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UNIVERSITY llfllll/
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JOHANNESBURG

A STUDY INTO THE EFFECT OF HUMAN ERROR ON SUBSTANDARD

MAINTENANCE PERFORMANCE, AND THE FORMULATION OF A COMPLETE
SOLUTION BASED ON THE EXPERJENCE OF SUCCESSFUL MAINTENANCE
ORGANISATIONS.

by

MFUNDO S. NKOSI

A dissertation submitted in partial fulfilment for the degree

MAGISTER PIDLOSOPIDAE

in

MECHANICAL ENGINEERING

in the

FACULTY OF ENGINEERING
(Department of Mechanical and Manufacturing Engineering)
(specialisation Maintenance Engineering)

UNIVERSITY OF JOHANNESBURG

Supervisor: Dr Jasper L. Coetue

November 2014

200830213 MS Nkosi
 'y 1'

UNIVERSITY
OF
JOHANNESBURG

A STUDY INTO THE EFFECT OF HUMAN ERROR ON SUBSTANDARD

MAINTENANCE PERFORMANCE, AND THE FORMULATION OF A COMPLETE
SOLUTION BASED ON THE EXPERIENCE OF SUCCESSFUL MAINTENANCE
ORGANISATIONS.

by

MFUNDO S. NKOSI

A dissertation submitted in partial fulfilment for the degree

MAGISTER PHILOSOPHIAE

in

MECHANICAL ENGINEERING

in the

FACULTY OF ENGINEERING
(Department of Mechanical and Manufacturing Engineering)
(specialisation Maintenance Engineering)

UNIVERSITY OF JOHANNESBURG

Supervisor: Dr Jasper L. Coetzee

November 2014

111111111
301.1151235 UJLIC

200830213 MS Nkosi
 DECLARATION

I hereby declare that this dissertation is my own work and effort and that it has not
been submitted elsewhere for the awarding of any degree. Where other sources of
information have been used, they have been duly acknowledged.

Name: Mfundo S. Nkosi

Place: Johannesburg, South Africa
Date of Submission:
Signature:
 DEDICATED TO:

My parents Mr A.M. Nkosi (late) and Mrs B.C. Nkosi

My wife Busisiwe

My daughters OlweNkosi and Oluminjalo

My siblings, all my relatives, friends and church brethrens

ii
200830213 MS Nkosi
 ACKNOWLEDGEMENTS:

First and foremost, 1 would like to thank the Lord God Almighty for giving me the strength and
courage and keeping me focussed during trying times of my career.

Second, 1 would like to thank my parents for their support, love and motivation over the years. I
would like to thank them for revealing the value of education and for always demonstrating hard
work and dedication.

I also wish to thank the following people who made a valuable contribution in making this
dissertation possible:
• My supervisor, Dr Jasper Coetzee who has been very patient and understanding during the
entire period of the programme, and for giving me full support and hints for successfully
conducting a research study. This dates back from four modules with a total of twenty four
assignments and four projects, till this dissertation.
• My mentor and role model Mr Geoff Kaschula who motivated me to enter into this
programme, and who initially financed it by paying tuition fees, buying books, printing, and
transport to deliver the assignments and projects from Midrand to Vanderbijlpark.
• Mrs Jenifer Peters for assisting with grammar review in some of the chapters (specifically
Chapter 2 and 3) of the dissertation.
• Mr Dalisu Mkhize who played a major role in connecting me with participants from
different mines around Witbank.

Lastly, I would like to thank my wife for her unconditional support and understanding during this
crucial time of my career.

Ill
200830213 MS Nkosi
 ABSTRACT:

The coal mining industry plays a major role in the global economy. Coal is required for the
provision of primary energy needs, generation of electricity and production of steel. Hence, there is
a high demand of coal worldwide. For the continuous supply of coal, mining equipment should be
in good working conditions and the maintenance teams should be highly equipped and motivated to
perform their maintenance activities.

Strategic and technological innovations have been applied in the past years to improve equipment
and system design, but breakdowns still occur in coal mines. It is believed that maintenance errors
are one of the main reasons for these breakdowns. Human error is part of these maintenance errors
encountered in coal mines. Human error is a pressing problem, yet most of the coal mines have not
launched the innovative initiatives aimed at addressing the issue of human errors. Human errors can
negatively impact the coal preparation plants in a number of ways, such as an increase in
maintenance and production costs due to rework, and loss of production.

The aim of this dissertation is to present a study into the effect of human error on substandard
maintenance performance, and the formulation of a comprehensive solution based on the experience
of organisations that have successfully managed humari errors. It reviews the common human errors
in maintenance, possible causes of human errors and their impact in maintenance and organisation's
processes. Its main aim is to find the best suitable approach for dealing with human ei;rors in coal
preparation plants.

This dissertation systematically categorises, analyses and reviews human errors in maintenance. A
questionnaire for surveying the coal preparation plants is developed and distributed to the
participants in order to determine the following:
• The existence and effectiveness of human error management programs and/or initiatives.
• Common human errors in coal preparation plant maintenance.
• Reasons for the occurrence of human errors in maintenance.
• The impact of human errors in maintenance.
• The elements for better managing human errors in maintenance.

The results obtained during the survey are analysed and benchmarked against the previous human
error research results presented in the literature survey. The benefits reaped by successful
organisations in the management of human errors are also reviewed and presented in this study in
order to assist in the development of the Coal Mine Maintenance Performance Improvement
Framework (CMMPIF). It is believed that this framework is an effective and efficient tool for
managing human errors in maintenance of coal preparation plants. It can also be adopted by other
industries that are willing to reduce or manage human errors and they can tailor it to their specific
needs.

The completion of this study leaves the coal mines, particularly those in South Africa, with a tool
for maintenance improvement that is based on theoretical human errors research and proven to be
practicable in the industry. It is believed that the recommended performance improvement
framework will also assist in fostering a new way of thinking about maintenance errors (specifically
human errors) and associated causes, and a new strategy for approachjng corrective action.
It will be useful to researchers, maintenance professionals and other people interested in
maintenance in order to understand the impact of human error and the importance of proper
managing human error in maintenance.

IV
200830213 MS Nkosi
 TABLE OF CONTENTS

ACKNOWLE.DGEMENTS: ............................................................................................................ iii

ABSTRACT: ...................................................................................................................................... iv
TABLE OF CONTENTS................................................................................................................... v
LIST OF FIG-URES: ........................................................................................................................ vi.i
LIST OF TABLES: ......................................................................................................................... vi.ii
ABBREVIATIONS: .......................................................................................................................... ix
Chapter 1 - INTRODUCTION ......................................................................................................... 1
Chapter 2 - PROBLEM DEFINITION ............................................................................................ 4
2.1 PROBLEM DEFfNlTION ......................................................................................................... 4
2.2 RESEARCH OBJECTIVES AND STRATEGY ....................................................................... 5
2.3 ROAD MAP FOR THE DISSERTATION ............................................................................... 5
2.4 SUMMARY ......................................................... :..................................................................... 6
Chapter 3 - LITERATURE SURVEY ............................................................................................. 7
3.1 fNTRODUCTION TO HUMAN ERROR IN MAINTENANCE ........................................ 7
3.2 PREVIOUS STUDIES INTO HUMAN ERRORS IN MAINTENANCE ........................... 8
3.3 HUMAN ERRORS IN COAL PREPARATION PLANT MAINTENANCE ................... 12
3.4 EXISTING HUMAN ERROR PROGRAMS/MODELS IN MAINTENANCE ................ 16
3.4.1 Swiss-Cheese Model (SCM) ........................................................................................ 16
3.4.2 SHEL model ................................................................................................................. 18
3.4.3 Incident Based Approach to Maintenance and Workforce Questionnaire ................... 19
3.5 Coal Mine Maintenance Performance Improvement Framework (CMMPIF) .................... 21
3.6 ADDRESSING THE RESEARCH QUESTION ................................................................ 23
Chapter 4 - RESEARCH METHODOLOGY ............................................................................... 24
4.1 RESEARCH DESIGN ........................................................................................................ 24
4.2 SOURCE OF DATA AND DATA GATHERING ............................................................. 24
4.2.1 Source of Data .............................................................................................................. 24
4.2.2 The Data Collector ....................................................................................................... 25
4.3 DATA EXAMINATION .................................................................................................... 27
Chapter 5 - RESULTS .................................................................................................................... 28
5.1 RESEARCH FEEDBACK AND DISCUSSION OF RESULTS ....................................... 28
5.1.1 Human Error Programs in Maintenance ...................................................................... 28
5.1.2 Effectiveness of Programs or Tools for Managing Human Error ................................ 29
5.1.3 Common Human Errors in Maintenance of Coal Preparation Plants ........:................. 29
v
200830213 MS Nkosi
 5.1.4 Impact of Human Errors in Maintenance .3 1
5.1.5 Managing Human Error or Improving Current Initiatives...........................................31
5.1.6 Additional Comments from the Participants................................................................32
5.2 COMPARING RESULTS WITH PAST RESEARCH ......................................................33
5.3 BENEFITS REAPED BY SUCCESSFUL ORGANISATIONS........................................ 35
Chapter 6— CONCLUSION AND RECOMMENDATION........................................................40
6.1 CONCLUSION ...................................................................................................................40
6.2 RECOMMENDATION.......................................................................................................42
6.3 FUTURE RESEARCH........................................................................................................47
REFERENCES . ............................................................................................................................... 48
APPENDIXA ................................................................................................................................... 51
APPENDIXB ................................................................................................................................... 52

VI
200830213 MS Nkosj
 LIST OF FIGURES:

Figure 1.1: Why- Human Perfonnance Approach? (FCOG, 2007)

Figure 2.1: The role played by human performance in failures (Hawkins, 1993)

Figure 3.1: Causes/major Contributory Factors to Shutdowns

Figure 3.2: Aspects which are Directly Responsible for Mine Stoppages

Figure 3.3: Swiss-Cheese Model rearranged by researcher was adapted from Reason (1990)

Figure 3.4: SHEL model rearranged by researcher was adapted from Edwards (1972)

Figure 3.5: Asian Study Survey Comparison between 1999 and 2003

Figure 5.1: The Benefits Reported just after Twelve Months of Implementing the Maintenance

Resource Management Training Program at one of Major Airlines.

Figure 6.1: Coal Mine Maintenance Performance Improvement Framework (CMMPif)

Figure Bl: Coal Mine Layout (Nkosi, 2011)

Figure B2: Workshop Layout (Nkosi, 2011)

Figure 83: Sub-store Layout (Nkosi, 20 l l)

vii
200830213 MS Nkosi
 LIST OF TABLES:

Table 3.1: Causes/major contributory factors to accidents (Safety Regulation Group, 2002)

Table 3.2: Asian Study survey comparison between 1999 and 2003(Xavier A.J, 2005)

Table 4.1: Survey Participants

Table 4.2: The Questionnaire

Table 5.1: Survey on the Human Error Programs in maintenance

Table 5.2: Effectiveness of the program/s or tools for managing human error

Table 5.3: Most common human errors in maintenance

Table 5.4: Reasons for the occurrence of the most common human errors in maintenance

Table 5.5: Impact of Human Errors in Maintenance

Table 5.6: Better management of Human Errors in Maintenance

Table 6.1: Performance Improvement Framework/Guide Aimed at Reducing Human Errors

VIII
200830213 MS Nkosi
 ABBREVIATIONS:

CAA- Civil Aviation Authority

CMMPIF- Coal Mine Maintenance Perfonnance Improvement Framework

CRM - Crew Resource Management

EFCOG - Energy Facility Contractors Group

HEIM- Human Errors in Maintenance

HFl - Human Factors Integration

HFIM - Human Factors in Maintenance

HFRG - Human Factors in Reliability Group

HSE - Health and Safety Executive

HSI - Human System Integration

IATA - International Air Transport Association

IFSDs - Flight engine shutdowns

MAC - Military Airlift Command

MANPRINT - Manpower and Personnel integration

MEDA - Maintenance Error Decision Aid

MBNQA-The Malcom Baldridge National Quality Award

NOTECHS - Non Technical Skills

OPOM- Offshore Production Operations Management

PEF- The Performance Excellence Frameworks

ROM - Running of Mine

SCM - Swiss-Cheese Model

TSM- Tivoli Storage Manager

USAF- United States Air Force

IX
200830213 MS Nkosi
Chapter 1 - INTRO,DUCTION

It is apparent that there is a high demand ofcoal worldwide and therefore there should be powerful
systems in place enabling the coal mines to meet this demand. "Coal provides 30% ofglobal
primary energy needs and generates 42% ofthe world's electricity and is used in the production of
70% ofthe world's steel.. (World Coal Association, 2011). According to the statistics by the World
Coal Association (2012), South Africa is number seven out often top coal producers and number
five out often top steam coal producers worldwide. South Africa is ranked number six (74Mt) out
of seven top coal exporters (World Coal Association, 2012) and its coal is exported to countries in
Asia (e.g. China and India) and other parts ofthe world. The other portion ofSouth African coal is
supplied to ESKOM and a few private power stations for the generation and supply ofelectricity to
the people and industries ofSouth Africa and a few neighbouring countries. The South African
coal mines have to ensure that there is a continuous supply ofcoal. For the continuous supply of
coal, these coal mines have to ensure that they have effective maintenance strategies and motivated
maintenance teams to keep coal plants' machinery in good working condition.

The continuous supply ofcoal requires various systems, machines and components to be installed in
the coal mines. These systems/machines have over time experienced a number ofbreakdowns
which resulted in the damage ofplant, injury to humans, and loss ofproduction. It should be noted
that whenever a machine stops due to a breakdown it incurs a significant cost. Most of the machines
in coal mines have been upgraded to incorporate the latest technology in order to decrease
unexpected breakdowns. However, unexpected breakdowns still occur and it is partly due to human
error in maintenance which is the focal point ofthis dissertation.

Example: Think qf an event where a team conducted maintenance and inspections on the conveyor
system (consisting of a belt, crushers. vibrating screens etc.) in a coal mine. Four hours after they
have completed and signed off the maintenance activities, they are told that the vibrating screen has
failed. The investigation or root cause analysis reveals that the screen failed due to a spring that
had deteriorated bad!y but it was not identified during maintenance and inspections. This is indeed
an embarrassing situation, but it is common in coal mines and also in other industries.
The coal mines are faced with a great challenge to carefully examine and address the issue of
human errors in maintenance.

Human errors committed during maintenance contribute to breakdowns encountered in coal mines
considerably. The effects ofhuman mistakes significantly increase the risks associated with the
failure ofmachines and human injuries and/or fatalities. According to the thematic analysis, "most
ofthe reasons for mine stoppages or possible stoppages may be related to human management
functions (45%), and then followed by equipment and maintenance (29%)" (Pires & Vorster, 2011).
It is in these two aspects where a number ofhuman errors are prominent, so there is a need for the
reduction ofhuman errors in maintenance ofcoal preparation plants. The maintenance team that is
well-empowered, given the precise and/or accurate training and information, and working with
machines that are designed and constructed to be maintenance friendly, will be able to accomplish
the predefined maintenance work to a higher quality. Thus human errors can be reduced, leading to
a more reliable and safer plant.

Based on the previous studies in maintenance, it is becoming increasingly difficult to ignore human
error in maintenance. H1,1man error is rated amongst the top maintenance errors that contribute to
plant shutdowns. Practical experience reveals that South African coal mines and even those of
other countries internationally, have not done much concerning management and reduGtion of
human errors in maintenance.
Aviation is a leading industry in the study of human errors in maintenance. This is due to the
criticality of aircrafI breakdowns and their negative impact. It has been estimated that about 80
percent of all accidents are due to human error in some form (Whittingham, 2004). It is generally
accepted in many studies that approximately 80% of plant shutdowns are due to human errors in
maintenance. These statistics are shown in Figure 1 .1.

