The Safety Health of Maintenance Engineering

(SHoMe) Tool

Steve MasonPrincipal Human Factors Consultant

HSEC Ltd

Error Types & Action Strategies

Cannot physically achieve goalCannot physically achieve goal

- improved ergonomics- improved ergonomics Slips & Lapses + DistractionsSlips & Lapses + Distractions

- design & interlocks- design & interlocks MistakesMistakes

- training, job aids- training, job aids ViolationsViolations - - safety culture + organisational factorssafety culture + organisational factors

Existing Guidelines/ToolsMaintainability Design HandbookBretby Maintainability IndexHFRG Guide to reducing violationsHFRG Guide to reducing maintenance

errorHSEC Human Factors SolutionsSHoMe

Reactive, Proactive, or Both?

INCIDENT REVIEWS QUESTIONNAIRESStrengths:Information available from incident investigationsBased on factual evidenceCost of accidents/incidents can be determined

Strengths:Quick to administerFindings reflect current attitudes Involves staff identifying areas of concernCan promote ‘ownership’

Weaknesses:Root issues not always well documentedOften insufficient incidents for analysisData relates to the past – may not be relevant to the future

Weaknesses:Findings based on perceptions may be influenced by range of factors unrelated to maintenanceNo factual information to gauge ‘spend’ justified on expected improvements

SHoMe Basic StructureSafety Health of Maintenance Engineering

Evidence of Non-Compliance•E.g: risk taking, errors through tiredness, supervisors condoning unapproved actions, etc

Potential Root Issues affecting Compliance•Factors known to have caused problems

•Factors that could cause problems

Part(s) of Job Causing Most Difficulties

SHoMe Staff Groups

Technical Certifying Staff

Technical Non-Certifying Staff

Management & Technical Support Staff

(e.g. planners, )

Questionnaire AdministrationStaff Group Generic Q Job

DifficultyOrg Q

Tech Cert version C

Tech Non-Cert version NC

Support Staff version NTN/A N/A

Questionnaire Administration

•Avoid issuing questionnaires & collecting them in at the end of a shift – response by committee!

•Preferably – organise small groups, lead with introduction my management (& unions if possible)

•Stress anonymity and purpose of the surveys

•Emphasise that feedback will be given & acted upon (if appropriate)

•Please: ensure correct question set is issued

Example Generic QuestionsPlease indicate the extent to which you agree or disagree with the following statements in relation to your work over the last 6 months of so

SA A ? D SD

Management and staff communicate well with each other

Managers always let us know of important safety findings

I am always properly briefed by those giving me a job

Before I start a job I am always given the necessary information

I know exactly what I am expected to do and my responsibilities

Extract Job Difficulty Questionnaire

AWas this

part of your jobs?

BNo

Problems

CSome

Problems

DMajor

Problems

PLANNING Y/N? PREPARATION Y/N? INSPECTION Y/N? ROUTINE WORK Y/N?

Extract from Organisational QuestionnaireThe ease with which general written procedures can be understood

The amount of jargon and ambiguity contained in procedures

Ambiguity as a result of different layouts of different types of forms you use

Systems for implementing temporary revisions to maintenance manuals

Previously encountered problems not highlighted

The ability of planners to minimise jobs running over other shifts

The amount of work your immediate boss expects you to do in a shift

The way management treat individuals who report mistakes or safety concerns

Prioritising Results

Ranked Human Factors Issues – Generic Q

Ranked Issues – Organisational Q

Ranked Major Root Issues [19]

Ranked Evidence of Non-Compliance

19 MAJOR H.F. ISSUESDesign & Maintenance InterfaceProvision of ResourcesTrainingFatigueComplacencyPlanningCommunicationsCommercial PressuresMaintenance ProceduresRoles & Responsibility

Management AttitudesSafety Commitment of StaffJob PressureWorking ConditionsFair-Blame CultureManagement of ChangeSupervisor EffectivenessSupervisor AttitudesCompetence

Results PresentationLevel

1Non-Compliance: Generic Q

Summary of Major Root Issues only

Level 2

Non-Compliance: Generic Q

Expanded Major Root Issues : Generic Q

Level 3

Expanded Non-Compliance: Generic & Org Q

Expanded Major Root Issues : Generic & Org Q

MEDA Results presented against relevant MEDA structure

HSEC SHoMe ToolVersion 1.0September 2003

This tool was developed by HSEC Ltd, on behalf of the UK CAAThe tool may be freely copied, distributed and used for flight safety purposes, but not resold for commercial purposesThe SHoMe tool must be used in conjunction with the user manualThe software is not supported

Scoring Criteria

GENERIC QUESTIONNAIRE:

Good < 35

Worthy of Attention > 55

Concern > 65

ORGANISATIONAL QUESTIONNAIRE:

Probably Acceptable < 15

Concern > 30

EVIDENCE OF NON-COMPLIANCE Mean Score

Completion of job despite the non-availability of appropriate tools and equipment

71

Regular non-compliance by the workforce 61

Aircraft released with work not done due to parts shortages 50

Direct pressure to deviate from procedures 43

Reports of colleagues making errors due to tiredness with last month

41

Direct pressure from the supervisor to deviate from procedures

36

Pride on getting aircraft back on time, even if this needs some non-compliance

34

Supervisors taking risks in releasing aircraft when maintenance incomplete

26

Supervisors condoning unapproved actions to get an aircraft away

22

POTENTIAL ROOT ISSUES Score

Design & Maintenance Interface 57

Planning 51

Fatigue 51

Provision of Resources 50

Commercial Pressures 49

Working Conditions 49

Training 47

Roles & Responsibility 41

POSITIVE FEATURES Scores

Supervisor Attitudes 29

Competence 30

Supervisor Effectiveness 31

No-Blame / Fair-Blame Culture 34

Management of Change 36

Complacency 38

Safety Commitment of the Engineers / Staff 39

Procedures – Accuracy, Relevance & Practicality 39

Job Difficulty

Using SHoMe data

Show Differences between Cert, Non-Cert, Support Staff

‘Big Picture’ – are there any major concerns?

Typical QuestionsAre there any significant differences between those who have worked in the Industry for > 20 years and those new to the Industry?

Are the problems with contract staff significantly different from those with permanent staff?

Differences within one company with staff at two sites.

Differences between those working long hours.

SUMMARYHuman Factors Issues are important & need to be managed

SHoMe requires investment in time by all staff

Hopefully – we agree it complements existing tools

Freely available + option for Industry benchmarking

SHoMe does not rely on incidents/near misses