Crossed Wires: Online Maintenance Human Factors Training Video

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. CASA Maintenance HF Training Video As part of a workshop activity participants could note down the human performance influencing factors and risk inducing behaviours as they occur. CASA Maintenance HF Training Video Then discuss these as a group afterwards and consider what controls your organisation has (or hasn’t!) got in place. CASA Maintenance HF Training Video 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. CASA Maintenance HF Training 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: CASA Maintenance HF Training Video

Extra Maintenance Continuation Training Resources

For further inspiration see our articles:

There are also these free case studies, already used by other maintenance organisations for continuation training, you can discuss:

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.

Misrigged Flying Control Cable, Air Astana Embraer EJ-190 P4-KCJ (Credit: GPIAFF)

Misrigged Flying Control Cable, Air Astana Embraer EJ-190 P4-KCJ (Credit: GPIAFF)

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: mop 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

Aerossurance will be presenting at EASA‘s 11th Rotorcraft Symposium on Cologne on 5 December 2017 on human centred design (HCD) for rotorcraft.  This presentation will be live streamed. easa logo

UPDATE 24 October 2022: The Royal Aeronautical Society (RAeS) has launched the Development of a Strategy to Enhance Human-Centred Design for MaintenanceAerossurance‘s Andy Evans  is pleased to have had the chance to participate in this initiative.

Aerossurance has extensive air safety, operations, airworthiness, human factors, aviation regulation and safety analysis experience.  For practical aviation advice you can trust, contact us at: