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Aviation MX

SEPTEMBER 2017

Vol 5, Issue 3

HUMAN FACTORS

About the Authors

Dr. William Johnson is the FAA Chief Scientic and Technical Advisor

for Human Factors in Aircraft Maintenance Systems. His comments

are based on nearly 50 years of combined experience as a pilot,

mechanic, airline engineering and MRO consultant, professor, and

FAA scientic executive.

Marc Szepan is a Lecturer in International Business at the University of

Oxford Saïd Business School, Oxford, United Kingdom, where he also

completed the doctoral program in management studies. Previously,

Marc’s primary professional experience has been in leading technical

and digital aviation businesses in Europe, Asia, and the U.S. Most

recently, he served as Senior Vice President, Airline Operations

Solutions, at Lufthansa Systems, the IT services business segment

of Lufthansa Group. He led a multi-business unit ight operations

support business that served a global airline customer base. He

also held leadership roles at Lufthansa Technik, the MRO business

segment of Lufthansa Group, and for two other German industrial

companies. In 2012, Marc was recognized as one of Aviation Week &

Space Technology’s “40 Under Forty: Rising Stars of Aerospace and

Aviation”. He holds previous graduate degrees from Harvard and

Duke

Dr. William Johnson

Marc Szepan

Comparing Aircraft Maintenance

for Patient Safety during Major

Repair and Replacement*

Introduction

This article started when Dr. Bill Johnson (aka. Dr. Bill) was discussing his upcoming

total hip replacement surgery (i.e. “major repair and replacement”) with Marc Szepan, a

former Lufthansa senior executive and now a Lecturer at the University of Oxford Saïd

Business School. We talked about the surgery and realized that there might be similarities

between performing “surgery” on Dr. Bill and on aging aircraft. Even more importantly,

from Bill’s point of view, there surely could be similarities in terms of what one would

expect from a repair station and a hospital. So, we discussed the characteristics of an

aviation maintenance service provider and a medical service provider that would be

most desirable to complete respective services in an efficient, effective, and safe manner.

Yes, even though the prospect of undergoing hip surgery was not all that pleasant, the

discussion itself was fun. The successful surgery is now over and we look back on the

pre-surgical considerations about patient safety during major repairs. Here is a short

summary …

Dr. Bill Johnson & Marc Szepan

Inside this issue

Table of Contents

COMPARING AIRCRAFT

MX FOR PATIENT SAFETY

DURING MAJOR REPAIR &

REPLACEMENT

by Dr. Bill Johnson & Marc

Szepan

4 MAINTENANCE HUMAN

FACTORS RECENT AND

UPCOMING EVENTS

QUARTERLY

Is A Repair Necessary?

First, there is the non-routine finding and the necessity to

undergo repair. Too many landing cycles or hard landings on an

aging airframe can result in the main landing gear attach fitting

(see Figure 1) not reaching its intended Original Equipment

Manufacturer (OEM) service life. Hopefully, any top-notch

maintenance, repair, and overhaul (MRO) facility detects such

damage, writes up a non-routine finding, and replaces the

damaged or worn attach fitting. In the case of human beings,

this sort of strain on the main landing gear system and its attach

fittings – i.e. the legs and hips – can occur as well. Dr. Bill was

fortunate that his doctor properly diagnosed failure of his right

hip prior to reaching its – for lack of a better term – “OEM design

life” and recommended to replace it as soon as reasonably

possible. As with an aircraft, Dr. Bill had to be scheduled for a

maintenance slot to accommodate the anticipated out-of-service

time for repair, recovery, and new component break-in.

Right Service Provider

In general, many maintenance facilities offer landing gear

services. It is very important to ask around to find the very best

maintenance provider. On the one hand, it is important to find

a MRO that is large enough to have top-notch hangars, shops,

and modern equipment. On the other hand, very busy large

maintenance providers may be more focused on major airframe

maintenance checks and structural repairs or full landing gear

overhauls. That may mean that a mere main gear attach fitting

replacement job may be squeezed in between the higher

revenue big item jobs. Dr. Bill wanted a well-known provider

that specializes in landing gear main attach fitting replacement

and that takes pride in performing this very procedure. Also,

his choice of service provider was influenced by prior family

experience with the repair facility (aka. hospital) and its good

track record. And repair facilities also value return and referral

customers.

Of course, Dr. Bill wanted to be able to perform an informal

on-site audit himself. Unfortunately, that is not always possible.

