eamtc master document€¦ · web view10.2 appendix y: intervention selection tool 27. document...

European Aviation Maintenance Training Committee

Attitudes and Behaviour Working Group

(MASTER DOCUMENT)

EAMTC WORKING GROUP MASTER DOCUMENT

TABLE OF CONTENTS

Table of Contents............................................................................................................................21 DOCUMENT DESCRIPTION..................................................................................................3

1.1 Revision Record................................................................................................................32 INTRODUCTION.......................................................................................................................4

2.1 Working Group organisation............................................................................................42.2 Abbreviations.....................................................................................................................42.3 Background........................................................................................................................5

3 MEETING REPORT.................................................................................................................63.1 Attendance.........................................................................................................................63.2 Organisation Categories..................................................................................................63.3 Organisational Representation.......................................................................................73.4 Minutes of Previous Meetings.........................................................................................83.5 Background of working group.........................................................................................93.6 Mission Statement.............................................................................................................93.7 Objective Statement.........................................................................................................93.8 Scope Statement...............................................................................................................93.9 Manifesto............................................................................................................................9

4 Definition of terms...................................................................................................................115 Attitudes and Behaviours.......................................................................................................126 Competencies..........................................................................................................................147 Systems approach..................................................................................................................168 Intervention planning tool.......................................................................................................19

8.1 Visual flow of actions......................................................................................................239 Type of interventions belonging to different categories.......................................................2510 Appendices...........................................................................................................................26

10.1 Appendix X: Intervention planning form......................................................................2610.2 Appendix Y: intervention selection tool........................................................................27

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1 DOCUMENT DESCRIPTIONPurpose: This document is issued by the EAMTC President when the WG is

established further to a GA vote for the establishment of such a group. The document is used to report the results of the WG to the EAMTC President and the GA.

Distribution: Participants of the Group, people designated by the WG President and / or EAMTC President and the EAMTC web site

Maintenance: WG President or as assignedUsage: This document records the ongoing work of the WG. It is the report

document for the WG. It is to be used to communicate the WG recommendations established to the EAMTC President and GA

Control: The control of the issuance of the document to the WG President rests with the EAMTC President. Once issued, the control of the document rests with the WG President.

Version: The version number is established by re-issue Revised: Revision number established by minor updates and editorial changesClassification: Restricted to members useValid from: Latest meeting minutesSoftware: The software used to edit this document is MS Word, Open Office (or

similar). The document is normally distributed in Adobe® PDF format.

1.1 Revision RecordVer Date Author Revision Highlights1 02/03/13 Anneke Nabben 12345678

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2 INTRODUCTION

2.1 Working Group organisationPresident Anneke NabbenVice PresidentWorking Group MembersMinutes Recorder

2.2 AbbreviationsAMT Aicraft Maintenance TechnicianATA Air Transport AssociationEAMTC European Aviation Maintenance Training CommitteeEASA European Aviation Safety AgencyGA General Assembly of the EAMTCHF Human Factors

WG Working Group

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2.3 BackgroundWith few aircraft accidents being caused by lack of knowledge on the part of maintenance personnel and with hand skills addressed by other training methods, various industry meetings concluded that attitude and behaviour may be areas on which the industry could focus to improve aircraft maintenance performance. Human Factors training, Safety Management Systems etc. all have their positive impact on the industry. However, with the notion that it is the people involved that are the cause of accidents and with all other supporting systems in place, attitude and behaviour of the personnel involved may not have been given the attention it deserves in order to cover all of the elements of competence (KSA). ”The Attitude and Behaviour Working Group originated to consider these areas with respect to aviation maintenance training.

The group’s objective is to produce guidelines and to recommend draft syllabi or areas to be trained.

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3 MEETING REPORT

3.1 AttendanceMeeting attendance is open to all nominated WG participants and any specialists that may be called, as needed, periodically by the WG President to provide particular support.

