Subject: MAINTENANCE RESOURCE

MANAGEMENT TRAINING

Date: 9/28/00

Initiated By: AFS-300

AC No: 120-72

Change:

1. PURPOSE.

a. This advisory circular (AC) presents guidelines for developing, implementing,

reinforcing, and assessing Maintenance Resource Management (MRM) training programs

for improving communication, effectiveness, and safety in maintenance operations.

These programs are designed to become an integral part of training and maintenance

operations.

b. This AC presents one method, but not necessarily the only method, to address

MRM training. MRM training focuses on situational awareness, communication skills,

teamwork, task allocation, and decision making.

2. RELATED REGULATIONS. Title 14, Code of Federal Regulations; Sections

121.375 and 135.433.

3. DEFINITIONS. For the purposes of this AC the terms listed below have the

following meanings:

a. Active Failure: A type of human error whose effects are felt immediately in a

system.

b. Assertiveness: The ability to verbalize a series of “rights” that belong to every

employee. Some of these “rights” include: the right to say no, the right to express feelings

and ideas, and the right to ask for information.

c. Asynchronous Communication: Communication in which there exists a time

delay between responses. Asynchronous communication is typified by a unique set of

characteristics, such as the lack of non-verbal communication cues (e.g., body language,

verbal inflection, etc.) Examples of asynchronous communication include an e-mail

message sent from the day supervisor to the night supervisor or memos left between

shifts or passed between a shop and the hanger.
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d. Authoritarian Leader: A person who dictates the action and the course of a

team with little input from team members.

e. Communication: The process of exchanging information from one party to

another.

f. Complacency: Satisfaction with a situation to the extent that a degradation of

vigilance occurs.

g. Crew Resource Management: Team-based human factors training for flight

crews.

h. Dirty Dozen: The twelve most common maintenance-related causes of errors.

These twelve causes are:

(1) Lack of Communication

(2) Complacency

(3) Lack of Knowledge

(4) Distraction

(5) Lack of Teamwork

(6) Fatigue

(7) Lack of Resources

(8) Pressure

(9) Lack of Assertiveness

(10) Stress

(11) Lack of Awareness

(12) Norms

i. Egalitarian: Relating to the doctrine of equal political, economic, and legal

rights for all human beings.

j. Ergonomics: The applied science having the objective of adapting work or

working conditions to enhance performance of the worker.

k. Human Factors: The scientific study of the interaction between people and

machines.

l. Inter-team: Occurring between separate teams.

m. Intra-team: Occurring within a team.

n. Instructional Systems Design: A generic term for the methodology of creating

and implementing a training program.

o. Latent Failure: A type of human error whose effects may lie dormant until

triggered later, usually by other factors.
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p. Leadership: The ability to direct and coordinate the activities of group members

and stimulate them to work together as a team.

q. Maintenance Resource Management: A general process for maintaining an

effective level of communication and safety in maintenance operations.

r. Mental Model: A depiction of a system in a person’s mind, i.e. how a person

thinks a system is put together and how it works.

s. Norms: Expected, yet implicit rules of behavior that dictate a person’s dress,

speech, and basic interaction.

t. Participatory Leader: A person who encourages member participation and

input to help lead the team's course of action.

u. Safety Culture: A pervasive, organization-wide attitude placing safety as the

primary priority driving the way employees perform their work.

v. Situational Awareness: Maintaining a complete mental picture of surrounding

objects and events as well as the ability to interpret those events for future use.

Situational awareness encompasses such concepts as attention, and vigilance.

w. Stressor: An event or object that causes stress in an individual.

x. Synchronous Communication: Communication in which a minimal delay exists

between the message being sent and the message being received. Examples include faceto-face conversation and communication via radio.

y. Team: A group of interdependent individuals working together to complete a

specific task..

z. Team Situational Awareness: Maintaining a collective awareness across the

entire team of important job-related conditions.

aa. Teamwork: Joint action by a group of people, in which each person subordinates

his individual interests and opinions to the unity and efficiency of the group.

4. ACRONYMS.

a. CRM: Crew Resource Management

b. HF: Human Factors

c. ICAO: International Civil Aviation Organization
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d. ISD: Instructional Systems Design.

e. MRM: Maintenance Resource Management

f. SOP: Standard Operating Procedure(s).

5. RELATED MATERIAL.

a. Crew Resource Management.

(1) AC 120-51, Crew Resource Management Training.

(2) Driskell, J. E., & Adams, R. J. (1992). Crew Resource Management: An

Introductory Handbook (DOT/FAA/RD-92-26). Washington, DC: Federal Aviation

Administration.

(3) Wiener, E. L., Kanki, B. G., & Helmreich, R. L. (1985). Cockpit Resource

Management. Orlando, FL: Academic Press.

b. Human Factors.

(1) Bailey, R. W. (1989). Human Performance Engineering: Using Human

Factors/Ergonomics to Achieve Computer System Usability (2nd edition). Englewood Cliffs,

NJ: Prentice Hall.

(2) Brown, O., & Hendrick, H.W. (Eds.) (1986). Human Factors in Organizational

Design and Management II. Amsterdam, Holland: North Holland.

(3) Federal Aviation Administration (1991). National Plan for Aviation Human

Factors. Springfield, VA: National Technical Information Service.

(4) Federal Aviation Administration. The Human Factors Guide for Aviation

Maintenance and Inspection (Version 3), [CD ROM] (1998) and FAA Human Factors in

Aviation Maintenance and Inspection Internet web site http://hfskyway.faa.gov. The Human

Factors Guide reviews and summarizes a variety of human factors issues, from workplace

design to human error to training, as they apply specifically to aviation maintenance. To

request a CD ROM free of charge (to those within the United States), you may do so on-line

via the Internet web site location.

(5) Federal Aviation Administration. Aviation Maintenance and Inspection Phase 9

report via FAA Human Factors in Aviation Maintenance and Inspection Internet web site

http://hfskyway.faa.gov.

(6) Reason, J. T. (1990). Human Error. Cambridge, UK: Cambridge Press.
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(7) Salvendy, G. (Ed.) (1997). Handbook of Human Factors. New York, NY: John

Wiley & Sons.

c. Training.

(1) Goldstein, I. L. (1986). Training in Organizations: Needs Assessment,

Development, and Evaluation (2nd Ed). Monterey, CA: Brooks/Cole.

(2) Knirk, F. G., & Gustafson, K. L. (1986). Instructional Technology: A Systematic

Approach to Education. New York, NY: Holt Rinehart and Winston.

(3) Reigeluth, C. M. (1983). Instructional-Design Theories and Models: An Overview

of Courseware. In D. H. Jonassen (Ed.), Instructional Designs for Microcomputer Courseware.

Hillsdale, NJ: Lawrence Erlbaum Associates.

(4) Wexley, K. N., & Latham, G. P. (1991). Developing and Training Human

Resources in Organizations (2nd Ed). Glenview, IL: Scott Foresman.

d. ICAO Documents. The following ICAO documents are available from:

ICAO

Document Sales Unit

1000 Sherbrooke Street West, Suite 400

Montreal, Quebec

Canada H3A 2R2

Phone: (514) 285-8022

Fax: (514) 285-6769

E-mail: sales unit@icao.org

(1) Human Factors in Aircraft Maintenance & Inspection (Digest No. 12). This

document provides a very good overview of the problems in aviation maintenance. It

uses a few high profile accidents to illustrate its points and discusses the importance of

looking past the obvious micro issues to organizational culture factors, which contribute

to latent failures and overall systems problems.

(2) Human Factors Digest No. 2 - Flight Crew Training: Cockpit Resource

Management.

(3) Circular 217 Line-Oriented Flight Training (LOFT).

(4) Circular 247 Human factors, Management and Organization.
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6. BACKGROUND.

a. Though crew resource management (CRM) on the flight deck is a topic of regular

discussion, relatively little attention has been paid to its maintenance-related counterpart,

maintenance resource management (MRM). Indeed, this inattentiveness is

understandable. Whereas a pilot or pilots’ errors can have immediate and highly visible

effects, the same can not necessarily be said of a maintenance-based error. Because of

this, aviation research into team activities first grew from investigations into aircrew

behaviors. This evolution is apparent whenever encountering references to crew resource

management.

b. The aviation community has expanded its approach to reducing human error.

Human factors programs now encompass not just the flight crew, but all aspects of

aviation in which a human may be involved. This activity includes such areas as aircraft

design and operation, air traffic control, and, of course, aircraft maintenance.

7. OBJECTIVES.

a. This AC provides background information on Maintenance Resource

Management. Maintenance Resource Management (MRM) is a general process for

improving communication, effectiveness and safety in aircraft maintenance operations.

Attention will be given specifically to the implementation and evaluation of MRM

training. Much as crew resource management (CRM) was created to address safety and

teamwork issues in the cockpit, the Federal Aviation Administration (FAA), in

conjunction with industry partners, developed MRM to address teamwork deficiencies

within the aviation maintenance environment.

b. MRM is a team-based safety behavior. It teaches managers and maintenance

personnel skills that enable them to work safely in a complex system. MRM teaches

more than just team skills; it teaches and reinforces an organizational philosophy in

which all members of the organization are oriented toward error-free performance. This

is accomplished by teaching:

(1) How the effects of individual actions ripple throughout organizations,

(2) How to utilize available resources safely and effectively, and

(3) How to propagate a positive culture of safety in the organizations through

specific, individual actions.

c. The overall goal of MRM is to integrate the technical skills of maintenance

personnel with interpersonal skills and basic human factors knowledge in order to

improve communication effectiveness and safety in aircraft maintenance operations.
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8. PHILOSOPHY OF MRM.

a. The philosophy of MRM is based on the philosophy of CRM with emphasis on

how maintenance operations differ from flight operations. The work environment of

maintenance personnel encompasses a great variety of tasks in varied settings with a

great number of people. Because the tasks and work differ from one domain to the other,

the basic plan for addressing concepts like human error, teamwork, and safety also differ.

b. This section outlines similarities and differences between MRM and CRM, in

order to characterize the philosophy of MRM. First, human error in both the flight and

maintenance environment is explored in more detail as a foundation upon which to build

the discussion of an organization’s safety culture. The section that follows investigates

the concept of a safety culture more thoroughly. The promulgation of a good, pervasive

safety culture is at the core of MRM’s basic philosophy.

c. Human error.

(1) The way to understand MRM is to explore the nature of errors in

maintenance operations. A widely accepted model of human error is the classification of

unsafe acts developed by J.T. Reason. This classification distinguishes between two

types of errors:

(a) Active failures, whose effects are felt immediately in a system, and

(b) Latent failures, whose effects may lie dormant until triggered later,

usually by other mitigating factors.

(2) The presence of defenses or safeguards in a system can usually prevent the

effects of latent failures from being felt by closing the window of opportunity during

which an active failure may be committed. For example, consider the case of a

mechanic who assembled a component incorrectly which eventually led to a plane crash

days or even weeks later. The defenses that should have normally caught this mistake

were not in place. These defenses include proper training (the mechanic was taught to fix

this particular component very informally and on-the-job), good situational awareness

(the mechanic was tired from a double shift the night before), and independent inspection

(the job was “pencil-whipped” to save time.)

(3) Active failures are usually the result of actions taken (or not taken) by frontline operators such as pilots, air traffic controllers, or anyone else with direct access to

the dynamics of a system. Latent failures, on the other hand, are caused by those

separated by time and space from the consequences of their actions in the dynamics of

the system. Personnel working in vocations such as architectural design, hardware

design and equipment maintenance are more prone to cause latent failures than active

failures.
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(4) Both active and latent failures may interact to create a window for accidents

to occur. Latent failures set the stage for the accident while active failures tend to be the

catalyst for the accident to finally occur. A good way to think of this model of accident

creation is as slices of Swiss cheese. Each slice can be thought of as a defense to an

accident (training, good management, teamwork, etc.) and each hole is a failure in that

defense. The last slice is the final action which could serve as a defense before the

accident event. The failure in that defense would constitute the active failure

precipitating the accident. If the defenses to a situation contain a sufficient number of

failures, which allow the holes to “line up,” an accident will occur.

