Understanding maintenance work in safety-critical organisations – managing the performance variability

Workforce perceptions of human factors as indicators of plant reliability and process safety

Human factors, as perceived by the maintenance workforce, were used as the measure for comparing work areas within a petroleum company. These factors were then compared to an objective measure of reliability (Mean Time Between Failures) in order to determine which factors would be most predictive of plant reliability and process safety. Maintenance personnel were surveyed using scales based on Problem-solving, Vigilance, Design and maintenance, Job-related feedback and Information about change. Analysis of Variance was used to assess the strength of these variables in relation to Reliability Level. Significant differences were observed between different reliability levels based on workforce perceptions of problem-solving requirements and the design and maintainability of plant. Conclusions were that perceptions of human factors in the workplace can be predictive of group-level performance, and that if issues relating to design and maintainability are not addressed at the design stage, greater problem-solving abilities will be required from maintenance personnel. Practitioner summary: Workforce perceptions of plant performance could provide a statistically valid measure of current and future reliability. A survey of perceptions of human factors was conducted with maintenance personnel in a petroleum company. Results indicated significant relationships between reliability and requirements for Problem-solving, as well as Design and Maintenance of equipment. Abbreviations: HFIT: human factors investigation tool, FPSO: floating production, storage and offtake, MTBF: mean time between failures, CPS: cognitive problem- solving, WDS: work design questionnaire, SPSS: statistical package for the social sciences, PAF: principal axis factoring, ANOVA: analysis of variance, ANCOVA: analysis of co-variance, M: mean, SD: standard deviation.

The Unexplored Link between Communication and Trust in Aviation Maintenance Practice

Communication and trust are fundamental factors in the operation of complex and highly regulated industries like aviation maintenance. This article reviews two preconditions of human error: communication and trust, as well as the way these are linked as aviation researchers have only recently started to study factors not individually, but rather by combining their effects. Communication is essential in the exchange of information and knowledge in aviation maintenance. The conditions that make communication effective and miscommunication avoidable are explored. Next, ways of communication, like aircraft maintenance documentation, are discussed along with appreciation of how communication is valued in aviation maintenance. Trust within different aspects of maintenance practice (interpersonal trust, trust towards technology, initial levels of trust) is presented and analysed, as well as examined as a prerequisite of effective communication. The characteristics of trust, its forms and results are identified in the literature with limited sources from the aviation bibliography, as it is a domain barely explored. Therefore, a gap has been identified in the study of trust and the exploration of the combined traits of communication and trust in aviation maintenance. Recommendations for additional research in this field are provided.

Distributed improvisation: a systems perspective of improvisation 'epics' by led outdoor activity leaders

Improvisation represents the spontaneous and real-time conception and execution of a novel response to an unanticipated situation. In order to benefit from the positive safety potential of this phenomenon, it is necessary to understand what influences its appropriateness and effectiveness. This study has applied the system-based methodology Impromaps to analysing accounts of improvisation aimed at mitigating adverse safety outcomes. These accounts were obtained from led outdoor activity (LOA) leaders through critical decision method interviews. Influencing factors and interactions have been identified across all system levels. The factors most influential to leaders' ability to improvise are 'Policy, procedures and rules', 'Organisation culture', 'Training', 'Role responsibilities', 'Communication/instruction/demonstration', 'Situation awareness', 'Leader experience', 'Mental simulation', 'Equipment, clothing & PPE' and 'Terrain/physical environment'. To enhance the likelihood of effective, appropriate improvisation, LOA providers are recommended to focus on higher level factors over which they are able to exert greater control. Practitioner Summary: To enhance resilience in safety-critical situations, organisations need to understand what influences appropriate, effective improvisation. To elucidate this, the Impromaps methodology is applied to in-depth interview data. The Impromap affords a graphical depiction of the influencing factors and interactions across the system, providing a basis for the development of interventions.

Latent error detection: A golden two hours for detection

Undetected error in safety critical contexts generates a latent condition that can contribute to a future safety failure. The detection of latent errors post-task completion is observed in naval air engineers using a diary to record work-related latent error detection (LED) events. A systems view is combined with multi-process theories to explore sociotechnical factors associated with LED. Perception of cues in different environments facilitates successful LED, for which the deliberate review of past tasks within two hours of the error occurring and whilst remaining in the same or similar sociotechnical environment to that which the error occurred appears most effective. Identified ergonomic interventions offer potential mitigation for latent errors; particularly in simple everyday habitual tasks. It is thought safety critical organisations should look to engineer further resilience through the application of LED techniques that engage with system cues across the entire sociotechnical environment, rather than relying on consistent human performance.

The Development and Deployment of a Maintenance Operations Safety Survey

OBJECTIVE

Based on the line operations safety audit (LOSA), two studies were conducted to develop and deploy an equivalent tool for aircraft maintenance: the maintenance operations safety survey (MOSS).

BACKGROUND

Safety in aircraft maintenance is currently measured reactively, based on the number of audit findings, reportable events, incidents, or accidents. Proactive safety tools designed for monitoring routine operations, such as flight data monitoring and LOSA, have been developed predominantly for flight operations.

