ROYAL AERONAUTICAL SOCIETY

ENGINEERING MAINTENANCE STANDING GROUP

CONFERENCE
AAIB FARNBOROUGH, 10 OCTOBER 2007

RISK IN THE MAINTENANCE

ENVIRONMENT
Alan P Simmons M.Sc., C.Eng., M.R.Ae.S.
Principal Inspector of Air Accidents,

Air Accidents Investigation Branch, United Kingdom

EMSG Conference 10 October 2007

AAIB Farnborough

EMSG Conference 10 October 2007

AAIB Farnborough

PRESENTATION OVERVIEW

SAFETY SYSTEMS AND HUMAN PERFORMANCE

MAINTENANCE ERROR AND BUSINESS RISK

REMEDIAL MEASURES

EMSG Conference 10 October 2007

AAIB Farnborough

SAFETY SYSTEMS AND HUMAN PERFORMANCE

IN MAINTENANCE

Our safety systems have evolved:

Checking/inspecting: Quality Control

Controlling the production process: QC, TQM

Managing safety: MEMS, SMS

EMSG Conference 10 October 2007

AAIB Farnborough

SAFETY SYSTEMS AND HUMAN PERFORMANCE

IN MAINTENANCE

SAFETY
MANAGEMENT
SYSTEMS

EMSG Conference 10 October 2007

AAIB Farnborough

SAFETY SYSTEMS AND HUMAN PERFORMANCE

IN MAINTENANCE

LIMITATIONS OF HUMAN PERFORMANCE

Perception and Cognitive limitations

Optical and Auditory limitations
Tunnelling and focusing

Man errs as long as he strives.

Goethe
EMSG Conference 10 October 2007
AAIB Farnborough

SAFETY SYSTEMS AND HUMAN PERFORMANCE

IN MAINTENANCE
ERROR TYPE

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

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

Source Ostrom et al, INEEL

EMSG Conference 10 October 2007
AAIB Farnborough

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

EMSG Conference 10 October 2007

AAIB Farnborough

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

Independent Inspections must be truly independent

Function checks must be carried out

EMSG Conference 10 October 2007

AAIB Farnborough

Can your maintenance staff actually perform the

required inspections?

EMSG Conference 10 October 2007

AAIB Farnborough

Do you have uncontrolled small parts?

EMSG Conference 10 October 2007

AAIB Farnborough

Do your engineers improvise?

EMSG Conference 10 October 2007

AAIB Farnborough

Are your engineers under pressure to avoid

ground runs at night?

EMSG Conference 10 October 2007

AAIB Farnborough

Do your engineers sign off task cards sight unseen?

EMSG Conference 10 October 2007

AAIB Farnborough

Is the Approved Data correct and is there a viable

procedure to amend errors?

EMSG Conference 10 October 2007

AAIB Farnborough

MAINTENANCE ERROR AND BUSINESS RISK

EMSG Conference 10 October 2007

AAIB Farnborough

MAINTENANCE ERROR AND BUSINESS RISK

EMSG Conference 10 October 2007

AAIB Farnborough

MAINTENANCE ERROR AND BUSINESS RISK

Most maintenance error events investigated by AAIB

are INCIDENTS not ACCIDENTS

Maintenance related incidents form a larger

proportion of total maintenance related events
investigated by AAIB than accidents
Incidents are less spectacular but very expensive

EMSG Conference 10 October 2007

AAIB Farnborough

MAINTENANCE ERROR AND BUSINESS RISK

EMSG Conference 10 October 2007

AAIB Farnborough

MAINTENANCE ERROR AND BUSINESS RISK

EMSG Conference 10 October 2007

AAIB Farnborough

MAINTENANCE ERROR AND BUSINESS RISK

Procedural deviations are at the root of many maintenance
related events

Maintenance error arising from non-procedural practices

incurs a dual risk to the business:

The risk of exposure to loss (loss of safety,earnings)

The risk of fines, litigation, denied insurance claims

EMSG Conference 10 October 2007

AAIB Farnborough

MAINTENANCE ERROR AND BUSINESS RISK

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
EMSG Conference 10 October 2007
AAIB Farnborough

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.
EMSG Conference 10 October 2007
AAIB Farnborough

MAINTENANCE ERROR AND BUSINESS RISK

How can we reduce the risk of maintenance error?
By promoting:
A culture which rewards procedural compliance
and discourages violations
Error-tolerant systems
Reporting systems which work and are used
An analytical approach to risk
EMSG Conference 10 October 2007
AAIB Farnborough

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.
EMSG Conference 10 October 2007
AAIB Farnborough

THANK YOU FOR YOUR ATTENTION

EMSG Conference 10 October 2007

AAIB Farnborough