Aviation 9.8.3-4 Implications, Avoiding and Managing Errors PDF

Implications, Avoiding and Managing Errors (9.8.3-4) Learning Objectives 9.8.3 Describe examples of incidents and accidents, near misses and other minor events (Level 2). 9.8.4.1 Describe error management (Level 2). 9.8.4.2 Explain the purpose of an error management system and the...

Implications, Avoiding and Managing Errors (9.8.3-4) Learning Objectives 9.8.3 Describe examples of incidents and accidents, near misses and other minor events (Level 2). 9.8.4.1 Describe error management (Level 2). 9.8.4.2 Explain the purpose of an error management system and the four broad target areas that an error management system seeks to address (Level 2). 9.8.4.3 Identify examples of an error investigation and management system (Level 2). 9.8.4.4 Describe aspects of aviation safety and the vigilance required to maintain safety (Level 2). 2023-01-12 B-09 Human Factors Page 295 of 340 CASA Part 66 - Training Materials Only  Implications of Errors Incidents and Accidents In the worst cases, human errors in aviation maintenance can and do cause aircraft accidents. However, as portrayed in the gure below, accidents are the observable manifestations of error. Like an iceberg which has most of its mass beneath the water line, the majority of errors do not result in actual accidents. It is often said that for every 1 accident, there are 30 serious incidents and 300 near misses or minor incidents. AHRQ (2018) The 'Iceberg Model' of Accidents Thankfully, most errors made by aircraft maintenance workers do not have catastrophic results. This does not mean the results will not be catastrophic should they occur again. Accidents and incidents are de ned by many authorities in slightly different ways, but the usual de ning factor is that an accident involves serious injury or death and substantial aircraft damage. Errors that do not cause accidents but still cause damage or operational disruption are known as incidents. This subject was introduced at the beginning of this module. 2023-01-12 B-09 Human Factors Page 296 of 340 CASA Part 66 - Training Materials Only  Some incidents are more high pro le than others, such as errors causing signi cant in- ight events that, luckily, or because of the skills of the pilot, did not become accidents. Other incidents are more mundane and do not become serious because of defences built into the maintenance system. However, all incidents are signi cant to the aircraft maintenance industry, as they may warn of a potential future accident should the error occur in different circumstances. Reporting As a consequence, all maintenance incidents must be reported via the various regulatory reporting methods. The data compiled by these reporting methods are used to illustrate worldwide trends and, where necessary, to suggest or implement action to reduce the likelihood or criticality of further errors. Many organisations and regulatory authorities also have con dential Human Factors Incident Reporting schemes which provide an alternative reporting mechanism for individuals who want to report safety concerns and incidents con dentially. Flight Safety Foundation Regulatory reporting 2023-01-12 B-09 Human Factors Page 297 of 340 CASA Part 66 - Training Materials Only  Most Errors are Reversible and Lessons can be Learnt It is likely that a large number of errors made by aircraft maintenance workers are spotted almost immediately after they are made and corrected. That is, they are reversible. An engineer may detect their own error, or it may be picked up by colleagues, supervisors or the quality control system. In these cases, the engineer involved should learn from their error and therefore be less likely to make the same error again. It is vital that AMEs learn from their own errors and from the errors made by others in the industry. These powerful and persuasive lessons are the positive aspects of human error and is the reason that manufacturers, regulators and operators all participate in a worldwide system of reporting signi cant defects found on aircraft, plus maintenance error and operational problems. Blame Discourages Open and Honest Reporting When an error occurs in the maintenance system of an airline, the engineer who last worked on the aircraft may be considered ‘at fault’. The engineer may be reprimanded, given remedial training or simply told not to make the same error again. Image by Rodolpho Zanardo from Pexels Blame is not always a positive force in aircraft maintenance However, blame does not necessarily act as a positive force in aircraft maintenance. It can discourage engineers from honestly reporting their errors. They may cover up a mistake or choose not to report an incident. It may also be unfair to blame the engineer if the error results from a failure or weakness inherent in the system, which the engineer has accidentally discovered (for example, a latent failure such as a poor procedure drawn by an aircraft manufacturer). 