Managing Human Error

in Maintenance
 Sandy Dunn
Director, Assetivity Pty Ltd
Booragoon, Western Australia

I
n their ground-breaking work that led to the establishment
of the technique that we now know as Reliability
Centred Maintenance, Nowlan and Heap found,
when analysing the failures of hundreds of mechanical,
structural and electrical components in aircraft, that these
Numerous research studies have
Abstract

failures exhibited six distinct patterns1 (see Figure 1)

shown that over fifty percent of
all equipment fails prematurely
after maintenance work has
been performed on it. In the
A D
most embarrassing cases, the of Failure 4% 7%
Conditional Probability

maintenance work performed Age

of Failure

Conditional Probability
was intended to prevent the very B 2% 14% E
failures that occurred. Building on
the latest academic research, and
C 5% 68% F
based on practical experience, this
paper outlines the key things that
maintenance managers can do to
Figure 1 Aircraft components: Patterns of failure
reduce or eliminate the impact of
human error in maintenance. The In the context of this paper the interesting finding
key points that will be covered was that more than two-thirds of all components
include: exhibited early-life failure. It was estimated that,
between 1982 and 1991, maintenance errors
 The inevitability of human
ranked second only to ‘controlled flight into terrain’
error - we ignore it at our peril; accidents in causing onboard aircraft fatalities
 The role of an optimum PM (despite the application of RCM techniques in the
programme in minimising the airline industry during that period)2. Furthermore,
impact of human error; a study of coal-fired power stations indicated that
56% of forced outages occurred less than a week
 The management of after a planned or maintenance shutdown3.
maintenance quality - an
essential element in the Other studies have been conducted which confirm
control of maintenance error; these findings, but until recent there has been little
 Writing effective maintenance research into the reasons for this. Several plausible
theories have been proposed; possible explanations
task instructions that minimise
that I have heard including –
the possibility of human error.

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Managing Human Error in Maintenance

 ‘Human Error’ – the repair or replace We can see from this that only one of these causes
task was not successfully completed due was unrelated to maintenance activities, and that
to a lack of knowledge or skill on the part such activities contributed to at least 80% of all
of the person performing the repair; IFSDs.
 ‘System Error’ – the equipment was
returned to service after a high-risk If poor quality maintenance causes so many
maintenance task without the repair having incidents in highly regulated and hazardous
been properly inspected and tested; industries such as nuclear power generation and
 ‘Design Error’ – the capability of the civil aviation, what proportion of failures is being
component being replaced was too close to caused by maintenance within your organisation?
the performance expected of it and lower
capability (lower quality) parts therefore failed What are the outcomes of maintenance-induced
during periods of high performance demand. failures? Clearly, depending on the industry in
The remaining higher capability (higher which you operate, there are potentially significant
quality) parts were capable of withstanding safety and environmental risks. There is a long list
all performance demands placed on them of catastrophic failures in which, the inadequate
performance of a maintenance task played a
 ‘Parts Error’ – the incorrect part or an
significant role. Some of these include –
inferior quality part was supplied.
 Flixborough
More recently, Reason has compiled a table
summarising the results of three surveys conducted  Three Mile Island
at nuclear power stations – two surveys performed  Piper Alpha
by the Institute of Nuclear Power Operations  American Airlines Flight 191
(INPO) in the USA, and one by the Central Research  Bhopal
Institute for the Electrical Power Industry (CRIEPI)
 Japan Airlines Flight 123
in Japan4. In all three studies more than half of all
identified performance problems were associated  Clapham Junction
with maintenance, calibration and testing activities.  etc. etc.
In comparison, on average only 16% of problems
occurred during operation under normal conditions.
But besides the obvious safety risks, perhaps the
Reason also quoted the results of a Boeing Study5 bigger consequences are economic. General Electric
which indicated that the top seven causes of in-flight has estimated that each in-flight engine shutdown
engine shutdowns (IFSDs) in Boeing aircraft were as costs airlines in the region of US$500,000. What
follows – could maintenance-induced failures be costing your
organisation?
 incomplete installation (33%)
 damaged on installation (14.5%) Clearly, we need to do something to reduce the
 improper installation (11%) number of equipment failures that are being caused,
 equipment not installed or missing (11%) not prevented, by maintenance. This paper suggests
 foreign object damage (6.5%) that the most appropriate approach is to –