Figure 1.1: Why - Human Performance Approach? Adapted from EFCOG (2007)

Most of the research studies reveal that about 50% of all machines fail prematurely after
maintenance activities have been conducted on them (Dunn, c.2007:1). This is also an indication
that there is a serious need to conduct further studies into human error in maintenance with an
intention of finding and/or developing efficient solutions to human errors.

"Human error in maintenance is a subject which in the past has not been given the amount of
attention that it deserves" (Dhillon & Liu, 2006:2 1). The South African coal mines also did not give
human errors in maintenance the amount of attention it deserves, even though coal mining is viewed
as one of the high risk industries. "Human error has been in existence since the beginning of
mankind, and only in the last 50 years has it been the subject of scientific inquiry" (Dhillon & Liu,
2006:22).

The aviation industry has done a lot of studies related to human error in the past years and it is
continuing to refine its studies until best solutions are developed and implemented. The research
reveals that even after many studies have been conducted and human factor programs have been
implemented in the aviation industry, human errors still occur. This is an indication that tools for
management and control of human errors need to be constantly monitored and improved.
Studies conducted in aviation and military address the issue of human errors, their causes and
implemented human factor programs, but they do not present sufficient benefits obtained after the
implementation of possible solutions. These studies have not adequately reviewed and presented the
benefits of having structured systems to deal with human error in maintenance. Many studies focus
on implementing human factor training programs, targeting maintenance managers, engineers and
other maintenance personnel. There are few studies indicating human factor programs or guides that
have been tailored to suit particular industries and specific systems. Most of these studies review the
current existing programs with an aim of selecting the best suitable human error management
approach.

200830213 MS Nkosi
This dissertation is intended to review the literature of human error in maintenance and to identify
and analyse the major human errors encountered in coal mines. It also seeks to present and analyse
the benefits obtained by those organisations that have successfully implemented human factor
programs. Hence, these will be used in the formulation of a comprehensive solution for better
managing human errors in maintenance.

This research has adopted a questionnaire as a tool for data collection. This questionnaire was
distributed to the participants from different mines around South Africa, most of them around
Witbank. The author of this dissertation has chosen qualitative and quantitative research methods to
provide both descriptive and interpretive results. The qualitative method was mainly used
throughout the collection of data and information, and the quantitative method was partially used in
the evaluation of results.

The interest and idea of conducting a research on human errors was highlighted to author of this
dissertation after reading a number of articles addressing human error in maintenance, prepared in
the aviation and military industries. He then took a journey down the memory lane when he was
still working in a coal mine where he observed a number of human errors in which the
consequences were detrimental to plant equipment and had negative effects on production. The
author then decided to engage in a study of human errors in maintenance of coal preparation plants
with the intention of developing a comprehensive solution that will be useful to the South African
mining industry in minimising human errors in maintenance.

This dissertation is arranged in a form of six chapters, including this introductory chapter. Chapter 2
starts by outlining the problem, setting up research objectives and strategy, and finally presenting
the roadmap for the dissertation.

The final chapter connects the whole dissertation and revisits various elements from the literature
survey to the discussion of results in order to make conclusions and recommend a tool for managing
human errors in maintenance.

200830213 MS Nkos
Chapter 2 - PROBLEM DEFINITION
2.1 PROBLEM DEFINITION

There is a high demand of coal worldwide. "Coal provides 30.3% of global primary energy needs
and generates 42% of the world's electricity" (World Coal Association, 2012:1). The table
presented by the World Coal Association (2012) indicates that South Africa is in the top five
(250Mt) of steam coal producers worldwide. According to the South African Coal Roadmap (2011),
67.6Mt of South Africa's coal was exported in 2010. It can be deduced that the remainder (182.4
Mt) was supplied to Eskom, Sasol, as well as to the ferroalloys, iron and steel, industrial and
manufacturing sectors. Eskom uses coal to generate and supply 95% of the electricity needs to the
country's industry and population of about 50 million people. This poses a big challenge to the coal
mines supplying this large bulk of coal. These coal mines, mostly situated in Witbank area have to
ensure that they have effective maintenance strategies and maintenance teams to ensure good and
safe working conditions of machines for the continuous supply of coal.

A few of the coal mines situated in Witbank were used in this dissertation for the collection of data.
The main focus of the study concerns the coal preparation plants' substandard maintenance
performance. One of the coal producers, two of its 17 collieries are used in this dissertation
produces about 50Mt of coal per annum. It can be deduced from the amount of coal it produces that
it is amongst the biggest suppliers of coal in the RSA. Its coal preparation plants consist of systems
which include but are not limited to conveyor systems (belts, gearboxes, motors, pulleys. bearings
etc.), screens, crushers, cyclones, spirals, classifier, magnetic separators, piping, pumps; motors,
bearings, and tanks. The layouts of the coal preparation plant, workshop and sub-store where
maintenance activities and support are conducted are attached as Appendix B.

The systems/machines in this plant have over time experienced a number of breakdowns ranging
from minor to major ones. Since these systems/machines are not equipped with standby units. any
machine stoppage due to a breakdown incurs a significant cost. This cost usually consists of the cost
of maintenance, production and other related operations, e.g. logistics. This has a major impact on
the continuous supply of coal. And the only way to reduce these catastrophic failures is that proper
maintenance should be conducted at the right frequency and under acceptable conditions by a well
trained and observant maintenance team.

Over the years, coal mine equipment design has improved by using the latest technology but
unexpected failures or shutdowns still occur. These shutdowns are mostly due to maintenance error.
Human error in maintenance plays a major role in the breakdowns encountered in coal preparation
plants. The effects of human mistakes significantly increase the risks associated with machinery
failure and personnel accidents (injuries and/or fatalities).

Figure 2.1: The role played by human

performance in failures by Hawkins
( 1993) rearranged by M Nkosi

200830213 MS Nkos1
Figure 2.1 indicates the relationship between failures due to human error and failures due to
machine failure. The figure shows that the improvement in machine design has over time led to a
reduction in percentage contribution of technical causes of failure, but has accentuated the human
factor as a contributory to failure in aviation. Although a coal preparation plant differs considerably
from an airplane, it also resembles the illustration in the figure somewhat.

A well motivated maintenance team, given the correct training and information, and working with
machinery which has been designed and constructed to be maintenance friendly, will most likely
accomplish the specified maintenance work at a higher level of quality. Thus human errors can be
reduced, leading to a more reliable and safer plant.

At present, most South African mines have no formal programs in place that were designed and
implemented to identify human errors and educate maintenance personnel regarding their potential
capabilities. Also they were not taught in the techniques and principles of correcting the issues and
creating an environment where a number of human errors are greatly reduced.

There is a necessity for a more integrated and comprehensive approach to human error management
in coal preparation plants. This approach will assist in an effort to reduce human error in coal
preparation plants.

2.2 RESEARCH OBJECTIVES AND STRATEGY

It is the objective of this dissertation to introduce to the reader some of the concepts of human error,
human error management, and to address the effect of human error on substandard maintenance
performance. It will then use these concepts to formulate a comprehensive solution to reduce human
error and hence improve maintenance performance in coal preparation plants.

The main objectives of this dissertation are:

To study and discuss human error concepts from various literature references.
• To identify and analyse common human errors presented in different articles and books from the
maintenance field. Also to identify major human errors encountered in coal preparation plant
maintenance.
To provide a brief background of the main human error management programs in maintenance,
and their historic development over the years.
• To collect data, discuss the results and benchmark them against previous research.
• To review and present benefits reaped by organisations that have successfully implemented and
executed human error management programs.
• To recommend a solution to human error in coal preparation plant maintenance.

2.3 ROAD MAP FOR THE DISSERTATION

The study undertaken in this dissertation is based on the development of an effective and practical
solution to managing the impact of human error on substandard maintenance performance.
Different literature references are used to gain knowledge of the current human error trend and its

200830213 MS Nkosi
effect on maintenance performance as well as the different approaches to human error management
that are available.

The following road map indicates how the chapters in this dissertation are arranged:
Chapter 1 - Introduction - provides an introduction to the information contained in the
dissertation, and the background of the problem. It also includes background of the research into
human error in maintenance.

Chapter 2 - Problem Definition - provides problem definition/statement and research objectives.

It also indicates the road map for the dissertation and summary.

Chapter 3 - Literature Survey - provides an overview of human error concepts; major human
errors in coal preparation plants and the existing human error approaches or management programs
in maintenance. It discusses the key elements to be used in the formulation of a comprehensive
solution to human problems in maintenance. It also addresses the research question.

Chapter 4 - Research Methodology - describes research design and model. It also discusses the
source of data, data gathering and data gathering tool.

Chapter 5 - Results - presents and discusses results obtained during the survey. It also compares
results of the survey with those obtained by other organizations that have done research in the field
in question. It also reviews and presents benefits reaped by those organisations that have
successfully implemented and executed human error programs.

Chapter 6 - Conclusion and Recommendation - contains the concluding statement/s of the

research and it also presents a recommendation for improving maintenance.

2.4 SUMMARY

It should be clear, based on the research objectives set above that the ground covered by this
research work (to address the issue of human error impact in coal preparation plant substandard
maintenance performance) is fairly extensive. This chapter serves as guide to the research
undertaken.

200830213 MS Nkosi
Chapter 3 - LITERATURE SURVEY

.
3.1 INTRODUCTION TO HUMAN ERROR IN MAINTENANCE

·'Human error in maintenance is a subject which in the past has not been given the amount of
attention that it deserves:· (Dhillon & Liu, 2006:21 ). From practical experience, it is clear that
South African coal mines have also not done much concerning human e1rnr management.

This dissertation is intended to give the results of a study into the effect of human error in producing
substandard maintenance performance. This investigation is to be conducted for a number of coal
mines that have surface operations (open cast and coal preparation plant). The coal mines which
will be used for this purpose are all located in Witbank, South Africa, an area with a huge coal
reserve. The area in which these mines operate is called ·'eMalahleni"' which simply means ··place
of coar·. The coal industry plays a major role in the South African economy. it is thus crucial that
the issues related to human error, which has a major impact on maintenance and production
performance, should be addressed.

Due to the fallibility of human beings, nothing man-made will live forever. However performing
maintenance activities at particular int�rvals can extend life. A maintenance team plays a major role
in the reliability of equipment and mechanical components. There are a number of maintenance
errors that affect the reliability of equipment and amongst those errors is human error. According to
Drury (2000:15-1) errors are ··active failures that lead directly to the incident, and latent failures
whose presence provoke the active failure." Human error is one of the main categories of errors or
mistakes encountered in the organisation. A major po11ion of these human errors occurs during
equipment maintenance.

Dhillon & Liu (2006) define human error as the failure to carry out particular tasks or to perform a
prohibited action that could lead to a disturbance of the planned operations or result in damage to
the facility and machinery. According to Dhillon & Liu (2006) human error has been in existence
since the origination of mankind, but it only started 50 years ago to be a subject of scientific
enquiry.

There are a variety of external factors contributing to the occurrence of human errors in
maintenance, including but are not limited to the following: the low level of skills including both
knowledge and experience, inadequate training, attitudes, poor communication, imperfectly
documented maintenance and operating procedures. poorly designed equipment, improper tools,
poor workstation layout, inadequate light in the work area and elevated noise levels.

In most industries, including coal mining, human error may occur during the following equipment
life cycle stages:
• Design;
• Assembly;
• Packaging;
• Transportation;
• Operation;
• Inspection;
• Installation; and
• Maintenance (overhauling, repairing, lubricating, etc.).

7
200830213 MS Nknsi
Dhillon & Liu (2006:22) state that maintenance error occurs due to incorrect repair or preventive
actions."
Incorrect repair or wrong preventive actions can be classified as human errors in maintenance and
they forin part of the categories mentioned above. Some examples of incorrect maintenance actions
include the use of old bolts or screws with damaged or worn threads, the application of the wrong
grade of oil/lubricant for lubrication, and the use of non-matching parts/components.

Human error can impact maintenance performance and safety of personnel, equipment, and the
surrounding environment in a number of ways. Substandard repairs, for example, can raise the
number of breakdowns. Furthermore, it can give rise to the risks related to equipment failure, plant
damage and accidents or injuries to people.

Numerous research studies have shown that over 50% of all equipment fail prematurely after
maintenance work has been performed on if' (Dunn. c.2007: I). The most disappointing cases are
when the maintenance tasks were performed with an intention to prevent the same failure from
recurring. The author of this dissertation has himself experienced such situations in the coal
preparation plant, for example, a vibratory motor which failed three days after maintenance due to
breakdown. The cause of the breakdown was the incorrect installation of balance masses in both
cases (the initial breakdown and again shortly after the repair).

Many organizations have experienced the negative impact of human errors in one way or another,
but few have taken an initiative to address the issue of human errors. The members of the Human
Factors in Reliability Group (HFRG) realised the impact of human errors related to maintenance on
the safety of equipment and personnel. Accordingly, they had limited some guidelines and ideas
available for the maintenance team to determine the issues which could diminish the quality, safety
and reliability of maintenance. By identifying these issues, they could establish practical solutions
to reduce human error. A subdivision of the HFRG members with knowledge, skills and experience
in the area of human errors was established to construct a guide to reducing human error in
maintenance. The intention of the guide was to provide maintenance managers with some of the
practical propositions to be used to improve the management of human errors in their maintenance
operations. The guide was firstly published by the Health and Safety Executive (HSE) in 2000, and
it was titled Improving Maintenance a Guide to Reducing Human Error". This guide has more
value to Aviation Industry as compared to other industries. Some of the elements of this guide will
nevertheless be reviewed and used in this dissertation to develop a solution for the coal preparation
plants.

Later in this chapter, human error approaches/programs will be studied with the aim of identifying
the key elements that can be used to develop a solution towards reducing the negative impact of
human error on maintenance.

3.2 PREVIOUS STUDIES INTO HUMAN ERRORS IN MAINTENANCE

This section presents the study of human error in maintenance based on studies conducted in
different organisations. Major study/research into human error in maintenance has been conducted
in the aviation industry. A thorough study into human error in Aviation/Aircraft maintenance is due
to the criticality of this sector. Accidents encountered in this sector due to human error during
maintenance and inspection phase usually led to a massive loss of human lives and property.
The task performed during maintenance and inspection is complex and the teams perform a variety
of tasks under time pressure and difficult environmental conditions.

8
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There are a large number of papers describing findings or results of the research conducted in
aircraft maintenance with a focus on human errors. This dissertation will look into some of the
human error approaches/programs which have been successfully developed and implemented in
different organizations so as to develop a complete solution to human error in a coal preparation
plant.

In 1940, it was calculated that approximately 70% of all aircraft accidents were attributable to
man's performance, that is to say human error (Safety Regulation Group, 2002:4). The Safety
Regulation Group (2002) indicates that this situation was reviewed by the International Air
Transport Association (IATA) 35 years later, but the statistics still revealed that there had been no
reduction in human error as a cause of accidents. The Safety Regulation Group compiled the CAP
715 document which presents elements such as the history of human error concepts, human error
approaches or models, and some of the accidents encountered in aviation.

The Safety Regulation Group (2002) under the Civil Aviation Authority indicated that Sears in the
USA conducted a study in 1986. That study looked at the major contributory factors in 93 aircraft
accidents. The causes or major contributory factors found during the study are indicated in Table
3.1 below.

Table 3.1: Causes/major contributory factors to accidents

No. Major causes of accidents: Contribution:

Divergence from fundamental operational procedures, 33%
Insufficient verification by the other crew member, 26%
Design defects resulting from an error during the component design, 13%
Inadequate maintenance and inspection, 12%
Lack of proper guidance, 10%
The captain/supervisor did not consider the input of the crew, 10%
The crew improperly, responds during unusual circumstances, 9%
Errors or failures arising in air traffic control, 9%
Provision of inadequate or wrong weather information, 8%
Running out of control hazards, and 7%
Improper decision making during landing 6%
Poor communication (air traffic control or crew) 6%

Table 3.1 indicates maintenance and inspection insufficiency as one of the major causes of
accidents and/or incidents.

