Human Factors Overlooked EngineeringDirectorateofXYZAirlinesisanAircraftMaintenanceOrganization(AMO) approved by the Civil Aviation Authority of Bangladesh (CAAB), the local regulatory authority for air transport operation. Engineering Directorate is headed by a Director under whom there are fivedepartmentsrunbyfiveDeputyChiefEngineers(DCEs).ChiefEngineerisindirect supervisionofthreeofthem.AmongfiveisadepartmentLineMaintenance.Therearefour Shift-in-charge(ShiftA,B,C,D)workingunderthesupervisionofDCELineMaintenance. Each shift consists of Aircraft maintenance Engineers (AMEs) and technicians. Engineering Directorate has its own training center headed by a Principal to build the employees uptotherequiredlevelthroughofferingthemappropriateclassroomandhands-ontraining. TrainingCoordinatoristhepersontoliaisonbetweenthetraineesandthetrainingcenter. Trainingneedsareidentifiedthroughmultiplewaysincludinginterviewswithsuperiors/ subordinates, performance appraisal system, career progression schemes etc. Employees are also encouraged to self-nominate themselves for the suitable training programs meeting their job and careerdemands.Generallyroleandtradespecifictrainingisofferedthroughin-housecourses. BesidesotherEngineeringandMaintenancecourses,SafetyManagementSystem(SMS)and Human Performance and Limitation (HPL) are two courses conducted frequently by the training center.Theformeronedealswithimplementationofsafetypolicyoftheairlinesandthelatter oneisassociatedwithhumancapabilitiesandlimitation,howtominimizetheerrorsdueto HumanFactors,improvingHuman-MachineInterface,andotherissueslikedocumentation, Shift/ Task turnover, Fatigue management, and adaptation with environmental conditions. SinceHumanFactorscontributedabout26%totheaircraftaccidentsoccurredworldwide, CAABmadethetwocoursesstatedabove(SMS&HPL)mandatoryfrom2004,asinstructed suchbyInternationalCivilAviationOrganization(ICAO),foreachoftheengineersand techniciansassociatedwithaircraftmaintenance.So,byturns,almostallpersonofthe directorate have been completing the courses with passing marks of 75%. TheessenceoftheHPLcoursedevelopedinlightoftheMurphyslaw:Ifanythingcango wrong,itwill.SwissCheeseModelisalsotaughtinthiscourseinrelationtominimizethe linkages associated with an error. The XYZ airlines policy for Human Factors implementation is thatitshouldbetreatedaseveryindividualsresponsibility,nospecificmanager(s)wouldbe assignedtosupervise/overseetheHumanFactorsimplementationintheorganization.Critics oftenquestionthisimplementationpolicybysayingthateveryonesresponsibilityisactually nobodys responsibility. Boeing737-800wasbeingoperatedbyXYZairlinesasFlightBG096fromKolkatatoDhaka. Few days back while the aircraft returned from Kolkata to Dhaka; it became inoperative due to a major component failure. This aircraft was scheduled for an immediate flight to Bangkok 3 hours later.So,tomaintaintheschedule,theotherBoeing737-800aircraft,whichhadbeenunder maintenancefortwodays,waspreparedquicklyfortheflightandallpassengersgotonboard. Whilethecaptaincheckedthenecessarypaperworkfortheflight,includingtheweather,flight plan,andaircraftmaintenancerecords,thefirstofficercompletedawalkaroundinspectionof the aircraft which revealed that 14 screws that secure the leading edge section to the bottom of the right wing were missing. Eventually, all passengers were off-loaded and the flight had been delayedforadditionalhours.Theaircraftlog-bookentriesincludedthestatement,Work package#446completed(A-Check).Therewasnootherinformationprovidedthatwould indicate to the flight crew what maintenance actions had been accomplished on the aircraft. The A-Check was a known 50-hour recurrent inspection that was not particularly complex; however, as the aircraft had been with maintenance for two days, an indication that the A-Check involved extensive maintenance work on the aircraft. Two days before the occurrence, the A shift maintenance engineers began their shift at 0600. The original shift-in-charge was absent that day and a Senior