 improper fault isolation, inspection, test (6%)  admit that human error is inevitable (even
 equipment not activated or deactivated (4%) in maintenance!) and design our systems
and processes around this inevitability;
 use appropriate tools to ensure that we are

maintenance & asset management • vol 20 no 4 19

Managing Human Error in Maintenance

not unnecessarily over-maintaining plant total available sensory data we receive.

and equipment (and therefore increasing - Unrelated matters can capture attention
the risk associated with the fact that this – such as preoccupation with other
work may not be performed correctly); sensory or emotional demands.
 work to improve the quality with which - Attentional focus (concentration) is hard to
maintenance activities are performed maintain for any longer than a few seconds.
– including error-proofing where possible.
- The ability to concentrate depends
strongly on the intrinsic capability of
HUMAN ERROR IS INEVITABLE the current object of attention
Traditionally, when it comes to eliminating - The more skilled or habitual our actions,
maintenance error most engineers tend to think the less attention they demand.
along two lines: either discipline, counsel and train - Correct performance requires the right balance
the personnel involved, or write a new procedure of attention, neither too much or too little.
or work instruction to make sure that it doesn’t  The vigilance decrement – it is more
happen again. Unfortunately, the recent work of common for inspectors to miss obvious faults
behavioural psychologists indicates that neither of the longer that they have been performing the
these approaches is likely to be successful. inspection. This is particularly the case when
the number of ‘hits’ is few and far between.
Work by Reason and Hobbs6 explains why
 The impact of fatigue – this could be due to –
maintenance activities can be particularly error-
provoking. In particular, it argues the futility of - time of day effects: our daily rhythms
trying to change the human condition, when a ensure that we are more likely to commit
more effective way of managing maintenance errors in the small hours of the morning;
errors is to treat them as a normal, expected, - stresses: physical, social, drugs, pace
and foreseeable aspect of maintenance work, of work, personal factors.
and therefore manage them by changing the  The level of arousal: too much or too
conditions under which that work is carried out. little impairs work performance.
 Biases in thinking and decision
Reason and Hobbs identified a number of
making. There is no such thing as ‘common
physiological and psychological factors which
sense’. In particular we are subject to –
contribute to the inevitability of human error.
These include – - confirmation bias, where we seek
information that confirms our initial (and
 Differences between the capabilities often incorrect) diagnosis of a problem.
of our long-term memory and our
- emotional decision making: if a situation
conscious workspace. In particular, what
keeps frustrating us, then we tend to
we call ‘attention’ is closely linked with the
move into ‘aggressive’ mode, but this
activities of the ‘conscious workspace’, which
often clouds our better judgement
has extremely limited capabilities, viz.
- Attention is an extremely limited As a result of these contributing factors, the types of
commodity – if it is drawn to one error that occur most often in maintenance include –
thing, then it is, by necessity, withdrawn  Recognition failures, viz.
from other competing concerns.
- Mis-identification of objects,
- These capacity limits draw attention signals and messages.
its selective properties – we can only
- Non-detection of problem states.
attend to a very small proportion of the