(5) Differences between active and latent failures cannot be over emphasized;

each type of error helps to shape the type of training required to correct them. For

example, because of the immediate demands and consequences of their actions, flight

personnel require training that includes the psychomotor aspects of physical skills such as

improving reaction time in emergency training. The strict physical requirements for

employment as a flight officer demonstrate this emphasis clearly. On the other hand,

maintenance personnel may require human factors and operations training to account for

their susceptibility to latent failures. In addition, the range of physical activities of

maintenance personnel on the job also requires emphasis on workplace ergonomics. For

example, maintenance personnel may be asked to lift heavy objects, work in awkward

positions, or perform tasks in extreme weather conditions. These difficult work

conditions all require knowledge of ergonomics to ensure safe, error-free performance.

Though CRM and MRM share the basic concepts of error prevention, the content of what

is taught is specific to what is actually performed on the job.

d. Safety Culture.

(1) Knowledge about complex systems alone only goes so far in mitigating

human error. To combat error, an organization must teach not just how error may be

avoided, but also it must adopt attitudes that promote safety above all else. Various

researchers call these attitudes an organization’s safety culture and identify top-level

organizational support as the main predictor of a positive safety culture. Put briefly, in

order for an organization to create and perpetuate a positive safety culture, senior

management must take certain actions, such as:

(a) Setting standards and expectations and providing resources to meet them.

(b) Developing and enforcing standards that emphasize safe work practice.

(c)Setting up meaningful incentive programs that reward safe and reliable

behavior either monetarily or through other means such as days off, or awards of

recognition for a job well done.

(2) An MRM training program provides personnel with the tools to assess and

change their own behaviors to work safer and reduce human error. Unlike other safety
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programs, MRM is most effective when ALL employees are oriented toward a positive

safety culture. Therefore, employees of all levels (upper-level managers included) are

encouraged to participate and are trained alongside maintenance personnel.

(3) MRM trains personnel to use the resources of their positions to encourage

safe operations. For example, managers learn that a positive safety culture can only be

fostered if line employees are provided the necessary resources to do their jobs correctly.

Line employees must be given the tools that teach them how to do their jobs without

error. As an example, upper-level managers provide and control resources such as the

number of aircraft serviced at one time, the selection of employees to do the work, and

the tools with which to perform the necessary tasks. Safety itself, however, is rooted in

the actual behaviors of maintenance personnel in the hanger (or on the line). MRM

training teaches employees what behaviors are best to use. MRM training also helps

managers understand how their own choices affect which behaviors are ultimately used .

In this way, the entire organization becomes oriented towards safe, error-free

performance.

9. MRM CONCEPTS.

a. Though MRM includes more than training, training is the foundation upon

which the program is built. MRM training teaches maintenance personnel specific

concepts, both theoretical and applied. Management commitment to a positive safety

culture allows maintenance personnel to put into practice the concepts they learn. This

section presents and defines MRM concepts in terms of the maintenance environment. In

addition, supplemental information on each implementation of a skill is also provided as

a sample of the content of an MRM training program.

b. This section and Appendix 1, the sample training course, were written with

relatively large maintenance and repair stations in mind; some of the large working group

practices may not apply in small stations.

c. Those people familiar with CRM training will see similarities with the skills

taught in MRM training. These similarities lie mostly in the broad areas of resource

management such as communication, team building, workload management, and

situational awareness. However, MRM is tailored to fit the unique demands of the

maintenance community; its content specifically addresses their problems. The following

sections discuss briefly each of the components of MRM.

d. Human Factors knowledge.

(1) Understanding the maintenance operation as a system. An understanding

of the systemic nature of the maintenance operation is vital to understanding how one’s

individual actions affect the whole organization. A person who understands the big

picture is more apt to think things through before acting.
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(2) Identifying and understanding basic Human Factors issues. Basic

Human Factors concepts are also taught in the course of MRM training. These concepts

typically include human perception and cognition, workplace and task design, group

behavior (norms), and ergonomics. However, this list is far from exhaustive and the

concepts taught should be tailored to meet the needs of each particular audience.

(3) Recognizing contributing causes to human errors. A basic primer on

human error is a key component to MRM training. By understanding the interaction

between organizational, work group, and individual factors that may lead to errors and

accidents, maintenance personnel can learn to prevent or manage them proactively in the

future. Reason’s model provides a good foundation for human error theory; however,

many other models of human error exist, such as the “Dirty Dozen” scenarios. These can

also be adapted for use in MRM training.

e. Communication Skills.

(1) Communication remains the backbone of both CRM and MRM, but specific

aspects of communication are different in each work environment. Mechanics, crew

leads, supervisors, and inspectors all must have the knowledge and skills to communicate

effectively. A lack of proper communication can have any or all of the following

undesired consequences:

(a) The quality of work and performance may be reduced.

(b) Time and money may be lost as errors occur because important

information is not communicated or messages are misinterpreted.

(c) Improper communication may cause frustration and high levels of stress.

(2) People communicate in many different ways, however this AC, will consider

three broad forms of communication:

(a) Verbal communication, which relates to the spoken word, whether face

to face or through some electronic medium such as a phone, radio, loud speaker, etc.

(b) Non-verbal communication, commonly referred to as “body language.”

Whether you wave, smile, or wink, you are communicating a message to other

individuals.

(c) Written or asynchronous communciation which includes everything that

is memorialized in writing or in electronic form, such as publications, letters, forms,

signs, e-mail, etc.

(3) Most people associate communication with verbal communication. For

maintenance personnel, communication encompasses much more than inter-team verbal

interaction. Communication not only includes face-to-face interaction, but also
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paperwork such as maintenance cards, procedures documents, work orders, and logs. In

addition, because maintenance is an ongoing process independent of specific teams, interteam communication, especially between shifts, is extremely important. In this way,

asynchronous communication (communication in which there exists a time delay

between responses) is used to a greater extent than real time, synchronous

communication.

(4) Asynchronous communication is typified by a unique set of characteristics,

such as the lack of non-verbal communication cues (e.g., body language, verbal

inflection, etc.) An example of asynchronous communication at work in the hanger

would be an e-mail message sent from the day supervisor to the night supervisor. Other

examples include memos left between shifts or passed between a shop and the hanger.

(5) Relying on asynchronous communication affects an organization’s ability to

adapt quickly to changing situations. The very definition of asynchronous

communication implies that a time lag is present between parties. In this way,

communication also affects other factors such as decision-making, teamwork (and

interdependence), and the ability to lead. MRM recognizes these differences in

communication from CRM and accounts for them in training.

(6) Similarities also exist between CRM and MRM, particularly in the form of

assertiveness. MRM researchers have identified assertiveness as a positive behavioral

skill. Not to be confused with aggressive behavior, assertive behavior in the context of

MRM and CRM is defined as verbalizing a series of rights to which a team member is

entitled. Some of these rights include the right to say no, the right to express feelings and

ideas, and the right to ask for information. Examples of these rights in action may

include refusing to sign off on an inspection that was not performed properly, questioning

the appropriateness of certain actions, or demanding the correct number of people to do a

job. It has been shown that teams in cooperation openly discuss opposing views. This

action is critical for making cooperative situations productive. Thus, assertiveness is a

necessary skill for effective team behavior and is addressed specifically in MRM training.

(7) To promote constructive, synchronous communication, peer-to-peer

performance feedback techniques are also typically addressed in MRM training, normally

in training on interpersonal relations. Teaching-specific, constructive behaviors that may

be useful in common situations can still be beneficial. MRM can also address this

specific training with examples such as how to handle a troublesome employee and/or

supervisor and conflict management or resolution. The specific content of each MRM

training module can be tailored to fit a particular organization; however, MRM would be

incomplete if the training of “people skills” were omitted.

f. Team Skills.

(1) Team skills and coordination are a vital part of the MRM concept.

Competence in team skills tends to be independent of competence in technical skills, yet

both skills are equally important in accomplishing the final goal. Unfortunately,
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organizations rarely devote time and resources to teach these team skills formally. MRM

training provides maintenance organizations the vehicle to accomplish this. The

discussion of teams has been inferential up to this point. This section will discuss teams

specifically. In this way, concepts like inter- and intra-team behavior can be understood

with more precision.

(2) Certain qualities differentiate a team of people from a group of people.

Among these are size, a common goal, and interdependence.

(3) First, team size is an important issue in what constitutes a team. Obviously,

teams consist of more than one person. The addition of more people does not necessarily

mean an increase in team performance. Additional team members increase the need for

all team members to expend time and resources in order to coordinate the team’s

activities toward accomplishing its goals. A team with many members may fracture and

create sub-groups or cliques that possess goals different from, or even in opposition to,

the team’s primary goal. In this sense, the return on performance decreases dramatically

as more people are added. For any one particular task, there are an optimum number of

people who can do the job; more or fewer people will result in a performance loss.

Though the optimum number depends on the team task, process loss becomes significant

with more than 10 members.

(4) Secondly, a team works together to accomplish a unified goal or goals. That

goal could be an engine change or performing a heavy maintenance check. It must be

understood that, just as repairing an airplane consists of numerous steps, a team’s

ultimate goal is also composed of sub-goals. Each sub-goal must be accomplished in

order to reach the team’s ultimate goal.

(5) A final quality that is needed to define a team is interdependence.

Interdependence is defined as a team situation in which members depend on one another

to finish the final job. An activity that can be completed by a single person without

having to rely on others is not highly interdependent. For example, even though a group

of maintenance personnel can fuel a plane more quickly than one individual alone, if each

individual should drop out over time, the person left could still finish the task.

(6) Taken together, a team is defined as a group of interdependent individuals

working together to complete a specific task. The amount of interdependence

demonstrated by team members may vary when completing their own individual tasks.

For example, a maintenance team washing a plane depends only on each team member to

contribute to his or her individual task. However, each member relies on one another to

achieve his or her final goal (finishing the wash). This is known as additive labor, i.e.,

each team member adds his or her work to the task at hand. A maintenance team

changing out a main gear, on the other hand, has a greater amount of interdependence

among the team members to finish the task. The essential characteristics of a team are:

(a) A team is a group of interdependent individuals working together to

complete a specific task.
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(b) All team members depend on one another’s knowledge, skills, and

abilities to finish the final job. The amount of interdependence among team members

may vary from one team to another.

(7) This analysis of teams and teamwork provides a clearer picture of the

composition of a maintenance team. Though teams are usually composed of members in

the same location at the same time, this may not always be the case. For example,

consider a team that performs a heavy maintenance check in a hanger. Because each team

member is working on separate parts of the aircraft, they are separated both in location

and sometimes in time. However, when analyzed in terms of the ultimate goal (finishing

the check) and being interdependent (each member may have unique maintenance skills,

such as airframe, powerplant, or avionics skills etc. that are necessary to perform the

heavy check), the definition of a team applies. Also note that the other MRM skills, such

as constant communication and people skills, are also at work in this example.

(8) Teams have certain characteristics that make them effective. The following

table lists ten important characteristics of an effective team.

Effective Teamwork

Ten Characteristics of an Effective Team

A Clear Purpose: The team has a clear purpose or mission that is accepted by all members.

Relaxed Interaction: The team is relaxed and informal, with no obvious tensions among

members.

Participation: There is a lot of discussion between members and everyone participates in

decisions and/or activities.

Listening: Each team member actively listens to one another.

Disagreement: Team members are comfortable enough to disagree with one another if the

situation calls for it.

Openness: There is full and open communication with no hidden agendas.

Clear Expectations: There are clear expectations about the role of each of the team, and work

assignments are fairly distributed among team members.

Shared Leadership: Although there may be a formal team leader, each team member may share

leadership responsibilities from time to time as the situation arises.

Relations with Others: The team maintains credibility and good relations with others who may

be outside the formal team but who can still affect its functioning.

Team Maintenance: Team members not only focus on their primary goal but spend time

recognizing and maintaining the functions of the team itself.

Table 1. Effective Teamwork

(9) Maintenance operations are frequently characterized by large teams, working

on disjointed tasks, spread out over a hanger. As a result, maintenance operations rely

heavily on asynchronous communication. Because the team members are spread out,

there is a lag between queries and responses among team members. As a result of this

dependence on asynchronous communication, the team adapts to changes in its
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environment very slowly. Consequently, as teams become increasingly interdependent,

more media for communications and more standardized procedures should be in place.

In addition, a maintenance task may require multiple teams (hanger, shop, management)

each with their own responsibilities. Therefore, MRM places emphasis on inter-team

(between crews) skills as well as intra-team (within crew) skills.

g. Norms.

(1) A side effect of working in teams is the use of norms to guide a person’s

behavior. For example, a maintenance team may meet regularly before and after a shift is

over or even socially, during days off. If this meeting is not required by the organization,

but expected by the team members, then it is a norm.

