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EMSG Conference 10 October 2007AAIB Farnborough
RISK IN THE MAINTENANCE
ENVIRONMENT
ROYAL AERONAUTICAL SOCIETY
ENGINEERING MAINTENANCE STANDING GROUP
CONFERENCE
AAIB FARNBOROUGH, 10 OCTOBER 2007
Alan P Simmons M.Sc., C.Eng., M.R.Ae.S.
Principal Inspector of Air Accidents,Air Accidents Investigation Branch, United Kingdom
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PRESENTATION OVERVIEW
SAFETY SYSTEMS AND HUMAN PERFORMANCE
MAINTENANCE ERROR AND BUSINESS RISK
REMEDIAL MEASURES
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SAFETY SYSTEMS AND HUMAN PERFORMANCE
IN MAINTENANCE
Our safety systems have evolved:
Checking/inspecting: Quality Control
Controlling the production process: QC, TQM
Managing safety: MEMS, SMS
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SAFETY
MANAGEMENTSYSTEMS
SAFETY SYSTEMS AND HUMAN PERFORMANCE
IN MAINTENANCE
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LIMITATIONS OF HUMAN PERFORMANCE
Perception and Cognitive limitations
Optical and Auditory limitations
Tunnelling and focusing
SAFETY SYSTEMS AND HUMAN PERFORMANCE
IN MAINTENANCE
Man errs as long as he strives.
Goethe
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ERROR TYPE MAINTENANCE EXPERT
DATA ASSESSMENT
Skip a step 0.15 0.001
Skip a task 0.026 0.001Ignore a warning/caution 0.042 0.013
Intentionally deviate 0.042 0.32
Improperly remove/replace 0.033 0.02
Improperly repair 0.089 0.0023
Incomplete installation 0.089 0.01
Improperly adjust 0.09 0.1Allow/cause debris to enter 0.17 0.01
SAFETY SYSTEMS AND HUMAN PERFORMANCE
IN MAINTENANCE
Source Ostrom et al, INEEL
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PROCEDURES MITIGATE RISK OF HUMAN ERROR
Clear documentation
Parts kitsChecklists
Inspections
Function checks
Even pre-flight checks
SAFETY SYSTEMS AND HUMAN PERFORMANCE
IN MAINTENANCE
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WHY PROCEDURAL ERRORS UNDERMINE SAFETY:
Clear documentation is useless if not used
Parts control cannot work if uncontrolled stocks are held
Independent Inspections must be truly independent
Function checks must be carried out
SAFETY SYSTEMS AND HUMAN PERFORMANCE
IN MAINTENANCE
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Can your maintenance staff actually perform the
required inspections?
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Do you have uncontrolled small parts?
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Do your engineers improvise?
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Are your engineers under pressure to avoid
ground runs at night?
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Do your engineers sign off task cards sight unseen?
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Is the Approved Data correct and is there a viable
procedure to amend errors?
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MAINTENANCE ERROR AND BUSINESS RISK
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MAINTENANCE ERROR AND BUSINESS RISK
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Most maintenance error events investigated by AAIB
are INCIDENTS not ACCIDENTS
Maintenance related incidents form a largerproportion of total maintenance related events
investigated by AAIB than accidents
Incidents are less spectacular but very expensive
MAINTENANCE ERROR AND BUSINESS RISK
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MAINTENANCE ERROR AND BUSINESS RISK
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MAINTENANCE ERROR AND BUSINESS RISK
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MAINTENANCE ERROR AND BUSINESS RISK
Procedural deviations are at the root of many maintenance
related events
Maintenance error arising from non-procedural practices
incurs a dual risk to the business:
1 The risk of exposure to loss (loss of safety,earnings)
2 The risk of fines, litigation, denied insurance claims
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THE COSTS OF A MAINTENANCE EVENT
Rework/re-instatement costs
Additional hangar time costs
Repair costs for consequential damageMaintenance re-scheduling and knock-on delays
Operational schedule related costs
Compensation costs
Cost of hiring a replacement aircraftBusiness costs
obtaining and retaining market share
MAINTENANCE ERROR AND BUSINESS RISK
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AAIB Farnborough
Recent examples from AAIB investigations into actual
incidents:
A technician assembled propeller de-icer boots withoutthe required sealant materials, which were difficult to
obtain. The boot detached causing injury and damage.
A mechanic assembled a helicopter rotor head without
the required shims, because the job was urgent. Thehelicopter suffered severe vibration and blade cracking.
After major maintenance, an engineer stamped up a
number of job cards to close all remaining open panels,
but not all the panels were open at the time. One of the
closed panels was not properly closed and latched. The
panel came off and penetrated the cabin.
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How can we reduce the risk of maintenance error?By promoting:
A culture which rewards procedural compliance
and discourages violations
Error-tolerant systems
Reporting systems which work and are used
An analytical approach to risk
MAINTENANCE ERROR AND BUSINESS RISK
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AAIB Farnborough
In 1994 AAIB stated: The Civil Aviation Authority shouldformally remind engineers of their responsibility to ensure
that all work is carried out using the correct tooling and
procedures, and that they are not at liberty to deviate
from the Maintenance Manual but must use all availablechannels to consult with a design authority where
problems arise; if full compliance cannot be achieved the
engineer is not empowered to certify the work.
[Airbus A320, G-KMAM AAIB Report 2/95, Safety
Recommendation 94-41]
This is still the only way forward.
MAINTENANCE ERROR AND BUSINESS RISK
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THANK YOU FOR YOUR ATTENTION
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