A lack of communication between the two shifts started the chain of events. There was no verbal exchange and the worksheets did not indicate that the left top screws had been removed. The evening shift did not document work performed on work cards because the package was kept together for the midnight shift. Better communication, both verbal and written, is a must if accidents like these are to be avoided. Any work done that is not covered on a work card must be written up. The lack of communication was a result of assuming that both leading edges would be changed that night. Sadly, 14 people paid with their lives for this simple error.