Aircraft Maintenance: Going for Gold?
We pose the question: Can aviation maintenance learn lessons from championship athletes?
Aerossurance is pleased to have sponsored the Royal Aeronautical Society (RAeS) conference Human Factors in Engineering - the Next Generation at Cranfield University on 12 May 2015.
In his opening address Cranfield University’s Professor Dave King (a former Chief Inspector of Air Accidents with the UK Air Accidents Investigation Branch [AAIB]) made the point that after a generation of attention on maintenance errors, similar occurrences were still repeating.
Professor King challenged the audience 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, reporting errors, investigating errors (for example using Boeing’s MEDA) and taking corrective actions. 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 wider range of activities.
Human Factors training alone is not considered sufficient to minimise maintenance error. Most of the [contributing factors] can be attributed to the safety culture and associated behaviours of the organisation.
Perhaps we should we start treating maintenance personnel more like athletes who need to achieve peak performance every day?
During a similar time frame British Cycling has gone from a historically rather lacklustre performance, for example wining two bronze medals in the 1996 Olympics, to producing spectacular performances. By the London 2012 Olympics, Britain was ranked number one in the world and British riders won 12 medals, including 8 of the available 14 gold medals, with Sir Chris Hoy winning a UK record 6th gold medal. The same year Sir Bradley Wiggins became the first Briton to win the Tour de France, a feat repeated in 2013 and 2015 by Chris Froome. There have been many reasons for this, not least the availability of funding from the National Lottery to support deserving British sports. However, this success is not just due to investment, but to talent, individual commitment and a highly effective strategy for improving performance. Much of the latter has been credited to Sir Dave Brailsford, first performance director of British Cycling (until 2014) and since 2010 general manager of Team Sky.
Sport is about continuous improvement, it’s about getting better. It’s about being better next year than you are this year. It’s a bit like Formula One. You have a car and the designers might say ‘we can’t think how we’re going to make this any better’. But ultimately you can. And that’s what we’ve got to do. We’ve got to keep looking, researching and working – trying things. And that’s what it’s all about.
One of the more quotable examples is his concept of ‘marginal gains’ (very much akin to a Japanese kaizen philosophy). Brailsford advocates 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 includes the ‘secret squirrel club’ dedicated to technological advances to enhance human performance (even hi-tech socks).
UPDATE 15 August 2016: To understand just how far the obsession with marginal gains went for Rio 2016 read: How scientific rigour helped Team GB’s saddle sore cyclists on their medal trail
We have previously reported on several maintenance organisational testing wearable technology for aircraft maintainers. Another part of the Brailsford philosophy is the CORE concept:
Commitment + Ownership + Responsibility = Excellence
We admit it is unlikely that a maintenance organisation will ever dispatch a working party to a remote site with their own personal pillows to maximise their sleep! However, a continual search for improvement opportunities to help maintenance personnel produce peak performance would certainly be more proactive than solely relying on retrospective analysing submitted reports of occurrences, errors or hazards.
Brailsford’s philosophy has also been discussed by David Denyer, Professor of Organisational Change and Director of Research at Cranfield University’s School of Management: 15 Steps to Peak Performance
UPDATE 7 March 2017: The Brailsford philosophy has not always delivered the desired results: Dave Brailsford admits ‘mistakes were made’ over Sky medical package
UPDATE 4 November 2015: See also our article: Coaching and the 70:20:10 Learning Model. We look at how people really learn. Formal pre-fab classroom training is the least effective method. So why do we do waste so much time and money on it?
UPDATE 3 May 2016: After their spectacular season, starting as 5000-1 underdogs and ultimately winning the English Football Premiership, a number of commentators have been discussing the success of Leicester City FC and their manager, Claudio Ranieri . In one article the Guardian observes (emphasis added):
They use other technology that is more commonplace at the highest level, such as the Catapult GPS system and Polar Team2 heart-rate monitors, regularly issue electronic questionnaires to gauge everything from energy levels to sleep patterns but, perhaps most importantly of all, strive to create an environment where everybody talks to each other.
