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System Safety Assessment - WCF Maintenance
System: Aircraft Maintenance (In House)
Pre Mitigation
Achieved?
Likelihood
Mitigation
Yes or No
Mitigation
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Medium
Remote
Manuals or maintenance instructions which Incorporate manual updates automatically.
Critical
are not current, on hand, or complete could Incorporate manual hard copy updates when they
cause use of improper parts and procedures are received.
Manuals
Medium
Remote
Maintenance instructions for added equipment Ensure maintenance instructions for additional
Critical
unavailable which could cause the use of equipment are incorporated and complete in the
improper parts and procedures aircraft maintenance procedures prior to use
Occasional
Serious
Record entries which are not accomplished
Critical
Ensure maintenance entries are made upon
may cause insufficient knowledge of
completion of work
airworthiness
Occasional
Record entries which do not sufficiently
Serious
Critical
Records describe discrepancy or work performed, or
Ensure entries are complete and legible
illegible, may cause insufficient knowledge of
airworthiness
Occasional
Aircraft removed from maintenance facility Serious
Critical
prior to maintenance entries being Ensure personnel are aware of proper aircraft
accomplished into aircraft records could release procedures from maintenance
indicate the work was not completed
Catastrophic Catastrophic
Occasional
High
Insufficient equipment and tools may cause Ensure proper equipment and tools are available
improper workmanship prior to performing work
Occasional
Change working hours to adjust for more
High
Inhospitable working environment may result acceptable temperatures. Utilize temporary wind
in improper workmanship or contamination breaks/weather shelters. Some mitigations may
not be possible.
Medium
Remote
Critical
Lack of technical support can cause improper Prearrange support prior to departure from home
Field Maintenance maintenance procedures base.
Catastrophic
Occasional
High
Lack of sufficient personnel could result in Ensure sufficient number of personnel prior to
injuries and damage to aircraft of equipment performing work
Catastrophic
Remote
Serious
Availability or insufficient parts may result in Ensure sufficient quantity of airworthy parts prior to
improvisation or the reuse of used parts performing work
1 Completed 2009
System: Aircraft Maintenance (In House - cont.)
Pre Mitigation
Achieved?
Likelihood
Mitigation
Mitigation
Yes or No
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Verify calibration prior to use. Maintain a list of
tools requiring calibration with expiration dates.
Medium
Remote
Specialized test equipment which is not
Critical
Assign person to manage tools requiring
calibrated could cause improper adjustments
calibration. Make notation of aircraft inspection
(torque wrenches, scales, multimeters, etc.)
checklist to check calibration of tools requiring
calibrati
Medium
Occasional Occasional Occasional Occasional Remote
Test Equipment Test equipment not available or properly used
Critical
Ensure test equipment is available and personnel
could result in improper adjustments or
are properly trained on use prior to performing work
calibration of aircraft systems
Test equipment functioning improperly could Take test equipment out of service when it fails.
Serious
Critical
result in improper adjustments, improper Keep test equipment properly maintained and
calibration/damage to aircraft systems, or calibrated. Attach "Red Tag" or "Do Not Use" tag
injure personnel to non-functional equipment
Serious
Temporary electrical equipment not installed
Critical
Ensure all equipment installed has proper
with engineering data or per AC 43-13 could
engineering or acceptable data prior to installation
result in damage to aircraft or personnel
Special mission equipment installed/removed
Serious
Ensure weight & balance is properly calculated
Special Mission without weight & balance being recalculated Critical
upon completion of removal or installation of
Equipment can cause the aircraft to be out of center of
special equipment
gravity (CG) limits
Modifications to special equipment, such as
Serious
Critical
equipment racks, does not have updated Ensure engineering data is updated prior to
engineering data which could damage aircraft installation of modified special equipment
and personnel
System: Facilities (Hanger)
Pre Mitigation
Achieved?
Occasional Remote Likelihood
Mitigation
Mitigation
Yes or No
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Medium
Power required for the task could overload
Critical
existing capacity which may cause a fire and Increase power capacity of facility.
damage to equipment
Serious
Frayed power cords or cords missing ground Inspect power cords before use. Replace
Critical
pin could cause a fire, injury to personnel, and frayed/damaged power cords. Repair/destroy
Power damage to equipment frayed/damaged power cords.
