By Richard Komarniski
The only way to prevent the loss of lives and money that is caused by human error in the workplace is a safety management system that addresses maintenance error prevention strategies. It amazes me that although the FAA, CAA, and Transport Canada have been promoting human factors programs for 16 years, we still have airlines, aircraft and engine manufacturers, maintenance and overhaul facilities, and corporate jet operations who have never attended a human factors conference or an awareness workshop. They seem happy to keep their heads in the sand and say they do not believe in all that touchy, feely stuff.
The 16th annual Human Factors Conference in San Francisco has wrapped up. And those who attended took home start-up plans for their own human factors programs and they have the ability to optimize the training in terms of tracking and analyzing incidents. We went home with a whole safety system program.
Emphasis on maintenance
The latest statistics from the National Transportation Safety Board show that 50 percent of the airline accidents during the past 20 years were caused by maintenance errors; it used to be 30 percent. Maintenance resource management (MRM) training is here to stay. Some countries are going so far as to regulate the implementation of these types of aircraft maintenance error prevention programs.
Management has to buy into the idea that human factors awareness training and a support system that helps to identify potential errors, poor policies, and the lack of safety nets in the organization are both required. There are aircraft operators and maintenance facilities providing awareness training without any support system in place or planned to help prevent further errors. As we have seen over the years, some organizations and countries have taken dramatic steps compared to others. Developing prevention strategies in an organization and implementation of a safety management program are not an option in some countries.
Management support required
Some operators are inclined to try and find the cheapest route to comply with the regulations in order to say they provide human factors awareness training. We will not name names in this article, but suffice it to say that airline size is not a good indicator of who is successfully implementing meaningful programs. In fact, some of the smallest operators have made the most progress institutionalizing human factors awareness training.
As we concluded at the conference, a successful human factors program takes a lot more than just complying with the minimum specified by the regulations. Without the wholehearted commitment of management, any safety program will be ineffective. The emphasis at the conference was on senior aircraft maintenance managers. They are the leaders who can "move and shake" others, if they so desire. First, however, they must have an understanding of modern accident prevention principles. Their decisions, based upon such understanding, should then be incorporated into system safety procedures. Safety management will succeed to the degree that senior management devotes the time, resources, and attention to safety as a core management program. A system of creating awareness, investigating errors, and measuring the effectiveness of training and error prevention strategies is necessary.
We have to remember that awareness training is only one spoke in the big wheel of error prevention. When providing human error prevention awareness training, it is best to have an experienced human factors specialist work with management on how to create an effective awareness program tailored to their maintenance department.
Keep it in the budget
If the safety system program and training are not implemented with the proper resources then management's role in an incident is part of a latent failure. Even though maintenance department budgets can consume a large amount of money, technician training can be low on the priority list and subjected to budget cutbacks. Far too often I see senior managers "nickel and dime" the training we provide to our technicians. Would these same managers swing their budget ax on the training that their surgeon was receiving on a new life-saving technique that would be used on them? If you must undergo a major operation, you want to feel confident that your surgeon has received the very best training, is up to speed on the latest techniques, has the proper tools, and will be able to count you as a success instead of a casualty. We should give the same importance to the human factors training we provide to our maintenance technicians. Any good and quantitative training we provide will be paid back tenfold. We owe it to ourselves, the flying public, and the rest of the industry to do things right and make sure we do not contribute to the number of accidents.
QA and error prevention
Most companies also found that the "keeper of the keys" to the error prevention program is usually the Quality Assurance Department, that oversees and evaluates the effectiveness or shortcomings of any program. It will also be instrumental in investigating incidents and errors and analyzing the effectiveness of prevention strategies to reduce future errors.
To those of you committed to error prevention because of the conference or because of your own initiative, I commend you for taking the steps necessary to learn from your errors by implementing error prevention strategies and a safety system in your organization.
Our goal is to prevent at least one major accident, what's yours?
Next year's FAA/CAA/Transport Canada Human Factors Conference will be held in September at Toronto's Royal York Hotel. AMT
Richard Komarniski is president of Grey Owl Aviation Consultants Inc. He has worked as an AMT for the last 27 years holding AME and A&P ratings. For information on Human Factors training or assistance in setting up an MRM program contact Grey Owl Aviation Consultants Inc., Box 233, Onanole, Manitoba ROJ 1NO Canada, (204) 848-7353, or fax (204) 848-4605, www.greyowl.com or firstname.lastname@example.org.
Your recent quality and performance data confirm an unacceptable trend. Last month you had damage to aircraft … and ground equipment … and people were injured. You identified the contributing...
Safety Management Systems (SMS) is an important new three-letter word from the International Civil Aviation Organization (ICAO). Federal Aviation Administration and national aviation authorities are...
What Now? By Rich Komarniski February 1999 Richard Komarniski is President of Grey Owl Aviation Consultants. He has worked as an Aircraft Maintenance Technician for the last...
Human Factors Error Prevention Communication is key By Richard Komarniski October 2004 After attending several aviation conferences this summer, I realized that the...