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Written by Maintenance Human Factors Professionals Dedicated to Identifying and Optimizing the Factors That SMS RELIES ON FAA HF RESEARCH AND DEVELOPMENT PRODUCTS WILLIAMILLIAM B. JOHNSON About the Author: Dr. William Johnson is the FAA Chief Scientific and Technical Advisor for Human Factors in Aircraft Maintenance Systems. His comments are based on nearly 50 years of combined experience as a pilot, mechanic, airline engineering and MRO consultant, professor, and FAA scientific executive. Introduction SMS Implementation Requires Tools for INSIDE THIS When I joined the FAA, in 2004, the Thinking and for Acting I S S U E : senior leadership that interviewed me The regulations currently require that insisted that FAA research must create and Part 121 operators have a Safety support products that can be used in Management System in place. That is SMS Relies on FAA HF government and industry. Of course, they clearly happening. The industry is Research and 1-3 expected FAA Technical Reports and embracing SMS for more reasons than Development Newsletter articles like this one. They also mere regulatory compliance. I have respected that selected basic scientific observed that the word “required” is Everything Old is New research helped to validate the ultimate hardly used when industry personnel talk Again: Revisiting the 4 applied products. Much of this short about SMS. I see enthusiasm for the “Dirty Dozen” article, also appeared in the May, 2016 recognized value in a structured approach AMT Magazine but this version has more to spot trends and to recognize and From “Dirty Dozen” to elaboration. address hazards before they cost money, “Filthy Fifteen” -- A key component, or guiding principle, of injure a worker, or threaten the continuing 5-7 Professionalism in today’s continuing aviation safety is the safety of flight for airline operators. The Aircraft Maintenance concept of Safety Management Systems. good news is that there is a large “trickle SMS has significantly raised the awareness down” approach where Part 121 operators The Dirty Dozen in towards the human factors hazards in are asking their suppliers to establish and Context: Aviation Case 8-11 maintenance. Increasingly, industry is capitalize on a SMS. Of course, a supplier Studies capitalizing on the last decades of is not likely to have the same requirement products/practices generated from FAA’s for a large SMS that a 7/24/365 airline has. Mx HF Lab Activities: Maintenance Human Factors Program. A Each SMS is different and matched to Updates, Fellows and 12-13 few examples are described below. organization needs. These organization- Events (continued on page 2) Written by maintenance human factors professionals dedicated to identifying and optimizing the factors that affect human performance in maintenance and inspection. Past newsletters @ humanfactorsinfo.com Page 2 Aviation MX SMS Relies on FAA HF Research and Development Products ( C o n t … ) specific needs, in my opinion, have holes of error in the cheese or the development to create a product, triggered a revised interest in human resilience represented by solid then industry applies the product to maintenance human factors. I offer four part of the cheese. PEAR overlaps with meet company-specific needs. LOSA examples here, to include 1) How to SHELL but is a bit easier to remember worked out that way. Thanks to categorize hazards, 2) Methods to collect and utilize. On the Bow Tie, PEAR is an some early industry adopters, like event data and predictive data 3) How to ideal way to offer the proactive United Airlines ( along with estimate return on investment, and 4) barriers that prevent the event of Continental’s LOSA legacy) and The best fatigue risk management focus. JetBlue , LOSA found early success. methods and training. All of these topics The purpose here is not to make you Boeing has provided extensive are worth revisiting. a PEAR expert but instead, to insist industry support for LOSA in the US Categorizing Human Factors that the concept is alive and well. If and worldwide. The high value of Increased attention to safety you want more detail then Google LOSA, for SMS, continues to evolve management, data collection, voluntary “Johnson PEAR Model.” from industry, rather than reporting, and hazard management begs Tools to Collect Data government, action. for an organized categorization of SMS requires data collection Justifying your Human Factors hazards and errors. Over the years methods must go well beyond Interventions maintenance personnel have used the standard post-event investigations. Engineering/Maintenance managers Swiss Cheese, SHELL, Bow Tie, and PEAR. Data collection must include not only know where the most significant Of course, I am partial to PEAR being the audit of daily operations but also a hazards are. Fostering the positive co-inventor and chief promoter the way to look ahead and predict possible safety culture, using the technical concept for 20 plus years. PEAR, for risk. FAA worked with Airlines for publications, and ensuring fitness for review, stands for People, the America to develop