2023-01-12 B-09 Human Factors Page 298 of 340 CASA Part 66 - Training Materials Only  The UK Civil Aviation Authority has stressed in CAAIP Lea et 11-50 that it: ‘seeks to provide an environment in which errors may be openly investigated in order that the contributing factors and root causes of maintenance errors can be addressed’. A just culture seeks open and honest reporting to allow thorough investigation. Therefore, slips, lapses and mistakes should not be punished, but a breach of professionalism may be (e.g., where an engineer causes deliberate harm or damage, has been involved previously in similar lapses, has attempted to hide their lapse or part in a mishap, etc.). Near Misses and Other Minor Events In a just culture, reporting and analysis of near misses is as important as the investigation of serious accidents and incidents. Like incidents, all near misses are signi cant to the aircraft maintenance industry. It is only circumstances that have prevented the near-miss from progressing to be an accident. Near misses may warn of a potential future accident should the error occur in different circumstances, so they should be investigated thoroughly to ensure they do not happen again. 2023-01-12 B-09 Human Factors Page 299 of 340 CASA Part 66 - Training Materials Only  Avoiding and Managing Errors Introduction While the aircraft maintenance engineering industry should always strive to ensure that errors do not occur in the rst place, it will never be possible to eradicate them totally. Therefore, all maintenance organisations should aim to ‘manage’ errors. Error Management To prevent errors from occurring, it is useful to predict where they are most likely to occur and then to put in place preventative measures. Within a maintenance organisation, data on errors, incidents and accidents should be captured with a Safety Management System (SMS), which should provide mechanisms for identifying potential weak spots, unsafe practices and error-prone activities or situations. Output of information from the SMS should guide local training, company procedures, and the introduction of new defences or modi cation of existing defences. Image by skeeze from Pixabay To prevent errors from occurring, it is useful to predict where they are most likely to occur 2023-01-12 B-09 Human Factors Page 300 of 340 CASA Part 66 - Training Materials Only  Error management includes measures to: Minimise the error liability of the individual or the team Reduce the error vulnerability of particular tasks or task elements Discover, assess and then eliminate error-producing (and violation-producing) factors within the workplace Diagnose organisational factors that create error-producing factors within the individual, the team, the task or the workplace Enhance error detection Increase the error tolerance of the workplace or system Make latent conditions more visible to those who operate and manage the system Improve the organisation’s intrinsic resistance to human fallibility. It would be very dif cult to list all means by which errors might be prevented or minimised in aircraft maintenance. In effect, the whole of this training module discusses mechanisms for this, from ensuring that individuals are t and alert, to making sure hangar lighting is adequate. The Importance of Following Approved Procedures One of the steps most likely to be effective in preventing error is to make sure that maintenance workers follow procedures. This can be helped by ensuring that the procedures are correct and usable, that presentation of the information is user-friendly and appropriate to the task and context, and that maintenance workers are encouraged to follow procedures and not to cut corners. Image by Philip Neumann from Pixabay User friendly presentation of information helps with procedure compliance 2023-01-12 B-09 Human Factors Page 301 of 340 CASA Part 66 - Training Materials Only  Responsibility for Error Management Organisational Responsibility for Error Management and Continuous Improvement Ultimately, maintenance organisations have to compromise between making a pro t and implementing measures to prevent, reduce or detect errors. Some measures cost little (such as changing light bulbs in the hangar), while others cost a lot (such as employing extra staff to spread workload). Incidents tend to result in short-term error mitigation measures but if an organisation has no incidents for a long time (or has them but does not know about them or appreciate their signi cance), there is a danger of complacency setting in and cost reduction strategies eroding the defences against error. Professor James Reason refers to this as 'the unrocked boat'. Elsewhere in this course, we have mentioned the phrase 'promote constructive worrying'. It is important that organisations balance pro t and costs and try to ensure that the defences which are put in place are the most cost-effective in terms of trapping errors and preventing catastrophic outcomes. Personal Responsibility for Error Management Ultimately, it is the responsibility of each and every aircraft maintenance worker to take every possible care in their work and be vigilant for errors. On the whole, aircraft