Marginal Catastrophic
Remote
Serious
Power cart old/unreliable could cause damage
Replace old/unreliable power carts with new.
to aircraft and/or personnel
Medium
Remote
High mineral content in water can damage
engines and aircraft surfaces when used for Install water conditioning system
cleaning
Water
2 Completed 2009
Water
Probable
Marginal
Serious
Standing water can be a slipping hazard Ensure proper drainage and remove water from
causing injuries to personnel floor prior to work being accomplished.
3 Completed 2009
System: Facilities (Hanger- cont.)
Pre Mitigation
Achieved?
Likelihood
Mitigation
Yes or No
Mitigation
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Verify calibration prior to use. Maintain a list of
Occasional
tools requiring calibration with expiration dates.
Serious
Tools not calibrated could cause improper
Critical
Assign person to manage tools requiring
adjustments (torque wrenches, scales,
calibration. Make notation of aircraft inspection
multimeters, etc.)
checklist to check calibration of tools requiring
Tools calibrati
Occasional
Tools broken, missing pieces, and tools not
Serious
Inspect tools before use. Replace
Critical
properly maintained can cause injury to
damaged/broken tools. Maintain tools in good
personnel and damage to aircraft and
working condition.
equipment
Occasional
Serious
GSE leaking may cause spill hazards resulting
Critical
Ensure GSE is maintained. Inspect GSE before
in injuries to personnel and aircraft in addition
use and repair/replace as necessary.
to damage to aircraft
Ground Support
Equipment (GSE)
Medium
Remote
GSE not being maintained or used improperly Ensure GSE is maintained. Inspect GSE before
Critical
may cause personnel injury or damage to use and repair/replace as necessary. Train
aircraft personnel on GSE prior to it being used.
Probable
Lighting insufficient can create an unsafe
Critical
High
working environment leading to damage to Ensure adequate lighting available.
aircraft and injuring personnel
Lighting
Occasional
Serious
Lighting device not properly installed or
Critical
Ensure all lighting devices are maintained and safe
maintained can cause injury to personnel or
to operate
damage equipment
Occasional
Aircraft towing capacity of tug exceeded may
Serious
Ensure towing vehicle is proper size for make and
Critical
cause loss of control during towing operations
model of aircraft and personnel are properly trained
damaging aircraft and possible injury to
in towing procedures.
personnel
Use of incorrect tow bar may cause loss of
Medium
Remote
Critical
Towing control during towing operations and could Ensure proper tow bar is used and train personnel
Equipment cause damage to aircraft and equipment and in proper towing procedures
possible injury to personnel
Occasional
Ramp conditions not considered during tow
Serious
Inspect ramp for conditions (ice, water, snow and
Critical
operations may cause loss of control during
etc) prior to towing operations. Do not tow if
towing operations damaging aircraft and
adverse conditions are observed.
possible injury to personnel
4 Completed 2009
System: Maintenance Contracting (contracting WCF Fleet maintenance)
Pre Mitigation
Achieved?
Likelihood
Mitigation
Mitigation
Yes or No
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Contractor does not have the correct Ensure contract specifies what is required to
Probable
tools/equipment (i.e. hand tools, GSE, test properly perform maintenance per model aircraft.
Critical
High
equipment) for the task which could result in Conduct site visit on contractor to ensure they have
damage to the aircraft and improper correct and properly maintained tools, GSE, and
maintenance procedures. test equipment.
Facilities
Occasional
Serious
Contractor does not have hanger and/or Ensure hanger is of proper size for contracted
Critical
hanger door to accommodate aircraft being aircraft. Conduct site visit to ensure hanger meets
contracted requirements.
No technical data available/out of
Probable
Technical Data
Critical
High
date/incomplete to properly maintain aircraft Ensure contractor has proper/current technical
(Manuals, ADs,
which could result in the aircraft's improper data for contracted aircraft
SBs, etc)
maintenance
Probable
Contractor facilities are located at a distant Issue contracts to only those facilities which are
Critical
High
site which causes oversight to be limited due within a reasonable distance (where possible) from
to travel/time constraints oversight personnel's home base.
Oversight
Probable
Oversight personnel not available due to Critical
High
Adjust staffing and budget to meet demands to
time/other duties which may result in
provide proper oversight of contractors
improper/incomplete maintenance
System: Safety
Pre Mitigation
Achieved?
