ICAO: Human Factors documents » ICAO: Human factors guidelines for aircraft maintenance manual
ICAO published in 2003, the Doc 9824 AN/450 Human factors guidelines for aircraft maintenance manual1. This manual as supporting document to the Human Factors Training Manual (Doc 9683), provides the Contracting States with practical guidance and supporting information in the establishing standards to comply with the Human Factors-related amendments to the Annex 1- Personnel Licensing and Annex 6 - Operation of Aircraft. Although a relatively old publication, the main ideas that are addressed in the manual currently remain relevant and described below is a synopsis of the contents in the manual.
Chapter 1. Why Human Factors in Aircraft Maintenance - Background Information and Justification.
The Chapter 1 of the Doc 9824 contains fundamental human factors concepts and it’s importance in the maintenance organizations, including training programmes for their technical staff and aircraft maintenance engineers. But the accident and incident reports continue to show that the actions taken by many organizations, such as Human Factors Training or Incident Investigation are not always successful. Some studies show that maintenance accidents and incidents are not only costly in terms of life and property, but they can also impose significant costs when flights are delayed or cancelled. Taking preventive measures in reducing maintenance errors can save great amount of money. Quality System and Training in Human Factors is important within Maintenance Organisation.
The Chapter 1 also contains a brief description of the SHELL framework and risk management
Chapter 2. Key Issues Related to Maintenance Errors.
This chapter contains some of the key issues which can lead to maintenance errors and contribute to incidents or accidents. These issues outlined in the Table below
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| Comparison of maintenance-related accident/incident causes between three States cross-referenced against the sections of Chapter 21 |
| (image embedded from Photobucket.com on 14 October 2011) |
To promote high level safety it is not just enough to comply with the regulations. The organizations need to establish own internal standard for safety. This should include: compliance with technical standards and best practice; effective management based on quality system and measurement of safety outcomes.
Organizations have to pursue two distinct objectives: production and safety.
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| A summary of some of the factors that contribute to fallible, high-level decision making1 |
| (image embedded from Photobucket.com on 14 October 2011) |
If too many resources allocated in one of these objectives the other one could be compromised. Employees are most important resource in any organization, therefore the way how the management deals with its employees will affect above objectives. To reduce human errors within Aircraft Maintenance Organization (AMO) “best principles of managing people” should be in all aspects of the production and management system. Maintenance personnel needs to receive formal training in order to get their licence and Annex 1 now requires that training should include the knowledge of “human performance”. For the management and inspection staff of State regulators such knowledge should be deeper and broader than for industry personnel.
Chapter 3. Countermeasures to Maintenance Errors
This chapter contains a brief description of Accident causation model. Therefore it’s evident that there is a need to manage and control errors and to lessen the errors negative consequences through a systematic error management system. This chapter identifies some of the countermeasures that need to be implemented within maintenance organization to reduce maintenance errors. These include but not limited to environmental, ergonomic, documentary and fatigue interventions.
Chapter 4. Reporting, Analysis and Decision Making
This chapter identifies the important aspects of collection, analysis and use of event. According the ICAO Standards and Recommended Practices (SARPs) all contracting states should establish the reporting system of incidents or errors. Reporting own error is always not easy, therefore States should ensure that no-punitive action to be taken against individual employees, in cases where the investigation reveals that the error was an unpremeditated or inadvertent lapse. Because error is an integral part of all human endeavour, eliminating it is an unachievable objective. Therefore the maintenance organizations should conduct the investigation and analyses of error and take preventive actions (“close the loop”).
Chapter 5. Training
This chapter identifies guidelines to maintenance organizations to meet the requirements of Annex 1 and Annex 6. These include: identifying the training needs and objectives; its implementation and syllabus development; conducting training and its assessment.
Chapter 6. Regulatory Policy, Principles and Solutions
This chapter identifies guidelines to a State’s aviation regulators to develop its own standards in compliance with the SARPs of Annex 1 and Annex 6.
Chapter 7. Additional Reference Material
This chapter contains sources of currently available material that was used as background information in this manual
Want to know more?
- ICAO's Doc 9824. Human factors guidelines for aircraft maintenance manual
- You can access the whole document online as "Doc 9824 AN/450. Human factors guidelines for aircraft maintenance manual". ICAO (Montreal, Canada), 2003.