20 maintenance & asset management • vol 20 no 4

Managing Human Error in Maintenance

 Memory failures, viz. - Routine violations: committed in order to

- Input failure: insufficient attention is avoid unnecessary effort, to get the job done
paid to the ‘to-be-remembered’ item. quickly, to demonstrate skill, or avoid what is
seen as an unnecessarily laborious procedure.
This in turn can include –
- Thrill-seeking violations, often committed in
- losing our place in a series of actions;
order to avoid boredom or win peer praise.
- the ‘time-gap’ experience.
- Situational violations: those committed
- Storage failure: remembered material because it is not possible to get the job done
decays or suffers interference. Most if procedures are strictly adhered to.
common in maintenance is the problem of
forgetting the intention to do something. Think of your own situation; have you never
- Output failure: things we know cannot committed an error? For most of us, the
be recalled at the required time (the consequences of our past errors are relatively minor
‘what’s his name?’ experience). – but that is largely due to luck, and the situation that
we were in at the time. The traditional approach to
- Omissions following interruptions: we
dealing with human error, viz. counselling and/or
rejoin a sequence of actions having
writing a procedure, cannot possibly effectively deal
omitted certain required steps.
with all of the types of errors listed above. We need
- Premature exits: we terminate a job a more holistic approach for managing maintenance
before all the actions are complete error, and assuring maintenance quality.
 Skill-based slips: generally associated
with ‘automatic’ routines, can include –
- Branching errors, such as intending to drive to AVOID UNNECESSARY ‘PREVENTIVE’
the golf course on a weekend, but missing the MAINTENANCE
turnoff, and continuing on towards the office Given the statistics mentioned earlier from the
as you would every other day of the week. work of Nowlan and Heap and others it is clear that
over-maintaining equipment is not only a waste of
- Overshoot errors, intending to stop at the
time and money, but also increases the risk of safety
shops on the way home, but forgetting
and environmental incidents, as well as having the
and continuing home without stopping.
potential for causing expensive, and unnecessary
 Rule-based mistakes: most maintenance work failures. Techniques based on the application of
is highly proceduralised, and consists of many Reliability Centred Maintenance principles, such
‘rules’, which can be formally written or exist only as the PMO2000™ approach supported by my
in people’s heads. Typically they include – own company (under license from OMCS), are
- Misapplying a good rule: using a rule in an extremely effective way of weeding out this
a situation where it is not appropriate. unnecessary maintenance, and streamlining and
- Applying a bad rule: which may get the optimising equipment PM programmes.
job done in certain situations but can have
unwanted consequences. This is most common Our analysis of PM programmes in place at our
when people pick up others’ bad habits. clients has indicated that in almost all organisations
 Knowledge-based errors: generally occurring there is a huge amount of unnecessary routine
when someone is performing an unusual task maintenance being performed. In some situations,
for the first time. These need not necessarily fewer than 10% of the existing PM tasks were
be committed by inexperienced personnel. optimal, and it is not unusual for us to identify that
as much as half of the routine maintenance activities
 Violations: deliberate acts which
were a complete waste of time (see Figure 2). The
violate procedures, viz.

maintenance & asset management • vol 20 no 4 21

 Managing Human Error in Maintenance

starting point in eliminating unnecessary routine Step 5: Consequence evaluation

maintenance tasks lies in ensuring that the need for Each failure mode is analysed to determine the nature
every single task is defensibly justified – which is the of the consequences if it was to occur while the
objective of the nine step PMO2000™ process, and equipment was in service.
which is as follows.
Step 6: Maintenance policy
determination
A structured decision making process is
Only 7 % of Changes to Tasks used, using Reliability Centred Maintenance
previous Nearly half
maintenance of the (RCM) principles, to determine the preferred
was 7% maintenance task for each failure mode.
effective! was a waste
of time!
9% Step 7: Grouping and review
9%
Delete The most efficient and effective method for
Extend Interval
From HT to CM
grouping maintenance tasks, given local
49%
1% From Mech to Operations production factors and other constraints, is
New Task
Use As Is determined.
Total number of tasks = 458

Step 8: Approval and implementation

25%
Implementation is the step that is most time-
consuming and most likely to face difficulties.
Figure 2. Analysis of PM programmes in place
Step 9: Living programme
The PM programme is consolidated and the plant is
Step 1: Task compilation brought under control. We would strongly suggest
PM optimisation starts by collecting or documenting that, if you have not already done so, a critical review
the existing maintenance programme (formal of your PM programme, using such an approach, is an
or informal) and loading it into a database via essential first step to managing the impact of human
a spreadsheet. It is important to realise that error in maintenance.
maintenance is performed by a wide cross-section of
people including operators.

