Spring/2000Volume 5 Issue 1$8.00 per issue

Website:www.marss.org

GroundEffectsReporting Maintenance and Groundcrew Error Reduction Efforts

M.A.R.S.S.

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MARSS

GroundEffects would like toextend our thanks to the

following companies for theirgenerous contributions.

The 14thInternational FAA/

CAA/TransportCanada Human

Factors in AviationMaintenanceSymposium

was a success

CAN THE OLD DOG LEARN NEW TRICKS?

Many of the books, articles, conferences dedicated to safety and whichone can learn from focus on making the system fool-proof, and, as oneof them writes, “building dikes against human frailty”, often with theassumption – stated or implied – that “you can’t change human nature”.You can’t change attitudes, is a statement frequently expressed withfeeling. It’s true, too… if it’s someone else’s attitude you are tryingto change. If the old dog chooses to cling to his ways, you’re on alosing wicket. But, now, if the old dog wants to learn, try and stop him!My colleagues and I contend that the aviation industry – like any otherhazardous industry - can help their employees become more “error-proof”, can help them reduce lapses of attention, or errors of judgement,and that unless they do so, the accident record will not improve much, nomatter how much attention they pay to improving systems.Helping their employees become as “error-proof” as possible meanshelping them grow in their ability to understand themselves and others, tounderstand their own personal vulnerabilities to their being distracted byexternal or internal events and to mitigate them, and to become morecomfortable with themselves and others.

If the industry invested in such training for their employees, would it makeany difference? Can attitudes and behaviour change in a deliberate andpositive direction?

And what a success it was. Therewere over 400 attendees from 28different countries that attended thisinternational symposium inVancouver BC. This made it themost successful of the symposiumsto date and a far cry from the firstback in 1988 where, according tothe moderator, Dr. Bill Johnson VicePresident, Galaxy ScientificCorporation, there were 30attendees, 10 of whom werespeakers.With a theme of “SafetyManagement: Theory topractice”, it was only fitting thatthe keynote speaker be Dr. JamesReason. Professor of Psychology,University of Manchester. As

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GroundEffects (ISSN 1094-0146) is theofficial newsletter of MARSS(Maintenance and Ramp Safety Society)and is published four times per year todiscuss issues affecting maintenancesafety. We offer practicable solutions tomaintenance managers, regulatoryauthorities, and unions charged withimproving safety and reducing costs.

Newsletter editor : Renee Dupont(604) 207-9100email: dupont@home.com

As we believe that safety information isof greatest value if it is passed on for theuse of others, readers are encouraged tocopy or reprint any item or article forfurther distribution (except wherecopyright is indicated), and shouldacknowledge GroundEffects as thesource.Trademark protection forGroundEffects has been applied for.Subscriptions (four issues per year) areavailable for a cost of $32.00 per year.(includes postage and handling)MARSS Ph: 604 207-9100Fax: 604 207-9101

Help us to preventaccidents beforethey happen!

Can you teach an old dog new tricks? ...................................................... 1The 14th International FAA/CAA/TC Human Factors in Aviation MaintenanceSysmposium ............................................................................................ 1Developing a Hazard Model for an Aviation Safety Case .......................... 2

MARSS Annual Meeting .......................................................................... 11

From the Editor ........................................................................................ 11

Table of Contents

DEVELOPING A HAZARD MODEL FOR ANAVIATION SAFETY CASE

- SAFETY MANAGEMENT SYSTEMSAuthor:Cliff J Edwards - Shell Aircraft (United Kingdom)Note about the author:The author is the Quality and Safety Development Manager for ShellAircraft Ltd., the London Heathrow-based organisation devlopingand assuring the standards of aircraft utilised in support of Shell’sworld-wide operations. Mr. Edwards may be contacted directly viaemail at cliff.j.edwards@si.shell.com.This article is an adaptation of a paper presented to a safety seminarorganised jointly by the Flight Safety Foundation (FSF), InternationalFederation of Airworthiness (IFA), and International Air TransportAssociation (IATA) in Rio de Janeiro in November 1999. An isreproduced in this magazine with the permission of ICAO Journal,who first published the article in February 2000Developing the generic hazard model for use in safety cases

The case for the Safety CaseSAFETY improvements have been achieved over the years throughnumerous developments, including better aircraft design, redundantsystems, improved working practices and the introduction of qualityassurance programmes, to name just a few.Despite all that has been accomplished, experts predict a proportionalincrease in the number of aircraft accidents as world-wide air trafficcontinues its steady growth in the years ahead. Unless significantchanges are made to improve the nearly flat accident rate, by 2010there could be an average of one airline accident per week. Leftunchecked, this level of accidents would alarm the public and couldplace many aircraft operators in financial difficulty or even out ofbusiness. For that reason alone, the cost of enhancing safety systemsis easily justified.

