Do the Right Thing Thing Right the Do © Chris Photography Sorensen to Get the Job Done

safetyCulture t I. Ba r on By Ro b e r

Professionalism and integrity are the last barriers against unapproved or unwise short cuts.

n experienced and qualified aircraft The reason for a procedural deviation may maintenance technician (AMT) with a stem from time pressure, working conditions tight deadline discovered that he needed or a lack of resources. This example is not only a special jig to drill a new door torque a classic maintenance human factors error, but Atube on a Boeing 747. The jig was not available, also speaks to the issue of professionalism and so he decided to drill the holes by hand with integrity conflicting with efficiency. a pillar drill — a fixed workshop drill and an The European Aviation Safety Agency unapproved procedure. (EASA), in its suggested syllabus for human fac- Subsequently, the door came open in flight tors training for maintenance, specifically men- and the flight crew had to make an emergency tions professionalism and integrity as a training landing. The AMT, being a “company man” and topic. But what is “professionalism and integrity,” trying to get the aircraft out on time, committed and can it even be taught? The Merriam-Webster what is known as a situational violation. A situ- dictionary defines professionalism as “the con- ational violation occurs when an AMT, typically duct, aims or qualities that characterize or mark a with good intentions, deviates from a procedure profession or a professional person” and defines Do the Right Thing Thing Right the Do © Chris Photography Sorensen to get the job done. integrity as “a firm adherence to a code of moral

www.flightsafety.org | AeroSafetyWorld | February 2011 | 27 safetyCulture

values.” The topic can be nebulous and difficult National Transportation Safety Board (NTSB) to develop into a training module, yet is unques- found serious omissions, however, in its final tionably a critical part of a healthy safety culture. report on the accident: Regulations offer some aviation-specific guid- “Carriers are permitted to develop their ance on teaching professionalism and integrity. own step-by-step maintenance procedures for a For instance, the U.K. Civil Aviation Authority specific task without obtaining the approval of has a small section in Civil Aviation Publica- either the manufacturer of the aircraft or the FAA tion (CAP) 716, Aviation Maintenance Human [U.S. Federal Aviation Administration]. It is not Factors (EASA Part 145) about the subject. Two unusual for a carrier to develop procedures which key points discussed are, first, that employees deviate from those specified by the manufacturer basically know how to behave in a professional if its engineering and maintenance personnel How can an manner but may be limited in doing so due to believe that the task can be accomplished more organizational issues such as pressure, lack of re- efficiently by using an alternate method. employee adhere sources, poor training, etc.; and that, in a human “Thus, in what they perceived to be in the inter- factors training course, it is up to the trainer to est of efficiency, safety and economy, three major firmly to a code determine whether problems with professional- carriers developed procedures to comply with the of moral values ism are on an individual or organizational level changes required in [service bulletins] by remov- and tailor the training accordingly. ing the engine and pylon assembly as a single that is largely CAP 716 does not elaborate on the topic unit. … Both American Airlines and Continental of integrity as it does with professionalism, Airlines employed a procedure which damaged a unwritten and not perhaps because it is assumed that they overlap. critical structural member of the aircraft. …

available to look That is partly true, but integrity still warrants a “The evidence indicated that American bit more elucidation. Airlines’ engineering and maintenance personnel up in the employee Based on the definition of integrity as “a implemented the procedure without a thorough firm adherence to a code of moral values,” this evaluation to insure that it could be conducted handbook? is where things can get interesting. How can without difficulty and without the risk of damag- an employee adhere firmly to a code of moral ing the pylon structure. The [NTSB] believes that values that is largely unwritten and not available a close examination of the procedure might have to look up in the employee handbook? A code disclosed difficulties that would have concerned of values is something that is learned through the engineering staff. In order to remove the load upbringing and life experiences. By the time a from the forward and aft bulkhead’s spherical person becomes gainfully employed, he or she joints simultaneously, the lifting forks had to be should have a good idea of what is morally or placed precisely to insure that the load distribu- ethically right. Yet corporate greed and power tion on each fork was such that the resultant can cause otherwise good people to cross the forklift load was exactly beneath the center of line, sometimes hazy, between right and wrong. gravity of the engine and pylon assembly. To ac- While financial scandals on a corporate level complish this, the forklift operator had to control are rare in aviation, significant events have oc- the horizontal, vertical and tilt movements with casionally led to deviations from integrity, typically extreme precision. The failure … to emphasize in the normal pursuit of cost savings and efficiency. the precision this operation required indicates For instance, the crash of American Airlines Flight that engineering personnel did not consider 191, a McDonnell Douglas DC-10-10, at Chicago either the degree of difficulty involved or the con- O’Hare International Airport on May 25, 1979, sequences of placing the lift improperly. Forklift was precipitated by procedures that were put in operators apparently did not receive instruction place by the company’s maintenance management. on the necessity for precision, and the mainte- Management accepted the use of a fork- nance and engineering staff apparently did not lift to change engines on the aircraft. The U.S. conduct an adequate evaluation of the forklift to