Step 2: Failure mode analysis (FMA) Operator

Computerised Condition
Involves people from the shop floor working in Rounds.
Maintenance Monitoring
cross-functional teams identifying what failure
Management Rounds.
modes each maintenance task (or inspection) is Systems.
meant to address.
Contractor Memory and
Step 3: Rationalisation and FMA review Schedules. Tradition
Grouping the data by failure mode and identifying
any task duplication. Additional failure modes are
added by reviewing failure history. Vendor
Lubrication
Maintenance Standard Rounds.
Step 4: Functional analysis (optional) Manuals. Operating
The functions associated with each failure mode Procedures
are identified.
Figure 3. Data sources for maintenance programme

22 maintenance & asset management • vol 20 no 4

Managing Human Error in Maintenance

MAINTENANCE QUALITY MANAGEMENT  Safety-significant errors can occur

– KEY PRINCIPLES at all levels in the system. Indeed, the
Following Reason and Hobbs6 the following are the higher in an organisation that an error is
principles that a maintenance quality management made, the more significant the consequences.
system must embrace –  Error management is all about managing
 Human error is both universal and the manageable. Situations are manageable,
inevitable. Human error is not a moral human nature, in its broadest sense, is not.
issue – making one is as much a part of
 Maintenance quality management is
human life as eating and breathing.
about making good people excellent.
 Errors are not intrinsically bad. Success Maintenance QM is not about making a
and failure spring from the same roots. We few error-prone people better – rather it is a
are error-guided creatures. Errors mark the way of making the larger proportion of well-
boundaries of the path to successful action. trained and motivated people excellent
 You cannot change the human condition,  There is no one best way. Different
but you can change the conditions in which maintenance QM methods will apply in different
humans work. There are two parts to an error, a situations, and in different organisations.
mental state and a situation. We have limited
 Effective maintenance quality
control over people’s mental states, but we can
management aims at continuous reform
control the situations in which they have to work.
rather than local fixes. The temptation is to
 The best people can make the worst resolve errors one at a time, as they arise, but
mistakes. No one is immune from error; if as errors tend to be systemic in nature, a more
only a few people were responsible for most appropriate method is to deal with human
of the errors, then the solution would be error systematically, and continuously.
simple, but some of the worst mistakes are
made by the most experienced people. There are a number of maintenance QM tools that
 People cannot easily avoid those can be applied. The exact combination of these that
actions they did not intend to commit. is most appropriate for any organisation varies, but
Blame and punishment are not appropriate they could include any of the following –
when people’s intentions were good, but their
actions did not go as planned. This does not  Person measures
mean, however, that people should not be Provide training in error-provoking factors.
accountable for their actions, and be given the Training maintenance personnel in order to give
opportunity to learn from their mistakes. them an understanding and awareness of the factors
 Errors are consequences, rather than and situations that may lead them to be more error-
causes. Errors are the product of a chain of prone is a starting point in successfully addressing
actions and conditions which involve people, human error. They should understand such factors
teams, tasks, workplace and organisational as: the limitations of human performance and
factors. Discovering a human error is the of short term memory; the impact of fatigue, of
beginning of the search for causes, not the end. interruptions, of pressure and stress; the types
 Many errors fall into recurrent patterns. of errors that they can make, and the situations
More than half of maintenance errors are in which these are most likely to arise. Once
recognised as having happened before, often many maintainers are aware of their own limitations, they
times. Targeting these recurrent errors is the most can start to detect the warning signals that indicate
effective way of addressing human error issues. a higher risk of an error being made, and can take
steps to avoid this.