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To further decrease the accidentrate, safety management needs tobe perceived by seniormanagement — especially acompany’s chief executive officerand board of directors — as anessential business requirement andnot an activity to be addressed onlyby subordinates. The introductionof a safety case offers a company’ssenior management the opportunityto identify the major safety risks.Based on this knowledge, acompany’s board can establishcontrols that reduce the likelihoodof such risks causing an accident.The commitment and organisationthat assures continuing safeoperations is achieved through theintroduction of a safetymanagement system. A safetymanagement system must be led bytop management and must addressall aspects of the business that havethe potential to cause harm.The structured approach taken toidentify, assess and control thehazards is known as hazardmanagement, a process that resultsin the development of a hazardregister. Throughout 1999, ShellAircraft worked with a number ofairlines and other operators to builda generic hazard register (Figure1) that can be tailored to anyoperator, enabling resources to befocused on the areas of greatestrisk. An efficient way to manage thisprocess is the Safety Case.Developing the safety caseA company’s safety managementsystem, which is defined as asystematic and explicit approach tomanaging risk, is largely a losscontrol management system. Itdefines how the company intendsto manage safety as an integral part

of its overall business. A safetymanagement system addresses allaspects of safety in the operationand should deal with all levels ofrisk. By comparison, a safety casefocuses on specific parts of anoperation and addresses only themajor hazards, such as the potentialfor fatal accidents, which are criticalto the company’s well being.Although a company’s safety caseis subordinate to its safetymanagement system, they shouldinteract so that each safety caseassures control of its hazards. Thesafety management system and thesafety case are linked in many ways,primarily through the hazardregisters, with the safetymanagement system’s hazardregister as the master list of allhazards.The key steps in developing a safetycase require that a corporate safetymanagement system exists or atleast is being developed. The safetycase draws on corporate safetyobjectives and safety policy, whichmust make safety an explicit priority,at least equal to any other businessimperative. Based on corporatedecisions as to what safety level isto be managed, hazards areidentified and risks assessed andcontrolled. Management must alsodevelop and maintain a supportiveculture that is “just” and “learning.”In aviation, this cultural changerequires a willingness to learn fromhazards and threats as well as fromaccidents and incidents. At the sametime, management must dealsensitively with those responsible,unless reckless or deliberatebehavior warrants disciplinaryaction. It is essential that trainingprovide all staff with anunderstanding of safety management

and the extent of the corporation’scommitment to safe operations.A safety case is the “systematic andstructured demonstration by acompany to provide assurance,through comprehensive evidenceand argument, that the aircraftoperator has an adequately safeoperation.” The company identifiesand assesses major hazards andsafety risks and then manages themto levels of risk which are as low asreasonably practicable. A safetycase may cover all or part of anoperation and, where more thanone case is developed, each isdescribed and controlled locally butmanaged through a corporatesafety management system.Delineating cases is a managementchoice, but the resulting package ofsafety cases should cover allsafety-critical activities. Safetycases may be set up for operations,for engineering, or both, or evenused for specific projects such asthe introduction of a new aircrafttype.Development of a safety case beginswith identification of what should bemanaged, and by describing theboundaries of each case andestablishing how a corporate safetymanagement system is applied. Thesafety case should list safety-criticalactivities undertaken by a companyand who is accountable; it alsoshould identify which hazardspertain to each activity. Hazards arelisted and analysed to identifythreats, escalations and controlsnecessary to forestall hazards; thisforms the hazard managementsection, an output of which is thehazard register. The safety caseshould list measures required toimprove safety. At the completion

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We believe so, based on ourtwenty-five years of working withThe Human Element.Now, it’s true that no one canmake anyone change; no one hasever made someone else lose apound, or stop smoking either. Butthe leverage is different if the chan-ges a person is seeking are inhimself – where only he hascontrol.The key, then, is how to encouragepeople to want to change? Whatmakes a person want to change?Over the years, we have identifiedthree givens that must be there if aperson is to make deliberate chan-ges in attitude and behaviour :1. He has to recognize that some

of his behaviours are limitinghim and/or others, or hurtful tohim and/or to others

