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'Human factors' is one of the most used terms in the aviation industry. It was quoted in the Civil Aviation Authority - CAP 715 that "aircraft accidents recorded from around the world brought the need to address human factors issues in this environment into sharp focus6". Human factor can be fairly described as a mistakes or error that is cause by a human behaviour. It is also the largest causal factor of accidents and so, it must be targeted for major safety efforts if an improved safety records is to be achieved. From human factor, the concept grew into a more in depth system that helps to improvise the aviation maintenance organization working condition and such a new system are; safety culture and safety management system are being implemented in to organization.
Safety Management System
Safety Management can be seen as a systematic implementation of Risk management in the planning, control and supervision in the process to ensure safe operations. In a publication by Civil Aviation Authority (CAA) on Safety Management Systems for Commercial Air Transport Operations, CAP-712 it defines Safety Management System as:
"'Safety Management' is defined as the systematic management of the risks associated with flight operations, related ground operations and aircraft engineering or maintenance activities to achieve high levels of safety performance." 5
"A 'Safety Management System' is an explicit element of the corporate management responsibility which sets out a company's safety policy and defines how it intends to manage safety as an integral part of its overall business." 5
In short, safety management system is the processes and arrangements set by an organization to manage the health and safety issues within an organization and through such a method of using a system to manage those important function in the organization; it can improve the performance of an organization and reduce the risks any accidents.
In the aircraft maintenance industry, safety management plays an important role of maintaining the satisfactory work output. Failure in this will cause a list of chain effect that could possibly increase the chances of causing an aircraft accident. For this reason, the Civil Aviation Authorities publish manuals on regards to this matter and one of such is the CAP 712 which focuses specifically on the safety management of the aviation industry to minimize the chances any factors that causes risks.
A typical Safety Management Systems found in aviation industry should be made up of 4 key components:7
Safety Policy and Objectives; 7
An organization should have a safety policy that outlines the methods and processes that they will use to achieve a positive result. It should declare the principles and philosophies that lay the foundation of the organization's safety culture and be communicated to all staff thorough the organization.
Safety Risk Management; 7
Safety risk management process starts with identification of hazards affecting the aviation industry and by assessing the risk associated with the hazards in terms of its seriousness and similarity to previous cases. When the risks are identified, only then can we make the appropriate implementation of remedial actions to reduce the level of risk as low as possible.
Safety Assurance; 7
Safety assurance assesses the safety performance of the organization and this will allow continuous improvement to the organization. Through monitoring, measurement and reviewing the safety of an organization, it is possible to create a safety assurance within the organization and allow a continuous improvement of the safety system.
Safety Promotion. 7
Promoting safety in an organization by means of training and educating employees will rather increase their safety responsibilities. This is especially effective for operational staffs, managers, supervisors, senior managers and the accountable manager since they are the ones that are responsible for the main production line of the company. Through training and continued maintenance of competence, it will provide an opportunity to reinforce the safety policy and establish the proper attitudes and behaviours for all levels of staff in the organization.
Safety culture can be defined as the product of individual and group values, attitudes, competencies and patterns of behaviour that determine their commitment to the health and safety issues. An organization with a safety culture is one that prioritizes the safety and the importance to manage them to reduce risk. However, a safety culture is more than just avoiding accidents or reducing the number of accidents, but an apparent measure of success in improving the safety of employees within the organization. In the aircraft maintenance industry, it is to do follow the correct procedures when carrying out a maintenance check or repairs.
Recognizing that accidents are preventable through following the key to achieving that safety culture is in:
recognizing that accidents are preventable through following correct procedures and established best practice;
constantly thinking safety; and
seeking continuous improvement
It is however, rare that new types of accidents to occur and many of those common ones continue to occur are normally due to the unsafe acts of employees, or technicians in these maintenance industry. These errors are usually the violation of good practice of establish rules. Those who make these errors are often aware of their foul actions but to cut a lengthy task short, they normally choose to take 'short-cuts' and this ultimately increase the risk of accidents occurring.
