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Putting people first

Helping staff to better understand their working environment and the sometimes subtle pressures that affect their well-being can have a beneficial effect on accident rates

There is a clear advantage to be gained from helping people face the challenges of a high-pressure environment in which safety is paramount. Understanding Human Factors (HF) has become increasingly significant for regulatory authorities over the years, with legislation evolving to make them a necessary consideration for any maintenance organisation. Unfortunately, HF is often associated with health and safety and is frequently viewed negatively by mere association. However, if carried out properly with real staff involvement, it is a powerful management tool that produces real safety benefits.


Paul Stone is a Technical Instructor on Boeing 737 and 787 at the Monarch Aircraft Engineering Training Academy (MAETA) at Luton Airport in London, UK, but he has also been running awareness courses for the past nine years, making use of his 30 years’ experience in the industry. He says he is fortunate to have a high level of support within the company, with Managing Director, Mick Adams, being an advocate and attendee of HF courses.


The company has a well-established Safety Management System and if a serious incident occurs, it is analysed using the Monarch Event Decision Aid (MEDA) process, to determine the lessons that can be learnt. This will look at things such as procedures, weather, tools or spares and human interaction. About 56% of incidents can be put down to procedural errors, Stone says.


The initial course takes two days and, to encourage a blame-free culture, it is held as an open forum where people can voice their opinions and discussion is encouraged. Another important aspect of the course is to empower staff to query activity in their work environment, which has a positive impact on reducing incidents. This is very similar to the concept of Cockpit Resource Management (CRM) for flight crew and Stone says CRM is now increasingly referred to as HF.


The participant groups have also expanded over time, which Stone feels is a particular benefit. As an example, the planning department have recently been included. This gave maintenance personnel the opportunity to discuss engineering tasks, and how they could be undertaken in a more effective way. He thinks the next step will be to recruit the IT department as the data-rich Boeing 787 is on the horizon and there will be a greater need to understand and process the system downloads as well as online maintenance manuals.


The 787 aircraft also brings in the need for what might be called ‘applied psychology’ as much as HF. It takes 3 minutes to start up when a ground power unit is used. Activation of the stick shaker is the sign that all systems are powered up, but a further 15 seconds is required before the APU can be started. With engineers always in a rush to complete checklists, he suggests adding a simple procedure as a distraction, such as carrying out a fire test – which could be much easier than training someone to wait.


Awareness of HF is also important for the planning department when it comes to the timing of maintenance tasks. Being aware of circadian rhythms means that critical tasks can be timed for periods when personnel are more alert – although for daytime work that would mean when the aircraft are supposed to be flying. The company carefully monitors the trend lines of MEDA incidents and it shows a rise during the winter months, mainly because of more work being carried out, but also in part due to longer hours of darkness.


Stone believes that the authorities will start paying closer attention to fatigue risks in maintenance. He has the Jeppesen CrewAlert app on his phone, which is designed for pilots and can be used to control tiredness and fatigue risk in crew planning and operation. A variant could be useful in planning duty rotas for technical personnel, especially those on night shifts.


One safeguard against oversight is split-system maintenance, which is especially used on ETOPS-certified aircraft. If multiple components or systems need to be inspected, an individual will carry out only a single check to avoid repeating an initial error. The reason for this caution is illustrated by a 1997 incident involving a BAe 146 of the UK Royal Air Force. Although compounded by failures in the inspection system, the root cause was an engineer replacing the magnetic chip detectors in all four ALF502 engines, but without an associated O-ring. The aircraft had to make an emergency landing after losing almost all of its oil. While the use of examples from within the company are the most beneficial to analyse, external examples like these are also important.


The course has now been extended to some third parties. Stone says that, on one occasion, he showed the participants a hammer, a screwdriver and a block of aluminium and asked which one they thought had been found in a life raft when it was returned to a customer after maintenance. To their astonishment it was the last item, but an investigation showed that similar pieces were used to exclude air pockets when packing the raft and this one had been overlooked. This also underlines another point – making the course content relevant to the work carried out by the participants increases understanding of its importance.


Because of this, Stone would like to expand HF further to include more outside agencies, with ramp damage caused by third-party contractors being one area of interest. A more surprising choice is security, but he quotes the example of the reaction of staff after the introduction of stricter rules on liquids, gels and sharp objects. Allowing a toolkit or a large can of oil through while confiscating a butter knife or a pot of yoghurt may not seem much, but when he watched an extremely irritated individual getting ever-more stressed about missing his lunch, the link to a potential safety problem was apparent. The further from the hangar floor, the greater the need to appreciate cause and effect.

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