The UK Civil Aviation Authority, in 1998, conducted a similar study to that of Sears which was
conducted in the USA. The study by the UK ACC was focused on identifying the factors that
caused 621 fatal accidents globally, between 1980 and 1996. In that study, inadequate maintenance
(with error and oversight) was featured as one of the top ten primary root causes of failures. These
studies clearly indicated that human error in aircraft maintenance is a serious issue, necessitating
careful consideration.

It was indicated by the Safety Regulation Group (2002) that several high profile incidents and
accidents experienced in various organisations and industries were due to human errors in
maintenance. Two examples of these incidents and accidents are presented below:

200530213 MS Nkosi
Example I (Adapted from Safety Regulation Group, 2002):

There was an accident which involved the Aloha flight 243 in April 1988. It was indicated that due
to strucura1 failure, the '18 feet" of the upper cabin structure was unexpectedly ripped away while
in flight. The Boeing 737 had been examined before it was involved in this accident. The
examination of the airliner was performed by two engineering inspectors as per US regulations. The
inspectors who examined the airliner had extensive experience. The inspector and the Chief
inspector had 22 and 33 years experience respectively. Neither the inspector nor the Chief inspector
identified any cracks in their inspection. The analysis that was done after the accident, established
that, at the time of inspection there were over 240 cracks in the skin of the aircraft. The ensuing
examination revealed plenty of human factor related issues which led to the failed inspections.
Based on the Aloha Accident, the US initiated a program of studies focusing on the issues related to
human factors and aircraft maintenance. The program had a particular focus on inspection.

Example 2 (A dapted from Safety Regulation Group, 2002):

In February 1995, a Boeing 737-400 in the UK lost the oil pressure on both of its engines. The
airplane was redirected to land at Luton Airport and it safely landed. The investigation conducted
revealed that, during the previous night, the boroscopic inspection had been conducted on both
engines of the airplane. The high pressure (HP) rotor drive covers had not been replaced after the
boroscopic inspection, therefore, both engines lost almost all the oil during flight. It was uncovered
that the line engineer who was initially supposed to do the inspection, decided to exchange the task
with the base maintenance controller. The maintenance controller and the fitter did the inspection,
but there were some interruptions. As indicated earlier, they failed to replace the rotor drive covers.
They did not even carry out ground idle engine runs which would have revealed the oil leaks. They
signed off the job as complete.

In most of the high profile incidents and accidents from different industries including the two
indicated above, engineers or maintenance personnel participated were regarded by their
organisations to be appropriately qualified, competent, skilful, knowledgeable and reliable
employees.

The incidents mentioned above, including the two which are given as examples were triggered by
the following:
• Improper preplanning of resources
• The shortage of the workforce;
• The existence of time pressures;
• Working at night;
• Handing over of the tasks to another shift;
• Overconfidence
• The interruptions while performing tasks;
• The failure to use correct procedures;
• Unclear manuals, etc.

Time pressure was reported on numerous occasions as a key factor to most incidents and accidents.
The risk usually attached to time pressure is the temptation to take shortcuts to get a component,
system, or facility back into service. The maintenance teams should be motivated to do their best
within the allocated time and they should not be rushed to complete the tasks. In most cases, the
cost of rushing is higher than the cost of taking more time to correctly complete the task.

10
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There were investigations on substandard that were recently conducted and the results of three of
them are highlighted below.

Dunn (c.2007) states that the Institute of Nuclear Power Operations located in the USA conducted
two of these investigations and the Central Research Institute for the Electrical Power Industry
situated in Japan the other one. The results of these investigations revealed that over half of
pinpointed performance matters were related to maintenance, testing and calibration activities. It is
therefore very crucial for the organisation to ensure that the maintenance, testing and calibration
activities are properly conducted, managed and controlled. Dunn (c.2007) also indicated that an
average of 16% of the problems emerged while these power plants were running under normal
conditions. It is very disappointing and devastating to experience plant failure at an unexpected time
period, especially when it occurs shortly after maintenance activities have been conducted.
To present some of the common human errors that can occur during maintenance, figure, 3.1 which
was developed using the results of the survey, which was performed by Dunn (c.2007) is inserted
below. Dunn (c.2007) states that the investigation from which the results were taken was conducted
for Boeing aircraft and these results presented the top seven major reasons for in-flight engine
shutdowns.

Equipment not
act:vatcci or
dcact:vatcd Due to other factors
4° 14%

rnproper isnpection.
tiult idcfltiticatOn.
and tetin '
6°

Ingress ofiregn o1jeci

causing Mw* ID
conVown
6.5%

14.5%
properly installed
components or
equment
11%
or
[iigure 3.1: Causes malor contributory factors to shutdowns

It can be seen from figure 3.1 above that only one of the causes was not related to maintenance
activities, and that 80% of the flight engine shutdown causes were related to maintenance activities.
The causes/major contributory factors to flight engine shutdowns presented in figure 3.1. although
not exactly the same to those causing machinery breakdowns in coal mines.

11
200830213 MS Nkosi -
Studies and examples indicated above revealed that substandard maintenance is responsible for
various incidents and accidents in the industries that are highly regulated and very hazardous such
as Nuclear Power Plants and Aviation.

The study of the history of human errors reveals that instead of trying to change human nature,
conditions under which people work should be improved and errors and their consequences should
be anticipated. Programs which were successfully used in different organisations to deal with
human error in maintenance will be introduced later in this chapter.

3.3 HUMAN ERRORS IN COAL PREPARATION PLANT MAINTENANCE

There are a number of failures due to maintenance errors that have been encountered in coal mines
over the years. Some of these failures led to major damage to mining machinery and personnel and
few of them led to fatalities. In a discussion with one of the managers of the manufacturer of
conveyor systems situated in Midrand, it was indicated that human errors play a major role in
breakdowns of the conveyor systems. This manufacturer is also involved in the maintenance of the
conveyor systems for coal mine industry and other mines. It was indicated during the discussion
that if the maintenance of mining machinery is conducted as per manuals, using well-trained
artisans or maintenance personnel, within properly maintained environment/work area etc., mining
equipment is likely to run for an expected time without failure. For example, a properly lubricated
bearing is likely to run for a long period without experiencing breakdowns. They also highlighted
that due to the harshness of the coal mine operations, it is necessary to ensure that all critical
components are attended to at specified intervals. The manager then emphasized that most of
equipment breakdowns are due to human error in maintenance, which might be triggered by short
cuts; lack of proper training, skills and knowledge etc.
Pires & Voster (2011) of JVR Consulting Psychologists indicates that there are costs incurred every
year in the coal sector due to shutdowns, incidents, accidents or unsafe environmental state. They
indicated that one of the coal mines in South Africa lost 95 full production shifts and 73 partial
production shifts with regard to safety related stoppages encountered in 2009 alone. The report by
Pires & Voster also indicated that these work stoppages may be caused by human error, acts of
nature, equipment failure, or poor management. The stoppages due to breakdowns are usually an
indication of substandard maintenance. This is because maintenance is categorized as an element of
bringing equipment to healthy life to avoid breakdowns that might lead to loss of lives of people
and equipment.

It is important, therefore, to investigate the possible reasons for human error during maintenance
and operation in mines.

The report by Pires & Voster (2011) also indicated that, for the research completed at a leading
mine in South Africa the aspects presented in Figure 3.2, are the ones most directly responsible for
mine stoppages.

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200M302 13 MS Nkosj
 45%
45
40
35 29%
30

50
15
10

Human
management Euipmentand -
activities maintenance Environmental
State Accidents

E Aspects directly responsible for mine stoppages

Figure 3.2: Aspects which are directly responsible for mine stoppages

Pires & Voster (2011) furthermore briefly describe human management activities, equipment and
maintenance, environmental sate and accidents as follows:
• "Human Management Activities: These are related operational, supervisory, training,
development, knowledge, quality control, and adherence aspects followed by the organization
on a management/operations/humanlworkforce level."
• "Equipment and Maintenance: This is any aspect related to the upkeep, issuing, condition,
availability, shortage, checking, and use of equipment. This equipment may include mobile or
heavy machinery, struts, jacks etc."
• "Environmental State: Any, and all, environmental variables which impact on production and
safety. This includes mud, illumination, ventilation, temperature, safety, dust, chemicals, and so
forth. Human hygiene issues such as a clean and pleasant environment also form part of this
theme"
• "Accidents: These are any accidents which occur within the mine and are related to human
judgment and decision making; accidents which are unrelated to people and their influence (acts
of God): and finally those calamities which may occur due to human management functions."

It can be noted from Figure 3.1 that most of the reasons for possible mine stoppages may be related
to human management functions (45%), and then followed by equipment and maintenance. It is in
these two aspects where a number of human errors are prominent. It can also be noted from these
findings that human error is the main factor which contributed to mine stoppages. The coal mines
should therefore focus on human errors and causes and effects of human error in order to deal with
mine stoppages. The coal mines can greatly benefit from paying attention to human error and not
only to equipment and environmental conditions.

Certain coal mines have recommended the use of various policies, procedures, control measures to
respond to maintenance and safety issues, but these measures are still unable to ensure a high
quality of maintenance and safety of plants. The coal mines have a challenge of ensuring that these
policies and procedures are adhered to, since one might have very good policies and procedures, but
if they are not properly followed, their existence become meaningless. The workers that are fully
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200830213 MS Nkosi -
aware of the causes and negative impact of human errors in the organization are less likely to
embrace behaviors and to ignore situations that might lead to error and to also take the easy way out
that can lead to equipment failure.

Common Human Errors in Coal Preparation Plants

The following are the common human errors in coal preparation plant maintenance:
• Maintenance tasks note done during planned maintenance shutdowns
V Some plant equipment or components are left out during planned maintenance due to time
pressure, improper pre-planning and also improper identification of faults.
V Bearings are normally the victims of this type of human error since there are a large number
of them in conveyor systems, pumps etc.
Proper preplanning and the maintenance team being given enough time to perform maintenance
tasks can certainly be part of the solution for this type of human error.

• Imp roper Installation

V Misalignment of pulley shafts for the conveyor system,
V Improper tensioning of belts,
V Incorrect size of the gap set between the toothed rolls of the crusher,
V Incorrect direction of pump propellers etc.
V Improper tightening and torque of bolts.
Clear checklists instead of manuals might be the best solution to this issue.
• Improper lubrication of bearings
V Under/over greasing of bearings for conveyor drives, pump drives etc.,
V Usage of incorrect grade of lubricant,
V Skipping lubrication intervals, etc.
The importance of lubrication and the negative impact of improper lubrication should be regularly
discussed with the maintenance teams, in order to deal with this human error type.

• Foreign object damage

V Ingress of coal dust particles due to lack of cleanliness,
V Ingress of water due to lack of inspections to detect water leaks or pathways that might lead
to continuous drops of water into the bearings.
To deal with this type of human error, cleanliness of the plant equipment should be emphasised to
the maintenance team, who should not only to rely on cleaners. The maintenance team should be
extra careful when performing maintenance tasks on bearings, gearboxes, etc. in order to avoid the
ingress of foreign particles.

• Utilization of deteriorated parts

V Usage of deteriorated screws and bolts etc.
V Usage of deteriorated equipment or machinery parts (e.g. volutes and casings for pumps, v-
belts, springs for vibrating screens etc.). This is sometimes due to shortcuts and also due to
improper control of inventory.
Proper control of inventory and developing a proper logistics strategy can be helpful in dealing with
this type of human error.

• Equipment parts damaged during maintenance

V Damage due to improper alignment and when the part is forced with a hammer (e.g. pins,
couplings etc.).

14
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 VImproper alignment of the mating flanges. Tightening bolts of the misaligned mating
flanges can lead to damage of threads and it can also induce stress to connected components
(e.g. pump casing and suction/discharge pipe).
V Improper handling of equipment or components
Proper training, fostering ownership and supplying the workforce with the proper tools can be of
great help in dealing with this issue.

• Improper inspection and identification of fault

V Improper inspections due to parts that are not easily accessible. The accessibility of parts
should have been considered in the design of the plant section or equipment.
V Lack of proper training regarding the identification of faults.
Training and awareness can be of great help in reducing this human error.

• Injury to personnel
V Due to lack of proper ergonomics planning (e.g. wrong way of carrying heavy parts, wrong
way of positioning when conducting certain maintenance tasks etc.)
V Fall of coal pieces due to plant sections that are not cleaned before maintenance work
commences.
V Usage of wrong tools for the job and usage of unsafe tools
Preplanning and safety culture enforcement are the key elements for dealing with this issue.

To avoid most of the human errors, maintenance managers should give the maintenance team
proper time to accomplish the maintenance tasks.

There are many types of human errors in coal preparation plants that one can look at. The intention
of presenting the above mentioned errors was to discuss the common human errors which are the
basis of the proposition to come up with a comprehensive solution to human error in maintenance.
The main framework of solutions will be presented in Chapter 6 as a recommendation to deal with
human errors in coal preparation plants.

The author of this dissertation collected examples of incidents from coal mine maintenance in order
to represent the negative impact of human error. The following examples were taken from the
mines/collieries which will be later surveyed in this dissertation.
• On Wednesday 01 August 2008 there was a planned maintenance shutdown in mine A.
Amongst the maintenance activities to be done to the conveyor system was the greasing of the
bearings. The maintenance activities were completed and the plant was brought back into
operation. On Friday 3 August 2008, just a day after maintenance, a bearing of the conveyor
pulley failed. The investigation revealed that the bearing had insufficient grease, which means
that the particular bearing was not greased during the planned maintenance shutdown.
• In mine A, On Friday 30 May 2007, there was a vibrating screen motor failure, and the plant
was shutdown so as to attend to the breakdown. The vibro-motor of the screen was attended and
repaired and the plant was brought back into operation. Four days after repair the vibro-motor
failed again. The investigation revealed that the balance masses of the vibro-motor were
improperly installed. It took four hours to repair on the first breakdown and three hours for the
second breakdown. Rework led to a production loss of approximately 403.2 tons. This is 12.5 %
of the day's production for this colliery which has a total production of 1.1 Mt per year.
• In another case in Mine B, there was an unplanned shutdown due to the leak on the casing of the
main pump in the wash plant. This happened one week after repairs were done to the pump. A
crack was discovered on the casing which was due to vibration. The vibration was caused by the
loose and deteriorated bolts of the base of the pump.

15
200830213 MS Nkosi
All of the above situations led to loss of production and rework which affects maintenance and
production costs.

Human errors observed in the above examples are: a) Missed greasing a component during
maintenance b) Improper installation c) Use of deteriorated parts

This dissertation aims to develop a solution to many of the unpleasant situations which are
encountered in coal mines, especially coal preparation plants. These unpleasant situations are
normally an indication of substandard maintenance due to maintenance errors in which human error
is a leading factor.

3.4 EXISTING HUMAN ERROR PROGRAMS/MODELS IN MAINTENANCE

3.4.1 Swiss-Cheese Model (SCM)

One of the models for addressing human error is the Swiss-Cheese Model. It was established by
Professor James Reason in 1987-1990 during the writing of Human Error (Eurocontrol, 2006:4).
Safety Regulation Group (2002) states that Reason conducted research in which he emphasized the
idea of protection against human error in the organisation. He has also has invented the concept of
defences in depth. The defences (protection) against human error play a major role in the system's
approach. Twofold inspections, simplified maintenance checklists, pre-start operational test etc., are
examples of the defences against human error. These defences help to prevent human errors from
occurring and also help in reducing the risk of the negative impact.

