Introduction

Aviation Maintenance Error is not only insidious but it also has the potential to lead to incidents and accidents.

Senior Management including the Executive Leadership Team as well as Line Managers should understand the key principles of error management. To ensure a positive learning culture together with the ability to drive change which will minimise exposure and prevent reoccurrence.

Note the need for the Senior Managers to be well versed in understanding the nature of Root Cause as well as Latent exposures and the challenge to deliver change within the framework of a Just Organisation Culture.

We have several existing elements in place which have the potential to support the effective Management of Aviation Maintenance Errors.

It is essential to optimise the reporting of Maintenance incidents, near misses, and accidents to both allow the organisation to learn from the errors as well as to develop mitigation strategies to cope with the exposures identified.

When working correctly these elements can lower the exposure to error as well as minimize the consequence of the maintenance error in the first place.

Human Reliability – Reality Check

Human error is both universal and inevitable and whilst we cannot change the human propensity to make errors, we can change the environments and conditions in which we perform the required work.

Understanding the nature of exposure particularly where this is related to critical environments and considering errors as being consequences rather than causes.

If we understand that error is typically driven by a chain of often small events that lead to an undesirable outcome. We can work to provide positive outcomes by determining and removing the elements that exist within the chain.

What’s Required for an Effective System

Required Components include the following:

1. Approved Data and Instructions for Continued Airworthiness (ICAW).
2. A strong and effective regulatory environment identifies Rules & Regulations.
3. Organisational Process & Procedures - Detailed guidance information which is followed by an engaged workforce goes a long way to lowering the risk of Maintenance Error.
4. Training for all maintenance staff to ensure the best possible engagement with the Maintenance System. To collectively Identify behaviours in the maintenance organisation that are unacceptable, inappropriate or undesirable.
5. Strong oversight – the development of Critical Tasks and Independent Inspections.
6. An Effective Quality Assurance system to identify weaknesses and non-conformity related to both organisational and regulatory obligations.

Support for Developing Your “In-company” MEMS Program.

Sofema Aviation Services offers Training, Support, and Guidance to help you understand, develop, and implement an Effective Error Management System to deliver the safest possible organization process.