Crossed Wires: Online Maintenance Human Factors Training Video
In need of inspiration for your maintenance human factor continuation training? Why not use this free CASA HF video?: ‘Crossed Wires’
The 8.5 minute video from 2013 portrays the incubation of an incident at the fictitious Perfect Twins maintenance organisation. As part of a workshop activity participants could note down the human performance influencing factors and risk inducing behaviours as they occur. Then discuss these as a group afterwards and consider what controls your organisation has (or hasn’t!) got in place. The video supports the CASA Safety Behaviours: Human Factors for Engineers resource kit that includes a detailed HF guide, facilitator’s guide and participant workbook, with other ideas to exploit the video. It can be followed by this, admittedly slightly idealistic, shorter video on how things could be at Perfect Twins Maintenance in which the maintenance manager in particular demonstrates safety awareness, safety leadership, improved communications skills and assertiveness:
Extra Maintenance Continuation Training Resources
For further inspiration see our articles:
- Critical Maintenance Tasks: EASA Part-M & -145 Change
- Airworthiness Matters: Next Generation Maintenance Human Factors
- James Reason’s 12 Principles of Error Management
- Back to the Future: Error Management
- The Power of Safety Leadership: Paul O’Neill, Safety and Alcoa an example of the value of strong safety leadership and a clear safety vision.
- Aircraft Maintenance: Going for Gold? looking at some lessons from championship athletes we should consider.
- Plus this book review The Field Guide to Understanding Human Error by Dekker, presented to the RAeS in 2006: The Field Guide to Understanding Human Error – A Review
There are also these free case studies, already used by other maintenance organisations for continuation training, you can discuss:
- Misassembled Anti-Torque Pedals Cause EC135 Accident
- EC130B4 Accident: Incorrect TRDS Bearing Installation and
- Misrigged Flying Controls: Fatal Maintenance Check Flight Accident which shows how the incident at Perfect Twins Maintenance could have turned out
- UPDATE 19 May 2018: Too Rushed to Check: Misrigged Flying Controls and another…
- 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 19 April 2019: FAA Rules Applied: So Misrigged Flying Controls Undetected in an accident to a Cessna 172 in Bermuda.
UPDATE 31 May 2019: The Portuguese accident investigation agency, GPIAAF, issued a safety investigation update on a serious in-flight loss of control incident involving Air Astana Embraer ERJ-190 P4-KCJ that occurred on 11 November 2018. The aircraft was landed safely after considerable difficulty, so much so the crew had debated ditching offshore. GPIAAF conformed that incorrect ailerons control cable system installation had occurred in both wings during a maintenance check conducted in Portugal.
GPIAFF note that: “By introducing the modification iaw Service Bulletin 190-57-0038 during the maintenance activities, there was no longer the cable routing and separation around rib 21, making it harder to understand the maintenance instructions, with recognized opportunities for improvement in the maintenance actions interpretation”. They also comment that: “The message “FLT CTRL NO DISPATCH” was generated during the maintenance activities, which in turn originated additional troubleshooting activities by the maintenance service provider, supported by the aircraft manufacturer. These activities, which lasted for 11 days, did not identify the ailerons’ cables reversal, nor was this correlated to the “FLT CTRL NO DISPATCH” message.”
GPIAFF comment “deviations to the internal procedures” occurred within the maintenance organisation that “led to the error not being detected in the various safety barriers designed” in the process. They also note that the error ” was not identified in the aircraft operational checks (flight controls check) by the operator’s crew.”
UPDATE 1 June 2019: Our analysis: ERJ-190 Flying Control Rigging Error
But don’t forget to discuss your own hazard and occurrence reports! 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.
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 8 April 2020: NTSB Confirms United Airlines Maintenance Error After 12 Years
UPDATE 24 October 2022: The Royal Aeronautical Society (RAeS) has launched the Development of a Strategy to Enhance Human-Centred Design for Maintenance. Aerossurance‘s Andy Evans is pleased to have had the chance to participate in this initiative.