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Line Operations Safety Assessment (LOSA): Maintenance (Mx) Operations – Base Training Scenarios Welcome to the scenario-based Line Operations Safety.

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Presentation on theme: "Line Operations Safety Assessment (LOSA): Maintenance (Mx) Operations – Base Training Scenarios Welcome to the scenario-based Line Operations Safety."— Presentation transcript:

1 Line Operations Safety Assessment (LOSA): Maintenance (Mx) Operations – Base Training Scenarios
Welcome to the scenario-based Line Operations Safety Assessment (LOSA) training for the base maintenance. August (v6)

2 Observer Training Preparation
Prior to the start of this training: Install a free copy of the M & R LOSA Database Software: Use the User ID and Password assigned by your LOSA Administrator to log in

3 Observation Forms Print the Mx LOSA Observation form and the Mx Threat Codes from the LOSA Database. You can locate them from the Observer Manage page by clicking the “Forms and Other References” button.

4 Mx Demographics form

5 Mx Threat Codes

6 General Guidelines The form is a guide and a place to record data for later analysis Do not need to observe everything on the forms Observe and take “samples” of behaviors in the hangar or shop or on the ramp The form is not in the spirit of a starting engine or pre-takeoff checklist The observer as a Subject Matter Expert (SME) will probably notice threats and errors without needing the form as a cue Take notes during observation then fill in the forms later In some respects, you are stepping into the role of a scientist investigating the maintenance environment. With naturalistic observations the observer will never have a complete view of the environment. Over time more threats and errors will bubble to the surface thus the need for repeated observations.

7 Observer Preparation Take a few minutes before an observation to review the form Make a general plan for your observations Be open to changing your plan and look for the unexpected There are several things to consider as you prepare for your observation. Are you conducting an observation after a previous LOSA that diagnosed consistent errors? Have the interventions worked? What do you need to look for? Do you as a subject matter expert in maintenance suspect previously unaddressed threats and errors? Another thing to keep in mind, be open to the possibility that years of exposure may have desensitized you to ongoing threats and errors.

8 Observation Example First, let’s review an observation sample together.

9 Situation The mechanic I was observing got to work at 6:00 am that morning and started a #2 engine change procedure on a B After disconnecting the first quick disconnect line, he got paged and went to take a phone call from his wife. He came back and finished up disconnecting and capping the remaining quick disconnects, but he did not cap the first quick disconnect line. He signed the work card without noticing his error. When answering the demographics questions, the mechanic stated that he was a midnight shift (10:00 pm to 6:00 am) mechanic. He was called in to work the day shift on his second day off. On his first day off, he went bowling with his family until 11:30 pm. He got the call to report at 6:00 am for the day shift after arriving back home around midnight. The mechanic I was observing got to work at 6:00 am that morning and started a #2 engine change procedure on a B After disconnecting the first quick disconnect line, he got paged and went to take a phone call from his wife. He came back and finished up disconnecting and capping the remaining quick disconnects, but he did not cap the first quick disconnect line. He signed the work card without noticing his error. When asking the demographics questions the mechanic stated that he was a midnight shift (10:00 pm to 6:00 am) mechanic. He was called in to work the day shift on his second day off. On his first day off, he went bowling with his family until 11:30 pm. He got the call to report for the day shift after arriving back home around midnight.

10 Here is a photograph of the quick disconnect line.
10

11 Mx LOSA Observation Form Sections
A. Planning B.1 Prepare for Removal B.2 Removal B.3 Prepare to Install B.4 Install B.5 Installation Test B.6 Close-up/Complete Restore C. Fault Isolation/Troubleshooting/Deferral D. Servicing There are 9 sections in the Mx LOSA Observation form. 11

12 LOSA Observation Form Now let’s look at the LOSA Observation Form. The correct section to record this observation sample is “Section B.2 Removal.”

13 Threat Codes Mx/A. Information
Mx/B. Equipment / Tools / Safety Equipment Mx/C. Aircraft Design / Configuration / Parts Mx/D. Job / Task Mx/E. Knowledge / Skills Mx/F. Individual Factors Mx/G. Environment / Facilities Mx/H. Organizational Factors Mx/I. Leadership / Supervision Mx/J. Communication Mx/K. Quality Control Mx/L. Other Contributing Factors Potential threat codes are categorized into 12 groups as listed here. [Pause briefly on the slide to give the trainee a chance to read through the categories.] Please refer to a print-out of Maintenance LOSA threat codes for details. 13

14 Form Section: B.2 Removal
Error “At Risk” item #12: REMOVAL PROCEDURES FOLLOWED Threat codes: Individual Factors: Mx/F2 (Fatigue), Mx/F8 (Workplace distractions or interruptions during task performance), Mx/F15 (Other; Technician worked on his regular day off). Error “At Risk” item #18: INDIVIDUAL WORK STEPS SIGNOFF COMPLETED Individual Factors: Mx/F8 (Workplace distractions or interruptions during task performance) Effectively managed?  No Error Outcomes  Undesired state (uncapped quick disconnect line). There are two items in this section of the LOSA observation form that should be recorded as “At Risk.” The first “At Risk” item is “Removal Procedures Followed.” Based on the description of this scenario, multiple threat codes apply here. “Fatigue” and “workplace distractions or interruptions during task performance” in Category Mx/F “Individual Factors” of the threat codes should both be recorded. The codes for these two threats are “Mx/F2” and “Mx/F8” respectively. Since this technician worked on his regular day off, we can also include the threat codes “Mx/F15 Other” and add a note in the “Remarks” section. An additional threat “Mx/J3 shift change” in Category Mx/J “Communication” should also be included. The above threats were NOT effectively managed. The error outcome is “2. Undesired state” since the technician failed to check his own work. The second “At Risk” item is “Individual work steps signoff completed.” One threat, “workplace distractions or interruptions during task performance,” with threat code “Mx/F8” existed according to the scenario description. This threat was NOT effectively managed. The error outcome is “2. Undesired state” since the technician failed to check his own work. You may fill out the other portion of this form section accordingly. However, the above two items should be the only ones that are marked as “At Risk.” 14

15 Mx/F. Individual Factors
Mx/F1. Physical health (including hearing and sight) Mx/F2. Fatigue Mx/F3. Time pressure Mx/F4. Peer pressure Mx/F5. Complacency Mx/F6. Body size/strength Mx/F7. Personal event (e.g., family problem, car accident) Mx/F8. Workplace distractions or interruptions during task performance Mx/F9. Memory lapse (forgot) Mx/F15. Other (Technician worked on his regular day off In section “Mx/F. Individual Factors” of the threat codes, notice the code for “Fatigue” is “Mx/F2”, “Workplace distractions or interruptions during task performance” is “Mx/F8”, and “Other (explain below)” is MxF15. 15

16 LOSA Observation Form Now let’s look at the LOSA Observation Form. The correct section to record this observation sample is “Section B.2. Removal.”

