1. Mistakes, I’ve made a few! An Engineers perspective RAeS Human FactorsGroup; Engineering Conference ‘Making a Difference’ Cranfield October 2008 Mick Skinner

2. Mistakes, I’ve made a few …. haveYou don’t have to make all the mistakes yourself! errorexperience learning opportunityCan yesterday’s error experience be today’s learning opportunity?

3. My Error (1980) Aircraft arrived on stand with a dragging RH inboard brake, tyre deflated after fusible plug activated RH MLG jacked, removed inboard wheel (with help from the Captain) Fitted new wheel, torque’d wheel nut, refitted brake fan Carried out refuel and departed the aircraft on time, thought I’d done everything to the book

4. Outcome wheel nut not locked, thought I’d followed the MM and checked thread depth engagement The following day I received notice that the wheel had become loose and that a board of enquiry had been formed not a very nice feeling!

5. Mitigation 12 months previously I had been given a one week type course in Transit maintenance However, this was condensed into 3 days as I was required for another assignment overseas This was my first wheel change on the type – no other experienced assistance was available

6. Culture Feeling that you’re on your own, who helps you or advises you? No HF awareness to help identify the things that can go wrong (until mid 90’s) Memory of the event remains, ensured that it never happened to me again!

7. My Background 4 years apprentice training – including self development training 6 years technical college – national education standard Type training on engine and airframes – CAA licence standard Gained BCAR Sect L A&C Licence Formal training in supervisory management, including 2 year diploma course 10 years experience, 6 years at supervisory level (at the time of the incident)

8. Fit for Purpose Training – Detailed type training to licence standard (CRS) Experience - Close supervision after apprentice training (‘’a/c are fraught with danger’’) Previously held delegated approval (non-licensed) Examination – written, multi-choice, oral (integrity check by CAA and company Quality dept)

9. New age engineer Same basic aptitude and inherent skills for the job as before More complex aircraft design – electronic not mechanical controls Multi tasking –wider trade groupings with EASA B1/B2 licence (A,C,E & E, I, R) Focused training designed for maintenance (not build) Pressure to keep training costs down Engineers sign for own work – cat A

10. New licensing structure Greater emphasis on basic knowledge scope Two tier licence – 2 years for Cat A task based CRS 4 years for Cat B Systems based CRS Education to Foundation Degree level (Cat B) Is there room for self development?

11. Maintenance Reliance Yesterday Yesterday – Type training very detailed, chalk & talk style; less complex systems & components, but common sense level assessed through CAA licence exam that included oral test (almost knew MM, applied in the ARB dessert! ) Today Today - Type training less detailed, emphasis on system functionality with computer enhanced aids; process driven with defined parameters, needs reference to AMM for complex troubleshooting and maintenance. Memorising technical detail kept to a minimum. **No EASA oral exam to test confidence**

12. Today’s ‘transitional’ environment Engineers eye for detail and an intuitive approach to maintenance hasn’t changed Today’s generation of engineers are being mentored by individuals who are experienced with a hands-on approach, less confident in the use of computers Aircraft system failure modes are more random with computer based technology, BITE checks are part of the tool box mustCannot ‘percussion test’ or re-rack!, computer reliant troubleshooting must be carried out but they are improving with experienceMany ‘mechanical’ based engineers who were trained under BCAR Section L licence system lack the confidence to fully embrace modern electronics, but they are improving with experience

13. Logical approach for today’s maintenance Maintenance philosophy derived from application of MSG3 logic, MRB and development of type MPD Focus on critical maintenance tasks and vital items lists Maintenance framework controlled by specific requirements of Part M for Maint. Control Programme Greater focus on processed approach to managing AMP and Life Control maintenance requirements Are engineers aware of their responsibilities to ensure that these systems are not compromised?

14. Has focus on error reduction changed? Basic errors occur due to lack of attention to detail and operational pressures (Same basic errors are being made today) Supervision (Cat B) reliant on Cat A authority (self certifying) IT interface essential (PC skills an absolute must) Focus on lower cost base and repeatable process (No fun any more!) Engineer works within a more tightly controlled environment (Focus on efficiencies, procedures and regulation) Error management mandatory (SMS), but is there the willingness for open discussion on causes of error? (lack of confidence in ‘Just Culture’) Little awareness of maintenance control structures (Part M) by engineers Greater insight through HF awareness of things that can go wrong

15. What can we do to reduce maintenance error Improve willingness of engineers to be more open in discussing mistakes Ensure no confusion between importance of meeting required standards and meeting operational demands Urge management to improve definition of a ‘just’ culture within the organisation Encourage engineers to use internal (or external) reporting systems Involve engineers in establishing an enlightened SMS

16. Questions?