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Douglas Aircraft used two different names for one part, and the National Transportation Safety Board asked the government to have the manufacturer reconcile the two names. The Board concluded that "because Douglas uses two different terms ('firing lanyard' and 'inflation cable') for the same part in its MD-80 and DC-9 maintenance manuals, the manual remains potentially confusing."1 Recommendation A-96-139 then asked the FAA to require Douglas to review and amend both manuals.1 The stated purpose was that the terminology used in graphics and instructions for the installation and removal of evacuation slides be "clear and consistent."1

What the regulations say about the manual

Under 14 CFR 43.13(a), each person performing maintenance must use the methods, techniques, and practices prescribed in the current manufacturer's maintenance manual or Instructions for Continued Airworthiness.2 The same sentence allows "other methods, techniques, and practices acceptable to the Administrator, except as noted in § 43.16."2 Paragraph (c) adds that for the holder of an air carrier operating certificate, the methods in that holder's own maintenance manual "constitute acceptable means of compliance with this section."2 A mechanic therefore works from a written procedure, and which document supplies it depends on who holds the certificate.

For a transport category airplane certificated under Part 25, Appendix H sets out what the Instructions for Continued Airworthiness must contain.3 It requires that "The contents of the manual or manuals must be prepared in the English language."3 It requires that "The format of the manual or manuals must provide for a practical arrangement."3 The required contents include troubleshooting information "describing probable malfunctions, how to recognize those malfunctions, and the remedial action for those malfunctions."3

What the accident record says about these documents

In the Air Midwest 5481 investigation, the Board looked at a work card and at the manual the card named. The manual "did not contain a stand-alone procedure for checking elevator cable tension, as called for on the D6 work card."4 The card's first step called for a temperature reading that determined the tension values for the cables, and the Board noted that the card "did not specify how to take the temperature."4 A step named a measurement without naming a method.

The FAA's account of a 1991 accident describes a different failure of the same kind. Work cards carried "no entries" that would have told the third shift a second shift had already begun work on the horizontal stabilizer deice boots.5 One written record did exist. "The second shift work on the accident airplane was indicated on the second shift inspector's written turnover sheet; however, the incoming third shift inspector reviewed the sheet before the entry was made."5 Air carriers are required to hold procedures for work "not completed as a result of shift changes or similar work interruptions."6

Auditors report the same pattern away from accidents

The Department of Transportation's Inspector General reported in 2010 on FAA oversight of American Airlines' maintenance programs. According to American officials, the report says, the carrier's engineers verbally requested in 2006 that quality assurance representatives inspect the Boeing 757's windshield heat components as the airplanes came in for maintenance.7 The auditors wrote that "the engineers did not document the request or inspection results, so we were unable to verify that the inspections were performed."7 An instruction that was never written down could not afterward be shown to have been carried out.

A 2013 audit of repair station oversight found employees who "did not complete work orders to document technical data they used during repairs."8 The same sentence lists incorrect employee stamps used to document completion of work steps, and work steps signed off by employees not authorized to complete them.8 In the same sample, officials could not produce training documentation for the tasks required in 45 of 119 work orders.8

An FAA Office of Aerospace Medicine proceedings report records an industry participant's observation about where technical data is held.9 "Technical data are rarely all in one place."9 Technicians "must assimilate information from multiple parts of a manual and even multiple manuals."9

What an editor reads, and what stays with the certificate holder

We make no airworthiness determination, and we do not approve anything for return to service. We do not judge whether a task was performed correctly, or whether a reference is acceptable data. Those acts belong to the people the regulations authorize to perform them.

What comes to us is the written material around the work. It includes maintenance procedures and task cards, quality and training manuals, and service bulletins. It also includes technical publications prepared for operators, and the internal instructions describing how a record entry is composed.

In that material we look for one name used for one part across the task card, the illustrated parts list, and the manual section. We look for a reference that names the procedure a reader needs, and not a number on its own. We look for steps set down in the order the client's own procedure states, and an abbreviation given in full at its first appearance. We look for a document control number and a revision date that match from the cover to the footer. Every document a client sends us is treated in confidence.

Appendix H tells a Part 25 manufacturer to prepare its instructions in English and to arrange them practically.3 Two questions recur in the findings above. The first is whether the writing was clear enough to act on. The second is whether it was written down at all.

