Maintenance Resource Management
By Stephen P. Prentice
March 1998
Stephen P. Prentice is an attorney whose practice involves FAA-NTSB issues. He has an Airframe and Powerplant license and is an ATP rated pilot. He worked with Western Airlines and the Allison Division of GMC in Latin America, servicing commercial and military overhaul activities and is a USAF veteran.
They say you can't teach an old dog new tricks. Prepare to be surprised if you are fortunate enough to attend a resource management workshop at your place of employment or in a more formal setting at a FlightSafety presentation. This writer recently had an opportunity to see and hear first hand just what the subject was all about and more importantly, learn from it.
We might say that maintenance resource management (MRM) is nothing but the application of common sense rules to our everyday work environment. But this is clearly an oversimplification. Common sense rules must be reinforced with clear, concise guidelines for uniform application. The reason for MRM is the mother of all reasons — safety.
ON THE JOB
In the normal course of our work day we are organizing, communicating,
and otherwise interacting with our fellow workers around the shop or hangar. Whether we are aware of it or not, we make MRM-type decisions all day long. We examine job requirements, gather the resources to complete the job, set a goal for completion, and then communicate with our fellow workers about the details. In essence, this is what MRM is all about job requirements, resources, goals, and communication. "People are more likely to communicate when there is a common goal or focus," says Bonnie Hendrix, FlightSafety's manager of MRM training. She goes on to say, "But don't let the goals drive you, you must drive the goals." Good advice. Furthermore, Hendrix says, "How people see you at work determines how they will communicate with you."
Work crews must interact with each other so they can recognize a potential problem before it becomes a hazard to flight operations. Hendrix relates the story of the midwest commuter aircraft that crashed because of poor communication between a day and a night maintenance crew. Leading edge fasteners attaching deice boots were inadvertently left off one side of the horizontal stabilizer causing a loss of control. Hendrix cites the accident as a classic example of what MRM is designed to prevent.
PREVENTING ACCIDENTS
If there is one significant, stand out feature of MRM training it has to be the recognition of situations that can lead to accidents. You have to be aware of your surroundings at all times. Working around machinery and aircraft can be a threatening environment when you don't keep your wits about you.
You have seen it all happen if you have been in the hangar long enough. Any action you take that can trigger a remote response that you can't see and monitor should be taken with great care and supervision. Just simply keep in mind that somebody can easily be injured or killed by the actions you take. You must have a safety goal in mind and that goal must be a specific procedure to complete the process. A procedure must be in place to prevent or reduce the potential for injury.
IMPORTANCE OF COMMUNICATION
In order to implement these procedures, you have to communicate. Communication is the mother of safe practices and a breakdown of communication can
be cited in many, if not all, accidents.
Technicians cannot be lone eagles. You have to talk to each other and to the operations people who control and dispatch aircraft maintenance instructions. No one can work alone efficiently or safely. Working alone in a hostile environment will surely create threats that may cause harm.
A recent sad example was that of a technician working on a DC-3 in the Midwest. He was up in the wheel well, in a remote aircraft storage area, removing a piece of equipment. Suddenly and without warning the landing gear started to fold, pinning him in the well and ultimately suffocating him by crushing his chest. He did not die quickly and must have suffered a lot.
Sometime later the aircraft was observed by another technician and it seemed to be down on one wing. He immediately called for help, but, by then it was too late. If another technician had been on hand for the job, chances are the accident could have been avoided or minimized.
Each technician must be aware of who is around him and what threat his surroundings present to him.
There were no gear lock pins in place on this aircraft. Perhaps the technician was not aware of them or had not been trained in this area. I doubt if anyone at this company will forget to check for gear downlock pins again. There has to be a standard operating procedure for such things as entering a dangerous place like a wheel well. Lock pins are mandatory items.
ACCIDENT OPPORTUNITIES
The accident described earlier where screws were left out of a tail leading edge boot retainer occurred as a result of shift change. You can't rely on simply having a conversation over coffee with one or two of the people on the previous shift. There must be a written shift turnover document in plain view at the work stations.
One of the best examples of a similar procedure is the "nurse's report." Anyone who has worked in a hospital will know that at shift change there is a formal meeting of the two shifts, including residents on staff, which gives the oncoming shift a clear statement of patient conditions, medication protocols, diagnostic tests to be completed, and a general outline of work in progress. This is a life and death meeting of the two work groups and the health of many people are in their hands. The similarity is uncanny. Our patient is the airplane in the hangar.
The aircraft maintenance record or paper notes are not the place for shift turnover instructions. A separate record should be present so there is no possibility of confusion. Furthermore, all members of both shifts should be present to review the written shift record and make appropriate notations and comments regarding work in progress. You must create a standard that can be followed by all of the technicians on the hangar or shop floor.
Clear and consistent guidelines or procedures for such things as gear retraction tests, high power turnups, testing of flight control movement, and hydraulic and electrical circuit testing are a must. Absent standard written procedures, that are rigidly followed, accidents will happen.
SAFETY AND REGULATION DIRECTOR
The Federal Aviation Regulations (FAR) spell out a safety management function for air carriers and the companion job at a repair stations
is generally described in the op specs for the chief inspector.
The FAA's "one level of safety" for air carriers rulemaking in 1996 set forth a new management safety function under FAR 119.65 and described it as a "director of safety" which includes regulatory compliance. Suddenly, at least for air carriers, the FAA decided that safety should be elevated to the status and responsibility of a management person. Awareness of the safety function is now squarely and by force of regulation placed on a management person. Awareness of regulatory responsibility and more importantly the compliance standards are a necessary and fundamental requirement. Your company could be under the gun for FAA civil penalties and/or certificate action if there is no oversight in the safety area. In addition, civil liability outside the FAA could be applied, if the inspection process reveals a failure of compliance. You can rest assured litigation and lawyers will follow any safety oversight!
THE LEGAL ANGLE
Everyone should be aware of the litigation circus that has haunted and continues to haunt the aviation industry. Every time there is an aircraft accident you can count on lawyers representing injured parties attacking vigorously.
Accidents are always costly. When an employee is injured on the job he is provided workers compensation coverage for medical and lost wages and is generally precluded from suing his fellow employees or his employer for damages. However, you can be sure that the workers compensation insurance carrier will look around for some third party to blame and recover their payments from.
This is called subrogation. The insurance people step into the injured parties' shoes and retain all rights to recover their money. If they fail to find somebody to recover from, you can count on your company's insurance premiums rising accordingly. They may rise anyway simply because of an accident history and the increased threat. Insurance companies don't give their money away without some effort to recover. Your company will pay for accidents one way or the other.
The safety function can help to reduce the threat of loss due to legal proceedings whether from the FAA or civil court proceedings. In all safety-related matters the bottom line remains to reduce and eliminate, if possible, the threat of pain, suffering, and death. In addition, potential legal threats and failures can and will expose your company to economic damages. Survival of your company could be at risk. There are sufficient examples in the news media in recent years to bring this point home.
MRM AND SAFETY
Any safety office should consider a maintenance resource program. MRM should be an integral part of any safety and accident prevention program.
The safety person in the air carrier setting or the chief inspector in the repair station should be the managers of a continuing MRM program and of course should be trained in the discipline. Once trained, these people can form the core of a continuing safety audit and compliance program. Your company's very existence could depend on it!