(2) Norms are omnipresent in society. Norms are expected, yet implicit rules for

behavior. That is, norms dictate fundamental rules of dress, speech, and basic interaction.

Because they are rules for behavior that define others’ expectations, norms facilitate

social interaction by reducing the number of surprises one may encounter in a given

social context.

(3) Violation of a norm can prove distressing. For example, a group of

maintenance technicians may vigorously enforce the wearing of proper personal

protective equipment (PPE) when at work. Not wearing PPE may be not only a source of

concern for the norm breaker, but may also elicit negative reactions from those who

conform. In this case, others in the surrounding group may sanction the norm breaker.

(4) Norms are usually developed to solve to problems that have ambiguous

solutions. When faced with an ambiguous situation, an individual may use another’s

behavior as a frame of reference around which to form his or her own reactions. As this

process continues, group norms develop and stabilize. Newcomers to the situation are

then accepted into the group based on adherence to norms. Very rarely do newcomers

initiate change in a group with established norms.

(5) Some norms are unsafe in that they are non-productive or detract from the

productivity of the group. Taking shortcuts in aircraft maintenance, working from

memory, or not following procedures are examples of unsafe norms. Newcomers are

better able to identify these unsafe norms than long-standing members of the group. On

the other hand, the newcomer’s credibility depends on his or her assimilation into the

group. The newcomer’s assimilation, however, depends on adherence to the group

norms. Everyone should be aware of the perceptiveness of newcomers in identifying

unhealthy norms and develop a positive attitude toward the possibility that norms may

need to be changed. Finally, as newcomers become assimilated into the group structure,

they build credibility with others. Once this has been done, a relative newcomer may

begin to institute change within the group. Unfortunately, such actions are often difficult

to do and rely heavily on the group’s perception of the newcomer’s credibility.
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(6) Norms have been identified as one of the dirty dozen in aviation maintenance

and a great deal of anecdotal evidence points to the use of unsafe norms on the line. The

effect of unsafe norms may range from the relatively benign, such as determining

accepted meeting times , to the inherently unsafe, such as pencil-whipping certain tasks.

Any behavior commonly accepted by the group, whether as a standard operating

procedure (SOP) or not, can be a norm. MRM courses should attempt to help individuals

identify group norms, ferret out unsafe norms and take appropriate action.

h. Health and Safety/Situational Awareness/Leadership.

(1) MRM training should contain modules that address worker health and safety,

situational awareness, and leadership. Each of these concepts has been identified as

important to maintaining an effective safety culture.

(2) Worker Health and Safety.

(a) Healthy employees are more productive and effective than non-healthy

employees. The focus of MRM training is on public safety (the effect of human error on

the flying public, for example). MRM also should encourage employee safety training.

Employee safety is an integral part of an overall safety culture in an organization.

(b) Working safely depends on eliminating human error and stressors in the

work environment. Human error models are reviewed and placed in the context of one’s

personal well-being. For example, a human error model used previously to analyze what

led to an aircraft accident could also be used by trainees to analyze an accident that

occurred within the hanger. By applying many of the same principles of human factors

analysis, trainees could learn to work more safely in an otherwise hazardous

environment.

(c) Second, MRM should emphasize the recognition and reduction of

stressors. Maintenance personnel perform a wide range of physical activities. Certain

ailments become stressors because they are aggravated by these physical activities.

Stressor ailments that maintenance personnel are most vulnerable to include lower back

pain (LBP), cardiovascular (heart) disease, fractures and/or chronic pain, hypertension,

hearing damage, and exposure to dangerous chemicals and other environmental

conditions. Therefore an effective MRM program should provide training in basic

ergonomics (what and how to lift, workspace requirements, effects of temperature, noise,

etc.). In addition, an effective MRM training program should teach maintenance

personnel how to assess these problems, judge their susceptibility to them and identify

how these problems ultimately impact well-being and performance.

(d) Cognitive and emotional stressors also exist for all people, regardless of

their job. The consequences of these stressors should be evaluated in terms of human

error in the maintenance environment and should be taught in the MRM course. The two

predominant, cognitive and emotional stressors are complacency and fatigue.
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(e) Complacency.

1 Complacency is defined as satisfaction with a situation to the extent

that the degradation of vigilance occurs. Put simply, a complacent person fails to pay

attention when performing a task. This, in turn, normally leads to error or deviations

from SOPs. Complacency is abetted by a number of factors but three primary ones are:

a Fatigue.

b Too many things happening simultaneously.

c Too few things happening.

2 The effect of fatigue is discussed in more detail in the next section.

3 Mental workload also affects one’s ability to pay attention. First, a

person possesses limited mental resources. If too many things are happening at the same

time, that person has to divert his or her attention from one task to another. He or she can

be “spread thin.” This situation leads to reduced attention and/or selective focus.

4 At the same time, a person may have too little to do. A situation may

seem boring, with little activity occurring. Or a task may seem routine, having been done

by a person a hundred times before. These situations commonly lead to complacency.

MRM training is structured so that complacency in maintenance and its effect on human

error can be addressed directly.

(f) Fatigue.

1 Fatigue degrades a person’s ability to work effectively. One cause of

fatigue is sleep deprivation. Some of the effects of sleep deprivation are reduced reaction

time, impaired short-term memory, decreased vigilance, reduced motivation, increased

irritability, and an increase in the number of errors made, among others. Failure to act on

stimuli, even dangerous ones, is also a common result of fatigue.

2 Sleep deprivation is not the only cause of fatigue. Time on duty and

time since awake are common criteria researchers use to determine if fatigue may be a

factor on the job. Environmental factors, such as extreme temperatures, noise, vibration,

and task difficulty can also induce fatigue.

3 A great deal of anecdotal evidence points to fatigue in maintenance

personnel as a factor leading to human error. MRM attempts to increase awareness of

fatigue and its causes. MRM also teaches individuals about the consequences of fatigue,

especially in terms of human error in maintenance. Though presently no significant

quantitative research has been conducted on fatigue in aviation maintenance, studies are

currently underway evaluating the factors associated with fatigue and its effect on

maintenance personnel.
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(3) Situational Awareness.

(a) Situational awareness is one of the foundational concepts of MRM.

Typically, situational awareness is thought of in terms of individual maintenance

personnel. In addition, situational awareness also encompasses other related concepts

such as mental arousal and vigilance. Many of the most common maintenance errors

involve the loss of situational awareness among different individuals, often across

different teams or shifts. The concept of team situational awareness relates to maintaining

a collective awareness of important job-related conditions and events.

(b) Five elements and activities are necessary to improve Team Situational

Awareness in the maintenance environment. These are:

1 Shared mental models.

2 Verbalization of decisions.

3 Better team meetings.

4 Teamwork and feedback.

5 Individual situational awareness training.

(c) Shared mental models. A mental model is simply how to depict a

system mentally--how the subsystems are put together and how the system works. Good

situational awareness at the team level depends on all team members having a clear

understanding of what information means when it is conveyed to team members. Such

shared mental models are provided by developing a good understanding of what other

team members know, don’t know, or need to know. Team members need to share not

only data, but also the significance of data relative to their jobs and the team’s goals.

(d) Verbalization of decisions. At times team members may find it

necessary to take actions that deviate from the norm or are otherwise unexpected. These

unexpected actions may cause confusion or other adverse reactions by other team

members. It is very difficult to know why a team member has taken a course of action

unless he or she tells us. Individual team members need to do a better job of

communicating information regarding why they decide to (or not to) take a particular

course of action.

(e) Team meetings. Team meetings are critical to sharing valuable and

necessary information. Team meetings may be used to share information among team

members on the same shift and for passing information across shifts. To increase the

effectiveness of team meetings in attaining team situational awareness, Team Leads need

to receive training in the following:

1 Running a shift meeting and stating common goals for the team.

2 Providing a common understanding of who is doing what.
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3 Setting up an understanding of the inter-relationship between tasks and

personnel activities.

4 Providing expectations regarding teamwork.

5 Maintaining good communication practices.

(f) Teamwork and feedback. It is important that maintenance personnel

receive feedback on the outcome of their work. Such feedback is crucial to the

development of better mental models. Without such feedback, it is difficult to improve a

person’s diagnostic skills. For example, a complex diagnosis and repair may have been

totally successful, but the unit may have failed again a few days later at another station; a

person would be unable to correct the diagnosis without feedback on the subsequent

failure.

(g) Individual situational awareness training.

1 Many common problems can be linked to situational awareness

failures, including the following:

a Forgetting information or steps--frequently associated with task

interruptions.

b Not passing information between shifts or team members.

c Missing critical information due to task-related distractions.

d Misinterpreting information due to false expectations.

2 Training maintenance personnel to recognize threats to situational

awareness and to cope with their effects can minimize these problems.

(4) Leadership.

(a) In the past, most people thought that the ability to lead was an inherent

trait of a person. Leadership was seen as a logical outgrowth of a person’s personality.

To add to the confusion, the types of groups that can be led vary as much as the leaders

who lead them. Today leadership is defined less in terms of a trait and more as a function

of the group being led. Leadership is seen to include managing individual organizational

components as well as their interaction with other groups in the organization.

(b) Leadership has many facets. In its simplest form, leadership is the ability

to direct and coordinate the activities of group members and stimulate them to work

together as a team. It includes being in a position to control the resources of a group.

Imagine how difficult it would be for a maintenance shift supervisor to lead if he or she

did not have a say in assigning people’s tasks, determining department budgets, or even

determining which planes will be serviced. The definition of leadership is now much

more complex than it was 30 years ago.
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(c) Two Specific Types of Leadership.

1 There are many different definitions of leadership. We will discuss two

of the more broadly accepted types of leadership. They are authoritative and

participatory. Authoritative is derived from the word “authority.” An authoritative

leader tends to make all team decisions and controls all resources because the team is

structured as a hierarchy. A hierarchical structure is one in which many levels of

management exist and there is a clearly defined boss.

2 A participatory leader allows each team member to have a say and to

participate in team processes. The team leader is more egalitarian, or equal, under

participatory leadership than with an authoritative leader. The participatory leader may,

however, ultimately decide the team’s actions, but takes into consideration the team

members’ experience, knowledge, and preferences.

a An authoritarian leader dictates action and the course of the team

with little input from team members.

b A participatory leader encourages member participation and input to

help lead the team's course of action.

3 One may ask if one form of leadership is better than another form. The

answer to that question usually depends on the organization of the team and the task

being performed. For example, a fully participative team where a vote is taken and every

team member surveyed on every little detail of the workday would be unable to perform

their duties in a timely manner. However, an overly authoritative supervisor or manager

who fails to request input from anyone may suppress the free flow of ideas and dictate

team activities that negatively impact safety. Good leadership is a balancing act between

the two. The following table presents some guidelines for when to choose which style,

but keep in mind that this list is far from complete.

Guidelines for Choosing a Leadership Style

When to use an authoritative leadership

style:

• If a task needs to be done quickly.

• If a task is structured and a clear-cut

answer exists.

• If conflict and a lack of communication

exists between team members.

• If you are certain all team members will

accept the final decision if made by a

single person.

When to use a participatory leadership style:

• If there is time to get input from all members.

• If a task is unstructured and may require

extensive group decision making.

• If team members get along and communicate

well.

• If you are certain team members will not

accept the final decision if made by a single

person.

Table 2. Guidelines for Choosing a Leadership Style.

4 In addition to his or her own team members, a frontline maintenance

supervisor on the job must interact with a variety of upper-level managers, shop
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personnel, shift/crew supervisors and their teams, union representatives, catering/other

ground support personnel. As a result, supervisors must be trained not only in the skills

to handle those in their assigned teams, but also in interacting effectively with others

outside the assigned team.

(d) Responsibilities of Leaders.

1 Leaders have a variety of responsibilities they must meet to ensure a

smoothly running team. The following table presents twelve important leadership

responsibilities.

Leader Responsibilities

Responsibilities of leaders

1. Supervise and coordinate crew activity.

2. Delegate tasks to appropriate crew members.

3. Define crew responsibilites and expectations.

4. Focus attention on critical aspects of the situation.

5. Adapt to internal and external environment changes.

6. Keep crew informed of work-relevant information.

7. Ask crew for work-relevant information and respond accordingly.

8. Provide feedback to crew on performance.

9. Create and maintain a professional atmosphere.

10. Promote teamwork.

11. Effectively manage workload issues/stress.

12. Train and mentor subordinates to be proficient at their tasks.

Table 3. Leader Responsibilities.

