Event Analysis Using Maintenance Error Decision Aid (MEDA) and Procedural Event Analysis Tool (PEAT)

Transcription

1 Event Analysis Using Maintenance Error Decision Aid (MEDA) and Procedural Event Analysis Tool (PEAT) William L. Rankin Steven P. Kimball, Mike Moodi, Steven L. Sogg Human Factors Boeing Commercial Aviation Services at Safety Management Systems Information Session October 13-14, 2005 The Fairmont Palliser Calgary, Alberta, Canada

2 Boeing Investigation Processes MEDA Maintenance Error Decision Aid for Maintenance and Engineering REDA Ramp Error Decision Aid for Ramp/Apron operations PEAT Procedural Event Analysis Tool for Flight Operations CPIT Cabin Procedural Investigation Tool for Cabin Operations 2

3 We Support Your Operations Senior Management Overview Investigator Workshop Implementation Planning 3

4 Presentation Outline Need for event investigation--safety and monetary costs Contributing factors Investigation tool and process How to implement 4

5 We Need to Continuously Improve Aviation Safety Boeing 11,000 Airplanes in service 25,400 14, Hull loss accidents per year Business as usual Our goal Millions of departures Hull loss accident rate per million departures Year Year FT-004Wc

6 Worldwide Accident Rate Last 20 Years Hull Loss and Fatal Accidents Per Million 1.00 Departures /8/05 AR-033 6

7 Causes of Accidents 100% 90% 80% Human Causes 70% 60% 50% 40% 30% 20% 10% 0% Machine Causes 1903 Today TIME 7

8 Primary Cause Hull Loss Accidents - Worldwide Commercial Jet Fleet Primary factor Number of accidents Cockpit crew Airplane Maintenance & Inspection Weather Airport/ATC Miscellaneous/other Total with known causes Unknown or awaiting reports Total Percentage of total accidents with known causes % 54.6% 15.8% 16.4% 3.7% 4.6%. 4.3% 11.8% 5.1% 3.6% 7.0% 8.9% Excludes:: Sabotage Military action Legend: 1959 through through

9 World Wide Accidents 2003 IATA Safety Report 2003 Total of 92 accidents in Western-built jets 32 Western-built turboprops 7 Eastern-built jets 11 Eastern-built turboprops. Poor operational flight crew decisions underlay many of the 2003 accidents 53 accidents during approach and landing 8 accidents were controlled flight into terrain 24 accidents began with a maintenance-caused event that was incorrectly handled by the flight crew Ramp operations have also been causal in airplane accidents, although not in

10 Monetary Costs Hull loss accidents can cost (hundreds of) millions of dollars. Maintenance error causes 20% to 30% of in-flight shutdowns (IFSDs) at a cost of US$500,000 per IFSD. World wide ramp damage costs ~US$4 Billion/year. 10

11 Event Philosophy Airline events can be caused by an error or an error/violation combination. Errors are not made on purpose. Errors result from a series of contributing factors in the work place. Violations, while intentional, are also caused by contributing factors in the work place. 11

12 Event Philosophy Most of the contributing factors to errors and/or violations are under management control. Therefore, improvements can be made to these contributing factors so that they do not contribute to future events. The airline must be viewed as a system, where the employee is one part of the system. Addressing lower level events helps prevent more serious events. 12

13 Definitions of Error and Violation An error is a human action (behavior) that unintentionally departs from the expected action (behavior). A violation is a human action (behavior) that intentionally departs from the expected action (behavior). 13

14 Violations What can be violated? Aviation regulations Company policies Company processes Company procedures Violations are often made by wellintentioned staff trying to finish a job, not staff who are trying to increase comfort or reduce their work load. 14

15 Errors and Violations Errors have been the focus of research, so we have more theories of why errors occur than theories of why violations occur. However, errors and violations often occur together to produce an unwanted outcome. Data from the U.S. Navy suggest that ~80% of maintenance-caused events involve an error, and ~40% of maintenance-caused events involve a violation. 15

