Difference between revisions of "Maintenance Resource Management"
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===Introduction to MRM=== | ===Introduction to MRM=== | ||
| − | + | BACKGROUND.a.Though crew resource management (CRM) on the flight deck is a topic of regulardiscussion, relatively little attention has been paid to its maintenance-related counterpart,maintenance resource management (MRM). Indeed, this inattentiveness isunderstandable. Whereas a pilot or pilots’ errors can have immediate and highly visibleeffects, the same can not necessarily be said of a maintenance-based error. Because ofthis, aviation research into team activities first grew from investigations into aircrewbehaviors. This evolution is apparent whenever encountering references to crew resourcemanagement.b.The aviation community has expanded its approach to reducing human error.Human factors programs now encompass not just the flight crew, but all aspects ofaviation in which a human may be involved. This activity includes such areas as aircraftdesign and operation, air traffic control, and, of course, aircraft maintenance.7.OBJECTIVES.a.This AC provides background information on Maintenance ResourceManagement. Maintenance Resource Management (MRM) is a general process forimproving communication, effectiveness and safety in aircraft maintenance operations.Attention will be given specifically to the implementation and evaluation of MRMtraining. Much as crew resource management (CRM) was created to address safety andteamwork issues in the cockpit, the Federal Aviation Administration (FAA), inconjunction with industry partners, developed MRM to address teamwork deficiencieswithin the aviation maintenance environment.b.MRM is a team-based safety behavior. It teaches managers and maintenancepersonnel skills that enable them to work safely in a complex system. MRM teachesmore than just team skills; it teaches and reinforces an organizational philosophy inwhich all members of the organization are oriented toward error-free performance. Thisis accomplished by teaching:(1) How the effects of individual actions ripple throughout organizations,(2) How to utilize available resources safely and effectively, and(3)How to propagate a positive culture of safety in the organizations throughspecific, individual actions.c.The overall goal of MRM is to integrate the technical skills of maintenancepersonnel with interpersonal skills and basic human factors knowledge in order toimprove communication effectiveness and safety in aircraft maintenance operations. | |
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9/28/00AC 120-72Par 8Page 78.PHILOSOPHY OF MRM.a.The philosophy of MRM is based on the philosophy of CRM with emphasis onhow maintenance operations differ from flight operations. The work environment ofmaintenance personnel encompasses a great variety of tasks in varied settings with agreat number of people. Because the tasks and work differ from one domain to the other,the basic plan for addressing concepts like human error, teamwork, and safety also differ.b.This section outlines similarities and differences between MRM and CRM, inorder to characterize the philosophy of MRM. First, human error in both the flight andmaintenance environment is explored in more detail as a foundation upon which to buildthe discussion of an organization’s safety culture. The section that follows investigatesthe concept of a safety culture more thoroughly. The promulgation of a good, pervasivesafety culture is at the core of MRM’s basic philosophy.c.Human error.(1)The way to understand MRM is to explore the nature of errors inmaintenance operations. A widely accepted model of human error is the classification ofunsafe acts developed by J.T. Reason. This classification distinguishes between twotypes of errors:(a)Active failures, whose effects are felt immediately in a system, and(b)Latent failures, whose effects may lie dormant until triggered later,usually by other mitigating factors.(2)The presence of defenses or safeguards in a system can usually prevent theeffects of latent failures from being felt by closing the window of opportunity duringwhich an active failure may be committed. For example, consider the case of amechanic who assembled a component incorrectly which eventually led to a plane crashdays or even weeks later. The defenses that should have normally caught this mistakewere not in place. These defenses include proper training (the mechanic was taught to fixthis particular component very informally and on-the-job), good situational awareness(the mechanic was tired from a double shift the night before), and independent inspection(the job was “pencil-whipped” to save time.)