Advanced technology systems incorporate various protective devices. Some of the protective
devices are designed and built using scientific theory (e.g. alarms and automated sensors), while
others rely on human (e.g. control room operators and samplers). There are also devices that rely on
procedural controls (e.g. manuals and checklists). The main aim of incorporating protective devices
or defences in a system is to protect the components or parts of that system from local hazards. The
defences are very effective in protecting the system from local hazards, but they also possess some
limitations or weaknesses.
Reason's model indicates that a combination of latent failures and active failures leads to system
breakdowns and consequently accidents result from these breakdowns. The unsafe acts that can be
directly connected to an incident/accident are classified as active failures. Errors or violations and
desired or undesired actions are classified as the unsafe acts of operators, supervisors, artisans, etc.,
directly involved in a system and are mostly associated with incidents/accidents. Unintentional
errors are categorised as slips and lapses. The intended errors which are categorised as faults or
mistakes occur when a person fails to do as required or do as required, but apply an incorrect
approach to the situation. The deliberate actions against or wilful disregard to the predetermined
rules and regulations are referred to as violations.

Latent failures are normally referred to as malfunctions of a system that are usually hidden until a
terrible incident or accident occurs. Latent failures can be classified as follows: those that create
error provoking conditions and those that create weaknesses in system defences" (Patterson,
2009:24). Reason's Swiss Cheese Model (SCM) of human error creates a strong link between the
active failures and latent conditions.

lime
200830213 MS Nkosi
 Reasons SCM is based on the assumption that there are fundamental components within an
organization that must work together properly in order to achieve a safe and efficient system
(Patterson, 2009:24). In other words, there are certain elements in an organization that cannot work
in isolation, but they require interconnection to one another in order to achieve an effective system.
Earlier during the development ofthe model. Reason described a normal system as five planes
placed in a sequence ofone after another. As it can be seen from Figure 3.1, five planes of the
system are: top management, line management. preconditions The Dirty Dozen', productive
activities, and defences. There are certain identifiable failures that are experienced at each stage or
plane. The notion ofthe Swiss cheese in the model is based on the holes' which develop in
different stages/planes ofthe system. The holes in the Swiss-Cheese Model are categorised as the
latent and active failures.

Defences -
Inadequate safety nets
ç r

Productive Activities -
:safe acts

L:nacd w:ndo%v
.4IiE: oppertuntv
Preconditions "The Dirty Docn' -
psychological & environmental
conditions of unsafe acts

line \lanagerncnt- Deticiencies

©
Ianagement Fallible

T
itIst &t atnt
I bilures

.ictive Failures

© C Latent tailures
latent Failures
Latent Failures

Figure 3.3: Swiss-Cheese Model rearranged by MS Nkosi - adapted from Reason (1990)

Figure 3.3 indicates that latent failures occur in the first three planes of the system (management,
line management and preconditions), while active failures occur in the last two planes (productive
activities and defences). Incidents and accidents are classified as the consequences of the latent
failures and active failures encountered in the organisation and also people who disrupt the defences
of the system to cause a loss.

One of the examples of people who disrupt the defences is that of the operators or maintenance
personnel in a coal mine who tamper with the safety feature which enables the alarm to sound and
the conveyor to automatically shutdown during overloading. They do this so that the conveyor
cannot shutdown during overloading and thereby achieve and exceed production targets which in

17
200830213 MS Nkosi
turn lead to increase in production bonus. They take a risk of damage that has a negative
consequential effect when the conveyor fails due to overloading.

The Swiss Cheese Model prescribes that before an active failure (unsafe act) occurs, there are
various !atent failures in the system. If the defence mechanism fails or if it is absent in a system, an
incident or accident should be expected. Reason's Swiss-Cheese model modified by Gordon
Dupont incorporates (Dirty Dozen) human error factors as the preconditions to unsafe acts which
could eventually cause an accident/incident" (Xavier. 2005:14). Xavier (2005) states that Gordon
regards about 70% of causes of incidents and accidents to be attributable to imperfect decisions by
top and line management and preconditions which are classified as the Dirty Dozen (human error).

The Swiss-Cheese Model can be effectively used in an organisation in order to understand and deal
with human errors in maintenance since it clearly describes the interlink between management, line
management. Dirty Dozen", activities and defences in a system. This model is also useful due to
the fact that it clearly describe an interconnection between the latent and active failures.

3.4.2 SHEL model

The SHEL model was originally developed by Edwards in 1972 (Rothblum et al., 2002) to include
human factors into system design. In this model the primary focus is based on the man—machine
interface when looking from a systems approach. By adopting the SHEL model, the organization
can develop an understanding of the human error concept. This model can be efficiently used as a
performance framework for improving maintenance performance and hence reduce human errors in
maintenance.

The SHEL model arranges failures into four categories: software, hardware, environment and
liveware. The name of the model was derived from these categories.
• Software - refers to the maintenance procedures, manuals, checklists, regulations, standards,
etc.;
• Hardware - this category includes tools, test devices, coal mining machines, the design of
mechanical components, the location of controls and operational condition of instruments, etc.
used within the system;
• Environment - included in this category are physical environment such as conditions of
basements in which coal mining machinery is fixed. In this section one can also look at the work
design, the formation of the management structure, environmental legislative framework, etc.;
• Liveware - refers to an individual or individuals as the primary focus of the model. The
individuals at the centre of the model include the maintenance engineer, foremen/supervisors,
maintenance planners, artisans, maintenance managers, etc. involved with the system.

The human error study focuses on the interaction between the liveware (human) and the other
components of the SHEL model, and where these elements can be deficient. The system's safety
can be affected by the deficiency of the elements of the SHEL model. It is believed that failures
occur in the system when any one of the components or the connections between the components
fails. See Figure 5: SHEL model.

Maintenance activities are still conducted by people, despite the well advanced latest technology on
some of the equipment installed in coal preparation plants. Some of these latest technologies
include computerised features that are automated, but there is still an involvement of human during
maintenance. It is a known fact that human beings have limitations and weaknesses. The Liveware
is the cornerstone of the SHEL model, so the other components (Software, Hardware and
18
200830213 MS Nkosi
Environment) should be modelled to aid the Liveware's performance and Liveware's limitations
should be recognised. If the performance and limitations of the Liveware are overlooked, human
beings (e.g. the maintenance engineer and the artisan) will not be able to perform their duties to the
best of their abilities. Therefore, they may err, and compromise safety. This is one of the
fundamental problems that lead to plant failure and unavailability. The maintenance management
and teams should work together towards a goal of reducing human error and unsafe practices in the
coal preparation plants. In order to achieve the best maintenance results and high safety standards
requires a lot of dedication and focus across the organisation. Figure 3.4 presents the SHEL model.

ENVIRONMENT:
• Uii.onifortablc uotkplace.
• Inadequate
• lExtreme teinperanire'..
• Excessive noise.
• Pooi liehtiiut. etc.

HARDWARE: SOFTWARE:
• Misinteipretation of procedures.
• Not enough tools.
• Badly 'a ii1ten iiiaiitials.
• hiappiopiiate cquipulellt.
• Pooi eqiupluelit desiii for • Poorly designed checklists.
• Untested or difficult to use
maintainability. etc.
computei softwai e. etc

I IVE WARE:
• Relationships with other people.
• Shortage of manpower.
• Lack of supervision.
• Lack of support from mana qers. etc.

Figure 3.4: SHEL model rearranged by MS Nkosi was adapted from Edwards (1972)

Through modern design and manufacturing, coal preparation plant equipment has become more
reliable. However, the human being cannot be redesigned, so it has to be accepted "that the human
being is intrinsically unreliable Safety" (Safety Regulation Group, 2002). For human beings to be
reliable, proper training, clear procedures, safe and correct tools, well-structured inspection
checklists, effective supervision, etc., are required. The possibility for error can also be reduced by
enhancing the design of the coal preparation plant equipment. For example, the equipment should
not restart when some of its parts are incorrectly connected.

This paper intends to study the impact of human error in substandard maintenance, so the Liveware,
Software and Hardware are the main focus of research. These are the core elements in maintenance
performance.

3.4.3 Incident Based Approach to Maintenance and Workforce Questionnaire

Incident based approach and workforce questionnaire forms part of the assessment method for
identifying the key issues (e.g., human error) adversely affecting maintenance in the organisation.

Drury (2000: 1 5-2) states that 'where humans are part of the system, errors cannot be separated from
the other two aspects of humans at work: performance speed and human well-being." Drury's
statement indicates the importance for proper evaluation of maintenance performance and human

'9
2001130213 MS Nkosi
reliability when dealing with human errors in the organisation. Any positive change in human
performance, speed and reliability can be very beneficial to improving the human-machine system.

Latent failures which are sometimes referred to as resident pathogens are hidden causes of incidents
or accidents. On the other hand active failures are at the sharp end" of the incident or accident, for
example a bearing which overheats and seize, and are thus usually discovered easily. Overheating
and seizing of the bearing might be due to ungreased bearing during maintenance shutdown or
improperly greased bearing (under-greased). Resident pathogens/latent failures, in contrast, can lie
dormant in a system for considerable periods before they become manifest, for an example, a
bearing which has been improperly greased. Another example is an improperly greased bearing
which might be due to lack of proper training of the maintenance person who greased the bearing, it
might be that the manual was not used or was incorrectly interpreted.
(Drury, 2000) indicates that there are two interdependent ways for locating pathogens or latent
failures in a system:
• Incident-ha.sed. In this approach a detailed analysis of incidents or accidents that have
occurred is conducted with an aim of locating resident pathogens as well as active failures.
• Task-A nalvsis-Based. In this approach a comparison or a critical evaluation is made for task
demands and human capabilities with an aim of locating task elements where errors might
occur. In this case resident pathogens are located whether incidents or accidents have or
have not occurred.
Both incident-based and task-analysis-based approaches have been successfully used in aviation
maintenance.

The above-mentioned programs/models (Swiss-Cheese Model, SHEL Model and Incident Based
Human Error Approach to Maintenance and Workforce Questionnaire) and other models that are
not mentioned in this paper had been used in different industries (Aviation, Nuclear Plants etc.) to
develop and implement several key initiatives such as:
• A training program in human factors which was established by Gordon Dupont in 1999;
• A Health and Safety Executive Guide - Irn proving maintenance a guide to reducing human
error" first published in 2000 by Health and Safety Executive and Human Factors in
Reliability Group;
• Adoption of the Malcom Baldrige Performance Excellence Framework by the military over
six years from 1998 as stated by Xavier (2005);
• Implementation of the Excellence in Aviation Safety Training as indicated by Anglemyer
(2014) in his course book; etc.

The results of the Asian Study survey for comparison between 1999 and 2003 revealed significant
improvements (Xavier, 2005). The results of the survey were categorised into safety culture,
violations (reasons, types, and frequency), call-out time, overtime, open reporting, and
safety/quality information. The other part of the results of this survey is presented in Figure 3.5,
while the other part is presented in Table 3.4.

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 1 1 11
100

80

60

40

20

Organ sat ton

Management
Supervtsors
- - --
Person ne

• (Participarttsrated the orgamsation, managernent,supervisors and personnel on how they

place/show strong emphasison safety and quality)

Figure 3.5: Asian Study survey comparison between 1999 and 2003

Table 3.2: The Asian Study conducted to compare results between 1999 and 2003.

No. Results
Taking short cuts which is also referred as the easy way out increased by: 11%
Unavailability of correct tools considerably increased by: 14%
For the usual types of violations encountered daily and once a week, there was a 4%
reduction of:
There was an improvement on violations which caused them to be very 22%
infrequent or the frequency of violations decreased by:
There was a reduction in call-out time (time worked outside normal working 11%
hours due to emergency) ot
The overtime was properly managed and the frequency (weekly) of the 16%
overtime significantly decreased by:
The open report ing culture in the organization considerably increased by: 16%
The availability of Safety/Quality information, registered an improvement of 8%

The results presented in Table 3.2 indicate some improvements, but there was also an increase in
some of the human errors. The increase in some of the factors that are contributing to the
occurrence of human errors is an indication that the organisation is required to establish, evaluate,
manage and control tools for dealing with human errors in maintenance.

3.5 Coal Mine Maintenance Performance Improvement Framework (CMMPIF)

The researcher will integrate perforniance excellence frameworks, Health and Safety Executive
(USE) "Improving maintenance - a guide to reducing human error" and other human error
programs/models in the creation of Coal Mine Maintenance Performance Improvement Framework
(CMMPIF).

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The Performance Excellence Frameworks (PEF's) that will be used in the creation of the (TMMPIF
have been adopted in a number of countries and in various sectors including but not limited
Aviation, Defence, Healthcare, Nuclear Plants, and Education. Xavier (2005:6) indicates that in
recent years. the Defence industry has been using such framework to gauge its quality health.'

The Malcolm Baidrige National Quality Award, (MBNQA) which was first known as the Baldrige
was established in 1988 and is amongst the first performance excellence frameworks. This guide or
framework was created to respond to the US issues/crisis pertaining competitiveness some at the
beginning of the global information period, some time ago. The MBNQA covers almost all the
elements of business such as leadership; strategic planning; customer focus; measurement, analysis,
and knowledge management; workforce focus, operations focus, results as outlined in the structure
presented in Schaefer (2011). The elements of the MBNQA framework form part of the main
components adopted in different frameworks. Many countries and various sectors have adopted
performance excellence frameworks based on the components of the MBNQA framework.

In aviation, a performance excellence framework called Aviation Performance Framework, (APE)

which is also based on the MBNQA framework has been developed and used in many countries and
gained popularity due to its best results. One of the major objectives of the MBNQA framework is
to establish the standards required by companies and consumers, and to develop a system that can
be used to sustain a competitive advantage and excellence for a longer period of time.

Health and Safety Executive (HSE) has worked closely with the Human Factors in Reliability
Group (HFRG) as part of the working group which produced Improving maintenance - a guide to
reducing human error" (Health and Safety Executive. 2000). The HSE guide was written primarily
for major hazardous industries such as chemical, nuclear, aviation and offshore, the guide addresses
a topic which is important to all industrial sectors and sizes of business (Health and Safety
Executive, 2000). The HSE's key message is that human error in maintenance can be distinctly
predicted and hence it is possible to identify and manage human error. The HSE guide is based on
practical situations intending to suggest and supply devices for progressive development of the
safety and quality of maintenance tasks thereby reducing human error. This guide further enables
maintenance management, engineers and maintenance personnel to point or recognise the main
factors that have a negative impact on maintenance performance.

Typical performance excellence frameworks are all made up of the following main elements:
• Leadership and Supervision
• Strategic Planning
• Evaluation, Measurement and Knowledge Management
• Human Resource Management
• Process/Operations Management
• Customer and Market Focus
• Business Performance Results

The major objective of the performance excellence framework is to develop a culture for continuous
improvement, motivation of an organization to create strategies, and stimulating innovative ideas
for establishing an effective basis for quality, safety, excellence, professionalism, etc. A well-
defined and structured approach to individual and organizational learning should be implemented in
order to achieve business performance excellence. This will enable the organisation to sustain the
competitive edge while ensuring that the employees are satisfied, motivated and developed to
perform to their maximum capabilities and thereby achieve performance excellence.
Such organisations should be led by knowledgeable and skilful management and should also have a
strong support team so as to maintain a high level of maintenance performance. The management
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team should ensure that the objectives of the performance excellence framework are achieved,
performance is monitored, and a comprehensible foundation for improving results is provided.

The selection of this framework includes a systematic and well-structured approach to managing
maintenance in the organization and is recommended in this dissertation as an aid for reducing a
coal preparation plant's maintenance human error considerably.

It has been indicated earlier in this chapter that several organizations including aviation and defence
have implemented this framework and tailored it to their needs. Later in this dissertation a
performance excellence framework tailored to coal preparation plant maintenance will be
developed.
The focus on the proposed CMMPIF will be on the following major elements of different
performance excellence frameworks:
Management and Supervision
• Communication
• Training, development and motivation
• Attitude and/or behaviour of maintenance personnel
• Maintenance performance
• Work design (e.g. worker capabilities, repetitive work etc.)
• Incident reporting systems -

This paper should assist all maintenance personnel (e.g. engineers, technicians, artisans, managers
etc.) in coal preparation plants to acknowledge their performance limitations, and to discover, shun,
and resolve errors or behavioural practices that are might lead to error. Although the element of
human error can never be eliminated completely, proper investigation and the application of an
appropriate solution can improve the situation in the organisation considerably.