2. He has to be uncomfortableabout it

• And - perhaps the most impor-tant part -

1. He has to discover thatchange is possible.

For many of our clients (especiallythose who have had - like manyaviation maintenance groups – verylittle exposure to “soft” training) therevelation that change is possible forthem comes when they understandthis one piece of information : muchof what we call “personality” isin fact a series of psychologicalhabits which we have copied,developed, created, adopted overthe years. Some of them explainour successes, some of them

explain our failures or our sufferings.You see, for anyone who believesthat “personality” is a geneticstraightjacket, change is impossible– he is helpless. (“Can I changethe colour of my eyes?” “I’vealways been this way.” “It’s mynature.” they say, referring to theirshort fuse, or to their tendency tosulk, or to their fear of expressingtheir thoughts and feelings. “Myfather was like that.” As long asthey see themselves this way, theyare stuck in their current state ofbeing.) For others, likeincompetent change agents, or likeold dogs who want to cling to theirways, these sayings are convenientexcuses for impotence or inaction.In fact, they are wrong : it isn’t true.Our attitudes and behaviours are,as I said earlier, a series ofpsychological habits that we use so“naturally” that we have forgottenthat they are choices we have made.One man says, “He provoked me,so of course I got angry.” What heis saying is, “I’ve never stopped tothink that I might do somethingdifferent in response to (what Iperceive as) provocation.” Hecould, for instance, ask, in aninquiring tone, “What do youmean?” He could say to himself,“Joe is doing his number again; I’llcome back and talk to him later.”He could laugh and say, “C’mon,Joe, let’s not get into it, we’ve gotwork to do.” In other words, hehas dozens of options. But his ha-bit is so well ingrained that any realor perceived provocation will - likea knee-jerk response – almost

guarantee a predictable reaction.Our success with our clients lieslargely in our ability to tap into theirdesire to improve their life : an as-pect of our work which continuallydelights us is the willingness of ourclients to make use of new infor-mation. Mind you, this is an admi-rable characteristic of aviation (Noone ever says, “Here’s a better,safer, faster way to fix thiscomponent, but I won’t botherusing it”). The fact is that – giventhe opportunity – just abouteveryone will take advantage ofnew information that he can use tomake his life less complicated, hisrelationships easier, his stress levelmore controllable, his work moreefficient and safer.I believe that very few people setout deliberately to be troublesome.(Have you ever heard of anyonewho looks into the mirror as heshaves each morning and says tohimself, “How can I screw up someof my relationships today?”) Theycontinue because they don’t knowhow to stop. They need new infor-mation – and it’s amazing how littlenew information is required forsome people to make importantchanges in their attitude andbehaviour.In the past, these opportunities tolearn were rarely made available tothe maintenance groups : ampletechnical training, but little or noenlightenment on the human sidewas the rule. Fortunately, this ischanging.One valuable aspect of almost any

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“soft” training is that – perhaps forthe first time in his life – a person isinvited to examine himself, to no-tice how he thinks, to see how heprocesses events around him, (e.g.,was it really a provocation or amI just bad-tempered because of thetraffic jam that made me late thismorning?) to become curiousabout the fact that others aroundhim respond differently to the sameevent. Many of our clients – intheir thirties and forties – tell us theyhave spent more timeunderstanding themselves in theirfour days with us, than they havein the rest of their lives to date!We were working with a team in amanufacturing plant, one day, whenan engineer said, “When I get anew machine on the shop floor, Istudy the thing backwards andforwards, until it has no surprisesfor me, I understand how it works,its strengths, its weaknesses. Andtoday, suddenly, I am realizing thatI am the machine through whichI experience my life, and that Idon’t know very much about itat all.” Then he laughed and said,“Of course, I didn’t come with aninstruction manual - and I see nowthat I will have to write it myself.”Many of our clients have spentmost of their life focused outward– thinking of their job, planning,taking care of others - and verylittle time examining “their ownmachine”.Now, as you read this, if you thinkthis is a great idea, you might bethinking, “OK, OK, I’ve got it.Now tell me how to do it.” And itwould be great if there were a

