11a WCFMaintAssess

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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

				
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