Safety in Aircraft Maintenance - System Safety

1 Safety in Aircraft MaintenanceSafety in Aircraft MaintenanceTrain the Person toAvoid the Error TheyNever Intend to MakePresentedPresentedforforFlight Safety FoundationFlight Safety FoundationCorporate Aviation Safety SeminarCorporate Aviation Safety SeminarTucson, ArizonaTucson, ArizonaMay 2010 May 2010 PresentedPresentedbybyReneeReneeDupontDu pontWe Humans Have Been MakingHuman Errors For a Very long TimeAnd, Sadly, Will Continue To Do SoFor a Very Long TimeAnd When These Errors OccurredWe Would Say They Were:DumbDumbLazyLazyOver 80% (plus) of our accidents are due toOver 80% (plus) of our accidents are due toHuman ErrorHuman ErrorThese Human Errors areThese Human Errors arenotnotmade on purposemade on purposeMany of these errors are made by some of theMany of these errors are made by some of thebest and most conscious employeesbest and most conscious employeesWe know:ThusThussomethingsomethingmust have interfered withmust have interfered withthatthat personperson ss performance and/orperformance and/orjudgment in order for the error to occurjudgment in order for the error to occur[ Maintenance ] errorsare not the cause of Safety FoundationAdapted by G.

2 DupontThe causes are to be found in whateverit was thatinterferedinterferedwith the[guilty party s]{performance/judgment}at a criticalmomenttheoutcomeoutcome(result) of which is a[ Maintenance ]errorWhere Was Their Common Sense?Common Sense is Not That CommonCommon Sense is Not That CommonAnd HasNothingNothingTo Do WithHuman Factors Human is responsible formost of our accidentsA + B = CA + B = had no intention ofmaking the error, thenIt makesIt makeseconomiceconomic(and(andcommon) sense to train thatcommon) sense to train thatperson in how to avoid the errorperson in how to avoid the errorthey never intend to makethey never intend to make+= Why Don t We TrainEveryone in Human Factors?

3 TheyThey don t want it AND WeWe can t afford it BullBullPuckyPuckyBesides no one has mandated it yetICAO (International Civil AviationOrganization) has dictated thatALL contracting states MUST provide human factors training to allmaintenance personnel with signing authority inan AMO (Approved Maintenance Organization)It has been a requirement in Canadasince 1999 Itwill bewill bea requirement in the USAone dayone dayBut it makes Economic Sense to traintodaytodayThey Don t Want ItBut theyBut theywillwillwant it if:want it if: a) The material is deemed to be usefulWhat we donWhat we don t understand, we avoidt understand, we avoidJAA ATPL TrainingRequirementsDiarrhoea??? Health & Safetyfrom Human ONLY What TheyCan Use on the HangarFloor to Avoid Making aHuman ErrorUseful?

4 They Don t Want It b)b)The material has examples thatrelate to their work c) The facilitator believes and ispassionate about the material d) The material is interesting e) The material has some Fun in itFor ExampleWhat we donWhat we don t understand, we avoidt understand, we avoidBut theyBut theywillwillwant it if:want it if: a) The material is deemed to be usefulStress and the Lack ofStress and the Lack of f)f)It is based on PBL (Problem Based Learning) to themaximum extent possible g)g)It has follow up to help maintain awareness thatthe training will provideFollow up can be the ongoing workshops that build on theprevious material as well as six month letter of Safety steps to be HF news short stories are company newsletter devoted to toolbox sessionsThey Will Accept AndUse The Training IF6.

5 Follow up Dirty DozenDirty Dozen Safety posters areput upone at a timeone at a timeand changed monthlyThey Will Accept AndUse The Training IF7. They are provided decals and remindercards that help keep the awareness level highThey Will Accept AndUse The Training IFWe CanWe Can t Afford Itt Afford It You canYou can t afford NOT to do everythingt afford NOT to do everythingyou can to avoid an error that couldyou can to avoid an error that couldresult in the end of your companyresult in the end of your company It only takes ONE human errorIt only takes ONE human error For example:For example:An airline with 16 aircraftAn airline with 16 aircraft5 Boeing 747s5 Boeing 747s1,200 employees1,200 employeesNever had a fatal accidentNever had a fatal accidentUntil this one fatal accidentUntil this one fatal accidentNo one survived their firstNo one survived their firstaccidentaccidentNot even the companyNot even the companyWhich tire is low?

6 261 persons died because one261 persons died because onetire was low on pressuretire was low on pressure Demonstrates a commitment to Safety byDemonstrates a commitment to Safety bybeing proactive ahead of a future Safetybeing proactive ahead of a future Safetyrequirementrequirement Fewer Maintenance and human errorsFewer Maintenance and human errors Improved morale resulting in greaterImproved morale resulting in greaterproductivityproductivity Will help the implementation of a SafetyWill help the implementation of a SafetyManagement SystemManagement System It is the morally right thing to doIt is the morally right thing to doYou Can Afford ItYou Can Afford ItThe BenefitsA Case companyA company s pilots were going on strike and all aircrafts pilots were going on strike and all aircraftwere brought back to the main basewere brought back to the main of the Aircraft was flown, nonOne of the Aircraft was flown, non--revenue, from arevenue, from aremote base with a nose gear problemremote base with a nose gear securing all of the fleet Aircraft it was decided toAfter securing all of the fleet Aircraft it was decided totroubleshoot and rectify the nose gear problem at 0300troubleshoot and rectify the nose gear problem at 0500, the problem had been rectified and called for aBy 0500.

7 The problem had been rectified and called for anose gear retraction test before sign offnose gear retraction test before sign a coffee break the twoAfter a coffee break the twoAMEsAMEsretracted the noseretracted the nosegear WITH THE FOLLOWING RESULT gear WITH THE FOLLOWING RESULTThe Result1.$850,000 dollars worth of damage2. The two very experiencedAMEswere firedfor their carelessness3. One more very experienced AME quit inanger over the firing4. Everyone began to work to rulework to rule resulting inmajor delays in work being done5. One week out of service6. The morale was as low as the hangar floorContributing Factors StressStress--Worry about how long the strikeWorry about how long the strikewould last and when they would be laid offwould last and when they would be laid off NormsNorms--The Aircraft ALWAYS came fromThe Aircraft ALWAYS came fromthe ramp with gear pins installedthe ramp with gear pins installed ComplacencyComplacency--They had done this jobThey had done this jobmany times beforemany times before Lack of TeamworkLack of Teamwork--Each thought theEach thought theother had checked for main gear pins installedother had checked for main gear pins installed FatigueFatigue--They did the work between 0300 They did the

8 Work between 0300and 0500and 0500 DistractionDistraction--They went for a coffee breakThey went for a coffee breakjust before the gear swingjust before the gear swingWhy did it happen?A Case StudyThe AnswerThe Big Picture-SMSG. Dupont1995A Case StudyThe ResultsThey have never seen morale so high= LessHuman ErrorsHuman ErrorsandImproved ProductivityImproved ProductivityA Measure of Success=SMSSMSIts Just Common SenseTrain theTrain theperson how toperson how toavoid the erroravoid the errorthey neverthey neverintend to makeintend to makeThey will thankThey will thankyou for ityou for itNo matter how right you are or hard you work,sometimes theMaintenance ErrorMaintenance ErrorDragon still wins!

9 Renee DupontSystem Safety Services