maintenance & asset management • vol 20 no 4 23

Managing Human Error in Maintenance

Implement measures to reduce the number of  Workplace and task measures

deliberate violations. Traditional approaches to
the avoidance of violations tend to focus on scaring Ensure that personnel only perform tasks when
people into compliance. This may have its place, they are properly trained, skilled and qualified. It
but an additional, effective, approach is to create goes without saying that quality work practices can
a social environment within the workplace where only be put in place when maintenance personnel
deliberate violations bring disapproval from within have the requisite technical skills and capabilities
people’s peer groups. There are several approaches required to perform the work that is allocated to them.
that are being tried, both within and external to the
workplace, which appear to be successfully creating Fatigue management. Ensure that a well-designed
this social environment, but overnight success stories shift roster is in place which minimises the impact of
are rare. fatigue. Ensure also, that there are adequate controls
in place for managing overtime work
Encourage mental rehearsal of tasks before
they are performed. There is significant evidence Assign tasks appropriately. There is evidence to
to suggest that achieving the right degree of mental suggest that there is a link between the frequency
readiness for a task before it begins has a significant with which a task is performed, and the likelihood
positive impact on the quality and reliability with that the task will be performed correctly. Both
which this task is performed. This is based on infrequently performed, and very frequently
studies of surgeons and Olympic athletes7. performed tasks tend to be those at greatest risk
of human error. Infrequently performed tasks
Control distractions. Anticipating the distractions are generally more at risk because of the lack of
that are likely to occur, and developing a strategy experience of the person performing the task, while
for dealing with them is most likely to enhance the very frequently performed tasks fall victim to skill-
quality of task performance. based slips and lapses, as the person performing the
work operates on ‘auto-pilot’. Intelligent allocation
Avoid place-losing errors. Employing such of work to individuals takes this into account, and
techniques as inserting place-markers at appropriate can assist in minimising human error.
points in the procedure.
Ensure that equipment, and tasks, are properly
designed. In order to minimise the likelihood
 Team measures of error in performing maintenance tasks, the
Provide teamwork training. Significant accidents equipment should be designed for maintainability,
have occurred as a result of poorly functioning considering such factors as –
teams. Most notable of these was an aircraft accident - easy access to components,
involving a KLM and PanAm 747s at Tenerife, - grouping together of components
which resulted in the loss of more than 500 lives. that are functionally related,
Effective teamwork training will focus on – - clear labelling of components,
- Communication skills, - minimal requirement for special tools,
- Crew development and leadership skills, - absence of need to perform high-
- Workload management, precision work in the field,
- Technical proficiency. - design of equipment to permit
easy fault diagnosis.

24 maintenance & asset management • vol 20 no 4

Managing Human Error in Maintenance

Enforce good housekeeping standards. at lower levels in the organisation. People must
Housekeeping practices are a good indicator not feel that reporting human failures is likely
of attitudes and culture relating to quality. The to lead to adverse personal consequences. Those
correct standards are those that avoid dangerous who have researched so-called ‘High Reliability
slovenliness, without resorting to anally-retentive Organisations’ (HROs) have noted that high levels
cleanliness. of failure reporting are a significant feature of those
organisations8.
Ensure that spare parts and tools are managed
well. Maintenance cannot perform high quality work
if the parts and tools that are needed are not available Put in place proactive processes for assessing the risk of
when required. This leads to potentially dangerous
future maintenance errors. Avoiding the recurrence of past
short-cuts and workarounds. An important aspect
of maintenance QM is ensuring that tool and spare failures is an admirable, but insufficient, goal for those
parts management processes and practices support seeking to achieve high quality maintenance outcomes.
the achievement of high quality work.

