Improving Communication about Technical Publications: A Safety Enhancement Report

Aug. 5, 2014
The Commercial Aviation Safety Team (CAST) SE 170 group studied how to ensure optimal communication between maintenance organizations, OEMs, and design approval holders (DAHs) for continued safety. What can we expect from that report?

There are many targets for “blame” when it comes to “failure to use written technical documentation/procedures.” The excuses include such factors as corporate culture, pressure to complete the work, and availability of documentation. A favorite excuse is that the documentation is hard to understand and follow or that it is incorrect.

The challenge is shared by airline and general aviation maintenance professionals. Whatever the explanation, a licensed technician/engineer is responsible and answerable to the FAA or other national aviation authority. This article is about new recommendations regarding improving the documents written by the manufacturers or by your organization.

The Commercial Aviation Safety Team (CAST) is an industry-government organization that reviews data to ensure continuing aviation safety. CAST not only evaluates the feasibility of safety intervention strategies but also creates and evaluates specific action plans. One such activity is the safety enhancement (SE) groups that address specific challenges. The SE 170 group was formed in response to the 2001 Alaska Airlines accident. There was apparent complexity in servicing the horizontal stabilizer jackscrew on the MD-83 aircraft. The group studied ways to ensure optimal communication between maintenance organizations, original equipment manufacturers (OEMs), and design approval holders (DAHs). 

There will be at least two reports on the SE 170 activity. One will be a CAST Committee Report and the other will be published as ATA Spec 119. Both are currently in final stages of press. Their likely recommendations are summarized in this article.  

The CAST SE-170 group responded to the common complaints like:

“When it is difficult to understand the written procedures I don’t use them.”

“Complaining about the instructions does not help.”

“When the documents are difficult to understand I don’t know who to call. I don’t what to look stupid.”

“It takes too long to get a document changed.”

“Calling an OEM for documentation support is harder than calling Apple or Microsoft to fix your software!”

While users complain about the documentation revision process, the company engineering department, the OEMs, and the DAHs are begging to get meaningful feedback so they can modify and validate problematic documentation. There seems to be a disconnect between users and those who write and revise documents – “What we got here is failure to communicate” (From the Captain in Cool Hand Luke). 

The SE 170 committee is likely to report on five major challenges and proposed recommendations, described here. I took the liberty of simplifying some of the expected SE 170 findings. I have also assigned example actions to responsible parties including OEMs/DAHs, maintenance engineering organizations (MxO), individual maintenance personnel (AMT), aviation safety inspectors (ASI), and all who should monitor the process. 

Challenge 1: Process to identify difficult tasks

It appears that many organizations do not know the internal or external process to get poor instructions corrected. In some cases it may be better to consider changes to the procedures, tools, or training as opposed to merely rewording a document. Reviewing the documentation is the place to start to understand the challenge.

Example Solutions: (Actions for users – MxO and AMT)

  • The aviation industry must develop and reinforce a culture that all mechanics work to the operator maintenance instructions, which are based on OEM/DAH maintenance instructions. (All)
  • The mechanic should understand that the carrier has a program for reporting and resolving problems with maintenance procedures. (AMT, ASI)

Challenge 2: Process to report issues to OEM

This challenge is an extension of the first challenge but is more of an issue between the maintenance organization and the document provider.

Example solutions:

  • OEM/DAHs maintenance instructions providers should enhance systems that allow rapid reporting of safety related problems with maintenance instructions. (OEMs/DAHs, ASIs)
  • When the operator maintains work instructions they must have document revision systems comparable or exceeding that of the OEM. (MxO, ASI)
  • When mechanics find a better way to complete a task then that should be reported and validated to improve efficiency and safety. Why not improve the documentation rather than ignoring it? (AMTs, MxO, ASI)

Challenge 3: Response time to operator issues is too slow

Operators and maintenance personnel want faster OEM/DAH feedback on reported issues.

Example Solutions:

  • OEM/DAHs and operators should improve the legacy process for faster response to reported concerns regarding maintenance instructions and task difficulty. (MxO, OEM/DAH, ASI)
  • Increasing quality and frequency of reports from operators will promote development of a faster response system. (All)

Challenge 4: Clarify information requirements to promote change

OEM/DAH must improve the specification for reported information from operators. OEMs/DAHs must be specific about the kind of information and format of reports.   Make it easy to report and there will be more reports.

