REGARDS
SANDEEP KEELU

First, Licensed Aircraft Maintenance Engineers (LAME) fall under the demarcations set out by the local airworthiness authority and the rules within Part66 of CAA rules. Maintaining the maintainers? LAME's have a delegation authorized by the CAA to certify maintenance iaw the above rules within the boundary's of his/her ratings and category.
Those who do not reflect on history are distend to repeat it. Human Factors research has influenced the overall safety of aircraft operations and maintenance.

A better question to ask is, Without Human Factor Research and interventions within aviation, how would this effect overall aircraft safety? I assume in the essence of safety, the answer is reasonably clear.

REGARDS
SANDEEP KEELU

REGARDS

SANDEEP KEELU

Does anybody has knownledge about Rolls Royce's Direct Accumulation Counts (DACs) for LLP's Calculation for RB211-535E4?

I have just read your email. Probably at this time you have made your decission.

Your diploma in A/C maintenance Engineering should be also applicable to work in modifications to the certified design ( called Type Design or Supplemental Type Design STC _ you may check FAA and EASA sites for more information). Within this field, you may dedicate to aircraft interiors design. As an engineer you will be not only able to draw a nice artistic concept but ALSO consider the technical complexities of the certification (ie Cabin Safety) , installation, testing and maintenance. There is a huge working area in Aircraft Interiors wnere creativity and artistic care are very appreciated. You may take a look on the site www.aircraftinteriorsinternational.com.
Good luck and go ahead! Then I wish you Selamat Jalan……

Warm regards

Juan

maintaining the maintainers? What impact has human factors research and intervention had on overall aircraft safety?

Myself and other Aircraft Engineers will agree the above statement is rubbish!

First, Licensed Aircraft Maintenance Engineers (LAME) fall under the demarcations set out by the local airworthiness authority and the rules within Part66 of CAA rules. Maintaining the maintainers? LAME's have a delegation authorized by the CAA to certify maintenance iaw the above rules within the boundary's of his/her ratings and category.
Those who do not reflect on history are distend to repeat it. Human Factors research has influenced the overall safety of aircraft operations and maintenance.

A better question to ask is, Without Human Factor Research and interventions within aviation, how would this effect overall aircraft safety? I assume in the essence of safety, the answer is reasonably clear.

Background

Embedded as a customer within an overseas-based aviation contractor working on an aircraft avionics upgrade project, I observed and experienced multiple safety incidents related to standard operating procedures. Documented below are two examples which highlight the importance of following procedures, describe the consequences of not following procedures, and demonstrate poor communication within an aviation organisation. Arguably, these examples demonstrate defences preventing potential accidents.

INCIDENT 1: CAPTAIN YOUR TEST FLIGHT IS DELAYED.

During the flight testing program the aircraft was configured for a particular serial and dispatched by the contractor in preparation for flight. As a part of this standard procedure/process the contractor maintenance team was to brief the aircrew on the serviceability state of the aircraft (during the pre-flight brief). The brief included the following:

• Project installations which had occurred since previous flight,
• Maintenance and repair carried out on the aircraft since last flight,
• Long term acceptable defects to be carried on the flight,
• General servicing and replenishment information,
• And any other relevant information pertaining to maintenance on the aircraft.

On this occasion the brief was completed and it was announced that the aircraft was serviceable for flight. When aircrew pre-flight was complete the contractor produced its maintenance release form fully signed, the aircraft maintenance log book was signed and the aircraft was released for flight.

As the aircrew were strapping into their seat and the aircraft ladder was about to be lifted the contractor’s quality assurance lead wandered into my office and handed me some paperwork. The paperwork indicated that during the evening the nightshift maintenance team had carried out rectification on a long-term defect on the autopilot system. Further inspection of the paperwork suggested that after a re-wire of a connector in the autopilot system, no functional and independent functional had been carried out. These are standard maintenance procedures. The contractor who briefed the aircrew on maintenance made no reference to this autopilot work and in fact had no idea the work had been carried out over night by the other shift.

After a quick exchange of words with the contractor I immediately went out to the aircraft to explain to the captain that his flight was going to be delayed, and that he needed to sign the aircraft back to maintenance so the contractor could carry out the functionals prior to the aircraft flying. Of note, in 25 years of working in aviation maintenance it was the first time I had to prevent an aircraft from flying.

Potential Safety Implications

The safety implications of this maintenance error have the potential to be catastrophic. An example would be an incorrectly wired autopilot system has the potential to place the aircraft in an incorrect sense (attitude). A functional and independent function confirms the autopilot system operates in the correct sense.

Incident Cause

• Lack of adherence to standard operating procedures.
• Poor communication between the two functional elements in the contractor’s maintenance team.