3.6 ADDRESSING THE RESEARCH QUESTION

It has been coal mines' mission to motivate maintenance teams in order to reduce equipment
breakdowns through the practice of maintenance excellence. Some steps have been taken to
educate/train and equip maintenance personnel to excel during the maintenance of
machinery/equipment. Other coal mines have gone to an extent of implementing certain mandatory
programs to assist maintenance personnel to enhance their skills and knowledge in maintenance.
Most of these programs and training initiatives have truly made coal mine environment, safer, and
some improvement in maintenance, but maintenance errors, especially human errors continue to be
a major contributing factor in substandard maintenance.
There is a need for a comprehensive approach to the management of human errors in maintenance
of coal mines. In this dissertation the focus will be on human errors in the maintenance of the coal
mine preparation plant. It is intended to investigate the effect of human error on substandard
maintenance performance, and the formulation of a complete solution based on the experience of
successful maintenance organisations.

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Chapter 4 - RESEARCH METHODOLOGY

4.1 RESEARCH DESIGN

A descriptive research methodology was selected in this dissertation. A qualitative approach was
used to collect data from different coal mines/collieries and a quantitative approach was used to
review the results. The main reason for data collection was to populate results which could be
analyzed and used to express the importance of the implementation or improvement of programs for
managing human error in coal preparation plants' maintenance. The results would then be used to
recommend a comprehensive solution to the issue of human error in maintenance of coal
preparation plants.

The data of human error in maintenance (HEIM) was collected and the results were generated from
few coal preparation plants in order to understand the current situation of HEIM and efforts that are
currently implemented. The participants from these mines included maintenance managers.
engineers, artisans, foremen and maintenance assistants. The research was administered to examine
the impact of human error in coal mines and to verify the existence and effectiveness of human
error management programs and other initiatives.

4.2 SOURCE OF DATA AND DATA GATHERING

4.2.1 Source of Data

The data was collected using a questionnaire to survey coal preparation plant maintenance. Table
4.1 indicates the number of mines involved in the survey. and it also indicates the number of
participants and range of experience.

Table 4.1: Survey Participants

No. of mines/collieries in which participants are working 8
No. of maintenance managers participated

No. of maintenance engineers participated 6

No. of foremen participated 2

No. of maintenance artisans participated 5

No. of maintenance assistants participated 3

Total number of participants in the survey 19

Years of experience (y) Less than 5 yrs Between 5& 10 yrs More than IO yrs
No. of participants by experience 4 10 5

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A formal letter requesting permission to interact with maintenance personnel was sent to the
relevant people in the mines. The data was collected from 19 participants from 8 mines/collieries.
Site visits were only done to two mines. The questionnaire was distributed to the participants via
emails nd hand delivery during site visits. It was sent to 28 delegates from these mines, but only 19
participated in the survey.

4.2.2 The Data Collector

The data collector selected in this dissertation is in a ft)rrn of a questionnaire. The questionnaire
included questions to determine the position, summary of duties and responsibilities, experience of
the participants. It also included other questions prepared to determine the implementation and
effectiveness of HElM programs.

The author of this dissertation was assisted by the information from several books and papers
written by renowned Human Factors in Maintenance experts and organizations to generate
questions for the questionnaire.

Table 4.2: The Questionnaire

Name or indicate Position:

anonymous:
Summary of Duties
& Responsibilities:
No. ofyears(y)in y<5 y 5to lO y> 10 Totalexperience y<7 y7to 15 y> 15
the current company in maintenance

Section 1: Questions about the existence of human error program/s in maintenance

(Please indicate 1. Strong/v agree, 2. Agree, 3. Disagree, 4. Strong/v disagree except row no. I (nd 3)
• Indicate your level of knowledge of human errors in maintenance? (Please indicate in
the block either 1. Poor, 2. Fair, 3. Better or 4. Excellent)
• Is there a program for managing human error in maintenance in your company?
y<5

= 5 to 10
• If it exists, how many years has it been in existence?
y> 10

• If it does not exist, is there a study or initiative taken to manage human error in
maintenance that was conducted in your organisation?
• If there was a study or initiative, when was that conducted?
• Do you think is there a need to have a program for managing human error in
maintenance?

Section 2: Questions about the effectiveness of the program/s or tools for managing human
error
(Please indicate 1. Strong/v agree, 2. Agree, 3. Disagree, 4. Strong/v disagree)
• Has the human error program currently implemented improved human errors in the
maintenance of your company?
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• Is the training and initiatives currently available sufficient to manage human errors in
the maintenance of your company?
• Is tIere more that needs to be done to manage human errors in the maintenance of
your company?

Section 3: Questions about common human errors in maintenance of a coal preparation plant
3.1 Which of the following human errors are most common in the maintenance ofyour company?
(Please indicate 1. Very likely, 2. Likely, 3. Unlikely, 4. Very unlikely)
• Incomplete installation
• Improper installation (part assembly)
• Equipment parts, damaged during maintenance
• Foreign object damage (e.g. Bearings by coal dust particles)
• Improper lubrication (e.g. Under/over-greasing)
• Improper inspection and identification of fault
• Injury to personnel
• Utilization of deteriorated parts (e.g. Screws and bolts)

3.2 Are the following the reason/s for the occurrence of the common human errors in your
company? (Please indicate I. Very likely, 2. Likely, 3. Unlikely, 4. Very unlikely)
• Time pressure
• Inadequate pre-planning (allocation of human resource, tools, spares etc.)
• Inadequate training, knowledge and skills
• Management functions (supervision, strategies, etc.)
• Poor communication and misinterpretation of manuals, procedures etc.
• Environmental conditions (e.g. in poor light during night shift etc.)
• Interruptions during maintenance
• Routine and repetitive, causing lack of paying attention to detail

Section 4: Questions about the impact of human errors in maintenance.

Which of the following are the impacts of human errors in maintenance? (Plea.s'e indicate 1. Very
likely, 2. Likely, 3. Unlikely, 4. Very unlikely)
• Unexpected shutdowns or breakdowns
• The cost of rework and stoppages which disrupt production
• Reduction in plant reliability/availability or direct damage to the plant
• Increased safety risk to maintenance personnel, operators, other employees and public
• Damage to environment

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Section 5: Question/s about managing human error or improving current program/s
Do you think the following needs to be done to better manage human errors in maintenance?
(PIea.seindicate 1. Strong/v agree, 2. Agree, 3. Disagree, 4. Strong/v disagree)
• Review of Management,
• Assessment of communication effectiveness,
• Assessment of training, development and motivation effectiveness,
• Assessment of the attitude and/or behaviour of maintenance personnel,
• Maintenance performance review,
• Work design review (e.g. Capabilities, repetitive, etc.)
• Assessment of incident reporting systems

Comments or -
additional input -

Your assistance in this study will be highly appreciated.

A sample letter for requesting permission to interact with maintenance personnel in order to
generate data is attached in Appendix A.

4.3 DATA EXAMINATION

The questionnaire was emailed to one of the maintenance specialists in order to evaluate the
relevancy of the questions. The feedback from the maintenance specialist indicated that the data
collector covered the most relevant and critical elements of human errors in maintenance. The
questionnaire was then used to collect data from participants working at different mines.
The data obtained was benchmarked with the existing research and/or results from those
organizations that have conducted research into human errors or factors in maintenance. The results
obtained were critically evaluated in order to recommend a comprehensive solution to human errors
in maintenance of coal preparation plants.

The author of this dissertation relied mostly the methods published in articles in refereed research
journals and other high quality sources to evaluate the data obtained.

Due to time constraints, the data was obtained as per questionnaire presented in this chapter, and
could not be further evaluated using probability study concepts, statistics or any other tool for
testing data over a reasonable time interval. The data collected and benefits obtained from different
articles of the successful organizations were used to recommend the best solution to human errors in
coal preparation plants. The recommended solution is presented in Chapter 6 after the presentation
and discussion of results in Chapter 5.

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Chapter 5 - RESULTS

5.1 RESEARCH FEEDBACK AND DISCUSSION OF RES ULTS

This section presents the results of the survey performed in the South African coal preparation
plants. The survey was conducted within a period of more than six months. This period includes the
request for permission to interact with the maintenance personnel in the mines, mine visits, issuing
the questionnaire to the relevant people and receiving feedback from the participants. Site visits
were only made to two mines, while the other mines were reached for participation through a
questionnaire which was emailed to the participants. The data was populated using the
questionnaire proposed in chapter 4 (Research Methodology). The results were arranged in the same
five sections as that of the questionnaire:
• Human error programs in maintenance,
• The effectiveness of the programls or tools for managing human error,
• Common human errors in maintenance of coal preparation plants,
• Impact of human errors in maintenance and other organisations· processes, and
• Managing human error or improving current initiatives.
Additional comments of the participants are also incorporated in this chapter and they are very
important when developing a recommendation.

5.1.1 Human Error Programs in Maintenance

The results of the survey indicated that, 90% of the participants had poor knowledge of the concepts
of human errors in maintenance. This alone indicates that there is very little that has been done in
the South African coal mine industry in directly addressing the issue of human erTOrs in
maintenance. Table 5.1 below presents the results obtained in the survey of Human Error Programs
in Maintenance of coal preparation plants.

Table 5.1: Survey on the Human Error Programs in Maintenance

Poor: fair good excellent
Level of knowledge of human errors in maintenance 90% 5% 5% 0%

Strongly agree disagree Strongly

agree disagree
Is there a program for managing human error in 0% 0% 0% 100%
maintenance in your company?
If it exists, how many years has it been in existence? NIA
If it does not exist, is there a study or initiative to 0% 0% 0% 100%
manage human error in maintenance that was conducted
in your organisation?
If there was a study or initiative, when was that NIA
conducted?
Do you think is there a need to have a program for 100% 0% 0% 0%
managing human error in maintenance?

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It was discovered that lOO°/ of the mines participated in the research survey did not have a
structured Human Error Program in Maintenance. It was also discovered that they have not taken
initiatives to directly address human error in maintenance.
All participants strongly felt that there is a need for having a structured Human Error Management
Program in the maintenance of coal preparation plants. They also believe that implementation and
execution of structured human error programs or initiatives will assist in reducing human errors in
maintenance and in return improve maintenance performance.

5.1.2 Effectiveness of Programs or Tools for Managing Human Error

The survey indicated that in the surveyed mines, there are no programs or tools in place for the
management of human errors in maintenance. The results of the survey indicated that the training
available is not sufficient to address human errors in maintenance. Table 5.2 presents the results of
the survey concerning the effectiveness of programs or tools for managing human error in
maintenance.

Table 5.2 The Effectiveness of the program/s or tools for managing human error
Strongly agree disagree Strongly
agree disagree
Has the human error program currently implemented N/A
improved management of human errors in your
organisation?
Is the training and initiatives currently available 0% 0% 0% 100 %
sufficient to manage human errors in maintenance of
your company?
Is there more that needs to be done to manage human 100 % 0% 0% 0%
errors in maintenance of your company?

All delegates participated in the survey, agreed that "more needs to be done to manage human
errors in maintenance". The main focus in these coal preparation plants is mainly on the reliability
of the equipment and the safety of people, but not on the reliability of the workforce.

5.1.3 Common Human Errors in Maintenance of Coal Preparation Plants

The survey revealed that the top four common human errors in coal preparation maintenance are:
Improper installation (part assembly), equipment parts damaged during maintenance, improper
inspection and identification of fault and utilization of deteriorated parts (e.g. screws and bolts). See
ratings by the participants presented in Table 5.3 below.

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 It was discovered that 100% of the mines participated in the research survey did not have a
structured Human Error Program in Maintenance. It was also discovered that they have not taken
initiatives to directly address human error in maintenance.
All patticipants strongly felt that there is a need for having a structured Human Error Management
Program in the maintenance of coal preparation plants. They also believe that implementation and
execution of structured human error programs or initiatives will assist in reducing human errors in
maintenance and in return improve maintenance performance.

5.1.2 Effectiveness of Programs or Tools for Managing Human Error

The survey indicated that in the surveyed mines, there are no programs or tools in place for the
management of human errors in maintenance. The results of the survey indicated that the training
available is not sufficient to address human errors in maintenance. Table 5.2 presents the results of
the survey concerning the effectiveness of programs or tools for managing human error in
maintenance.

Table 5.2 The Effectiveness of the program/s or tools for managing human error
Strongly agree disagree Strongly
agree disagree
Has the human error program currently implemented N/A
improved management of human errors in your
organisation?
Is the training and initiatives currently available 0% 0% 0% 100 %
sufficient to manage human errors in maintenance of
your company?
Is there more that needs to be done to manage human 100 % 0% 0% 0%
errors in maintenance of your company?

All delegates participated in the survey. agreed that more needs to be done to manage human
errors in maintenance". The main focus in these coal preparation plants is mainly on the reliability
of the equipment and the safety of people, but not on the reliability of the workforce.

5.1.3 Common Human Errors in Maintenance of Coal Preparation Plants

The survey revealed that the top four common human errors in coal preparation maintenance are:
Improper installation (part assembly), equipment parts damaged during maintenance, improper
inspection and identification of fault and utilization of deteriorated parts (e.g. screws and bolts). See
ratings by the participants presented in Table 5.3 below.

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Table 5.3 The Most common human errors in maintenance
Very Likely Unlikely Very
likely unlikely
• Incomplete installation 0% II % 26 % 63 %
• Improper installation (part assembly) 84 % 16 % 0% 0%
• Equipment parts damaged during maintenance 50 % 26 % 14 % 10 %
• Foreign object damage (e.g. bearings by coal dust 5% 21 % 53 % 21 %
particles)
• Improper lubrication (e.g. under/over-greasing) 16% 32% 36% 16%
• Improper inspection and identification of fault 79% 16% 5% 0%
• Injury to personnel 0% 5% 74 % 21 %
• Utilization of deteriorated parts (e.g. screws and 53 % 26 % 21 % 0%
bolts)

Looking at the percentage of participants who selected very likely and likely for improper
lubrication makes it to be one of the common human errors in maintenance. See Table 5.3.

Time pressure, inadequate preplanning, management functions, poor communication and

misinterpretation of manuals, procedures, etc., are the four top major reasons for the occurrence of
common human errors. Table 5.4 presents the ratings by participants.

Table 5.4: Reasons for the occurrence of the most common human errors in maintenance
Very Likely Unlikely Very
likely unlikely
• Time pressure 89 % 11 % 0% 0%
• Inadequate preplanning (allocation of human 74% 16% 10% 0%
resource, tools, spares etc.)
• Inadequate training, knowledge and skills 16 % 26 % 1 32 % 26 %
• Management functions (supervision, strategies 53 % 26 % 21 % 0%
etc.)
• Poor communication and misinterpretation of 42 % 32 % 21 % 5%
manuals, procedures, etc.
• Environmental conditions (e.g. poor light during 0% II % 26 % 63 %
night shift etc.)
• Interruptions during maintenance 0% 0% 47 % 53 %
• Routine and repetitive work causing lack of paying 0% 10 % 32 % 58%
attention to detail

Even though inadequate of training, knowledge and skills were rated by only 16% of the
participants as very likely and by 26% as likely, it is still very crucial for the coal mines to invest in
the continuous development and training of its workforce. This is also even more necessary due to
advancing technology which maintenance workers have to maintain. The training should not only
address safety related matters, and skills enhancement, but should also address concepts of human
error in maintenance.

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5.1.4 Impact of Human Errors in Maintenance

On the impact of human errors in maintenance unexpected shutdowns or breakdowns; the reduction
in plant reliability/availability or direct damage to the plant; the cost of rework and stoppages which
disrupt production; Increased safety risk to maintenance personnel, operators, other employees and
public were found to be the top four impacts of human errors in coat preparation plants. See Table
5.5 below with ratings by the participants.