(3)Active failures are usually the result of actions taken (or not taken) by front-line operators such as pilots, air traffic controllers, or anyone else with direct access tothe dynamics of a system. Latent failures, on the other hand, are caused by thoseseparated by time and space from the consequences of their actions in the dynamics ofthe system. Personnel working in vocations such as architectural design, hardwaredesign and equipment maintenance are more prone to cause latent failures than activefailures. | 9/28/00AC 120-72Par 8Page 78.PHILOSOPHY OF MRM.a.The philosophy of MRM is based on the philosophy of CRM with emphasis onhow maintenance operations differ from flight operations. The work environment ofmaintenance personnel encompasses a great variety of tasks in varied settings with agreat number of people. Because the tasks and work differ from one domain to the other,the basic plan for addressing concepts like human error, teamwork, and safety also differ.b.This section outlines similarities and differences between MRM and CRM, inorder to characterize the philosophy of MRM. First, human error in both the flight andmaintenance environment is explored in more detail as a foundation upon which to buildthe discussion of an organization’s safety culture. The section that follows investigatesthe concept of a safety culture more thoroughly. The promulgation of a good, pervasivesafety culture is at the core of MRM’s basic philosophy.c.Human error.(1)The way to understand MRM is to explore the nature of errors inmaintenance operations. A widely accepted model of human error is the classification ofunsafe acts developed by J.T. Reason. This classification distinguishes between twotypes of errors:(a)Active failures, whose effects are felt immediately in a system, and(b)Latent failures, whose effects may lie dormant until triggered later,usually by other mitigating factors.(2)The presence of defenses or safeguards in a system can usually prevent theeffects of latent failures from being felt by closing the window of opportunity duringwhich an active failure may be committed. For example, consider the case of amechanic who assembled a component incorrectly which eventually led to a plane crashdays or even weeks later. The defenses that should have normally caught this mistakewere not in place. These defenses include proper training (the mechanic was taught to fixthis particular component very informally and on-the-job), good situational awareness(the mechanic was tired from a double shift the night before), and independent inspection(the job was “pencil-whipped” to save time.)(3)Active failures are usually the result of actions taken (or not taken) by front-line operators such as pilots, air traffic controllers, or anyone else with direct access tothe dynamics of a system. Latent failures, on the other hand, are caused by thoseseparated by time and space from the consequences of their actions in the dynamics ofthe system. Personnel working in vocations such as architectural design, hardwaredesign and equipment maintenance are more prone to cause latent failures than activefailures. | ||
AC 120-729/28/00Par 8Page 8(4)Both active and latent failures may interact to create a window for accidentsto occur. Latent failures set the stage for the accident while active failures tend to be thecatalyst for the accident to finally occur. A good way to think of this model of accidentcreation is as slices of Swiss cheese. Each slice can be thought of as a defense to anaccident (training, good management, teamwork, etc.) and each hole is a failure in thatdefense. The last slice is the final action which could serve as a defense before theaccident event. The failure in that defense would constitute the active failureprecipitating the accident. If the defenses to a situation contain a sufficient number offailures, which allow the holes to “line up,” an accident will occur.(5)Differences between active and latent failures cannot be over emphasized;each type of error helps to shape the type of training required to correct them. Forexample, because of the immediate demands and consequences of their actions, flightpersonnel require training that includes the psychomotor aspects of physical skills such asimproving reaction time in emergency training. The strict physical requirements foremployment as a flight officer demonstrate this emphasis clearly. On the other hand,maintenance personnel may require human factors and operations training to account fortheir susceptibility to latent failures. In addition, the range of physical activities ofmaintenance personnel on the job also requires emphasis on workplace ergonomics. Forexample, maintenance personnel may be asked to lift heavy objects, work in awkwardpositions, or perform tasks in extreme weather conditions. These difficult workconditions all require knowledge of ergonomics to ensure safe, error-free performance.Though CRM and MRM share the basic concepts of error prevention, the content of whatis taught is specific to what is actually performed on the job.d.Safety Culture.(1)Knowledge about complex systems alone only goes so far in mitigatinghuman error. To combat error, an organization must teach not just how error may beavoided, but also it must adopt attitudes that promote safety above all else. Variousresearchers call these attitudes an organization’s safety culture and identify top-levelorganizational support as the main predictor of a positive safety culture. Put briefly, inorder for an organization to create and perpetuate a positive safety culture, seniormanagement must take certain actions, such as:(a)Setting standards and expectations and providing resources to meet them.(b)Developing and enforcing standards that emphasize safe work practice.(c)Setting up meaningful incentive programs that reward safe and reliablebehavior either monetarily or through other means such as days off, or awards ofrecognition for a job well done.