original was a job task performed in accordance with appropriate data which means approved data did i use all the methods techniques and practices applicable to the industry and did i perform the task without the presence of stress pressure or distraction did i reinspect my work or did i get somebody else to do it for me to help me out did i make the proper record entry did i make sure that when i wrote up the record entry that i put in there exactly what would i found wrong with the aircraft and then when i finished it up that i put in there what i did to repair that what i did that made it okay for to be approved for return to service did i perform the operational checks if necessary after that there again if it's performed according to the flight character if something goes with the flight characteristics of the aircraft if there's something performed there that changes those then we have to have a test flight on the aircraft am i willing to sign on the bottom line for the work performed and then the key to this is uh am i willing to fly in the aircraft once it's approved for return to service when i was in the military that was the team lead on a direct support operation and when my crew finished up a job most everything we did required a test flight matter of fact just about everything except the work on our own aircraft required a test flight well who do you think that the the flight test officer came to to go flying with him when that uh came time to do the test flight on the aircraft i got a lot of time in a QE helicopter and an OH-58 helicopter because we would do the things on the aircraft that would require a test flight and the maintenance officer the test pilot would come out as a charge top in the airplane with me and there wasn't any time when i didn't say yes sir let's go because i weren't ready i think my people had done it they were good mechanics they were well trained we had the resources i'd researched it i'd look back at the work and when that aircraft when i told that guy that aircraft was ready to go it was ready to go and i was ready to fly in it and to me that's the key so here we are back to the nuts and bolts we've taken the nuts off and now we're going to reassemble them we're going to do it in a proper order so we're going to do them in alphabetical order based on the elements of the presentation that i gave and this is where you come in and you do some participating it's a prevention of failure to follow procedures recognizing and managing contributing factors breaking the change of events and mitigating maintenance related accidents and aviation that's what we want to do so what aviation regulation identifies the performance rules for persons performing maintenance i know i've got an answer out there somewhere do we have a microphone okay i'm going to put you on we're not going okay i didn't want to get in trouble here we're not in trouble it's 4313 maybe 4313 43.13 and so we got what do we have on now we have nut a nut b performance rules contained in 14cfr part 4313 apply to what functions or tasks there's three of them and i don't know if i'm going to have my order mine in the same order that you do or not but there are three things that discusses can you give me one of them and i hear somebody say maintenance alteration or preventing maintenance i think that was one of them okay nut c additional performance rules are found in what federal aviation regulation 4315 additional performance rules apply to what tasks or functions anyone 4315 covers inspection 4313 is the performance standards this is the inspection standards nut d what is the number one maintenance error that results in or contributes to aircraft accidents so it came from the statistics came from it comes from my the title of my presentation and see if i can remember what that is failure to follow procedures that's the number one and that's the causal factors of down the line are failure to follow procedures national aircraft accident statistics indicate what percentage of all aviation accidents are a result of maintenance error 12% okay i'm glad i put that answer up there before everybody knew that everybody was even watching this question number five nut e the chain of events can lead to an accident there are four examples of those contributing factors that we looked at today we looked at more than four but what are four i need a microphone lack of experience lack of experience okay anyone else anyone else i heard training okay having the current data there were more than just four but these are the ones that we put up here supervision now how do we cover supervision we're talking about management and supervision and i was a supervisor out there and i had a we had a small shop in west kentucky and i had a guy a young mechanic pilot that had been to school just got out of a np school and he came to me to work he was going to get some flying time he was going to work on aircraft to help pay for that so he's working on assessing the 150 or 172 and i'm working on the other one either 150 or 172 and i finished up my job and i went over and got him those kids 21 years old i'm 45 at the time i was just a couple of years ago and uh told him come over here and this is what i did i replaced the mags on this aircraft i want you to inspect my work and i get that look like you want me to inspect your work you know and so we're all older mechanics and uh we've had a lot of experience and we understand of course i want you to inspect my work because when you look at it if i've done something wrong and you don't find it then we're both in trouble so don't hesitate when i go inspect yours your work and i find something wrong what do you expect me to do he said i expect you to