3.2 Organisation CategoriesMembers and Attendees are categorized by the organisation to which they belong.Group Member Category - Company LocationAnneke Nabben Educational Specialist - NLR NetherlandsDaniela Mohr Educational Specialist – Air Berlin GermanyBettina Möhring Educational Specialist – Infowerk AustriaAachim Blass Training Manager – Eurocopter GermanyNeil Williams Training Manager – LRTT Ltd UKVangelis Demosthenous Director and HF expert – Kratis CyprusSam Cromie Lecturer – Dublin University IrelandPaul Liston Researcher – Dublin University IrelandH. Gumus Technical Instructor – Turkish Airlines TurkeyM. Uhlisa Technical Instructor – Turkish Airlines TurkeyMargriet Bredewold Human Factors and Safety

management - Co-GuardSwitzerland

Michaela Heese Senior Expert Safety Management/HF Austria

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3.3 Organisational RepresentationThe following table totals the represented category by organisation. Only Active members are included in the totals. Multiple members from the same organisation or observers do not influence the totals.Category Numbers

Turkish Airlines– Turkey 1Air Berlin – Germany 1

Airlines Total 2

Manufacturer – Original Equipment Manufacturers Total 0

Turkish Airlines– Turkey 1Air Berlin – Germany 1Bettina Möhring - Educational Specialist – Infowerk 1

Training Schools Total 3

Margriet Bredewold- Human Factors - Co-Guard 1Vangelis Demosthenous - Director and HF expert – Kratis 1Anneke Nabben – Training Specialst - NLR 1Paul Liston - Researcher – Dublin University 1

Consultants Total 4

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3.4 Minutes of Previous MeetingsThe minutes of the previous meetings, are held by the group’s President and Minutes Recorder. They can be accessed from the Members area of the web site with member held passwords.

Past meeting minutes:Place Date Minutes Filename

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3.5 Background of working groupAs mentioned in the Green Paper that has been produced for and presented at the EAMTC in 2010 it is clear that even though Human factors are now a well-established part of training and organizational regimes, they are still underestimated and will be of increasing importance in the future environment. With the advent of better improved information it becomes increasingly clear that the main contributing factor to accidents and incident rates is not insufficient knowledge and insufficient manual skills but the focus should be on non-technical and cultural issues. This implies changing the paradigm from an individual approach to a system approach

3.6 Mission Statement“To develop training industry Guidelines and Recommendations for the training of attitude and behaviour”

3.7 Objective StatementThe Working Group will create: - 1. Recommended draft syllabi or areas to be trained 2. Industry training guidelines and recommendations

3.8 Scope StatementThe target areas and focus of the Working Group include: 1. Pre-training 2. Part 145 training 3. Basic training 4. Type training 5. Continuation / updating training

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3.9 ManifestoScope out an informed understanding of attitudes, behaviours and the role they play in determining safety and competence.Explore areas of potential improvement with regards to competence and behaviourOffer a practical intervention selection tool to improve organizational support for competent and safe performance.

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4 DEFINITION OF TERMSSystem approach: During the organizational era, safety began to be viewed from a systemic perspective, to encompass organizational factors in addition to human and technical factors. (ICAO 2012)Systems thinking is the process of understanding how things, regarded as systems, influence one another within a whole. System thinking has been defined as an approach to problem solving, by viewing "problems" as parts of an overall system, rather than reacting to specific part, outcomes or events and potentially contributing to further development of unintended consequences. Systems thinking is not one thing but a set of habits or practices[2] within a framework that is based on the belief that the component parts of a system can best be understood in the context of relationships with each other and with other systems, rather than in isolation (Wikipedia 2013)Attitude: an intention to behave in a certain way (see page 12)BehaviourCompetencePerformanceContextCulture: Culture is referred to in its simplest form as a ‘collective mapping of the mind’. It influences the values, beliefs and behaviour that we share with other members of our various social groups. It binds us together as members of groups and provides clues and cues as how to perform in both normal and unusual situations.A working definition of culture is proposed as a ‘A pattern of shared basic assumptions that the group has learned as it solved its problem of external adaptation and internal integration, that has worked well enough to be considered valid, and therefore, to be taught to new members as the correct way to perceive, think and feel in relation to those problems.’In simpler terms, culture is not ‘a set’. Culture is dynamic, it changes. Only solutions once proven successful and therefore valid develop into shared assumptions. While dealing with new problems, new solutions are found and their validity judged. Therefore, culture is learned and negotiated.Safety The state in which the possibility of harm to persons or of property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and safety risk management. (ICAO 2012)A working definition of safety is proposed as follows: Safety is the probability of an accident (risk) that is acceptable to society. As long as society perceives the benefits of a certain activity to be greater than the risk of failure, that activity will be considered safe.InterventionValid: Something that is valid is not right or wrong but understandable or explainable given the circumstances.

