AIRBUS CRM

for

MAINTENANCE PERSONNEL

Trainee's Booklet

February 2001

MAINTENANCE CREW

A.C.R.M. ADDITIONAL INFORMATION

Overview
The goal of this ACRM workshop is to help you make the best possible use of your available resources (procedures and documentation, tools and equipment, other personnel, time, etc.) taking into account your environmental constraints (e.g. bad weather, poor lighting) and operational constraints (e.g. production and time pressure), in order to enhance safety and efficiency. Another goal is to help you transition efficiently and smoothly to your new aircraft. The course covers: Human performance and flight safety Error, performance and safety Factors affecting performance Learning a new aircraft Communication Procedures and practices in maintenance Team performance Conclusion and debriefing

Module 1: Human Factors and Flight Safety

An example of incident: Summary of facts

A330: an operator reported a shutdown of one engine N The oil quantity quickly dropped closed to zero with an ECAM advisory message and decreasing oil pressure N The engine was shut down when the oil pressure fell below 10psi N An In Flight Turn Back was made with a single-engine landing
N
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Which human factors contributed to the incident ?

N

Welcome

N N

On ground investigation revealed that the N2 engine boroscope mount cover of the accessory gearbox was not re-installed and was hanging by one stud An ultrasonic inspection of HP compressor stages 3-5 had been performed during an A check prior the event flight The mounting cover plate procedure was not followed The procedure for idle leak check was not performed

Events like this one often reveal communication problems, work organization problems within a team or between teams, and other factors such as time pressure, human error, and non-adherence to procedures. Those factors can result in incidents but also in accidents. Are accidents rare events? Let us have a look at the current safety level in aviation.

ACRM stands for Airbus Crew Resource Management, and this ACRM workshop is the CRM developed by Airbus for the maintenance personnel.

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A.C.R.M. ADDITIONAL INFORMATION a total of 38 accidents (18.68 million departures), including 18 hull losses and 379 fatalities. Even if number of fatalities is low compared to other transportation means, nonetheless, and perhaps unfairly, the public remembers fatal accidents, especially those involving large numbers of fatalities. To keep and improve the publics trust, we must do better!

The sharp improvement in the rate of hull losses in the 60's - early 70's is often attributed to progress made in the reliability of jet engines and to other technical improvements. These improvements are also associated with upgrades in the operational environment: better safety equipment, more structured procedures and better technical training for all personnel, including maintenance. However, since the mid 70's, there has been a leveling off and the accident rate has not decreased significantly since. In the 80's the introduction of new generation aircraft was supposed to improve the safety record. But the airline industry still experiences about 2 accidents per million departures. This, however, makes commercial aviation the world safest means of transportation. We could stop with such a positive statement, but there is a problem: because the traffic increases on average by a 5% rate per year, by 2010 we might end up with more than one accident per week! This is not acceptable, for human as well as commercial reasons!

Actually maintenance is not a frequent cause of accidents: it is ranked number 4 in terms of frequency, just after Flight crew, Airplane and Weather. While if we dont focus only on maintenance as a primary cause of accident, a 1995 industry study found that maintenance was a contributing factor in about 15% of the accidents. But, on average, maintenance related accidents tend to be very serious. As indicated by the statistics (source: Boeing), maintenance was the second highest cause of fatalities related to air accidents, from 1982 to 1999, after CFIT and before Loss of control. 15 % of accident fatalities have been attributed to maintenance in the official accident investigation reports. Thus there is a great potential for improving safety in the maintenance area! Not only is safety a critical issue, but economics is also a matter of concern. For example, maintenance contributed to about 15% of flight delays with respect to Airbus aircraft. It also contributed to 50% of delays and to 50% of flight cancellations due to engine problems, and to 20% of IFSD. How can we improve safety (both flight safety and occupational safety) in maintenance? CRM is an answer.

There have been 23,514 onboard fatalities in the 40 years 1959-99. Almost 30% of them have occurred in the last 9 years 1990-99. In 1999, there has been
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A.C.R.M. ADDITIONAL INFORMATION

Module 2: Error, Performance and Safety

Why is that the case? The first step is to distinguish error and error consequences. Most errors committed in the maintenance domain do not develop consequences because they are detected, corrected or recovered by the maintenance itself or by other personnel (e.g. cockpit crew). This multilayer in depth protection system is called the safety chain.