magic one-size-fits-all formula.Here’s the good news : the “cure”does not require a five-yearpsychoanalysis! You don’t need tobe or to hire a psychologist.Fortunately, there are a number ofgood training opportunities available,with somewhat different objectives,with somewhat different value – butthe chances are that all are helpfulon the way to self-improvement.Check with your friends, find outabout their experiences, choose thetraining that is likelier to serve yourpurposes, and generally speaking,look for any opportunity that canadd to your self-knowledge, anddon’t discount your own ability to“learn new tricks” in this area thatyou may not have explored before.As you begin to notice yourselfmore, another good place to learn isto start listening to people’scomments about you : your co-workers, your spouse (“What thehell does she know?” said one crustyfellow . . . until he gave it somethought!), your kids.They might help you notice habitsyou have adopted that hinder yourenjoyment of life; then you can seewhat it is you want to replace themwith.The message through all of this is :You are in charge. If you can, andwant to, improve the quality of yourlife in some way, pick up yoursocks, and find out how to write yourown instruction manual! You haveproven your skills and determinationat problem-solving, at trouble-shooting, at finding different ways offixing things – apply these good ta-lents for your own benefit! And in

the process, you will becontributing to the greater safety ofyour industry.

Gisèle Richardson

Gisele is President of RichardsonManagement Associates Ltd. Shewas responsible for RMA’spioneering work in bringing in-formation about the humanelement to the aviation industry.She has served on the ExecutiveBoard of the International Con-sultants Foundation, the Boardof OD Canada, and is a formermember of the OrganizationDevelopment Institute’s AdvisoryBoard. She contributes tonumerous publications here andabroad. She trained at NationalTraining Laboratories forApplied Behavorial Sciences,studied Psychology at McGillUniversity, is an Advancedmember of ITAA, and a memberof the Academy of Management.Gisele can be reached at 514 935-2593 Fax 514 935-1852

Lack of Teamwork

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of the exercise, and each time thesafety case is renewed or updated,conclusions must be drawn on howit meets the case objectives, and astatement of “fitness for purpose”provided.An additional benefit delivered bythe safety case is the interface withother service or product providerswhere there are shared hazards.Interfacing in this instancedescribes the contractualrelationship between companieswhere a supplier is responsible forpart of an activity or product andthe company is responsible foranother part. Typically, an airline’sfuel supplier is responsible fordelivering the correct product,while the flight or ground crew areresponsible for its acceptance.Each shared safety-critical activityis covered by an interfacedocument that defines precisely thepoint at which responsibilitychanges hands. The documentassures mutual awareness ofhazardous activities and ensureseach party is clear about itsresponsibilities. Interfacedocuments are typicallyattachments to the contractbetween the parties and may havelegal connotations.Central to a safety case is theidentification and management ofhazards. Clearly, without a robustlist of hazards, a company cannotassure itself that it has establishedeffective controls. Hazards, onceidentified, are assessed by utilisinga safety assessment matrix todetermine their level of risk. Theresult of these assessmentsrequires management to makedecisions as to what, if any, actions

need to be taken. Without such asystematic review, it would bedifficult for management to ensurethat all parts of the operation needingrisk assessments have beenidentified.The generic hazard model developedin the workshops was designed tocover only those hazards that wouldbe common to a wide range ofairlines or helicopter operations.Each individual company, using thegeneric hazard model, needs toaccount for specific hazards (i.e. theaircraft type, the location, or theexistence of non-standardoperations). A hazard, onceidentified, must be contained throughprocedural, organisational orphysical controls. These measuresalone are not enough as they can becircumvented if their purpose is notwell understood, or if there is a lackof commitment by anyone involved.Training, assurance, awareness andaccountability are all needed.Identification of hazards started withthe definition of each hazard andwhat analysis tools would be usedto define them. In the safety casedescribed here, standard tools anddefinitions that had been usedsuccessfully elsewhere wereemployed. The primary tools werethe “bow-tie” analysis model and arisk matrix. The bow-tie hasproactive and reactive elements(Figure 3) that systematically workthrough a hazard and itsmanagement, using a methodologythat Shell Aircraft calls the hazardsand effects management process(HEMP). This requires that thehazards be identified, assessed andcontrolled — and also sets outrecovery measures.