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http://en.wikipedia.org/wiki/System

http://en.wiktionary.org/wiki/component

http://en.wikipedia.org/wiki/Systems_thinking#cite_note-2

http://en.wikipedia.org/wiki/Unintended_consequences


5 ATTITUDES AND BEHAVIOURS

An attitude can be defined as a positive or negative evaluation of people, objects, event, activities, ideas, or just about anything in your environment (Zimbardo et al., 1999). An attitude is an intention to behave in a certain way.

Having an attitude does not automatically result in a behaviour. Knowledge and skills are needed to be able to behave in the intended way. Attitudes of people can be influenced by the national, professional and/or culture of the organization. Behaviour is influenced by the context in which it takes place and includes the social context, the physical, environmental and organizational context. E.g. an aircraft maintenance technician has a positive attitude about following procedures (he always makes sure to follow the procedures as he has the skills and knowledge about why it is important). For one particular task the technician finds himself unable to follow the procedure because the procedure is incorrect and cannot be completed as written. The maintenance organization knows about this problem on this task and has communicated to the manufacturer the problem with the procedure. As such, having a strong professional commitment to getting the job done the technician deviates from the procedure and uses an informal yet organizationally accepted deviation. It is clear that the technician has a positive attitude about following procedures, he has the knowledge and the skills but this did not result in the behaviour that the attitude would suggest because the context did not allow for it.

Attitudes are undoubtedly an important mediating factor and they contribute to behaviour but they are less tangible than behaviour and, as it is clear from the example above, they don’t always predict behaviour accurately. For this reason the working group chooses to prioritize behaviour as the basic building block for our suggestions and recommendations. This is not to ignore the role of attitude in determining behaviour but is merely a pragmatic measure to ensure an achievable impact in the real world that is measurable, observable and tangible. Our aim is still to improve attitude by leveraging the role of behaviour and context in changing people’s attitudes. We believe that by improving the context, behaviours that as a function, attitudes will improve. Attitudes are learned and when people have negative attitudes towards their work they should be considered valid as they derive from direct and indirect experiences. For example, sometimes technicians don’t report inaccurate procedures because they know from experience that nothing ever comes of it. In this sense the organisation/manufacturer has taught them indirectly to have a negative attitude toward reporting. We aim to improve attitudes such as this by taking a systems approach and exploring what organisations can do to improve culture in order to achieve change in attitudes and behaviours.

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Nabben, Anneke, 08/03/13,

PAUL can you ad d here that we want to train attitudes by examples that emphasize the importance of e.g. handover but make sure that you train it with skills and that it works within the organization looking at tools, processes etc. Anchor attitude training to behaviours and organizations


6 COMPETENCIES

Competence is about having an appropriate understanding of the work, possessing appropriate knowledge, skills and abilities and being able to demonstrate these through performance in a particular context. As we saw in the example of the technician in section X (above) the role of attitudes in determining behaviour or performance is sometimes problematic. So, too is the role of context. In order for a technician to be deemed competent the context has to allow it to be demonstrated.

Behaviour is the observable action (performance) in a certain context. It can be individual or collective and it is the output of skills, knowledge and more remotely attitudes and is mediated by context. Behaviour is formed by attitudes which are an input to knowledge and skill which workers use to perform (produce behaviour). Context is the cultural (organizational, professional, national), physical and social environment in which a person operates. It can both influence the attitudes of people within that context and it determines the behaviour. Knowing this, competent performance is not just about knowledge, skills and attitudes but also behaviour. The AMT mentioned above has the attitude and the necessary knowledge and skills but was not able to demonstrate competent performance because of the context. Up until now the focus of training has been on knowledge and to a lesser extent skills but it is clear that our focus needs to broaden to include the central role of context in allowing competent behaviour to emerge.

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7 SYSTEMS APPROACH

Boeing has developed a useful and pragmatic systems model for aircraft maintenance for the purposes of defining contributing factors in event investigation. This model has been used to form the development of MEDA (Maintenance Error Decision Aid) - an industry standard tool for maintenance error and incident investigation, in support of managing safety. We use a diverted version of this model for the purposes of determining areas and levels of interventions, including training. This model is chosen also for the fact that it is in line with the systems approach that guides our work.