2 Certain behaviors make a leader more effective. Conversely, some

behavior detracts from effective leadership. Some of the behavior characteristics that

affect leadership effectiveness are listed below.

Leadership Guidelines

Effective and Ineffective Leadership

Effective Leadership Skills Barriers to Good Leadership

• Make suggestions

• Make the crew want to perform

activities

• Lead by inspiration/example

• Provide feedback to the crew

• Micromanagement (trying to do everything

oneself)

• Poor interpersonal skills

• Inexperience

• Pressure

• New situations

• (Personal) rigidity/stubbornness

Table 4. Leadership Guidelines
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3 To conclude, leadership is the application of a cluster of teamwork

skills on an individual level. These skills include communication, coordination, and

decision making as well as technical knowledge. However, though some appear to be

born leaders, leadership skills are not innate. Instead, individuals can be trained to be

good and effective leaders.

10. SAMPLE MRM TRAINING COURSE. The behaviors and skills described in

section 9 are what comprise a typical MRM course. Appendix 1 is a typical MRM

training course reflecting many of the concepts discussed in that section. Some of the

concepts discussed in Appendix 1 may not apply equally to all organizations. The

organization developing the MRM course should tailor the course to fit the particular

organization.

11. IMPLEMENTING MRM TRAINING.

a. This section describes a number of the techniques to analyze the necessity and

identify the benefits of implementing MRM in an aviation maintenance organization.

The emphasis of this section, therefore, is on the introduction of MRM-related knowledge

and skills into the workplace, i.e., conducting MRM training.

b. Do not anticipate or assume that most aviation maintenance managers will have

the training, skills, time, or inclination to develop an MRM training program. However,

there are many tasks associated with such a program that are within the responsibility of

managers. Managers should understand the most important aspects of the framework

within which MRM training programs should be developed and evaluated.

c. MRM training should be implemented through the use of the Instructional

Systems Design (ISD) method, modified to be applicable directly to MRM and the

aviation maintenance workplace. ISD is a generic term for the methodology of creating

and implementing a training program. This section describes this tailored ISD approach.

d. The ISD approach places a heavy emphasis on user needs. It incorporates

extensive user testing during the design and development phases. Involving maintenance

workers and managers on an MRM training design team is essential when using the

systems design approach. Each of the major activities in the ISD framework is described

in the following sections.

e. Analysis.

(1) The first phase of the ISD process consists of analysis, usually called frontend analysis. Activities in this phase consist of gathering and analyzing information,

followed by writing the objectives, goals and functional specifications for the training

program. The idea is for the MRM design team to identify the organizational and trainee

needs and constraints before it begins designing the training program.
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(2) The analysis phase begins by assessing the requirements, or needs, that the

MRM training program must satisfy. There are three levels of needs assessment,

organizational analysis, task analysis, and trainee analysis.

(3) Organizational analysis.

(a) Organizational analysis consists of an evaluation of the maintenance

organization in which the trainee performs the job, and an evaluation of the training

resources that could be applied. The training may be provided by the maintenance

organization or by a training organization separate from the maintenance organization.

The MRM training design and development team is selected during this phase of the

process. It is critical to the success of the training program to include representatives

from all of the essential areas of the maintenance organization. Likewise, senior

management must allow team members to devote the necessary time to the project.

(b) In determining the reasons why an MRM training program is being

undertaken, it is important to analyze:

1 The current performance of the organization and workers.

2 The desired performance of the organization and workers.

(c) If a difference between current and desired performance exists, then

there is a performance gap. Organizational analysis determines the probable cause(s) of

performance gaps and includes a distinction between needs that can be solved by training

and other needs that must be addressed by a change in organizational procedures or

policies.

(d) For example, issues that should be addressed by developing a company

policy might consist of re-designing of workcards or re-formatting an engineering

authorization (EA) form. Training could address the problems of engineers and technical

writers in writing a workcard or an EA that is clearly understood by others. MRM

training could teach maintenance personnel the skills that allow them to recognize how

the environment, such as the readability of a workcard, impacts human performance.

(e) The second part of organizational analyses is evaluating the resources

available for the development and delivery of the MRM training program. This consists

of identifying various constraints, such as the availability of equipment, time, money, and

instructors. This information is transformed into a set of functional design specifications,

a specific list of training goals, and system requirements that will provide the boundaries

of the training program. The initial specifications document helps the training

designer(s) generate appropriate design solutions. Later in the design phase, these

functional specifications may be expanded to include detailed specifications for training

program development.

(f) As part of organizational analysis, identify training costs and the

outcomes or benefits from implementing MRM training. Benefits can be measured by
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the company’s typical performance measures related to maintenance tasks, such as

dependability (departures, in-flight shutdowns, return-overnights, no fault found

removals and replacements), safety (ground damage, occupational injuries), and

efficiency and quality (component shop statistics).

(4) Task analysis. Conducting a task analysis is the second step in a needs

assessment. The task analysis is performed to determine the tasks required in a job, the

subtasks performed for each task and the knowledge and skills required to successfully

perform the subtasks. The task analysis is a critical step in the design process. If the

necessary knowledge and skills are not adequately identified, then the designers will have

difficulty determining the required content for the training program. In other words, a

trainer must know what skills to train and which of them are important to completing a

task before he or she can create an effective training program. This need not be a

resource intensive endeavor; it may entail observing employees over the course of a few

days, or by interviewing experts or highly experienced individuals. It is vital, however,

that these data are obtained systematically and as completely as possible. If not, a trainer

may end up providing the wrong or irrelevant knowledge, skills and abilities, resulting in

an ineffective training program.

(5) Trainee analysis. One of the major goals of MRM training is to provide

maintenance personnel with the knowledge and skills that will allow them to function

well as part of a maintenance team. Trainee analysis is performed to identify the relevant

characteristics of the people who will be participants in the program. Information

obtained in this analysis includes demographic data (such as age and gender),

occupational experience, existing knowledge and skills relevant to the training program,

and a list of elements the trainees regard as important. Trainee analysis should identify

the trainees’ perceptions of the job-related skills and knowledge they need to effectively

perform their jobs.

f. Design.

(1) In the design phase, goals and objectives, content, instructional strategies,

and testing procedures are developed for each training topic identified in the front-end

analysis. The design process consists of four hierarchical levels are program, curriculum,

course, and lesson.

(2) The program and curriculum levels are associated with a high level, or

macro, type of design. At this point, training is linked with the strategic plans of the

organization. A series of course needs is also identified for different groups of trainees.

(3) The course and lesson levels comprise a more in-depth, low level, or micro,

type of design. At this point, decisions are based on instructional theory and research.

Thus the designers are concerned with the learner’s ability to understand, remember, and

transfer the training concepts to the work site.
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(4) It is important to note that a successful design for MRM training courses

includes a high level of interaction, i.e., group exercises, case studies, and practice

sessions. This type of design is known as adult inquiry learning, in that learners

manipulate materials and equipment, participate in problem solving discussion groups,

respond to open-ended questions, and collect data from direct observation of instructional

events. This type of learning promotes effectively acquiring and processing information.

Participation in specific activities is highly motivating and tends to promote better

retention.

(5) The design concept includes a description of one or more delivery methods,

as well as the form and content of the actual lesson material. In some cases, several

alternative design concepts might be generated for preliminary testing and evaluation.

(6) Macro design.

(a) During the macro design step, goals are developed that position the

MRM training program to achieve the company’s goals and mission. General training

areas are specified and organized into curricula. Curricula may be organized by subject

matter, such as MRM awareness or MRM skills development. Once training needs are

placed into curricula categories, they are further organized into individual courses or

training modules that are then prioritized and scheduled for development and

implementation. An additional component of macro design is the initial selection of

methods and media that can be used to deliver the training.

(b) It is important to note that it is not the choice of a particular technology

that ultimately determines the effectiveness of a training program. Rather, the soundness

of the instructional design will set the stage for the efficiency and effectiveness of the

training. The design process should not be media technology driven. Do not decide on a

particular delivery system or medium until your analyses are complete.

(c) Do not deliver a training lesson via videotape or lecture without

considering the underlying instructional objectives. A medium inherently is neither good

nor bad, but it can be either appropriate or inappropriate. If sound instructional design

principles are used, the designer will choose instructional materials and technologies that

meet identified learning objectives and functional requirements.

(7) Micro design.

(a) Micro design moves from the broad categorization of curricula into

courses or modules to the detailed design of the individual course or module and the

lessons within each course or module. Micro design is based on the educational goals for

each training topic. Learning objectives--what the trainees are expected to know and be

able to do after training--guide the selection of “enabling objectives.” Course

prerequisite knowledge and skills are established. The differences between pre-training

and post-training knowledge and skills are transformed into learning objectives for

individual lessons.
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(b) Learning objectives are used to develop a content outline for individual

lessons and to finalize the selection of instructional methods and media. A curriculum

hierarchy is developed. The terminal objectives are at the top of the hierarchy, followed

by enabling objectives. At the bottom of the curriculum hierarchy are the trainees’

prerequisites for the course. This learning task hierarchy flows from the bottom to the

top. A trainee must successfully meet one training objective before moving to the next

higher training objective.

(c) Media selection.

1 Training designers determine if it is possible to purchase existing

courses, lessons, and audio-visual materials from vendors that will meet their

requirements, or if training materials need to be developed.

2 During the micro design phase, media and instructional methods are

selected for each lesson. For example, a videotape clip may be selected to present the

lesson objective, followed by a group exercise. Media selection is dependent on the

learning objectives that are to be achieved. There are media selection models that suggest

what media (technology) is optimal for specific types of learning objectives.

3 Often, the design of a lesson will include several complementary

media. A module related to shift turnover might include a one- to two-hour videotape

describing and demonstrating an effective shift turnover meeting followed by roleplaying at a mock shift turnover meeting with feedback from the training facilitators.

(d) Design of evaluation tools. The tools for evaluating the training

program should be identified and developed during the design phase. A number of

evaluation tools are commonly used for MRM training. Typically, questionnaires are

used to measure how well the trainees have met the course objective(s) immediately after

completing the training course. Included in the post-training and follow-up (2-12 months

after training) questionnaires are questions concerning how useful the course was to the

learner, and opinions on how the course accomplished the stated training goals. All of

these questionnaires need to be designed, validated, and developed in order to be

included in the evaluation phase of the ISD model.

g. Development.

(1) Following the design phase, the actual MRM courseware must be developed.

This includes developing all training material, in whichever media are selected during the

design process. Since various media interact with certain instructional methods, the

development phase includes walkthroughs of all modules that include some type of live

instructor/trainee interaction.

(2) Developing training materials.
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(a) The design team develops drafts of the materials required and seeks the

artistic and production expertise of audiovisual specialists. Specifications developed in

the design phase are completed for each lesson. Tasks include writing a detailed outline

and developing conceptual sketches for audiovisual aids. The outline and sketches are

generally reviewed by the entire design team before they are fully developed into

instructor scripts, handouts, and participant exercises. Generally, drafts are reviewed and

revised before a formal walkthrough takes place.

(b) Prior to conducting a walkthrough, or other type of formative testing, the

training materials should be considered to be prototypes. They should have the look and

feel of the final product to the extent possible. Prototyping provides the basis for a

formative evaluation in which feedback is solicited from the trainee population,

managers, peer professionals, and subject matter experts.

(3) Walkthrough.

(a) It is necessary to identify problems or shortcomings early in the design

cycle. The prototype test, or walkthrough, is designed to identify and correct problems

before the materials are produced for company-wide use. In a walkthrough, the design

team meets with members of a review team and walks them through the prototype course

materials. The two groups identify potential problems and discuss any suggestions for

improving the materials.

(b) It is possible at this time to have the design team test various instructional

options with the actual learners to determine whether less resource-intensive alternatives

will result in satisfactory learning. This prototyping phase determines whether certain

instructional strategies are necessary and sufficient to accomplish the training goals.

User testing should be carried out to ensure that the training program fulfills the needs

identified in the instructional functional specifications and learning task hierarchy. Based

on the data obtained through user testing, the prototype can be modified and re-tested.

(4) Final development.

(a) Final user testing and full-scale development occur after the materials

have been modified and re-tested, based on information obtained during the walkthrough

and other user testing. After the training program is fully developed, it should be

subjected to final user testing before being implemented.

