On May 9th 2019, I attended this very interesting conference and here are my views and summary. (Note that these are my personal views and interpretations of the talks I listened to, and by no means signify the views of the Royal Aeronautical Society or the speakers).

For a complete list of speakers and their biographies, please see programme details : https://www.aerosociety.com/events-calendar/maintenance-error-are-we-learning/

SYNOPSIS:

Analysis of mandatory occurrence reports and Civil Aviation Authority (CAA) airworthiness audit findings over the past decade suggest that trends remain largely unchanged in terms of the number and types of findings and occurrences. From the CAA’s perspective, the understanding of human performance, quality of industry investigations and proposed corrective actions to events vary considerably, often leading to repeated or similar findings or occurrence reports.

There are shortcomings in root cause analysis with a broad spectrum in application, ranging from a “root cause” being more of a symptom of the problem, or a statement which is completely off the mark, to precise isolation of an accurate root cause which will solve the problem once and for all. The former is more prevalent.

MY SUMMARY:

All in all, I found the conference very enlightening but the following speakers and their talk really stood out for me:

CAA Airworthiness Surveyor, Dr Marie Langer’ s talk highlighted interesting areas and a particular point I took from it is that failing to follow procedure is still one of the leading problems in maintenance errors. Also new technology brings more complexity and this has its own challenges in the effectiveness of training. It is a two-edged sword: in some cases, the procedures are not written well enough and are not fit for purpose or easily understood, and in other cases, the user has evidently not studied or read the procedure correctly and for various reasons, does not follow the procedure.

The CAA raises about 3,500 audit findings per year, and this is not changing year in year out. Advice on how to do root cause analysis to handle the findings and take effective corrective actions to rectify the matter so it does not occur again is not getting through. Learning is not sticking! The CAA is trying to change tactics to accomplish some positive changes.

From my perspective as a specialist in training and education, I firmly believe that there is much room for Study Technology® including educating employees at all levels, from top to bottom, about the three barriers to study, their symptoms and how to spot them and handle them, so that learning in any subject DOES STICK!!

The most important barrier to study, and that which produces the most significant difficulties is the MISUNDERSTOOD WORD. Here is an extract from The Three Barriers to Study , 2003, Applied Scholastics :

“ ‘Mis’ means not or wrongly. “Misunderstood” means not understood or wrongly understood. A misunderstood word is a word which is not understood or a word which is wrongly understood.

Have you ever been reading a book or a report, gotten to the end of the page and couldn’t remember what you read? Therein lies the phenomena of the misunderstood word—all becomes distinctly blank beyond a word not understood or wrongly understood.

It can make you feel blank or washed out . It can make you feel “not there” and a sort of a nervous upset feeling can follow after that.

The matter is far more critical than one might surmise and of the three barriers it is the misunderstood that bears most upon human relations, the mind and understanding.

It is the misunderstood word that establishes aptitude—or lack of it.

It produces a vast panorama of reactions and is the prime factor involved with stupidity . It also determines whether or not one can actually perform a learned skill , and to what degree of proficiency. All of these are the result of one or more words or symbols not understood or wrongly understood.

The misunderstood word can stop a student in his tracks completely. Knowing how to determine when there is a misunderstood word or symbol, how to find it and how to handle it are critical to the success of any student.”

If an engineer, or any employee for that matter, is given a procedure to study but fails to look up words in the text which he or she does not fully understand, the symptoms and phenomena of the misunderstood word will manifest in one form or another. One manifestation could simply be the inability to apply the procedure correctly (assuming the procedure is well written) i.e. fail to follow the procedure, or do the procedure the wrong way around, or perhaps even add to it or subtract from it. Other outcomes could include failure to retain the information despite thorough training, a refusal to change, etc.

Another situation where the misunderstood word is evidently wreaking havoc is in the area of root cause analysis. It is very evident from several talks during the conference that difficulty in isolating accurate root causes during inspections, despite using a “root cause analysis process” indicates to me that this is an area where the user hasn’t grasped what the words mean, perhaps has not read the root cause analysis procedure fully due to misunderstood words which made him or her go “blank” or “washed out” and distracted. (And let’s not forget the very bad practice, of which a great number of companies including the European Aviation Safety Agency (EASA) are guilty, of using plenty of acronyms and terminology which are not defined in the documents where they appear. A lack of a comprehensive glossary at the back of a document intended for use adds to the problem.)