17 Additional Comments When answering the demographics questions the mechanic stated that he was a midnight shift (10:00 pm to 6:00 am) mechanic. He was called in to work the day shift on his second day off. On his first day off, he went bowling with his family until 11:30 pm. He got the call to report for the day shift after arriving back home around midnight. The mechanic I was observing got to work at 6:00 am that morning and started a #2 engine change procedure on a B After disconnecting the first quick disconnect line, he got paged and went to take a phone call from his wife. He came back and finished up disconnecting and capping the remaining quick disconnects, but he did not cap the first quick disconnect line. He signed the work card without noticing his error. You are encouraged to write down detailed notes during and post LOSA observation. These notes will help you reconstruct, record, and code your observation into the database. We all work fatigued but we need to be more careful.

18 Practice Observations
OK, let’s look at some scenarios and practice conducting LOSA observations together.

19 Practice Observation Instructions
Complete the appropriate section of the observation form for each of the following scenarios. Identify and mark down the threats and error outcomes and include any remarks. Following your observation, enter your information into the Mx LOSA software database. For each of the following 4 scenarios, please choose and complete the appropriate section or sections of the observation form you printed out earlier. When filling out the form, identify and mark the threats and error outcomes, and include any remarks. Following your observation practice run, enter your information into the maintenance LOSA software database.

20 Scenario #1: Incorrect Tires

21 Situation After a test flight following heavy maintenance, a arrived late for its scheduled flight in 15 degree F (-9 C) weather. On a maintenance walk-around, the #1 tire (main landing gear) was completely deflated, which required both the #1 and #2 tires to be changed. The technician had a limited amount of time to do the job and to get the aircraft turned around in time to meet the Estimated Time of Release. He installed the tires for a ER on a The two aircraft require different tires, although both tires look the same and will fit on either aircraft. The inspector found the mistake before the aircraft was returned to the line. After a post-heavy Mx test flight a arrived late in 15 degree F (-9 C) weather. On a maintenance walk-around, the #1 tire (main landing gear) was completely deflated, which required both #1 and #2 tires to be changed. The technician had a limited amount of time to do the job and to get the aircraft turned around in time to meet the Estimated Time of Release (ETR). He installed the tires for a ER on a The two aircraft require different tires, although both tires look the same and will fit on either aircraft. The inspector found the mistake before the aircraft was returned to the line.

22 In these photographs, you can see the 737 tires with proper marking and the main landing gears.
Please take a few minutes to code this observation. 22

23 LOSA Observation Form The correct section for recording this observation sample is “Section B.4 Install.” For easy tracking of LOSA observations conducted in your organization, please make sure to record observation number for each observation you perform. All observation numbers will be assigned by your maintenance LOSA coordinator. It is usually composed of three segments: “station code” – “observer code” – “observation code.” For example, like “ ” illustrated here (“No.12 station in an organization” – “No.3 observer at No.12 station” – “the first observation completed by this observer”). For other sections of the LOSA observation form, you can check the “did not observe this section” box on the top right corner when your observation doesn’t apply to those sections. 23

24 Threat Codes Mx/A. Information
Mx/B. Equipment / Tools / Safety Equipment Mx/C. Aircraft Design / Configuration / Parts Mx/D. Job / Task Mx/E. Knowledge / Skills Mx/F. Individual Factors Mx/G. Environment / Facilities Mx/H. Organizational Factors Mx/I. Leadership / Supervision Mx/J. Communication Mx/K. Quality Control Mx/L. Other Contributing Factors Potential threat codes are categorized into 12 groups as listed here. [Pause briefly on the slide to give the trainee a chance to read through the categories.] Please refer to the print-out of Maintenance LOSA threat codes for details. 24

25 Errors and Threats Error “At Risk” item #5: Effectivity/Configuration Verified. Threat codes: Aircraft Design/Configuration/Parts: Mx/C3 (Aircraft configuration variability) Error “At Risk” item #8: Installation procedures followed. Aircraft Design/Configuration/Parts: Mx/C6 (Easy to install incorrectly) Environment/Facilities: Mx/G3 (Environment/Facilities – Cold) Effectively managed?  Yes Error Outcomes  Inconsequential Based on the description of Scenario #1 “Incorrect tires,” three threats existed: aircraft configuration variability, easy to install incorrectly, and undesired environment/facilities factor (the temperature was “cold”). Your sheets and software entries should contain threat codes that are similar to the codes listed… 25

26 Mx/C. Aircraft Design / Configuration / Parts Mx/C1. Complex
Mx/C2. Inaccessible Mx/C3. Aircraft configuration variability Mx/C4. Parts unavailable Mx/C5. Parts incorrectly labeled/certified Mx/C6. Easy to install incorrectly Mx/C7. Parts not used Mx/C8. Other (explain below) In section “Mx/C. Aircraft Design / Configuration / Parts” of the threat codes, notice the code for “Aircraft configuration variability” is “Mx/C3,” and “Easy to install incorrectly” is “Mx/C6.” 26

27 Mx/G. Environment / Facilities Mx/G1. High noise level Mx/G2. Hot
Mx/G3. Cold Mx/G4. Humidity Mx/G5. Rain Mx/G6. Snow Mx/G7. Lightning In section “Mx/G. Environment/ Facilities” of the threat codes, notice the code for “Cold” is “Mx/G3.” 27

28 LOSA Observation Form In “Section B.4 Install” of the LOSA Observation Form, this practice scenario should be recorded as follows: “Item 5. Effectivity/configuration verified” should be marked as “At Risk” in the “Safety Risk” column with the corresponding threat codes “Mx/C3.” This threat was effectively managed. The error outcome is “1. Inconsequential” because the inspector identified and, by assumption, corrected the mistake before the aircraft was returned to the line. “Item 8. Installation procedures followed” should be marked as “At Risk” in the “Safety Risk” column with the corresponding threat codes “Mx/C6” and “Mx/G3.” These threats were effectively managed. The error outcome is “1. Inconsequential” because the inspector identified and, by assumption, corrected the mistake before the aircraft was returned to the line. You may fill out the other portion of this form section accordingly. 28

29 Additional Comments After a post-heavy Mx test flight a arrived late in 15 degree F (-9 C) weather. On a maintenance walk-around, the #1 tire (main landing gear) was completely deflated, which required both #1 and #2 tires to be changed. The technician had a limited amount of time to do the job and to get the aircraft turned around in time to meet the Estimated Time of Release (ETR). He installed the tires for a ER on a The two aircraft require different tires, although both tires look the same and will fit on either aircraft. You are encouraged to write down detailed notes during and post LOSA observation. These notes will help you reconstruct, record, and code your observation into the database. The inspector found the mistake before the aircraft was returned to the line. This is fine but we need to find a way to reduce the chance of this happening. The extra work and expense of fixing the mistake probably cost more than some solutions.