maintenance workers are very conscious of the importance of their work and typically expend considerable effort to prevent injuries, prevent damage and keep the aircraft they work on safe. © Aviation Australia Technicians inspecting Rolls Royce engine 2023-01-12 B-09 Human Factors Page 302 of 340 CASA Part 66 - Training Materials Only  Error Management Systems The purpose of an Error Management System is to provide maintenance organisations with reporting mechanisms and techniques to deal with human performance problems. Error management systems seek to: Prevent errors from occurring (error reduction) Eliminate or mitigate the bad effects of errors (error containment). Error management seeks to prevent errors from occurring 2023-01-12 B-09 Human Factors Page 303 of 340 CASA Part 66 - Training Materials Only  Proactivity and Reactivity An Error Management System in a large organisation may be a coordinated suite of software to generate reporting, create and analyse meaningful data trends and capture continuous improvement. Or, in smaller organisations, it may be an informal way of storing information about error in the organisation and the steps put in place to ensure those types of errors do not happen again. The more coordinated systems represent proactivity in error management. The latter is more reactive, as it waits until errors become apparent before recording the details and acting on them. It is obvious that every organisation should strive for proactivity to tackle potential error before it becomes apparent. There is no single best Error Management System. Different mixes of techniques and practices suit different organisations. A system should provide a set of guiding principles for error management and a variety of measures and techniques for managing error at different levels of the organisation. Proactivity vs Reactivity 2023-01-12 B-09 Human Factors Page 304 of 340 CASA Part 66 - Training Materials Only  The Targets of Error Management How do you best reduce errors and limit their bad effects? There are four possible target areas: The person The task The workplace The organisation. Error Management Target 2023-01-12 B-09 Human Factors Page 305 of 340 CASA Part 66 - Training Materials Only  Aim for the Person? When bad things happen, most organisations aim for the person because they believe people are more changeable than situations. Typical responses to engineering quality lapses are: Blame and train Counsel the error-maker, or discipline them, or tell them to be more careful, and then, if necessary, send them for retraining. Write another procedure All industries tend to write procedures to prohibit actions that have been implicated in some event or incident. The result is that the range of permitted actions is often less than the range of actions necessary to get the job done. Search for the ‘missing piece’ When these measures fail (and they usually do), managers start looking for psychological ways of nding the piece that will remove violations and errors. Somewhere out there, they think, is a ‘magic bullet’ solution. When bad things happen, some organisations aim for the person 2023-01-12 B-09 Human Factors Page 306 of 340 CASA Part 66 - Training Materials Only  Aim for the Task, Workplace and Organisation? Comprehensive error management, however, prefers to focus most of its efforts on: Identify and correct error-prone tasks Improve error-producing work situations Identify and correct latent organisational conditions. Aim for the Task, Workplace and Organisation Changing the Future Fallibility is part of the human condition. We are not going to change the human condition substantially, but we can make people more aware, and change the conditions under which they work. It seems easier to try to change the human, but changing situations is more effective than trying to change human nature. Learning the right lessons from past incidents -not ‘Who’s to blame?’ but ‘What were the task, workplace and organisational factors that contributed to the incident?’ Identifying task, workplace and organisational problems that could combine to cause some future incident or accident - being proactive as well as reactive. To use a mosquito analogy, swatting and spraying individual mosquitoes is like focusing on the individuals that make errors. Better to drain the swamp where mosquitoes breed. This is similar to examining the organisational aspects of how errors develop and become prevalent. 2023-01-12 B-09 Human Factors Page 307 of 340 CASA Part 66 - Training Materials Only  There are two ways of dealing with the underlying and fundamental problems: One way is reactive – to trace mosquitoes (errors) back to their point of origin, to their breeding grounds, and then eliminate them; The other is proactive – to use this knowledge to destroy potential breeding grounds before they create problems. A variety of techniques are currently in use in the world’s modern maintenance facilities. Some of them start with an event and then work back into the system to identify and remove their fundamental causes. Others involve regular system ‘health checks’ in which potential problems are identi ed and corrected before they cause trouble. Aviation Australia Changing situations is more effective than trying to change human nature Maintenance Error Decision Aid (MEDA) An example of an error investigation and management system applicable for maintenance engineering is the Maintenance Error Decision Aid (MEDA), originally produced by Boeing. 