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at many major air carriers have routinely received training to
recognize “dirty dozen” factors and prevent their occurrence.
This month we take a look at how the “dirty dozen” human
factors play a role in maintenance incidents reported to the
ASRS. The “dirty dozen” factors are:
• Lack of Communication • Lack of Resources
• Complacency • Pressure
• Lack of Knowledge • Lack of Assertiveness
• Distraction • Stress
• Lack of Teamwork • Lack of Awareness
• Fatigue • Norms
Lack of Awareness and Teamwork
The tail jack screw assembly of a commercial jet, part of
the horizontal stabilizer system, is very important to safe
fl ight. In an incident reported to ASRS, several “dirty dozen”
factors contributed to misplacement of a jack screw lockout
tool:
Lack of Awareness: Losing track of tools
Lack of Teamwork: Lack of mutual support
Lack of Communication: Failure to discuss job completion
􀂄 Finalization of all paperwork and work was complete.
Close to shift’s end, I was called to the supervisor’s offi ce.
A tool (horizontal stabilizer lockout) I checked out had not
been turned in. I asked my partner [who] worked on the
project with me if he’d seen the tool. He asked me if I had
looked on the shelf behind the jack screw for the tool. I had
not. I quickly went to the line to search for the tool, but the
aircraft was already gone. We reported the situation to a
supervisor who called where the aircraft was headed and left
specifi c instructions. Upon arrival the tool was found.
1) My partner and I failed to do a tool list check-off. I turned
in some tools and he turned in some. 2) The tool room
discovered that the tool had not been turned in at shift’s end
and saw that the others were in. 3) We both had different duties
and did not come together at the end to discuss fi nalization. 4)
Upon cleaning the work area...I had no idea that the tool was
placed on the shelf behind the jackscrew.
The hero in this incident was the alert tool room mechanic
who noticed that a tool had not been returned prior to shift
end, and quickly notifi ed a supervisor. Fortunately, the
A Monthly Safety Bulletin from
The Offi ce of the NASA
Aviation Safety Reporting
System,
P.O. Box 189,
Moffett Field, CA
94035-0189
http://asrs.arc.nasa.gov/
July 2008 Report Intake
Air Carrier/Air Taxi Pilots 3226
General Aviation Pilots 941
Controllers 83
Cabin/Mechanics/Military/Other 400
TOTAL 4650
lockout
tool was not installed. If the lockout tool had been
engaged
with the horizontal jack screw, and the fl ight crew
did not
do an adequate prefl ight check of the stabilizer trim,
the outcome could have been serious.
The Perils of Pressure
Aviation maintenance personnel are
often assigned tasks on multiple aircraft
during a single shift, and are under
continual pressure to return aircraft
to fl ight status. Several incidents
reported to ASRS highlight the need for
technicians to slow down and take the
time to do the job right, the fi rst time.
A lead technician succumbed to a “dirty dozen” maintenance
error factor while servicing a BE1900:
Pressure: Multi-tasking and high workload
􀂄 I did not properly secure the altimeter into place. This
happened because I was working 3 different things at the
time, while answering questions that my junior employees
had, pulling me off the current task to instruct them on how
to do things…I changed [the] First Offi cer’s altimeter on
aircraft air carrier ‘X.’ It was not secured properly, and the
altimeter fell out of the instrument panel on takeoff roll. The
pilots pushed it back into place, no damage occurred to the
altimeter, and outstation maintenance re-secured it into place.
A B767-300 technician experienced a maintenance
discrepancy that is frequently reported to the ASRS. The
responsible “dirty dozen” factor:
Pressure: Rushing to complete the task
􀂄 Aircraft came in with a pilot write-up, which was also a
repeat of nose shimmy on takeoff and wheel retraction. Before
the previous fl ight leg the right nose tire was changed…It
came down to replacing the left nose tire in order to more
evenly match-up tire wear and tread. The tire was changed in
accordance with the Aircraft Maintenance Manual (AMM).
The fl ight was nearing departure time and obviously rushed,
I inadvertently forgot to reinstall the nose tire assembly
　
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