Human Factor

 Managers and supervisors have a key role to play in ensuring that work is carried out safely. It is no good instilling the engineers and technicians with ‘good safety practice’ concepts, if these are not supported by their supervisors and managers. The Management Role Line Managers, may be placed in a situation where they may have to compromise between commercial drivers and ‘ideal’ safety practices (both of which are passed down from ‘top management’ in the organisation).  The Supervisory Role   Supervision may be a formal role or post (i.e. a Supervisor), or an informal arrangement in which a more experienced engineer ‘keeps an eye on’ less experienced staff. The Supervisor is in a position not only to watch out for errors which might be made by engineers and technicians, but will also have a good appreciation of individual engineer’s strengths and weaknesses, together with an appreciation of the norms and safety culture of the group which he supervises. It is mainl...

  Teams  --- may comprise a number of individuals working together towards one shared goal.    -----may consist of a number of individuals working in parallel to achieve one common goal.                                                                                                                                                 Teams generally have a recognized leader and one or more follower(s).                         Teams need to be built up and their identity as a team needs to be  maintained in some way. Important Elements of Te...

 The key elements of a human factors programme are:  top level commitment to safety and human factors;   a company policy on human factors;   human factors training (of all appropriate personnel, including managers - not just certifying staff);  reporting, investigation and analysis scheme(s) which will allow reporting of errors, actual & potential safety risks, inaccuracies and ambiguities with Maintenance Manuals, procedures or job cards (not just those which have to be reported as Mandatory Occurrence Reporting (MOR)s); a clear disciplinary policy stressing that genuine errors will not result in punishment;  human factors and ergonomics audits / Line Operations Safety Audits (LOSA) (of workplaces, lighting, noise, tooling, adequacy of procedures, actual compliance with procedures, manpower, adequacy of planning, etc.);   the resources and willingness to act upon the findings arising from occurrence reports and audits, and to provided f...

         Human factors initiatives will be more effective if they are integrated within existing company processes, and not treated as something additional or separate or shortterm.                        Human factors initiatives have sometimes failed in the past because they have been marginalised and regarded as a temporary ‘fashion’. Much of human factors, in the context of maintenance organisations and Part-145 requirements, is common sense, professionalism, quality management, safety management – ie. what organisations should already have been doing all along.                                                                                                  ...

Safety and quality policy   is the part of the MOE.                                                                Safety policy define the  management’s intentions in terms of commitment to ensuring that aircraft are returned to service after maintenance in a safe condition.                                                      O rganisation should list (ideally in the MOE) the processes which contribute towards safety, including                                                                          ...

 An organisation with a good safety culture is one which has managed to successfully institutionalise safety as a fundamental value of the organisation, with personnel at every level in the organisation sharing a common commitment to safety.  One of the key elements is effective support from the top levels of the organisation, for safety. It is necessary for senior management to demonstrate their commitment to safety in practical terms, not just verbally or only as long as safety is a no-cost item.  It is all very well for an organisation to commit to putting in place, for example, a safety reporting and investigation scheme but if such a scheme is not resourced properly, or if safety recommendations are not acted upon, it will be ineffective.  It is also important that such commitment to safety is long-term, and that safety initiatives are not the first items to be cut in terms of financial support when the organisation is looking for cost savings.  Safety mana...

The incident occurred when, during its first flight after a flap change, the aircraft exhibited an undemanded roll to the right on takeoff, a condition which persisted until the aircraft landed back at London Gatwick Airport 37 minutes later. Control of the aircraft required significant left side stick at all times and the flight control system was degraded by the loss of spoiler control. CAUSAL FACTORS: i) During the flap change compliance with the requirements of the Maintenance Manual was not achieved in a number of directly relevant areas: - During the flap removal the spoilers were placed in maintenance mode and moved using an incomplete procedure, specifically the collars and flags were not fitted. - The re-instatement and functional check of the spoilers after flap fitment were not carried out. ii) A rigorously procedural approach to working practices and total compliance with the Maintenance Manual was not enforced by local line management. iii) The purpose of the collars and t...