2023-01-12 B-09 Human Factors Page 308 of 340 CASA Part 66 - Training Materials Only  The MEDA Philosophy Traditional efforts to investigate errors are often aimed at identifying the employee who made the error. The usual result is that the employee is defensive and is subjected to a combination of disciplinary action and retraining. Depending on the error, retraining may add little to what the employee already knows, so it may be ineffective in preventing future errors. In addition, by the time the employee is identi ed, information about the factors that contributed to the error has been lost. Because those factors remain unchanged, the error is likely to recur, setting what is called the 'blame and train' cycle in motion again. To break this cycle, MEDA was developed to assist investigators to look for the factors that contributed to the error, rather than concentrating on the employee who made the error. The MEDA philosophy is based on the following principles: Positive employee intent (maintenance technicians want to do the best job possible and do not make errors intentionally). No error exists in isolation, there is usually a contribution of multiple factors (a series of factors contributes to an error). Manageability of errors (most of the factors that contribute to an error can be managed). Positive Employee Intent Employee engagement and positivity is key to a successful investigation. Traditional 'blame and train' investigations assume that errors result from individual carelessness or incompetence. This is no longer the way robust investigations are conducted. Starting instead from the assumption that even careful employees can make errors, MEDA interviewers need to gain the active participation of the technicians closest to the error. When technicians feel that their competence is not in question and that their contributions will not be used in disciplinary actions against them or their fellow employees (i.e., just culture principles), they more willingly team with investigators to identify factors that contribute to error and suggest solutions. By following this principle, operators can replace a negative ‘blame and train’ pattern with a positive ‘blame the process, not the person’ practice. 2023-01-12 B-09 Human Factors Page 309 of 340 CASA Part 66 - Training Materials Only  Multiple Factors Contribute to Each Error Technicians who perform maintenance tasks daily are often aware of factors that can contribute to error. These include information that is dif cult to understand, such as work cards or maintenance manuals, inadequate lighting, poor communication between work shifts, and aircraft design. Technicians may even have their own strategies for addressing these factors. One of the objectives of a MEDA investigation is to discover these successful strategies and share them with the entire maintenance operation. Manageability of Errors Active involvement of the technicians closest to the error re ects the MEDA principle that most of the factors that contribute to an error can be managed. Processes can be changed, procedures improved or corrected, facilities enhanced, and best practices shared. Because error most often results from a series of contributing factors, correcting or removing just one or two of these factors can prevent the error from recurring. The MEDA Process To help maintenance organisations achieve the dual goals of identifying factors that contribute to existing errors and avoiding future errors, Boeing initially worked with British Airways, Continental Airlines and United Airlines to produce a process to follow: Events Decisions Investigations Prevention strategies Feedback. When an Event Occurs When an event occurs, such as a gate return or air turn back, it is the responsibility of the maintenance organisation to select the error-caused events that will be investigated. Decision After xing the problem and returning the aircraft to service, the operator makes a decision: Was the event maintenance-related? If yes, the operator performs a MEDA investigation. Investigation Using the MEDA results form, the operator carries out an investigation. The trained investigator uses the form to record general information about the airplane, when the maintenance and the event occurred, the event that began the investigation, the error that caused the event, the factors contributing to the error, and a list of possible prevention strategies. 