Managing aviation maintenance organizational errors and risks
A focus on the importance of safety awareness to enhance performance
Research Paper (undergraduate) 2011 10 Pages
To manage risks and errors, there must be a good understanding, not just as to what has happened but why did it happen in order to determine the root problems and causes. Using the Reason model (Reason, 1991), investigations into these occurrences are made possible to provide the basis for identifying threats, flawed defense mechanism and conducting unsafe organizational conditionals. It makes sense as a continuum effort to manage aviation maintenance errors and risks to enhance safety and performance in the long term through identifying them and implanting vital defenses. A safety culture can foster these safe activities by creating trust and dialogue between management and individuals within a maintenance repair organization (MRO). The good safety culture aspects are pervasively within the shared attitudes of concern and care in the MRO and involves with the management. Surrounding this open atmosphere, there should have systems that share important data whereby the workforce are encouraged to make reports with trust and fairness. One shared concensus on collecting these data is by implementing of maintenance error management system (MEMS). Implications of active and latent failures and the benefits of maintenance resource training (MRM) are further discussed.
When an Aloha Airlines Boeing 737 suffered a decompression in flight due to a large chunk of fuselage crown detachment in 1988, the aviation domain began to recognize and realize that aviation safety relies greatly on all aspects throughout the interdepartmental chains, besides the flight operations (Kanki, 2010). Investigators cited the causal of this accident was the failure of maintenance personnel to find fatigue cracks in the fuselage skin. Subsequently, this latent condition developed into a major consequence over many flight cycles (National Transportation Safety Board, [NTSB], 1989).
In most cases, the intrinsic nature of maintenance performance and errors with their negative outcomes do not immediate cause a failure, but one that can lie in dormant for an amount of time, even forever (Kanki, 2010). This relationship between the adverse outcome and latent failure requires a systematic approach to research and to establish the principles and information that can direct the corrective actions, preventive interventions and implementing defenses for managing the maintenance errors and risks. Moreover, human errors are already being found to involve in aircraft accidents and investigation. In contrast, active failure has a direct and immediate result of the consequence (Maurino, Reason &Lee, 1995). This error is normally committed at the sharp end by frontline individuals such as air traffic controllers, pilots and aircraft maintenance technicians (AMTs).
There has been a great concern with safety in aviation maintenance as NTSB’s major accidents investigations during the years preceding 2002, of which one-half have been associated to be rooted from maintenance deficiencies (‘Human Factors Programs’, 2002, as cited in Hobbs &Williamson, 2003). Moreover, maintenance errors are costly as they imposed airlines with financial burden due to the extended technical delay to resolve the problems (Marx &Graeber, 1994). An estimation cost of each engine in-flight shutdown (IFSD) due to maintenance errors are calculated to an approximate US$500,000 (Rankin, 2005, as cited in Hackworth, Holcomb, Banks, Schroeder &Johnson, 2007). It would seem sensible as a continuum effort to manage these errors and risks to enhance safety and performance in the long term through identifying those specific hazards and implanting vital defenses.
Overview and definition- The Reason Model
Maintenance error is considered to have happened when the maintenance system which includes the individual who fails to carry out the planned work in the manner as predicted in order to achieve its desired safety goals (Civil Aviation Authority, [CAA], 2003). Risk is defined as a product of failure probability of an undesirable occurrence and the resulting consequences of the failure (Sheridan, 2010).
To manage risks and errors, there must be a good understanding, not just as to what happened, but rather how the incident occurred, what caused it, why did it happen in order to determine the root problems and causes (Maurino, Reason &Lee, 1995). One theoretical conceptual of why accident happens is the result of Reason’s researches (1990, 1997, as cited in Martinussen &Hunter, 2010). This theory has been frequently articulated by Reason and is popularly known as the “swiss-cheese model” or “The Reason model” (p. 184).
The elements of occurrences and incidents are triggered through a big collection of weaknesses influenced by factors such as organizational flaws, ineffective supervision, preconditions for errors and violations, and unsafe acts (Reason, 1991). The system comprises of individuals within a maintenance repair organization (MRO) structure can produce active or latent failures. The classic metaphor begins when each failure penetrates through the holes in every single layer of successive barrier, and they are concentrically aligned that the window of opportunity will be ripe to happen. Countermeasures include barriers, defences and safeguards are implanted against latent and active failures since it is impracticable to eliminate errors nor can it be risk free holistically. Another proactive defensive approach is maintenance resource management (MRM) application using a threat and error management framework to neutralize errors by detecting, trapping the error and correcting them so that no harm can penetrate further along the unexpected journey of disaster (Kanki, 2010).
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