The central of a Safety Culture is a 'leadership' that is capable of communicating with everyone in the company as a means of actions and setting a standard to the safety culture. Once everyone in the organization are capable of doing their job in a safe ways and vigilance of the hazardous environment of the maintenance organization, only then can they reach a new standard of safety driven through attitudes. At the same time, as a leader they must actively encourage and demonstrate regularly to encourage all employees to participate in order to achieve a new level of safety.
A safety culture in an aircraft maintenance industry shouldÂ consist ofÂ five elements2:
An informed culture
In an informed culture the organization should collects and analysesÂ relevant data, and actively disseminates safety information to update on their safety management system.
A reporting culture
ThroughÂ cultivating an atmosphere where peopleÂ have confidenceÂ to report safety concerns without fear of blame.Â Employees must know that confidentiality will be maintained and that the information they submitÂ will be acted upon, otherwise they will decide that there is no benefit in their reporting
A learning culture
In a learning culture, the organization is able to learn from its mistakes and make improvements.Â It will also ensure that people understand the Safety Management System processes at a personal level.Â
A just culture
A just culture,Â errors and unsafe acts will not be punished if the error was unintentional. However, for those who act recklessly or take deliberate and unjustifiable risks will still be subject to disciplinary action.
A flexible culture
A flexible cultureÂ inÂ the organization and the people in itÂ are capable of adapting effectively to changing demands.
Safety Management System with Safety Culture
In a term, safety culture lays the foundation of the safety management system which can also be treated as the lifeblood of an organization. The safety culture can influences how well its people and structure work together therefore it can determines how successful an organization can be for the long term and short term period at the same time. Safety culture in a maintenance organisation can be also described as the way it operates and particularly in the way it manages safety. To put it simply, a safety culture influences all important thing that go on in an organization.
In order for Safety Management System to accomplish its goals, the organization must first be able to establish a safety culture within the working environment. From the key components that made up the Safety Management System and Safety Culture, it is understandable that why without safety culture, a safety management System will not be effective. The Safety culture elements refers to the work environments, such as values, rules and understandings that influence the employees' perceptions and attitudes toward the importance of a safety of the organization. On the other hand, the Safety Management System is the arrangements made by the organization in order to promote a safety culture and achieve good safety performance.
Without a Safety Culture the industry will not be able to minimize the risks of accidents with just having a Safety Management System. It is the combine effects of the 2 that create a balance of risk management. The safety culture works by providing the proper analysis of risk faced by the industry and by using this information, the Safety Management System can make arrangement to strengthen the safety culture, for example, the attitude of employees when performing a task can be strengthen if they have beneficial claims if they done the task with correct procedure. Therefore, we can conclude that in order for a Safety Management System to establish in the aviation industry, a safety culture must coexist with Safety Management System.
Reprimanding an engineer is a process where they are judge on their mistakes. However, the chances of that engineer making the same mistakes in the future is very low but if we are looking at a different type of mistakes, it is almost impossible to say that by reprimanding an engineer can actually prevent them from making the mistakes in the future. Even if we reprimand the engineer who is at fault it is difficult to put the blame on him/her as we are well aware of human factors and other factors that plays a role in such situation. Therefore, even if we were to reprimand the engineers for the mistakes, it is not entirely possible to say that they will not make other mistakes in the future. The only way to answer the question is the type of mistakes which is either something that we can't control i.e. human factors, and those that are caused by poor management in the organization. By learning from mistakes, the management team will be able to adjust or improve the working culture so that the same mistakes will not every happen again in the organization.
The few aspects to that place the engineer in a position where he or she is at fault of the mistakes but the fact reveals that they are not entirely at fault. They are:
In the maintenance department of aviation industry, with the ever changing working environment it is hard for engineers to cope with it. The maintenance department will have aircraft going in and out of the hangar every day and it should be able to accommodate the specific type and number of aircraft in the base to carry out the maintenance. If the engineer have been working in a tight space area there are bound to have human errors mistakes going on in the maintenance base.