Likelihood
Mitigation
Mitigation
Yes or No
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Occasional
Marginal
Medium
Personnel
Inadequate hearing protection can cause Provide hearing protection (ear plugs and/or ear
Protective
permeate hearing loss muffs)
Equipment
Frequent
Critical
High
Annual audio testing not being accomplished
Provide annual audiogram testing
can result in undetected hearing loss
Medical
Equipment
Occasional
Serious
Insufficient medical supplies (first aid kit, eye
Critical
Provide adequate medical supplies and inspect
wash station) on hand may result in injuries
monthly for serviceability and inventory
not being treated In a timely manner
Probable
Identify a standardized procedure for all
Critical
High
Not using the Safecom System reduces
maintenance personnel to use the Safecomm
awareness of problems in the field
System
SAFECOM
Probable
Critical
High
Safecomm System does not provide Revise Safecomm System to meet the needs of
information needed for awareness maintenance
5 Completed 2009
System: Safety (cont.)
Pre Mitigation
Achieved?
Occasional Probable Likelihood
Mitigation
Yes or No
Mitigation
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Marginal
Serious
The lack of a standardized procedures in Create standardized Safecom trending procedures.
using the Safecom System can result in Create a centralized collection point to develop and
invalid maintenance trending data analyze trend data
Policy & Doctrine
Marginal
Medium
FSH 5709.16, CH 40 is not kept current so Assign a person or committee to update and
procedures are not standard maintain manuals as required
Probable
Marginal
Serious
The lack of a central bulletin board to relay Create a central bulletin board accessible to all FS
Communications
maintenance issues between regions maintenance personnel. (Intranet based)
Probable Frequent
Marginal
Serious
Job Hazard Analysis (JHA) use is not Create standardized JHAs and conduct annual
standardized refresher training
Marginal
Serious
Non-standard operational risk management
Risk Management (ORM) process is not available Develop a standard ORM procedure
Maintain current MSDS binder along with
Probable
Material Safety Data Sheets (MSDS) binders
Critical
High implementing recommended safety measures.
are not current which exposed personnel to
Ensure personnel are properly trained in use of
unknown hazards
chemicals per MSDS.
System: Personnel (Government)
Pre Mitigation
Achieved?
Likelihood
Mitigation
Yes or No
Mitigation
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Catastrophic
Frequent
Adhere to establish work-rest policy/guidelines and
High
Fatigue promote additional off-time. Request additional
staffing and/or detailers during high fire activity
Occasional
Serious
Emphasize importance of "situational awareness"
Critical
Acceptance of risk as normal as a means to recognize risk. Provide human
factors and risk management training.
Frequent
Critical
Human Factors
High
Prioritize assigned tasks. Request additional
Task saturation
staffing, detailers, and/or contractors as needed.
Occasional
Bring issues to supervision. Discuss conflict with
Marginal
Medium
nemesis. Attend CRM training. Give honest
Conflicting personalities
feedback. Keep a positive attitude. Take
immediate action.
6 Completed 2009
Frequent
Special emphasis with personnel in regard to
Critical
High
Sense of urgency/pressure/mission driven safety vs. urgency and re-enforce this throughout
entire operational period
7 Completed 2009
System: Personnel (Government - cont.)
Pre Mitigation
Achieved?
Likelihood
Mitigation
Yes or No
Mitigation
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Medium
Remote
Policy deviation causing differences in Emphasize the importance of understanding policy
Critical
maintenance procedures which could lead to and be familiar with consequences of policy
non-standard maintenance practices deviation
Occasional
Marginal
Medium
Differing standards between regions causing Stress standardization between regions to adhere
Policy/ confusing and differences in maintenance to established policies and procedures. Place all
Procedures procedures maintenance personnel under a single manager.
Frequent
Marginal
Serious
Policies subject to differing interpretations Create policies which are clear. Have a single
creating an unclear direction to accomplish the person to interpret policy once a question arises
work which would be disseminated among all involved.