(2)An MRM training program provides personnel with the tools to assess andchange their own behaviors to work safer and reduce human error. Unlike other safety | AC 120-729/28/00Par 8Page 8(4)Both active and latent failures may interact to create a window for accidentsto occur. Latent failures set the stage for the accident while active failures tend to be thecatalyst for the accident to finally occur. A good way to think of this model of accidentcreation is as slices of Swiss cheese. Each slice can be thought of as a defense to anaccident (training, good management, teamwork, etc.) and each hole is a failure in thatdefense. The last slice is the final action which could serve as a defense before theaccident event. The failure in that defense would constitute the active failureprecipitating the accident. If the defenses to a situation contain a sufficient number offailures, which allow the holes to “line up,” an accident will occur.(5)Differences between active and latent failures cannot be over emphasized;each type of error helps to shape the type of training required to correct them. Forexample, because of the immediate demands and consequences of their actions, flightpersonnel require training that includes the psychomotor aspects of physical skills such asimproving reaction time in emergency training. The strict physical requirements foremployment as a flight officer demonstrate this emphasis clearly. On the other hand,maintenance personnel may require human factors and operations training to account fortheir susceptibility to latent failures. In addition, the range of physical activities ofmaintenance personnel on the job also requires emphasis on workplace ergonomics. Forexample, maintenance personnel may be asked to lift heavy objects, work in awkwardpositions, or perform tasks in extreme weather conditions. These difficult workconditions all require knowledge of ergonomics to ensure safe, error-free performance.Though CRM and MRM share the basic concepts of error prevention, the content of whatis taught is specific to what is actually performed on the job.d.Safety Culture.(1)Knowledge about complex systems alone only goes so far in mitigatinghuman error. To combat error, an organization must teach not just how error may beavoided, but also it must adopt attitudes that promote safety above all else. Variousresearchers call these attitudes an organization’s safety culture and identify top-levelorganizational support as the main predictor of a positive safety culture. Put briefly, inorder for an organization to create and perpetuate a positive safety culture, seniormanagement must take certain actions, such as:(a)Setting standards and expectations and providing resources to meet them.(b)Developing and enforcing standards that emphasize safe work practice.(c)Setting up meaningful incentive programs that reward safe and reliablebehavior either monetarily or through other means such as days off, or awards ofrecognition for a job well done.(2)An MRM training program provides personnel with the tools to assess andchange their own behaviors to work safer and reduce human error. Unlike other safety | ||
9/28/00AC 120-72Par 8Page 9programs, MRM is most effective when ALL employees are oriented toward a positivesafety culture. Therefore, employees of all levels (upper-level managers included) areencouraged to participate and are trained alongside maintenance personnel.(3)MRM trains personnel to use the resources of their positions to encouragesafe operations. For example, managers learn that a positive safety culture can only befostered if line employees are provided the necessary resources to do their jobs correctly.Line employees must be given the tools that teach them how to do their jobs withouterror. As an example, upper-level managers provide and control resources such as thenumber of aircraft serviced at one time, the selection of employees to do the work, andthe tools with which to perform the necessary tasks. Safety itself, however, is rooted inthe actual behaviors of maintenance personnel in the hanger (or on the line). MRMtraining teaches employees what behaviors are best to use. MRM training also helpsmanagers understand how their own choices affect which behaviors are ultimately used .In this way, the entire organization becomes oriented towards safe, error-freeperformance.9.MRM CONCEPTS.a.Though MRM includes more than training, training is the foundation uponwhich the program is built. MRM training teaches maintenance personnel specificconcepts, both theoretical and applied. Management commitment to a positive safetyculture allows maintenance personnel to put into practice the concepts they learn. Thissection presents and defines MRM concepts in terms of the maintenance environment. Inaddition, supplemental information on each implementation of a skill is also provided asa sample of the content of an MRM training program.b.This section and Appendix 1, the sample training course, were written withrelatively large maintenance and repair stations in mind; some of the large working grouppractices may not apply in small stations.c.Those people familiar with CRM training will see similarities with the skillstaught in MRM training. These similarities lie mostly in the broad areas of resourcemanagement such as communication, team building, workload management, andsituational awareness. However, MRM is tailored to fit the unique demands of themaintenance community; its content specifically addresses their problems. The followingsections discuss briefly each of the components of MRM.d.Human Factors knowledge.