(b) Final development of the training program includes all training material

and media development. This is usually the most time-consuming step of the entire

design process. Final pre-implementation user testing consists of actually conducting the

training in a typical training environment. This test training uses all the training materials

and the trainees perform all of the course exercises. The follow-up questionnaires should

be administered after the test training is complete.
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g. Implementation.

(1) In this phase of the ISD process, the fully pre-tested MRM training is moved

to the production environment. Implementation typically consists of two parts:

scheduling and facilitator training.

(2) Scheduling.

(a) A schedule delineates how and when MRM training is to be delivered.

For most large-scale programs, it is beneficial to implement the training in stages. A

staged approach is useful because it allows trainers, trainees, and management to evaluate

the program as it is being rolled out. It also promotes a readiness for change by

demonstrating results.

(b) Often, a tentative implementation plan is developed at the end of the

front-end analysis phase, once curriculum requirements are identified and a schedule for

course development can be determined. As part of this plan, program evaluation criteria

should be specified.

(3) Facilitator training.

(a) In many instances, the facilitators or instructors are not part of the design

team. Even when they are involved in the design process, they may have to learn certain

facilitator skills, as well as learning the course materials and the intent of the training.

Such training is usually designed and written during the development phase and

presented as required throughout the prototyping and implementation stages of the ISD

process.

(b) For MRM training programs, co-facilitation is essential as it provides the

opportunity for two representative workers to actively present and facilitate the

instructional process. Having co-facilitators allows for a high level of interaction among

the course participants as well as providing subject matter expertise in the field of

aviation maintenance.

(c) Early experience from MRM courses has shown that MRM training is

highly effective when maintenance personnel co-facilitate with Human Factors experts.

Together, they can be a dynamic team representing a valid combination of knowledge

and work experience. Additionally, they can respond to course participants with

examples and scenarios that demonstrate the training concepts being presented.

i. Evaluation.

(1) It is very important to evaluate the effects of the MRM training program.

This step is often overlooked in industrial settings. However, a reasonable evaluation

effort can determine whether the overall program was successful and met the training
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program goals. The output of the evaluation can be used to determine whether and what

type of revisions or modifications needs to take place.

(2) Evaluation types.

(a) There are two types of evaluations: formative and summative.

Formative evaluation occurs as the instructional program is being developed and will not

be discussed in this Advisory Circular. Summative evaluation occurs after the training is

implemented. Summative evaluation takes place during the implementation stage of the

ISD process. It is typically conducted at the end of each training presentation. It acts as a

summation of that course session.

(b) Summative data collection includes the assessment of the trainees’

mastery of the course material, as well as the appropriateness of the training design.

Summative evaluation can also be conducted some time after the instruction has been

taught. In these instances, it is often called follow-up evaluation. Its purpose is to

determine if the participants are using the training. It is most often used to determine the

success and effectiveness of the training program.

(3) Summative evaluation.

(a) The summative evaluation process can be viewed as a five-step process:

1 Baseline Assessment: In order to establish if your training has had

any effect on the organization, a baseline assessment must be made. A baseline

assessment is merely a measure of the current environment before testing. It is important

to use consistent measures for post-training assessment; baseline and post-training

measures will be compared to evaluate the effect of training.

2 Reaction: Post-training questionnaires are administered immediately

after the training to evaluate and measure the program success. The facilitators are also

evaluated. The main thrust of this evaluation should occur during final user testing as

well as upon completion of the course.

3 Learning: Subject mastery is measured before and after training.

Criteria used to measure the level of learning is identified in the design phase. Typically a

pre/post training questionnaire is used to evaluate the learning that takes place as a result

of the training. Learning includes gaining principles, facts, techniques and attitudes.

4 Behavior: The effect of training on the learners’ work performance

is evaluated at this step. Has the trainee transferred the concepts from the training

program to the work site and applied them so that there is an observable difference? Selfreported comments on follow-up questionnaires as well as interviews and observations of

the trainees in the field are most valuable.
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5 Organizational results: At this step, organizational performance

measures identified in the analysis phase are tracked over time to determine if a

difference (attributable to the training program) has occurred. Any evaluation at this point

can be viewed as a secondary result of the training program. That is, changes in attitudes

and behavior affect job performance, which, in turn, affects organizational factors such as

safety, dependability, quality, and efficiency.

(b) It is important to measure the effectiveness of the training program using

all four evaluation criteria levels. Commonly, after the Baseline Assessment,

organizations apply evaluation criteria to only Reaction and Learning, and do not conduct

an evaluation of Behavior and Organizational Results. This is because it typically takes

additional resources to conduct these evaluations. However, it is critical to evaluate the

training program in a comprehensive manner to fully understand its effects.

12. TRAINING SUMMARY.

a. Implementing a training program seems at once simple and complicated. On one

hand, training programs are implemented everyday; on the other hand, the guidelines

outlined above show that proper implementation is made up of a variety of tasks and

subtasks, each one building upon another. However, when broken down into its basic

parts of development, implementation, and evaluation, training is not complicated. It

requires only the ability to manage a variety of tasks, combined with the skill to perceive

these tasks as a whole. Keeping in mind how training will be evaluated months in the

future will help in the initial design of the program.

b. The big picture does not just stop there, however. It must also be remembered

that MRM is more than just a training program or its parts. That is easy to forget when

one is bogged down in the details of creating a Human Factors course, for example.

MRM represents a shift in thinking about how one does his or her job. It encourages

individuals to feel personally responsible for safety and provides the tools for them to

begin to move down that path. To that effect, a holistic approach must be taken when

developing and implementing an MRM training program. It should not be done halfheartedly with shoddy materials and insufficient resources. This does not demonstrate

full commitment, and will not inspire trainees to embrace a safety culture. MRM’s

effectiveness does not necessarily lie in a training program; the training program only

provides MRM’s tools. For MRM to be fully effective, employees should be encouraged

to use those tools, believe that they can use those tools, and be shown that those tools

make a difference. This remains the basic philosophy of MRM.

/s/

L. Nicholas Lacey

Director, Flight Standards Service

9/28/00 AC 120-72

Appendix 1

Page A1

APPENDIX 1. MAINTENANCE RESOURCE MANAGEMENT

SAMPLE CURRICULUM

(The following sample curriculum is a guideline only and is not meant as the only presentation method.

Facilitators should tailor the course material and presentation to meet their specific objectives.)

Module 1 MRM Human Factors Training: Introduction

Maintenance Resource Management

Day 1: Training Goals:

1. To understand what Human Factors and MRM principles are.

2. To increase the awareness of how Human Factors and MRM principles impact

human performance.

3. To understand how MRM and Human Factors principles can promote a safe and error free

workplace.

4. To examine the human role in maintenance operations in relation to a chain of events.

5. To provide Human Factors and MRM techniques and skills that will help you interact with

others.

6. To develop an understanding of available Human Factors and MRM resources, internally and

externally to your company.

Day 1: Training Objectives:

1. To recognize and identify Human Factors elements

2. To understand human error and recognize contributing causes

3. To identify the chain of events in an accident

4. To develop safety nets or “link busters”

5. To identify and recognize norms

6. To be aware of individuals differences and behavioral styles

7. To be aware of how written communication can reduce human error

8. To develop effective communication skills
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Page A2

Activity/Overhead Facilitator Notes

Handout

Pre-training questionnaire

Explain: This course is being evaluated. We need a

before and after picture to determine the effectiveness of

this training. Here is a survey we want you to complete.

Your answers, combined with those of all other people

who take this course, will help us better evaluate our

MRM Human Factors training program. Of course, the

survey is completely confidential. Please do not put you

name on it anywhere.

Assign group names: types of

aircraft

Overhead: History

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

History of Human Factors Training

Q The information below represents events that led to the

development of Human Factors in the airline industry.

United Airlines Flt 173

Portland , Oregon

December 28, 1978

Aloha Airlines Flt 243

Maui, Hawaii

April 28, 1988

Air Ontario Flt 1363

Dryden, Ontario

March 10, 1989

CRM

Cockpit Resource Management

CRM

Crew Resource Management

LOFT

Line Oriented Flight Training

CCC

Crew Coordination Concept

HPIM

Human Performance in Maintenance

MRM

Maintenance Resource Management

Explain: This overhead illustrates the events that led to

the development of Human Factors training. We are here

today in our MRM course to learn about error

management, by using Human Factors skills and

understand what error-prone tasks are.

The importance of Human Factors and maintenance

resource management can be traced back to the Aloha

Airlines accident in 1988 followed by the Dryden Air

Ontario accident in 1989. Maintenance Resource

Management built on Crew Resource Management

programs that had been developed for pilots.

In today’s course we will be introducing MRM principles

and concepts to you as they are related to aircraft

maintenance. This course was developed for

maintenance personnel from the start based on a review

of how you do your jobs and where problems occur.

Overhead: Class Introduction

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Introduction

– What is your name and job description?

– How did you get into aviation?

– How many years have you been

aviation?

MRM Human Factors Training

Introduce facilitators and participants (Allow 30 seconds

for each participant).

Name/Title

Years of service

How did you get into aviation?

After introduction, explain: As you can see there is a

considerable amount of experience within this room. We

have different backgrounds and cultures, but we all are

part of aircraft maintenance.
9/28/00 AC 120-72

Appendix 1

Page A3

Overhead: Workshop Agenda

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

MRM Workshop Agenda:

Day 1

– Introduction

– Maintenance Resource Management

– Human Error

– Human Factors elements

– Chain of events

– Safety Nets and link busters

– Norms

– Individual Differences

– Communication

MRM Human Factors Training

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

MRM Workshop Agenda:

Day 2

– Teamwork

– Stress Management

– Fatigue & shiftwork

– Task Interruptions & complacency

– Situation Awareness

– Human Factors/MRM initatives in this

company

– Human Factors/MRM resources

MRM Human Factors Training

We understand that some of the terms we will discuss

may be new to you, but as the day goes on, you will

understand what these terms mean. Please be prompt on

returning from your breaks. Lunch and breaks are at...

Feel free to use the restroom.

First we’ll begin by presenting and discussing what

Human Factors and MRM are. This includes identifying

important Human Factors elements, understanding human

error and causes, recognizing the “dirty dozen” or Human

Factors elements in aircraft maintenance, identifying

chains of events and breaking chains of events by

implementing safety nets or “link busters.”

Next, we will recognize norms and understand their

impact on human performance. Then we will cover the

idea of individual differences and how they can influence

our behavior on the job. Understanding the importance of

effective communication that is written and verbal will be

our last MRM training area and we will have some great

group exercises in this section. That will wrap up Day 1.

Day 2 will build on the MRM concepts you learned on

Day 1 and you will begin to become more aware of the

importance of Human Factors and MRM. Our first

activity will be to discuss teamwork and have a group

exercise. Next we will talk about stress management, how

to recognize stress, and how to manage it. We will also

talk about fatigue and shift work and how it effects our

performance. Recognizing how task interruptions impact

our performance and can cause us to make errors is our

next area of discussion. We will also talk about

complacency and how we can develop safety nets or link

busters to avoid errors.

We’ll also learn to recognize and avoid situation

awareness problems, and understand the factors that can

impact situation awareness within a maintenance team.

To better understand what MRM and Human Factors

programs our company has developed and what

departments exist to help you we are going to tell you

what our MRM and Human Factors activities are. This

will also include what MRM and Human Factors

resources we have in our company and who you should

contact. We want you to understand who and what

departments you can contact to present and discuss MRM

and Human Factors issues and ideas.
AC 120-72 9/28/00

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Page A4

Video or “visible” support from

top management regarding

MRM/HF course. Plans and

actions for implementing MRM in

maintenance operations.

Examples: Senior manager(s)

comes to the beginning of course;

“talking head” video; letter;

newsletters

Explain: MRM is Maintenance Resource Management.

As you can see, we are dedicated to enhancing safety

through implementing MRM principles. Together our

efforts can enhance the safety of all actions taken by all

maintenance and operations personnel at our company.

Overhead: MRM definition

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Definition of MRM

Q MRM addresses Human Factors errors

and problem resolution through open and

honest communication among

Technicians, Managers, and FAA.

Q MRM is working together, using available

resources, to reduce errors and to

promote safety.

MRM Human Factors Training

Refer to current MRM and Human Factors articles in the

appendix section of your handbook.