However, in our experience, nothing really beats walking around

the flight line, the hangar floor, and engineering offices just to

observe cleanliness, attitudes, and overall demeanor of people

and to get a feel for the facility. The fact that the hospital and

medical team welcomed patient safety questions before the

procedure was a good sign that they were on the right track. He

found the right place.

Right People and Right Team

Maintenance work is based on highly qualified and experienced

personnel, working together as a team and accomplishing

the job with the highest care and resulting quality. Individual

specialists must be properly trained and be current in their

respective areas of work. For an individual one-time customer, it

might not be feasible to check the credentials of all maintenance

staff and to verify the level of recurrent training across the entire

maintenance team. For MRO services one must rely on the

certification agency, like the FAA. For medical services one can

turn to a broad range of data sources for individual hospitals. For

example, Consumer Reports, U.S. News & World Report, the U.S.

Medicare website, along with numerous others provide data and,

in some cases, ratings pertaining to patient safety. We all know

that there is variance across different Part 145 maintenance

Continued from p. 1

Figure 1. The Main Gear Attach Fitting

facilities but the certification agency(ies) must ensure an

acceptable level of compliance to established standards. In the

same spirit, Dr. Bill selected medical professionals with the right

type of initial training (i.e. medical school), evidence of adequate

levels of recurrent training, and appropriate certifications.

Successful maintenance work is not just a function of the

excellence of an individual contributor but a true team sport.

Replacement of a landing gear main attach fitting can require

Airframe and Power Plant (A&P) mechanics to remove and

reinstall the landing gear, avionics mechanics to work on

disconnecting and reconnecting wiring, structural experts to

perform the replacement of the attach fitting itself, engineers

to develop or coordinate repair schemes in case of secondary

findings that are out of limit, tooling and logistics specialists

to ensure availability of spare parts, consumables, and tooling,

facility experts to keep the hangar and shops in good condition,

and – depending on an aircraft operator’s standards – pilots to

perform a post-maintenance test or verification flight. Similarly,

Dr. Bill did not judge the hospital of his choice by the quality and

reputation of the orthopedic surgeon alone. Instead, he made

sure to have a good feel for all other members of his surgical

team – anesthesiologists, nurses, facility managers, etc. – in their

own right and, above all, in terms of their team spirit.

Right Organizational Culture

Even the best people and the best team are likely to fail in

a maintenance organization that has the wrong culture. A

dedication to safety and to an appropriately configured safety

culture must be a shared and non-negotiable goal throughout

the entire organization. This safety culture must be lived daily

reality and priority, and not just be relegated to second fiddle.

Sometimes that is difficult to ascertain during a short on-site

visit. But it certainly is worthwhile trying to verify this and to look

for visible indications of a service provider’s safety culture. For

example, walk past bulletin boards and pay attention whether

safety-related matters are displayed prominently, are kept up-to-

date, and measure the right Key Performance Indicators (KPIs).

Ask about voluntary reporting systems. Ask how the organization

deals with honest errors. Ask if individual employees get

sufficient rest and if teams are adequately staffed for the tasks at

hand. And given Dr. Bill’s background, you will not be surprised

that he recommends inquiring about human factors training.

Sometimes even the marketing material talks about safety. That’s

worth looking for! Bill checked on all of this and only settled for a

hospital once he was reasonably sure that the hospital had

the same type of safety culture that he would expect from

a repair station to which he would entrust an airliner repair.

Right Facilities, Equipment, Procedures, and Parts

The best people and best team working in the best

organizational culture will struggle to produce high-quality

repairs if they are forced to work without being properly

resourced. If possible, check the facilities, the equipment,

and the tooling that are made available to MRO employees.

Good lighting, work stands for easy access, and cleanliness

are important. Consider tooling and equipment-related

procedures as well. Check specifics. For example, look into

tool control procedures. Do mechanics perform a toolbox

check upon completion of maintenance work? You don’t

want tools left behind inside the airframe after closing

up. And you certainly don’t want your doctor to leave

behind a scalpel or the like after closing your personal

“cowling”. In the case of Dr. Bill’s medical service provider,

an old fashioned television in the pre-operating prep room

did raise concern. However, his nurse commented that it

was the oldest device in the hospital except for a couple

of the other nurses and doctors. She said that all surgical

equipment was state-of-the-art and in calibration.

Regarding Standard Operating Procedures (SOPs), in

general, are working procedures clearly documented,

sound, and consistently applied? Dr. Bill observed that

his medical service provider was extremely diligent about

explaining the procedure. The hospital also demanded that

patients take a class, prior to the repair, to be sure that post-

surgery rehabilitation was accomplished properly.