let me know about it and show me how to do it better next time i said that's exactly what you're doing with me i said hopefully we won't find anything on either one of them but if we do then that's we're going to look at them together and he liked that idea and then the other one was failure to follow procedures so there were eight safety nets that we covered that we discussed what are some of those can you remember i'm looking for answers this is where you perform the task the best of your ability you want it to be equal to or or better than its original condition or properly altered condition done in accordance with appropriate data and we know that appropriate means approved data and you want to do it using acceptable techniques methods and practices and this this doesn't just pertain to license mechanics this pertains to everyone who is working on an aircraft you have to follow 43 43 is where you get the regulations that cover how you're supposed to repair aircraft if you are a pilot with a certificate doing the maintenance items that you're allowed to do you have to do it in accordance with acceptable techniques methods and practices you have to use the tools that are required this is for everyone if you are uncertificated you still have to do this but in order to return the aircraft to service you have to have someone with a certificate that will do that it will look over your work and sign it off for you but anyone working on an aircraft has to do it use an acceptable techniques methods and practices okay we're on question seven now nut g about to get this thing put back together so what's your safety motivation to perform your job what are the practices or traits that you have integrity remember self-regulation you don't have to know the first part what's the second part what was one of the other things that a mechanic takes on when he's putting an aircraft back together he's not uh i'm not hearing anything from this group you want a responsibility okay that'll come up later i guess lower your risk through the liability of it make pride in your ownership your character this affects your character pride of ownership and there's a responsibility part the professionalism that goes into it when i was working on a tractor when i was 10 years old my uncle instilled in me the idea of paying attention to detail paying attention to detail meant to know what you have going on what is in front of you what can you get out of this and how do you know exactly what is wrong the way he taught me this was so i can't see everybody but if you're as old as i am you remember the tractors that had magnitos and he had the magneto off of the tractor and he was overhauling it and he took the lead wires and he said i want you to hold that while i work on this i needed when i did he turned the wheel and it popped me real good and he said now you knew this was electrical and you still held the two wires i said yes but that was from trust so he said well i guess you got me there but along i learned that you got to pay attention to detail you got to understand what's going on and you got to understand what is happening when you uh are dealing with whatever you're working with and the other thing is that we had out her recently is called a three-foot rule and uh your responsibility you're looking in here you're working on one item on this aircraft but three-foot rule is a radius of three feet around there that you need to be paying attention to see if there's anything there that looks out of the ordinary anything there that you can work with that uh is not right maybe something you see some chafing over here a wire chafing or you maybe you see a wire that's loose maybe somebody needs clamps something that needs to go in there and this is not a failure to follow procedures but this is a procedure that you should follow there's an instant recently that i worked with on a self-disclosure where that the aircraft left the gate went out and it got an overheat warning and came back and the clamp that came loose from a uh the heat part of the that came off of the engine that the clamp it came loose from the line and uh it had caused an overheat symbol that cut shut down the engine the light went out and there was there was no fire involved but it was an overheat uh symbol that was there and uh what happened was that they were working on this area we have no clue what happened on that but uh in the in looking at it you could see that what they were working with they had no reason to go into this area but it was within that three feet and so we talked to the people and talked about the responsibility of knowing what's going on around you and the bottom line to all of this that we're talking about is safety so the safety motivation perform your job the bottom line is safety and that's one of the practices or one of the traits and it comes from being a in a safety culture being in one and if it's not in if you're not in one then creating one we have a system safety that's out there that's being integrated into all of our air carrier programs think no system safety something that is as simple as that that uh maybe the system safety has been there all along our aircraft industry is like I said the safest in the world safest that as safe as it is and as low as our accident rate is we want it better so we look into the bottom line that was our safety motivation is safety so the final question we have is on number eight one safety tool can you employ to prevent or mitigate the likelihood of a finger to follow procedures did I show it to you see checklist it's my finger trigger finger okay the personal minimums checklist I don't work on aircraft anymore but I do other things I've got my ID behind my