30 Scenario #2: Transducer Out of Rig

31 Situation Two technicians replaced a #1 engine T/R inboard center drive unit (the CDU) on a B The LOSA observer overheard the manager say that the airplane needed to be ready in three and a half hours and there was another plane they needed to work after this one. The airplane was outside the hangar on a 100-degree F. (38 degree C.) sunny day. The LOSA observer also saw the technicians begin work without reviewing the procedure. Although they read the manual after beginning the task, the transducer was not rigged properly during the installation. The T/R subsequently failed the operational check. Two technicians working within normal work hours were given an assignment to Remove and Replace the #1 engine inboard center drive unit (the CDU). They were told the aircraft needed to be ready in three and a half hours, and that there was another aircraft they needed to repair after this one. Work began outside the hangar, in a 100-degree heat. They referenced the Boeing 767 AMM Chapter for removal-replace instructions. That Maintenance Manual has references for changing out attached Components from the old CDU and into the new one. While one technician was pre-installing the CDU to the aircraft, the other was printing more AMM references. The first technician glanced through the manual while installing the CDU and its components. After the CDU was installed he read through the rigging and operational check procedures for the thrust reverser. He also skimmed through the smaller Components Maintenance Manual for operational checking. The thrust reverser failed the ops check.

32 In this photograph is the #1 engine thrust reverser, inboard center drive unit (CDU). Now, please take a few minutes to code this observation. 32

33 LOSA Observation Form The correct section for recording this observation sample is “Section B.4 Install.” 33

34 Threat Codes Mx/A. Information
Mx/B. Equipment / Tools / Safety Equipment Mx/C. Aircraft Design / Configuration / Parts Mx/D. Job / Task Mx/E. Knowledge / Skills Mx/F. Individual Factors Mx/G. Environment / Facilities Mx/H. Organizational Factors Mx/I. Leadership / Supervision Mx/J. Communication Mx/K. Quality Control Mx/L. Other Contributing Factors Potential threat codes are categorized into 12 groups as listed here. [Pause briefly on the slide to give the trainee a chance to read through the categories.] Please refer to the print-out of Maintenance LOSA threat codes for details. 34

35 Errors and Threats Error “At Risk” item #8: INSTALLATION PROCEDURES FOLLOWED Threat codes: Knowledge/Skills: Mx/E6 (Task planning; did not take enough time to go over the procedure) Individual Factors: Mx/F3 (Time pressure) Environment/Facilities: Mx/G2 (Hot) Effectively managed?  No Error Outcomes  Undesired state (improperly rigged transducer) “Installation Procedures Followed” is the only item in this section of the LOSA observation form that should be recorded as “At Risk.” Based on the description of this scenario, multiple threat codes apply here. The first threat is “Task planning,” which is in Category Mx/E “Knowledge/ Skills” of the threat codes. The code for this threat is “Mx/E6.” There is a second threat “Mx/F3: Time pressure” in Category Mx/F “Individual factors” and a third threat in “Mx/G2: Hot” in Category Mx/G “Environment/ Facilities” that should also be marked. The three threats were NOT effectively managed. The error outcome is “2. Undesired state” because the technician failed to check his own work. You may fill out the other portion of this form section accordingly. However, the above item should be the only one marked as “At Risk.” 35

36 Mx/E. Knowledge / Skills Mx/E1. Technical skills
Mx/E2. Computer skills Mx/E3. Teamwork skills Mx/E4. English proficiency Mx/E5. Task knowledge Mx/E6. Task planning Mx/E7. Company process knowledge Mx/E8. Aircraft system knowledge Mx/E9. Other (explain below) In section “Mx/E. Knowledge / Skills” of the threat codes, notice the code for “Task planning” is “Mx/E6.” 36

37 Mx/F. Individual Factors
Mx/F1. Physical health (including hearing and sight) Mx/F2. Fatigue Mx/F3. Time pressure Mx/F4. Peer pressure Mx/F5. Complacency Mx/F6. Body size/strength Mx/F7. Personal event (e.g., family problem, car accident) Mx/F8. Workplace distractions or interruptions during task performance Mx/F9. Memory lapse (forgot) In section “Mx/F. Individual Factors” of the threat codes, notice the code for “Time pressure” is “Mx/F3.” 37

38 Mx/G. Environment / Facilities Mx/G1. High noise level Mx/G2. Hot
Mx/G3. Cold Mx/G4. Humidity Mx/G5. Rain Mx/G6. Snow Mx/G7. Lightning In section “Mx/G. Environment/ Facilities” of the threat codes, notice the code for “Hot” is “Mx/G2.” 38

39 LOSA Observation Form Here is a summary of LOSA observation recording for the “At Risk” item in Scenario #2. 39

40 Additional Comments Two technicians replaced a #1 engine T/R inboard center drive unit (the CDU) on a B The LOSA observer overheard the manager say that the airplane needed to be ready in three and a half hours and there was another plane they needed to work after this one. The airplane was outside the hangar on a 100-degree F. (38 degree C.) sunny day. The LOSA observer also saw the technicians begin work without reviewing the procedure. Although they read the manual after beginning the task, the transducer was not rigged properly during the installation. The T/R subsequently failed the operational check. Although they read the manual the transducer was not rigged properly during the installation. The thrust reverser failed the ops check and needed to be re-rigged. 38

41 Scenario #3: B737-500 Down-Jacking
Scenario #3: Boeing Down-Jacking.

42 Situation Technicians were performing gear swing on a After completing the operational check, one of the technicians cleared the aircraft for down jacking. As the aircraft was being lowered, the LOSA observer realized a maintenance stand had not been removed from under the tail compartment access door, and stopped the down jacking. They removed the stand and continued lowering the aircraft. Technicians were performing gear swing on a Boeing After completing the ops check, one of the technicians cleared the aircraft for down jacking. As the aircraft was being lowered, the LOSA observer realized a Mx stand had not been removed from under the tail compartment access door, and stopped the down jacking. They removed the Mx stand and continued the lowering the aircraft.