Figure x. MEDA Representation of an aircraft maintenance context

‘In this model a maintenance technician works within an immediate environment under supervision within an organization. Any of these levels or any of the listed items in the model can affect how a maintenance technician does his/her job and, therefore, could contribute to an error’ (MEDA users guide, page 3, 2003). Our diverted model has of 5 layers, the individual or collective behaviour of mechanic(s), the social context, the environmental context, organizational context including organisational culture and the last layer is the professional culture, national culture and regulatory culture.

In order to make sure that the maintenance mechanic is able to perform his job correctly we need to make sure that all those layers and its constituent items are in support of the job. The mechanic is at the sharp end of the operation and should not bear all the responsibility for safe performance because the immediate environment, supervision and the organization share this burden. When we want to improve safe performance we should address issues at all layers, acknowledging that it is not just the mechanic who can be the change agent.

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This model is based upon a working definition of HF and how it relates to behaviour and attitudes. It takes as a starting point the behaviour in the workplace. This behaviour takes place in a social context which impacts upon this behaviour. This social context is in turn affected by the environment in which it takes place. At a higher level there is an organizational context which impacts the environment and the social context and ultimately behaviour. Organizations do not exist in a vacuum and are formed by the professional, national and regulatory culture in which they operate. The items mentioned in the categories are not exhaustive and not prescriptive. We have listed communication as featuring in two categories as a way of illustrating the fact that some issues, such as communications, are features of various contexts.

Social context: work behaviour happens in a social context, whether interaction is direct or indirect. Sometimes you rely on informal networks to get support, you have a chain of leadership under which you operate, sometimes you work as part of a team, sometimes on your own, etc.

Environmental context: This relates to the physical and tangible context in which people operate.

Organizational context and organizational culture: This relates to the particular way an organization interprets and implements its rules, procedures and practices to support the operation. These are formed by professional, national and regulatory culture.

Professional culture, national culture and regulatory culture: every European company operates in the same regulatory context which impacts its regulations and rules. In addition the national culture in which a company operates forms norms and expectations about behaviour at work. On top of this there is a professional culture which informs the way a particular occupational group (in this case AMTs) will perform their job. There is also the organizational context and organizational culture which is individual to one particular organization or operation in a professional, national and regulatory culture which pertains to them.

Take an example of three different national carriers A (Airwings), B (Bluewings) and C (Coldwings), from two different countries of the EU. A being in one country, B and C are in another. Formed by their shared regulatory context, they share a very similar, if not the

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same, regulatory culture. Each country in the EU implements and oversees the regulation in a slightly different way, formed by their respective national cultures which affect the way rules and regulations are implemented in their country, partially accounting for differences between A on the one hand and B and C on the other. Lastly, there is organizational culture to consider and it can be reasonably expected that B and C do things differently even though they operate in the same national, professional and regulatory culture.

As an organization you can intervene in those areas to have an impact on the above described layers of the maintenance context to assure safe performance of a maintenance task. A strong organization, an organization in which it is very clear what the strategy, structure etc. is, normally means a more unified culture. As people know better what to expect, they behave in an expected manner. Referring to the example of reporting when a reporting system is not supported by the structure of the organization because there is nobody to read the reports, to follow up on actions and provide feedback, the formal reporting behaviour will decrease or disappear and a negative attitude towards reporting is created. On the other hand, while creating a reporting system, organizing the structure, communication channels as well as on training the people will have a greater chance of creating positive behaviour and therefore positive attitudes towards reporting.

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8 INTERVENTION PLANNING TOOL

To identify suitable interventions necessary to improve behaviour and attitude related to a certain topic or incident, this tool can be used. This tool guides you through the different steps necessary to tackle the problem from a systemic approach and achieve a durable solution.

The intervention selection tool comprises of 4 main steps, Analysis, intervention selection, smart objective/ implementation planning and evaluation. Below the different steps of the model are described. To support the explanation, see figure XX to find a worked example. The ‘handwritten’ text is what has to be entered by the user of the tool.

Step 1-Analysis: Before a course or workshop is being prepared it’s necessary to analyse which problems occur on the floor or what is being spoken about. To analyse this, the 5 why method can be used. This is a simple method based on Six Sigma principles and it reveals root causes that need to be dealt with.