ID I have my personal minimums checklist the before and the after and I carry that with me I use that when I work on my automobile I've got the my personal minimum checklist we have them we have hundreds of the small ones that you can carry with you most everywhere you go most every job that you have whether you're in a building away totally away from aviation or whether you're involved in the terminal out on the ramp somewhere along you have to wear a badge and when you can put this in there and this works whether you're working in an office whether you're working in in the field it just works everywhere this is a personal minimum checklist something that you can use so we have the before task here I don't think I have the other one okay right now we have prevention of the failure to follow procedures we want to prevent failure to follow procedures so nut a performance rules 4313 4313 under nut b is a maintenance alteration preventing maintenance nut c 4315 additional performance rules where we get the inspections from and then under nut d we're talked about the statistics change of events under number e safety nets under f safety motivation on g safety tools under h so now we've taken this butt this bolt with all of the nuts on it apart and we put it back together on the first try because we knew all the answers somewhere out there you may not get the answers exactly right but you can there's several ways to put this back wrong and if you failure to follow procedures this will not happen so in summary we introduce you to the fast team we talked about f a a safety dot gov we'd like for you to register on f a a safety dot gov we want you to sign up we want you to put in your zip code we want you to so we know your geographic area we'll have fast team representatives out there that would be setting up and doing things and make putting on programs we want to send you the information on that so we want you to sign up on f a safety dot gov to do that most of you if you're looking at this or if you're out here in the audience you probably have already done that so now what's my next statement tell your friends we have cards out there you can give them a card you can pick up a half a dozen or so cards hand them to your friends and family that anybody that needs it we went through the regulations we did an overview of those performance rules and the safety standards we went through about the chain of events how the chain of events can come up and bite you if you're not careful because one little thing starts out you remember the story of the kingdom that was lost because the lack of a horseshoe the whole kingdom was lost i'm not going to go through the whole thing but the the night had a horse the shoe lost they lost the night out of the battle they lost the battle and the battle was lost the kingdom was lost and the king and queen didn't have a kingdom anymore all because of the loss of a horseshoe and now we have the same thing in aviation we don't want to lose that kingdom that's the aircraft with the people on board we want every little thing to count and we found this as a problem we don't see it as a as a problem that is something that is going to be a catastrophic but sometimes the failure to follow procedures can lead to that we've talked about the safety nets the things that go into it and how that you can use those to help keep these things from happening keep to break the chain of events the professionalism part of it and how that helps you're do the thing to the best of your ability and the best of your ability means keeping yourself physically and mentally on top in top shape it means to understand human factors get the human factors down and when you understand human factors you don't it's not just that you know what the human factors are it's just that you know what the human factors are and then when it's happening to you then you know that that's what is wrong we have safety motivation we want to be the safest environment in the world we are the safest environment in the world we want it even better we're using safety tools to do it the minimum checklist we're going to one other thing is that i've talked about one problem in here one example of what was going on and each one of you out there can think of a hundred different things the hundred different examples of failure to follow procedures such as working on an aircraft for you to i've got the engine there i get on it the piston engine i put all the spark plugs in and when i get to the end of it i've got them all tightened down i'm getting ready to torque them and i get a important phone call well this important phone call is very distracting because it's causing an emotional reaction okay so i'm doing this i go back out or maybe i send the maybe i send the other mechanic out there and i said go put the plug lead the lead wires on those plugs what i meant was go finish up the job but what i told him to do was go put the plug wires on when he did that he went out and put the plug wires on so he's flying over an area and one of the plugs pops out because it loosened up failure to follow procedures didn't finish the job didn't give him a good briefing on how to do it and that was a failure to follow procedures whose fault was it it turned right back on me so to have any questions about anything that's been covered so far i have a question for you how many of you are signed up on faasafety.gov that's what i thought most of you how many of you that are watching this are signed up take those cards give them to your friends and make sure that when they when you get the cards you get out there and get everybody signed up on faasafety.gov so if i don't have any more questions that i thank you for your time