43 These photographs show the main gear jacking.
Now, please take a few minutes to code this observation.

44 LOSA Observation Form The correct section for recording this observation sample is “Section B.6 Close-up/Complete Restore.” 42

45 Threat Codes Mx/A. Information
Mx/B. Equipment / Tools / Safety Equipment Mx/C. Aircraft Design / Configuration / Parts Mx/D. Job / Task Mx/E. Knowledge / Skills Mx/F. Individual Factors Mx/G. Environment / Facilities Mx/H. Organizational Factors Mx/I. Leadership / Supervision Mx/J. Communication Mx/K. Quality Control Mx/L. Other Contributing Factors Potential threat codes are categorized into 12 groups as listed here. [Pause briefly on the slide to give the trainee a chance to read through the categories.] Please refer to the print-out of Maintenance LOSA threat codes for details. 45

46 B.6 Close Up/Complete Restore
Form Section: B.6 Close Up/Complete Restore Error “At Risk” item #11: Return to normal condition procedures followed Threat codes: Individual Factors: Mx/F13 (Situational Awareness) Communication: Mx/J4 (Maintenance crew and lead) Effectively managed?  No Error Outcomes  Undesired state (LOSA observer intervened due to imminent damage) Based on the description of this scenario, two threat codes apply here: First, “Situation awareness” with a code “Mx/F13” in Category Mx/F, “Individual Factors,” of the threat code. Second, “Mx/J4 Maintenance crew and lead” in Category Mx/J, “Communication.” The two threats were NOT effectively managed. The error outcome is “Undesired state (the aircraft was almost lowered with the tail stand still in place).’ You may fill out the other portion of this form section accordingly. However, “Verified effectivity/configuration correct for procedure” should be the only item marked as “At Risk.” 46

47 Mx/F. Individual Factors
Mx/F1. Physical health (including hearing and sight) Mx/F2. Fatigue Mx/F3. Time pressure Mx/F4. Peer pressure Mx/F5. Complacency Mx/F6. Body size/strength Mx/F7. Personal event (e.g., family problem, car accident) Mx/F8. Workplace distractions or interruptions during task performance Mx/F9. Memory lapse (forgot) Mx/F10. Visual perception Mx/F11. Assertiveness Mx/F12. Stress Mx/F13. Situational awareness Mx/F14. Not properly dressed (e.g., for weather) Mx/F15. Other (explain below) In section “Mx/F. Individual Factors” of the threat codes, notice the code for “Situational awareness” is “Mx/F13.” 47

48 Mx/J1. Between departments Mx/J2. Between mechanics
Mx/J. Communication Mx/J1. Between departments Mx/J2. Between mechanics Mx/J3. Between shifts Mx/J4. Between maintenance crew and lead Mx/J5. Between lead and management Mx/J6. Between flight crew and maintenance Mx/J7. Other (explain below) In section “Mx/J. Communication” of the threat codes, notice the code for “Between maintenance crew and lead” is “Mx/J4.” 48

49 LOSA Observation Form Here is a summary of LOSA observation recording for the “At Risk” item in Scenario #3. 47

50 Additional Comments Technicians were performing gear swing on a Boeing After completing the ops check, one of the technicians cleared the aircraft for down jacking. As the aircraft was being lowered, I realized a Mx stand had not been removed from under the tail compartment access door, and stopped the down jacking. They removed the Mx stand and continued the lowering the aircraft. I had to intervene before they damaged the aircraft. We need to take a closer look at what went wrong.

51 Scenario #4: Improperly Pinned Slide

52 Situation A senior mechanic with 24 years of experience was working a double shift following a “trade” day. He was installing a B aft entry door slide assembly. He did not use the maintenance manual, even though he was providing on-the-job training to two inexperienced technicians. The R & R was done under very poor lighting conditions. The mechanic forgot to remove the safety pin from the new slide raft after installation. The QC inspector found that the pin was not removed from the installed slide.

53 Here are two photographs of the door slide assembly packed in a storage box.
Please take a few minutes to code this observation. 53

54 LOSA Observation Form The correct section for recording this observation sample is “Section B.4 Install.” 54

55 Threat Codes Mx/A. Information
Mx/B. Equipment / Tools / Safety Equipment Mx/C. Aircraft Design / Configuration / Parts Mx/D. Job / Task Mx/E. Knowledge / Skills Mx/F. Individual Factors Mx/G. Environment / Facilities Mx/H. Organizational Factors Mx/I. Leadership / Supervision Mx/J. Communication Mx/K. Quality Control Mx/L. Other Contributing Factors Potential threat codes are categorized into 12 groups as listed here. [Pause briefly on the slide to give the trainee a chance to read through the categories.] Please refer to the print-out of Maintenance LOSA threat codes for details. 55

56 Errors and Threats Error “At Risk” item #8: INSTALLATION PROCEDURES FOLLOWED Threat codes: Individual Factors: Mx/F9 (Memory lapse; forgot) Environment/Facilities: Mx/G8 (Illumination) Organizational Factors: Mx/H8 (Work process/procedure not followed) Information: Mx/A9 (Information not used) Effectively managed?  Yes (caught by QC inspector) Error Outcomes  Inconsequential “Installation procedures followed” is the only item in this section of the LOSA observation form should be recorded as “At Risk.” Based on the description of this scenario, multiple threat codes apply here: First, “Memory lapse; forgot” with a code “Mx/F9” in Category Mx/F, “Individual Factors,” of the threat code. Second, “Mx/G8 Illumination” in Category Mx/G, “Environment/Facilities.” Third, “Mx/H8 Work process/procedure not followed” in Category Mx/H, “Organizational Factors.” Lastly, “Mx/A9 Information not used” in Category Mx/A, “Information.” Fortunately, the threats were effectively managed because the improperly pinned slide was caught by a Quality Control inspector. The error outcome is “1. Inconsequential.” You may fill out the other portion of this form section accordingly. However, the “Installation procedures followed” should be the only item marked as “At Risk.” 56

57 Mx/F. Individual Factors
Mx/F1. Physical health (including hearing and sight) Mx/F2. Fatigue Mx/F3. Time pressure Mx/F4. Peer pressure Mx/F5. Complacency Mx/F6. Body size/strength Mx/F7. Personal event (e.g., family problem, car accident) Mx/F8. Workplace distractions or interruptions during task performance Mx/F9. Memory lapse (forgot) In section “Mx/F. Individual Factors” of the threat codes, notice the code for “Memory lapse (forgot)” is “Mx/F9.” 57

58 Mx/G. Environment / Facilities Mx/G1. High noise level Mx/G2. Hot
Mx/G3. Cold Mx/G4. Humidity Mx/G5. Rain Mx/G6. Snow Mx/G7. Lightning Mx/G8. Illumination In section “Mx/G. Environment/ Facilities” of the threat codes, notice the code for “Illumination” is “Mx/G8.” 58

59 Mx/H. Organizational Factors
Mx/H1. Quality of internal support from technical organizations Mx/H2. Quality of external support from technical organizations Mx/H3. Company policies Mx/H4. Not enough staff Mx/H5. Corporate change / restructuring Mx/H6. Labor action Mx/H7. Work process / procedure Mx/H8. Work process / procedure not followed In section “Mx/H. Organizational Factors” of the threat codes, notice the code for “Work process / procedure not followed” is “Mx/H8.” 59