28 | flight safety foundation | AeroSafetyWorld | February 2011 safetyCulture

ascertain that it was capable of providing of FAA surveillance to detect and verify also can be confounding because many the required precision.” compliance with approved procedures.” instructors have a hard time compiling Maintenance management failed Such failures can be extrapolated to a relevant information. Overall, there is to discover that using the forklift was fundamental question about personal in- not much guidance compared with that creating an unseen crack in the acci- tegrity. Why would employees, as individ- available for other human factors topics. dent aircraft’s engine pylon. This crack ual professionals, go “along for the ride” So, again, can professionalism and continued to propagate and eventu- with these types of breaches in integrity if integrity be taught? Perhaps in prin- ally caused the left engine to depart they know they are working contrary to ciple, but applying them in the work- from the aircraft on its takeoff rotation approved procedures? Sometimes this is place is largely the responsibility of and the aircraft to crash shortly after a matter of norms of the safety culture, or the individual, since they are based on becoming airborne. Two hundred and the “normal” way work is being conduct- values, not a technical process that can fifty-eight people (including 13 crew- ed, whether right or wrong. be measured and supervised. members) aboard the aircraft and two Social psychological phenomena such What should be the baseline expec- people on the ground were killed. as cognitive dissonance and confor- tation for professionalism and integrity The crash of American Flight 191 mity also may be involved. Cognitive among AMTs? From my own search for can be interpreted as an example of dissonance occurs when reasoning is common principles, I propose these as the integrity line being crossed in one consonant (in agreement) and dissonant starting points: respect. The forklift procedure was de- (incongruous) at the same time. This • Arrive at work on time and be signed so that the aircraft would spend might happen when an employee knows prepared to work. less time in maintenance and more time that an incorrect procedure is being used generating income. When management universally but, at the same time, does not • Stay current on procedures, and changed a procedure without adequate want to speak up for fear of castigation. strive to increase your knowledge. safety analysis, however, lower level Similarly, conformity is a strong • Respect your peers — even if you employees were “along for the ride.” social psychological phenomenon that don’t particularly care for them. Integrity also encompasses adequate occurs when an employee chooses to company and regulatory oversight of a “go with the crowd” rather than stand • Be part of the team effort to make maintenance procedure. This issue was out as a complainer, loner, non–team safety the no. 1 priority. involved in the crash of Continental player, etc. Conformity can be further • Be assertive with management Express Flight 2574 in 1991, in which exacerbated by the tremendous peer whenever necessary for safety. 47 screws were not re-installed on the pressure that often develops in groups. horizontal stabilizer during a shift Individual employees need to realize • Watch for opportunities to draw turnover. The NTSB said, “The probable that, although these pressures are com- the line between right and wrong. cause of this accident was the failure monplace and perhaps inevitable, they • Be alert for business expediency of Continental Express maintenance do not relieve the employee from the that drives unsafe deviations from and inspection personnel to adhere responsibility to speak up and chal- approved procedures. to proper maintenance and quality lenge unsafe instructions. Otherwise, assurance procedures for the airplane’s on a personal level, they are overstep- • Do not “go with the flow” when horizontal stabilizer deice boots that ping the bounds of integrity and their the flow is going the wrong way. led to the sudden in-flight loss of the actions may become a contributing fac- • Ask yourself if actions deemed partially secured left horizontal stabilizer tor in an aircraft accident or incident. legally or technically acceptable leading edge and the immediate severe The topic of professionalism and could be morally wrong.  nose-down pitchover and breakup of integrity is clearly not popular in the the airplane. Contributing to the cause field of aviation human factors. It is Robert I. Baron, Ph.D., is the president and chief consultant of The Aviation Consulting of the accident was the failure of the reasonable to assume that this is due Group. He has more than 23 years of experience Continental Express management to to the topic’s socially awkward nature in the aviation industry and is an adjunct pro- ensure compliance with the approved and the diversity of opinion and work fessor at Embry-Riddle Aeronautical University maintenance procedures, and the failure experiences. Trying to “teach” the topic and Everglades University. www.flightsafety.org | AeroSafetyWorld | February 2011 | 29