Mistakes, I’ve made a few! An Engineers perspective

1. Mistakes, I’ve made a few!An Engineers perspective RAeS Human FactorsGroup; Engineering Conference ‘Making a Difference’ Cranfield October 2008 Mick Skinner

2. Mistakes, I’ve made a few …. • You don’t have to make all the mistakes yourself! • Can yesterday’s errorexperience be today’s learning opportunity?

3. My Error (1980) • Aircraft arrived on stand with a dragging RH inboard brake, tyre deflated after fusible plug activated • RH MLG jacked, removed inboard wheel (with help from the Captain) • Fitted new wheel, torque’d wheel nut, refitted brake fan • Carried out refuel and departed the aircraft on time, thought I’d done everything to the book

4. Outcome • wheel nut not locked, thought I’d followed the MM and checked thread depth engagement • The following day I received notice that the wheel had become loose and that a board of enquiry had been formed • not a very nice feeling!

5. Mitigation • 12 months previously I had been given a one week type course in Transit maintenance • However, this was condensed into 3 days as I was required for another assignment overseas • This was my first wheel change on the type – no other experienced assistance was available

6. Culture • Feeling that you’re on your own, who helps you or advises you? • No HF awareness to help identify the things that can go wrong (until mid 90’s) • Memory of the event remains, ensured that it never happened to me again!

7. My Background • 4 years apprentice training – including self development training • 6 years technical college – national education standard • Type training on engine and airframes – CAA licence standard • Gained BCAR Sect L A&C Licence • Formal training in supervisory management, including 2 year diploma course • 10 years experience, 6 years at supervisory level (at the time of the incident)

8. Fit for Purpose • Training – Detailed type training to licence standard (CRS) • Experience - Close supervision after apprentice training (‘’a/c are fraught with danger’’) • Previously held delegated approval (non-licensed) • Examination – written, multi-choice, oral (integrity check by CAA and company Quality dept)

9. New age engineer • Same basic aptitude and inherent skills for the job as before • More complex aircraft design – electronic not mechanical controls • Multi tasking –wider trade groupings with EASA B1/B2 licence (A,C,E & E, I, R) • Focused training designed for maintenance (not build) • Pressure to keep training costs down • Engineers sign for own work – cat A

10. New licensing structure • Greater emphasis on basic knowledge scope • Two tier licence – 2 years for Cat A task based CRS 4 years for Cat B Systems based CRS • Education to Foundation Degree level (Cat B) • Is there room for self development?

11. Maintenance Reliance Yesterday – Type training very detailed, chalk & talk style; less complex systems & components, but common sense level assessed through CAA licence exam that included oral test (almost knew MM, applied in the ARB dessert! ) Today - Type training less detailed, emphasis on system functionality with computer enhanced aids; process driven with defined parameters, needs reference to AMM for complex troubleshooting and maintenance. Memorising technical detail kept to a minimum. **No EASA oral exam to test confidence**

12. Today’s ‘transitional’ environment • Engineers eye for detail and an intuitive approach to maintenance hasn’t changed • Today’s generation of engineers are being mentored by individuals who are experienced with a hands-on approach, less confident in the use of computers • Aircraft system failure modes are more random with computer based technology, BITE checks are part of the tool box • Cannot ‘percussion test’ or re-rack!, computer reliant troubleshooting must be carried out • Many ‘mechanical’ based engineers who were trained under BCAR Section L licence system lack the confidence to fully embrace modern electronics, but they are improving with experience

13. Logical approach for today’s maintenance • Maintenance philosophy derived from application of MSG3 logic, MRB and development of type MPD • Focus on critical maintenance tasks and vital items lists • Maintenance framework controlled by specific requirements of Part M for Maint. Control Programme • Greater focus on processed approach to managing AMP and Life Control maintenance requirements • Are engineers aware of their responsibilities to ensure that these systems are not compromised?

14. Has focus on error reduction changed? • Basic errors occur due to lack of attention to detail and operational pressures (Same basic errors are being made today) • Supervision (Cat B) reliant on Cat A authority (self certifying) • IT interface essential (PC skills an absolute must) • Focus on lower cost base and repeatable process (No fun any more!) • Engineer works within a more tightly controlled environment (Focus on efficiencies , procedures and regulation) • Error management mandatory (SMS), but is there the willingness for open discussion on causes of error? (lack of confidence in ‘Just Culture’) • Little awareness of maintenance control structures (Part M) by engineers • Greater insight through HF awareness of things that can go wrong

15. What can we do to reduce maintenance error • Improve willingness of engineers to be more open in discussing mistakes • Ensure no confusion between importance of meeting required standards and meeting operational demands • Urge management to improve definition of a ‘just’ culture within the organisation • Encourage engineers to use internal (or external) reporting systems • Involve engineers in establishing an enlightened SMS

16. Questions?