16 UK Flight Safety Committee 2004 Top 10 Causes of Maintenance Mishaps 1. Failure to follow published technical data or local instructions 2. Using unauthorized procedure not referenced in technical data 3. Supervisors accepting non-use of technical data or failure to follow maintenance instructions 4. Failure to document maintenance properly in maintenance records, work package 5. Inattention to detail/complacency 6. Incorrectly installed hardware on an aircraft/engine 7. Performing an unauthorized modification to the aircraft 8. Failure to conduct a tool inventory after completion of the task 9. Personnel not trained or certified to perform the task 10. Ground support equipment improperly positioned for the task 16

17 Types of Violations There are three types of violations that we are interested in Routine Situational Exceptional. 17

18 Violation Definitions Routine These are common practice. Often occur with such regularity that they are automatic. Violating this rule has become a group norm. Routine violations are condoned by management. 18

19 Violation Definitions (contd.) Situational Employee strays from accepted practices, bending a rule. Occur as a result of factors dictated by the employee s immediate work area or environment. Due to such things as Time pressure Lack of supervision Unavailability of equipment, tools, or parts Insufficient staff. 19

20 Violation Definitions (contd.) Exceptional Employee willfully breaks standing rules while disregarding the consequences. 20

21 Levels of Causation Cause-in-Fact: If A exists (occurred), then B will occur. Probabilistic: If A exists (occurred), then the likelihood of B increases. Applies to: Contributing factors leading to an error or a violation, and Errors leading to an event 21

22 Contributing Factors Anything that affects how an employee does his/her job can be a contributing factor to an error or a violation. Employee Knowledge Skills Abilities Other characteristics Immediate Environment Facilities Weather Aircraft design/configuration Component design Equipment/tools/parts Technical documentation Tasks Time pressure Teamwork On-the-Job training Communication Supervision Planning Organizing Prioritizing Delegating Instructing Feedback Performance Management Team Building Organization Philosophy Policies Procedures Processes Selection Training Continuous Quality Improvement 22

23 Initial Error Model Probability Probability Contributing Factor Leads to Error Leads to Event 23

24 Enhanced Error Model CF Probability Probability CF CF Error Event Experience has shown that there is an average of 3 to 4 contributing factors to each error. 24

25 Further Enhanced Error Model Probability Probability Probability Probability CF CF CF CF CF Error Event CF CF Also, there are contributing factors to the contributing factors. 25

26 Error and Violation Model 1 Probability Probability Probability Contributing Factors Violation Error Event Maintenance Example Mechanic does not use a torque wrench (violation), which contributes to an incorrect installation (error) because of an under torqued bolt. This leads to an in-flight shutdown (event). There are reasons why (contributing factors) the violation occurred (e.g., torque wrench not available in time to do task or work group norm is not to use a torque wrench). 26

27 Error and Violation Model 2 Probability Probability Contributing Factors Error Event Contributing Factors Violation Maintenance Example The mechanic mistakenly misses a step in the maintenance manual (contributing factor), which leads to an incomplete installation (error). The mechanic decides not to carry out the operational check (violation), thereby missing the fact that the task was not done correctly. Because an error was made and this was not caught by the operational check, an in-flight shutdown (event) occurs. 27

28 Final Event Model Probability CF Probability CF CF CF CF Probability CF Contributing Factors Violation Error Event CF CF Contributing Factors Violation 28

29 MEDA/REDA/PEAT/CPIT Results Form General Information Event(s) Error Description Contributing Factors Error Prevention Strategies 29

30 Results Form - Events Section II -- Event Please select the event (check all that apply) 1. Operations Process Event ( ) f. Diversion ( ) a. Flight Delay (write in length) _ days hrs. min. ( ) g. Other (explain below) ( ) b. Flight Cancellation ( ) 2. Aircraft Damage Event ( ) c. Gate Return ( ) 3. Personal Injury Event ( ) d. In-Flight Shut Down ( ) 4. Rework ( ) e. Air Turn-Back ( ) 5. Other Event (explain below) Describe the incident/degradation/failure (e.g., could not pressurize) that caused the event. Process loss Aircraft damage Personal injury Rework 30

