Considering the Potential for HF Error within the CAMO Roles – Pressure Causes Stress!

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Steven Bentley MD of SAS www.sassofia.com considers the potential for HF Error with an EASA/GCAA compliant CAMO

Introduction

The Primary Roles of the CAMO are Maintenance Planning, Technical Records, Reliability & Engineering. Each “Role” brings the challenges of how we can ensure enough attention to both personal and organisational responsibility, when we consider the potential for HF error.

HF Example – Stress Caused by Pressure from “Poor Planning”

We are not considering here that it could be the Maintenance Planning Worker who is stressed – however this is of course a possibility, and we should always make sure that our team members have the appropriate level of “Competence” for the role.

Note - When we talk about “Competence” we are considering a combination of knowledge, skills and attitude towards the work that needs to be performed. (Consider the Organisational Role in the management of Competence)

So how does this work then how can bad planning cause stress, well simply it goes like this and remember that almost all HF events are a composite – where several factors conspire together to lead to a negative outcome.

Within Maintenance Planning we have an obligation to provide the “Work Package” in the most effective way. Each time we leave a gap we create an exposure.

a) New Task loaded as an AD Hoc on the check – not researched – tooling required which is not available – AOG for tooling leading to time constraints
b) Excessive work loaded onto the check when considered against the time and manpower available
c) Tasks loaded without consideration for HF exposure – for example perform a dual borescope at 1500 HRS when it would be possible to perform 1 borescope at each 750 Hrs
d) Poor layout of the work instruction or task card

In the case of both a) & b) we are creating an environment which applies pressure to the worker, the natural outcome of any pressure is to feel stress and it is in relation to this stress that the worker can make human error mistakes.

In the case of c) above we are setting up the process to increase the exposure to “Fail” Multiple exposure raises the possibility of simultaneous mistakes being made, in this example by creating a problem on both engines.

On 23 February 1995, a British Midland Boeing 737-400 made an emergency landing at Luton airport UK after losing most of the oil from both engines during initial climb out from East Midlands airport UK, attributed to failures in the quality of maintenance work and procedures during routine inspections of both engines prior to the flight.

In the case of d) above we are failing to provide information in a user-friendly way which acknowledges the potential for HF error by carefully identifying Warnings, Cautions and Actions and Notes.

Sofema Aviation Services provides both Classroom and Online HF Training – for details please see www.sassofia.com & www.sofemaonline.com or email office@sassofia.com & online@sassofia.com

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