(1)Understanding the maintenance operation as a system. An understandingof the systemic nature of the maintenance operation is vital to understanding how one’sindividual actions affect the whole organization. A person who understands the bigpicture is more apt to think things through before acting. | 9/28/00AC 120-72Par 8Page 9programs, MRM is most effective when ALL employees are oriented toward a positivesafety culture. Therefore, employees of all levels (upper-level managers included) areencouraged to participate and are trained alongside maintenance personnel.(3)MRM trains personnel to use the resources of their positions to encouragesafe operations. For example, managers learn that a positive safety culture can only befostered if line employees are provided the necessary resources to do their jobs correctly.Line employees must be given the tools that teach them how to do their jobs withouterror. As an example, upper-level managers provide and control resources such as thenumber of aircraft serviced at one time, the selection of employees to do the work, andthe tools with which to perform the necessary tasks. Safety itself, however, is rooted inthe actual behaviors of maintenance personnel in the hanger (or on the line). MRMtraining teaches employees what behaviors are best to use. MRM training also helpsmanagers understand how their own choices affect which behaviors are ultimately used .In this way, the entire organization becomes oriented towards safe, error-freeperformance.9.MRM CONCEPTS.a.Though MRM includes more than training, training is the foundation uponwhich the program is built. MRM training teaches maintenance personnel specificconcepts, both theoretical and applied. Management commitment to a positive safetyculture allows maintenance personnel to put into practice the concepts they learn. Thissection presents and defines MRM concepts in terms of the maintenance environment. Inaddition, supplemental information on each implementation of a skill is also provided asa sample of the content of an MRM training program.b.This section and Appendix 1, the sample training course, were written withrelatively large maintenance and repair stations in mind; some of the large working grouppractices may not apply in small stations.c.Those people familiar with CRM training will see similarities with the skillstaught in MRM training. These similarities lie mostly in the broad areas of resourcemanagement such as communication, team building, workload management, andsituational awareness. However, MRM is tailored to fit the unique demands of themaintenance community; its content specifically addresses their problems. The followingsections discuss briefly each of the components of MRM.d.Human Factors knowledge.(1)Understanding the maintenance operation as a system. An understandingof the systemic nature of the maintenance operation is vital to understanding how one’sindividual actions affect the whole organization. A person who understands the bigpicture is more apt to think things through before acting. | ||
AC 120-729/28/00Par 9Page 10(2)Identifying and understanding basic Human Factors issues. BasicHuman Factors concepts are also taught in the course of MRM training. These conceptstypically include human perception and cognition, workplace and task design, groupbehavior (norms), and ergonomics. However, this list is far from exhaustive and theconcepts taught should be tailored to meet the needs of each particular audience.(3)Recognizing contributing causes to human errors. A basic primer onhuman error is a key component to MRM training. By understanding the interactionbetween organizational, work group, and individual factors that may lead to errors andaccidents, maintenance personnel can learn to prevent or manage them proactively in thefuture. Reason’s model provides a good foundation for human error theory; however,many other models of human error exist, such as the “Dirty Dozen” scenarios. These canalso be adapted for use in MRM training.e.Communication Skills.(1) Communication remains the backbone of both CRM and MRM, but specificaspects of communication are different in each work environment. Mechanics, crewleads, supervisors, and inspectors all must have the knowledge and skills to communicateeffectively. A lack of proper communication can have any or all of the followingundesired consequences:(a)The quality of work and performance may be reduced.(b)Time and money may be lost as errors occur because importantinformation is not communicated or messages are misinterpreted.(c)Improper communication may cause frustration and high levels of stress.(2) People communicate in many different ways, however this AC, will considerthree broad forms of communication:(a)Verbal communication, which relates to the spoken word, whether faceto face or through some electronic medium such as a phone, radio, loud speaker, etc.(b)Non-verbal communication, commonly referred to as “body language.”Whether you wave, smile, or wink, you are communicating a message to otherindividuals.