60 Mx/A1. Not understandable Mx/A2. Unavailable or inaccessible
Mx/A. Information Mx/A1. Not understandable Mx/A2. Unavailable or inaccessible Mx/A3. Incorrect Mx/A4. Inadequate (e.g., missing graphics) Mx/A5. Uncontrolled (e.g., outdated) Mx/A6. Too much conflicting information Mx/A7. Updated process is too long or complicated Mx/A8. Incorrectly modified manufacturer’s Maintenance Manual/Service Bulletin Mx/A9. Information not used Mx/A10. Other (explain below) In section “Mx/A. Information” of the threat codes, notice the code for “Information not used is “Mx/A9.” 60

61 LOSA Observation Form Here is a summary of LOSA observation recording for the “At Risk” items in Scenario #4. 61

62 Additional Comments I was observing a senior mechanic. He was performing a B aft entry door slide assembly install. He did not use the maintenance manual, even though he was providing on-the-job training to two inexperienced technicians. The remove and replace task was done under very poor lighting conditions. During the demographics questions he stated he has 24 years of experience. He was also working a double shift following a “trade” day. The mechanic did not remove the pin from the new slide raft after installation. The QC inspector found that the pin was not removed from the installed slide.

63 This Concludes the Line Operations Safety Assessment (LOSA): Maintenance (Mx) Operations – Base Training Scenarios This concludes the scenario-based LOSA training module for the base maintenance. 63

64 Line Operations Safety Assessment (LOSA): Maintenance (Mx) Operations – Line Training Scenarios
Welcome to the scenario-based Line Operations Safety Assessment (LOSA) training for line maintenance. August (v6)

65 Observation Example First, let’s review an observation sample together. 65

66 Situation A technician was observed performing routine maintenance on an ATR-42. He was closing out the aircraft during a Remain Over Night (RON) check following a RON work card. The work card listed the systems that needed to be checked but did not include instructions to switch the main battery off. The technician left the main battery switch on. Another more experienced technician was assisting him with closing the aircraft, and found the main battery switch on. He switched it off thereby correcting the first technician’s error. A technician closing an ATR-42 aircraft at night during a Remain Over Night (RON) check left the main battery switch on. A more experienced technician, closing the aircraft with him, found and corrected his error. The first night shift technician, being primarily a Heavy Maintenance Technician, was unaccustomed to checking the cockpit to ensure power was "off" prior to closing the aircraft.

67 In this photograph, you can see the main battery.
67

68 LOSA Observation Form Let’s go over your coded form. The correct section to record this observation sample is “Section B.6 Close-up/Complete Restore.” 68

69 Threat Codes Mx/A. Information
Mx/B. Equipment / Tools / Safety Equipment Mx/C. Aircraft Design / Configuration / Parts Mx/D. Job / Task Mx/E. Knowledge / Skills Mx/F. Individual Factors Mx/G. Environment / Facilities Mx/H. Organizational Factors Mx/I. Leadership / Supervision Mx/J. Communication Mx/K. Quality Control Mx/L. Other Contributing Factors Potential threat codes are categorized into 12 groups as listed here. [Pause briefly on the slide to give the trainee a chance to read through the categories.] Please refer to the print-out of Maintenance LOSA threat codes for details. 69

70 B.6 Close Up/Complete Restore
Form Section: B.6 Close Up/Complete Restore Error “At Risk” item #7: SERVICING PROCEDURES FOLLOWED Threat codes: Information: Mx/A4 (Inadequate) Knowledge/Skills: Mx/E5 (Task knowledge) Mx/E8 (Aircraft system knowledge) Effectively managed?  Yes Error Outcomes  Inconsequential In this section, “Servicing Procedures” should be marked as “At Risk.” Based on the description of this scenario, there are multiple threat codes that apply here. The first threat is “Mx/A4 inadequate,” which should be marked in Category Mx/A, “Information.” The second and third threats of “task knowledge” and “aircraft system knowledge” should be marked in Category Mx/E of the threat codes (“Knowledge/skills”). The codes for these two threats are “Mx/E5” and “Mx/E8” respectively. The threats were effectively managed. The error outcome is “Inconsequential” because the error was found and corrected. You may fill out the other portion of this form section accordingly. 70

71 Mx/A1. Not understandable Mx/A2. Unavailable or inaccessible
Mx/A. Information (e.g. work cards, maintenance manuals, service bulletins, maintenance tips, non-routines, IPC, warning/signal, etc.) Mx/A1. Not understandable Mx/A2. Unavailable or inaccessible Mx/A3. Incorrect Mx/A4. Inadequate (e.g., missing graphics) Mx/A5. Uncontrolled (e.g., outdated) Mx/A6. Too much conflicting information Mx/A7. Update process is too long or complicated Mx/A8. Incorrectly modified manufacturer’s Maintenance Manual/Service Bulletin Mx/A9. Information not used Mx/A10. Other (explain below) In section “Mx/A. Information” of the threat codes, notice the code for “Inadequate” is “Mx/A4.” 71

72 Mx/E. Knowledge / Skills Mx/E1. Technical skills
Mx/E2. Computer skills Mx/E3. Teamwork skills Mx/E4. English proficiency Mx/E5. Task knowledge Mx/E6. Task planning Mx/E7. Company process knowledge Mx/E8. Aircraft system knowledge Mx/E9. Other (explain below) In section “Mx/E. Knowledge / Skills” of the threat codes, notice the code for “Task knowledge” is “Mx/E5,” and “Aircraft system knowledge” is “Mx/E8.” 72

73 LOSA Observation Form Here is a summary of LOSA observation recording for the “At Risk” item in this situation. 73

74 Additional Comments They sent us one of the base mx guys because we were short. He did bring the RON work card for the close out. The work card listed the systems that needed to be checked but did not have instruction to secure the main battery switch. The technician left the main battery switch on. One of our senior line guys was also on the close out and found the main battery switch on. Nothing came of this but we would almost had a dead aircraft in the morning. You are encouraged to write down detailed notes during and post LOSA observation. These notes will help you reconstruct, record, and code your observation into the database. When we have inexperienced mechanics we should have a second set of eyes if we have the manpower. 74

75 Practice Observations
OK, let us look at some scenarios and practice conducting LOSA observations together. 75

76 Practice Observation Instructions
Please complete the appropriate section of the observation form for each of the following scenarios. Identify and mark down the threats and errors and include any remarks. Following your observation, enter your information into the Mx LOSA software database. For each of the following 4 scenarios, please choose and complete the appropriate section or sections of the observation form you printed out earlier. When filling out the form, identify and mark the threats and error outcomes and include any remarks. Following your observation practice run, enter your information into the maintenance LOSA software database. 76

77 Scenario #1: Rag Left in Equipment Bay
77

78 Situation A technician was in the aft equipment bay searching for fluid leaks of a CRJ-700. The LOSA observer noticed that a technician left a rag which was stuck in one of the control pulleys. A second technician found and removed the rag during the final check before closing the bay. Two technicians were called out on Aircraft X, the first flight of the day, per Maintenance Control. The problem was described as 'Fluid coming from APU.' When they arrived, the aft equipment bay door was open. They went to the flight deck to talk with the Captain. He said he thought “the leak was coming from the ACM in the equipment bay, not the APU.“ One technician entered the aft equipment bay and found no leaks. However, the moisture/condenser unit clamp to the forward duct was loose, so he re-secured the clamp. The second technician handed him some rags and went to retrieve the logbook, because the aircraft was already boarded. The first technician cleaned the moisture off the forward duct, put the rags in his back pocket and slid down and out of the aft equipment bay. When the second technician returned, the first technician told him to check the equipment bay. The LOSA observer noticed the rag during his own check and waited to see if the rag would be found in the final check. The second technician found and removed the rag during his final check.

