First that when we consider all the

First of all, as humans we all are not
perfect. We sometimes hear that the main cause of an accident was always a
“human error.”  After investigation, it may be found to be true.

At present most of the aviation related accidents and errors
are related to some way or some form of human caused error. It’s really
surprising the fact that when we consider all the time, money put into
management, research, training and modification of new technology such as
automation. Yes, the safety has improved a lot over the period of last 50 years
making air transport one of the safest way to people to travel around the
world. But still accident occur due to human error. For those interested
aviation safety, from trainers and pilot to managers and human factors
researchers, a better knowledge of what human error is and how it can clear
itself as an aviation accident is foundational. (Human error in aviation, 2107)

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The
assignment video given is a good example for Murphy’s Law ‘If anything can go wrong then it will go wrong. If there is a task that
can be performed incorrectly then someone will do it incorrectly’. In present era humans submit
unsystematic work for number of various reasons. For example, they might feel hurry for time due to delay or poor
time scheduling, or they might not understand the importance of checking their
work again and again. They might cut corners while doing the task in order to
complete the job or they have low intention and not care about the quality of
the job. Carless job might also indicate that someone doesn’t like to the
particular work or that they have withdrawn from their job (mindtools.com,
2017)

 

In
this video the aircraft technician was given a task to check the right governor
of the aircraft during the night of Christmas and the aircraft should be in a
serviceable condition for next day flight. Due to work pressure and limited
amount of time given by company to complete the task, insufficient detail
regarding the problem, fatigue, stress and unavailability of stock for the job.
The aircraft technician was unable to perform a successful job and lead to
dismissal by the company. From the information given in the video let’s see
what are the errors when we are talking about errors I personally think the
technician should not be the one to be blamed alone the company also to be
blamed for the incorrect job performed by the technician and also the corrective
measures or the procedure should have followed to prevent the dismissal of the
aircraft technician.

 

THE ERRORS AND CORRECTIVE ACTIONS

·      POOR COMMUNICATION 

Communication
in aviation is been suggested an important issue in all aspects of how human
interact, which also reported to be the crucial element contributing toward
aviation accidents. Communication is one of the most important element for
organization and managerial performance and success in any endeavor, including
aviation surrounding. In order for decision maker to come to perfect and
accurate decision from a set of alternative decision, correct and legit
information is a must and this is the importance of communication, which
requires attention from aviation management to initiate and practice the best
way to reduce communication related problems within aviation industry. Verbal
communication is an important way of communicating within the aviation operational
context, between pilots and ATC, operational and managerial personnel. Being
able to communicate effectively without any errors will help to the reduce aviation
related accidents. Verbal communications is one the biggest media for
communicating within the aviation operational context, and needs to be improved
along the practical drift for all workers in aviation environment. The video
given shows an example of poor communication between the pilot and the director
of maintenance, pilot calls the director of maintenance to report a problem
occurred during flight but the DOM refuses to listen to the complete
information regarding the problem. In my point of view the director of
maintenance should have listen to the entire problem before appointing an aircraft
technician to perform the task.

·      CARELESSNESS

Is the one of the major error caused by the human’s which
leads to dangerous accidents in aviation industry. When the aircraft technician
asked about the aircraft, the dispatch room was unable to inform regarding the
fact that aircraft was delayed to the technician earlier. Due to the carelessness act performed by
the dispatch room resulted the technician stress level increases higher
regarding the maintenance task that was due to be completed. If the aircraft is
running late for any reasons
it is the duty of dispatch room to inform the aircraft technician
about the issue, so that it can ease the stress level on technician. Aviation maintenance can be a very stressful task due to so any factors.  Aircraft should be in a serviceable condition
in order for airlines to make money, which means that maintenance task should
be completed within a very tight time period to avoid flights getting delayed
and cancellations. As humans everyone handles stress in a different manner and
particular situations can bring about different kinds of difficulty for
different people For example, working under a short time period can be a
stressor for one person and normal for another person.

·      NOT FOLLOWING THE CORRECT PROCEDURE

As a part of aviation policies and procedures are
essential to follow. Both policies and procedures gives a road map for every
single aviation operations. They ensure passivity with regulation and laws,
gives information for making decision, and smooth internal process. However
policy and procedures won’t do any good for the organization if the workers or
technician don’t follow them, usually employees doesn’t like the idea of always
following the rules. But policy implementation is not just a matter of randomly
forcing employees to do things that they don’t like to do. For employees and
organization it’s a good practice to follow policies and procedure so that we
can reduce the chances of getting an error. While the technician was performing
the maintenance task the most important thing he failed to implement, was to
follow the correct procedure from the aircraft maintenance manuals during
troubleshooting the right governor of the aircraft. Aircraft maintenance
manuals are the fixed or formal documents which details the way in which all
maintenance tasks carried out on an aircraft shall be completed. This includes items
such as functional checks, lubrication system, avionics, and servicing of the
airplane but usually excludes modification and structural repairs. In short
words it is the Wikipedia for an aircraft maintenance engineer. All the
procedures for the desired maintenance tasks are given in maintenance manual.
According to my point of view what the technician did was unacceptable, it can
be any maintenance task for example changing a bolt or opening a cowling it’s
always better to follow the maintenance manuals instruction to avoid the
chances of getting a mistake while performing the job.

