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Maintenance Human Factors Leaders Workshop Proceedings Maintenance Human Factors Leaders Workshop Proceedings William B. Johnson, Ph. D. Chief Scientific and Technical Advisor Human Factors in Aviation Maintenance US Federal Aviation Administration This workshop was conducted in cooperation with the Human Factors Research Division of the Civil Aerospace Medical Institute under funding from the AVS Chief Scientific and Technical Advisor Program. September 15, 2010 Final Report Acknowledgments This report summarizes the proceedings of the first AVS Maintenance Human Factors Leader’s Workshop held at the Civil Aerospace Medical Institute in Oklahoma City, Oklahoma, August 4 & 5, 2010. This report documents a lasting legacy that will benefit the U.S. and international aviation maintenance community. Dr. Bill Johnson, Chief Scientific and Technical Advisor for Human Factors in Maintenance, facilitated the workshop for key AVS and selected industry and international personnel responsible for developing and delivering maintenance human factors (MX HF) information relevant to Parts 65, 91,121, 135, and 145. Workshop delegates participated in guiding organizational human factors initiatives and curricula development based on their experience in human factors R&D, operations, or investigation. We wish to thank the workshop delegates for wholehearted participation and responsiveness to coordination requests. Their contributions will advance the knowledge and understanding of Maintenance Human Factors in the industry. Special thanks to Drs. Robert Johnson and Melchor Antunano of the Civil Aerospace Medical Institute and to the Human Factors Research Division for the use of their training facility, to Joy Banks and Dr. Katrina Avers for coordinating the workshop and report, to Tara Bergsten for transcribing the presentations, to Darin Nei for analysis and administrative support, to Lena Dobbins and Erin McManus for administrative support, and to Janine King and Suzanne Thomas for final proofing and formatting of the report. Delegates William (Bill) Johnson Jennifer Ciaccio Mark Brock Brian T. Capone Jim R. Hein Martin Maurino Bill Huntley John Jay Hiles Mary Schooley William (Bill) Rankin John Sims Michele Wallentine Bobby Reed Joy Banks Nadine Yeager Carl (Steve) Keesey Katherine Wilson Richard (Rick) Anglemyer Dwayne Pittsenbarger Katrina Avers Terry Kleiser Fred Etheridge Keith A. Frable Vickie A. Stahlberg Greg Carroll Ken Larcher Victoria Anderson Guy Minor Kevin Gildea Victoria Frazier Executive Summary Thirty delegates, mostly from the FAA’s Office of Aviation Safety (AVS), but also from U.S. industry, the National Transportation Board (NTSB), and Transport Canada assembled for two days, at the Civil Aerospace Medical Institute (CAMI) in Oklahoma City. The workshop was hosted by the Chief Scientific Technical Advisor’s (CSTA) program to discuss challenges and potential solutions associated with human factors in aviation maintenance. The workshop was the first formalized gathering of such personnel with this dedicated focus. The meeting format combined key presentation topics (i.e., fatigue, maintenance event data reporting, maintenance accidents, calculating the return-on-investment (ROI) in human factors, human factors training, and the Original Equipment Manufacturer/Maintenance Repair Overhaul (OEM/MRO) industry perspective) with extensive discussion. The rank order, based on significant deliberation, of the top eight significant challenges included: 1) Use of Technical Publications 2) Fatigue/Alertness 3) Safety Culture 4) Event Data (MEDA, LOSA, ASAP) 5) ROI for Human Factors 6) Prioritization of Human Factors 7) Professionalism and Generational Issues 8) Attention to Required Inspection Items (RII). The workshop delegates felt that the FAA is addressing some of these challenges, but there is substantial opportunity to increase attention to each of these topics. The consensus opinion was to increase attention to the top eight challenges both with research and development as well as with operational funding. Challenges surrounding technical publications continue to be a significant contributing factor to maintenance events. This issue crosses many FAA airworthiness organizations including Flight Standards and Aircraft Certification. It is a major challenge that will require significant effort. The group believed that maintenance fatigue risk management issues should be addressed immediately, with the emerging flight crew regulations. The attention to maintenance fatigue rulemaking should be elevated while the maintenance fatigue risk management applied research is delivering significant educational materials. The group consensus was that continued efforts should be supported by FAA research and operational funds. A well established safety culture is a critical foundation that must be in place before many of the human factor challenges can be addressed effectively. The group members agreed that safety culture is a significant challenge in current operational environments and will require substantial effort. Ultimately, the group felt that it was difficult to separate safety culture from the other seven high priority challenges and attention to the seven challenges will address safety culture. Voluntary reporting systems, like the Aviation Safety Action Program (ASAP), Boeing’s Maintenance Error Decision Aid (MEDA), and the evolving maintenance and ramp line operations safety audits (LOSA), are critical for the proactive and predictive risk assessment necessary for Safety Management Systems (SMS). Attention to these programs should increase. A number of the maintenance events, presented by accident investigators, evidenced numerous causal factors associated with attention to Required Inspection Items (RIIs). A combination of situational awareness, personal responsibility, critical workplace culture and communication, and adherence to technical publications are factors that affect compliance and safety to RII. Group members agreed human factor (HF) programs can and must address this issue. There were a number of additional topics discussed and recommended. The list includes, but is not limited to: creation of a maintenance (MX) HF audit system, revision of the Advisory Circular 120-72 on MX HF, expansion of the MX HF presentation system and other support media, and creation and support of a process to calculate on-going cost and safety ROI in HF programs. There was also discussion about rebranding the term maintenance human factors. Finally, there were repeated suggestions that the communication and coordination value of this first AVS MX HF Leaders’ Workshop warrants a regularly scheduled annual meeting. All suggestions are detailed in the following report. Table of Contents Section 1.0 Workshop Proceedings .....................................................................................1 1.1 Background ...............................................................................................................................1 1.2 Workshop Delegates.................................................................................................................2 1.3 Workshop Format......................................................................................................................3 1.4 Workshop Presentations – Day 1..............................................................................................3 1.4.1 Welcome Session ..............................................................................................................3 1.4.2 Workshop Introductions .....................................................................................................3 1.4.3 MX HF Requirements in the Canadian Aviation Regulations............................................4 1.4.3.1 Actions from Mr. Maurino’s Presentation. ..................................................................4 1.4.4 International Perspective on MX HF with Special Emphasis on Event Reporting Systems ......................................................................................................................................5 1.4.4.1 Actions from Dr. Rankin’s Presentation......................................................................5 1.4.5 Fatigue Risk Management for Aviation Maintenance: A Status Report ............................6 1.4.5.1 Actions from Dr. Avers Presentation ..........................................................................7 1.4.6 Current Aviation Safety Inspector Training and Discussion of Recurrent Training Ideas. ..........................................................................................................................................7 1.4.6.1 Actions from Mr. Anglemyer’s Presentation ...............................................................8 1.4.7 Maintenance Repair Overhaul (MRO) Presentations ........................................................8 1.4.7.1 Human Factors from the AAR Corporation Perspective ............................................8 1.4.7.2 Human Factor Challenges at an Original Equipment Manufacturer (OEM) with Multiple Repair Stations..........................................................................................................9 1.4.7.3 Actions from MRO Presentations from AAR and Gulfstream Aerospace ..................9 1.5 Day 2 Presentations................................................................................................................10 1.5.1 Maintenance-related Accidents .......................................................................................10
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