Return on investment from our regulated Human Factors programmes?

1. Return on investment from our regulated Human Factors programmes? Keven Baines Managing Director Baines Simmons Limited

2. 28th September A major regulatory compliance milestone has been reached. One key question remains: Will it deliver Return on investment (ROI)?

3. The regulations and why they were amended? • The objective of the CAA Safety Goal back in 1998/9: ‘to reduce the maintenance human factors contribution to aircraft accidents’ • Training is unlikely to affect the following…

4. Middle of the iceberg example… September 2003

5. Middle of the iceberg… June 2004

6. Delivering HF training is only one aspect of a successful programme The aims of Human Factors training should be to: (i) impart knowledge on human factors, (ii) to develop skills, where appropriate, (iii) to influence people’s attitudes and (iv) to influence behaviour (all in support of improved safety). “Training will not be successful in the long term unless what it teaches is supported within the organisation on a day-to-day basis. The human factors training requirement within Part 145 should not be considered in isolation but, rather, as a part of the total package of measures” CAP 716 Issue 2

7. OMS includes (but is not limited to) Human Factors training, and the consistent management of: • Workplace: lighting, temperature, climate and noise • Behaviour: error provoking, non-compliance with procedures and violations • Interruptions whilst performing tasks • Personal performance: eyesight, hearing, physical condition and repetitive tasks • Design: manufacturer’s documentation, maintainability and Maintenance Manual validation • Design/Maintenance Interface – reporting bad data/design • Tools and equipment, design, accessibility and availability • Safety culture • Internal Occurrence Reporting • Shift and task handover • Fatigue of personnel • Error management (Reduction, capturing and/or tolerating) • Preparation of work (tasks, equipment and spares) • Responsibility for “Signing off” tasks • Non-compliance with procedures • Excessive time pressure

8. ROI through a reporting culture • Pushing reports through the existing continuous Improvement processes (Quality Assurance) • adding the human investigation element when it's appropriate. • Have a means of escalation to raise unaddressed items to a higher level. • Feedback…feedback…feedback – show them that reporting is worthwhile

9. Sit back and wait? • We are warned by the FAA ‘Human Factors in Aviation Maintenance’ Operator’s Manual : • “to be prepared; as it will typically take 2 - 3 years before maintainers report to the level you should wish for”. • This is not our experience • If the training course on initial Human Factors was competence driven, and one of those competencies was reporting (what, where, who, when, how and why), the maintainer is typically willing to report (test the water) immediately following the training course…

10. Even though in Europe our Human Factors programs are a regulatory requirement, The regulators behaviour continues to have a major part to play!

11. Return n Investment (ROI)? • Safety is a dynamic non-event • We know more about safety by its absence rather than its presence. • The ROI is that we get an improved window into what is and is not happening to achieve a safe (cost effective) product

12. Potential Return On Investment • Continual improvement as the motivator • Insurance • Regulatory compliance Defence Industrial Strategy (DIS) • Building customer confidence and good public relations • People (learning culture) = increased professionalism • Staff at all levels behaviour modelled – error and violation management • Legal duty of care • Competence… where it counts • Risk mitigation • Better manage the cost of error • Efficiency/productivity gains • Securing regulatory compliance - be it EASA Part 145 or DAOS/MAOS

13. The ‘buy-in’ venturi This is obtained during their 1 day training session – not normally too difficult for this group to largely agree to the ‘message’ once they can see the business (ROI), risk, and safety benefits Top Management ‘Buy-in’ When it comes to the middle (production) managers and supervisors – this group we call the ‘treacle layer’ are the hardest to influence. They perceive the old metrics and measurements will be even harder to achieve if we have ‘do’ human factors as well as their day job. They then revert to their learned behaviours, giving rise to the shop floor ‘I told you so’ moment middle managers & supervisors Production pressure opposite to Bernoulli’s theory HF buy in equates to flow pressure When it comes to the ‘doers’, they are normally very keen to see change rather than coping with the status quo – however are hugely cynical that they will see any evidence of change for the good – they are waiting for the ‘I told you so’ moment Shop floor ‘Buy-in’

14. Corporate Manslaughter & Corporate Homicide Bill – nearly there? Insurance Litigation Alert - 27 July 2006 • The proposed new offence permitting the court to consider the overall picture of how an organisation's activities were managed by senior managers, as opposed to focusing on the actions of one individual • The new bill also adopts the Committees’ suggestion, in response to the previous bill, to build in a consideration of whether the organisation’s culture encouraged or tolerated and therefore led to the management failure. • Copies of the bill can be found at: www.publications.parliament.uk/pa/pabills.htm

16. Summary • If Human Factors training was the sole focus of our HF (compliance) efforts, we will have done almost nothing to deliver ROI

17. But people in different organisations keep making the same mistakes……. We have an ongoing need to help the maintainer the HF programme is our opportunity to achieve this ROI…