Table 5.5: Impact of Human Errors in Maintenance

Very Likely Unlikely Very
likely unlikely
• Unexpected shutdowns or breakdowns 89 % 11 % 0% 0%
• Cost of rework and stoppages which disrupt the 79 % 16 % 5% 0%
production
• Reduction in plant reliability/availability or 84 % 16% 0% 0%
direct_damage_to_the_plant
• Increased safety risk to maintenance personnel. 74% 21 % 5% 0%
operators,_other_employees_and_public
• Damage to environment 0% 10 % 16 % 1 74 %

5.1.5 Managing Human Error or Improving Current Initiatives

This section presents the results on the management of human error or improvement of current
initiatives. According to the survey (see Table 5.6), the following needs to be done to better manage
human errors in coal preparation plants:
• Assessment of the attitude and/or behaviour of maintenance personnel.
• Review of management.
• Assessment of communication effectiveness.
• Assessment of training, development and motivation effectiveness,
• Maintenance performance Review,
• Work design review (e.g. capabilities, repetitive etc), and
• Assessment of the incident reporting systems
Table 5.6 Better management of Human Errors in Maintenance
Strongly agree disagree Strongly
agree disagree
• Review of Management 79 % 21 % 0% 0%
• Assessment of communication effectiveness 74% 21 % 5% 0%
• Assessment of training, development and 63 % 26 % 11 % 0%
motivation effectiveness
• Assessment of the attitude and/or behaviour of 84 % 16 % 0% 0%
maintenance_personnel
• Maintenance performance review 47 % 37 % 16 % 0%
• Work design review (e.g. capabilities, repetitive 42 % 32 % 26 % 0%
etc)
• Assessment of incident reporting systems 42 % 1 37 % 21 % 0%

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The percentages in indicated on the above tables (Table 5.1 to 5.6) are not additive. Each
percentage was calculated only within its category rather than as a percentage of categories added
together.

5.1.6 Additional Comments from the Participants

Time Pressure
Some of the artisans indicated that management and foremen should give them more time than
usual when dealing with complex maintenance tasks. One artisan emphasized the issue of being
rushed to complete the maintenance tasks so as to bring the plant into operation at normal scheduled
times.

Supervision
One of the managers indicated that there is an issue with foremen (supervisors) not spending
enough time in the plant during maintenance activities. Even though they want to give artisans and
other maintenance personnel freedom to work independently, they need to properly supervise them.
Foremen should always request feedback from the maintenance team concerning the maintenance
activities they have conducted during the planned shutdown and also during unplanned shutdown.
Usage of deteriorated parts
One of the artisans indicated that there is an issue of improper logistics control which leads to
contractors using spare parts reserved for the organisations maintenance team for use during
maintenance. When the maintenance team requires spare parts, they discover that spare parts are no
longer available, and then resort to using deteriorated parts.
Human error management training
I believe training on human error awareness and management presented to managers, engineers,
and other maintenance personnel will assist in dealing with the issue of human errors in
maintenance of our coal mine. These were the words of one of the engineers of the surveyed coal
mines. It was also picked up from few of the participants that, they believe human error
management training will assist in the reduction of maintenance errors and also some of the
production errors which contribute to plant shutdowns.

Incomplete maintenance tasks

A few participants believed that Incomplete installation' indicated in Table 5.3 should have been
indicated as 1ncomplete maintenance tasks. This is because in the coal mines there is an issue of
incomplete maintenance tasks planned for a particular day, but not much have been observed
concerning incomplete installations. They indicated that at times they would not finish maintenance
tasks planned for the day. This is because the plant is normally required to be back in operation at
the certain time, so this leads them to skip certain maintenance tasks.

Improper inspection and identification of faults

One of the managers and some of the engineers believed that improper inspection and identification
of faults is one of the major human error contributors. In maintenance some machines or
components are not attended to due to this error and as a result possible failures that might lead to
breakdowns are not identified and dealt with during maintenance.

Some of the artisans mentioned that they will like training programs and/or presentations which will
enhance their skills in developing proper checklists, inspections and identification of faults to be
introduced in their coal mines.

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Violations and Short Cuts
One of the violations indicated by few participants was usage of wrong tool/s for the job due to lack
or misplacement of proper tools.

It was also indicated that the other violation is to perform complex maintenance tasks without
following procedures or manuals and hence omitting certain steps. The reason for this violation is
associated with time pressure to complete maintenance tasks.

It was also discovered that there is also a usage of unsafe tools. This is normally due to poor
preplanning and lack of logistics control which leads the maintenance team to use available tools
which are not safe. The researcher remembered his first week of his career in a coal mine. On the
first day he attended safety induction where he was inducted on many safety aspects including even
lifting equipment and their safety use. To his surprise a day after induction, during maintenance
planned shutdown when they were working on a 12 x 10 centrifugal pump. a chain block without
a safety latch and an inspection date was used for rigging the motor and the pump. When
condemning the usage of unsafe tool, it was mentioned to him that it had been done like that for
several times in the past without a problem and why should it be stopped at that time. Some
violations become part of the culture of certain maintenance teams. It is also evident that
management should pay close attention to the issue of violations since not all violations are due to
intentional short cuts.

Other violations can be associated with the rush to complete maintenance tasks.

The author of this dissertation confirmed the relevancy of the feedback and/or additional comments
provided by the participants, based on his previous coal mine surface experience.

5.2 COMPARING RESULTS WITH PAST RESEARCH

Many research papers addressing human error in maintenance were prepared in the aviation
industry. There are also studies that were conducted in nuclear and military organizations, but not
much have been done in coal mines. Patterson (2009) conducted a research study at doctorate level
which addresses human error in mining, but it focuses on mining accidents/incidents in Queensland,
Australia and the USA without much emphasis on maintenance. It is the responsibility of
management to ensure that routine maintenance is scheduled and carried out, proper equipment is
ordered and available to workers, and defective equipment is removed from service (Patterson,
2009). It gives a few recommendations regarding maintenance, but it does not detail the main
human-system issues in maintenance.

There was a noticeable difference between the results obtained in this research and those results
obtained in human error studies done in aviation. One of the main differences is that in the literature
study it was discovered that many of the aviation industries in different countries have implemented
human factor programs and initiatives for managing human error in maintenance. It differs from the
results of this study in a sense that, not even one of the mines from where the participants are
working had implemented initiatives or programs to directly address human errors in maintenance.

It was heartening to note that even though the surveyed coal mines have not implemented human
factor programs or initiatives to address human error in maintenance, they all agree that it is
essential to implement such programs. This was supported by a supervisor from one of the conveyor
system manufacturers who agreed that the main issue in maintenance of conveyor systems is human
error. Hence, the coal mines should pay more attention to it. He mentioned an example of a bearing
which is properly lubricated and/or maintained as per the manuals, stating that it is unlikely to fail
33
2001130213 MS Nkosi
before its expected lifetime. He then mentioned that there is a need for initiatives to deal with the
human-system relationship.

This study also differs from previous research studies in a sense that there are more areas in which
the participants indicated that they agree on a very likely' or strongly agree' level. In other recent
studies, there is a balance due to the fact that they have implemented human error programs which
have already improved maintenance through reduced human errors. There is a commonality
between this study and previous research studies, especially in causes of human errors and also
regarding the elements that need to be reviewed in order to better manage human errors in
maintenance.

Most common human errors in maintenance

The Boeing Study conducted by James Reason, which is quoted in the literature survey of this
research revealed top seven causes of in flight engine shutdowns (IFSDs). These top seven causes
or major contributory factors are:
• Incomplete installation,
• Damaged on installation,
• Improper installation,
• Equipment not installed or missing,
• Foreign Object Damage,
• Improper fault isolation, inspection, test, and
• Equipment not activated or deactivated.
Three of the top seven causes indicated above form part of top four most common human errors in
maintenance which are indicated in Table 5.3. The three commonalities between literature study
and research feedback are highlighted in bold on the above list.

Reasons for the occurrence of the most common human errors in maintenance

Results of this research concerning reasons for the occurrence of the most common human errors in
maintenance have a similarity with results obtained in aviation which were presented in the
literature survey. The similarity between literature survey and results (Table 5.4) is highlighted in
bold on the list presented below. It was indicated in the literature survey that most of the incidents
were characterised by, but not limited to the following:
• Improper preplanning of resources
• Shortages in the workforce ('inadequate number ofpersonnel) ;
• The existence of time pressures;
• Working at night;
• Handing over of the tasks to another shift;
• Overconfidence
• The interruptions while performing tasks;
• The failure to use correct procedures;
• Unclear manuals, etc.
The Impact of Human Errors in Maintenance

In the article by Pires & Vorster (2011) which is referenced in the literature survey, it was indicated
that in the mining industry costs are incurred every year due to work stoppages, accidents or
unsafe work environments". It was also quoted that human error is part of the reasons for unplanned
shutdowns in South African mining.

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A comparison between the Pires & Vorster (2011) study and the results of this research indicates
some commonalities. The commonalities are highlighted in bold on the list below.
It can be identified from the above results that the following are the impacts of human error:
• Costs incurred due to
• work stoppages,
• accidents,
• unsafe work environments, and
Unplanned equipment shutdowns.

Managing Human Error or Improving Current Initiatives

Almost all the elements indicated on Table 5.6 have been addressed in the literature under various
human error management programs and/or initiatives. The study reveals that these are the important
elements in the management of human errors in maintenance. The researcher used these elements to
develop a recommendation for coal preparation plants for improvement of their maintenance
performance. Chapter 6 presents the recommendation in a form of maintenance performance
improvement framework.

5.3 BENEFITS REAPED BY SUCCESSFUL ORGANISATIONS

This section presents various benefits reaped by some of the companies that have successfully
managed human error in maintenance. These benefits are presented with an aim of supporting
recommendations to better manage human error in maintenance of coal preparation plants. These
recommendations are presented in Chapter 6.

The attention to maintenance human factors can raise efficiency, effectiveness and safety in
aviation environments (Anglemyer. 2014:3). If coal mines can make it their focal point to develop
and implement strategic ways to manage human error in maintenance, the results and benefits can
be very impressive. In some organisations, implementing proper strategies to deal with human error
in maintenance gives good results within a period of six to twelve months. Others may take longer
depending on the structure of the organisation and the type of the strategy that has been
implemented. In his study notes, Anglemyer (2014) revealed that at one major airline, the benefits
indicated below were reported just after twelve months of implementing Human Factors Training in
Aviation Maintenance, which is also called Maintenance Resource Management. Figure 5. 1
presents these benefits.

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200830213 MS Nkosi
 68%
70

60

so
34%
40

30 Ii 27%

20
12%
10

Reduction in costs
1IIIJ
of repairing Adeclinein - - - --
Adecrease i - /
grounddamage grounddamage
hours of A reduction in
due to
maintenance oCcupatiofla medical payoff
injuries related to
errors
occupational
injures

Figure 5.1: The benefits reported just after twelve months of implementing the \laintcnance
Resource Nlanagcmcnt training program at one major airline.

It can be noted from these benefits, that a reduction in costs of repairing ground damage was a
significant benefit.

A study into human factor management which was conducted in oil and gas industry reveals good
benefits of implementing initiatives to deal with human error.

The International Association of Oil and Gas Producers (2005) indicated that an Offshore
Production Operations Management (OPOM) paid attention in seeking ways to improve and
maintain Health, Safety and Environmental (HSE) performance results. The OPOM discovered that
the main driver for promoting employee engagement with shared responsibility substantiated by
openness and honesty in communication is leadership and management commitment.
The following system and organisational changes were made in order to achieve the goal of the
OPOM for improving and maintaining the USE performance results:
• Initiated quarterly meetings for employees, with an aim of highlighting Health, Safety and
Environment performance,
• All on-site safety meetings to be attended by management.
• Presenting HSE goals in management reviews and performance audits,
• Promoting and discussing HSE strategic initiatives, and communicating achievements.
• Regular reviews on incident investigations and reporting, and
• Encouraging the employees to stop or withdraw from the job when conditions become
unsafe.

The International Association of Oil and Gas Producers (2005) revealed that after the OPOM had
implemented the system and organisational changes, between 1998 and 2000, there were reductions
in employee and contractor incident rates:
• The significant drop of7l% for total recordable incidents,

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 • The lost time incidents had a considerable decrease of 100%,
• Savings/profits were enhanced by the:
o decrease in damage of property,
o reduction in medical costs, compensation or insurance expenses, and legal funds,
and
o decrease in system/equipment downtime
The organisations reputation/image was improved

These results are not obtained through an overnight exercise but through a progressive process that
takes months and years and also through the integration of organisation's systems or programs. This
is an indication that when coal mines implement strategic changes for improvement, they should
expect that those changes will take some time after implementation before they produce impressive
benefits.

Edkins (2002) indicates that there were several studies conducted with an aim of examining the
financial benefit of implementing the human factors training in aircraft maintenance. They "have
generally found investment returns on training programs in the form of reductions in equipment
damage incidents, the employee down time. or lost time injuries" (Edkins, 2002:13).

In the study by Edkins (2002) for International Air Transport Association (IATA), the following
benefits were identified:
• After implementing a two days' training course on human factors, there was a decrease of
75% in events of the damage encountered during ground-towing and hence a saving of
$195,000 per annum,
• After implementing an education program on human factor with the main focus on shift
turnover, there was a decline of 2474 average man-hours required to complete a "D" check
and therefore there was a saving of $94,000 per annum,
• A two days training course on human factors which was implemented by Continental
Airlines, gave the following benefits:
o a 68% decrease in incidents related to ground damage,
o job injuries dropped by 12%,
o overtime declined by 10%, and
o a saving of $60,000 per annum for a period of five years.
The D - Check indicated on the benefits stated above is a check that occurs almost after every 5
years, where the entire aircraft is stripped off for inspection and overhaul.
Edkins (2002) has indicated that the outstanding cost benefit research until now is after the
implementation of the introduction in a maintenance resource management program. Hence, it
resulted in a drop of 80% of lost-time injuries over a period of two years, and thereby giving a
$1,300,000 saving over that interval.

It was also indicated in a study by Edkins (2002) that when contemplating the efficiency of human
factors training, a careful consideration should be given to a claim by some researchers that the
efficiency of training had already been substantiated prior to the establishment of human factors
training program such as NOTECHS (Non Technical Skills). Until recent, the most compelling
proof of the efficiency of human factors training "within the military aviation environment has been
published by Salas, et al., (1999a)" (Edkins. 2002:10). The participants went through a training
program which focused on the behaviour and this program applied an integration of behavioural and
attitudinal indices. These indices were measured before and after training. The results obtained on
the examination of people's perspectives were favourable which was said to be correlating with
previous research studies. The results of the training revealed that, teams who had undergone
training had an outstanding performance as compared to teams who only applied standard

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teamwork behaviours. These results are correlating with the results of the foregoing research study
by Salas and associates which demonstrated moderate but continuous improvement in behaviour of
the teams.

Based on the study by Edkins and other studies in the military field, it can be noted that the military
has placed more attention in creating strategies for better managing human errors in maintenance.
Edkins (2002) further states that a holistic paper was prepared by Diehl (1991) where he reviewed
the efficiency of the training related to human factors within the military sector, with the main focus
on rotary wing aircraft. The review of the data from various sources revealed that the training
programs had led to a decrease in human error rates. One of the examples where error rates were
reduced: there was a 36% drop of human error accident rates across the globe after human factors
training was introduced for the Jatranger helicopter crew within a period of four years. These results
were impressive as compared to those of the preceding four years prior the introduction of the
human factor training program. At one of the largest US operators of commercial helicopters,
Petroleum Helicopter Inc, the CRM training program was introduced and this resulted in an
accident rate drop of 54% within a period of two years. It was revealed that for the six preceding
years, the rates remained fairly steady. Edkins (2002) further states that the most authentic proof
came from the USAF Military which introduced the CRM training program in 1985. After this
training program was introduced, in the following five years there was a decline of 52% in
accidents rates. There was also a drop of 5 1 % on flight-related adversities. The benefits extracted
from Edkins (2002) were presented. in this research as part of indicating the benefits reaped through
the implementation of strategic ways of dealing with human errors in maintenance. One of the ways
to reduce human errors which was common in these studies is the implementation of human factors
training programs. It is important for organisations who wish to implement initiatives for dealing
with human error in maintenance to also consider human factor training programs.

