Top safety occurrence during aircraft maintenance: system operated unsafely

Flap handle in aircraft cockpit is locked out.
Flap handle in aircraft cockpit is locked out.
Michael Spinks

We all want to meet the operational demands of our business and we might even be compelled to take short-cuts, deviate or skip steps in a procedure to meet that demand. All in the name of saving time. You might say to yourself, “I’m just going to reach my hand in there for just a second or poke my head in to take a quick look”. The area may be a landing gear wheel well, an open fuel tank, behind a circuit breaker panel or in a prop arc. What is your reward for such risk taking?

Ray Clouatre of Evergreen Safety Council says,

“There are some safety activities that definitely slow production. It may take half an hour to properly lock-out-tag-out (LOTO) a process that allows you to safely perform a maintenance procedure that only takes five minutes to perform. Proper confined space entry procedures certainly require more time, manpower, and equipment than just "jumping in for a minute". But even these slowdowns pale in comparison to the cost of the potential injury or fatality that these situations pose.”

According to James Reason,

"Almost everyday we choose whether or not to cut corners in order to meet operational demands. For the most part, such short-cuts bring no bad effects and so become an habitual part of routine work practices. It’s easy to forget to fear things that rarely happen. Unfortunately, this gradual reduction in the systems safety margins exposes it to increasingly vulnerable accident-causing factors."

The top safety occurrence during maintenance as a result of these accident-causing factors is an aircraft system operated unsafely. This is defined as activating an aircraft system such as flaps or thrust reversers when it was not safe to do so, either because personnel or equipment were in the vicinity, or the system was not properly prepared for activation.

This top safety occurrence is according to a survey by Hobbs and Williamson for the Australian Transport Safety Bureau designed to identify safety issues in maintenance, with a particular emphasis on human factors, which were distributed to 1400 Licensed Aircraft Maintenance Engineers in Australia.

Some of the top factors and unsafe acts for these types of occurrences are:

Aircraft systems just don’t magically operate. They are commanded to operate. These initial commands come from inputs from humans. Unless we intercede by deactivating and LOTO the systems, the potential to lose life or limb or damage to the aircraft increases. Also, communicating to your coworkers who are working on other systems of the aircraft to let them know what task you’re preparing to perform is critical to a safe outcome.

When we practice safety techniques that are designed to protect us from the hazards of maintenance, we take responsibility and are accountable for our own safety as well as the safety of the aircraft. This mind-set translates to an overall safer environment and an on time and airworthy product. Aircraft need to be treated with the respect they deserve. It only takes a second to be seriously injured or worse. Follow the procedures and take time to lock-out-tag-out.

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Very Educational Article.