Occasional
Insufficient personnel to accomplish
Serious
Critical
maintenance in a timely manner which could Increase staffing to a level where safe
Utilization
cause improper maintenance, damage to maintenance practices occur.
aircraft and/or injuries to personnel
Occasional
Serious
Aircraft Specific Technical training insufficient Critical
or lack of may cause improper maintenance Provide aircraft specific training
procedures resulting in damage to the aircraft
Occasional
Serious
Lack of regulatory training can result in
Critical
Provide regulatory training annually or as
Training inconsistent application of policy (CFRs, FS
mandated
regulations, COR, etc)
Occasional
Serious
Lack of equipment / facilities training (GSE
Critical
and test equipment) may cause injury to Provide equipment/facilities training annually
personnel and equipment
8 Completed 2009
System: Personnel (Contractor)
Pre Mitigation
Achieved?
Likelihood
Mitigation
Yes or No
Mitigation
Outcome
Catastrophic Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Frequent
Adhere to established work-rest policy/guidelines
High
Fatigue and promote additional off-time. Request
additional staffing.
Frequent Occasional Frequent Occasional
Serious
Emphasize importance of "situational awareness"
Critical
Acceptance of risk as normal as a means to recognize risk. Provide human
factors and risk management training.
Critical
High
Human Factors Prioritize assigned tasks.Request additional
Task saturation
staffing or subcontract work.
Bring issues to supervision/management. Discuss
Marginal
Medium
conflict with nemesis. Attend CRM training. Give
Conflicting personalities
honest feedback. Keep a positive attitude. Take
immediate action.
Have discussion with contractor and personnel in
Critical
High
Sense of urgency/pressure/mission driven regard to safety vs. urgency and re-enforce this
throughout entire contract operational period
Medium
Remote
Emphasize the importance of understanding
Critical
Policy/contract specification deviation could
policy/contract requirements and FAA regulations.
lead to non-standard maintenance practices
Policy/contract Be familiar with consequences of deviations
Procedures and
FAA regulations Policies/contract specifications and Create policies/contract specifications and
Frequent
Marginal
Serious
regulations subject to differing interpretations regulations which are clear. Have a single person
creating an unclear direction to accomplish the to interpret policy once a question arises which
work would be disseminated among all involved.
Occasional
Insufficient personnel to accomplish
Serious
Critical
maintenance in a timely manner which could Increase staffing to a level where safe
Utilization
cause improper maintenance, damage to maintenance practices occur.
aircraft and/or injuries to personnel
Occasional
Aircraft Specific Technical training insufficient
Serious
Critical
or lack of may cause improper maintenance
Provide aircraft specific training
procedures resulting in damage to the aircraft
and/or possible injury to personnel
Occasional
Serious
Lack of regulatory training can result in
Critical
Training
inconsistent application of policy (CFRs, FS Provide regulatory training annually
regulations)
Occasional
Serious
Lack of equipment / facilities training (GSE
Critical
and test equipment) may cause injury to Provide equipment/facilities training annually
personnel and equipment
9 Completed 2009
Draft System Safety Assessment - Dry Lease Contracts Maintenance
System: Contracts
Pre Mitigation
Achieved?
Likelihood
Mitigation
Yes or No
Mitigation
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Experienced maintenance personnel are not
Occasional
being used to evaluate and write the
Probable
Ensure experienced maintenance personnel review
High
specification in the solicitation. Which can
and help write the maintenance specifications of all
result in improperly altered or un-airworthy
contracts.
aircraft being awarded. This can result in
damage to equipment and injury to personnel
Specifications not writen to hold vendors
Maintenance accountable to comply with federal aviation Ensure language in contract provides a means to
Frequent
Critical
Specifications
High
regulations and the manufactures hold the vendor accountable for not complying with
maintenance recommendations. Which can Federal Aviation Regulations and Manufactures
cause damage to equipment and injury to Recommendations
personnel.
Occasional
Serious
Specifications are not adequate to ensure Ensure contract maintenance specifications are
Critical
proper over site for airworthiness. This can adequate to ensure oversight for quality control by
result in injury to personnel. maintenance inspectors.
Proposal package technical information not
Frequent
always correct or complete which could result Critical Ensue experienced maintenance personnel are on
High
in awarding un-airworthy aircraft. This can evaluation team to look for and chatch inproper
result in injury to personnel and damage to information.
Proposal equipment.
Evaluation
Probable
Aircraft specific experienced personnel not
Critical
High
Ensure maintenance personnel with specific
always used to evaluate proposals which can
aircraft experience are on evaluation team.
result in un-airworthy aircraft
System: Initial & Recurrent Inspection
Pre Mitigation
Achieved?
