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William J. Bramble, Jr., Ph.D.

William J. Bramble, Jr., Ph.D. Senior Human Performance Investigator. Factors Affecting Maintenance at the Huntington Facility. Training Procedural guidance On-site supervision Continuing analysis and surveillance. Training. Heavy use of on-the-job training (OJT) Vague procedures for OJT

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William J. Bramble, Jr., Ph.D.

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  1. William J. Bramble, Jr., Ph.D. Senior Human Performance Investigator

  2. Factors Affecting Maintenance at the Huntington Facility • Training • Procedural guidance • On-site supervision • Continuing analysis and surveillance

  3. Training • Heavy use of on-the-job training (OJT) • Vague procedures for OJT • Noncompliance with company training policy • Inadequate record keeping

  4. Procedural Guidance Detail 6InspectionWork Card AircraftMaintenanceManual Nonspecific references Inadequate instructions Inapplicable steps Inadequate instructions

  5. On-Site Supervision • Air Midwest personnel were not usually present when maintenance was performed • Raytheon Aerospace did not provide enough foremen and inspectors • Inspectors performed some of the foreman’s duties in addition to their own

  6. Continuing Analysis and Surveillance Systems (CASS) • Air Midwest’s program had a historyof deficiencies • Program did not identify deficiencies in training and procedural guidance • Program identified a staffing deficiency, but did not correct it

  7. Federal AviationAdministration Oversight • FAA was aware of deficiencies in training and CASS program before the accident • FAA staff proposed delay of new routes to encourage change, but reconsidered • Deficiencies still existed at the time ofthe accident

  8. Programs to Reduce Human Error in Aviation Maintenance and Inspection • 15-year FAA-sponsored research program • Emphasis on development of written guidance and voluntary programs • Maintenance-related accidents continue

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