the safety health of maintenance engineering (shome) tool steve mason principal human factors...
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The Safety Health of Maintenance Engineering
(SHoMe) Tool
Steve MasonPrincipal Human Factors Consultant
HSEC Ltd
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Error Types & Action Strategies
Cannot physically achieve goalCannot physically achieve goal
- improved ergonomics- improved ergonomics Slips & Lapses + DistractionsSlips & Lapses + Distractions
- design & interlocks- design & interlocks MistakesMistakes
- training, job aids- training, job aids ViolationsViolations - - safety culture + organisational factorssafety culture + organisational factors
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Existing Guidelines/ToolsMaintainability Design HandbookBretby Maintainability IndexHFRG Guide to reducing violationsHFRG Guide to reducing maintenance
errorHSEC Human Factors SolutionsSHoMe
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Reactive, Proactive, or Both?
INCIDENT REVIEWS QUESTIONNAIRESStrengths:Information available from incident investigationsBased on factual evidenceCost of accidents/incidents can be determined
Strengths:Quick to administerFindings reflect current attitudes Involves staff identifying areas of concernCan promote ‘ownership’
Weaknesses:Root issues not always well documentedOften insufficient incidents for analysisData relates to the past – may not be relevant to the future
Weaknesses:Findings based on perceptions may be influenced by range of factors unrelated to maintenanceNo factual information to gauge ‘spend’ justified on expected improvements
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SHoMe Basic StructureSafety Health of Maintenance Engineering
Evidence of Non-Compliance•E.g: risk taking, errors through tiredness, supervisors condoning unapproved actions, etc
Potential Root Issues affecting Compliance•Factors known to have caused problems
•Factors that could cause problems
Part(s) of Job Causing Most Difficulties
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SHoMe Staff Groups
Technical Certifying Staff
Technical Non-Certifying Staff
Management & Technical Support Staff
(e.g. planners, )
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Questionnaire AdministrationStaff Group Generic Q Job
DifficultyOrg Q
Tech Cert version C
Tech Non-Cert version NC
Support Staff version NTN/A N/A
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Questionnaire Administration
•Avoid issuing questionnaires & collecting them in at the end of a shift – response by committee!
•Preferably – organise small groups, lead with introduction my management (& unions if possible)
•Stress anonymity and purpose of the surveys
•Emphasise that feedback will be given & acted upon (if appropriate)
•Please: ensure correct question set is issued
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Example Generic QuestionsPlease indicate the extent to which you agree or disagree with the following statements in relation to your work over the last 6 months of so
SA A ? D SD
Management and staff communicate well with each other
Managers always let us know of important safety findings
I am always properly briefed by those giving me a job
Before I start a job I am always given the necessary information
I know exactly what I am expected to do and my responsibilities
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Extract Job Difficulty Questionnaire
AWas this
part of your jobs?
BNo
Problems
CSome
Problems
DMajor
Problems
PLANNING Y/N? PREPARATION Y/N? INSPECTION Y/N? ROUTINE WORK Y/N?
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Extract from Organisational QuestionnaireThe ease with which general written procedures can be understood
The amount of jargon and ambiguity contained in procedures
Ambiguity as a result of different layouts of different types of forms you use
Systems for implementing temporary revisions to maintenance manuals
Previously encountered problems not highlighted
The ability of planners to minimise jobs running over other shifts
The amount of work your immediate boss expects you to do in a shift
The way management treat individuals who report mistakes or safety concerns
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Prioritising Results
Ranked Human Factors Issues – Generic Q
Ranked Issues – Organisational Q
Ranked Major Root Issues [19]
Ranked Evidence of Non-Compliance
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19 MAJOR H.F. ISSUESDesign & Maintenance InterfaceProvision of ResourcesTrainingFatigueComplacencyPlanningCommunicationsCommercial PressuresMaintenance ProceduresRoles & Responsibility
Management AttitudesSafety Commitment of StaffJob PressureWorking ConditionsFair-Blame CultureManagement of ChangeSupervisor EffectivenessSupervisor AttitudesCompetence
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Results PresentationLevel
1Non-Compliance: Generic Q
Summary of Major Root Issues only
Level 2
Non-Compliance: Generic Q
Expanded Major Root Issues : Generic Q
Level 3
Expanded Non-Compliance: Generic & Org Q
Expanded Major Root Issues : Generic & Org Q
MEDA Results presented against relevant MEDA structure
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HSEC SHoMe ToolVersion 1.0September 2003
This tool was developed by HSEC Ltd, on behalf of the UK CAAThe tool may be freely copied, distributed and used for flight safety purposes, but not resold for commercial purposesThe SHoMe tool must be used in conjunction with the user manualThe software is not supported
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Scoring Criteria
GENERIC QUESTIONNAIRE:
Good < 35
Worthy of Attention > 55
Concern > 65
ORGANISATIONAL QUESTIONNAIRE:
Probably Acceptable < 15
Concern > 30
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EVIDENCE OF NON-COMPLIANCE Mean Score
Completion of job despite the non-availability of appropriate tools and equipment
71
Regular non-compliance by the workforce 61
Aircraft released with work not done due to parts shortages 50
Direct pressure to deviate from procedures 43
Reports of colleagues making errors due to tiredness with last month
41
Direct pressure from the supervisor to deviate from procedures
36
Pride on getting aircraft back on time, even if this needs some non-compliance
34
Supervisors taking risks in releasing aircraft when maintenance incomplete
26
Supervisors condoning unapproved actions to get an aircraft away
22
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POTENTIAL ROOT ISSUES Score
Design & Maintenance Interface 57
Planning 51
Fatigue 51
Provision of Resources 50
Commercial Pressures 49
Working Conditions 49
Training 47
Roles & Responsibility 41
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POSITIVE FEATURES Scores
Supervisor Attitudes 29
Competence 30
Supervisor Effectiveness 31
No-Blame / Fair-Blame Culture 34
Management of Change 36
Complacency 38
Safety Commitment of the Engineers / Staff 39
Procedures – Accuracy, Relevance & Practicality 39
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Job Difficulty
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Using SHoMe data
Show Differences between Cert, Non-Cert, Support Staff
‘Big Picture’ – are there any major concerns?
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Typical QuestionsAre there any significant differences between those who have worked in the Industry for > 20 years and those new to the Industry?
Are the problems with contract staff significantly different from those with permanent staff?
Differences within one company with staff at two sites.
Differences between those working long hours.
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SUMMARYHuman Factors Issues are important & need to be managed
SHoMe requires investment in time by all staff
Hopefully – we agree it complements existing tools
Freely available + option for Industry benchmarking
SHoMe does not rely on incidents/near misses