79 In this photograph, you can see a rag lodged in a rudder cable pulley.
Please take a few minutes to code this observation. 79

80 LOSA Observation Form Let’s go over your coded form. The correct section to record this observation sample is “Section B.6 Close-up/Complete Restore.” 80

81 Threat Codes Mx/A. Information
Mx/B. Equipment / Tools / Safety Equipment Mx/C. Aircraft Design / Configuration / Parts Mx/D. Job / Task Mx/E. Knowledge / Skills Mx/F. Individual Factors Mx/G. Environment / Facilities Mx/H. Organizational Factors Mx/I. Leadership / Supervision Mx/J. Communication Mx/K. Quality Control Mx/L. Other Contributing Factors Potential threat codes are categorized into 12 groups as listed here. [Pause briefly on the slide to give the trainee a chance to read through the categories.] Please refer to the print-out of Maintenance LOSA threat codes for details. 81

82 B.6 Close Up/Complete Restore
Form Section: B.6 Close Up/Complete Restore Your sheets and software entries should contain something similar to the following… Error “At Risk” item #5: Parts, materials, and wastes dispositioned Threat codes: Individual Factors: Mx/F9 (Memory Lapse; forgot) Environment/Facilities: Mx/G19 (Restricted/confined Work Area) Effectively managed?  Yes Error Outcomes  Inconsequential Based on the description of this scenario, multiple threats apply here: the individual factor is “memory lapse/forgot,” and the undesired environment/facilities factor “restricted work area.” Your sheets and software entries should contain threat codes that are similar to those listed… 82

83 Mx/F. Individual Factors
Mx/F1. Physical health (including hearing and sight) Mx/F2. Fatigue Mx/F3. Time pressure Mx/F4. Peer pressure Mx/F5. Complacency Mx/F6. Body size/strength Mx/F7. Personal event (e.g., family problem, car accident) Mx/F8. Workplace distractions or interruptions during task performance Mx/F9. Memory lapse (forgot) Mx/F10. Visual perception Mx/F11. Assertiveness Mx/F12. Stress Mx/F13. Situational awareness Mx/F14. Not properly dressed (e.g., for weather) Mx/F15. Other (explain below) In section “Mx/F. Individual Factors” of the threat codes, notice the code for “Memory lapse (forgot)” is “Mx/F9.” 83

84 Mx/G. Environment / Facilities … Mx/G8. Illumination Mx/G9. Wind
Mx/G10. Jet blast Mx/G11. Vibrations Mx/G12. Cleanliness Mx/G13. Hazardous or toxic substances Mx/G14. Contaminated surfaces Mx/G15. Power sources Mx/G16. Inadequate ventilation Mx/G17. Slippery Mx/G18. Uneven work surface Mx/G19. Restricted/confined work area Mx/G20. Elevated work space In section “Mx/G. Environment/ Facilities” of the threat codes, notice the code for “Restricted/confined work area” is “Mx/G19.” 84

85 LOSA Observation Form In “Section B.6 Close-up/Complete Restore” of the LOSA Observation Form, this practice scenario should be recorded as follows: “Item 5. Parts, materials, and wastes dispositioned” should be marked as “At Risk” in the “Safety Risk” column with the corresponding threat codes “Mx/F9” and “Mx/G19.” These threats were not effectively managed because the rudder cable pulley was impaired by a rag. However, the error outcome is “1. Inconsequential” since the problem was caught and corrected by the second mechanic. You may fill out the other portion of this form section accordingly. However, “Item 5” should be the only one marked as “At Risk.” For easy tracking of LOSA observations conducted in your organization, please make sure to record observation number for each observation you perform. All observation numbers will be assigned by your maintenance LOSA coordinator. It is usually composed of three segments: “station code” – “observer code” – “observation code.” For example, like “ ” illustrated here (“No.12 station in an organization” – “No.3 observer at No.12 station” – “the first observation completed by this observer”). For other sections of the LOSA observation form, you can check the “did not observe this section” box on the top right corner when your observation doesn’t apply to those sections. 82 85

86 Additional Comments Two mechanics came out for the first flight of the day because of 'Fluid leak from APU.' The Captain had the aft equipment bay door open because he thought “the leak was coming from the ACM in the equipment bay, not the APU.“ One mechanic entered the aft equipment bay and tightened the moisture/condenser unit clamp to the forward duct. The second technician handed him some rags and went to retrieve the logbook, because the aircraft was already boarded. When the second technician came back, the first technician told him to check the equipment bay. The second technician found and removed a rag during his final check. The mechanic in the equipment bay did not do a good enough check on his way out. The rag he left behind was caught in one of the control pulleys so this was not a small problem. You are encouraged to write down detailed notes during and post LOSA observation. These notes will help you reconstruct, record, and code your observation into the database. Final checks and accounting for all materials are critical. This could have been a bad situation. 83 86

87 Scenario #2: MEL Violation
87

88 Situation A line technician deferred inoperative ground power lights on an B737 aircraft which was allowed by the Minimum Equipment List (MEL). However he did not carry out the maintenance procedure that was required by the MEL to verify that the avionics vent fan warning horn was operative. A line technician received a gate call concerning inoperative ground power lights. Three of four ground power lights were inoperative on test. He immediately started looking through the MEL in the Operating Manual for ground power lights. He thought the power light was cosmetic and serviceable since only the light function was out. The LOSA observer had to tell the line technician before he dispatched the aircraft that he needed to complete the check on the avionics vent fan horn. The technician was ready to dispatch the aircraft with an illegal deferral. This is an example of where a LOSA observer should intervene.