31 Results Form - Maintenance Error S e c tion III -- Maintenanc e Erro r Please select the maintenance error(s) that caused the event: 1. Installation Error ( ) 3. Repair Error (e.g., component or) 6. Airplane/Equipment Damage Error ( ) a. Equipment/part not installed structural repair) ( ) a. Tools/equipment used improperly ( ) b. Wrong equipment/part installed ( ) b. Defective tools/equipment used ( ) c. Wrong orientation 4. Fault Isolation/Test/Inspection Error ( ) c. Struck by/against ( ) d. Improper location ( ) a. Did not detect fault ( ) d. Pulled/pushed/drove into ( ) e. Incomplete installation ( ) b. Not found by fault isolation ( ) e. Other (explain below) ( ) f. Extra parts installed ( ) c. Not found by operational/ ( ) g. Access not closed functional test 7. Personal Injury Error ( ) h. System/equipment not ( ) d. Not found by inspection ( ) a. Slip/trip/fall reactivated/deactivated ( ) e. Access not closed ( ) b. Caught in/on/between ( ) i. Damaged on installation ( ) f. System/equipment not ( ) c. Struck by/against ( ) j. Cross connection deactivated/reactivated ( ) d. Hazard contacted (e.g., electricity, hot ( ) k. Other (explain below) ( ) g. Other (explain below) or cold surfaces, and sharp surfaces) ( ) e. Hazardous substance exposure (e.g., 2. Servicing Error 5. Foreign Object Damage Error toxic or noxious substances) ( ) a. Not enough fluid ( ) a. Material left in aircraft/engine ( ) f. Hazardous thermal environment ( ) b. Too much fluid ( ) b. Debris on ramp exposure (heat, cold, or humidity) ( ) c. Wrong fluid type ( ) c. Debris falling into open systems ( ) g. Other (explain below) ( ) d. Required servicing not performed ( ) d. Other (explain below) ( ) e. Access not closed ( ) 8. Other (explain below) ( ) f. System/equipment not deactivated/reactivated ( ) g. Other (explain below) Describe the specific maintenance error (e.g., auto pressure controller installed in wrong location). 31

32 Results Form - Contributing Factors Information Equipment/Tools/ Safety Equipment Airplane Design/ Configuration/Parts Job/Task Technical Knowledge/Skills Individual Factors Environment/Facilities Organizational Factors Leadership/Supervision Communication 32

33 Current Investigation Process Event Occurs Event Caused by Employee Performance Find Who Caused the Event Punish Employee 33

34 Investigation Process Event Occurs Investigation Finds Event Caused by Employee Performance Find Employee Who Did the Work Interview Employee Determine errors/violations Find Contributing Factors Get Ideas for Process Improvement Follow up to Obtain Additional Contributing Factors and Information Add to Event Data Base Make Process Improvements Based on This Event Based on Analysis of Data for Multiple Events Provide Information to All Employees Affected By Process Improvements 34

35 Things that Affect Investigation Process Use Organization culture Lack of management support Management fails to put process in place History of punishment for errors National culture Country Aviation Authority 35

36 Steps to Implement Investigation Process 1. Pick a manager/department to be responsible for investigation process. 2. If needed, develop and use a new discipline policy. 3. Pick the events that will be investigated. 36

37 Steps to Implement Investigation Process 4. Pick staff to be on the investigation team and train them on the process. 5. Inform other staff about the investigation process. 6. Set up a management team to review ideas for improvement. 37

38 Steps to Implement Investigation Process 7. Begin investigations. 8. Follow investigations and make sure ideas for improvement are put in place. 9. Tell Boeing when its aircraft design or support products contribute to errors. 10. Tell employees about investigation results and improvements. 38

39 Summary Safety Management Systems require reactive event investigations. Boeing has four tools to investigate humanperformance caused events Flight deck (PEAT) Passenger cabin (CPIT) Maintenance and engineering (MEDA) Ground/ramp operations (REDA). These tools will not only help you improve safety, but they will also improve efficiency and reduce costs. 39

40 Who to Contact MEDA/REDA William L. (Bill) Rankin PEAT/CPIT Mike Moodi