The bow-tie output is tested againsta risk assessment matrix adaptedfor aviation . Judgements are madeas to the probability or frequencyof a hazardous event and theseverity of its consequences. Thehazardous events that are seen assafety-critical to the operator areadded to the company’s hazardregister. Senior management mustthen decide what level of risk thecompany will accept in order tomanage hazards. If the likelihoodof an occurrence is judged to beextremely remote, it may not beworth expending significant energyor resources on managing the risk.Conversely, if hazardous events arefrequent and the consequences areminor, but could escalate, it wouldbe appropriate to manage suchrisks within the safety case.Although the likelihood ofoccurrence or consequences isminor, it is appropriate to deal withthem through normal workplacemanagement. However, if theoutcome of a hazardous event issignificant and there is a likelihoodof its occurrence, risk reductionmeasures should be taken tominimise the risk to be as low asreasonably practicable (ALARP).This principle requires that if acontrol is technically possible,reasonable and achievable withoutcausing financial distress, then thecontrol must be put in place.The hazard modelShell Aircraft set up and facilitatedtwo workshop groups, onefocusing on fixed-wing airline typeservices, and the other on offshorehelicopter operations. Theworkshops involved pilots andengineers from a number of airlines

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and aircraft operators. Hazardmanagement techniques learned inthe workshops required that ahazard, once identified, is controlledto prevent the uncontrolled releaseof the hazard. For instance, anaircraft in flight is an example of acontrolled hazard, in that it has thepotential for harm through its inherentenergy. If the aircraft is notmaintained in a controlled state ahazardous event may occur, andtherefore measures are required toprevent the situation fromworsening. The intent is that crewaction, in accordance withprocedures and checklists, willrestore operating equilibrium byusing these measures. If thesemeasures fail, the aircraft will likelysuffer a consequence.The initial task of the workshops wasto identify hazards and list these asan entry point. Defining a hazard as“something with the potential tocause harm” enabled participants toidentify hazards and confirm they hadenergy which could be released andcause harm. The process thencontinued, identifying potential flightand ground hazards, includinglocations. The presence of a hazardin different locations could warrantdifferent controls or recoverymeasures.The workshops moved on to identifyprimary hazards and, specifically,the hazardous events that resultedfrom first release of a hazard. Eachevent required the bow-tie analysis.Typical in such a complicatedindustry as aviation, this could haveled to an unmanageable number ofanalysed events. The number ofanalyses was reduced throughadditional identification of hazards,which were prime sources of

energy. For example, an aircraftcould be affected by severein-flight weather, which wouldrequire its own bow-tie. However,if the aircraft is seen as the primehazard, then weather is only oneof many threats that could disruptflight. Conversely, a parkedunattended aircraft has little or nopotential to cause harm, but severeweather could damage the aircraftand, as such, would be the hazard.Statement of fitness:

After a master list ofhazardous events was

established, each possibilitywas subjected to a

brainstorming session. Afterthe proactive side of thebow-tie was taken into

account, it required only asimple process to addrecovery measures. A

typical example was whenan unairworthy aircraft wasreleased to service: there

were 24 threats andassociated controls, butrecovery measures were

limited to informing the flightcrew with the intent of

recalling the aircraft ordealing with the problem

after landing.In documenting development of asafety case structure, theworkshops agreed that the safetycase would need tocross-reference company manualsusing signposting techniques. Thissignificantly reduces the textualvolume of a safety case. The otherprinciple was to ensure that allcontrols identified to managethreats or escalation factors wereembedded in operator ormanufacturer processes,

procedures and checklists. Withinthe safety case, the hazard analysisinformation produced in the bow-tieexercise is also processed intooperator checklists.The final safety case output was toproduce the conclusion andstatement of fitness (SOF). In thefield this would be signed by thecompany’s chief executive officer.The SOF is crucial in that it confirmsfulfilment of commitments needed toimplement a comprehensive andstructured approach to safetymanagement. Also, the SOF is avisual demonstration to staff,regulators and customers of howwell objectives, as defined by thesafety management system, arebeing met.The work of identifying hazards andhazardous events has not resultedin any major breakthroughs infinding new hazards. However, itwas ground-breaking to gain anunderstanding of all hazardousevents and highlighted that much ofwhat is needed to control hazardsis already in place. The 85 per centof controls already in place are notnecessarily as robust as they shouldbe. Additional controls can be listedas remedial actions that needmanagement decisions about whichto address, and when.

