IFA Forum Dubai March 2010 1 Fatigue and Maintenance Error Philip Hosey with Frank Jaregui...

IFA Forum Dubai March 2010 1

Fatigue and Fatigue and Maintenance ErrorMaintenance Error

Philip Hosey with Frank Jaregui International Federation of Airworthiness


Is it a fact that maintenance

errors cause accidents? If so does fatigue play a part in these?

Are there other factors?

Do we know enough?

Are we improving?

Perhaps a later speaker today can help on this

point


Boeing Facts

For years the highly regarded Boeing data gave 3% for maintenance caused accidents, however:

These were hull loss numbers only.


FAA Facts!

Maintenance was the primary cause of over 8% of the US accidents in the 1990s for larger passenger aircraft.

A maintenance event started the accident chain in 26% of the worldwide accidents in recent years.


Maintenance related accidents and incidents The list contain total loss and non fatal accidents, damage and non-damage incidents. Some are old, some new!

They all have a feature in common and then there is one which is unique.

I will tell you which one later!!


B747 JA8119 Structural Failure 12 August 1985

B732 N242US Engine Fell From Aircraft 20 January 1989

DC10 N1819UCentre Engine Non Contained Failure

19 July 1989

Embraer Brasilia N33701 Loss of Control 11 Sept 1991

B734 G-OBMM Loss of engine oil, Both Engines 23 Feb1995

Fokker F100 G-UKFA Spoiler Actuator not connected 12 October 1995

Avro RJ HB-IXP Controls not Connected 30 April 1996

B747-100 F-GKLJ Gear Retraction on Ground 15 June 1996


Boeing 757 G-BIKF Large fairing fell from aircraft 11 September 1996

B757 N52AW Loss of Control 2 October 1996

Airbus A300ST F-GSTA Panel missing 21 Jan 1997

Dornier 228 VT-EJW Loss of Control 30 July 1998

Fokker F100 G-UKFK Wheel departed aircraft 24 September 1998

DC8F 9G-MKH Gear retraction on the ground 20 July 1999

Learjet 35 N47BA Loss of Cabin Pressure 25 October 1999

B747F HL-7451 Loss of Control 22 December 1999


A320 G-VCED Loss of engine cowlings 20 January 2000

A330 C-GITS Fuel leak and complete loss of power 24 August 2001

B732 N322DL Engine Fell From Aircraft 7 January 2002

B747 B-18255 Structural Failure 25 May 2002

Pegasus Quik G-STYX Structural Failure 21 August 2004

SA227 Metro C-FIPW Gear Collapse 21 September 2004

ATR72 TS-LBB Fuel Exhaustion 6 August 2005

B734 PK-KKW Loss of Control 1 January 2007


Accident Reports

Open and Factual

We in IFA pay tribute to them

Something is missing!

Why?


Facts

Let us examine facts highlighted in the charts

Every accident report provides data on the overall and recent experience of the flight crew. Even if this factor has no bearing on the accident!


Few, if any, accident report give similar data for the people involved in the maintenance considered to be the causal factor. Why?

Facts


The worst accident involving faulty maintenance? The failure of a bulkhead repair to B747SR

JA 8119 resulted in the second highest fatalities in a single accident.

The report resulted in a large number of actions (AD’s etc.)

However, I quote from the report;“Resulting AC's, Regulatory Guidance and Policy - No

regulatory changes were made because this accident resulted from an incorrect repair.”


Neither can I find any record in the investigation report of a substantive reason why the repair was not performed properly!


Most data confirms that human error in

maintenance continues as a significant cause of accidents.

Little improvement has been apparent in recent years.

Comparatively better progress is seen in reducing crew related accidents.


In reviewing many reports some factors seem to be common. Little hard data on fatigue (as opposed to

human error) is available as a prime cause. Working patterns are part of working life

dominated by 24 hour availability. Regulation is widespread


A Contrast in Accident Investigation Almost every accident report I have ever seen

faithfully and properly sets out the qualifications, experience and recent duty periods of the crew (as required by ICAO Annex 13)

I would like someone to show me equivalent data for maintenance staff who are implicated in an error leading to an accident!


Perhaps if we were cynical we might say

“Well for only 3% of hull loss accidents such

detail is to difficult to obtain”.

Because IFA believes otherwise, it must be

time the world’s Investigators gave

appropriate data for those involved in the

maintenance of an accident aircraft.


