Aviation Human Factor Considerations in a Maintenance Planning Environment Introduction

Introduction

Whilst currently (October 2018) EASA does not mandate the obligation to ensure CAMO & Maintenance Planning Staff receive HF training, the reality is that the potential for Human Factor Error knows no bounds and it is just as likely that a Human Factor (HF) error could originate from an exposure within the Maintenance Planning Environment as anywhere else within the “Aviation System”.

Currently, some 80% of aircraft accidents are attributable to human error however, this is a situation where it is possible to manage and or address by managing the exposure.

Human Error is recognised as rectifiable through the process of raising awareness, implementation of effective process and procedure and effective communication within the workplace.

Maintenance Planning Exposure

When we talk about Human Factor (HF) errors and related issues within the Maintenance Planning environment we need to consider that “the can is kicked down the road” means that more often the visibility of the outcome is moved to another area of the business.

For example if due to planning considerations work is loaded onto the check-in an uneven way (Due for example to Service Bulletins / Modification - Spares Shortages).

Then it is possible to create an environment where we see commercial pressure, which as we know may directly lead to stress and the possibility of an unwanted HF event.

We should look at proactive ways of improving our process and reducing the exposure.

For example to discuss in small groups where are the gaps, and where are the traps? What can we do to reduce the exposure without increasing the administrative burden?

Another issue also relating to visibility may be connected with the iceberg theory of accidents and incidents.

We know that for every significant incident or accidents which occur there are maybe 10 externally reportable events (to the regulator) and 30 internally reportable events however, there are in the region of 300 unreported transgressions which not only go unreported, may in fact be considered in isolation to have minimum direct consequence may in fact become either precursors or contributors to a more serious event.

Often it is the unreported events which form a significant portion of the HF exposure within the Maintenance Planning department and whilst in isolation the exposure may appear low, the potential exists in combination with other exposures the HF related action may trigger an unwanted or unwelcome outcome.

How to deal with the issue of HF Exposure in a proactive way?

To ensure all persons have an awareness of the potential exposure or “knock on effect” of even the smallest human related error. To use this awareness to empower a cultural change which brings a sense of obligation together with a defined HF reporting process.

Consider the most simple internal reporting process possible, encourage people to use the substitution test - I have nearly made a mistake but I corrected myself! Would my colleague or a new person also “self correct” or to fall into a trap. If the answer is that a potential trap exists then we should be looking at ways to communicate and report.

Is the documented process or procedure correct or ambiguous? If it is not 100% clear then this is becoming another exposure which we should address, we should understand and accept that we have an obligation to identify and raise awareness rather than to ignore.

HF Analysis Steps to Consider (See Example)

Consider how a simple mistake may be initiated!

How should a part which needs to be controlled when life is attached to lower assembly while replacement at higher assembly (which includes lower assembly) is being done?

Is this related to Human Factors?

What would be considered as mitigations?

Training, Awareness & Procedures!

In addition to the above we should look at proactive ways of improving our process and reducing the exposure, for example to discuss in small groups where are the gaps, and where are the traps? What can we do to reduce the exposure without increasing the administrative burden?

 

Sofema Aviation Services www.sassofia.com and our sister site www.sofemaonline.com offer classroom and online Human Factor Training.

For information please email office@sassofia.com or online@sassofia.com