If human error was simply the result of careless or reckless individual behaviour, managing human error would be straightforward, in that disciplinary action could be measured against the gravity of the event.
The reliability of a task is influenced by many factors including the maintenance system which shapes the performance of the technician, for example, management of the underlying factors can potentially deliver the mitigation’s which can diffuse or alleviate these pre cursors.
Because of the “Human Element” and regardless of how much effort we put into the system, we will never eradicate fully our exposure however we can still aspire to deliver 100% reliability without actually achieving it (and for this to be a meaningful objective).
We have to accept that the philosophy of human factors view that human error is a both normal and even expected component, regardless of the regulations, procedures or control environment which we develop to “protect” the task.
So the rational of the Maintenance Error Management System approach is that we have to strive to design organisational systems which take errors into consideration whilst at the same time affording the maximum protection.
By the same token we also have to accept that it is also incorrect to say that the responsibility for human error may always be found within the maintenance system, and never with the individual perpetrator of the error.
Part of the problem is that we all make risk based decisions in our daily life, without considering always the consequences. So it is not surprising that even within the environment of Aircraft Maintenance a degree of risk taking will be inevitable. The question we have to ask following an event is did the technician knowingly and unjustifiably increase the probability that a particular error would occur?
So we have strive to strike a balance initially by developing an understanding as to why the error occurred, determining what if any organisational factors impacted the error or event and off course for such factors the Organization must stand accountable.
Next we have to consider, that even though the technician did not intend to commit the error, that there exists a degree of culpability related not because of the error directly but because of the fact that the technician has a personal responsibility over his own human reliability.
Whilst we should accept that there are fundamental differences between Equipment Failure and Human Error. In the case of Human Error some blame must in fact fall on the person who committed the “error”. In an attempt to create a positive reporting environment, policies which promote a “punishment free approach” are promoted.
We may also have to look further than the employee who commits the error and to consider if responsibility lay in other areas for example the writer of the procedure or the manager will the “blame” shift and will we still be maintain the “punishment free approach” or will ultimately all blame then sit on the shoulders of the Maintainer. Could this have litigation implications down the road, particularly if it appears the Organization shows a lack of due diligence, could this lead to organisational culpability?
It may even be that in the final analysis the cause was that event occurred within the expectations of “normal” human error. However it may also be that the company policy will describe actions which it believes are appropriate and that the company will consider initiating disciplinary action where, “in the Company’s view, the employee is deemed to have acted recklessly, or omitted to take a required action, (or both) in a way that is not in keeping with his/her responsibilities, training, and/or experience.”
Sofema Aviation Services provides both Maintenance Error Management System MEMS and Safety Management System SMS training for additional details please see www.sassofia.com or email office@sassofia.com
Tags:
Aircraft Maintenance, Human Error, Maintenance Error Management System, Safety Management System SMS, Sofema Aviation Services