Overhead: Goals

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

MRM Training

Goals

Q Our goal today is to provide you with

specific Human Factors techniques and

principles that will help you do your job

safer.

Q As you leave today it is our intention that

you can immediately use these skills.

MRM Human Factors Training

Emphasize: you can immediately use these skills!

MRM Goals:

1. Increase safety

2. Reduce human error

3. Reduce the effects of human error

4. Enhance teamwork

5. Increase situation awareness

6. Increase effective communication
9/28/00 AC 120-72

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Page A5

Overhead: MRM Skills

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

MRM Skills

– The skills that you will learn are:

• Identify Human Factors elements

• Recognise the “Dirty Dozen” of aviation maintenance

• Identify human error

• Identify the chain of events of accidents

• Effective communication

• Identify norms

• Establish safety nets

• Recognise safety mechanisms/approaches

• Understand situation awareness

• Recognize stress and how to handle stress

• Idenitfy teamwork skills

• Understand MRM & HF resources

MRM Human Factors Training

We are going to learn these skills today in class.
AC 120-72 9/28/00

Appendix 1

Page A6

Module 2 Human Error

Training Objectives:

1. To understand human error and recognize contributing causes

2. To be aware of how errors can impact human performance

3. To identify human error types

Activity/Overhead Facilitator Notes

Video: Show Dryden video

or Show Nation Air video

Note: Depending on time, MRM facilitators will need to

decide whether to show two videos or one. The Nation

Air video is produced by MARS. Contact them to

acquire the video. The Dryden video can be purchased

from Qantas airlines (CRM training). Both videos clearly

demonstrate crew management problems as well as

several other Human Factors problems. Design this

specific module carefully to use these videos to

accomplish specific training objectives and skills. You

may want to break the presentation into two parts. Have a

discussion or group exercise to begin to de-brief the

video.

Let’s watch a short video.

Question: Why did this accident

happen?

Discuss the role human error played in the accident.

Debrief the class as to why this accident happened. Make

the class aware that an accident was caused by human

error.

Question: What is human error?

Overhead: Human Error is..

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Human Error

Q Human Error is the unintentional act

of performing a task incorrectly that

can potentially degrade the system.

MRM Human Factors Training

Human error can also be defined as:

Slip: a good plan, bad execution

Mistake: bad plan

Infringement can be seen as an intentional deviation from

safe operating practices, procedures, standards or rules.
9/28/00 AC 120-72

Appendix 1

Page A7

Overhead: Two types of errors or

failures

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Types of Errors & Failures

Q Active Failure: Action with immediate

effects

Q Latent Failure: Caused by someone

or something having a delayed effect

MRM Human Factors Training

These errors are very important to recognize in our

maintenance operations. Latent failures are ones that we

really need to pay attention to. These types of failures

sneak up on us and we sometimes do not know why they

happened. There are so many causes and the errors all

have to line up in order for an accident to happen.

Reference (Reason, 1997)

Overhead: Factors Line up to

Cause an Accident

Active and latent failures and conditions are present and

can become “holes” in several layers of defenses. If these

holes “line up,” an accident can occur.

Overhead: A Human Factors

Accident

This slide shows how an accident can occur when all the

holes are lined up and active and latent conditions or

failures exist.

Let us walk through an accident scenario where all of the

defenses did not work.

Overhead: Types of Human

Errors

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Three types of Human Error

Q

– 1. Error of omission: Not performing an

act or behaviour--simply just didn’t do it

– 2. Error of commission: Substituting an

act or behaviour

– 3. Extraneous error: Performing an

additional action

MRM Human Factors Training

Explain error of omission.

Example of error of omission:

Elevator scenario: get in elevator, door closes, forget to

push button-- error of omission. Get in elevator, want to

go to ninth floor and push the fourth floor button instead--

error of commission. Get in elevator, want to go to ninth

floor and pushes fourth button instead--, gets off on

fourth floor--- extraneous error.

Question: Ask class what type of errors did the crew do in

the Dryden accident.

Overhead: Nuts & Bolt

Class demonstration

Group Exercise

Questions:

There is only one way to disassemble

40,000 ways to error in reassembly

(Reference: Reason, 1997)

Have either facilitator or groups study a bolt with a series

of nuts on it. Discuss the implications of removing the

nuts. What are the Human Factors implications? What

type of errors could occur?

What type of Human Factors design principles could be

used to prevent errors?

These are called safety nets or link busters.
AC 120-72 9/28/00

Appendix 1

Page A8

Overhead: What are the levels of

consequences of human error?

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Levels of Consequences:

 Human Error

– Little or no effect

– Physical damage to equipment

– Personal injury

– Catastrophic event

MRM Human Factors Training

Ask: What was the level of the consequences of the

Dryden incident?

Answer: Catastrophic

Overhead: Aviation accident chart

Aviation Accidents

Human Causes

Machine Causes

1903 Today TIME

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0%

Explain chart: State that 80% of accidents are caused by

human error.

If we look at aviation accidents over the course of history,

we see that accidents due to mechanical deficiencies have

declined. Systems are much safer than they were for

Orville & Wilbur Wright.

Correspondingly, however, those accidents with an

underlying human component have increased. (Mainly

because that’s what is left to blame when something goes

wrong.)

Overhead: Accident

causes/percentages

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Significant accident causes and percentage present

in 93 major accidents: (Graber & Marx, 1992)

– Pilot deviated from basic operational procedures 33%

– Inadequate cross-check by second crew member 26%

– Design faults 13%

– Maintenance and inspection deficiencies 12%

– Absence of approach guidance 10%

– Captain ignored crew inputs 10%

– Air traffic control failures or errors 9%

– Improper crew response during abnormal conditions 9%

– Insufficient or incorrect weather information 8%

– Runways hazards 7%

– Air traffic control/crew communication deficiencies 6%

– Improper decision to land 6%

MRM Human Factors Training

In general, around 80% of accidents have human error as

a major causal factor.

Not only pilot errors are included in human error--

12% involved maintenance and inspection errors.

Therefore, pilots are not the only ones—maintenance

personnel cause errors in aviation also. Show the role that

maintenance and inspection play (other crews).

Video: Show short video clips of

AA#1 and Dash 8

Maintenance contributed to both of these accidents.

(Incorrect wiring on AA#1, improper fuel filter

installation on Dash 8) (Boeing company manufacturing

and safety video).
9/28/00 AC 120-72

Appendix 1

Page A9

Group or class exercise

Overhead: Top 8 maintenance

problems

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Top eight maintenance problems listed in order of

occurrence: (Graber & Marx, 1992)

Q

– 1. Incorrect installation of components

– 2. The fitting of wrong parts

– 3. Electrical wiring discrepancies (including crossconnections)

– 4. Loose objects (tools, etc.....) left in aircraft

– 5. Inadequate lubrication

– 6. Cowlings, access panels and fairings not secured

– 7. Fuel/oil caps and refuel panels not secured

– 8. Landing gear ground lock pins not removed before

departures

MRM Human Factors Training

Facilitator’s note: class exercise

Before showing slide, ask, “What do you think are some

of the maintenance problems that contribute to

accidents?” Take the class’s reasons. Then show this

slide. Compare.

This is a list of the most frequent maintenance errors.

Any of these can lead to a loss of airworthiness, delays,

inflight emergencies, or an accident or incident if not

corrected.

Most of these problems involve human error.

Unfortunately, within the term human error is an

underlying theme of “finding who is to blame?” It is our

natural tendency to look for the last person who touched

the aircraft or part and blame that person for the error.

However, error can be caused by many contributing

factors. Human Factors studies those factors that can lead

to problems or failures in the human component of a

system.

Now lets look at how these maintenance problems relate

to human lives lost in aircraft accidents.

Overhead: Maintenance Costs

Example

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Maintenance Costs: Example

Q Engine shutdown average cost is $500,000

Q Flight cancellation averages $50,000

Q Return to gate averages $15,000

Q One airline estimated $75-$100M/yr. on error

Q ATA estimates $850M/yr. ground damage

Q Average ground damage incident is $70,000

MRM Human Factors Training

Maintenance errors can be translated into costs. These are

some examples of maintenance costs.

Can you think of any others?
AC 120-72 9/28/00

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Page A10

Overhead: Maintenance &

Organizational Culture

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Organization Culture

Q A pattern of beliefs and expectations

shared by an organizaiton’s members

Q Shaped by rules and procedures stated

by upper-levle management

MRM Human Factors Training

An organization’s culture also can contribute to error.

For example, an organization that makes on-time

departures its number one priority may, in fact, be

neglecting or even eroding safety. The company may not

give its employees enough time for a proper aircraft

turnaround, and second, may not give them the power to

ground a suspect plane. Even though management may

not intend to, their practices may encourage unsafe

aircraft.

Overhead: List of organizational

and local factors

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Organizational and Local Factors

Q Organizational Factors:

– structure

– quality & availability of resources

– training and selection

– incentives

– career paths

Q Local Factors

– knowledge, skills and abilities

– morale

– resources

– environment

MRM Human Factors Training

In any company, organizational factors interact with local

factors. Organizational factors include the organizational

structure, the quality and availability of resources and

their distribution to employees, the training and selection

of personnel, and the awareness of how incentives, career

paths, and other management factors affect employees.

Local factors are those factors found on the hanger floor

itself. These include the knowledge, skills and abilities of

those in the work group, employee morale, the

availability and quality of resources in the hanger itself,

and the environment. Other local factors include your

own personality, disposition, and mood. Local and

organizational factors may interact in such a way to create

an extremely error-prone work environment.

Overhead: Safety issues vs.

Onboard fatalities

Safety Issues vs. Onboard

Fatalities

0 500 1000 1500 2000 2500

CFIT

Loss of Control

Approach/Landing (nonCFIT)

In-flight Smoke/Fire

Windshear

Out-of-configuration Takeoff

Rejected Takeoff

Frequency (%)

(Worldwide Jet Fleet 1982-1991)

Reference:

Explain maintenance’s involvement toward the loss of

life in aircraft accidents.

Worldwide, maintenance problems are the second

greatest contributor to onboard fatalities, following

controlled flight into terrain (CFIT).
9/28/00 AC 120-72

Appendix 1

Page A11

Comment

Errors affect profit.

Errors may be frequent but tolerance is high.

A small percentage of errors actually cause accidents or

incidents.

Most of these discrepancies involve human error.

Unfortunately, within these definitions of error is an

underlying theme of who is to blame. It is our natural

tendency not to search for a root cause, but to look for the

last person who touched the broken object. However,

human error can be caused by one or more contributing

factors. These are as Human Factors elements. Now, lets

discuss what Human Factors is and how to recognize

Human Factors elements and understand how they impact

our performance, thus contributing to human error.

Remember that we want to understand these elements so

that we can contribute to reducing errors.
AC 120-72 9/28/00

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Page A12

Module 3 Human Factors Elements

Training Objectives:

1. To understand what Human Factors is.

2. To identify Human Factors elements.

Activity/Overhead Facilitator Notes

Question:

Overhead: Human Factors

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Human Factors

Q The interaction between:

– People and Machines

– People and People

– People and Procedures

– People and Environment

MRM Human Factors Training

What is Human Factors?

Human Factors is the interaction between human and

machine, human and environment, human and

procedures, and human and human. We are the core of

this model. We interact with other humans to get our job

done. We interact and work with procedures, tools, and

equipment to get our job done. We also interact with the

environment—that is, the weather, physical structures,

organizational structures (departments), and other

companies. They are external environments. We interact

and work with them to get our job done; if we need parts,

we borrow from them, with paperwork and procedures to

follow.

Overhead: SHELL Model

19

SHELL MODEL

LivING

(Human)

-Physical

-Knowledge

-Attitudes

-Cultures

-Stress

Software

-Procedures

-Policies/Rules

-Manuals

-Placards

Hardware

-Tools 

-Aircraft 

-Equipment

-Workspaces

-Buildings

Environment

-Physical: weather, noise, light

-Organizational: depts, teams

-Political: FAA, OSHA,NTSB

-Economic: competition

LIVING

(Human)

-Teamwork

-Communication

-Leadership

-Norms

Define the acronym of SHELL.

Software

Hardware

Environment

Liveware (Living)

The design of hardware and software impacts our

performance. The environment also impacts our

performance as we interact with these technologies and

work in physical environments. We interact as we work

with co-workers, and they each have individual

differences like us. We have to interact with others in

order to get our job done safely and error free. We are

affected by other co-workers’ attitudes.