References

  1. National Transportation Safety Board, Safety Recommendations A-96-128 through -140, 31 December 1996. https://www.ntsb.gov/safety/safety-recs/recletters/A96_128_140.pdf
  2. Office of the Federal Register, Electronic Code of Federal Regulations, 14 CFR 43.13, Performance rules (general). https://www.ecfr.gov/current/title-14/chapter-I/subchapter-C/part-43/section-43.13
  3. Office of the Federal Register, Electronic Code of Federal Regulations, 14 CFR Part 25, Appendix H to Part 25, Instructions for Continued Airworthiness. https://www.ecfr.gov/current/title-14/chapter-I/subchapter-C/part-25/appendix-Appendix%20H%20to%20Part%2025
  4. National Transportation Safety Board, Loss of Pitch Control During Takeoff, Air Midwest Flight 5481, Raytheon (Beechcraft) 1900D, N233YV, Charlotte, North Carolina, January 8, 2003, Aircraft Accident Report NTSB/AAR-04/01. https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR0401.pdf
  5. Federal Aviation Administration, Lessons Learned from Transport Airplane Accidents, Embraer EMB-120RT N33701, Continental Express Flight 2574, 11 September 1991. https://www.faa.gov/lessons_learned/transport_airplane/accidents/N33701
  6. Office of the Federal Register, Electronic Code of Federal Regulations, 14 CFR 121.369, Manual requirements. https://www.ecfr.gov/current/title-14/chapter-I/subchapter-G/part-121/subpart-L/section-121.369
  7. US Department of Transportation, Office of Inspector General, FAA's Oversight of American Airlines' Maintenance Programs, Report Number AV-2010-042, 16 February 2010. https://www.oig.dot.gov/sites/default/files/WEB%20FILE_FAA%20Oversight%20of%20AA.pdf
  8. US Department of Transportation, Office of Inspector General, FAA Continues To Face Challenges in Implementing a Risk-Based Approach for Repair Station Oversight, Report Number AV-2013-073, 1 May 2013. https://www.oig.dot.gov/sites/default/files/FAA%20Repair%20Station%20Oversight%5E5-1-13.pdf
  9. Avers K, Johnson B, Banks J, Wenzel B. Technical Documentation Challenges in Aviation Maintenance: A Proceedings Report. Civil Aerospace Medical Institute, FAA Office of Aerospace Medicine, DOT/FAA/AM-12/16, November 2012. https://www.faa.gov/sites/faa.gov/files/data_research/research/med_humanfacs/oamtechreports/201216.pdf

A worked example: Evacuation Slide Task Card

Maintenance task card

A task card carries a procedure from a manual to the person doing the work. Under 14 CFR 43.13(a) the methods a mechanic uses are the ones a written procedure prescribes, so the card and the document it names are the instruction being followed. The recurring faults on a card are not technical. In 1996 the National Transportation Safety Board recorded a manual that used two names for one part. "Because Douglas uses two different terms ('firing lanyard' and 'inflation cable') for the same part in its MD-80 and DC-9 maintenance manuals, the manual remains potentially confusing." The Board asked the FAA to require that the terminology in graphics and instructions be "clear and consistent." In the Air Midwest 5481 investigation the Board found a manual that "did not contain a stand-alone procedure for checking elevator cable tension, as called for on the D6 work card." It also found that the card "did not specify how to take the temperature" its first step called for. The technical content below belongs to the manufacturer and to the operator's engineering staff. Nothing in the corrected card changes a step, adds a step, or alters the order in which the steps are performed.

Before

SPECIMEN, PREPARED BY EDITFAST FOR ILLUSTRATION. NOT A REAL RECORD.
TASK CARD TC-25-62-04 Rev. 3
Kestrel 420 (fictitious type) - Evacuation Slide, Girt Bar Installation
Meridian Air Services (fictitious)

1. Install the slide pack in the door sill.
2. Route the inflation cable through the tab grommet.
3. Connect the firing lanyard to the retaining ring.
4. Verify routing IAW AMM 25-62-00.
5. Check that the lanyard is secure as required.
6. Sign off when complete.

Form TC-25-62-04 Rev. 2

After

SPECIMEN, PREPARED BY EDITFAST FOR ILLUSTRATION. NOT A REAL RECORD.
TASK CARD TC-25-62-04 Rev. 3
Kestrel 420 (fictitious type) - Evacuation Slide, Girt Bar Installation
Meridian Air Services (fictitious)

Note: the manufacturer's manual uses two names for this part. This card uses inflation cable throughout.

1. Install the slide pack in the door sill.
2. Route the inflation cable through the tab grommet.
3. Connect the inflation cable to the retaining ring.
4. Verify the routing in accordance with AMM 25-62-04, Evacuation Slide Installation, paragraph 3.B.
5. Check that the inflation cable is secure.
6. Sign and date this card when steps 1 through 5 have been performed.

Form TC-25-62-04 Rev. [query to client: the header reads Rev. 3 and the footer reads Rev. 2]

What changed, and why

WasNowReason
Connect the firing lanyard to the retaining ring.Connect the inflation cable to the retaining ring.One part carries two names inside one card, at steps 2, 3, and 5. A reader cannot tell whether two components are involved or one. The step itself is unchanged.
Verify routing IAW AMM 25-62-00.Verify the routing in accordance with AMM 25-62-04, Evacuation Slide Installation, paragraph 3.B.IAW is an abbreviation the card never expands. The reference also gives a number where a named procedure and a paragraph are available, so a reader has to locate the right passage inside it.
Check that the lanyard is secure as required.Check that the inflation cable is secure.The same part again, under a third form of the name. The phrase "as required" also states no condition a reader can test, and it cannot be signed against, because nothing on the card says what the requirement is.
Sign off when complete.Sign and date this card when steps 1 through 5 have been performed.Complete is not defined anywhere on the card, and the original does not ask for a date. Naming the steps gives the signature something to refer to.
Form TC-25-62-04 Rev. 2Form TC-25-62-04 Rev. [query to client: the header reads Rev. 3 and the footer reads Rev. 2]The header and the footer disagree about which revision this is. Which one is correct is a document control question for the client, so the point is raised as a query rather than settled by an editor.

Final specimen (PDF, 4 KB) Marked-up specimen (PDF, 6 KB)

Specimen prepared by EditFast for illustration only. Not a real document, record or filing. Any resemblance to an actual organization, person or record is unintended. Not legal, regulatory, clinical or professional advice.

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