2023-01-12 B-09 Human Factors Page 310 of 340 CASA Part 66 - Training Materials Only  Prevention Strategies The operator reviews, prioritises, implements and then tracks prevention strategies (process improvements) to avoid or reduce the likelihood of similar errors in the future. Feedback The operator provides feedback to the maintenance workforce, so engineers know that changes have been made to the maintenance system as a result of the MEDA process. The operator is responsible for af rming the effectiveness of employees' participation and validating their contribution to the MEDA process by sharing investigation results with them. Image by fotogra erende from Pexels Feedback 2023-01-12 B-09 Human Factors Page 311 of 340 CASA Part 66 - Training Materials Only  Management Commitment The resolve of management at the maintenance operation is key to successful MEDA implementation. Speci cally, after completing a program of MEDA support, managers must assume responsibility to support the process before any investigations are started. MEDA is a long-term commitment, rather than a quick x. Operators new to the process are susceptible to 'normal workload syndrome'. This occurs once the enthusiasm generated by initial training of investigation teams has diminished and the rst few investigations have been completed. In addition to the expectation that they will continue to use MEDA, newly trained investigators are expected to maintain their normal responsibilities and workloads. Supervisors must manage this. Management at all levels can maintain the ongoing commitment required by providing systematic tracking of MEDA ndings and visibility of error and improvement trends. MEDA Summary The Maintenance Error Decision Aid (MEDA) process offered by Boeing continues to help operators of airplanes identify what causes maintenance errors and how to prevent similar errors in the future. Because MEDA is a tool for investigating the factors that contribute to an error, maintenance organisations can discover exactly what led to an error and remedy those factors. Image by -X-TREME- from Pixabay The Maintenance Error Decision Aid (MEDA) process helps operators of airplanes identify the cause of maintenance errors 2023-01-12 B-09 Human Factors Page 312 of 340 CASA Part 66 - Training Materials Only  Maintaining Safety in Aviation The public demand a high level of safety in the aviation industry. With a global network of manufacturers, operators and regulators, there is a mostly free ow of safety-related information between interested parties. When individual aviation businesses also participate in proactive error minimisation and error containment procedures, then this builds on the overall safety within the industry. © Aviation Australia Aircraft hangar The Two Faces of Safety There is a negative and positive face of safety: A negative face is embodied by bad events, incidents, accidents and near-misses. A positive face, refers to the system’s resistance to operational hazards. Most of the time when we speak of ‘safety’, we are usually referring to the absence of danger (or non- safety) over a given period. Safety is usually measured in terms of the number of incidents or accidents that occur during a given interval of time, say a 6- or 12-month period. Most technical people like these kinds of measures because they can be quanti ed easily. But what happens when you start having very few bad events? This is what has happened in the aviation industry. In the aviation business, accidents and maintenance incidents are comparatively rare, so they tell you very little about the true safety health of your system. 2023-01-12 B-09 Human Factors Page 313 of 340 CASA Part 66 - Training Materials Only  Safety is a Dynamic Non-Event There is a misconception that states: 'If we go on doing what we did yesterday (because nothing bad happened yesterday), then nothing bad will happen today.' But the ‘nothing bad’ from yesterday was achieved by many different people doing many different things to compensate for disturbances. To maintain ‘nothing bad’, we must understand exactly what is happening and appreciate the day-to- day efforts people make to keep the system safe from ever-present dangers. Image by Msporch from Pixabay Maintaining vigilance 2023-01-12 B-09 Human Factors Page 314 of 340 CASA Part 66 - Training Materials Only  How to Maintain Vigilance Organisations should introduce and use a Safety Management System. Organisations should implement and adhere to principles of a just culture. Organisations should encourage free and open reporting of incidents, but also near misses and de ciencies that are noticed outside of formal workplace inspections. Organisations should be proactive, not reactive. Don't wait for bad things to happen before seeking or implementing improvements. Organisations should learn the right lessons from past incidents, not ‘Who’s to blame?' Organisations should promote constructive worrying. Just because nothing has happened recently, doesn't mean it’s okay to become complacent. Maintain regular workplace inspections, keep the staff informed and congratulate each other for the constant effort to keep bad things from happening in the inherently dangerous aviation environment. 2023-01-12 B-09 Human Factors Page 315 of 340 CASA Part 66 - Training Materials Only