The organizational environment consists of the company

culture, departments, team structure, divisions, and other

organizational structures. We all work in a department

that interacts with other departments in this company and

each department has its own policies and procedures. We

also have company policies that outline our work tasks.

These all impact our performance.

Outside external economic factors are political factors,

regulations, (FAA, NTSB), the public, and other airlines.

They are our competition. We have many airlines that are

responding to the market; they have changed their public
9/28/00 AC 120-72

Appendix 1

Page A13

image by changing their name, painting aircraft,

changing logos and themes, etc.

Let’s look at how these Human Factor elements interact

with us individually. Any interactions between us and

these Human Factors components provide the opportunity

for human error which can potentially result in an

accident. We are in the center of the model and play a

central role in error management. If we understand how

all of the HF elements affect us we can move toward

increasing our awareness of how human errors can occur

and begin to manage the process better.

We have to accept that we as humans are fallible,

however, we can change the working conditions and

awareness in which people work. This type of thinking

leads us toward increasing our human reliability and

ultimately the systems reliability (human reliability +

equipment reliability = system reliability).

Question: Are there any questions on this model?

Let me provide some more examples of these Human

Factors elements and how they impact our performance.

Overhead: Human Factors

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Human Factors

Our performance is impacted by:

– Design of tools, equipment (manufacturing, computers)

and workplaces (hangars, offices, warehouses)

– Design of training programs and personnel selection

– Design of software and procedures/manuals (Citext,

DDE, MPP, workcards)

– Job Design (shiftwork, schedules and job tasks)

– Design of the organizational environment (structure,

departments, teams , decision making)

– Physical environment factors (weather, noise, light)

– Physical body size and dimensions.

MRM Human Factors Training

The design of machines, tools, software, and

organizations all can impact our performance. Our

performance is impacted by the following Human Factors

elements. It is the interaction between these Human

Factors elements that provides the opportunity for human

error which can potentially result in an accident.

How do any of these HF elements affect you? Any

examples?

Transition We’ve been looking at what HF elements are and how

they affect our performance. Now, let’s look at 12 error

causes that have been identified as the most frequent

factors that play a role in maintenance related accidents.

These errors are caused by Human Factors elements.

They have been called the “Dirty Dozen” (Dupont,

1997); or simply Human Factors elements. They are

specifically related to maintenance operations All of

these factors can affect our performance and lead to

human errors. These are not excuses. These are identified

factors that can lead us to make errors.
AC 120-72 9/28/00

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Page A14

Overhead: Human Factors

Elements

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Human Factors Elements:

Error causes

Q

1. Lack of Communication 7. Lack of Resources

2. Complacency 8. Pressure

3. Lack of Knowledge 9. Lack of Assertiveness

4. Distraction 10. Stress

5. Lack of Teamwork 11. Lack of Awareness

6. Fatigue 12. Norms

MRM Human Factors Training

Human Factors elements

“Dirty Dozen” (reference Dupont,1997)

Overheads:

Examples of Human Factors

Elements & Concepts

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Human Factors Elements: Examples

Q Equipment/Tools/Parts

Q Aircraft Design/Configuration

Q Job/Tasks

Q Technical Knowledge/Skills

Q Environment/Facilities

Q Organizational Environment

Q Leadership/Supervision

Q Communication Issues

Q Information Transfer

Q Procedures,manuals

MRM Human Factors Training

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Human Factors Concepts

Q Error Recognition

Q Detection and

Perception

Q Human Capabilities

& limitations

Q Physical

Compatiblity

Q Habituation

Q Behavior

Q Stress

Q Systems Approach

Q Usability

Q User Population

Q Vigilance Tasks

Q Workload

MRM Human Factors Training

These two overheads provide examples of Human

Factors elements and concepts. More discussion could

occur here with the class.

Overhead: Human Factors

Elements: Examples

Presented here are the definitions of the Human Factors

elements and Human Factors causes which consists of the

“Dirty Dozen.” (Reference, Dupont)

We will be discussing some of these Human Factors

elements later in more detail. Others will be covered in

future MRM courses.
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5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Human Factors Elements

Examples

– Lack of Communication: A lack of clear

direct statements and good, active

listening skills.

– Complacency: Self-satisfaction accompanied

by a loss of awareness of the dangers.

– Lack of Knowledge: Lack of experience or

training in the task at hand.

– Distraction: Draw one’s attention away; mental

emotional confusion or disturbance.

MRM Human Factors Training

Overhead: Human Factors

Elements: Examples

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MRM HF Awareness Training; Robertson & Sian

Human Factors Elements:

Examples

– Lack of Teamwork: Lack of working together to

achieve a common goal.

– Fatigue: Weariness from labor or exertion,

nervous exhaustion; temporary loss of power

to respond.

– Lack of Resources: Failure to use or acquire

the appropriate tools, equipment, information

and procedures for the task at hand.

– Pressure: Pushing against opposing forces;

Creating a sense of urgency or haste.

MRM Human Factors Training

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Human Factors Elements:

Examples

– Lack of Assertiveness: A lack of positive

communication of one’s ideas, wants and

needs.

– Stress: Mental, emotional or physical

tension, strain, or distress.

– Lack of Awareness: Failure to be alert or

vigilant in observing.

– Norms: The commonly accepted practice

of working routine jobs without the manual.

MRM Human Factors Training
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Module 4 Chain of Events

Training Objectives

1. To understand an accident chain of events.

2. To be aware of how Human Factors elements contribute to each link of the chain.

3. To understand what a safety net is and how it can break the chain of events.

Activity/Overhead

Overhead: An accident is..

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MRM HF Awareness Training; Robertson & Sian

Definition of an Accident

Q An accident is caused by a variety of

contributing factors that interfere with

your good judgement. This permits a

series of events to develop eventually

resulting in damage to people or property.

MRM Human Factors Training

In every accident there are a series of events that link

together to form a chain. We call this a chain of events.

This is the Human Factors definition of an accident. The

FAA, NTSB, and the company have different definitions,

but this is how we will be defining it for this course.

Overhead: Root cause

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MRM HF Awareness Training; Robertson & Sian

Root Cause

A single event determined to be the source

of the incident or accident.

This root cause coupled with physical,

environmental, psychological, operational,

and scheduling issues become the “links”

in a chain of events that lead to accidents.

MRM Human Factors Training

Overhead: Chain of events

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Chain of Events

Multiple contributing causes that can

lead to an accident.

MRM Human Factors Training

Example of chain of events, use examples from the

SHELL model

-poorly designed tools

-poorly designed procedures

-weather

These could be possibly be links in a chain of events to an

accident.
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Overhead: Chain of events

Chain of Events

n Chain of Events

uu Multiple contributing causes that can lead

to an accident.

Accident

Management

Envrionmental

Issues

Maintenance

Ramp

Crew

A/C Design

As stated earlier, in every accident there is a series of

events that link together to form a chain. We call this a

chain of events.

Each one of these links could represent a component of

the SHELL model, i.e., procedures, weather, tooling, etc.

Accident Chain:

1. Contributing factors

2. Serial events

3. Conditional events

4. All factors must be present

5. Break the chain

Domino’s Effect

Overheads

“Swiss cheese” Model or

Reason, Model

Show line up of causes, failures,

filters, defenses—accident scenario

Class Exercise/Demonstration

Set up Domino’s in a line and

demonstrate how they fall. Take

one out and see how that can

“break” the chain.

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Domino #1 - Management

Q Possible error actions:

– Planning

– Organizing

– Directing

– Controlling

– Staffing

– Developing Standards

– Organizational culture

MRM Human Factors Training

This domino model shows how components in a

maintenance operation or airline system can interact to

create an accident. Think of an accident as the last

domino in a line of dominoes. Human Factors such as the

environment, policies that are in place, equipment, and

the people who take part in the system are all represented

as the earlier dominoes. Remember how we discussed

active and latent failures and how they need to line up in

order for an accident to occur. We are using the domino

effect as another example of a chain of events. Each

domino can also be thought of as an accident causal

factor.

If each domino is faulty and falls, it will cause the next

domino to fall, until the last one, the “accident,” falls. The

purpose of Human Factors is to identify each of those

dominos and try to remove at least one, if not all from the

line. If we do this, the last domino won’t fall and we’ll

prevent an accident.

One way we can do that is by developing a safety net.

We’ll talk about safety nets soon.

Reference: Reason, 1997

Reason Model : These factors line up, that is

Underlying Cause (Management)

Basic cause (System)

Immediate Cause (Individual)

Safety Defenses: Filters (Countermeasures)

Consequences; Results (Incidents, accidents)

Management; communication, decision making

System: Policies, procedures, structure

Individual: Physical & Mental limitations

Filters: (Counter Measures—Developing Safety nets

Results: (Accidents, Incidents, Near misses, mishaps,

close calls)
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MRM HF Awareness Training; Robertson & Sian

Domino #2 - System

Q Possible errors made:

– Task

• Arrangement/Time/Demands on People

– Material

• Supplies/Materials/Design/Maintenance

– Environment

• Physical/Organizational/Sociological

– Weather

– Training

• Initial/update/Skill Development/Reinforcement

– Person

• Selection

• Motivation/Attitudes/Values/Culture

MRM Human Factors Training

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Domino #3 - Individual

Q Possible errors made by Individual:

– Not following instructions; unsure of technical

knowledge

– bypassed or ignored rule, regulations,

procedures to save time

– Failed to use protective equipment

– Didn’t think ahead to possible consequences

– Used the wrong equipment to do the job; not

calibrated equipment

– Didn’t look/listen/pay attention

– Didn’t recognize physical limitations

– Complacent

MRM Human Factors Training

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Domino #4 - Filters

Q Defenses include:

– Management- Setting standards, effective planning,

organizing, directing

– Systems- ensuring availability of training, manuals,

selection, policies & procedures, protective clothing &

equipment & tools to do job

– Individual - Behavior changes so that they are less likely

to make errors

– Consequences - Controlling damage & limiting the

extent & effect of:

• accident

• incident

MRM Human Factors Training

We discussed earlier active and latent (or hidden) errors.

The domino theory focuses on what the underlying ,

basic, and immediate causes are. There can be several

causes and this is why we view an accident chain as a

system problem. There can be several safety defenses and

filters. These are safety nets or link busters. They are the

result of applying of Human Factors and MRM

principles, such as effective communication and

teamwork, aware of others in the workplace, stress

management, accurate procedures, etc.

Note: You may want to provide several maintenance

examples to illustrate the domino theory and layers.

Explain and demonstrate Domino Collapse.

Overhead: Broken Chain

Break the Chain of Events

If we can break the chain,

the accident doesn’t happen

Preventing any event could prevent the accident

Management

Maintenance

Crew

Ramp A/C Design

Enviornmental

Issues

IF we can break the chain at any link, the accident doesn’t

happen.

Harry Truman had a sign on his desk that said “the buck

stops here.” In maintenance we need the same

philosophy.

If we can break the chain at the maintenance level, the

accident doesn’t happen.

“Link Buster”

Any mechanism or filter that is put in place that can help

break the chain of events (Porter, 1997).

Read: Dryden: Case Study (Part I)

Two parts of Dryden

Allow 12 minutes to read the case study on pilot and

cabin crew coordination issues and the case study on

maintenance issues in the Dryden accident. Why are we
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using a crew resource management case in MRM

training.

Ask Question: What was the role of maintenance in the Dryden case?

Discussion: It is important to understand the chain of events and that

maintenance did have a role in this accident. If the chain

of events had been broken, the accident would not have

occurred. What we could have done as a technician is to

have broken that chain by ensuring that the APU was

working.

Video: Dryden (part II):

Maintenance

Let’s watch the Dryden video to identify other Human

Factors contributing causes that we discussed in the

SHELL model and the Dirty Dozen. Refer to a worksheet

in your participant workbook. Also identify the chain of

events. Look around the room for the posters of the Dirty

Dozen, the SHELL model, and chain of events.

De-brief exercise Charts are given to each group and then a member is

selected as a spokesperson to present the group work.

Other class members provide suggestions and comments.

Group Exercise One group identifies the “Dirty Dozen,” (break into two

groups and one group identifies the first six of the dirty

dozen and the other group identifies the last six “Dirty

Dozen”), another the SHELL components, another the

chain of events.

*Class Exercise

*Note: The Nation Air video could be substituted for the

Dryden video. MARS has produced a maintenance video

about this accident involving Nation Air. Check

references to order the video.