Safety improvementsMany of the improvementsidentified could be made withoutmuch effort or cost. Even so, someadditional controls were identifiedthat would have real costs. Theprime findings of the process werethat:

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• management reviews must bemore active to ensure thatintended improvements takeplace;

• safety competence andaccountability are oftenill-defined or missing in theorganisation, in particular theability to trace safetyaccountability from the CEOdown;

• training in non-flying/technicalareas was lacking, especiallywhen staff are promoted tomanagement with significantchanges in skill and knowledgerequirements;

• there was a significant amountof work being done with thebest of intentions but withoutregard to proceduralrequirements;

• use of procedures, notably inengineering, was not systematicand often not assessed bysupervision or audit;

• workplace monitoring andsupervision practices wereinadequate;

• processes to manage changewere ineffectual;

• audit processes werefrequently inadequate;

• human factors were not welladdressed, with shortfalls intraining and/or application ofthe principles; and

• incident investigation oftenaddressed effect rather thancause and therefore denied thecompany the chance to learn.

The hazard modelling workshopswere carried out over eight months

in 1999 with pilots and engineersfrom eight airlines and five helicopteroperators. These workshopsproduced two generic hazardmodels, one each for fixed- androtary-wing application. Nineteengeneric hazards were identified.Each of the hazardous events wasdiscussed at length, and controlmethodologies defined. It becameclear that the means of controlling ahazard varied, depending onwhether the aircraft was in flight,undergoing maintenance or movingon the ground. In all, fourfixed-wing and six rotary-winglocations were defined. To aid withgeneration of bow-tie models foreach hazardous event, genericthreat and threat control lists wereassembled. These includeddescriptions for each threat and thesource where the threat or controlwould be relevant. These genericmodels can be adopted for anyaircraft operation. The generichazard model is now beingtranslated into the field by a numberof operators who are customising itto specific operations.Conclusion.Development of a safety caseinvolves significant effort by aircraftoperators. However, projectedgrowth in the number of accidentsis unacceptable. Current efforts aresomewhat piecemeal and are notreducing the accident rate. Apositive, integrated approach withsupport structures is required toimprove the situation. To makefurther progress will requirechanges in corporate culture,including management’s approachto safety. Some would argue thatthe industry is over-regulated, butthis viewpoint is insupportable when

the costs of human life andcorporate liability are taken intoconsideration.Possible Pull Quotes:A generic hazard register can betailored to any operator, enabling acompany’s resources to be focusedon the areas of greatest risk.

A safety culture existswhen there is a willingnessto learn from hazards and

threats as well as fromaccidents and incidents.

Central to a safety case is theidentification and management ofhazards.A hazard must be contained throughprocedural, organisational orphysical controls — but thesemeasures alone are not enough.

Hazard model workshops werecarried out over eight months withcurrent pilots and engineers fromeight airlines and helicopteroperators.

Cliff John EdwardsQuality Safety managerShell Aircraft Limited

Cliff Edwards served from 1961in the Royal Air Force, then from1973 in civil aviation as aLicensed Aircraft Engineer.Between 973 and 1989 he heldseveral management positionsincluding Aircraft EngineeringManager for Shell in Brunei. In1984 he also became DeputyHead of Aircraft Services, whichadded to the management ofmaintenance, those of the airfieldand flight operations.

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always, he came out with many“gems” of knowledge. He added aninteresting addition to his famousSwiss cheese model with a mouseeating at the last block of cheesethat is the companies “copingresources” to the error. He calledthe mouse nibbling “an accumulationof minor events” that have beenignored or unrecognized until anevent occurs.Don Sherritt, Director,Maintenance & Manufacturing,Transport Canada than gave apresentation of what the regulatoris doing in Canada to promote asafety environment. He discussedin detail, the maintenance safetyprogram that is now at theCARAC (Canadian IndustryAdvisory Committee) level. Onerather new approach is the callingfor an “Accountable Executive” forall approved maintenanceorganizations.Captain Daniel MaurinoCoordinator, Flight Safety andHuman Factors Programmes,ICAO (International Civil AviationOrganization) presented a look atrisk and deviation management.One of the things he called for were:“Think about the spirit rather thanthe letter of the law” and ended with“Stop the beatings - morale won’timprove”.Ms. Angela Elgee Manager,Continuing Airworthiness Division,FAA, substituting for NicholasLacey, outlined what the FAA isdoing to reduce maintenance errors.Many of her success stories camefrom the Human Factors Research