(c)Written or asynchronous communciation which includes everything thatis memorialized in writing or in electronic form, such as publications, letters, forms,signs, e-mail, etc.(3) Most people associate communication with verbal communication. Formaintenance personnel, communication encompasses much more than inter-team verbalinteraction. Communication not only includes face-to-face interaction, but also | AC 120-729/28/00Par 9Page 10(2)Identifying and understanding basic Human Factors issues. BasicHuman Factors concepts are also taught in the course of MRM training. These conceptstypically include human perception and cognition, workplace and task design, groupbehavior (norms), and ergonomics. However, this list is far from exhaustive and theconcepts taught should be tailored to meet the needs of each particular audience.(3)Recognizing contributing causes to human errors. A basic primer onhuman error is a key component to MRM training. By understanding the interactionbetween organizational, work group, and individual factors that may lead to errors andaccidents, maintenance personnel can learn to prevent or manage them proactively in thefuture. Reason’s model provides a good foundation for human error theory; however,many other models of human error exist, such as the “Dirty Dozen” scenarios. These canalso be adapted for use in MRM training.e.Communication Skills.(1) Communication remains the backbone of both CRM and MRM, but specificaspects of communication are different in each work environment. Mechanics, crewleads, supervisors, and inspectors all must have the knowledge and skills to communicateeffectively. A lack of proper communication can have any or all of the followingundesired consequences:(a)The quality of work and performance may be reduced.(b)Time and money may be lost as errors occur because importantinformation is not communicated or messages are misinterpreted.(c)Improper communication may cause frustration and high levels of stress.(2) People communicate in many different ways, however this AC, will considerthree broad forms of communication:(a)Verbal communication, which relates to the spoken word, whether faceto face or through some electronic medium such as a phone, radio, loud speaker, etc.(b)Non-verbal communication, commonly referred to as “body language.”Whether you wave, smile, or wink, you are communicating a message to otherindividuals.(c)Written or asynchronous communciation which includes everything thatis memorialized in writing or in electronic form, such as publications, letters, forms,signs, e-mail, etc.(3) Most people associate communication with verbal communication. Formaintenance personnel, communication encompasses much more than inter-team verbalinteraction. Communication not only includes face-to-face interaction, but also | ||
Revision as of 12:46, 13 October 2019
Vaughn College AAM490 (hereinafter, the Course) is the maintenance resource management course delivered by Vaughn College of Aeronautics and Technology (hereinafter, the College). ENG110 is the prerequisite to the Course.
Contents
Description
The aviation maintenance technician's work environment encompasses a wide variety of tasks. MRM will be used to enhance the safety culture of an aviation organization by encouraging a profound awareness of safety issues. Safety program failure is indicated by occupational injuries, ground damage, accidents, incidents, decreased reliability and airworthiness.
Course objectives
- Students will learn the objective of the Human Factors Dirty Dozen and the results of the chain reaction effect dealing with human factors. The students will also understand the relation of human factors related to the everyday operations in aviation. Students will also have an understanding of how a maintenance organization is composed of, the difficulties and the handling of daily maintenance non-routine issues and how scheduled maintenance is accomplished and maintained.
- This will help the students to fulfill the concept of Maintenance Resource Management.
Course outcomes
- Students will have a good understanding of how maintenance management works, the fundamentals in building a successful maintenance organization and its relation to human factors. Students will work together to develop there skills in managing an overnight workload and the handling of multiple aircraft at one time. They will also have grasp the concept of scheduling work and the effect when the scheduling is disrupted and what is required to get back on track. This class environment will aid the students when applying to companies that handle aviation maintenance as they will have the knowledge on how the system works and its applications to the maintenance environment. This knowledge will excel their chances for advancement in the industry.
Course requirements
- Student must follow the online course attendance policy in order to receive attendance credit for the week. 30 different sign-in application (2 per week) is the requirement.
- Assignments: As directed by the instructor on a weekly basis with a written essay response for each assignment. Fourteen assignments over the fifteen week course.
- Four tests including mid-term and the final. Quizzes added at the instructors discretion.
