One of the areas that, as an organisation we go into
with the topic of maintenance/human factors,
is discussing how humans are fallible within a maintenance system
because of all the surrounding elements
such as co-workers, complex tasks, shift patterns,
but as well as some internal limitations that we have as well
such as things like memory, levels of health, our size, agility, etc.
What we need to also take into consideration
is how we prepare ourselves to be able to complete the task ahead
and that includes the shift that we're about to perform,
whether it's a day shift or whether it's a late or afternoon shift,
and even perhaps if it's a night shift,
what we need to be able to succeed during that shift
and that starts from before we come to work.
Let's also think about what we expose our LAMEs to.
Do they have repetitive tasks?
Same old thing they've potentially done
hundreds, possibly even thousands, of times.
Absolutely. OK.
Now, one thing to be aware -
we actually know in a risk spectrum
that sometimes our greatest risk
is not when we're operating in the high end.
When we've got lots that we're doing and we're fairly busy
and it's a task I haven't done for a little while.
'Cause sometimes you're a little more risk-aversed.
"Gee, whiz, I will make sure I've got the book out,
"I'm re-reading, I'm managing that."
In part, you've got to be very careful
about those tasks that you know you're starting to get complacent
or you generally find boring.
Because one of the things we know,
if you combine complacency, boredom and fatigue,
there's a good chance that they're some of the scenarios
that you're just not going to pick up
and they're the ones that you'll miss.
And it could be as simple as,
"I've got to go out and I've just got to take an oil line off,
"I've got to put a blank on, perform some other work
"and reconnect that oil line."
But we've seen cases where the line doesn't get reconnected,
the blank's left on, it's not picked up in independent inspection, OK?
Aircraft actually gets through its initial checks,
the engine runs for a little while in some cases.
And then eventually we get mechanical failure
because at the time, the task was actually being done during the day,
it's been done lots of times before,
it's considered a relatively easy task
and the biggest thing for people to understand
is sometimes it's not just the tasks
that you're generally feeling like you're under pressure
and that are trying you and testing you.
Equally, from a mature human factors perspective,
you need to recognise any of those tasks that you believe in your mind
are easy, that you're complacent.
"I don't need to look at the book for those."
Because the chances are, on a good day,
you might do some things that maybe it's not ideal behaviour.
OK? You may not get the book.
But on a bad day, if that's the way you've grown that behaviour
and you've missed it and you're complacent
and you're a little bit bored with the task
and you don't use your biggest risk control
which is to actually go and get the manual
and step through the checks to make sure as your backup,
that's what's going to cost you some grief
and we've seen many serious incidents and accidents
that are related to such events.
It starts off with seeing and hearing
and understand how things should be in our environment.
We all notice something when it doesn't seem quite right,
but the very next thing that enters our mind
is, "What is it that's not quite right?"
and more importantly, "How should it be?"
And in the context of aviation maintenance,
it involves a fair degree of what we refer to as projection,
which is looking at future effects.
For example, if an aircraft engineer is performing an inspection,
they may see a defect during the course of that inspection.
Before they start consulting any literature
to determine whether or not the defect is allowable
or whether further work is required,
they're already entering a state
where they're thinking about the future effects of that defect,
you know, how would this actually affect the safety of the aircraft?
What could happen if the aircraft was to fly
without that defect being discovered?
In looking at those three elements of situational awareness,
comprehension, perception and projection,
I often use the example of when we're driving our cars.
We know that when we're driving our cars,
we're well aware of the first two - perception and comprehension.
But if we're driving along the street
and a ball bounces out in front of us, what happens next?
What do we expect to happen next?
And often people will say that the ball will be chased by a child.
So they automatically slow their vehicle down.
In a maintenance hangar, we could be performing some work.
We need to take into consideration how our work affects those around us.
If we were to activate systems on the aircraft to conduct tests,
would the activation of those systems
affect other people that are working on the aircraft?
For example, putting the hydraulic systems on
to function check a flight control
whilst there are personnel working on the landing gear.