Likelihood
Mitigation
Yes or No
Mitigation
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Hurried time frame to do inspections causes
Occasional
Marginal
Medium
insufficient inspections and items missed.
Ensure there is enough time to do the inspection
Time Available Missed items can cause improper
properly and with in the inspectors schedule.
maintenance procedures causing damage to
equipment and injury to personnel.
10 Completed 2009
System: Initial & Recurrent Inspection
Pre Mitigation
Achieved?
Likelihood
Mitigation
Yes or No
Mitigation
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Facilities and equipment available are not
Occasional
always adequate to perform a proper
Marginal
Medium
Ensure the facilities are adequate and proper
inspection where the aircraft is located.This
euipment is availabele or have the aircraft moved
could result in an inadequate inspection. This
to a proper facility.
may cause injury to personnel and damage to
aircraft.
Aircraft are not always inspected at the
Frequent
Serious
vendors facility, so their capabilities are
Critical
Have all pre-use inspections performed at the
overlooked or not evaluated at all. This could
vendors base facility
lead to improper maintenance peocedures and
damage to equipment and injury to personnel.
Facility Some vendors have no in-house maintenance
capabilities so the maintenance is performed
by a sub-contracted facility which allows no
Frequent Require vendors to have in house maintenance
Critical
High
oversight by the gov. inspector for quality or
facilities and support or use only Manufaactures
technical capability on specific aircraft. This
Service Centers
could lead to improper maintenance which
could result in damage to equipment and
injury to personnel.
Current and proper maintenance manuals for
specific make, model and s/n aircraft are not
Frequent
Serious
Critical
always available at inspection site. This can Ensure proper manuals are available during
cause improper maintenance pricedures which inspections
could cause damage to equipment and injury
to personnel.
Copies of the current aircraft maintenance
Marginal
Medium
Remote
records are not always available with the
Ensure copies of current maintenance records are
Records aircraft which could lead to improper
available for the inspections
maintenance procedures and items missed on
inspection.
11 Completed 2009
System: Continuous Maintenance
Pre Mitigation
Achieved?
Likelihood
Mitigation
Yes or No
Mitigation
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Occasional
Serious
Contract specifications do not always provide Ensure Maintenance specifications in contract
Critical
for adequate maintenance oversight during provide for adequate adequate oversight for quality
operation under contract control during operation period of contract.
Vendors are not being held accountable for
Frequent
Airworthiness
Critical
High
not complying with the federal aviation
Oversight
regulations, and manufactures
recommendations
Probable
Personnel are not always available to provide Privide sufficient number of personnel to provide
Critical
High
adequate quality assurance oversight during oversight for quality control during operation period
contract period of operation of contract.
Occasional
Maintenance inspectors only do a return to Provide in contract maintenance specifications for
Serious
Return to
Critical
contravt availability ony when they are asked the maintenance inspector to do a return to
Contract
and not after the aircraft has had unscheduled contract availability after unscheduled
Availability
maintenance performed maintenance.
System Safety Assessment - Contract Oversight, Aircraft Maintenance
System: Writing Contract Specifications
Pre Mitigation
Achieved?
Likelihood
Mitigation
Yes or No
Mitigation
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Occasional
Personnel not familiar with aviation
Serious
Critical
maintenance and/or program requirements Ensure experienced maintenance personnel are
Program
can cause improper aircraft equipment and involved when writing contract specifications
maintenance requirements
Marginal
Medium
Remote
FAA approved maintenance programs not Ensure experienced maintenance personnel are
being required in contract specifications involved when writing contract specifications
Aircraft
Marginal
Medium
Remote
No specifications for Maintenance records to
Ensure experienced maintenance personnel are
be maintained in accordance with FAA
involved when writing contract specifications
requirements
Frequent
Critical
High
Specifications for qualified/experienced Ensure specifications for qualified and experienced
maintenance personnel are not in all contracts mechanics are written in contracts
Maintenance
Personnel
No duty limitations for maintenance personnel
Probable
Critical
High
in most contracts which can cause fatigue Ensure specifications for duty limitations are written
leading to mistakes being made and causing in all contracts
damage to equipment and injury to personnel.
12 Completed 2009
System: Vendor Proposals
Pre Mitigation
Achieved?