program now run by Ms. JeanWatson Program Manger, AviationMaintenance & Inspection HumanFactors Research. Their websitewww.hfskyway.faa.gov has hadover six million hits over the yearsand can be recommended toanyone interested in human factorsfor maintenance.Jim Done Deputy Chief Surveyorof the UK Civil Aviation Authoritydiscussed the changes occurring inthe UK. One very interesting onediscussed the work being done toremove the punitive aspect ofunintentional human error. It ishoped that this will bring about abetter reporting of all human errors.Art LaFlamme Director GeneralCivil Aviation, Transport Canada,outlined “Flight 2005, A CivilAviation Safety Framework forCanada” The Target is to see airlineaccidents reduced by 40% over afive year average and commuterand air taxi by 50%. Details canbe found on their website atwww.tc.gc.ca/aviation.In the afternoon, Keith Jones VicePresident Maintenance, Air Novawith the assistance of CharlesDunstan and David Deveauprovided insight into their “Journeytowards Error ReductionManagement” They expressed thebelief that: “Diligent attention tohuman factors in error reduction gohand in hand with improved safetyand improved financialperformance”.Dr. Drew Dawson, DirectorCenter for Applied Behavioral

Research, University of SouthAustralia provided an interestingand entertaining insight into fatigue.Part of his talk outlined a study theycarried out that correlated theeffects of fatigue and that of alcoholon one’s judgment. He concludedby saying we are very concernedabout drugs in the workplace butfatigue is four times more likely tocause impairment than drugs oralcohol.Bill Ashworth, Vice PresidentMaintenance, Quality &Engineering, BF GoodrichAerospace, with the assistance ofTim Killion, Quality LiaisonAirframe Services Division,discussed Safety Managementemphasizing the safety assessment,data analysis and informationfeedback. Using MEDA(Maintenance Error Decision Aid)they were able to demonstrate theirsignificant reduction in errors.Ed Frederick OrganizationEffectiveness Coordinator provideda spellbinding recounting of theThree Mile Island near nucleardisaster. Like most accidents, it wasa series of small errors that neverseemed to stop. A lot of latentconditions lay in the thought that aseries of little things would neveroccur until it did and they wereoverwhelmed by the mixed signalsthey got.The first day finished with RichardDesmarais Safety Manager AirCanada recounting his companiesapproach to the issue of discipline.The “Dirty Dozen” are used as part

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of the human factors investigationinto any incident/accident with theprimary purpose to learn from andprevent a reoccurrence.Day Two started off with Dr. JohnLauber Vice President Safety &Technical Affairs, Airbus Industriesof North America detailing theintegration of safety managementinto corporate cultures. Hisdefinition of a safety culture was“You’ll know it when you see it”.Or perhaps more easily defined:“the integration of safetymanagement principles”.Clifford Edwards Quality &Safety Development Manager,Shell Aircraft outlined an excellentmodel of managing human factorsthrough safety management. Anarticle by Cliff is in this issue and iswell worth the reading.John Gogola Board member ofthe National Transportation SafetyBoard gave an impassionedpresentation of where we are andwhere we still have to go. Oneinteresting fact he related was thatof the last 14 major accidents in theUSA, 7 have had a majormaintenance component.Dr. James Taylor Ph.D. with theable assistance of Manoj S.Patankar Ph.D. from Santa ClaraUniversity and San Jose Universitytook us through the evolution ofMRM (Maintenance ResourceManagement) and the role ofcommunication in this evolution.Dr. Jose Blanco LaurentianUniversity presented a return oninvestment of safety managementwhile with only a short time before

lunch, John Stelly Jr. ManagingDirector Systems and Training, andKarin L. Poehlmann SeniorTechnical Analysis MaintenanceHuman Factors Engineering forContinental Airlines took us througha fast but very interesting model forinvesting in Human Factors Training:Assessing the Bottom Line. Theyused “Icarus Airways” and providedan excellent model for defining thetrue cost/benefit of training. TheirAdvise: Talk to finance first, not last.The remaining 1 ½ days were takenup with workshops. All theworkshops were filled to capacityand I believe well received.Workshop #1 was a one and one-half day workshop conducted byWill Boles, Regional AviationSafety Officer – MaintenanceTransport Canada and GordonDupont CEO System SafetyServices. This workshop introducedthe new Transport Canada humanfactors course that will be availableto the public for a nominal cost.Workshop #2 was repeated threetimes and covered the topic ofIntegrating Human FactorsPrograms into your Management ofSafety. This workshop wasmediated by David Hall of the UKCAA and had as speakers. ChowHock Lin Senior Quality Engineer,Singapore Airlines EngineeringCompany, and Josef Salik HumanFactors Steering Group Leader,Engineering & Maintenance, QantasAirways Ltd.Workshop #3 covered theintroduction to the tools of safetymanagement: Shift management and