·      LACK OF RESOURSES 

In order to complete a maintenance task, necessary stocks or
spare should be available. Any shortage of resources can disrupt the person’s
ability to complete a task, Poor quality products also effect one’s capability.
To accomplish a task aviation maintenance requires proper parts and tools to
maintain an aircraft organization any shortage of resources has a huge effect
on maintenance task it can cause both fatal and non-fatal accidents. For
example, if an aircraft is dispatched without a serviceable system that is
normally not needed for flight but suddenly becomes important, this could
create a problem. Parts are not the only resources needed to do a task
properly, but all too common parts become a critical issue. During the aircraft
technician was carrying out the maintenance task on right governor he was
unable to access the special tools for the relevant job. Within the
organization always make sure that the technician or the one who carrying out
the maintenance have the correct tools for the job is just as important as
having the correct parts when they are needed. The right tools for the relevant
job needed to be used at all the times and if they are broken, out of
calibration or missing they should be fixed and in a serviceable condition to
use.

                              

 

 

 

 

 

 

 

 

 

The above figure shows a damaged gasket from the right
governor where the technician was unable to replace it due to lack of stocks in
the stores. If the parts are unavailable for the task he should have informed
the store manager, but without informing he used the same old gasket in order
to complete his job before the deadline given by the organization and also the
technician was unable to carry out a test run after completing the maintenance
task on the governor. When the proper parts are available for the job there is a
much higher chance of that maintenance will do a better, more effective job, a
higher chances of that the job will be done correctly at the first time. The
most important thing before carrying out a job try to be enthusiastic by
checking suspected areas or task that may require parts at the beginning of the
inspection and always do a test run after completing the job so that we can
make sure a successful task was carried out or required further maintenance.
Finally the responsibility of aircraft technician is always about the safety of
passenger, crew and the aircraft a small error could lead to a catastrophic
disaster.

·     
DISTRACTION

A single distraction on a maintenance
task may disrupt the entire procedure, most importantly during the technician
performing the task. When the job continuous it is possible that details which
needs attention can be missed by the technician. Distraction causes 15 percent
of maintenance related error. In nature distraction can be physical or mental,
they can normally appear if the work is either in Hager or aircraft, they can
also occur in the individuality of the technician independent of the work
surrounding, less noticeable is the family issues or financial difficulties or
other personal issues that may distract technician state of mind as work is
performed and Less effective performances on the required maintenance job. The
distraction normally effect human skills or capability by causing us to avoid
correct procedure steps forgot to complete the relevant job and use short cut
methods to complete the task. In this scenario the maintenance task was given
to the aircraft technician at the night of Christmas. At first he was forced to
do the job by the director of maintenance, after the aircraft got delayed the
technician losses all his interest for the task. While performing job the
technician was not fully focused on his work, omitted most of the important
procedures, was unable to do double check and always in a rush to complete the
task and get back to his family as quick as possible. What should have done to
prevent this, firstly when the maintenance was given to the technician should
have appointed another technician for the same job so that it can ease the work
pressure on Joe. The technician should always notice when concentration to a
job at hand is missed and make that work continuous accordingly. A good
practice is that to go back three steps in the job instructions when a person
is distracted and continuous the task from that point. Use an accurate step by
step checklist and signing off each and every checked, completed task also
helps.

 

The
final outcome was that the technician was dismissed by the company for the low
standard performance on the right governor of the aircraft. According to me the
dismissal of technician was a good action taken by the company even though the
company also should take part of his low quality maintenance work. But when it
comes to maintenance it’s the responsible of the technician for ensuring an aircraft
operates safely and properly, if something goes wrong during flight not only
money the company losses also passengers and crew, as well as the reputation of
the organization. If a task was appointed to a technician he should be focus on
completing the task successfully leaving all the distraction behind. A
maintenance task can be complex but if we follow the correct procedure and
relevant step there will be no room for error, as seen in the video the
technician didn’t follow the maintenance manual for the entire task which is
not a good practice for an aircraft engineer. While carrying out the
maintenance the technician used incorrect tools, incorrect installation of
parts used worn or deteriorated parts, unable to do a test run after completing
the work and cut corners to complete the task early these action are not simply
errors these are called violations. Taking into consideration of all the points
I described earlier the dismissal of the AME was a correct action taken by the
company so that in future these types of careless and unacceptable work can be
minimized