Airworthiness Matters: Next Generation Maintenance Human Factors
Aerossurance’s Andy Evans wrote an article in the current issue of the International Federation of Airworthiness (IFA) Airworthiness Matters magazine on: Next Generation Maintenance Human Factors (available here: IFA Airworthiness Matters 2016).
The article starts by discussing a Royal Aeronautical Society (RAeS) conference: Maintenance Human Factors: The Next Generation. At that event Professor Dave King highlighted we needed to think”about a next generation approach to human factors in engineering”.
Over the last 10-15 years, much attention has been focused on maintenance human factors training and reporting & investigating errors. While we could concentrate on simply doing more of these and certainly can find ways to do these things better, perhaps the next generation approach needs to include a much wider range of activities.
At the conference the results of an on-line RAeS survey were discussed that indicated a need to:
- Share data better across the industry.
- Integrate HF more fully into Safety Management Systems.
- Get better at actually implementing improvements.
In relation to improvements, the Airworthiness Matters article goes on to discuss topics first raised in our on-line article: Aircraft Maintenance: Going for Gold? This posed the question: Can aviation maintenance learn lessons from championship athletes? It advocated seeing aircraft maintenance engineers less as the generators of errors and more a needing to deliver peak performance every day, hence the need for:
…a near obsessive attention to detail, to focus on every element that can affect human performance, seeking out opportunities to make small improvements, that collectively lead to noticeable performance improvement.
This also means less time spent on determining if someone should be blamed after an error and more time on systemic improvement. Evans quotes management consultant Yves Morieux of BCG commented in a TED Talk on business generally:
If you think about it, we pay more attention to knowing who to blame in case we fail, than to creating the conditions to succeed. We are creating organizations able to fail, but in a compliant way, with somebody clearly accountable when we fail. And we are quite effective at that: failing.
Evans discusses the misapplication of bureaucratic Just Culture ‘decision aids’ to ‘judge’:
…individuals not the system, with the potential to inadvertently reduce trust rather than enhance it. The circumstances that influenced an individual’s performance are seen as factors that mitigate culpability rather than systemic opportunities to improve. Inappropriate use of these mechanisms help normalise failure at the expense of collective improvement.
Questions to ask are:
- Are we over-emphasising formal reporting at the expense of open, continuous and proactive dialogue?
- Are we applying our just culture process (i.e. judging culpability) too often and just highlighting we don’t trust our
- own people?
- Do we spend as much time on optimising our process for improvement?
- Do we value continuous improvement more than compliance with the status quo?
Evans goes on to advocate that:
As an industry we need to be better at eliminating hazards in the design and planning stages. Design Organisations shape both the products being maintained and the supporting data. In the last few years UK AAIB have published a number of reports that highlighted maintenance tasks that are vulnerable to human error.
- BA A319 Double Cowling Loss and Fire – AAIB Report
- ANSV Report on EasyJet A320 Fan Cowl Door Loss
- When Down Is Up: 747 Actuator Installation Incident
The RAeS Human Factors Group: Engineering (HFG:E) has published a short guidance document on 11 steps an aviation Design Organisation (DO) can take to “deliver safer, more effective and reliable aircraft through improved design for maintenance”: First Eleven: Guidance for Designers on Maintenance Human Performance
However to really make progress managing Maintenance Human Factors, we need a collaborative effort between designers and maintainers.
As an industry we need to put a greater emphasis on collaborative improvement if we are to break the cycle of repetitive failure and use a wider range of techniques than traditionally.
In his introduction to the whole issue, IFA President Frank Turner says, that while learning from investigations has been:
…an effective approach in the past, it is no longer appropriate for the future of a very safe industry, but one affected more than most by social media that will expose and sensationalise any shortcomings in the industries’ ability to adequately predict risk and effectively mitigate it.
Turner then echoes the Aerossurance view:
You will see from this magazine a number of papers which approach this subject, but we in IFA believe that to meet our objective of continuously improving airworthiness, we need to take the Olympic Athlete’s approach of continuous improvement in identifying those weaknesses in our risk prediction across the critical interfaces, from design through to senior management We are going for “Gold” on this one.
The big question is: are you and your suppliers?!
Other articles in the same Airworthiness Matter issue include:
- Implementing a Regulatory Safety Management System to Enable Performance Based Regulation by Matthew Margesson, UK CAA
- The FAA Compliance Philosophy by Bill Johnson, Chief Scientist and Technical Advisor for Human Factors in Aircraft
- Maintenance Systems, FAA
- Risk Culture – The Missing Link in the Safety Culture Debate by Cengiz Turkoglu, IFA Chair of Technical Committee
See also our article in Airmed & Rescue on contracting for aviation services: The Tender Trap
UPDATE 16 February 2017: See also our article Consultants & Culture: The Good, the Bad and the Ugly
UPDATE 16 February 2017: Aerossurance is delighted to be sponsoring an RAeS HFG:E conference at Cranfield University on 9 May 2017, on the topic of Staying Alert: Managing Fatigue in Maintenance. This event will feature presentations and interactive workshop sessions.
UPDATE 26 February 2017: Smoke in Cabin: Anatomy of a Wash Rig Error
UPDATE 1 March 2017: Safety Performance Listening and Learning – AEROSPACE March 2017
Organisations need to be confident that they are hearing all the safety concerns and observations of their workforce. They also need the assurance that their safety decisions are being actioned. The RAeS Human Factors Group: Engineering (HFG:E) set out to find out a way to check if organisations are truly listening and learning.
The result was a self-reflective approach to find ways to stimulate improvement.
UPDATE 19 March 2017: The Rule Illusion: Organisations should beware of a ‘rules bias’, a tendency to give in to risk aversion by establishing ever more rules:
Just like in the real world, stricter rules in an organization are rarely effective in stopping the most egregious transgressions.
In practice, those who make the rules are often insulated from the true consequences. The lack of a good feedback mechanism to adjust the rules would be bad enough if the rules were based on evidence and logic. But it’s often even worse, because rules often originate from received (but dubious) wisdom, unproven ‘common sense’, or reactions to one-off events. Rules that are based on beliefs rather than evidence, and never tested, are unlikely to produce net benefits. Yet such rules are precisely the ones the makers feel most protective of. Attempts to budge them meet with the backfire effect. That’s how we end up with sledgehammers to crack a nut.
Many rules were originally intended to be guidelines to help shape behaviour, but instead over time get codified into rigid laws. Often most people in the organization no longer know why the rules were even implemented. And yet depressingly, “Rule Nazis …. They cling to the rules like Leonardo DiCaprio clung to that door in Titanic — as if their lives depend on it. And they make sure everyone else does too, even when the rule doesn’t make sense or stands in the way of productivity,” as Heidi Grant says.
Rules mostly creep in one by one. As their number grows, they contribute to a culture of conformity, rather than one of intelligent judgement and empowered employees who do what is right.
Hence the need to only establish the right rules and still leave room for empowered good judgement.
UPDATE 22 March 2017: Which difference do you want to make through leadership? (a presentation based on the work of Jim Kouzes and Barry Posner). Note slide 6 in particular:
UPDATE 25 March 2017: In a commentary on the NHS annual staff survey, trust is emphasised again:
Developing a culture where quality and improvement are central to an organisation’s strategy requires high levels of trust, and trust that issues can be raised and dealt with as an opportunity for improvement. There is no doubt that without this learning culture, with trust as a central behaviour, errors and incidents will only increase.