Required text(s)
- Aviation maintenance management Second Edition Harry A. Kinnison
- Aircraft Gas Turbine Engine Technology Third Edition by Irwine Treager
- Human Factors in Aviation, Second Edition Eduardo Salas (Editor), Dan Maurino (Editor)
Required materials
- Textbooks, pen, notebook, colored highlighter pens. No additional materials required unless specified by the instructor or directed by the weekly assignments.
Grading policy
Area Percentage Assignment 40% Tests 40% Attendance weekly 20% Total 100%
Late work policy
- If a student turns in an assignment following the scheduled due date, the student will receive minimal feedback and a lower grade. Assignments turned in late will be assessed with a grade penalty. Late work will not be accepted if overdue by more than seven days.
Academic honesty
- The College is committed to ensuring quality and integrity in all its academic and evaluative activities. A learning environment that promotes high academic standards is beneficial to students and faculty alike. Academic dishonesty such as cheating and plagiarism is in opposition to the values and mission of the institution and will not be tolerated.
Disability support services
- It is the policy and practice of the College to promote inclusive learning environments. If you have a documented disability, you may be eligible for reasonable accommodations in compliance with the College policy, the Americans with Disabilities Act, and/ or Section 504 of the Rehabilitation Act. Please note, students should not negotiate accommodations directly with professors; however, professors may assist students in providing information about the self- identification process and the College-based services.
Absences and lateness
- Regular attendance is essential for satisfactory academic performance. Institutional policy mandates students missing more than three classes are subject to an overall grade decrease. Students are also advised that additional attendance requirements may be mandated depending on the faculty member and/ or the department from which a particular course is taken. The final grade in any subject may be reduced in proportion to the number of unexcused absences.
Discrimination and harassment
- The College does not discriminate on the basis of age, race, color, creed, religion, national origin, citizenship status, gender, sexual orientation, marital status, disability, or status as a military veteran, or for any other category recognized by local, state or federal law. In the programs, activities, and services offered, including but not limited to admissions, recognition of performance, and achievement, which the College provides to students, staff, and applicants, it continually strives to maintain a nondiscriminatory environment.
Course schedule
The course schedule established for this semester is a guide. The schedule is subject to change and will vary accordingly. After the 15 module schedule all required material will be covered and reviewed for the final exam.
Introduction to MRM
BACKGROUND.a.Though crew resource management (CRM) on the flight deck is a topic of regulardiscussion, relatively little attention has been paid to its maintenance-related counterpart,maintenance resource management (MRM). Indeed, this inattentiveness isunderstandable. Whereas a pilot or pilots’ errors can have immediate and highly visibleeffects, the same can not necessarily be said of a maintenance-based error. Because ofthis, aviation research into team activities first grew from investigations into aircrewbehaviors. This evolution is apparent whenever encountering references to crew resourcemanagement.b.The aviation community has expanded its approach to reducing human error.Human factors programs now encompass not just the flight crew, but all aspects ofaviation in which a human may be involved. This activity includes such areas as aircraftdesign and operation, air traffic control, and, of course, aircraft maintenance.7.OBJECTIVES.a.This AC provides background information on Maintenance ResourceManagement. Maintenance Resource Management (MRM) is a general process forimproving communication, effectiveness and safety in aircraft maintenance operations.Attention will be given specifically to the implementation and evaluation of MRMtraining. Much as crew resource management (CRM) was created to address safety andteamwork issues in the cockpit, the Federal Aviation Administration (FAA), inconjunction with industry partners, developed MRM to address teamwork deficiencieswithin the aviation maintenance environment.b.MRM is a team-based safety behavior. It teaches managers and maintenancepersonnel skills that enable them to work safely in a complex system. MRM teachesmore than just team skills; it teaches and reinforces an organizational philosophy inwhich all members of the organization are oriented toward error-free performance. Thisis accomplished by teaching:(1) How the effects of individual actions ripple throughout organizations,(2) How to utilize available resources safely and effectively, and(3)How to propagate a positive culture of safety in the organizations throughspecific, individual actions.c.The overall goal of MRM is to integrate the technical skills of maintenancepersonnel with interpersonal skills and basic human factors knowledge in order toimprove communication effectiveness and safety in aircraft maintenance operations. 