Write, and use, effective maintenance work Put in place proactive processes for assessing
instructions. Omission of necessary steps is the most the risk of future maintenance errors. Avoiding
common form of maintenance error. Some estimates the recurrence of past failures is an admirable, but
suggest that omissions account for more than half insufficient, goal for those seeking to achieve high
of all human factors problems in maintenance. The quality maintenance outcomes. One possible
development, and use, of effective maintenance work proactive method that could be employed to
instructions is an important tool in managing these proactively manage maintenance quality is to
types of errors, and will be discussed in more detail perform a risk assessment of maintenance activities,
in a later section of this paper. in order to assess whether the likelihood of human
error is high. Possible areas that could be assessed
 Organisational measures could include
Put in place effective processes for analysing, - the knowledge, skills and experience of
and learning from, past failures. It is vitally maintenance personnel at all levels,
important that any significant failures should be - employee morale,
investigated using an effective Root Cause Analysis.
- the availability of tools, equipment and parts,
RCA, to be effective, should fully investigate all the
contributing causes to the failure, whether these - workforce fatigue, stress and time pressures,
be physical, human, or organisational. The most - shift rosters,
effective solutions to preventing these failures from - the adequacy of maintenance procedures and
happening again will be those that deal effectively work instructions.
with the organisational causes of failures.
One example of a risk assessment process that
However, in order to effectively analyse those failures is used in the aviation industry is Managing
that are occurring as a result of human failures, it Engineering Safety Health (MESH), which was
is also necessary to engender a ‘reporting culture’ developed initially by British Airways in the early
within the organisation – where all failures, no 1990s, and has been further developed and adapted
matter how seemingly insignificant, are reported. by Singapore Airlines4.
This, in turn, particularly when we are dealing
with human errors, requires the development of a In addition, more specific review and assessment of
high level of trust between management and those error detection and containment defences can be

maintenance & asset management • vol 20 no 4 25

Managing Human Error in Maintenance

performed. This could ask questions such as – who will be performing the work will be familiar
- Are there adequate processes in place for with the task (or be guided by someone who is).
independent inspection of high-risk tasks?
 Group complex work instructions into phases,
- Are functional tests and checks ever with each phase consisting of many, related
omitted or abbreviated, for any reason? tasks. Remember that losing one’s place in a
- Have tasks ever been signed off as sequence is a frequent human error. We can
completed, when this was subsequently reduce the likelihood of this happening by
found not to be the case? grouping logically related tasks into phases. It is
- After maintenance, is equipment adequately much easier to remember that you are at Step 8 in
tested before being returned to service? Phase 4, rather than try to remember whether you
were at Step 48 or 49 in the entire sequence.
Ultimately, even putting both proactive and reactive
measures in place will not guarantee the absence  Are written clearly, and use simple and
of human error, but together, these strengthen the consistent language. Once again, remember
organisation’s intrinsic resistance to human error. the type of person that is going to read the
instruction. Use language that you are sure they
will be familiar with. Be consistent in the use
WRITING EFFECTIVE WORK INSTRUCTIONS of terms. Is inspecting something the same as
As previously mentioned, some estimates suggest checking it? If not, then be sure that the reader of
that omissions account for more than half of all the instruction understands the difference. If it
human factors problems in maintenance. The is, then use only one term, and not the other in
development and use, of effective maintenance work order to avoid possible confusion.
instructions is an important tool in managing these  Focus on the key risks that may prevent the
types of error. job from being performed safely and to the
required quality standard. For example, if there
What are the characteristics of a good Maintenance are certain dimensions that must be checked and
Work Instruction? Briefly, good work instructions – are critical to the subsequent operation of the
 Are written with the person who is going machine, make sure that these are highlighted so
to read the instruction in mind. This sounds that the reader is aware of this – and always make
obvious, but in practice is not always so easy. sure that the required dimension is specified
We know that the person who is going to be in the work instruction, and easily readable. If
performing the task is a qualified tradesperson, certain steps MUST be performed in a specific
but we generally do not know the specific order, and there is a risk that they could be
individual who will be doing the work, and their performed in a different order, then make sure
familiarity with the task. Do we write the work that this is communicated clearly and strongly to
instruction assuming that this tradesperson has the reader.
never performed the task before? Do we assume
that they are very familiar with the task? Or Some other aspects of tasks that may represent high
something in between? To a certain extent, we risk are those that –
need to know more about the nature of the task.
- have been omitted or performed
If it is rarely performed, then it is probably safe to
incorrectly in the past,
assume that the tradesperson will be unfamiliar
with it. On the other hand, if it is frequently and - are associated with assembly or installation
regularly performed (such as a lubrication PM) (these tasks represent a much greater risk
then it is probably more likely that the person than disassembly or removal tasks),