Likelihood
Mitigation
Yes or No
Mitigation
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
There is not always an aviation maintenance
Occasional
Negligible
person on the evaluating team resulting in
Ensure Maintenance personnel are included on
Low
vendors with unapproved maintenance
evaluation teams
programs and unqualified maintenance
personnel being awarded contracts
Evaluating
Occasional
Evaluating team not paying close attention to
Negligible
Ensure Qualified Maintenance personnel are
what the proposals are stating, which results
Low
included on evaluation teams and are and aware of
in the FS receiving poor or substandard
all the solicitation requirements
equipment and personnel
System: Inspection of Aircraft after Award for Contract Compliance
Pre Mitigation
Achieved?
Likelihood
Mitigation
Yes or No
Mitigation
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Aircraft records not maintained in accordance
Marginal
Medium
Remote
with FAA requirements which can cause Inspector verify records are maintained in
Aircraft
improper maintenance procedures due to lack accordance with FAA CFR's
of proper documentation Medium
Remote
Adequate number of trained and experienced Inspector verify the training and experience of the
Critical
Personnel maintenance personnel can cause fatigue and maintenance personnel that will be working on the
injuries to personnel aircraft offered under the contract
Probable
Inadequate number of inspectors to complete
Critical
High
Provide adequate number of inspectors to
work load in time frame required resulting in
accomplish the work load in a timely fashion
inadequate inspections
Occasional
Serious
Critical
Fatigue resulting in lack of detail on Provide adequate number of inspectors to
inspections accomplish the work load in a timely fashion
Human Factors
Medium
Remote
Critical
Urgency of mission results in missed items on Provide sufficient amount of time to accomplish the
inspection inspection properly
Probable
When vendors uses contract maintenance the
Critical
High
Ensure more and better oversight of contracted
quality of work is usually a lower standard than
maintenance
when performed in house on owned aircraft
13 Completed 2009
System: Evaluating Vendors Maintenance Facility
Pre Mitigation
Achieved?
Likelihood
Mitigation
Yes or No
Mitigation
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Catastrophic Marginal Marginal
Medium
Remote
Facilities not adequate in size to house aircraft
Inspector verify facility is adequate in size for
during maintenance can cause inadequate
aircraft offered under the contract
maintenance to be performed
Medium
Remote
Sufficient tools and special equipment to Inspector verify vendors specialized tools are
properly maintain aircraft can cause improper available to maintain the aircraft offered under the
maintenance procedures contract
Probable
Improper and not current manuals for aircraft Inspector verifies the vendor has correct and
High
offered under contract can cause improper current manuals for the aircraft offered under the
Facilities
maintenance procedures contract
Sufficient lighting and equipment (heater,
Marginal
Medium
Remote
janitorial and etc) to maintain a proper work
Inspector verify condition of work area
environment can cause inadequate
inspections
Marginal
Medium
The vendors sometimes uses special tools Remote
Ensure when equivalent tools are used, they meet
that are equivalent to and not what the
the minimum performance standard
manufacturer call out in the manual
System: Evaluating Vendor Maintenance Program
Pre Mitigation
Achieved?
Occasional Likelihood
Mitigation
Yes or No
Mitigation
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Serious
Instructions for Not incorporating instructions into inspection Inspector verifies that the ICA's for installed items
Critical
Continued program causes items on aircraft to not be have been incorporated into the inspection
airworthiness inspected properly program
Tracking programs not kept up to date causes
Probable
Critical
Tracking of time time items to be over flown (overhaul times,
High
Inspector verifies the latest revision date on the
compliance Items retirement times and etc) and possible failure tracking sheet with maintenance record entries
of component
No or partial manuals for specific make, model
Medium
Remote
Critical
and serial Number May cause improper inspector verify complete set of manuals for
maintenance procedures causing damage to specific aircraft offered
equipment and injury to personnel
Manuals
Catastrophic
Probable
Out of date manuals may cause improper
High
Inspector verify the latest revisions are installed in
maintenance procedures causing damage to
manuals for the specific aircraft offered
equipment and injury to personnel
Medium
Remote
Critical
Unapproved parts may cause damage to Inspector check maintenance records and aircraft
equipment and/or injury to personnel for any suspected unapproved parts
Approved Parts
14 Completed 2009
Approved Parts
Improper tracking of time life parts can cause
Medium
Remote
Inspector verify the tracking records in aircraft
Critical
the retirement time to be over-flown and
maintenance records for tracking of timed
possible failure of part causing damage to
components
aircraft and/or injury to personnel
15 Completed 2009
System: Evaluating Mechanic Qualifications
Pre Mitigation
Achieved?