9/28/00AC 120-72Par 8Page 78.PHILOSOPHY OF MRM.a.The philosophy of MRM is based on the philosophy of CRM with emphasis onhow maintenance operations differ from flight operations. The work environment ofmaintenance personnel encompasses a great variety of tasks in varied settings with agreat number of people. Because the tasks and work differ from one domain to the other,the basic plan for addressing concepts like human error, teamwork, and safety also differ.b.This section outlines similarities and differences between MRM and CRM, inorder to characterize the philosophy of MRM. First, human error in both the flight andmaintenance environment is explored in more detail as a foundation upon which to buildthe discussion of an organization’s safety culture. The section that follows investigatesthe concept of a safety culture more thoroughly. The promulgation of a good, pervasivesafety culture is at the core of MRM’s basic philosophy.c.Human error.(1)The way to understand MRM is to explore the nature of errors inmaintenance operations. A widely accepted model of human error is the classification ofunsafe acts developed by J.T. Reason. This classification distinguishes between twotypes of errors:(a)Active failures, whose effects are felt immediately in a system, and(b)Latent failures, whose effects may lie dormant until triggered later,usually by other mitigating factors.(2)The presence of defenses or safeguards in a system can usually prevent theeffects of latent failures from being felt by closing the window of opportunity duringwhich an active failure may be committed. For example, consider the case of amechanic who assembled a component incorrectly which eventually led to a plane crashdays or even weeks later. The defenses that should have normally caught this mistakewere not in place. These defenses include proper training (the mechanic was taught to fixthis particular component very informally and on-the-job), good situational awareness(the mechanic was tired from a double shift the night before), and independent inspection(the job was “pencil-whipped” to save time.)(3)Active failures are usually the result of actions taken (or not taken) by front-line operators such as pilots, air traffic controllers, or anyone else with direct access tothe dynamics of a system. Latent failures, on the other hand, are caused by thoseseparated by time and space from the consequences of their actions in the dynamics ofthe system. Personnel working in vocations such as architectural design, hardwaredesign and equipment maintenance are more prone to cause latent failures than activefailures. AC 120-729/28/00Par 8Page 8(4)Both active and latent failures may interact to create a window for accidentsto occur. Latent failures set the stage for the accident while active failures tend to be thecatalyst for the accident to finally occur. A good way to think of this model of accidentcreation is as slices of Swiss cheese. Each slice can be thought of as a defense to anaccident (training, good management, teamwork, etc.) and each hole is a failure in thatdefense. The last slice is the final action which could serve as a defense before theaccident event. The failure in that defense would constitute the active failureprecipitating the accident. If the defenses to a situation contain a sufficient number offailures, which allow the holes to “line up,” an accident will occur.(5)Differences between active and latent failures cannot be over emphasized;each type of error helps to shape the type of training required to correct them. Forexample, because of the immediate demands and consequences of their actions, flightpersonnel require training that includes the psychomotor aspects of physical skills such asimproving reaction time in emergency training. The strict physical requirements foremployment as a flight officer demonstrate this emphasis clearly. On the other hand,maintenance personnel may require human factors and operations training to account fortheir susceptibility to latent failures. In addition, the range of physical activities ofmaintenance personnel on the job also requires emphasis on workplace ergonomics. Forexample, maintenance personnel may be asked to lift heavy objects, work in awkwardpositions, or perform tasks in extreme weather conditions. These difficult workconditions all require knowledge of ergonomics to ensure safe, error-free performance.Though CRM and MRM share the basic concepts of error prevention, the content of whatis taught is specific to what is actually performed on the job.d.Safety Culture.(1)Knowledge about complex systems alone only goes so far in mitigatinghuman error. To combat error, an organization must teach not just how error may beavoided, but also it must adopt attitudes that promote safety above all else. Variousresearchers call these attitudes an organization’s safety culture and identify top-levelorganizational support as the main predictor of a positive safety culture. Put briefly, inorder for an organization to create and perpetuate a positive safety culture, seniormanagement must take certain actions, such as:(a)Setting standards and expectations and providing resources to meet them.(b)Developing and enforcing standards that emphasize safe work practice.(c)Setting up meaningful incentive programs that reward safe and reliablebehavior either monetarily or through other means such as days off, or awards ofrecognition for a job well done.