Managing maintenance error
This article reviews Franklin’s (20081) 'Fighting the war on maintenance error' article, which provides an insight on the concept of maintenance error and how to manage it. His target audience was the military aviation environment but this could equally be applied across to civil aviation.
Franklin defines maintenance error as a performance failure of the maintenance system where the system did not perform the correct way or as expected. Examples of maintenance errors include, among others, foreign objects or tooling lost in an aircraft during maintenance, contamination of a fuel system due to poor procedures or practices, and failure to correctly install components.
A number of elements are in place to prevent error and minimise the consequences of maintenance error. These elements include publications, rules and regulations, procedures, functional testing, training, authorisations, inspections, independent inspection, supervision, and quality assurance. Despite these maintenance system elements and functions, maintenance error still occurs with associated causation chains leading to incidents and accidents. To combat the consequences of maintenance error, managers need to understand key principles of error management, do more to investigate and learn from maintenance error, and apply appropriate techniques to prevent it from occurring.
Principles of error management
- Human error is inevitable and universal. Maintenance personnel make errors and it is as much a part of life as breathing. It is inevitable.
- Errors are not intrinsically bad. Maintenance personnel can learn from their errors.
- You cannot change the human trait of making errors, but you can change the environments and conditions in which humans work. In critical environments, Maintenance personnel must recognise and understand error conditions, and derive the approach for preventing error from this recognition and understanding.
- Humans who are experts and masters in their professions will still make mistakes and errors. Even expert maintainers or masters of a technical trade will make errors, and some will be serious.
- Humans can not simply avoid errors they did not intend to commit. Unintentional errors should not be met with blame and punishment. Maintenance personnel should be accountable for their actions, but punishment will not necessarily prevent the errors made from reoccurring.
- Understand errors as being consequences rather than causes. Understand that error has a chain of causation which leads to an outcome. It will be possible to provide positive outcomes by determining and removing the elements which create the chain.
- Maintenance error is about managing what is manageable. Maintenance personnel can be managed but not fully controlled. Uncontrollable traits like personal distraction will always be evident.
Techniques for managing error
- Identify behaviours in the maintenance organisation which are unacceptable, inappropriate, or undesirable. An example would be poor documentation or the perceived requirement/pressure to work long hours to complete a task.
- Replace unacceptable behaviour with correct behaviour. Establish boundaries and framework for maintenance organisations to operate under. An example would be to establish rules on work hours and overtime.
- If something is not correct in the maintenance organisation and system, get it corrected for the future. However, in applying this concept it must be understood that at a working level what is deemed the correct approach might not be correct across the organisation. Communication and information flow across all levels must be achieved during the correction process.
- Maintenance incidents, near misses and accidents must be reported to allow the organisation to learn from error and to put mitigation strategies in place. An easily accessible, non-punitive, and anonymous reporting system can be very valuable.
- Investigating and reporting maintenance error generates understanding as to why an incident occurred. Expand investigations wider to include latent errors and defects, not just the active errors and physical causes.
Want to know more?
- AviationKnowledge - Threat and error management
- Explaining the interaction between safety and human performance within an operational context.
- AviationKnowledge - Maintenance resource management
- Crew resource management for maintenance personnel
- Civil Aviation Authority of New Zealand - Safety management systems policy
- The CAA's policy on Safety management systems.
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