Likelihood
Mitigation
Yes or No
Mitigation
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Catastrophic
Occasional
Mechanic with lack of experience on make
Experience/ Ensure maintenance personnel have the
High
and model could result in improper
Training on make experience and training on the make and model of
maintenance procedures and/or damage to
and model aircraft offered under the contract.
aircraft and/or personnel injury
System: Personnel (Vendor)
Pre Mitigation
Achieved?
Likelihood
Mitigation
Yes or No
Mitigation
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Catastrophic
Occasional
Mechanic has little experience on make and Inspector verify experience level of maintenance
High
Experience model aircraft can cause improper personnel on make and model of aircraft provided
maintenance procedures under contract
Lack of technical training on make and model
Catastrophic
Occasional
aircraft offered under the contract can cause Inspector verify technical training of maintenance
High
Training improper maintenance procedures leading to personnel on make and model of aircraft provided
damage to equipment and/or injury to under contract
personnel
Probable
Fatigue and stress can cause errors resulting
Critical
High
in damage to equipment and/or injury to Ensure contract duty limitations are not exceeded
personnel
Occasional
Marginal
Medium
Mission urgency may cause neglect of policy
Ensure sufficient time is provided for proper
and/or regulations which can cause injury to
maintenance procedures
personnel
Human Factors
Occasional
Serious
Distractions may cause things to be
Critical
Ensure as few distractions as possible during
overlooked or procedures forgotten during
maintenance functions
maintenance
Not enough personnel to do maintenance
Medium
Remote
Critical
functions properly could cause mechanic to Ensure sufficient personnel are provided to
improvise and may cause damage to accomplish maintenance procedures properly
equipment and/or injury to personnel
16 Completed 2009
System: Personnel (Government)
Pre Mitigation
Achieved?
Frequent Likelihood
Mitigation
Yes or No
Mitigation
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Critical
High
Too many duties and not enough personnel to Provide sufficient personnel to accomplish work
Utilization
do a proper job load
Catastrophic
Occasional
High
Not following set policies can cause injury to
Policy Ensure policies are followed
personnel
Occasional
Marginal
Medium
Lack of technical training for specific aircraft
Provide technical training to inspectors on specific
may result in lack of thorough inspection of
make and model aircraft
critical areas
Lack of knowledge of current regulations,
Occasional
Serious
manufacturer requirements may allow Provide training and/or refresher training for
Critical
improper maintenance procedures resulting in inspectors and inspectors should verify
Training damage to equipment and/or injury to requirements as they come due.
personnel
Lack of knowledge of current aviation
Occasional
Serious
contracts of how to read and interpret Provide training and/or refresher training for
Critical
language and specifications may allow inspectors on reading and interpreting aviation
improper maintenance procedures resulting in contracts
damage to aircraft and/or injuries to personnel.
Catastrophic
Probable
Fatigue due to long hours and urgency of
High
Provided sufficient time to accomplish tasks
getting job accomplished can cause injury to
required in a timely manner
personnel and damage to equipment
Human Factors
High workload for maintenance inspectors
Probable
may compromise their ability to do a thorough
Critical
High
Provide sufficient personnel and time to
inspection resulting in possible improper
accomplish proper inspections
maintenance procedures and injuries to
personnel and/or damage to equipment
System: Avionics
Pre Mitigation
Achieved?
Likelihood
Mitigation
Yes or No
Mitigation
Outcome
Severity
Value
Post
Suggested Mitigation
Sub-systems Hazards Additional Local Mitigation
Negligible
Probable
Medium
Fatigue due to long hours and urgency of
Provided sufficient time to accomplish tasks
getting job accomplished can cause injury to
required in a timely manner
personnel and damage to equipment
Human factors High workload for avionics inspectors may
Negligible
Probable
Medium
compromise their ability to do a thorough
Provide sufficient personnel and time to
inspection resulting in possible improper
accomplish proper inspections
maintenance procedures and injuries to
personnel and/or damage to equipment
17 Completed 2009