(2)An MRM training program provides personnel with the tools to assess andchange their own behaviors to work safer and reduce human error. Unlike other safety 9/28/00AC 120-72Par 8Page 9programs, MRM is most effective when ALL employees are oriented toward a positivesafety culture. Therefore, employees of all levels (upper-level managers included) areencouraged to participate and are trained alongside maintenance personnel.(3)MRM trains personnel to use the resources of their positions to encouragesafe operations. For example, managers learn that a positive safety culture can only befostered if line employees are provided the necessary resources to do their jobs correctly.Line employees must be given the tools that teach them how to do their jobs withouterror. As an example, upper-level managers provide and control resources such as thenumber of aircraft serviced at one time, the selection of employees to do the work, andthe tools with which to perform the necessary tasks. Safety itself, however, is rooted inthe actual behaviors of maintenance personnel in the hanger (or on the line). MRMtraining teaches employees what behaviors are best to use. MRM training also helpsmanagers understand how their own choices affect which behaviors are ultimately used .In this way, the entire organization becomes oriented towards safe, error-freeperformance.9.MRM CONCEPTS.a.Though MRM includes more than training, training is the foundation uponwhich the program is built. MRM training teaches maintenance personnel specificconcepts, both theoretical and applied. Management commitment to a positive safetyculture allows maintenance personnel to put into practice the concepts they learn. Thissection presents and defines MRM concepts in terms of the maintenance environment. Inaddition, supplemental information on each implementation of a skill is also provided asa sample of the content of an MRM training program.b.This section and Appendix 1, the sample training course, were written withrelatively large maintenance and repair stations in mind; some of the large working grouppractices may not apply in small stations.c.Those people familiar with CRM training will see similarities with the skillstaught in MRM training. These similarities lie mostly in the broad areas of resourcemanagement such as communication, team building, workload management, andsituational awareness. However, MRM is tailored to fit the unique demands of themaintenance community; its content specifically addresses their problems. The followingsections discuss briefly each of the components of MRM.d.Human Factors knowledge.(1)Understanding the maintenance operation as a system. An understandingof the systemic nature of the maintenance operation is vital to understanding how one’sindividual actions affect the whole organization. A person who understands the bigpicture is more apt to think things through before acting. AC 120-729/28/00Par 9Page 10(2)Identifying and understanding basic Human Factors issues. BasicHuman Factors concepts are also taught in the course of MRM training. These conceptstypically include human perception and cognition, workplace and task design, groupbehavior (norms), and ergonomics. However, this list is far from exhaustive and theconcepts taught should be tailored to meet the needs of each particular audience.(3)Recognizing contributing causes to human errors. A basic primer onhuman error is a key component to MRM training. By understanding the interactionbetween organizational, work group, and individual factors that may lead to errors andaccidents, maintenance personnel can learn to prevent or manage them proactively in thefuture. Reason’s model provides a good foundation for human error theory; however,many other models of human error exist, such as the “Dirty Dozen” scenarios. These canalso be adapted for use in MRM training.e.Communication Skills.(1) Communication remains the backbone of both CRM and MRM, but specificaspects of communication are different in each work environment. Mechanics, crewleads, supervisors, and inspectors all must have the knowledge and skills to communicateeffectively. A lack of proper communication can have any or all of the followingundesired consequences:(a)The quality of work and performance may be reduced.(b)Time and money may be lost as errors occur because importantinformation is not communicated or messages are misinterpreted.(c)Improper communication may cause frustration and high levels of stress.(2) People communicate in many different ways, however this AC, will considerthree broad forms of communication:(a)Verbal communication, which relates to the spoken word, whether faceto face or through some electronic medium such as a phone, radio, loud speaker, etc.(b)Non-verbal communication, commonly referred to as “body language.”Whether you wave, smile, or wink, you are communicating a message to otherindividuals.(c)Written or asynchronous communciation which includes everything thatis memorialized in writing or in electronic form, such as publications, letters, forms,signs, e-mail, etc.(3) Most people associate communication with verbal communication. Formaintenance personnel, communication encompasses much more than inter-team verbalinteraction. Communication not only includes face-to-face interaction, but also