Improving a person’s ability to learn and assimilate data so that he or she can successfully apply it is a very positive activity. Rather than be concerned only with Safety-I (i.e. only looking at what can go wrong and getting as little things to go wrong), we can obtain a significant push towards Safety-II. According to Safety-II, the everyday performance variability needed to respond to varying conditions is the reason why things go right. Therefore humans are consequently seen as a resource necessary to make things go right.

Let’s help us humans make things righter than we are already doing by improving our ability to actually learn so that we can apply! Not just learn rote, but learn with purpose and understanding with consequent competence and proficiency.

Another speaker whose talk was most interesting to me was Mr Charlie Brown, from Virgin Atlantic Airways , who gave an in-depth review of the events leading to the air turn-back and subsequent partial gear landing at London Gatwick of Boeing 747-400 G-VROM on 29 December 2014.

He covered the maintenance activities prior to the incident and the investigation after the incident. Here again we have a number of factors in action, with one being inadequate written procedure from Boeing among others. It was fascinating to hear how Mr Brown and his team, with great persistence and good sense, were able to have Boeing amend a procedure which had been as-is for many years. It goes to show that things can indeed change, and be changed, but it may require a great persistence.

The penultimate speaker, Mr Colin Russell from Thomas Cook Airlines, gave a lively presentation of his personal reflections working in safety in an aircraft environment. What I really liked about his talk was the stress on communication and talking with engineers or others who actually have to do the work. Too many people are sat in offices, creating endless procedures, rules, orders etc. without ever consulting the end-user. Mr Russell gave some personal examples of his experience early in his career of being at a desk producing such documents to the detriment of the users and how he eventually came to the realisation that this was not the way.

I support Mr Russell’s views wholeheartedly as I have myself, on many occasions (and again very recently) been involved in situations where I am dealing with some individuals who are churning out documentation to do this or that, without once having consulted those who would use it. Such an approach is very destructive to a business.

If there is a problem with procedure, or procedure is not being followed, or some other issue is happening on the “front line”, then the right thing to do is to talk to those who are doing the work and really find out what is happening, what the problem is, and as a team, find a solution which will work. Working in ivory towers is not the solution in this current day and age of fast-paced communication and production.

The final speaker, Mr Andy Evans from Aerosurrance Ltd , gave a talk which to me was like a nice cherry on the cake at the end of the day.

Mr Evans challenged the audience to consider if we did not need a new generation approach to human factors in maintenance, since we are still repeating incidents that have happened before. A reference to the UK CAA reporting in Civil Aviation Publication (CAP) 1367 (2016) Aircraft Maintenance Incident Analysis “ …the extent to which detailed error investigations are conducted appears to have decreased and industry’s commitment to error investigation has waned. ” was rather apt.

Therefore, Mr Evans’ intent was to encourage the audience to challenge some preconceptions and consider next generation approaches. Issues highlighted included: Have we got the emphasis right when we consider safety culture? Are we driving the right safety reporting behaviours? Are we proactively learning? Do our safety software tools stimulate real learning, sharing and debate?

A next generation approach that I certainly would like to see broadly used is Study Technology. Empowering each person in the industry to understand and be able to recognise the three barriers to learning and their specific symptoms, and understand the importance of the misunderstood word or symbol as a major factor behind a person’s inability to grasp their post or their job or procedure, and any other object of study, could potentially produce exceptional positive changes. It is highly probable that with this approach we could start seeing true reductions in maintenance errors and perhaps even further afield.

In closing, I must comment on an excellent conversation I had with Mr John Vincent from the International Federation of Airworthiness (IFA). Mr Vincent informed me of an event which takes place yearly in the US, the Aerospace Maintenance Competition, https://www.aerospacecompetition.com . The competition is held annually in conjunction with Aviation Week ’s MRO Americas (MRO stands for maintenance, repair and overhaul). Teams representing educational institutions, commercial airlines, repair and manufacturing companies, general aviation and space compete to find out who's the best of the best.

I promptly visited the competition’s on-line site upon returning home. I was enthused that such a fabulous event exists. The USA clearly values its aviation maintenance technicians, and such an event can only be a win-win for everyone involved!

Being a STEM ambassador myself (science, technology, engineering and maths) I have been involved in a number of activities in the UK including the Big Bang Science Fair in Liverpool. Those type of events are just incredible and truly promote a sense of camaraderie, competence, and sheer enthusiasm which is infectious.

Wouldn’t it be great to start up a similar project here in the UK? Perhaps for the UK and Europe, or also including the Middle East? What do you think?

What a way to encourage people to take up a maintenance engineering professional or other related aerospace maintenance career!