Human Factors Lessons

It could be argued system defences captured this error prior to the aircraft taxiing but in reality it was a matter of timing which allowed this error to be picked up. Equally it could be argued if there was a problem on engaging the autopilot the pilot's skills, expertise and SOP's would mitigate the likelihood of an accident. However, if this maintenance error remained latent and lined up with other active and latent errors, and defences were breached, then a major accident could occur (Accident Causation Model).

Two important lessons can be derived from this incident:

• Standard operating procedures are an important element in a safety management system. Procedures are put in place to reduce error and mitigate consequences of error so they should be followed, and this ethos should be followed in all levels of the organisation.
• Communication is an important aspect of a safety management system. It allows information flow from top/down and bottom/up. The positive aspects of good communication contribute to safety and efficiency. In this case good communication between the maintenance shifts would have highlighted the functionals were not carried out and the customer would have been fully informed that the work had been completed.

INCIDENT 2: SAFETY LOCKING DEVICES AND PROCEDURES.

During standard post-flight maintenance on the aircraft described in incident one, the contractor’s maintenance staff were required to follow the customer’s standard operating/maintenance procedures, and these were laid out in the form of work cards.

On this aircraft there are two hydraulically activated large doors on the underside of the aircraft. To make these doors safe there is a safety pin (locking device) which is inserted at all times on the ground which prevents the inadvertent or accidental actuation of the doors with the aircraft hydraulic systems powered on the ground.

In short on two occasions this procedure was not followed correctly and the safety pin was inserted incorrectly, and on both these occasions the error was made by the same tradesman. On both occasions the error was noticed by customer representatives and brought to the attention of the contractor’s line management. Of note, no ground safety incidents were raised for these errors because an easily accessible, non-punitive and anonymous safety reporting system was not in place, and if there was it was not communicated well.

In the weeks following this incident another procedural issue occurred with contractor’s staff which involved the application of external power to the aircraft without using standard operating procedures. On this occasion, one of the aircraft hydraulic systems was left on when power was applied and there were people standing in area where the doors close. If this error had occurred with an incorrectly inserted safety pin and incorrectly positioned door switch (a part of external power on check), an accident would have been inevitable. This tradesman’s failure to follow procedures was investigated as a result of this incident and she was given remedial training.

Potential Safety Implications

The safety implications of this error have the potential to be fatal. In short, if a person was caught in these doors as they were being closed they would be literally cut in half.

Incident Cause

• Lack of adherence to standard operating procedures.
• Poor or lack of thorough training for the contractor maintenance team on aircraft type.
• The competence of the tradesman could be questioned.
• After discussing the incident with the tradesman he was hesitant about notifying his management of uncertainty or lack of confidence in carrying out the task correctly.
• Poor design on the aging aircraft which could allow the pin to be fitted incorrectly.

Human Factors Lessons

This incident highlights latent errors documented in the Accident Causation Model. Important lessons can be derived from this incident:
• Standard operating procedures need to be trained, followed and their use embedded in the organisations safety culture.
• Training to generate expertise is an important aspect to be managed in a safety management system.
• Building a safety culture with open communication is important in aviation organisations. A ‘rule with an iron fist’ type attitude has no place in aviation at all organisational levels. This would help to mitigate tradesman having fears of ‘putting their hand up’ when they are uncertain, uncomfortable or feel safety and efficiency is being compromised.
• The value in having an easily accessible, non-punitive and anonymous safety reporting system has a necessary place in aviation organisations to allow collection of data on near-misses, incidents and accidents. This will provide data for reducing error and mitigating error consequences.
• Redesign of the safety pin (locking mechanism) is a valid option.

Interestingly I work for the same organisation as others who have posted information on maintenance fatigue in this forum, and I would like to comment on an experience I endured while working on a project team.

The organisation I am employed with and its management are well known to employ insufficient manpower on project teams to save costs and this particular project was no different. The project involved the upgrading of the avionics systems on an aging, turboprop aircraft by an overseas based contractor. The project team to be discussed was the customer in this upgrade and our responsibilities involved:
• Maintaining quality assurance,
• Ensuring the project met the contract specification,
• Providing operational and engineering liaison with the contractor,
• Ensuring the basic aircraft systems (non upgraded systems) were serviceable,
• And to ensure my organisation’s standards and documentation were correct and complete.
My role was the lead flight line/hanger specialist on aircraft type in a small engineering and maintenance team with four members (2x engineers and 2x senior technicians).

Over three and half years the aircraft was subjected to a major upgrade to its systems followed by integration and test phase. While the aircraft was in the hangar it was regularly inspected and serviced while in preservation. Prior to the flying phase the aircraft was subjected to a comprehensive wake-up servicing plus functional testing.

