The Continuing Threat of Aviation Maintenance Error

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The Role of Maintenance Error Management Systems (MEMS)

The ability of the organisation to investigate Maintenance Error is a valuable tool to understand causal, contributory and root elements and to develop and provide appropriate mitigation's to reduce ongoing exposure.

If we wish to minimize re-occurrence we should address not only the root cause (or causes) of a given outcome, but to also consider all the contributing causes (and there could be many!) as this will have a significant positive impact on the lowering of the threat level (reduction in exposure).

Maintenance Error

Maintenance Error is unfortunately an ever-present component of any maintenance system. It is unlikely we can ever fully remove the possibility of “maintenance error”.

We can however strive to minimize the consequences of Maintenance Error through the introduction of “Quality Control” steps in the production process as well as to continually to learn from both industry and our “own” errors, incidents, accidents and exposures.

Technology has provided a continuing upgrading regarding the aircraft, equipment & systems and whilst this has led to a lower incidence of catastrophic events caused by failure of the “machine” the potential exposure to human error in general and maintenance error is ever present.

The Fallibility of Humans

As long as we have humans engaged in the aviation maintenance process, we will be exposed to Maintenance Error. Our challenge both through the organisation and individually is to engage with the understanding of both our personal and system vulnerabilities.

The key to addressing the exposure is through the management of competence, effective training, as well as good oversight systems which will go a long way to minimizing the potential exposure.

Talking about Culture

The challenge facing the Organisation is the top down development of an effective culture of safety awareness and behaviour throughout the organisation.

A positive environment where the maintenance working can focus on achieving the required task with the minimum of external pressure. Where the organisation culture actively promotes the minimization of violations whether they are organizationally or personally optimizing.

Building Competence

Each person who engages with the maintenance system should have role specific competence to ensure the best possible task outcome.
Competence is an amalgam of knowledge, attitude & skill and it is essential that the Organisation is able to assess the competence of the maintenance staff and where necessary to develop a training needs analysis (TNA).

Note Regarding Training - Training on its own is unlikely to provide a lasting solution to any issue rather it is better to understand the perceived “driver” for the training which should then be considered in the light of an organisational exposure rather than an individual failing. Paying more attention to the underlying safety culture will provide a more lasting and positive outcome.

Sofema Aviation Services (SAS) and our Sister Company SofemaOnline (SOL) offer EASA compliant regulatory training including Human Factors and Maintenance Error Management System in company and online training - for details please see www.sassofia.comwww.sofemaonline.com or email office@sassofia.com and online@sassofia.com

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