3rd Annual European Airline Engineering & Maintenance Conference

Zurich, 21-22 February 2007

AIRLINE SAFETY AND THE EFFECTS OF MAINTENANCE

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

PRESENTATION OVERVIEW

Review of Maintenance Error Events The Contribution of Maintenance Error to Accident Statistics Safety Systems and Human Performance in Maintenance Maintenance Error and Business Risk

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

REVIEW OF MAINTENANCE ERROR EVENTS

ALOHA BOEING 737

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

REVIEW OF MAINTENANCE ERROR EVENTS

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

REVIEW OF MAINTENANCE ERROR EVENTS

AIRBUS A320 SPOILER INCIDENT

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

REVIEW OF MAINTENANCE ERROR EVENTS

BOEING 737 DOUBLE ENGINE OIL LOSS

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

REVIEW OF MAINTENANCE ERROR EVENTS

G-CEPR

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

REVIEW OF MAINTENANCE ERROR EVENTS

777 fuel panel

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

REVIEW OF MAINTENANCE ERROR EVENTS

COMMON FACTORS IN THESE INVESTIGATIONS Procedural deviations Inadequate regulatory oversight

Inadequate maintenance programme

Failure to respond to cues and warnings Inadequate promulgated information

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

REVIEW OF MAINTENANCE ERROR EVENTS Non-use of available resources

Failure to communicate Design deficiency Failure to anticipate effects on the operation of the aircraft Inadequate maintenance environment Human performance limitation Inadequate management oversight

Incorrect parts or tools

Inadequate knowledge or training
3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

THE CONTRIBUTION OF MAINTENANCE ERROR

TO ACCIDENT STATISTICS

Accident rate plots

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

THE CONTRIBUTION OF MAINTENANCE ERROR

TO ACCIDENT STATISTICS

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

THE CONTRIBUTION OF MAINTENANCE ERROR

TO ACCIDENT STATISTICS

Most maintenance error events investigated were INCIDENTS not ACCIDENTS Maintenance related occurrences form a larger proportion of total incidents investigated by AAIB than accidents.

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

THE CONTRIBUTION OF MAINTENANCE ERROR

TO ACCIDENT STATISTICS

THE COSTS OF A MAINTENANCE EVENT

Rework/re-instatement costs Additional hangar time costs Repair costs for consequential damage Maintenance re-scheduling and knock-on delays Operational schedule related costs Compensation costs Cost of hiring a replacement aircraft Business costs obtaining and retaining market share
3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

SAFETY SYSTEMS AND HUMAN PERFORMANCE

IN MAINTENANCE

Maintenance Error Management Systems Safety Management Systems UK CAA CAP 716 Transport Canada has SMS requirement US FAA - intent for the future?

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

SAFETY SYSTEMS AND HUMAN PERFORMANCE

IN MAINTENANCE

SAFETY MANAGEMENT SYSTEMS

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

SAFETY SYSTEMS AND HUMAN PERFORMANCE

IN MAINTENANCE
Man errs as long as he strives. Goethe

LIMITATIONS OF HUMAN PERFORMANCE

Perception and Cognitive limitations Physical limitations PERFORMANCE LEVEL Skill-based level Rule-based level Knowledge-based level ERROR TYPE Slips and lapses RB mistakes KB errors
3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

SAFETY SYSTEMS AND HUMAN PERFORMANCE

IN MAINTENANCE
ERROR TYPE MAINTENANCE DATA 0.15 0.026 0.042 0.042 0.033 0.089 0.089 0.09 0.17 EXPERT ASSESSMENT 0.001 0.001 0.013 0.32 0.02 0.0023 0.01 0.1 0.01

Skip a step Skip a task Ignore a warning/caution Intentionally deviate Improperly remove/replace Improperly repair Incomplete installation Improperly adjust Allow/cause debris to enter

Source Ostrom et al, INEEL

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

SAFETY SYSTEMS AND HUMAN PERFORMANCE

IN MAINTENANCE PROCEDURES MITIGATE RISK OF HUMAN ERROR Clear documentation Parts kits Checklists Inspections Function checks Even pre-flight checks

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

SAFETY SYSTEMS AND HUMAN PERFORMANCE

IN MAINTENANCE

WHY PROCEDURAL ERRORS UNDERMINE SAFETY Clear documentation is useless if not used

Parts control cannot work if uncontrolled stocks are held

Duplicate Inspections must be truly independent

Function checks must be carried out

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

MAINTENANCE ERROR AND BUSINESS RISK

EXAMINING THE RELATIONSHIP BETWEEN BUSINESS RISK AND MAINTENANCE ERROR

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

MAINTENANCE ERROR AND BUSINESS RISK

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

MAINTENANCE ERROR AND BUSINESS RISK

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

MAINTENANCE ERROR AND BUSINESS RISK

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

MAINTENANCE ERROR AND BUSINESS RISK

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

MAINTENANCE ERROR AND BUSINESS RISK

Non- compliance is the norm in many situations in daily life. It is human nature to resolve conflicts pragmatically. Pragmatic solutions become Norms. Norms become the way we do things around here.

Non - compliance becomes part of the culture.

The non- compliance may continue for years before the risk 3rd Annual European Airline Engineering & Maintenance Conference emerges. Airline Safety and the Effects of Maintenance

MAINTENANCE ERROR AND BUSINESS RISK

JUST CULTURE Validity of the Just culture rather than blame or noblame.

SUBSTITUTION TEST The substitution test if another mechanic would have done the same thing, then the issue is an organisational problem.

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance

MAINTENANCE ERROR AND BUSINESS RISK

BUT there are hidden risks of rule-breaking If your organisation experiences rule-breaking, then it is exposed to an unknown level of risk. Dual risk 1 the risk that the rule was intended to prevent: (when we break the rule, we do not know the extent of our exposure)

The risk of being caught out. (Fines, litigation, Insurers deny claims)

MAINTENANCE ERROR AND BUSINESS RISK

Recent examples from AAIB investigations into actual incidents: A technician assembled propeller de-icer boots without the required sealant materials, which were difficult to obtain. The boot detached causing injury and damage. A mechanic assembled a helicopter rotor head without the required shims, because the job was urgent. The helicopter suffered severe vibration and blade cracking. After major maintenance, an engineer stamped up a number of job cards to close all remaining open panels, but not all the panels were open at the time. One of the closed panels was not properly closed and latched. The panel came off and penetrated the cabin.

MAINTENANCE ERROR AND BUSINESS RISK

Unexpected consequences!

XXX was the mechanic who fitted a non-standard titanium strip to a DC-10... He allegedly fixed the titanium alloy part instead of a softer metal strip in the maintenance unit in Houston, Texas, even though its use was not sanctioned by US civil aviation authorities. His supervisor was questioned in June by the judge but has thus far not been put under criminal investigation. The airline itself was placed under investigation for manslaughter and injuries in March, but has vowed to fight any charges that may ensue.

MAINTENANCE ERROR AND BUSINESS RISK In 1994 AAIB stated: The Civil Aviation Authority should formally remind engineers of their responsibility to ensure that all work is carried out using the correct tooling and procedures, and that they are not at liberty to deviate from the Maintenance Manual but must use all available channels to consult with a design authority where problems arise; if full compliance cannot be achieved the engineer is not empowered to certify the work. [Airbus A320, G-KMAM AAIB Report 2/95, Safety Recommendation 94-41] This is still the only way forward.

THANK YOU FOR YOUR ATTENTION

3rd Annual European Airline Engineering & Maintenance Conference

Airline Safety and the Effects of Maintenance