Why did you not stand with the fire extinguisher in the ready to use position?- Because nobody does it!

1. Why does nobody do it?- Because nobody cares.

2. Why does nobody care?- Because nobody checks.

3. Why does nobody check?- Because nobody knows who is responsible

4. Why does nobody know who is responsible?- Because the responsibility is shared and therefore badly organized.

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Vangelis can you rewrite this example toward the hand over problem?

Margriet, 08/03/13,

Proposal: why is Task handover during shift increasingly reported s contributing factor in occurrence reports?


I mention course and workshops here because I think we should write this paper out the viewpoint of trainers and managers .


In this paragraph I tried to describe how the intervention planning tool works. Can all of you check if this is correct? And Paul, as my phraseology is by far not as good as yours, can you look at it with a double critical eye??


ANALYSISProblem identificationPossible future events

5 Why’s…Triggering event or data (more general, the problem that people talk about)

Audit findings Incident with task handover as a

contributing factorExtra analysis if needed Evaluation

Identify where the problem is and why?E.g. Assess the process (procedure, tools, environment, time available etc)

- Observations (communication etc.)

- Records (handover)- Audits- Incidents, Reports- Interviews- Survey

Problem behaviour Inadequate Shift / Task HandoverNote that this method is a light analysis tool. The outcome together with the common sense of the stakeholders can be enough to know what the problem is. If a deeper analysis is needed the process or problem can be evaluated by means of observations, records, interviews, surveys etc.

Step 2-Intervention selection: To select interventions that solve the problem step 2 of the intervention planning tool asks to look critically at the different items in each category (social, environmental, organizational and the professional, national and regulatory culture). If, for example, it seems that the organisational process to plan a certain task is not optimized and causes mistakes you will select, in the category ‘Organisational context and culture’, the intervention area ‘process’. In the left column a short description of the problem can be given. The union model, which sums up possible areas that contain inefficiencies and therefore need an intervention, can help to carry out this step. In the right column the intervention can be described. After having looked at all categories, the necessary knowledge, skills and attitudes need to be defined.

Once the necessary knowledge, skills and attitudes are defined the training interventions can be selected and described in the right column. Appendix XX gives a list of different interventions like workshop types, training topics, training objectives, training methods, coaching methods etc. This is neither an exhaustive, nor a prescriptive list but can be used as a support.

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Is this in line with your thought of the ‘intervention toolbox’ we want to create? Or did you have something completely different in mind.


Once we all agree on the intervention planning tool we can try to make something more pretty of it. I propose to leave the lay it as it is right now…unless you have brilliant ideas and lots of time to do it. Note: I might have to color it up myself a bit for the presentation…but this can be changed at all times.


Intervention selectionContext Sub category of context InterventionSocial Communication

Ineffective verbal communication

Communication training focused on handover

Cultural Professional National regulatory

Procedure Procedure is not

detailed enough Procedure is not

reflecting current operational conditions (since procedure development company doubled in size)

Modify procedure by adding relevant details involving the usersModify the procedure to reflect current operational conditions involving the users

Environmental Tool Handover form is

ambiguousRedesign the form also involving the users

Facilities Handover is

performed in a noisy and distracting environment

Select and provide a suitable environment (quiet, well lit, PC etc)

Organizational Time available Not enough overlap

time between shifts for handover because of parking space issues if there is a team overlap

Set sufficient time for shift overlapLook for solution for parking place problems (e.g. do the handover between shift leaders)

Supervision Supervisors are not

held responsible for the quality of the handovers

Include the handover supervision in the responsibilities and job descriptions for supervisors

Desired behaviour/TrainingObjectives

Attitudes: Appreciation of the importance of good handovers

Training: using accident cases, videos, discussion of experiences linked to own company

Knowledge: Explain the Training: procedure and

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procedure, explain the logic of procedure (best practice)

best practice, linked to the incident

Skills: Be able to conduct a satisfactory shift handover – using the procedure, verbal communication

Training: completing form, listening, explaining

Step 3 - Smart objective/ implementation planning: Once all the interventions are selected and defined, different stakeholders must be held responsible for the execution of these interventions. Usually there is more than one area of intervention and thus more than one stakeholder. They have to come to an agreement on how to achieve the task. In this tool this agreement is described in the format of a SMART objective (Specific, Measurable, Achievable, Realistic, Time specific) that is supported by all stake holders and that can be easily evaluated by upper management.