Booher (1997) conducted a human factor integration study at the Army Research Laboratory. The
title of the study was Human Factors Integration: Cost and Performance Benefits on Army
Systems" and its focal point was the Army's Comanche. The Army's Comanche has been
developed as a lightweight, twin engine helicopter capable of performing armed reconnaissance and
light attack missions" (Booher, 1997:9). There were a number of determined objectives set by the
Comanche in order to improve maintenance performance.
The objectives of the Comanche were:
To integrate the latest airplane technology in order to substantially improve performance
especially during adverse conditions such at night with poor lighting, and detrimental
weather conditions,
• To increase safety efficiency for air crew, and
• To improve performance without much adjustment on operational and support costs.

There were several strategic changes in design and acquisition methods that the Army could make,
in order to overcome the challenges that could hinder their process of achieving predefined
objectives. The manpower and personnel integration (MANPRINT) and human system integration
(HSI) approach, Human Factors Integration (HFI) technique was adopted at the beginning of the
process of establishing the requirements. They decided that a 5 years' period would be the duration
of record-keeping of the results. Booher (1997) indicated in the study that the following results were
obtained:
• Improved Army acquisition process (e.g., Source Selection, TSM-Forward),
• Drove human-centred design - 500 design improvements,
• Maximization of total system performance (the pilot workload, maintenance ease, personnel
safety),
• Cost Avoidance> $3.29B, and
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 • Avoids 91 fatalities, 116 disabling injuries
A decision to implement human factor programs or approaches that will deal with the human errors
in maintenance, hence improve maintenance requires a precise evaluation, brilliant strategies and
comLnitment. The cost savings are normally not achieved in a short period of time, but they require
some time and a lot of work from the relevant stakeholders of the organisation.
Booher (1997) also indicated in the study that human-driven analyses, computer simulations, and
physical models for demonstration were adopted in order to embitter and evaluate the efficiency of
the aircraft's total system performance.

The study by Booher (1997) on the Comanche indicated that there were cost avoidance figures
attributable to Human Factor Integration, and these figures are indicated below:
• There was a cost avoidance of 32% ($2.67 billion) on predecessor manpower,
• There was a 33% ($440 million.) cost avoidance on personnel and training , and
• 4.5% ($180 million) health, safety and soldier endurance cost was avoided.

The percentages indicated above are not additive. Each percentage is calculated only within its
category rather than as a percentage of total cost avoidance, since within category savings is a more
meaningful percentage.
The total Comanche cost avoidance because of human factors integration was $3.29 billion. It was
concluded in this study that the performance was enhanced, safety was improved, and costs were
avoided. The results obtained can be used to predict future cost savings for the company applying
such methods for human error management.

It was discovered in the survey that there is a need for the implementation of human error
management programs or initiatives in the coal preparation plants. This will assist in reducing
human errors in maintenance, and hence improve maintenance performance. Based on the benefits
reaped by successful organisations, it can be concluded that initiatives based on similar concepts
can improve coal preparation plants maintenance performance. The information presented in this
chapter leads to the formulation of recommendation which will be presented in the next chapter.

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Chapter 6 - CONCLUSION AND RECOMMENDATION

'
6.1 CONCLUSION

In this dissertation, a concept of improving maintenance perfom1ance through the reduction of

human errors in coal mine maintenance was elaborated. This study revealed that there is a lot that
needs to be done in the South African coal mines in order to better manage and reduce human errors
in maintenance.

The aviation and military industries have conducted some studies of human error in maintenance.
The results of these studies assisted the author of this dissertation to do a literature survey with an
aim of critically reviewing common human errors, their causes, and impact. These studies were also
used in the identification and critical evaluation of the benefits reaped by those organisations that
have successfully managed human errors in maintenance.

After discovering that the aviation industry has done a lot of studies in human errors, the author of
this dissertation was compelled to do a study into of effects of human error on substandard
maintenance performance in coal preparation plants. The study was aimed at improving coal mine
maintenance since coal mines ph�y a major role in the supply of electricity in South Africa and also
globally. They also play a major role in the South African and global economy.

This dissertation reveals that most of the incidents and shutdowns in aviation, military and coal
mining industries are due to human error. Human errors have a major impact on coal preparation
plant maintenance quality, safety, costs, and equipment reliability. Yet there is not much done to
establish proper understanding concerning the causes of error in maintenance activities, and to
establish proper tools and techniques to reduce and/or avoid the consequences of error.

In summary. this study was conducted with an aim of suppo11ing the researcher" s proposition for a
comprehensive solution to reduce human errors in maintenance, hence improve maintenance
perfonnance for the South African coal mines. The study reviewed various human errors
encountered in maintenance, such as improper installations, missed maintenance tasks, improper
inspections and fault identification, equipment/components damaged during maintenance,
utilization of deteriorated parts, and misinterpretation of manuals. These human errors have a
negative impact on the maintenance perforniance and they lead to unexpected shutdowns or
breakdowns; disruption of production; the significant cost of rework and stoppages; reduction in
plant reliability/availability or direct damage to plant; increased safety risk to maintenance
personnel, operators· and other employees and public etc.

The human errors discovered and reviewed in this dissertation were associated with the factors such
as time pressure; inadequate preplanning (allocation of workforce, tools, spares etc.); management
functions (strategic planning, supervision etc.); poor communication and misinterpretation of
manuals, procedures etc.; and inadequate training, knowledge and skills (including awareness in
human errors) etc. Most of the human errors and their causes discovered in coal preparation plants
were similar to those discovered in aviation and military industries. Based on the findings of this
dissertation, it was concluded that there is a lot that needs to be done in the coal mines to better
manage human errors in maintenance.

In this dissertation, it was discovered that aviation has adopted various types of models that are
designed to address human errors in aviation maintenance. The most common approaches or models

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that were reviewed in this study include SHELL model, Swiss Cheese Model and the Incident
Based Approach and Workforce Questionnaire. The Malcom Baldridge National Quality Award
(MBNQA) framework was indicated as one of the frameworks that other organisations have
adopted in order to reduce human errors in their business processes. The Malcom Baldridge
framework has been implemented by many industries such as aviation, military, nuclear power
plants, health care and education. Various benefits have been reaped out of this framework.
The author of this dissertation also reviewed Health and Safety Executive (HSE) Improving
Maintenance - A guide to Reducing Human Error' which played a major role in elaborating the
elements of the proposed performance improvement framework.

The information obtained from different human factor programs/models presented in different
papers was integrated to develop a maintenance performance improvement framework or guide.
The Coal Mine Maintenance Performance Improvement Framework was recommended as a better
tool for:
Reviewing human error management programs,
• Improving management and supervision,
• Evaluating and improving work design, communication and incident reporting systems, and
• Assessing attitude/behaviour, motivation, and training.
These elements were identified to be the key elements for better managing human errors in
maintenance and they should be implemented in a structured manner.
The recommendation was based on the results of this dissertation and benefits reaped those
organisations that are successful in managing human error in maintenance.

The study revealed that the reduction of human errors in maintenance requires the dedication of
management, maintenance personnel and maintenance support personnel. It is also believed that
human errors can be reduced through a progression which is aimed at transforming people,
integrating and transforming processes, and fostering strategic innovations.

In order to improve maintenance, the focus should be directed towards human-machine system
performance rather than only machine reliability as it is with most maintenance systems. The
companies should not only pay attention to machines/equipment to achieve higher profits and
production rate, but should also focus on their workforce; the very same workforce that is driving
their production. The organisation can only improve its efficiency and effectiveness if its
management takes good care of the employees; if employees are highly motivated, empowered; and
if employees are given a more central role in the maintenance system i.e. to identify and resolve
problems, as they appear during maintenance.

It has been observed that one of the main things that motivate the workforce to conduct their duties
with high quality is high salaries. In addition to higher pay, the workforce is also looking for
additional element reward. Managers should also take into consideration that even simple
acknowledgement (e.g. well done and your effort is much appreciated) in order to keep their team
motivated. Small personal gestures (e.g. calling employees by their full names and remembering
employee's birthday) can also contribute in the motivation of the maintenance team. A well-
motivated team can do very well in improving maintenance performance.

The completion of this study leaves the coal mines, particularly those in South Africa, with a tool
for maintenance improvement that is based on theoretical concept of human error management and
proven to be practicable in the industry. It is believed that the recommended performance
improvement framework will also assist in fostering a new way of thinking about maintenance
errors (especially human errors) and associated causes, and new strategy for approaching corrective
action. Since different types of human error require different approaches, knowing the most
common error types will enable maintenance management to develop targeted approaches as
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opposed to "one size fits aIF' approaches. In short, the approach should be tailored to address the
particular common error type.

6.2 RECOMMENDATION

The main objective of this section is to make a recommendation on what the coal mines should do
in order to improve maintenance performance through a facilitation of human error management. It
is of paramount importance for the management to engage the workforce in whatever they decide to
implement.

A coal mine that is concerned about the reduction of human error or human error rate in
maintenance should implement or adopt a comprehensive approach such as the Coal Mine
Performance Improvement Framework (CMMPIF). The CMMPIF is recommended by the author of
this dissertation as a best tool for better managing human errors in maintenance.

CMMPIF is presented in Figure 6.1 and Table 6.1 presents a discussion of the elements of this
framework.

Management and
Supervision

Conimunicatiun
Attitude and/or
behaviour and
Motivation
Improving Maintenance Performance

(Reducing Human Errors)

Incident reporting
sstems Work design

l'raining and %Iaintenance

Development performance Review

Figure 6.1: Coal \Iine Maintenance Performance lmproement Framework (CMMPIF). MS Nkosi, 2013

Coal mines that are willing to implement the CMMPIF, can even select certain elements of the
framework directly related to their needs, rather than implementing the whole proposed framework.
It was discovered that the key for improving maintenance performance is to develop a culture for
continuous improvement and the ideology that builds upon strong emphasis on high quality
standards.

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Table 6.1: Performance Improvement Framework/Guide Aimed at Reducing Human Errors

The Maintenance Policy

• Create a clear maintenance policy consistent with the overall organisation's business
objectives and should be easily accessible to all workers.
• One of the maintenance objectives should be to reduce human error in maintenance and to
educate the maintenance teams about human error and the importance of understanding it.
• Properly communicate the policy and objectives to all employees and it should incorporate
their views in order to foster awareness and ownership.
• Clearly define the purpose and importance of the maintenance activities and establish a
powerful plan for managing these activities.
The Strategic Maintenance Planning

• Set clear strategic objectives and action plans and their progress must be constantly measured.
• The strategies should be aimed at improving maintenance activities (e.g., repair and
inspection) and better managing the maintenance errors, specifically human error.
• It should be indicated how the risk associated with maintenance activities should be reviewed.
• Strategic planning should also address design improvement, e.g. of procedures and equipment.
• The maintenance plan should be flexible to incorporate strategic changes that might be
required. Hence, a proper approach for evaluating the effects of these changes should be
developed.
The Allocation of Resources
Management
and Supervision • The availability of adequate resources (manpower, money, tools, spare parts, equipment,
premises, procedures, etc.) should be ensured during the planning phase.
• Resources should be ascertained prior maintenance activities are conducted, their condition
should be examined, and they should be regularly evaluated.
• Resources should be easily accessible to the maintenance workers. They must be properly
located and controlled.
• In case contractors are used, it must be agreed on who will supply the essential resources. The
resources used by contractors should be regularly assessed to ensure provision and usage of
appropriate and/or predefined resources.
Defining specific roles, responsibilities and accountabilities

• Roles, responsibilities and accountabilities based on skills and competences of workers should
be clearly defined and it must be ensured that all employees know and understand theirs.
• The maintenance engineer should ensure proper coordination of the maintenance activities.
• The maintenance manager should ensure that the contractors work efficiently, safely and
within the acceptable and high standards quality.
• The purpose, importance and contribution of maintenance towards profits should be clearly
communicated across the organisation since in most cases it is seen as an overhead.
Effectiveness of Supervisors

• One of their roles should be to ensure that the maintenance teams are effective and are
working efficiently and safely.
• They should monitor and control the workshop and plant maintenance activities and also give
directions on how the workshop and plant workers should perform these activities.
• They should promote good organisational culture and best maintenance practices, at the same
time they must strive to correct bad culture and practices.
• The maintenance management should support and continuously empower supervisors in order
to always devote themselves to high standards of performance, quality and safety.
• They must pay more attention to new maintenance workers in order to ensure that they adopt
the organisation's high standards of performance, safety culture and quality.
• Managers should ensure the effectiveness and efficiency of supervisors and that they make
necessary improvements. They should also review the performance of the supervisors aiming
to identi1' the opportunity for training and improvement.

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 Communication

• Develop proper communication channels and methods with an aim of ensuring a clear and
effective communication within the organisation.
• Adopt powerful communication methods and/or devices such as presentations, group briefings
and discussions, and feedback forms.
• Ensure that the recipient receives and understands the message and that the messenger receives
and understands the feedback. The message and the feedback should reach relevant people on
time.
• Establish an open and accommodating platform that enables workers to easily and without fear
express their concerns to the management.
• Transparency, honesty and trust should be promoted when raising concerns. Nevertheless,
where it is deemed necessary, confidentiality and anonymity methods should be adopted.

Communication Procedures, work instructions and permits

• Develop clear and adequate maintenance procedures, permits and rules to ensure high
standards of performance, quality and safety. The wording should be clear with visible font
size and simple language should be used to avoid double meaning and/or misinterpretation.
• Those who will use procedures, work instructions, and permits should be engaged and their
comments should be incorporated when developing and/or updating them.
• The information contained in the procedures and work instructions should enable the workers
to appropriately perform their tasks.
• On the other hand the information contained in the permits and isolation instructions should
enable the workers to perform their tasks safely.
• Checklists should be generated based on procedures and work instructions aiming to achieve
simplicity, specifically for complicated jobs.
• Hazards and risks associated with maintenance activities should be clearly indicated.
• It should be ensured that procedures and work instructions are presented in a logical and
sequential order.
• Workers should have an easy access to procedures, work instructions and permits.
• The appropriateness and adequacy of the procedures used by contractors should be ensured.
• Procedures should be evaluated on regular basis and when changes are made, they should be
clearly indicated.

• Duties of the maintenance workers should be clearly defined and their workload should be
closely monitored in order to reduce extreme stress or fatigue.
• Tasks should be allocated in a manner which takes the individual's physical, educational and
psychological abilities into consideration.
• The maintenance workers should be adequately utilized in order to avoid lack of interest and
diminishing skills. Underutilizing the workforce is as bad as over-utilizing the workforce.
• The availability and adequacy of resources should be ensured in order to meet or manage
workload pressure.
• Intervals taken to complete the maintenance tasks should be closely monitored and properly
recorded in order to serve as a basis for improving efficiency.
Work Design • A reliable back up should always be available in order to assist in the event of breakdowns.
• Enhance the motivation and productivity of workers by adopting a job rotation or multitasking
strategies. This creates an opportunity for the workforce to advance capabilities and
competences, to improve their attitudes, and to gain new skills.
• There should be a strong and appropriate integration between the maintenance and other
processes e.g., operational processes.
• Workers employed on permanent basis should possess core competences and they must have a
strong understanding of the maintenance activities. To have such competences and knowledge
can aid the permanent workers to have proper control over the contractors.
• Maintenance teams should work towards common objectives, and should develop effective
systems for supporting each other. Specifically, they should provide more support to new
workers.