The safety chain

Maintenance procedure Technicians action Operational test
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Hasards

Inspector check Flight crew check-list Errors

We make errors when our actions deviate from what we intended to do, or when our intentions are not appropriate. So an error is never, by nature, intentional. Errors are often confused with violations. The difference, simply, is that unlike an error, a violation is an intentional deviation. It is a deviation from a rule, a regulation, a procedure. We will return to violations later in this module. For now, lets concentrate on error and its consequences. There is another way to define the term error in the maintenance domain, and this is a source of ambiguity. ICAO for example states in its 1995 Circular that: "Human error in maintenance usually manifests itself as an unintended aircraft discrepancy (physical degradation or failure) attributable to the actions or non-actions of the aircraft maintenance technician. Notice that these actions or non-actions can be either errors or violations, referring to definition 1.

Accident or incident

Adapted from J. Reason

8 / 29

But the safety chain is not fully reliable: when failures or weaknesses in each line of defense are aligned, the error(s) continue their own way up to producing and incident or worst, an accident.

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A.C.R.M. ADDITIONAL INFORMATION

One of the major points of this module is to emphasize that To err is human. In an ideal (or very unrealistic) world, we would simply say humans in aviation should not make errors, therefore they are not allowed to make errors! BUT, we are living in the real world, and in the real world, humans sometimes make errors. There are two meanings we can take from the saying. First, it means that even the most experienced maintenance personnel can make mistakes. And second, it implies that human beings can learn from making errors. So we have an interesting contradiction in that we need errors to remain safe! It is often the way we calibrate our performance - an error tells us to pay more attention, rethink things, to get back on track, etc.

And how can we explain that fact? Because installing components is more difficult than removing components. The following model, proposed by the US psychologist D. Norman, can help us grasping why.

But a lot of errors made in the maintenance domain are not detected immediately. One of their main characteristics is their lack of visibility: they can remain silent in the system for a very long time. What are the most frequent maintenance errors, in the sense of definition 2?

You need more knowledge to install components than to remove them. And where is the knowledge found? Either in the head (what we know from our experience and from training), or in the objects or systems themselves (what the objects tell us about the way to use them) or in the documentation and procedures (either in paper, micro-film or electronic format). As you see in this slide, knowledge in the head, knowledge in the objects and knowledge in documentation form a kind of triangle. In maintenance, as in other professions, even if design is constantly improved, some systems remain difficult to install or to operate, and memory can be misleading. Therefore, the only way to interact safely with todays aircraft technology is to refer to standard procedures, that is to say knowledge from the documents. Let us now consider violations.

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A.C.R.M. ADDITIONAL INFORMATION Professional protections are briefings, procedures and documentation, check-lists, checks, doublechecks and cross-checks, warning notices and design protections (e.g., padders and error tolerant software). The following good practices will also help preventing or managing errors: remain in your domain of competence, set your priorities, manage your time and your workload, work as a team (communicate, share intentions, share tasks, coordinate and report actions) and use the reference procedures and documentation. And, last but not least, report your experience to your airline: your colleagues will learn from you, and you will learn from your colleagues. (Note: Airbus has its own Reporting System, AIRS, which it provides to interested airlines. Airbus also provides training for its use).

What factors favor violations and lead to the transformation of violations into norms? The first one is a decrease in risk awareness due to habit or even risk taking in order to get short term benefits, including saving time, helping colleagues or smoothing problems. A common type of violation is not to comply with procedures. Non adhering to procedures can make you losing time because of induced problems, like the impossibility to locate and fix a fault when departing from the TSM (See module 6). Moreover, deviating from official rules may even be considered positively within the team. For instance, technicians may develop the misleading belief that "a good technician can work without protections and without procedures, because he knows the job". Violations are also particularly likely to occur under strong time pressure or other operational constraints because technicians see no other way to perform the job. (This organizational issue mainly concerns management). How to cope with errors in maintenance? Here are some basic error management principles:

Module 3: Factors affecting Performance

Performance is affected by several factors constitutive of the maintenance working environment.

The first one is fatigue. Fatigue comes from consuming our physical or mental resources. Our resources, mental and physical, are like fuel in a car. During a normal day, we consume our fuel at a fairly constant level (like being in cruise mode on the highway). But if we have to go faster or if we have to work harder, then just like a car, we will consume our fuel more quickly. Here are the main effects of fatigue:

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A.C.R.M. ADDITIONAL INFORMATION

Maintenance technicians work in shifts, and everyone knows it is harder to work overnight. The explanation comes from the way fatigue combines with the effect of the circadian rhythm. Many biological processes indeed evolve in a sinusoidal way over a period of about 24 hours. This circadian regulation tends to optimise human functional capabilities during the day and decrease them during the night (this is the case for the sleep/wake cycle, the body temperature cycle, the secretion of hormones, blood pressure, etc.). The situation which results from that combination is thus different in day and night shifts:

If sleep is not properly managed, shift work (irregular work patterns) and night work tend to result in an accumulation of sleep loss called the accumulated sleep debt:

How to cope with fatigue and sleep deprivation (either in sleep quantity or quality)? Respect your sleep needs, take naps (NASA, the US National Space Agency studies show that short naps of 20 minutes increase alertness for about 1.5 - 2 hours), and adopt a healthy lifestyle: perform regular physical activity, eat balanced meals, make a limited use of coffee and tea, drink water and be careful with self-medication: refer to a medical doctor. Also avoid doing a second job. Moreover, external stimulation helps combat fatigue and this stimulation can be provided by other team members. So, keep communicating, exchanging ideas and jokes within the team. Share tasks and ask for support whenever possible. Stress is another factor affecting performance.

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A.C.R.M. ADDITIONAL INFORMATION

Module 4: Learning a new aircraft

Learning also affects performance. The main consequences are:

How to cope with stress? First accept the situation first (especially if it is being difficult to handle), stick to the documented procedures. Share the problem with others, and more generally, try to use all available resources (people, equipment, information...). Plan ahead, buy time: give yourself the time needed to perform your job with some reasonable margins. Work as a team, express your doubts, ask for assistance when you need some and provide assistance to the others when you can. Breaks should be proposed, especially in situations of high stress. And finally, humour can ease the pressure. Conflicts are a particular source of stress. Maintenance staff may have conflicts with other maintenance staff, cockpit crew, cabin crew, etc. Conflicts need to be properly managed.

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MAINTENANCE CREW Let us now consider the learning process in more details. Suppose for example that you are used to work on a B767. Then you go to the Airbus Training Center for an A340 type rating. We recognize this is a hard time because you have to learn a lot in a limited period of time. (Note that the Airbus instructors are there to help!). There you will learn that certain things remain the same (in particular the basic maintenance rules of thumb) while others are different. Learning is a demanding process: it is a little like building physical muscle. With repetition, just as with a physical work-out, we develop skills based on the rules we have learned, and we build our knowledge of the world. In this way, acquiring expertise enables us to lower workload and use our mental resources in an extremely efficient and effective manner. When you return to your airline, you will practice and develop what you have learned (On the Job Training). The learning process thus continues well beyond your formal training at Airbus. An extra difficulty can come from working on several aircraft types during this particular phase, and even afterwards. To avoid the risk of confusion, adhering to procedures is the only safe way! What are the main transition challenges?

A.C.R.M. ADDITIONAL INFORMATION

Motivation is a key factor! Airbus has wanted to facilitate the transition from an Airbus aircraft type to another, through the concept of Airbus Family. This concept means a commonality of philosophy and principles. For example, the way documentation is organized as well as the way to use it are also similar. They are 3 families which also represent subsequent aircraft generations: the A300-A310 family, the A319A320-A321 family, and the A330-A340 family. They are more similarities within families than between families. For example an A340 is closer to an A330 than to an A320. Beware of the differences in order to avoid errors! To conclude, here are some tips about how to ease the transition:

By the way, how you approach your transition experience can greatly affect the efficiency of the learning:

Module 5: Communication
Communication can be either in oral, written or computerized forms, face-to-face or remote (telecommunication). Improving communication

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MAINTENANCE CREW helps avoid communication errors, which often are involved in incidents and accidents. Maintenance personnel first communicate with maintenance personnel: inside the team, with the supervisor, between teams, during shift hand-over, and with other personnel including the Engineering and Quality Assurance Departments, and the overall maintenance organization. And communication is not always easy nor fully reliable. In line maintenance, maintenance staff also communicates with cockpit crews. How can we improve?

A.C.R.M. ADDITIONAL INFORMATION

Technical terminology and abbreviations greatly varies between manufacturers, and, within the same manufacturer between aircraft types. For example 'Pylon valve' (Boeing culture), 'Bleed valve' and 'PRV valve' (Airbus culture) all designate a same type of valve. We thus recommend to solve possible ambiguities using feed-back and cross checking and to use the FIN (Functional Item Number). Task interruptions are disturbing and therefore need to be properly managed:

Messages often get distorted when verbally transmitted along a line of persons. Thus it is important to always refer to the initial message or information and, whenever possible, to use written aids.

Beside interruption management, there are more general means to secure communication:

But there are also other sources of difficulties. What are the main barriers to communication?

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Maintenance is driven by paperwork, and written communication is a very disciplined exercise.

