U.K. Leads the Way

By July 2005, new rules in Europe will require maintenance operations to train key personnel in human factors.

The explosive decompression came abruptly and with a roar, tearing the cabin roof and forward walls of the Boeing 737 like so much matchboard as large pieces flew into the void. Somehow, the flight crew got the Aloha Airlines aircraft on to the ground, to the relief of the terrified passengers, but not before one cabin attendant was killed and seven passengers and another crew member were seriously injured.

This was in April 1988, and the world airline industry took serious note of this calamity, especially when it was later attributed to failures in maintenance inspection and repair. In Europe, Britain’s CAA decided to "shadow" the event by monitoring accidents, occurrences, or potentially dangerous situations directly attributable to errors in maintenance and engineering. The CAA had for some time ruminated on the reasons why MRO technicians performed some tasks wrongly or illogically. An eye would now be kept on problems relating to U.K.-registered aircraft.

The CAA did not have long to wait. In June 1990, a British Airways BAC 1-11 on a scheduled flight at cruising altitude had the windscreen blow out under the effects of cabin pressure, almost taking the captain with it. Eighty four of the 90 securing bolts were found by BA’s engineering department to be of smaller diameter than specified. This frightening event concentrated the minds of the CAA. By August 1993–on the occasion of the forced return of an Excalibur Airways A320 to Gatwick following an uncommanded roll after a flap change–the CAA set up industry working groups on a formal basis to research the MRO operation and establish why people did what they did, the end point being to avoid and prevent similar accidents recurring.

Moving towards new rules

The CAA took the view that little or nothing was achieved merely by a philosophy of apportionment of blame. The real issue was to examine a maintenance fault to establish the cause; the system could then be corrected.

The CAA’s initiatives aimed to move away from the industry’s hitherto prevailing culture of blame and take on board the credo that somewhere the system had failed. The CAA team carried with it a range of disturbing facts: 12 to 15 percent of air transport accidents were shown in studies to have maintenance as a contributing factor and 6 percent were directly attributable to maintenance failings. The death toll internationally in accidents in which maintenance errors were a contributing factor was shown to be in excess of 3,000 lives. "Moreover," said David Hall, deputy regional manager of the CAA’s Aircraft Maintenance Standards Department, "maintenance errors are increasing, for as the maintenance system becomes more complex, more errors occur."

It is a familiar fact of life that something that is fairly obvious is only recognized when it is closely examined from a fresh standpoint. So it was in the aircraft maintenance workplace. The human factor is as important here as it is on the flight deck, where it was recognized as an issue some time ago. The CAA noted the obvious fact that a mechanic could replace a bolt or part incorrectly unless it was made perfectly clear which was the right way. In the workplace, he could also be subjected to interruptions in his task, distractions, and undue pressure. Mistakes were made because of poor communication among team members, poor task planning, inadequate or poor quality technical manuals, work overload, non-compliance with procedures, complacency stemming from task repetition, and poor working conditions, amongst other reasons.

The conclusions in the CAA’s various working group reports was that human factors were at the heart of the problem and this issue, for a variety of reasons, was not being properly addressed.

With this understood, the question was how to proceed in changing things for the better. A number of enlightened airlines and maintenance companies have already been practicing enhanced MRO training and introduced improved work practices to reduce the possibility of mistakes, but this was on an in-house basis, not regulated, and not industry-wide. The long-term objective, it was felt, should be a standardized and officially authorized program of training in human factors issues in civil aviation maintenance, with safety as the bright beacon.

In March 2000, the CAA drew up airworthiness notice Number 71, encouraging those involved in aircraft maintenance to adopt a human factors program known as MEMS (maintenance error management system). Later, an amendment to the JAR 145 requirement would be drawn up with occurrence reporting and investigation as elements. With persuasion rather than diktat as its watchword, the CAA also provided guidance material in the form of CAP 716, which contained guidelines for the design of procedures in maintenance tasks and initial guidance in human factors training.

Rules for tomorrow

The upshot of the CAA’s work in MRO human factors has been a mandatory training requirement that was drawn up in concert with the European Joint Aviation Authorities and comes into force on July 1, 2005. The new requirement applies to all JAR 145 maintenance operations.

While all such organizations will be required to provide training, the CAA/JAA will monitor, oversee, and approve the process without laying down hard and fast rules on the methods by which its goals are achieved. "We are not being prescriptive about this," said Hall, "but rather saying ‘Carry out the training in a manner you feel best suits the needs of your company and as long as you meet the requirements.’"

Staff to be trained in human factors in maintenance must include all of those whose work has a direct or indirect affect on the safety of the aircraft or affects compliance with JAR 145. This includes, but is not limited to:

• Post-holders, managers, supervisors
• Certifying staff, technicians and mechanics
• Planners, engineers
• Quality control/assurance staff
• Specialized services staff
• Human factors staff/trainers
• Stores department staff/Purchasing department staff
• Ground equipment operators
• Contract staff in the above categories

While the JAA has now laid down a syllabus for human factors training, this is designed to be flexible, reiterating the end objectives of increasing "safety, quality, and efficiency in aircraft maintenance operations by reducing human error and its impact in maintenance activities," as the JAA guidance notes. That guidance goes on to say that "the maintenance organization may combine, divide, or change the order of any subject of the syllabus to suit its own needs, so long as all subjects are covered to a level of detail appropriate to the organization and its personnel."

Europe is first

While safety specialists have long recognized that human factors in maintenance could contribute much to air safety, the industry has been slow to embrace it. "We were not accomplishing enough through encouragement," said Hall. "We had to move to regulatory action."

Industry response was expected to be cool, especially if the new mandates increased costs. Lufthansa concluded shortly, however, that human factors training would produce a positive return, and the company’s Lufthansa Technik subsidiary has already drawn up a course to train 10,000 staff.

In the U.S., a number of major operators have offered human factors maintenance training off and on, including Northwest, United, American, Delta, and US Airways, but budget cuts and other factors hampered those programs. The FAA is expected to move towards some regulatory requirement in the future, however. ICAO has mandated changes for the future in human factors in maintenance.

The matter is not being left by the CAA/JAA at 2005, as the U.K. body is now developing a tool by which safety improvements can be measured as a result of human factors training and plans to look at these results five years down the line.

European Views on Human Factors Training

"We’ve been practicing human factors training for some five years at KLM UK Engineering and are surprised that it’s taken the industry so long to catch up," said Andy Beale, managing director of the Norfolk, England arm of the Dutch carrier. "We are perfectly happy with the requirements because there is a benefit at the end, and while there is a cost penalty for the training, the saving in reduced costs of incidents and accidents should more than compensate for the costs."

"Virgin Atlantic started human factors training in 1995 and has continued to enhance and develop the training program given to all maintenance staff. We have recruited a full-time human factors instructor within the engineering division to ensure all staff remain current and aware of the latest human factors issues," said Mark Robinson, Virgin’s engineering safety officer. "We shall be working with the authorities to ensure that we meet and exceed their expectations and requirements. Yes, costs do increase but you might otherwise ask the question: how do you quantify the cost of a significant incident where human factors are identified as the cause?"

Uncertain about statutory requirements at first, Lufthansa Technik officials decided that there would be a positive return and gave full blessing to the introduction of new regulations. In any case, human factors had long been given attention within Lufthansa Technik. As a new move, the company has drawn up a new training course to teach staff in the subject.