A performance improvement case study in aircraft maintenance and its implications for hazard identification

Aircraft maintenance is a highly regulated, safety critical, complex and competitive industry. There is a need to develop innovative solutions to address process efficiency without compromising safety and quality. This paper presents the case that in order to improve a highly complex system such as aircraft maintenance, it is necessary to develop a comprehensive and ecologically valid model of the operational system, which represents not just what is meant to happen, but what normally happens. This model then provides the backdrop against which to change or improve the system. A performance report, the Blocker Report, specific to aircraft maintenance and related to the model was developed gathering data on anything that ‘blocks’ task or check performance. A Blocker Resolution Process was designed to resolve blockers and improve the current check system. Significant results were obtained for the company in the first trial and implications for safety management systems and hazard identification are discussed. Statement of Relevance: Aircraft maintenance is a safety critical, complex, competitive industry with a need to develop innovative solutions to address process and safety efficiency. This research addresses this through the development of a comprehensive and ecologically valid model of the system linked with a performance reporting and resolution system.

[1]  Richard Ennals,et al.  Doing Action Research in Your Own Organisation , 2009 .

[2]  David Coghlan Putting "Research" Back into OD and Action Research: A Call to OD Practitioners , 2002 .

[3]  P. Teague,et al.  Social Partnership and the Enterprise Some Lessons From the Irish Experience , 2004 .

[4]  Alan Hobbs,et al.  Managing Maintenance Error: A Practical Guide , 2003 .

[5]  Melvin Alexander,et al.  Six Sigma: The Breakthrough Management Strategy Revolutionizing the World's Top Corporations , 2001, Technometrics.

[6]  Daniel Roos,et al.  The machine that changed the world : the story of lean production , 1991 .

[7]  James T. Reason,et al.  Managing the risks of organizational accidents , 1997 .

[8]  Rob McLean,et al.  Alignment: Using the Balanced Scorecard to Create Corporate Synergies , 2006 .

[9]  A L Schutz,et al.  Assessment of patient safety research from an organizational ergonomics and structural perspective , 2007, Ergonomics.

[10]  J. Hughes,et al.  Commentary: Participatory Action Research Leads to Sustainable School and Community Improvement , 2003 .

[11]  Y. Wadsworth What is participatory action research , 1998 .

[12]  Christopher Nemeth,et al.  Remaining sensitive to the possibility of failure , 2008 .

[13]  Erik Hollnagel,et al.  Joint Cognitive Systems: Foundations of Cognitive Systems Engineering , 2005 .

[14]  Manoj S. Patankar,et al.  Applied human factors in aviation maintenance , 2004 .

[15]  Edgar H. Schein,et al.  Organization development : science, technology, or philosophy? , 1989 .

[16]  Saint Louis,et al.  FACTORS AFFECTING THE SUCCESS OR FAILURE OF AVIATION SAFETY ACTION PROGRAMS IN AVIATION MAINTENANCE ORGANIZATIONS , 2004 .

[17]  M. Hult,et al.  TOWARDS A DEFINITION OF ACTION RESEARCH: A NOTE AND BIBLIOGRAPHY , 1980 .

[18]  James W. Fairfield-Sonn,et al.  The Awakening Giant: Continuity and Change in ICI. , 1987 .

[19]  Colin G. Drury,et al.  Task Analysis of Aircraft Inspection Activities: Methods and Findings , 1990 .

[20]  Manoj S. Patankar,et al.  Risk Management and Error Reduction in Aviation Maintenance , 2003 .

[21]  Nick McDonald,et al.  Human Integration in the Lifecycle of Aviation Systems , 2007, HCI.

[22]  Ian Alexander,et al.  Handbook of Action Research Participative Inquiry and Practice , 2001, Eur. J. Inf. Syst..

[23]  P. Grinyer Book reviewThe awakening giant: Continuity and change at ICI : Andrew W. Pettigrew, Basil Blackwell (1985), 519 pp. £25.00 (hardback) , 1986 .

[24]  Neville A Stanton,et al.  On the cost-effectiveness of ergonomics. , 2003, Applied ergonomics.

[25]  Marie Ward Contributions to human factors from three case studies in aircraft maintenance , 2006 .

[26]  Matthias Buderath,et al.  The operational impact to the maintainer (Ground Crew Support and human factors) , 2008 .

[27]  Colin G. Drury,et al.  Human factors in aviation maintenance: How we got to where we are , 2000 .

[28]  Erik Hollnagel,et al.  Cognitive reliability and error analysis method : CREAM , 1998 .

[29]  R. Dorf,et al.  The Balanced Scorecard: Translating Strategy Into Action , 1997, Proceedings of the IEEE.

[30]  Erik Hollnagel,et al.  Cognitive reliability and error analysis method , 1998 .

[31]  M A Sinclair,et al.  Ergonomics issues in future systems , 2007, Ergonomics.

[32]  B. Sckell,et al.  Just Culture: Balancing Safety and Accountability , 2009 .

[33]  Robert L. Wears,et al.  Resilience Engineering: Concepts and Precepts , 2006, Quality and Safety in Health Care.

[34]  Baranzini Daniele Aircraft Maintenance Teams , 2009 .

[35]  Roland Akselsson,et al.  Resilience Safety Culture , 2009 .

[36]  M. Jelinek Managing change for competitive success , 1993 .

[37]  J. E. Groves,et al.  Made in America: Science, Technology and American Modernist Poets , 1989 .

[38]  D. L. Simms,et al.  Normal Accidents: Living with High-Risk Technologies , 1986 .