SMART OBJECTIVE* / IMPLEMENTATION Improve the handover process by involving all stakeholders (users, supervisors, procedure writers, trainers, management) in a working group that tackles the intervention mentioned above in the following six month period with the following output: Eliminate audit finding related to shift handover Decrease incident reports in which the shift handover is a contributing

factor *The formulation of the smart objective should be undertaken as the kick-off task by all relevant stakeholders who are going to champion the interventions relevant to the department.

Step 4 –Evaluation: As well as the SMART objectives there are also the interventions as defined in step 2. Each defined intervention can and should be evaluated in order to know if all actions are properly implemented and effective.

EVALUATIONFollow-up Check the audit finding

Check the incident reportsObservations Observe the hand over process :

are the forms filled in properly,

is the verbal communication effective

do the team leaders take enough time to do the hand over

are the procedures modified is there a redefined form do the supervisors take their

responsibilities is there a proper room for

shift hand over

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8.1 Visual flow of actions

Step 1: AnalysesFind out what the problem is. Do this via simple or more detailed analysis as mentioned in the table below.

Step 2: Intervention selection Now we have an idea what the problem is we can have a look at the possible areas of interventions that can solve the problem with help of the union model.

Once the intervention areas are defined, different interventions can be selected and/or defined. As a support the intervention list can be used.

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Step 3: SMART objective / implementationNow we know which interventions are needed in the different areas the SMART objective can be defined. This will help you set a common goal with respect to time and quality for implementation.

Step 4: EvaluationAfter implementation the behaviour should be evaluated.

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X XXXXXX


9 TYPE OF INTERVENTIONS BELONGING TO DIFFERENT CATEGORIES

Interventions that can take place in order to influence the behaviourTo know in which areas you have to intervene you need to perform analyses and identify the root causes (look for an analysis model…)Attitude

Create awareness by training and (continuous) assessment Encourage reflection (through training or via supervisor/manager) Creating experience and giving feedback Leading by example (mentorship / peer to peer/ manager) Safety communication …

Context Cultural environment (Organizational, professional, national)

o Changing working procedureso Changing Resourceso Improve / promote organizational learning (how…)o ….

Social environmento Improved supervision o Improve management styles (example of different styles?)o Union / management relations o Communication channelso Team relations o ….

Physical environmento Lighting, temperatures, room sizes, location, hangar or lineo …

Knowledge / skills Theoretical and practical training Assessment

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10 APPENDICES

10.1 Appendix X: Intervention planning form

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ANALYSISRoot cause analysis/Possible future events

5 Why’s…Triggering event, data or a more general problem that people talk about

Extra analysis (if needed)

Evaluation

Identify where the problem is and why?

E.g. Assess the process (procedure, tools, environment, time available etc)

- Observations (communication etc.)- Records (handover)- Audits- Incidents, Reports- Interviews- Survey

Problem behaviour

Intervention selectionContext Sub category of context Intervention

Social

Cultural Professional National regulatoryEnvironmental OrganizationalDesired behaviour/TrainingObjectives

Attitudes: Training: Knowledge: Training: Skills: Training:

SMART OBJECTIVE* / IMPLEMENTATION

EVALUATIONFollow-up

Observations


10.2 Appendix Y: intervention selection tool

Creating clarity about the responsibility of the procedure within the whole organizationIntervention area

Question Y/N Possible interventions/action

Skills Are the procedures clearly written? Are the procedure writers skilled enough to write clear procedures?

Y -

Structure Is the format of the policy clear, simple and concise?

Y -

Social Is there interaction between aircraft maintenance technicians, Supervisors and Quality insurance personnel?

N Workshop with all parties

Staff Are the following people clear about the procedure: flight line chief, aircraft maintenance technicians, Supervisors and Quality Assurance personnel, Human Resources for legal disciplinary actions?

N

System Is there a good distribution system for informing the organization on the procedure?

Soft Style Is the style in which the message/information is communicated appropriate for the target group?

N Analyses and training in how messages are best passed within the organization

Strategy Is the intervention in line with the overall strategy of the company?

Y

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