As the customer, our under-manned engineering team was responsible to ensure we were ready to fly and all the documentation was complete by a certain date, and this dead line had been set under the contract. The final few weeks leading up to the first flight (Functional Check Flight) were hectic due to the significant amount aircraft documentation, recording and aircraft inspections required. In short, to achieve this task our team worked on average 14-18 hours per day and weekend work for over a week to achieve the deadline. The task was complicated by poor and slow documentation of the work completed by the contractor. In the end our small team met the deadline and the aircraft completed its post-upgrade flight with reasonable success, apart from a flight safety incident which was unrelated to any of the engineering teams actions.

This experience has left lasting impression for me personally of what not to do in aviation and as an aviation human factors manager. Our small team was physically and mentally fatigued after 4-5 days but we pushed on to achieve the task, with a ‘can do attitude’. Key fatigue issues experienced included:
• Making mistakes with the documentation (which were corrected),
• Lost concentration during inspections where I had to walk away at times to clear my thoughts,
• Behavioural issues (Short temper),
• General tiredness and malaise with degrading health and appearance,
• Observation similar issues with my fellow team members.

At one point in the process one of the engineering leads and I put our hands up to demand a break, which did occur but was still not sufficient to relieve our fatigue. We also requested more staff during this period but continually had replies suggesting there was no money to make this happen and no staff available to supplement the team. Operational staff observed and expressed their concern to management of the hours worked by engineering, but the reality was that meeting the deadline was more important, especially for the contractor. Eventually, during the flight testing program, our concerns were recognised and the team’s composition was increased. However, it could be argued the manpower increase was valid and still required at the later date but should been actioned prior to the start of flight testing.

From this experience I learnt the following lessons:
• Fatigue in aviation maintenance is a real threat. Fatigue has the potential to generate latent errors which may go unnoticed until errors line up to create an accident (See Accident Causation Model)
• As a human factors manager in aviation projects or any aviation maintenance operation it is important to ensure there is enough employees or time to allow careful management of employee health and fatigue. This approach will maintain safety and keep the operation more efficient.
• As a human factors manager in aviation maintenance there is a requirement to be aware and understand the risks of pushing team members to their extremes and in this circumstance there was no true requirement. Note, it must be understood in some organisations like the military, there may be a necessary requirement to work to extremes (although it is discouraged).
• As a member at all levels in aviation organisations, and in the interest of maintaining safety and efficiency, there should not be any hesitation in notifying management of unsafe circumstances and practices.
• There is no place for the ‘can do’ approach in aviation if it has negative consequences on safety and efficiency.
• I would like to endorse the lessons learnt on fatigue described by Charger007 and Robere in this forum.
• SAFETY is a key requirement or outcome in any aviation maintenance or project activity so contract deadlines and financial drivers must NOT take precedence.

This shift pattern had substantial potential for a team of four individuals to become extremely fatigued via substantial changes in their sleeping patterns and circadian rhythms.

I was part of an early team who had a shift pattern very similar to the one described. We had worked the previous week’s night shift, had dispatches to undertake to facilitate flying in the weekend and then the aircraft we were responsible for had parachute tasking during the week which required us to start most days at 4:30 am. This shift pattern, in hindsight, left us very fatigued and greatly increased the risk of errors to occur.

An error did occur during the early shifts, thankfully though it was not a substantial one and certainly no one was in any danger, but it was an error none the less. The aircraft we had to dispatch required that their fuel tanks have a fuel drain conducted every dispatch. On the Thursday morning of our shift the four of us all assumed that someone else in the team had conducted the fuel drains. This assumption was incorrect. Normally this sort of assumption would not have occurred, so to speculate was it the fatigue that led the four of us to an assumption. This error was picked up by the aircrew when they queried if the fuel drains had been completed. Each of us then realised that our assumption was incorrect. The fuel drains were subsequently completed and the aircraft was only delayed 20 minutes.

Lessons

Shift patterns and work-loads have a massive impact in maintenance technicians fatigue levels and need to be managed better than in this example.
There is absolutely no place in aviation for assumptions.

Wonder who you were working for.

An excellent lesson on maintenance fatigue. I work for the same organisation and became aware through a variety of experiences how fatigue was managed differently for aircrew and maintenance.

Aircrew have strict rest and duty requirements that are exceeded in only rare instances and with good justification. Yet maintenance crews work exceedingly long shifts in order to present serviceable aircraft for the scheduled flying. On deployments shifts can be over 12 hours long with short rests. On occasions I noticed the effects of this cumulative fatigue manifesting in behaviors and maintenance events. One event that was reported, involved a propeller almost being lifted incorrectly. Had an aware technician not stopped the lift the result surely would have been damage to the tune of thousands of dollars not to mention the indirect costs of lost flying time and experience.

I made a couple of deductions from that experience. Firstly fatigue on maintenance can have similar effects to safety and efficiency that it does on aircrew and therefore needs to be managed just as carefully. Secondly as a manager on the organisation I relied to much on my 'know how' style of management and needed to incorporate other styles such as a functional perspective and dare I say it a legislative approach in order to impose some limits to the hours the maintenance shifts were pulling.