Example Solutions:

  • Maintenance personnel must understand what kind of problems and best format to report. (OEM/DAH, MxO, ASI)
  • Operators should implement a practice of submitting reports, regarding safety-related issues, using the OEM/DAHs designated format. (All)

Challenge 5: Comprehensive fix to task difficulty and instructions

OEM/DAH documentation changes are not transmitted well and are not comprehensive enough to ensure that the fix considers not only the documentation but also considerations such as task complexity, accessibility, tooling, and other factors.

Example Solutions:

  • The OEM/DAH should partner with the operator to validate procedurally complex maintenance instructions, including an evaluation of the task and the environment in which it is performed. (OEM/DAH, ASI)
  • The OEM/DAH should incorporate human factors principles and techniques in the development of maintenance instructions and the maintenance task itself. (OEM/DAH, ASI)

The solutions are in your hands?

The expected SE 170 and ATA Spec 119 recommendations are not necessarily bold and innovative. However, the recommendations remain relevant and valuable. They should be followed.

Many, including writers and maintenance engineering departments, would insist that they already follow the recommendations. However, reports to the NASA Aviation Safety Reporting System and through the FAA Safety Action Program suggest otherwise. Mechanics still fail to follow the written documentation every day.

This industry can affect change with increased leadership commitment. That must include industry leaders, from both management and labor.   Regulatory management can make an impact as well. They must motivate safety inspectors to focus to ensure the continuing quality of the documents and the document update process. When it is obvious that procedures were not followed there should always be sufficient cooperative root cause analysis that could include the regulator and the company. The industry must continue to strive to ensure that documents are written and delivered in a way that today’s work force will increase their respect, reliance, and compliance.

Advanced document delivery technologies, with embedded communication systems, should make it easier for users to note difficulties and to add those “work-arounds” that are commonplace in the industry. When the work force sees that their recommendations can make a difference then the SE 170 recommendations will blossom.

Finally, the most important impact on the quality and application of documentation is the aircraft maintenance technician. Technicians must refuse to repeatedly accept instructions that are difficult to understand and use. They understand how work is conducted on the flight line, hangars, and shops, and the documents must reflect real-world working conditions. They must insist on timely responses to their recommendations. As that happens, the documentation culture can evolve to one where mechanics get the job done because of great procedures rather than in spite of the procedures.

FAA applied research

FAA research and guidance related to maintenance procedures and documentation never ends. In 2010, a Government-Industry Maintenance Human Factors Workshop, conducted by the Chief Scientific and Technical Advisor Program and the Civil Aerospace Medical Institute, identified “Technical Documentation” as the No. 1 human factors challenge in maintenance. In 2012 the FAA dedicated a workshop to that topic (see Another FAA survey, completed in May 2014, reinforced that issues with use of technical documentation is a top maintenance challenge.

The new edition of the Operator’s Manual for Human Factors in Maintenance, out in Fall 2014, has a chapter dedicated to the technical documentation challenge. During 2014, the FAA research team is sifting through nearly 800 technical documentation reports submitted to the NASA Aviation Safety Reporting System. 

We know that the research will not invent the “silver bullet” to remedy the technical documentation challenge. That solution will come from many small steps that foster positive evolution of our industry safety culture. The expected SE 170 findings are but one good example of steps in the right direction.

Author: Dr. Bill Johnson is the FAA Chief Scientific and Technical Advisor for Human Factors in Aircraft Maintenance Systems. He is an Aviation Maintenance Technician and a pilot for over 45 years. He publishes additional information on this and other human factors topics at

About the Author

Dr. Bill Johnson | Chief Scientific and Technical Advisor Human Factors in Aviation Maintenance, FAA

““Dr. Bill” Johnson is a familiar name and face to many industry and government aviation audiences. Johnson has been an aviator for over 50 years. He is a pilot, mechanic, scientist/engineer, college professor, and senior executive during his career. That includes 16+ years as the FAA Chief Scientific and Technical Advisor for Human Factors.

Dr. Bill has delivered more than 400 Human Factors speeches and classes in over 50 countries. He has 500 + publications, videos, and other media that serve as the basis for human factors training throughout the world.

Recent significant awards include: The FAA “Charles E. Taylor Master Mechanic” (2020); The Flight Safety Foundation - Airbus “Human Factors in Aviation Safety Award” (2018), and the International Federation of Airworthiness “Sir Francis Whittle Award” (2017).

Starting in 2021 Johnson formed LLC. In this new venture he continues to bring decades of human factors experience to aviators, worldwide.