Do employees have easy access to and perform

maintenance work in accordance with authorized and

up-to-date and controlled documentation such as Aircraft

Maintenance Manuals (AMMs) or Structural Repair Manuals

(SRMs)? Replacing the main attach fitting of a landing

gear is a complicated procedure. First, the gear must

be removed from the airframe (see Figure 1). Then the

main attach fitting must be replaced. In case of finding

secondary corrosion, that must be removed. The gear must

be mechanically reinstalled and all electrical and hydraulic

lines must be reconnected. Hip replacement is similarly

complicated (see Figure 2). You want your surgeon to work

in accordance with proper procedures. You surely don’t

want your surgeon to – no pun intended – just “wing it”.

When undergoing parts replacement – i.e. a new hip – you

want to make sure that the replacement part itself is of

acceptable quality. Both in the case of “surgery” on human

beings and on aircraft you want to beware of Suspected

Unapproved Parts (SUPs). Ask about the procedures your

maintenance provider – i.e. hospital – has in place to

control the risk of SUPs. Ask about procedures designed to

ensure that consumables have not expired.

Dr. Bill looked into all of this before feeling at ease with his

choice of hospital!

Aircraft Maintenance vs. Medicine

As aviation safety professionals, we all appreciate the

direct comparison between aircraft maintenance and

surgery. Our maintenance processes, particularly our

Continued from p. 2

Safety Management Systems, ensure continuing safety

worldwide. Our industry strives to identify hazards thus

seizing every opportunity to manage safety.

Especially before his surgery, Bill did not want to ponder

medical patient safety statistics. They are not positively

impressive. While the worldwide commercial airline total

accident fatality rate has been about 500 lives lost per year

during the past ten years, a recent study suggests more

than 250,000 deaths per year due to medical error in the U.S.

alone; that is, a rate more than 500 times as high! The good

news is that medical professionals and hospitals are seeking

advice from aviation safety risk experts. Some aviation

safety consultancies have even reduced their aviation

workload in favor of medical patient safety consulting,

where the help is most certainly needed. Medical schools

are increasing their offerings related to patient safety as

well. Insurance companies have stepped up to incentivize

with lower rates for patient safety initiatives.

After having tried to do his homework of checking

on people and teams, the organizational culture, and

facilities, equipment, procedures, and parts at the hospital

of his choice, Dr. Bill was ready for his major repair and

replacement. His total hospital turn-around-time was less

than six hours and he was hobbling around by the end of

the day. He is looking forward to returning to walking and

running his favorite trails. Better yet, to doing more “walk-

arounds” at your MRO.

* This article is a slightly edited version of an article that

was published in the August-September 2017 issue of AMT

Magazine and is reprinted with the publisher’s permission.

Figure 2. Simplied Front View of Human Gear

Attachment Fitting

OPERATOR’S MANUAL: HUMAN

FACTORS IN AVIATION MAINTENANCE

(PDF LINK)

MAINTENANCE HUMAN FACTORS

RECENT AND UPCOMING EVENTS

Human Factors &

October 9-13, 2017

Ergonomics Society

Austin, TX

Conference

Dr. Michelle Bryant

Airlines4America MX

October 17, 2017

Safety Council Meeting

San Diego, CA

Dr. Michelle Bryant

Aviation Safety InfoShare

October 18-20, 2017

Dr. Michelle Bryant

San Diego, CA

Flight Safety Foundation

October 24-26, 2017

International Air Safety

Dublin, Ireland

Summit, Session Chair

https://ightsafety.org/

and Panelist on Fatigue

summit-seminar/iass-

Risk Management in MX

2017-home/program/

Dr. Bill Johnson

Royal Aeronautical

November 1-2. 2017

Society, Human Factors

London, England

in Aircraft MX, Lessons

https://www.aerosociety.

Learnt from Recent

com/events-calendar/

Accidents & Incidents -

human-factors-in-aircraft-

Summary Panelist

maintenance/

Dr. Bill Johnson

Talent Solutions Coalition

November 7-8, 2017

- Integrating Soft Skills

Indianapolis, IN

into Technical Training,

https://

Session Chair and Panelist

talentsolutionscoalition.

Dr. Bill Johnson

org/event/talent-

solutions-coalition-forum-

ii/

Boeing/A4A Safety

November 15-16, 2017

Conference on MX

Seal Beach, CA

Procedure Complexity

Dr. Bill Johnson &

Dr. Michelle Bryant

European Human Factors

November 28-29, 2017

Analytics Group, Group

Cologne, Germany

Member

Dr. Bill Johnson

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