26 maintenance & asset management • vol 20 no 4

Managing Human Error in Maintenance

- involve routine and highly practised actions, CONCLUSION

- are different in some way The impact of human error on maintenance quality
from previous practice, and costs, safety and equipment reliability is huge.
Yet we are only just starting to develop a better
- involve actions that are not required
understanding of what causes error in maintenance
in other, very similar tasks,
activities, and to develop better tools and techniques
- if omitted, would not be detected to avoid or minimise the consequences of this
at a later step in the procedure, error. This paper has attempted to outline some of
- are liable to be subject to the latest research findings, and provide you with
distractions or interruptions, some ideas that you may find useful in addressing
- are likely to be completed by a different maintenance error within your organisation.
person from the one who began the task6.
 Are written in the first person, not the third,
and use the active voice, not the passive.
‘Press the test button and check that all the lamps
illuminate’ is far preferable, and more easily REFERENCES
understood than ‘The test button is then pressed 1. Nowlan F S and Heap H, Reliability Centered Maintenance,
National Technical Information Service, US Department of
and operation of all the lamps checked’. Commerce, Springfield, Virginia 1978.
 Are written in both upper and lower case, not 2. Davis R A, Human factors in the global marketplace, Keynote
address, Annual Meeting of the Human Factors and Ergonomics
upper case only. Research has shown6 that text Society, Seattle, 2 October 1993
that is written in both upper and lower case is 3. Smith A, Reliability Centered Maintenance, McGraw Hill, Boston
absorbed and understood 17% more quickly than 1992
4. Reason J, Managing the Risks of Organizational Accidents, Ashgate
text that is written completely in capital letters.
Publishing, 1997
 Make appropriate use of pictures and 5. Boeing, Maintenance error decision aid, Boeing Commercial
Airplane Group, Seattle 1994
graphics. Some things are far more quickly and
6. Reason J and Hobbs A, Managing Maintenance Error, Ashgate
easily communicated with the use of a diagram or Publishing, 2003
a photo than in words. 7. Orlick T, In Pursuit of Excellence, Zone of Excellence, Ottowa
2000
Make sure you make use of these tools.
8. See, for example, Weick K E and Sutcliffe K M, Managing
 Incorporate adequate independent the Unexpected – Assuring High Performance in an Age of
Complexity, Jossey-Bass, 2001
inspections at key points in the instruction.
For particularly high risk tasks, it may be worth
For more information or discussion of the points
ensuring that someone other than the person
contained in this paper, feel free to contact the
performing the task verifies that it has been
author at –.
performed correctly at an appropriate breakpoint
PO Box 1315
in the procedure.
Booragoon WA 6154
 Incorporate appropriate, conspicuous, Tel: +61 8 9474 4044
reminders in order to ensure that critical Fax: +61 8 9474 4055
steps are not omitted. For example, pitot tube E-mail: sandy.dunn@assetivity.com.au
covers for civil aviation aircraft, if not removed
before flight, can have fatal consequences. These For further information and reviews of many of the
covers are fitted, therefore, with large, brightly books mentioned in the footnotes to this paper (and
covered ‘flags’ that make it obvious to anyone on the opportunity to purchase these books through
the ground when the pitot tube cover is fitted to amazon.com) visit www.plant-maintenance.com/
the aircraft. maintenance_books.shtml.

maintenance & asset management • vol 20 no 4 27