Brief Debrief Never Events

One Minute Prebrief

What about this task…

1. Could cause injury?

2. Could result in aircraft damage?

3. Could result in equipment damage?

4. Could be different than expected?

Two Minute Debrief

Where on this task...

1. Did we do something unsafe?

2. Did we violate standards?

3. Did we not understand something?

4. Did we learn something about doing it better?

Aviation Maintenance NEVER EVENTS Wrong Person - allowing someone who is not trained, qualified, certified, authorized, or is otherwise mentally or physically compromised to work, or approve work, on an aircraft.

Wrong Part - the use of ‘bad parts’ (incorrect, untracked time, untrusted source, single-use parts multiple times, etc.) or the incorrect/incomplete installation of good parts.

Improper Movement - the act of moving aircraft and/or aircraft equipment in a manner that is unsafe or outside established approved procedures; includes jacking.

Wrong Fluid - using an unapproved or contaminated fluid or lubricant, or improper servicing or application.

Lost Tool or item - signing off an aircraft maintenance task without accounting for all tools and other equipment or material used or created on the job.

Unsecured Panel - releasing an aircraft with a panel, door, fairing, cowling, or latch that is not fully and properly secured.