89 In this photograph, notice the ground power lights
In this photograph, notice the ground power lights. Now please take a few minutes to code this observation. 89

90 LOSA Observation Form LOSA Observation Form
The suitable section to record this observation sample is “Section C. Fault Isolation/Troubleshooting/Deferral” 90

91 Threat Codes Mx/A. Information
Mx/B. Equipment / Tools / Safety Equipment Mx/C. Aircraft Design / Configuration / Parts Mx/D. Job / Task Mx/E. Knowledge / Skills Mx/F. Individual Factors Mx/G. Environment / Facilities Mx/H. Organizational Factors Mx/I. Leadership / Supervision Mx/J. Communication Mx/K. Quality Control Mx/L. Other Contributing Factors Potential threat codes are categorized into 12 groups as listed here. [Pause briefly on the slide to give the trainee a chance to read through the categories.] Please refer to the print-out of Maintenance LOSA threat codes for details. 91

92 Errors and Threats Error “At Risk” item #20: Maintenance action properly execute. Threat codes: Information: Mx/A9 (Information not used) Organizational Factors: Mx/H8 (Work process/procedure not followed) Effectively managed?  No Error Outcomes  Undesired state (A/C would have been dispatched in a non-airworthy condition) “Notes, cautions and warnings followed” is the only item in this section of the LOSA observation form that should be recorded as “At Risk,” because the technician didn’t use the right manual and minimum equipment list (MEL). Based on the description of this scenario, multiple threat codes apply here: “Information not used” in Category Mx/A “Information” of the threat codes “Work process/procedure not followed” in Category Mx/H “Organizational Factors.” The codes for the above threats are “Mx/A9” and “Mx/H8” respectively. The above threats were NOT effectively managed. The error outcome should be “2. Undesired state” because the aircraft was dispatched without catching the MEL violation. You may fill out the other portion of this form section accordingly. However, the above item should be the only one marked as “At Risk.” 92

93 Mx/A1. Not understandable Mx/A2. Unavailable or inaccessible
Mx/A. Information (e.g. work cards, maintenance manuals, service bulletins, maintenance tips, non-routines, IPC, warning/signal, etc.) Mx/A1. Not understandable Mx/A2. Unavailable or inaccessible Mx/A3. Incorrect Mx/A4. Inadequate (e.g., missing graphics) Mx/A5. Uncontrolled (e.g., outdated) Mx/A6. Too much conflicting information Mx/A7. Update process is too long or complicated Mx/A8. Incorrectly modified manufacturer’s Maintenance Manual/Service Bulletin Mx/A9. Information not used Mx/A10. Other (explain below) In section “Mx/A. Information” of the threat codes, notice the code for “Information not used” is “Mx/A9.” 93

94 Mx/H. Organizational Factors
Mx/H1. Quality of internal support from technical organizations (e.g., engineering, planning, technical pubs) Mx/H2. Quality of external support from technical organizations (e.g., manufacturer) Mx/H3. Company policies Mx/H4. Not enough staff Mx/H5. Corporate change / restructuring Mx/H6. Labor action Mx/H7. Work process / procedure Mx/H8. Work process / procedure not followed Mx/H9. Work process / procedure not documented Mx/H10. Work group normal practice (norm) Mx/H11. Team building Mx/H12. Other (explain below) In section “Mx/H. Organizational Factors” of the threat codes, notice the code for “Work process / procedure not followed” is “Mx/H8.” 94

95 LOSA Observation Form LOSA Observation Form
Here is a summary of LOSA observation recording for the “At Risk” item in Scenario #2. 95

96 Additional Comments A line technician found that three of four ground power lights were inop on test. He checked the MEL in the Operating Manual for ground power lights. He thought the power light was secondary and that the aircraft was serviceable since only the light function was out. I told the line technician before he dispatched the aircraft that he needed to complete the check on the avionics vent fan horn. He was ready to dispatch this aircraft with an illegal deferral. You are encouraged to write down detailed notes during and post LOSA observation. These notes will help you reconstruct, record, and code your observation into the database. All of the safety nets failed on this. I had to intervene and have him do the checks before he dispatched this unairworthy aircraft. 96

97 Scenario #3: Engine Oil Filler Cap
97

98 Situation An inexperienced line technician was servicing oil on the right engine on a B after engine shutdown. The technician was observed putting on the oil filler cap, but did not lock it down. A lead technician standing nearby saw that it was not locked and corrected the problem. The technician was unfamiliar with the cap. An inexperienced line technician was servicing oil on the right engine on a B two hours after engine shutdown. The technician was observed putting on the oil filler cap, but did not lock it down. A lead technician standing nearby saw that it was not locked and corrected the problem. The technician was unfamiliar with the cap.

99 These photographs show the oil filler spout
These photographs show the oil filler spout. Now, please take a few minutes to code this observation. 99

100 LOSA Observation Form The correct form section for recording this observation sample is “Section D. Servicing.” 100

101 Threat Codes Mx/A. Information
Mx/B. Equipment / Tools / Safety Equipment Mx/C. Aircraft Design / Configuration / Parts Mx/D. Job / Task Mx/E. Knowledge / Skills Mx/F. Individual Factors Mx/G. Environment / Facilities Mx/H. Organizational Factors Mx/I. Leadership / Supervision Mx/J. Communication Mx/K. Quality Control Mx/L. Other Contributing Factors Potential threat codes are categorized into 12 groups as listed here. [Pause briefly on the slide to give the trainee a chance to read through the categories.] Please refer to the print-out of Maintenance LOSA threat codes for details. 101

102 Form Section: D. Servicing
Error “At Risk” item #18: CLOSE UP PROCEDURES FOLLOWED Threat codes: Job/Task: Mx/E1 (Technical Skills) Effectively managed?  Yes Error Outcomes  Inconsequential “Close up procedures followed” is the only item in this section of the LOSA observation form that should be recorded as “At Risk.” Based on the description of this scenario, one threat code applies here: “Mx/E1: Technical Skills” in Category Mx/E “Job/task” of the threat code. The threat was effectively managed. The error outcome is “1. Inconsequential.”   You may fill out the other portion of this form section accordingly. However, “Close up procedures followed” should be the only item marked as “At Risk.” 102

103 Mx/E. Knowledge / Skills Mx/E1. Technical skills
Mx/E2. Computer skills Mx/E3. Teamwork skills Mx/E4. English proficiency Mx/E5. Task knowledge Mx/E6. Task planning Mx/E7. Company process knowledge Mx/E8. Aircraft system knowledge Mx/E9. Other (explain below) In section “Mx/E. Knowledge / Skills” of the threat codes, notice the code for “Task knowledge” is “Mx/E5.” 103

104 LOSA Observation Form Here is a summary of LOSA observation recording for the “At Risk” item in Scenario #3. 104

105 Additional Comments I was observing an inexperienced line technician servicing oil on the right engine on a B He waited two hours after engine shutdown so there was no issue with drain down. The technician didn’t lock the oil filler cap down. A lead tech saw that it was not locked and showed the new tech what needed to be done. You are encouraged to write down detailed notes during and post LOSA observation. These notes will help you reconstruct, record, and code your observation into the database. This was a good example of a lead tech doing his job by working with the inexperienced technician. 105

106 Scenario #4: 757 Blind Oil Fill
106

107 Situation The crew of a B that had been parked for over an hour called with the #2 engine EICAS showing only 12 quarts static at the gate. Because of time pressure, the lead technician had a line technician do a blind fill of 14 quarts of oil without running the engine first. This resulted in an overfilled oil reservoir. The crew called requesting oil service for #2 engine due to EICAS reading 7 quarts static. Since flight crews would not do maintenance runs, the lead technician had a line technician do a blind addition of oil. The lead did not ask the crew to run the engine for him. The line technician added 14 quarts. It did not generate a red alert automated log in the maintenance computer. The crew ran the engine for 10 minutes prior to taxi out with no leaks or problems.