Finally, man-machine communication also needs to be addressed. The introduction of new generation aircraft (the A320 and A340 family) has had several consequences on communication. How can we make communication more reliable? Here are some practical recommendations:

Because we rarely see the person who has written or who will read our written document, there are specific traps to avoid: writing too little or too much, writing in a complicated, clumsy or ambiguous way, and using the wrong verbal form (e.g. tightened for tighten: is it done or does it need to be done?). Specific protections therefore need to be used: write things in the right order, in other words, respect the chronology of the events, be clear and unambiguous, and ask for feed-back whenever possible. Whether written or oral, there is a basic communication principle to comply with:

Module 6: Procedures and Practices in Maintenance

Complying with procedures is of primary importance with todays aircraft generations! Consider the following incident case:

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A.C.R.M. ADDITIONAL INFORMATION properly trained to follow instructions the way they were intended to be followed. Safe procedure application requires that maintenance staff understand the main reasons behind the procedures (i.e. that modern technology is too complex to be operated without proper guidelines) and the consequences of their actions.

Procedures are here to help! Job cards are a form of procedure. Caution is needed when using job cards: be sure that the required conditions are satisfied before starting a task, after an interruption, take care of resuming the task at the proper step and keep a critical attitude: remember that people can be tired and forgetful, particularly at the end of a night shift The maintenance logbook is another sort of procedure, and an important means of communication. It supports troubleshooting because it describes the overall history of the works performed on the aircraft. The logbook also allows legal traceability: it is mandatory that all actions performed on any aircraft be recorded. Thus it will in particular be required after an accident. Fill the logbook carefully and make sure you have signed off only for the work completed! In real operational life, we know that procedures are not always adhered to! What factors affect compliance with procedures?

This incident highlights the potential pitfalls of working by norms or habits (the way I did before or the way we do it here) rather than the procedures. This in a technical sense represents a violation of procedures (see chapter 2). Lack of knowledge also played an important role.

A procedure is like a music score, it is interpreted during the course of action and transformed into practice. In other words, instructions cannot tell you everything. You need to be knowledgeable and
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A.C.R.M. ADDITIONAL INFORMATION Maintenance personnel sometimes face difficulties in locating a fault. This often results in undue removals of properly working components, which represents costs for the airline. The No Fault Found policy has been developed by Airbus Industrie in close collaboration with the major avionics manufacturers for coping with that problem. This policy remains the only NFF reduction procedure in use in the aerospace industry today.

It many airlines around the world, people are not at ease with English, mainly because English is not their native language. For them, the risk of misunderstanding and execution error is increased. It is also true that maintenance technicians are not (yet) at ease with electronic documentation. But this new technology is so convenient that once you have learned how to use it, your job will be easier. Motivation to learn here again plays an important role. A last word regarding procedure modification: Maintenance personnel are sometimes tempted to modify the procedure during execution, using personal short cuts or expert tricks. Such a practice is absolutely unsafe: never modify a procedure while on the job, but report any possible failure or surprise encountered during procedure implementation as well as any proposal for modification to your airline.

Module 7: Team Performance

Maintenance personnel often work in long lasting teams. This work organization presents both advantages and drawbacks for safety:

Beware when using the MCDU!

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A.C.R.M. ADDITIONAL INFORMATION Let us focus on leadership. Leadership first comes from a recognized social position providing authority. For example, the status of Team Supervisor / Chief technician / Technician is always attributed by the airline. But leadership also stems from proficiency and other technical, personal, social and cultural characteristics such as personality, attitudes, age, look and origin. A good leader doesnt need to resort to authority to lead the others: he naturally gets from the team members what he wants because he is trusted and respected. The leader is normally the team supervisor: leadership and authority normally correspond. But sometimes, the leadership may be taken by someone who is not officially in command, for example because of some specific skill or knowledge that fits the situation well (situational leadership).

Not only does maintenance work in long lasting teams, but also in shifts. Shift hand over is of particular importance for safety, because this is the place where many problems occur or are passed on.

Team performance obviously depends on individual performance unqualified personnel will never make a good team. But even highly qualified personnel may do a poor job as a team! Here are the main conditions required for effective teamwork:

A good leader also monitors results and praises the team members for success and achievement. Praise reinforces good practice, improves team spirit and increases motivation. While leadership is the ability to lead the others, followership is the ability to properly follow the leader. What does that mean? All team members must express their willingness to follow the leader, but not blindly. So in case of doubt or if you have any question related to the job or to safety, you should express your concern (the concepts of assertiveness and advocacy) in the most suitable manner according to your airline culture and policy.

Module 8: Conclusion

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A.C.R.M. ADDITIONAL INFORMATION

This course is not the end... In order to comply with the recent ATA 104 regulation, Safety and Human Factors will be addressed in an integrated manner in your technical training, starting with the MTD 3D briefings of the ATA chapters. Thanks for your participation to this ACRM workshop!

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