When we talk about working environment, it also includes the environmental issues such as temperature, lighting, noise and tools. In different countries the working temperature can play a role in causing human errors which is can be prevented by having proper ventilation in the working environment. Lighting on the other hand plays an important role because a working environment with poor lighting can also promote poor working environment and expose engineers to make mistakes. Noise levels should be controlled to the point where it will not distract engineer when carrying out tasks such as inspection if it is not practical to control the noise source, engineers should be provided with the proper gear to stop the excessive noise that cause distraction.
Working environment also includes the different types of tools that are used for specific tasks. If a maintenance need to carry out a task that requires tools that the maintenance department are not prepared with, engineers might be forced in a situation where they need to improvise to get the job done which include using non-compatible tools to do a job.
An increased workload may also be considered to be associated as the cause of the mistakes. Workload can affect engineers' psychological and physical performance. With increased workload, the amount of stress that builds up slowly can ultimately cause an unwanted problem to happen. This is a common problem that can be found in most aviation maintenance industry as engineers are constantly asked to accomplish a task within a specific amount of time. If for some reason they are unable to accomplish the task in time, their stress level will rise to a point where they might complete the task without proper inspection of being done correctly. Therefore, engineers are not the only reason that will link them to making mistakes but originated from the maintenance department that schedule the amount of work that needs to be done.
In the aviation maintenance industry, it is common to find that engineers work in a team with a handful of technicians or other engineers to accomplish a certain job. However, it is impossible to judge who's at fault when a problem appears in the task that they performed. As a team, it is not justify putting the blame on 1 engineer that performs the task as a team be it the correct way or not. The issues should be raise up against the whole team in order to maintain a balance in the working culture so that everyone in the maintenance department are well aware of such a problem and will be more vigilance. After such an incident, the management team can set up a system that need all team members to inspect that the task is done correctly and without any problems and reducing the chances of repeating the same mistakes in the future.
From the unintentional cause of mistakes, we now move on to discuss on the violation of aircraft maintenance practice. Although most engineers stern from a genuine desire to do a proper job but there are always some that chooses to be the odd ones and decided to violate the practices intentionally and pose as a threat to the aviation maintenance. There are 4 types of violation which can be classified:
Routine violations is when engineers believe that procedures may be over prescriptive and decided that they can be violated to simplify a task or commonly known by us as 'cutting corners', to save time and efforts.
Situational violation only occurs due to time pressure, high workload, unworkable procedures, inadequate tooling, and poor working conditions. So in order to get the job done, engineers consider that a procedure cannot be followed completely and again skipped the full procedure.
Optimizing violations involve breaking the rules for 'kicks' or pleasure. These are often quite unrelated to the actual task. The person just uses the opportunity to show that he is very skillful in doing specific task.
Exceptional Violations are when engineers have no other options to proceed with a task without violating a few rules. Even if the engineers have no ill intention of violating any procedure but circumstances persists.
When an error occurs in the maintenance department, the engineer who last worked on the aircraft is usually consider to be 'at fault' and may be reprimanded and requires to go through some remedial training or simply told not to make the same error again. However, by blaming the engineer who is at fault may not be a positive ways of sending message across the maintenance department since other engineers may be discourage to 'come clean' about their mistakes and cover up their mistakes. Ultimately, through reprimand it deny a safety culture to effectively establish in the maintenance department. Without a safety culture, the engineer will not be aware of the other mistakes and subsequently that engineer will make another mistake.
All in all, it is not possible that the engineer will avoid making mistakes since there is always a human limit. So, in order to reduce or prevent errors, the maintenance organization needs to compromise between implementing measure to prevent or reduce errors and making profits. Perhaps the most important of all is to achieve a level of management where engineers have no means of intentionally violates the proper procedure to accomplish tasks.
In conclusion, human factor is one of the most common factors that cause error or accidents in the aviation maintenance industry. In order to prevent or reduce this risk, organization implemented many new types of safety system and culture to counter this problem. Human factor forces people to make mistakes and mistakes leads to accident, be it a serious or minor ones but the end result will be organization not making any profits. Having that said, since it's not possible to avoid human factors in the aviation industry, engineers making a mistakes unintentionally can help the maintenance organization to learn from such an incident and implement new system so that they can reduce or prevent such mistakes from happening again in the future.