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Fatigue and Maintenance Error. Philip Hosey with Frank Jaregui International Federation of Airworthiness. Is it a fact that maintenance errors cause accidents? If so does fatigue play a part in these? Are there other factors? Do we know enough? Are we improving?
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Fatigue and Maintenance Error Philip Hosey with Frank Jaregui International Federation of Airworthiness IFA Forum Dubai March 2010
Is it a fact that maintenance errors cause accidents? If so does fatigue play a part in these? Are there other factors? Do we know enough? Are we improving? Perhaps a later speaker today can help on this point IFA Forum Dubai March 2010
Boeing Facts • For years the highly regarded Boeing data gave 3% for maintenance caused accidents, however: • These were hull loss numbers only. IFA Forum Dubai March 2010
FAA Facts! Maintenance was the primary cause of over 8% of the US accidents in the 1990s for larger passenger aircraft. A maintenance event started the accident chain in 26% of the worldwide accidents in recent years. IFA Forum Dubai March 2010
Maintenance related accidents and incidents The list contain total loss and non fatal accidents, damage and non-damage incidents. Some are old, some new! They all have a feature in common and then there is one which is unique. I will tell you which one later!! IFA Forum Dubai March 2010
Accident Reports • Open and Factual • We in IFA pay tribute to them • Something is missing! • Why? IFA Forum Dubai March 2010
Facts Let us examine facts highlighted in the charts Every accident report provides data on the overall and recent experience of the flight crew. Even if this factor has no bearing on the accident! IFA Forum Dubai March 2010
Facts • Few, if any, accident report give similar data for the people involved in the maintenance considered to be the causal factor. Why? IFA Forum Dubai March 2010
The worst accident involving faulty maintenance? The failure of a bulkhead repair to B747SR JA 8119 resulted in the second highest fatalities in a single accident. The report resulted in a large number of actions (AD’s etc.) However, I quote from the report; “Resulting AC's, Regulatory Guidance and Policy - No regulatory changes were made because this accident resulted from an incorrect repair.” IFA Forum Dubai March 2010
Neither can I find any record in the investigation report of a substantive reason why the repair was not performed properly! IFA Forum Dubai March 2010
Most data confirms that human error in maintenance continues as a significant cause of accidents. Little improvement has been apparent in recent years. Comparatively better progress is seen in reducing crew related accidents. IFA Forum Dubai March 2010
In reviewing many reports some factors seem to be common. Little hard data on fatigue (as opposed to human error) is available as a prime cause. Working patterns are part of working life dominated by 24 hour availability. Regulation is widespread IFA Forum Dubai March 2010
A Contrast in Accident Investigation Almost every accident report I have ever seen faithfully and properly sets out the qualifications, experience and recent duty periods of the crew (as required by ICAO Annex 13) I would like someone to show me equivalent data for maintenance staff who are implicated in an error leading to an accident! IFA Forum Dubai March 2010
Perhaps if we were cynical we might say “Well for only 3% of hull loss accidents such detail is to difficult to obtain”. Because IFA believes otherwise, it must be time the world’s Investigators gave appropriate data for those involved in the maintenance of an accident aircraft. IFA Forum Dubai March 2010
Who says people make mistakes when they are tired? Just about everybody. Just look at CHIRP reports, and the New MX Fatigue Newsletter. Oddly though, some evidence claims that tired people work as well, even better when sufficiently stimulated (that’s another word for terrified). However, for maintenance people, terror rarely intrudes as they finish a long night shift. IFA Forum Dubai March 2010
Working time rules The US Congress passed a law limiting daily working time to eight hours for federal employees. When? The EU has progressively tightened limitations Australia broadly reflects the EU The UK enacted The Working Time Regulation in 1998 ICAO gives guidance in the latest issue of the SMM Some countries don’t say much at all! 1868 IFA Forum Dubai March 2010
