AVIATION SAFETY MANAGEMENT SYSTEM

Aviation Safety Management System



Aviation Safety Management System

Introduction

Aviation maintenance in our rapidly changing world is a multifaceted and demanding undertaking. The success of today's aviation maintenance, which is eventually measured by the safe travel of the flying public, depends on clear communication and full cooperation of all team members. Today's aviation maintenance operations are most successful when maintenance professionals function as fully integrated crews working, communicating, and striving for a common goal. The aviation maintainers described of in past decades will no longer be individuals engaged in independent actions to accomplish a desired outcome. The total safety of the flying community will no doubt increase by improvements to all components of aviation and that includes maintenance.

Discussion

Over the past decade, the high importance of teamwork and cooperation in the maintenance arena has been widely acknowledged and documented. The consequence has been the materialization of human factors training, Maintenance Resource Management (MRM) programs, and other team-based activities within the aviation maintenance community.

MRM grew from the result of a series of events that drove its development. Just as CRM grew from a reaction to a tragic event, another key accident led to the development of MRM and maintenance-based human factors training. In 1988, Aloha Airlines Flight 243 suffered a near-catastrophic failure. Eighteen feet of fuselage was torn off the aircraft at an altitude of 24,000 feet, forcing an emergency landing (NTSB 1989). Following this accident, the FAA issued an Airworthiness Directive (AD) requiring a close visual inspection of 1300 rivets on B-737 aircraft. (AD 93-13-02).

The Aloha B-737 involved in this accident had been examined by two inspectors, one with 22 years experience, and the other, the chief inspector, with 33 years experience. Neither of the inspectors found any cracks in their inspection (Robertson 1998). However, post-accident analysis determined there were over 240 cracks in the skin of this aircraft (NTSB 1989). The resulting investigation identified many human-factors-related problems leading to the failed inspections. These findings focused attention onto maintenance as a potential accident causal factor, and led to the development of MRM and human factors training.

Currently, there are no FAA rules directing any type of human factors awareness or training program, including MRM-specific knowledge or training. However, an Advisory Circular is being designed and written and will soon distributed to the airline industry. According to Robertson (1998) "The Aviation Rule Making Advisory Committee (ARAC) has revised FAR Part 121.375 to include Maintenance Resource Management and human factors training. The new rule has not yet approved and released by the FAA."

Statistics

Aircraft maintenance errors have been reported as a contributing factor in approximately 15% of major aircraft accidents from 1982 to 1991, at a cost of over 1400 lives (Boeing/ATA 1995). In addition to lives lost, maintenance errors can also contribute significantly to operational expenses. For example, Rankin et al. (1995) states that 50% of flight delays due to engine problems are maintenance error related and cost the airlines about $10,000 per hour. At least 20-30% of in-flight error shutdowns are similarly related ...