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Error Reduction in Practice

Error Reduction in Practice. RAeS Human Factors Working Group Bentley Priory 2006. A change of name. Maintenance ‘events’ Maintenance event ‘reviews’ Less ‘fault’ based than using words like ‘error’ and ‘investigation’. Impact of maintenance error. Comparison to Bill Johnsons’ data.

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Error Reduction in Practice

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  1. Error Reduction in Practice RAeS Human Factors Working Group Bentley Priory 2006

  2. A change of name Maintenance ‘events’ Maintenance event ‘reviews’ Less ‘fault’ based than using words like ‘error’ and ‘investigation’

  3. Impact of maintenance error

  4. Comparison to Bill Johnsons’ data

  5. Contributing factors all events to date

  6. Information not used is the largest element - combination of information not used or ignored, can be AMM, troubleshooting, cautions in SB detail

  7. Post interventions

  8. Contributing factors

  9. Individual factors - time constraints - sometimes self imposed. Distraction - complacency particularly in inspection where the error is not detected - assuming the person doing the task is competent.

  10. Post interventions

  11. Inadequate task knowledge and inadequate airplane systems knowledge. In many errors the person who made the error was not lacking skills but lacking knowledge.

  12. Post interventions

  13. Contributing factors

  14. The level of supervision applied is often inadequate to detect error.

  15. Post interventions

  16. Contributing factors

  17. A lack of communication - shift handovers, task handovers in particular

  18. Post interventions

  19. Post MEDA workshops – run by the line manager where all staff involved go through the event and discuss the circumstances

  20. !Wheel Spacer!

  21. Door arming and slide systems

  22. Compliance monitoring in the workplace- RAeS EMSG sub group working on this subject

  23. Data Sharing UK MEMs Data sharing Group See the CHIRP website for more details

  24. Suggested Immediate Activity • Acquire your MEDA Data • Compare contributing factors among participating organizations • Identify common interventions • Create a matrix of best practices/interventions • For each factor access value of interventions to predict error reduction

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