Fatigue by Dr. Drew Dawson,University of South Australia.Workshop #4 facilitated by JimMcMenemy, HumanPerformance Specialist, SystemSafety covered: Introduction to thetools of safety management.Assessing safety within yourorganization through errorreporting, data management anddata analysis.Panel members were: Jerry AllenJr. Manager Human Factors DeltaAirlines, Commander JohnSchmidt Medical Service Corps,United States Navy, CaptainRene Dacier Flight Safety OfficerAir Nova, Maury Hill ManagerMacro Analysis, TransportationSafety Board of Canada and Dr.Gary Eiff Aviation TechnologyProgram Purdue University.This symposium saw the largestgathering ever of personsinterested in human factors inaviation maintenance. It was atremendous opportunity to mix andmeet.At the icebreaker receptionGordon Dupont and his wifeBirgitta were recognized by theFAA with a plaque: “In recognitionand appreciation of your dedicationto Aviation Maintenance andInspection Human FactorsInitiatives March 1993 to August1999”.

Next year the 15th Symposiumwill be held in London UKMarch 2001: Plan to be there.

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FROM THE EDITOR!MARSSAnnual General MeetingThe AGM was held on March29th.,2000 at the VancouverWaterfront Hotel at 1900hrs. It washeld with several members ofMARSS present.Bob Rorison, the president,mentioned the successes that thesociety had achieved in the previousyear, including the completion ofvideos, and the advanced state ofthe latest “Ramp Safety’ posters.He also referred to the alteration inthe role that MARSS had adopted,with the commencement ofCanadian Airlines splendid coursein HPIM training. In addition,Gordon Dupont, has now createda new company, System Safety ,with the help of Bill Foyle, JohnnyRush, and Paul Jenkins.• All three candidates were elected

to office, the directors slate for2000 being :-

E.J Braund - Executive SecretaryW. Foyle - ConsultantG. Dupont - ElectedP. Jenkins - Dept. of National

DefenseL. O’Brien - ElectedS. Mikituk- Canadian Airlines

International LtdR. Rorison - British Columbia

Institute OfTechnology

J. Rush - ElectedA. Schellekens- S.I.L Industries

LtdR.Wisniewski – ElectedThanks are extended to everyonefor helping to make this a successfulyear, and helping form the newboard.

Hello and welcome to the spring edition ofGroundEffects! Spring is finally here! Thefeature article is an article written by thewell famous Gisele Richardson ofRichardson Management. It is an articlethat deals with the fact that everyone of usCAN change. Gisele simply points outthat if someone truly wishes to change and

learn then the odds are that they will change but if someone isdetermined that they cannot change then they most likely neverwill. I was taking the HPIM part one workshop for the first timeand there was a man in our team who sat down accross from meand looked at me and said, “This is a waste of my time, there isnothing that these two fools can teach me, that I don’t alreadyknow!” I simply smiled and thought to myself (this guy is an idiotthat is going to be a big pain for the next two days). At the endof the second day, we were filling out the questionnaire about thecourse and he looked up at me and smiled and said, “Wow, Inever knew that I could have so much fun and learn so much intwo days.” This time I thought, see it is possible to teach an olddog new tricks. Everyone has the ability to learn and start to dothings differently perhaps more safely.Our second article is an artilce written by Cliff J. Edwards. Thisarticle deals with the ways to develop the generic hazard modelfor use in safety cases. This is a great learning article. Thebehind the scences look at how models are made for us to use aslearning tools. Take a minute and see how the process is evolved.In this edition we also have a report of what happened at the14th International FAA/CAA Transport Canada Human Factorsin Aviation Maintenance Symposium. If you missed it, you donot want to miss this article.On a more personal level, this is the last issue of GroundEffectsthat I will be publishing before I become Mrs. Paul Seabrook.So, please do not panic when you see the name of theGroundEffects editor has been changed. Please wish for lots ofsun in Vancouver on May 27, 2000.Take care and remember that every dog has the ability to changeand learn new tricks and as I am sure that I will learn many newthings in my new venture as a happy wife.

NOTE:

Transport Canada System Safety is holding it’s HPIAMcourse June 28/29. Please contact Gerrry Binnema at

(604) 666-9519 for further details.

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MARSS

5750 Cedarbridge Way

Richmond, B.C. V6X 2A7

Canada

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