Quality Management Mistakes

A spanner and a screwCommon Quality Management System errors found on audit.

List of effective pages (LEPs)

Your manuals should contain a list of effective pages. It is important to ensure that the list corresponds with the pages in the document.

In this real life example, and highlighted during a review of a particular manual submitted for approval, the LEPs did not match the revision status of the pages themselves in the document.

The List of Effective Pages shown below shows page iii as dated 1st November 2012, when actually page iii is dated 15th December 2013:

Image of a list of effective pages

Here is another example, ensure the number of pages in the document corresponds to the number of pages listed in the LEPs:

Image of a list of effective pages

Such errors may lead or contribute to serious incidents.

The use of online subscriptions

In this technical age, we are moving every day towards online shopping, and online subscriptions. Over-reliance with online subscriptions has led to the following effects on manual amendments.

Below is an actual finding against an operator’s document amendment system. The operator’s identity and document reference numbers have been removed.

Hard copy document control register: Online:
Engine overhaul manual ref: xxxxxxx dated March 1999 Dated October 2013
Aircraft ‘A’ Maintenance Manual Rev 15 dated August 2013 Aircraft ‘A’ Maintenance Manual Rev 16 dated November 2013
Aircraft ‘B’ Maintenance Manual Rev 49 Aircraft ‘B’ Maintenance Manual Rev 50 dated November 2013
Aircraft ‘C’ not listed in the document control register Aircraft ‘C’ Structural Repair Manual available listed online

The above example can lead an unsuspecting engineer, unsure of a maintenance procedure, to pull an out of date manual from a shelf and carry out an incorrect adjustment, measurement or lubrication task. Consider if this was associated with a flying control system!

If you are using the online subscriptions, lose the hard copy manuals that do not require approval by your NAA.

Stores inventory lists

Ensure your stores inventory lists are regularly reviewed and kept up to date. Ensure you track:

  • what comes into stores;
  • where is it stored (each aircraft type should have its unique store location to reduce the chances of fitting the wrong parts to the wrong aircraft);
  • what goes out of stores; and
  • where does it go (apart from other information required as part of NAA requirements, the aircraft registration should be listed in the store’s issue book).

Here is an actual finding from an audit of an operator’s stores system. The operator’s identity and part numbers have been removed.

  1. Packing Wheel O-ring P/N xxxxxxx was located on the aircraft ‘A’ shelf, as opposed to the correct aircraft ‘B’ shelf.
  2. Lock nut P/N 12345 was on aircraft ‘A’ shelf, as opposed to the correct aircraft ‘B’ shelf.
  3. O-rings XXXXXXXX, YYYYYYY, and ZZZZZZ have expired.
Paper roll


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Next Issue

The next issue, Winter 2014/15, will be focusing on Just Culture/Enforcement Policy so if you have something you wish to contribute or useful sources of information on this subject please submit to: enquiries@airsafety.aero.