We think that reinforces the observations in our original article, even more so in relation to safety. We discuss that further here: 5000-1 Safety Lesson: Communication
UPDATE 10 May 2016: F1 Crew Helps Nurses Save Premature Babies:
The Williams team practises around 2,000 pit stops a season in the hope of shaving a few tenths-of-a-second from the tyre-change. Small mistakes can cost positions on the track. Gemma Fisher, a human-performance specialist at Williams, said: “That’s a lot of pressure to deal with. It’s a different pressure to what the doctors and nurses are dealing with at the [University Hospital of Wales] but it binds those people and builds that team ethic: even more so because they are in such a complex and stressful environment.” The collaboration between the Formula One team and the hospital has already resulted in unneeded equipment being removed from the emergency trolley and a dedicated area being marked out in maternity operating theatres for the neonatal team to work in. The doctors and nurses now hope to start filming resuscitation attempts from cameras attached to their bodies so they can learn from any mistakes or hesitation to further improve their performance.
According to a Williams article:
Claire Williams, Deputy Team Principal of Williams, added; “When we were approached by the Neonatal team at the University Hospital of Wales last year to offer some advice we were delighted to assist. If some of the advice we have passed on helps to save a young life then this would have been an extremely worthy endeavour. We are increasingly finding that Formula One know-how and technology can have benefit to other industries and this is a great example.”
UPDATE 11 May 2016: As discussed in another article on F1 based initiatives:
The physical and mental demands of a two-second stop are such that F1 teams employ specialists to train and prepare mechanics, who must be as agile and focused as the drivers. Adam Hill is a surgeon and engineer at McLaren Applied Technologies, a spin-off from the McLaren F1 team. He’s responsible for things such as “task sequencing” and “designing out failure”, as well as the care of the mechanics, who work under stress in a risky environment (less so since the 2009 ban on mid-race refuelling, which allowed pit times to drop significantly). Drugs giant GSK used McLaren’s pit-stop skills to cut the time it takes to switch toothpaste flavours in one of its production lines from 39 to 15 minutes, allowing it to produce an extra 6.7m tubes a year. But can we pit stop everyday life, saving seconds in pasta preparation or the school run? Absolutely, Hill says. “We hear so much about disruptive innovation but very little about incremental innovation. I’m obsessed with making improvements in everything I do, measuring it and analysing that data.” Away from the track, he also takes this approach with his kids. “It helps me modify their behaviour, whether it’s eating their carrots or going to bed earlier,” he says.
This exchange of ideas has not been just one way. McLaren and the GSK Human Performance Lab (GSK HPL) have started cooperating on research to enhance the performance of FI drivers and mechanics.
UPDATE 21 May 2016: We do like this TED talk by Yves Morieux of BCG: How too many rules at work keep you from getting things done which compares the US and French women’s 4x100m teams’ performances and how an overload of rules, processes and metrics keeps us from doing our best work together – cooperatively.
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. All the human intelligence put in organization design – urban structures, processing systems – what is the real goal? To have somebody guilty in case they fail. 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.
UPDATE 19 August 2016: The influential Behavioural Insights Team of HM Government’s Cabinet Office discuss: Applying behavioural insights to the Rio Olympics. In particular they note:
…we were delighted to see the approach being taken up across a range of other GB teams, who are paying much closer attention to every element of their athlete’s training programmes. For example, Chris Spice, performance director for Team GB Swimming, introduced a strict regime that has included a number of environmental tweaks – late night swims to adjust to time differences, special mattresses and blackout blinds to improve sleep quality and strict meal plans designed to enhance performance. Could these changes lie behind the team’s most successful spate of medals since 1908?
Over the past week, the British public have been treated to the incredible sights and sounds of Team GB Cycling dominating the Rio De Janeiro Velodrome – winning 6 of the 10 track cycling golds on offer, and elevating Sir Bradley Wiggins, Jason Kenny, and Laura Trott as some of the most successful British Olympians of all time.
UPDATE 25 October 2016: Smells like Team Spirit:
The Olympics creates an intensity every four years that may be difficult to recreate in many workplaces. But perhaps the essence of ‘team spirit’ gleaned from GB’s Olympic and Paralympic success in Rio could be applied to a more standard workplace setting.
1) A sense of belonging – and a sense of loyalty to a collective cause – a sense of ‘we’, not just ‘I’
2) A sense of identity, a name and even some rituals that contributed to that sense of collective identity
3) An inspiring collective goal and purpose that their individual goals could tangibly contribute towards
4) A willingness for big stars to be members of a wider team, able to come alongside and encourage fellow, relatively unknown, less experienced team members – for a collective purpose.
5) A celebration of success in the spirit of community – each individual success celebrated by the whole.
UPDATE 29 October 2016: 7 Gold Standards Of Deliberate Practice: Why F1 Driver Max Verstappen Has No Talent This article quotes Anders Ericsson, who in his book Peak: Secrets From The New Science Of Expertise says the gold standards of deliberate practice are as follows:
- Having A Specific Goal.