108 In this photograph, you can see an oil fill reader
In this photograph, you can see an oil fill reader. Now, please take a few minutes to code this observation. 108

109 LOSA Observation Form The correct form section for recording this observation sample is “Section D. Servicing.” 109

110 Threat Codes Mx/A. Information
Mx/B. Equipment / Tools / Safety Equipment Mx/C. Aircraft Design / Configuration / Parts Mx/D. Job / Task Mx/E. Knowledge / Skills Mx/F. Individual Factors Mx/G. Environment / Facilities Mx/H. Organizational Factors Mx/I. Leadership / Supervision Mx/J. Communication Mx/K. Quality Control Mx/L. Other Contributing Factors Potential threat codes are categorized into 12 groups as listed here. [Pause briefly on the slide to give the trainee a chance to read through the categories.] Please refer to the print-out of Maintenance LOSA threat codes for details. 110

111 Errors and Threats Error “At Risk” item #12: Documentation available and reviewed Threat codes: Information: Mx/A9 (Information not used) Individual Factors: Mx/F3 (Time pressure) Error “At Risk” item #16: Proper cool down/drain down/temperature requirements observed Error “At Risk” item #17: Replenishment procedures followed Organizational Factors : Mx/H8 (Work process/procedure not followed, Mx/H10 (Work group normal practice; norm) Leadership/Supervision: Mx/I6 (Other; Lead instructed technician to act against procedure) Effectively managed?  No Error Outcomes  Undesired state (overfilled oil reservoir) “Documentation available and reviewed,” “Proper cool down/drain down/temperature requirements observed,” and “Replenishment procedures followed” are the items in this section of the LOSA observation form that should be recorded as “At Risk.” Based on the description of this scenario, five threat codes apply here: For “Documentation available and reviewed” in Category Mx/A “Information” use threat code Mx/A9 for “Information not used”, in Category Mx/F “Individual Factors” threat code “Mx/F3 Time pressure” For “Proper cool down/drain down/temperature requirements observed,” in Category Mx/F “Individual Factors” threat code “Mx/F3 Time pressure” For “Replenishment procedures followed” in Category Mx/H “Organizational Factors” use threat codes “Mx/H8 Work process/procedure not followed” and “Mx/H10 Work group normal practice (norm).” In Category Mx/I select threat code “Mx/I6 Other (explain below). You will then need to explain in the notes that the lead instructed the technician to act against procedure. The threats were NOT effectively managed. The error outcome is “2. Undesired state” because an overfilled reservoir was the result. You may fill out the other portion of this form section accordingly. However, “Documentation available and reviewed,” “Proper cool down/drain down/temperature requirements observed,” and “Replenishment procedures followed” should be the only items marked as “At Risk.” 111

112 Mx/A1. Not understandable Mx/A2. Unavailable or inaccessible
Mx/A. Information (e.g. work cards, maintenance manuals, service bulletins, maintenance tips, non-routines, IPC, warning/signal, etc.) Mx/A1. Not understandable Mx/A2. Unavailable or inaccessible Mx/A3. Incorrect Mx/A4. Inadequate (e.g., missing graphics) Mx/A5. Uncontrolled (e.g., outdated) Mx/A6. Too much conflicting information Mx/A7. Update process is too long or complicated Mx/A8. Incorrectly modified manufacturer’s Maintenance Manual/Service Bulletin Mx/A9. Information not used Mx/A10. Other (explain below) In section “Mx/A. Information” of the threat codes, notice the code for “Information not used” is “Mx/A9.” 112

113 Mx/F. Individual Factors
Mx/F1. Physical health (including hearing and sight) Mx/F2. Fatigue Mx/F3. Time pressure Mx/F4. Peer pressure Mx/F5. Complacency Mx/F6. Body size/strength Mx/F7. Personal event (e.g., family problem, car accident) Mx/F8. Workplace distractions or interruptions during task performance Mx/F9. Memory lapse (forgot) In section “Mx/F. Individual Factors” of the threat codes, notice the code for “Time pressure” is “Mx/F3.” 113

114 Mx/H. Organizational Factors
Mx/H1. Quality of internal support from technical organizations (e.g., engineering, planning, technical pubs) Mx/H2. Quality of external support from technical organizations (e.g., manufacturer) Mx/H3. Company policies Mx/H4. Not enough staff Mx/H5. Corporate change / restructuring Mx/H6. Labor action Mx/H7. Work process / procedure Mx/H8. Work process / procedure not followed Mx/H9. Work process / procedure not documented Mx/H10. Work group normal practice (norm) Mx/H11. Team building Mx/H12. Other (explain below) In section “Mx/H. Organizational Factors” of the threat codes, notice the code for “Work process / procedure not followed” is “Mx/H8” and the code for “Work group normal practice (norm)” is “Mx/H10.” 114

115 Mx/I. Leadership / Supervision
Mx/I1. Planning / organization of tasks Mx/I2. Prioritization of work Mx/I3. Delegation / assignment of task Mx/I4. Unrealistic attitude / expectations Mx/I5. Availability of supervision Mx/I6. Other (explain below) In section “Mx/I. Leadership / Supervision” of the threat codes, notice the code for “Other (explain below)” is “Mx/I6.” 115

116 LOSA Observation Form Here is a summary of LOSA observation recording for the “At Risk” item in Scenario #4. 116 116

117 Additional Comments A flight crew called requesting oil service for #2 engine due to EICAS reading 7 quarts static. The flight crew would not do a maintenance runs so the lead technician had a line technician do a blind oil fill. The line technician added 14 quarts. It did not generate a red alert automated log in the maintenance computer. The crew ran the engine for 10 minutes with no leaks or problems. This was one of those few times when I had to intervene as a LOSA observer. They checked the level and fortunately it was within limits. You are encouraged to write down detailed notes during and post LOSA observation. These notes will help you reconstruct, record, and code your observation into the database. Another one of those times when nothing bad happened but could have. We are heading down a slippery slope with this type of norm. 114 117

118 This Concludes the Line Operations Safety Assessment (LOSA): Maintenance (Mx) Operations – Line Training Scenarios This concludes the scenario-based LOSA training module for the base maintenance. Visit the LOSA website: 118


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