Has rule making changed things. • Over several recent decades many laws have progressively reduced working hours. • Transport, public services, industrial and service industries have been affected. • Most industrial countries have enacted rules. • Of late there has been a discernable relaxation of these hitherto strict limits perhaps related to economic factors. IFA Forum Dubai March 2010
Effective or not. • The IFA contends that few of the scores of legislative changes enacted internationally over the years truly address the issue of fatigue related error! • If this were really the case why do we see people such as the NTSB and AAIB still mentioning crew fatigue as a possible contributory factor? IFA Forum Dubai March 2010
IFA published its first “white paper” on this subject in February 2005 followed by a second in November 2007. Both were aimed at raising the awareness of fatigue in the context of flight safety. Both are available on the IFA Web Site. (www.ifairworthy.com) We also promote the formality required in maintenance. IFA recognises the high standard of all accident reports What the IFA says. IFA Forum Dubai March 2010
Is this why is it so difficult to find meaningful data on the human elements of people directly involved in maintenance errors? IFA Forum Dubai March 2010
What do we know? There is wide recognition that errors of skill, judgment or perception can be related to fatigue. There is apparently less formal acceptance and thus less factual data on this in relation to aviation maintenance. We have the greatest respect for the high level of data related to flight crew published in accident reports. The international standard as laid down by ICAO Annex 13 is impeccable but…... IFA Forum Dubai March 2010
The Quiet Hours! • Evidence shows that maintenance errors often occur during night working. • Is fatigue the main ingredient? • Do other factors count more? IFA Forum Dubai March 2010
Other Factors It would be foolish to discount the many other factors influencing night work. • Lack of many of the facilities (e.g. specialists) afforded day work. • Less supervision and mentoring. • Less favourable working environment such as lighting. • Human susceptibility to circadian effects. • Schedule pressures. • Distraction. IFA Forum Dubai March 2010
Fatigue and night working. • First, recognise that the formality of the CRM steeped flight deck culture is not achievable in maintenance. • The level of support, consideration and oversight should be increased. CHIRP reports cover this. • Critical items should be treated more carefully. • Critical Inspection Items need a thorough review and beefed up for night work tasks. • Remuneration is an issue in encouraging long working hours. • FTL should be required reading for maintenance planners! Even if it varies from country to country! IFA Forum Dubai March 2010
Tiredness is cumulative. • Shift patterns can lead to excessive fatigue • Tiredness has some of the following traits. • Poor judgement. • Lack of dexterity. • Ignoring SOP’s • Over confidence. • And most important in the view of IFA :- • The acceptance threshold is lowered! IFA Forum Dubai March 2010
Fatigue • We asked in our first slide if fatigue is a factor. IFA considers that it is! • Operators, Regulators, OEM’s and the MRO industry had better find a way forward or the legal system will find it for them! IFA Forum Dubai March 2010
The OEM’s can help • Put as much thought into maintainability as to elegant solutions for flight deck ergonomics. • Maintainability is at least as important as IFE systems. • If designers had given as much thought to flight deck displays as they have to maintenance error, cockpits would still look like this! IFA Forum Dubai March 2010
Which Regulators have published proposals to control fatigue and shift working? IFA Forum Dubai March 2010
Just one actually. • The Maldives! [NPRM 2007-05] • What is the rest of the world doing? • Most have advisory or qualified rules only. IFA Forum Dubai March 2010
What was the answer to my question? • Every one had a common feature. • The crew details were set out in the report in every case! • Which was the incident that was unique (the odd one out)? • The B734 incident in February 1995 [total oil loss] and the difference was that this report set out in detail the qualifications and duty periods of the maintenance people! IFA Forum Dubai March 2010
We have beaten the maintenance issues arising from the challenges of recent times. • ETOPS • Low Visibility Operations • RVSM • Two crew operation • TCAS • Digital Systems • New technology airframes and engines • CFIT is in decline thanks to an industry wide campaign. • Why is it not possible to take on maintenance error in the same way? IFA Forum Dubai March 2010
If we do, the chances are that we will see many more beautiful Gulf dawns. Thank You IFA Forum Dubai March 2010