- Expert Coaching.
- Consistently Learning From Feedback.
- Learning In Your Discomfort Zone.
- Building A Strong Foundation.
- Being Focused And Involved.
- Using Mental Representations.
Ericsson’s message is very optimistic: …people are often capable of achieving much more than they and others around them realize. This is essentially a growth-oriented view that offers a different approach to developing expertise. The standards are based on a combination of deliberate training and practice, and can be seen as a vindication of the principles of the 70:20:10 reference model.
UPDATE 26 February 2017: Smoke in Cabin: Anatomy of a Wash Rig Error
UPDATE 26 March 2017: Why the Command and Control Mindset is Killing Your Company
In this game it is not anymore relevant to optimize an organization’s efficiency based on a stable set of known variables. Instead, there’s a strong need to adapt as fast as possible to increasingly complex working conditions. Efficiency has to make place for engagement and adaptability. The organizations that know how to fully engage their employees and those who are natives in this information-rich, densely interconnected world of the 21st century are the ones that thrive.
We are talking about designing workplaces that are able to meet the intrinsic needs of employees. Over the last 14 months, we have visited over 50 of such workplaces. They show us the promised land time and time again. A promised land where highly engaged employees are responsible for high levels of agility, productivity, profitability and talent retention.
To get to this promised land we first have to unlearn almost everything we think we know about organizing work. Almost everything we have witnessed during our visits to these organizations is contrary to the beliefs of traditional organizations. We therefore need to spread this new management paradigm that does no longer support rigid hierarchies with managerial command-and-control.
We should stop to reinvent practices that do not work, but go beyond our traditional beliefs and ideologies. And we should clear our mind from the old paradigm so we can start to fill in an entirely new canvas.
UPDATE 12 April 2017: Leadership and Trust
UPDATE 23 July 2017: Germ warfare at Team Sky
UPDATE 30 July 2017: “When you understand what you’re great at, and design your capabilities and strategy accordingly, you can define how you want to compete, and shape your own future rather than waiting for others to do it for you”. Olympic speed skater John K. Coyle understands this.
UPDATE 2 March 2018: An excellent initiative to create more Human Centred Design by use of a Human Hazard Analysis is described in Designing out human error
HeliOffshore, the global safety-focused organisation for the offshore helicopter industry, is exploring a fresh approach to reducing safety risk from aircraft maintenance. Recent trials with Airbus Helicopters and HeliOne show that this new direction has promise. The approach is based on an analysis of the aircraft design to identify where ‘error proofing’ features or other mitigations are most needed to support the maintenance engineer during critical maintenance tasks.
The trial identified the opportunity for some process improvements, and discussions facilitated by HeliOffshore are planned for early 2018.
UPDATE 24 June 2018: B1900D Emergency Landing: Maintenance Standards & Practices The TSB report posses many questions on the management and oversight of aircraft maintenance, competency and maintenance standards & practices. We look opportunities for forward thinking MROs to improve their maintenance standards and practices.
UPDATE 25 August 2018: Crossed Cables: Colgan Air B1900D N240CJ Maintenance Error On 26 August 2003 a B1900D crashed on take off after errors during flying control maintenance. We look at the maintenance human factor safety lessons from this and another B1900 accident that year.
UPDATE 17 October 2018: How McLaren Learned to Treat Its Pit Crew Like Athletes: “It started with stealth video recordings and ended with visual tracking goggles and orange nuts”, as discussed in Game Changers: How a Team of Underdogs and Scientists Discovered What it Takes to Win.
Aerossurance worked with the Flight Safety Foundation (FSF) to create a Maintenance Observation Program (MOP) requirement for their contractible BARSOHO offshore helicopter Safety Performance Requirements to help learning about routine maintenance and then to initiate safety improvements:
Aerossurance can provide practice guidance and specialist support to successfully implement a MOP.
Aerossurance is pleased to be supporting the annual Chartered Institute of Ergonomics & Human Factors’ (CIEHF) Human Factors in Aviation Safety Conference for the third year running. We will be presenting for the second year running too. This year the conference takes place 13 to 14 November 2017 at the Hilton London Gatwick Airport, UK with the theme: How do we improve human performance in today’s aviation business?
Aerossurance has extensive air safety assurance, airworthiness management, maintenance human factors and improvement experience. For practical aviation advice you can trust, contact us at: firstname.lastname@example.org
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