METHOD

In Study 1, development of MOSS, 12 test peer-to-peer observations were collected to investigate the practicalities of this approach. In Study 2, deployment of MOSS, seven expert observers collected 56 peer-to-peer observations of line maintenance checks at four stations. Narrative data were coded and analyzed according to the threat and error management (TEM) framework.

RESULTS

In Study 1, a line check was identified as a suitable unit of observation. Communication and third-party data management were the key factors in gaining maintainer trust. Study 2 identified that on average, maintainers experienced 7.8 threats (operational complexities) and committed 2.5 errors per observation. The majority of threats and errors were inconsequential. Links between specific threats and errors leading to 36 undesired states were established.

CONCLUSION

This research demonstrates that observations of routine maintenance operations are feasible. TEM-based results highlight successful management strategies that maintainers employ on a day-to-day basis.

APPLICATION

MOSS is a novel approach for safety data collection and analysis. It helps practitioners understand the nature of maintenance errors, promote an informed culture, and support safety management systems in the maintenance domain.

Maintenance: organizational modes, activities and health and safety. Use of a French national survey and in-situ analyses

Maintenance activities are identified as critical both to operator safety and to systems safety and reliability. However, it is still difficult to identify maintenance workers in French occupational accident and disease statistics. Moreover, few analyses of these activities and of organizational changes in this field have been conducted. This paper presents two different approaches to this same issue. Analyses were aimed firstly at identifying the occupational exposures of these operators and at comparing them with occupational exposures of production staff and, secondly at developing understanding of normal real maintenance activities, i.e. maintenance activities that are normally actually carried out, while taking into account the socio-technical system and maintenance organization within which they lie. The use of the French SUMER 2003 survey shows that occupational exposures of maintenance staff to various constraints are more frequent than occupational exposures of their production colleagues. However, maintenance staff appear to have greater independence. Analyses were also conducted in a subcontracting urban public transport company, who outsources some maintenance work. Those analyses highlight a complex network of companies involved in maintenance activities, a substantial number of work interruptions and a significant fragmentation of the internal technicians' activities that can be cognitively costly, reduce anticipation possibilities and lead to incidents or accidents. Above all they underline internal technicians' contributions to the completion of outsourced interventions and interdependent relationships between the activities of the internal and the external technicians. Outsourcing maintenance interventions thus raises the question of risks associated with the interdependence of actual work activities undertaken by the different types of staff, since they contribute to the same maintenance intervention. This study therefore pinpoints the need to integrate inter-organizational interactions in order to understand the variability of maintenance activities and its relationships with reliability and safety. In this respect, some suggestions are provided with a prevention aim.

Resilient Practices in Maintaining Safety of Health Information Technologies

Electronic health record systems (EHRs) can improve safety and reliability of health care, but they can also introduce new vulnerabilities by failing to accommodate changes within a dynamic EHR-enabled health care system. Continuous assessment and improvement is thus essential for achieving resilience in EHR-enabled health care systems. Given the rapid adoption of EHRs by many organizations that are still early in their experiences with EHR safety, it is important to understand practices for maintaining resilience used by organizations with a track record of success in EHR use. We conducted interviews about safety practices with 56 key informants (including information technology managers, chief medical information officers, physicians, and patient safety officers) at two large health care systems recognized as leaders in EHR use. We identified 156 references to resilience-related practices from 41 informants. Framework analysis generated five categories of resilient practices: (a) sensitivity to dynamics and interdependencies affecting risks, (b) basic monitoring and responding practices, (c) management of practices and resources for monitoring and responding, (d) sensitivity to risks beyond the horizon, and (e) reflecting on risks with the safety and quality control process itself. The categories reflect three functions that facilitate resilience: reflection, transcending boundaries, and involving sharp-end practitioners in safety management.

Using cognitive work analysis and the strategies analysis diagram to understand variability in road user behaviour at intersections

In this article, an application of cognitive work analysis (CWA), using the strategies analysis diagram (SAD) method, to model performance variability in road transport, is presented. Specifically, the method was used to describe performance variability across four road user groups (drivers, cyclists, motorcyclists and pedestrians) when turning right at an urban signalised intersection. The analysis demonstrated that the method was able to identify a comprehensive range of strategies that road users can potentially use while turning right at an intersection, thereby describing a range of performance variability within intersection systems. Furthermore, the method identified constraints, disturbances, changes in circumstances and other influences on road user performance variability. It is concluded that the CWA/SAD approach was able to describe both the different ways in which activities can be executed and disturbances, situations and constraints that create performance variability. The implications of these findings for road design and intersection safety are discussed along with the benefits and drawbacks of the methodology used.

PRACTITIONER SUMMARY

Recently, the strategies analysis diagram was proposed as a method to support the cognitive work analysis framework in modelling performance variability. This article evaluated this method within a complex sociotechnical system, namely road transport. The application provided insight into performance variability across road user groups when turning right at intersections.