Engineer has been assigned as shift-in-charge.HeassignedanotherEngineerasaTeamLeaderfortheA-Check.Althoughthe responsibilitiesoftheteamleaderarenotwelldocumentedandnoformaltrainingisprovided, thegeneralunderstandingisthattheteamleaderistheliaisonbetweentheshift-in-chargeand the AMEs/ technicians and is responsible for assigning and supervising the AMEs/ technicians work.Inthisinstance,theteamleaderwasworkingonadefectofanothertypeofaircraft (Boeing 777-300ER) while carrying out his team leader duties.One of the junior AMEs (AME 1), who had been a licensed AME for three months, was tasked with showing some of the most recently hired technicians how to complete the line check. AME 1 had minimal experience on Boeing 737-800 aircraft maintenance and did not hold a company authorization.Itwaslefttotheengineersandtechnicianstodetermineamongthemselveswho wouldberesponsibleforeachtaskontheA-Check.Theteamleaderwasnotinvolvedinthe work assignments, but he was subsequently informed by the Shift-in-Charge of the work package that had been handed out. TheA-checkconsistsof11individualtasks.Oneofthesewastaskwas3010/08,Operational CheckofPneumaticEquipmentHeatingSystem,whichisafunctionalcheckoftheelectric heatersinthede-icesystem.AME1volunteeredforthistask,althoughhehadnoprevious relatedexperience.AME1wasbriefedbytheteamleaderandreviewedthemaintenance instructionsbeforehestartedtask3010/08.Hesetupaworkstandtogetuptowinglevel, approximately 15 feet above the floor, then removed the screws from the number 4 leading edge paneloftherightwing.Withoutcompletingworkontherightwing,becausehewasunsureof how to complete the removal of the leading edge, AME 1 moved the work stand and tools to the leftwingandstartedremovingthescrewsfortheleft,number4leadingedgepanel.Theright wing was not marked or flagged to indicate that the screws had been removed and that the work was incomplete. At approximately 1400, AME 1 received voluntary help from an apprentice AME (AME 2) who was working on the afternoon shift (B shift) and who had previously worked on a task 3010/08. Beforeleaving,AME1gaveAME2thescrewsfortherightwingleadingedgeandinformed him the tail heaters were functional. Since the right wing heaters had not been tested, AME 1 did notsignthatthetask3010/08wascomplete.AME1leftfortheday.AME2movedthework standtotherightwingtocompletetheremainingpartofthejob.Inthemeantime,Shift-in-Charge called AME 2 away from the aircraft to send him to the ramp. He repositioned the right wingleadingedgeandinstalledonescrewsotheleadingedgewouldnotfall.Hethenputthe remaining screws in a latex glove, taped it to the leading edge section and left for the ramp. When the team leader reviewed the work sheets on the following day before releasing the aircraft forflight,henotedthattask3010/08hadnotbeensignedout.Hehadpreviouslytalkedwith AME 1 and believed that he had checked all 13 heaters. The team leader certified task3010/08 asbeingcomplete,eventhoughsometaskshadnotbeencompleted,becausehedidnotwant anotherengineertohaverecheckall13heatersashewasundertimepressuretoreleasethe aircraft for flight as soon as possible. Task3010/08wasnotacomplexjob;therewerenopressingtimeconstraintswhiledoingthe job,andcompletemanufacturersinstructionsonhowtolocate,accessandtesttherelevant components were available to the AMEs involved. Therefore,analysis will focus on the human factors that led to the aircraft about to dispatch with an unsecured leading edge and without the heating elements in the right wing leading edge being inspected. If this could not be revealed in pilots walk around check, the last line of defense, it might be a potential source of accident. Questions: 1.What are the main factors that contributed to the incident? 2.DoyouthinkTransferofTrainingoccurredhereeffectively?Ifyes,towhatextent?If No,whataretheobstaclesintheworkenvironmentthatinhibitTransferofTrainingin this case? 3.What initiativesXYZ airlines management should take to createand retain the positive climate for transfer of training?