the Maintenance duty are a few most common Environment in which they work, the and Ramp Line Operations Safety opportunities to address hazards. Actions workers perform, and the Assessment (LOSA) system (see Article However, organizational-specific Resources necessary to perform the by M. Ma in this Newsletter). The information, discovered by voluntary work. PEAR is the main human factors system uses a formal checklist-like reports or SMS data will identify training paradigm for FAA and Civil method to permit peer-to-peer specific hazards, like aircraft ground Aviation Authority of Australia inspector observation of normal procedures. movement, availably of specific tools/ training. It is a key part of FAA’s web LOSA is a positive method to support equipment, scheduling challenges, product, The Maintenance Human SMS because it recognizes daily shift turnover communications and Factors Presentation System, which has hazards and strengths. All LOSA forms more. Unlimited resources would been an international training application and training materials are on the FAA permit organizations to address all for a very long time. Training support Maintenance Human factors website hazards, but that’s not the real world. resources are available at at www.humanfactorsinfo.com. For that reason organizations must www.humanfactorsinfo.com as well as at In a “perfect world” government apply risk assessment to look at the the CASA website. PEAR is significant conducts the initial research and likelihood that the hazard may cause because the categories can represent the Figure 1. Categorizing Human Factors using the SHELL, “Swiss Cheese,” Bow Tie and PEAR methods. (continued on page 3) Page 3 Aviation MX SMS Relies on FAA HF Research and Development Products ( C o n t … ) an error and what is the severity of Figure 2. The FAA ROI Model such an outcome. But organizations must also determine the financial and corrective action, promote the action, safety impact of a hazard in order to and assess the impact. prioritize which hazard reductions My recent experience suggests that have the highest payoff. That’s where industry is becoming increasingly the FAA Maintenance Human Factors aware of the hazards associated with Return on Investment tools can come worker fatigue. I believe that SMS in handy. programs have an impact on the Figure 2 shows that one does not awareness of worker fatigue hazards. have to be an economic expert to The numbers of users on the 2-hour Comments – Send comments to calculate return on investment. In fact, web-based training continues to grow Dr. Bill Johnson at it is more about understanding your (estimated at over 200k users in the [email protected] hazards and the associated number of past 5 years. (Course # ALC-258 events (or potential events) that will available at www.faasafety.gov). The result in an unmanaged hazard. SMS multiple award winning video, entitled data can help assign costs if you are “Grounded,” is available as part of that motivated to assign costs. The training or accessible on YouTube. aviation maintenance expert will Demand Remains High for assign cost to the hazard intervention Maintenance Human Factors Support and predict the level of confidence in Industry has stepped up to address the estimation. The rest is the hazards associated with human multiplication and division. The tools factors challenges in maintenance. For and detailed directions are available in the most part, they have done that the tools section at www.humanfactorsinfo.com. without extensive regulations. The Many have seen me write or speak safety and business case speak louder that SMS, regulated or not, is the best than regulation. FAA intends to approach to fatigue management continue to support the maintenance regulations in maintenance. Most human factors website and is open to authorities do not have strict rules for all suggestions for additions to our fatigue risk management. Even when website and associated resources. there are national industrial fatigue rules they are usually trumped by a variety of stipulations that permit aviation maintenance personnel to work more consecutive days and longer hours than they should. Proper SMS will quickly discover if there is a maintenance fatigue issue in an organization. By design, an SMS must identify such hazards, determine the Page 4 Aviation MX Everything old is new again; revisiting “The Dirty Dozen” GUEST AUTHOR: JEFF GRENIER About the Author: Jeff Grenier is currently the Manager of Regulatory Programs & Compliance for Southwest Airlines and is an Adjunct Instructor for the Transportation Safety Institute’s (TSI) Aviation Division. He has directed aircraft accident investigations and Human Factors and safety initiatives for over 20 years. He has a Master’s in Aeronautical Science from Embry-Riddle University, is an Airframe & Powerplant Mechanic, a Certified HFACS Professional, and a Registered Safety Professional. All of the comments and opinions expressed in this article are solely his own and not representative of the views of Southwest Airlines, TSI or any entity therein.
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