Who says people make mistakes when they are tired? Just about everybody. Just look at CHIRP

reports, and the New MX Fatigue Newsletter. Oddly though, some evidence claims that

tired people work as well, even better when sufficiently stimulated (that’s another word for terrified).

However, for maintenance people, However, for maintenance people, terrorterror rarely intrudes as they finish a long night rarely intrudes as they finish a long night shift.shift.


Working time rules

The US Congress passed a law limiting daily working time to eight hours for federal employees. When?

The EU has progressively tightened limitations Australia broadly reflects the EU The UK enacted The Working Time Regulation in

1998 ICAO gives guidance in the latest issue of the SMM Some countries don’t say much at all!

1868


Has rule making changed things. Over several recent decades many laws have

progressively reduced working hours. Transport, public services, industrial and service

industries have been affected. Most industrial countries have enacted rules. Of late there has been a discernable relaxation

of these hitherto strict limits perhaps related to economic factors.


Effective or not. The IFA contends that few of the scores of

legislative changes enacted internationally over the years truly address the issue of fatigue related error!

If this were really the case why do we see people such as the NTSB and AAIB still mentioning crew fatigue as a possible contributory factor?


IFA published its first “white paper” on this subject in February 2005 followed by a second in November 2007.

Both were aimed at raising the awareness of fatigue in the context of flight safety.

Both are available on the IFA Web Site. (www.ifairworthy.com)

We also promote the formality required in maintenance.

IFA recognises the high standard of all accident reports

What the IFAIFA says.


Is this why is it so difficult to find meaningful data on the human elements of people directly involved in maintenance errors?


What do we know? There is wide recognition that errors of skill, judgment or

perception can be related to fatigue.

There is apparently less formal acceptance and thus less factual data on this in relation to aviation maintenance.

We have the greatest respect for the high level of data related to flight crew published in accident reports. The international standard as laid down by ICAO Annex 13 is impeccable but…...


The Quiet Hours!

Evidence shows that maintenance errors often occur during night working.

Is fatigue the main ingredient?

Do other factors count more?


Other Factors It would be foolish to discount the many other

factors influencing night work. Lack of many of the facilities (e.g. specialists)

afforded day work. Less supervision and mentoring. Less favourable working environment such as

lighting. Human susceptibility to circadian effects. Schedule pressures. Distraction.


Fatigue and night working. First, recognise that the formality of the CRM

steeped flight deck culture is not achievable in maintenance.

The level of support, consideration and oversight should be increased. CHIRP reports cover this.

Critical items should be treated more carefully. Critical Inspection Items need a thorough review

and beefed up for night work tasks. Remuneration is an issue in encouraging long

working hours. FTL should be required reading for maintenance

planners! Even if it varies from country to country!


Tiredness is cumulative. Shift patterns can lead to excessive fatigue

Tiredness has some of the following traits.

Poor judgement.

Lack of dexterity.

Ignoring SOP’s

Over confidence.

And most important in the view of IFAIFA :-

The acceptance threshold is lowered!The acceptance threshold is lowered!


Fatigue

We asked in our first slide if fatigue is a factor.

IFAIFA considers that it is!

Operators, Regulators, OEM’s and the MRO industry had better find a way forward or the legal system will find it for them!


The OEM’s can help Put as much thought into maintainability as to

elegant solutions for flight deck ergonomics.

Maintainability is at least as important as IFE systems.

If designers had given as much thought to flight deck displays as they have to maintenance error, cockpits would still look like this!


Which Regulators have published proposals to control fatigue and shift working?


Just one actually.

The Maldives! [NPRM 2007-05]

What is the rest of the world doing?

Most have advisory or qualified rules only.


What was the answer to my question? Every one had a common feature.

The crew details were set out in the report in every case!

Which was the incident that was unique (the odd one out)?

The B734 incident in February 1995 [total oil loss] and

the difference was that this report set out in detail the

qualifications and duty periods of the maintenance

people!


We have beaten the maintenance issues arising from the challenges of recent times. ETOPS Low Visibility Operations RVSM Two crew operation TCAS Digital Systems New technology airframes and engines

CFIT is in decline thanks to an industry wide campaign.

Why is it not possible to take on maintenance error in the same way?


If we do, the chances are that we will see many

more beautiful Gulf dawns.

Thank You

IFA Forum Dubai March 2010 1 Fatigue and Maintenance Error Philip Hosey with Frank Jaregui...

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