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 • Veri1' the effectiveness of the maintenance strategies which are currently implemented and
assess the efficiency of the resources in relation with meeting maintenance workload demands.
• To review the methods used in the identification of maintenance errors and correction of these
errors,
• To identi1' and improve substandard maintenance practices.
• To serve basis for the formulation of a future strategic direction aimed at reducing and/or
eliminating substandard maintenance practices and should be in line with the overall business
strategy.
Maintenance • It should adopt proper, efficient and cost effective maintenance performance indicators such as
Performance measuring the efficiency (e.g. repair times), measuring the reliability of equipment (e.g. mean
Review times between repairs) and measuring financials (e.g. maintenance costs, cost savings).
• There should be continuous review of the maintenance activities, specifically the significant
ones with the highest probability of error.
• Quality assessments, safety audits, comparison of maintenance performance within the
industry etc., should be considered during maintenance performance review.
• Questionnaires and interviews with staft incident reviews; workplace audits; task analysis and
human reliability analysis, etc., can also be used for maintenance performance review.
• In spite of high daily maintenance demands, managers should create time for maintenance
reviews.

Competency

• The maintenance workers should be acquired based on education, knowledge, skills and
experience since these are very crucial elements for performance excellence.
• The workforce should demonstrate a high level of interpersonal skills needed for proper team
interaction and effective communication skills.
• There should be a proper application of individual's capabilities in order to correctly and
efficiently accomplish specific maintenance tasks.
• It must be ensured that the workers are always having work to do in order to ensure continuous
development.
• Maintenance workers should strive to gain imperative knowledge of safety hazards and best
work practices with an aim of avoiding, reducing or managing maintenance errors.
• Inclusion of particular skills, abilities and knowledge concerning the usage of particular tools
and application of specific methods should be incorporated in the enhancement of workers'
effectiveness and efficiency.
• Competence of the maintenance workers should be constantly assessed with an aim of
indentil'ing areas for improvement. Workers should also be inspired to indicate their
inabilities or weaknesses and assistance they require to enhance their skills and knowledge.
Training
and Training
Development
• Training is required to enhance the maintenance teams' knowledge, skills and performance.
• There should be a training and/or awareness session or programs introduced to equip
maintenance workers with essential understanding and capabilities for handling complicated
tasks and uncommon maintenance situations.
• The culture of continuous career development should be promoted with an aim of enhancing
interpersonal, special and supervisory skills. These skills assist in gaining competitiveness.
• The organisation should introduce human factors training for the better management of human
errors, for fostering awareness on those factors which can influence maintenance workers'
performance.
Organisational learning

• The company should be able to review its performance with an aim of identi1iing past failures
and learning from them, hence avoid repeating mistakes which led to those failures. This will
assist the organisation to gain competitive advantage.
• There must be a commitment to performance excellence, continuous improvement of quality
and safety culture and development of the maintenance teams.
• There should be a strong collaboration of the maintenance teams aimed at exchanging skills,
and knowledge, therefore enhancing their performance and robustness.

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200830213 MS Nkosi
 • Proper reporting of incidents can assist the organisation in developing strategic ways of
dealing with human error. Without proper recording of incidents it is very difficult to prevent
such incidents in future.
• Efficient incident reporting systems promoting openness/transparency and trust when
reporting incidents should be implemented with an aim of allowing the workers to report even
their own mistakes without fearing sanctions.
• Reported incidents should be properly analysed and recorded and the feedback must be given
Incident timely.
reporting • Safety related issues should be reported and the main emphasis should be on putting up
systems preventive measures or taking appropriate corrective actions.
• The maintenance manager, engineer and foreman working closely with the workforce should
be responsible for reviewing the incident reports and to come up with corrective actions and
preventative measures.
• The incidents should be recorded and the incident report should be submitted within a short
space of time, normally 24 to 72 hours after the incident was identified or known.
• Criminal pursuit, substance abuse, forgery, deliberate violations and intended disregard of
safety, are more personal and should not form part of the incident reporting, but rather be
addressed in the relevant forums supported by the specific business policy.
• The accountability on violations during maintenance should not only be on people directly
involved, but also maintenance managers and/or engineers managing the workers.
• The reporting systems should be continuously improved with an aim reducing human error

• Paying more attention to the improvement of the attitude and behaviour of the maintenance
people is very important when aiming to reduce or eliminate human errors in maintenance.
• The maintenance staff should always be motivated to devote themselves to performance
excellence, maintaining positive attitude and acceptable behaviours.
• To foster the sense of ownership and positive attitude towards changes, management should
engage employees when taking strategic decisions.
• Fairness, openness and respect should be always taken into consideration when treating the
maintenance workforce.
• The level of motivation of the workers can be assessed using various ways such as reviewing:
The level of knowledge concerning their duties and required performance standards,
The extent at which they perform their duties with minimum supervision, and
The level of support they give to one another.
• The management should always strive to protect and improve the morale of the maintenance
team/s. The following should be considered:
The management should put their subordinates first. "They must listen more before
issuing answers"
> "Say what you mean and mean what you say". The management should keep their words
Attitude and/or and/or promises. When means of fulfilling those promises vanish, it should be discussed
behaviour and with the workforce.
motivation The management should be consistent with their treatment or dealings towards the
workforce.
• The changes should be introduced in a manner that enables the workforce to adjust with and
support these changes. Hence, it will reduce resistaiice towards the changes.
• Changes should be closely monitored since they can have a damning impact on the staffs
morale and stress levels.
• The organisational culture and/or behaviour that enhance productivity and efficiency the
maintenance teams should be protected and improved.
• When supervisors are promoted from within the teams, managers should strongly support the
supervisors and clearly communicate the authority of the supervisors to the rest of the
workforce.
• There should be team alignment sessions where the management engages with the
subordinates with an aim of aligning certain organisational behaviours, knowledge, visions
and opinions. This will assist in enhancing innovation, assertiveness and confidence.
• The management should ensure that the workers do not perceive non-compliance to give
greater benefits as compared to unfavourable consequences. This can be controlled through
training aimed at addressing the impact of non-compliance.

46
200930213 MS Nkosj
It can be concluded based on the research findings that if a coal mine properly implements the
CMMPIF, it can reap the following benefits:
• The reduction in human errors or recordable incidents,
• Reduction of unexpected shutdowns or reduction in equipment downtime,
• Decrease in maintenance and operational costs due to breakdowns, rework etc.,
• Reduction in unnecessary overtime,
• Decrease in on-job injuries,
• Decrease in equipment, plant and environmental damage,
• Create an opportunity for design improvement,
• Identification for opportunity of training and maintaining core competences,
• Highly motivated employees, and
• Increased awareness of human errors and strategic innovations towards corrective actions.
It is important to note that these benefits are not an overnight reward, but it takes time and proper
implementation and execution of a performance framework/guide.

6.3 FUTURE RESEARCH

This research can be continued by collecting human error data in coal preparation plants, thereby
developing trends that can be used with probability or statistical theory in the analysis of data. This
can help in predicting human.errors and in the formulation of tailored preventive measures.
The other element that is supposed to be looked at in future research is the proper collaboration of
benefits obtained from implementing frameworks such as the one proposed in this study.
Future research can also focus on each segment of the maintenance performance improvement
framework e.g.:
• Developing a model that will assist organizations to improve the incident reporting systems
in maintenance, and hence be an aid for better managing human error.
• The analysis of technical teamwork communication issues in maintenance so as to identify
their role in human error and hence develop or apply communication models that will assist
in the reduction of human errors in maintenance.
Development and validation of a management and supervision model in maintenance, with
an aim of reducing human error in maintenance.

47
200830213 MS Nkosi
 REFERENCES:

I. Aglemyer, R. (2014). Excellence in Aviation Safety Training, Course Scheduled for 02-04 Apr
2014 and 03-05 Sep 2014. Southern California Safety Institute.
2. Attwoo, D., & Fennell, D. (2001). I. Attwoo D & Fennell D, Cost Effective Human Factors
Techniques for Process Safety - CCPS International Conference and Workshop. Toronto.
3. Booher, H. (1997). Human Factors Integration: Cost and Performance Benefits on A1my
Systems. Hughes Training, Inc.
4. Bove, T. (2002). Development and Validation of a Human Error Management Taxonomy in Air
Traffic Control. PhD Thesis. University of Roskilde.
5. Carthey, J., & Clarke, J. (2010). Implementing Human Factors in Healthcare .. How to Guide··.
Making the Sqfety of Patients Eve,yone 's Highest Priority. United Kingdom: Patient Safety
First.
6. Department: Minerals and Energy RSA. (2004). Operating and Developing Coal Mines in the
Republic of South Africa. Pretoria, RSA: Directorate: Mineral Economics (Minerals Bureau).
7. Dhillon, 8., & Liu, Y. (2006). Human Error in Maintenance a Review. Journal of Quality in
Maintenance Engineering . Vol. 12 (No1).
8. Drury, C. (2000). Human Factors in Aircraft Maintenance. New York: State University of New
York.
9. Dunn (c.2007). Managing Human Errors in Maintenance. Retrieved March 10, 2012. from
www.uhfg.se: www.uhfg.se/pdf/Artikelarkiv/ManagingHEMaintenance
I0. Edkins, G. (2002). Developing a Business Case for Aviation Human Factors Training: Show Me
The Benefit! . Qantas Airways.
11. EFCOG. (2007). Human Pel'jormance Improvement and Feedback & Improvement, Cause
Analysis Workshop. Retrieved September 3, 2013, from www.efcog.org:
http://www.efcog.org/wg/ism/events/Spring07Mtg/docs/Grant HPI Presentation.pdf
12. EUROCONTROL. (2006). Revisiting The S.viss Cheese Model of Accidents - EEC NoteNo.
I 3106. Bretigny-sur-Orge Cedex - France: European Organisation for The Safety of Air
Navigation.
13. Govender, T. (2008). Strategic Issues for l(fe Extension of Boiler Feed Pump Drives at Coal
Fired Power Stations, M. Ing Dissertation. Johannesburg: University of Johannesburg.
14. Hawkins, F. (1993). Human Factors in Flight. Ashgate.
15. Health and Safety Executive. (2000). Improving Maintenance a Guide to Reducing Human
Error. HSE Books.

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 International Association of Oil & Gas Producers. (2005, June 1). ui'ii'.ogp.org.uk. Retrieved
August 9, 2013, from http://www.ogp.org.uk/publications/safety-cornmittee/human-factorsa
means-of-improving-hse-performance/
Johnson, W., & Hackwork, C. (2008). Human Factors in Maintenance (Surveys reveal the
importance of regulations mandating Ii uman factors programs). AEROSA F ETY WORLD.
Knee, H., & Haas, P. (1981). The Nuclear Pmt'er Plant Maintenance Personnel Reliahility
Prediction (NPP/MPRP) Efjbrt at Oak Ridge National Laboratory. Oak Ridge: Applied
Psychological Services, Inc.
Malotaux, N. (2008). Recognizing and Understanding Human Behaviour to Improve Svtems
Engineering Results. APCOSE.
Nkosi, M. (2011). Maintenance Logistics Project - Preparation of a Total Maintenance LogLs'tic
Strategy and Action Plan. Johannesburg: University Of Johannesburg.

Partteson, J. (2009). Human Error in Mining: A Multivariable Analysis of Mining Accidents or

Incidents.., a Thesis fhr Doctor of Philosophy in Industrial Engineering. Clemson University.
Pires, A., & Vorster, P. 201 1, July 12). www.psvcologvafrica. psvchologyafrica.com . Retrieved
July 3, 2012, from www.psycologyafrica. psychologyafrica.com/20 11/07/thematic-analysis-of-
the-reasons-for-mine.
Reason, J. (2000). Journal digest (Human Error: Models and Management) BMJ. Manchester:
University of Manchester.
Safety Regulation Group. (2002). An Introduction to Aircraft Maintenance Engineering Human
Factors for JAR 66. Civil Aviation Authority.
Schaefer, C. (2011). Baldrige 201120 "An Executive s Gui/dc to the Cr//er/afar Per/brmance
Excellence '. USA: National Institute of Standards and Technology.
Steve, M. (n.d.). Improving Maintenance by Reducing Human Error, Health Safety &
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maintenance.com/articles/maintenance - human - error: www.plant-
maintenance.com/articles/maintenance human error
The South African Coal Roadmap. (2011). Overview of The South African Coal Value Chain.
The South African Coal Roadmap.
Whittingham, R. (2004). The Blame Machine: Why Human Error Causes Accidents? Elsevier
Butterworth-Heinemann.
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 3 1. World Coal Association. (2011, August). Coal Statistics. Retrieved June 10, 2012, from
www.worldcoal.org: http://www.worldcoal.org/resources/coal -statistics/
32. Xavier, A. (2005). Managing Human Factors in Aircraft Maintenance through a Performance
Excellence Framework, Masters of Aeronautical Science. Embry-Riddle Aeronautical
University.

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200830213 MS Nkosi -
 APPENDIX A

Mfundo S. Nkosi
29 Mynhardt Street
Birchleigh North
Kempton Park
1618
04 April 2013

The Maintenance Manager

Company Name

Dear Sir

APPLICATION FOR PERMISSION TO INTERACT WITH MAINTENANCE PERSONNEL

I wish to request a pennission to interact with maintenance management (Manager and Engineer),
artisan�, maintenance assistants and other relevant maintenance employees.

I'm a part time student at University ofJohannesburg who is currently busy with Masters of
Philosophy in Mechanical Engineering (Maintenance Engineering). One ofthe requirements ofthe
degree is to do a mini disse11ation (research project). J have selected a study into the impact of
maintenance errors (specifically human error) in a coal preparation plant, which is where l require
assistance.

I have formulated a questionnaire as part ofthe survey which will be filled in by maintenance
personnel, and I will then analyze the results based on the questionnaire feedback. This is a
descriptive research, which will not require me to engage with machinery.

I was once an Engineering Trainee in one ofthe mines and I have treated all infomrntion collected
during my training period as confidential.

I will indicate the names ofthe participants and mining collieries as anonymous (e.g. Mine A or
Colliery A, etc.) on the dissertation which will be submitted to the university.

If you would like to see a summary ofresults after completing my study, you can indicate so that I
can prepare it for you.

Your assistance with my'research survey will be highly appreciated.

Yours Faithfully
Mfundo S. Nkosi
0762084326
Work: 012 667 7727

51
200830213 MS Nkosi
 APPENDIX B

)pen Cut \\".;1�1·

Tr�eu:1em Diesc:
Pllllll Storage

\\"orkshop To:!ets Otliccs­

(itragcs
Chenl!e Boardrooms
l.3eth rooi:i.,
Depot
Sub-stores

Figure Bl: Coal Mine Layout (Nkosi M.S, 2011 :19)

)leehanical Department Elect.-ic.d Department

.-----,----------,-1IEntrJncc -'�1--..------------------,.-----.
Onrhaubng Welding :\lotor
Pha�ing

Cable Joints
and other
- ]:: �
<.;.j related
,:
,... ";; Oeanmg & Cuttmg. Grinding timcuons
� � .; Exammation of

-s�
Damage ci'f
::; Components
�
[)

I I
-:..., !J

0
.: .:
S'D, Drg § �
1Entr.inec 11 !---'------'"' �---iD-
Lmng Arca

0
---------------�40m

52
200830213 MS Nkosi
Figure B2: Workshop Layout (Nkosi M.S, 2011:20)

"k.ntrancr )Lntranc
Puiips - I (carboxcs Stoi-es & Contiol
Parts - Of1ic
I Parts
E cc Lr: c a.
Motors -
\avcs P arts
Convcror Pucvs. Idcrs Bcar:ns
Parts & othcr
- othcr orivcyor parts
c.ccti :cu
Components '-I
P:pc
FTarizcs.
\ 13i t'
Bcd

Rates—
Parts for
L L: ft
Rattbrms. Equ:pmcrit
(;rdt BdIT aJc'

311 rn

Figure B3: Sub-store Layout (Nkosi M.S, 2011:20)

53
200830213 MS Nkosi