When we talk about Human Factor (HF)-related issues within the Maintenance Planning environment, we need to consider also that often visibility of the outcome is moved to another area of the business. For example, if due to planning considerations work is loaded onto the check in an uneven way, then it is possible to create an environment where we see commercial pressure, which, as we know, may directly lead to stress and the possibility of an unwanted HF event.
Another issue also relating to visibility may be connected with the iceberg theory of accidents and incidents. We know that for every significant incident or accident that occurs, there are maybe 10 externally reportable events (to the regulator) and 30 internally reportable events (to the quality or safety system); however, there are additionally in the region of 300 unreported transgressions that not only go unreported but may in fact, when considered in isolation, appear to have minimum direct consequence; nevertheless, they may in fact become either precursors or contributors to a more serious event.
Often it is the unreported events that form a significant portion of the HF exposure within the Maintenance Planning department; in isolation, the exposure may appear low; however, in combination with other exposures, the HF-related action or precursor may trigger an unwanted or unwelcome outcome.
How to deal with this issue in a proactive way?
To ensure all persons have an awareness of the potential exposure or “knock-on effect” of even the smallest human-related error. To use this awareness to empower a cultural change that brings a sense of obligation, together with a defined HF reporting process.
Consider the introduction of the simplest internal reporting process possible; encourage people to use the substitution test—I have nearly made a mistake, but I corrected myself!—Would my colleague or a new person also “self-correct” or fall into a trap? If the answer is that a potential trap exists, then we should be looking at ways to communicate and report.
Is the documented process or procedure correct or ambiguous? If it is not 100% clear, then this becomes another exposure that we should address; we should understand and accept that we have an obligation to identify and raise awareness rather than to ignore.
In addition to the above, we should look at proactive ways of improving our process and reducing the exposure, for example, to discuss in small groups where the gaps are and where the traps are. What can we do to reduce the exposure without increasing the administrative burden?
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