Video: Nation Air We are going to watch another aircraft accident. As you

watch the video, see how many HF elements you

recognize as well as the “Dirty Dozen.” This accident

cost 264 people their lives.

Read: Nation Air Have the participants read the Nation Air case study.

Group exercise Break into groups and have one group identify the

SHELL components, “Dirty Dozen”, and chain of events.

Remember: to change the assignments for each group.

Discussion on Nation Air What caused this accident?
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Module 5 Safety Nets

Training objectives:

1. To understand what a safety net is.

2. To develop safety nets to break the accident chain.

Overhead:

Fundamental Assumption

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MRM HF Awareness Training; Robertson & Sian

Fundamental Assumption

Q If any AMT, Inspector, or Manager is

aware of information or a situation,

perceives that it is not proper, and

knows that it has airworthiness or other

safety implications,

Q then they WILL act to break the

accident chain

MRM Human Factors Training

The fundamental assumption stated on the overhead is

important. We will be discussing more about the concept

of situation awareness and how we can increase our

situation awareness to break the accident chain.

This situational awareness is just one Human Factors

element we need to be aware of that can help us break the

chain of events.

Overhead: Safety Nets

5/4/98 MRM HF Training; Robertson & Sian

MRM HF Awareness Training; Robertson & Sian

Safety Nets

Q A mechanism that YOU put in place

that could help YOU break the chain.

MRM Human Factors Training

Overhead:

Break the Chain of Events

Break the Chain of Events

If we can break the chain,

the accident doesn’t happen

Preventing any event could prevent the accident

Management

Maintenance

Crew

Ramp A/C Design

Enviornmental

Issues

Safety nets are mechanisms that you can put into place to

help break the chain and insure an error doesn’t go on to

create an accident. All of the factors in the SHELL

model that we talked about can be designed to prevent

errors, just as they can help create errors if they aren’t

supporting human performance and your job.

We need to learn how to develop safety nets so that we

can break the chain of events leading to an accident.

Discuss “Link Busters”

A ‘link buster” is any mechanism or filter that is put in

place that can help break the chain of events.
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De-brief Nation Air video for

developing safety nets

Group exercise

Question:

What are some safety nets that you can put into place to

prevent the errors we’ve talked about in the Nation Air

accident?

Group Exercise: break into groups and discuss what types

of safety nets could have been developed in order to

break the chain of events in the Nation Air accident. List

them on a chart. Have a spokesperson present to class.

Tape the list on the wall.

Overhead:

Review of modules 1-5

MRM Review

n Maintenance Resource Management

n Human Error

n Human factors model (SHELL)

n Human Factor elements: “Dirty Dozen”

n Chain of events

n Developing safety nets

 Summarize the key issues from MRM.

Review the definitions of Maintenance Resource

Management and Human Factors.

Discuss how the SHELL model describes software,

hardware, environmental and liveware factors that can all

contribute to what gets labeled as “human error.”

Review the ‘Dirty Dozen”--Human Factors elements that

have been found to be particular problems in aircraft

maintenance.

Talk about the idea of a chain of events and how you can

put safety nets into place to prevent errors or prevent

errors that do happen from going on to become accidents.

Discuss how to recognize and identify the chain of events

and how to develop safety nets or “link busters.”
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Module 6 Norms 

Training Objectives:

1. To understand norms

2. To recognize norms

3. To develop safety nets to break norms

Activity/Overhead Facilitator Notes

Overhead: Norms

Maintenance Resource Management Training; Human Factors Awareness Robertson & sian, 1998 

MRM Training

Norms

u What we are going to learn next:

– 1. Understanding norms

– 2. Recognising norms

– 3. Developing safety nets to change

norms

– 4. Case Study: Eastern flight 855 L-1011

 

Training Objectives for this module on norms.

Overhead: Norms

Maintenance Resource Management Training; Human Factors Awareness Robertson & sian, 1998 

Norms

u Norms are:

– Informal work practices or unwritten

rules that are accepted by the group

What are norms?

Define norms.

Norms are tolerated and even encouraged by

the group.

If one person demonstrates a certain behavior it

could be considered a personal preference.
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Overhead: Different types of norms

Maintenance Resource Management Training; Human Factors Awareness Robertson & sian, 1998 

Different types of norms

u Norms can be positive (effective)

u Norms can be negative (ineffective)

There are different types of norms; positive and

negative norms.

Overhead: Positive Norms

Maintenance Resource Management Training; Human Factors Awareness Robertson & sian, 1998 

Positive Norms

u Positive norms have an overall

positive effect on the organization.

– Example:

• Double checking your work

Positive norms are expected behavior condoned

for the betterment of the group.

Maintenance Resource Management Training; Human Factors Awareness Robertson & sian, 1998 

Negative Norms

u Negative norms have a negative

effect on the organization and have

the potential to cause errors.

– Example:

• Completing the job from memory

These types of norms are unsafe.
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OVERHEAD: Negative Norms

Maintenance Resource Management Training; Human Factors Awareness Robertson & sian, 1998 

Negative Norms

u Negative norms are short cuts or

accepted practices which the group

encourages or tolerates.

These types of norms are unsafe.

We act in accordance with them because they

generally save us time and steps. We can get

the job done faster. An example of a negative

norm would be when an experienced individual

shows the novice worker a “short cut.”

OVERHEAD: KILLER NORMS

Maintenance Resource Management Training; Human Factors Awareness Robertson & sian, 1998 

“Killer Norms”

u “Killer Norms” are those norms that

may affect the safe operations.

u Negative norms can become “killer”

norms when the group fails to see

the danger in the short cut or

accepted practice.

– Example:

• Deviating from the manufacturers

maintenance manuals

Negative norms can become killer norms when

the group fails to see the danger of the shortcut

or accepted practice.

Example: Improvising tools or equipment use.

QUESTION:

Maintenance Resource Management Training; Human Factors Awareness Robertson & sian, 1998 

Question?

u How can we identify the positive

from the negative norms?

u Does it enhance or detract from an

established procedure?

Just ask yourself...
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CLASS EXERCISE: QUESTION?

OVERHEAD: EXAMPLES OF NORMS

Maintenance Resource Management Training; Human Factors Awareness Robertson & sian, 1998 

Examples of Norms

– Performing a final walk-around before

each flight

– Working without using a maintenance

manual

– Asking a fellow AMT if s/he would recheck your work

– Signing for work not done in order to

get the aircraft out on time.

OVERHEAD: EXAMPLES OF NORMS

Maintenance Resource Management Training; Human Factors Awareness Robertson & sian, 1998 

Examples of Norms

– Pushing the aircraft back without using

a wing walker

– Checking all “B” nuts by hand after the

job is done.

– Signing off on someone else’s work

– Verbal turnover

– Running with scissors

Ask the class if these are positive or negative

norms.

OVERHEAD: “BREAKING NORMS”

Maintenance Resource Management Training; Human Factors Awareness Robertson & sian, 1998 

“Breaking” Norms

u What can we do about norms?

– Look for the norms we live and we work with

– Identify the positive norms from the negative

norms

– Accentuate the positive and eliminate the

negative

– Do this by discussing them and using your

influence in the group to change the negative

norms.

– If you’re sure, maintain your standard

To know what we can do about norms, we first

have to recognize them.

This is easier said than done. How do we do

this?

It’s not easy. It can be uncomfortable if the

norm is accepted by the group and the group is

pushing that something be done according to

the norm.
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Remember negative norms may set you up for

an accident.

OVERHEAD: ORGANIZATIONAL

CULTURE & NORMS

Maintenance Resource Management Training; Human Factors Awareness Robertson & sian, 1998 

Organizational Culture & Norms

u Corporate culture breeds norms

u Corporate culture either encourages

or discourages norms.

Just the fact that we are sitting here today is a

very good indication of our company’s

corporate culture and norms.

This is a commitment to change our company’s

culture.

How are we going to do this?

By increasing awareness of Human Factors and

MRM in every employee of this company. This

Human Factors-MRM training course is a part

of increasing this awareness.

Human Factors training is the key to reducing

maintenance errors.

GROUP EXERCISE:

BACKGROUND

OVERHEAD: CASE STUDY

Maintenance Resource Management Training; Human Factors Awareness Robertson & sian, 1998 

Case Study: Norms

u Case Study:

– Eastern Flight 855, L-1011

• Group Exercise

• Identify Norms

• Develop Safety Nets to change norms

• List norms on flipchart

• Select spokesperson

We are going to look at a case study of EAL

#855. This case study involves a maintenance

error as a primary cause of a near fatal

accident.

Group Exercise: Have participants read case

study of EAL #855. Have each group identify

the norms, develop safety nets, and list them on

a chart for presentation to the class.

Background and Discussion:

In the appendix of your handbook you will find

this case study. This maintenance error was not

a complicated one.

The O-rings were not installed on the master

chip detector.

Norms played a key role in this incident.

The company culture and everyone in

maintenance all contributed to allow for these

norms to exist.
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Maintenance Resource Management Training; Human Factors Awareness Robertson & sian, 1998 

Case Study: Norms

u What were some of the norms in this

incident?

u How could we break these norms?

u What were the “killer” norms?

u Was this accident preventable?

For discussion after group presentations:

What was the level of consequences of this

accident?

Maintenance Resource Management Training; Human Factors Awareness Robertson & sian, 1998 

Case Study: Norms

u What were some of the norms in this

incident?

u How could we break these norms?

u What were the “killer” norms?

u Was this accident preventable?

Further discussion and questions:

What were some of the Human Factors

elements that you saw in this case study?

Example of safety nets: Special training

procedures are safety nets. They are here for

our protection—read them.
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GROUP EXERCISE: IDENTIFYING

ORGANIZATIONAL NORMS

OVERHEAD: ORGANIZATIONAL

NORMS

Maintenance Resource Management Training; Human Factors Awareness Robertson & sian, 1998 

Organizational Norms:

“Our organizaiton”

u Group Exercise:

– Identify norms in own organization

– Which norms are negative (ineffective),

and positive (effective) norms?

– Write on easel paper

– Identify spokesperson

– Could any of the negative norms

become “killer” norms?

Break participants into DIFFERENT groups

now.

Have them identify norms in their own

workplace, listing them on a chart, and select a

spokesperson to present to the class.

What are some examples of norms you have

observed in your work place?

Place a + sign by the positive norms

Place a - sign by the negative norms

Discuss the positive and negative norms

identified by the class.

Our company culture will allow positive norms

to become policy.

How do we go about making a positive norm ?

At this time, it is important to show “within the

company” examples of how individuals can use

the right resources and processes to have a

positive norm recognized. Show examples of

previous positive changes in procedures.

Emphasize MRM and Human Factors

principles in any discussion of the examples.

Company newsletters also are great written and

documented examples of how positive norms--

that is, safe actions and processes--were

adopted.

The next overhead emphasizes developing

safety nets. This is where the facilitator can

point out in the participant handbook the

appendix section that has a Who’s Who of

MRM and Human Factors resources and

references, internally and externally to the

company.
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Maintenance Resource Management Training; Human Factors Awareness Robertson & sian, 1998 

Norms: Safety Net

u A safety net is a mechanism YOU put

in place that could help YOU break

the chain of events.

Chain of Events

Multiple Contributing Causes That

Can Lead To An Accident.

Management Accident

Flight Crew

Ramp

A/C Design Environmental Issues

A/C Planning

Vendors

FAA / ATC

Work cards / EAs

AMT

Tools & Equip

Break the Chain of Events

If we can break the chain,

the accident doesn’t happen

Preventing any event could prevent the accident

Management

Maintenance

Crew

Ramp A/C Design

Enviornmental

Issues

Norms

Let’s look again at what a safety net is.

Reminder of breaking the chain of events.

Norms are part of the chain of events.
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Link “Busters”

Preventing Any One Could Prevent The Accident

Management

Flight Crew

Ramp Environmental Issues

A/C Design

A/C Planning

Vendors

FAA / ATC

Work cards / EAs

AMT

Tools & Equip Accident

Maintenance Resource Management Training; Human Factors Awareness Robertson & sian, 1998 

Safety Nets

u Developing Safety Nets:

– How can you break norms?

– What can you do with positive norms?

Class exercise or group exercise

What type of safety nets, link busters or filters

could be developed or introduced that would

break our negative norms?

What can you do with your own positive

norms?

What experiences have you had in identifying

positive norms, and changing procedures?
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MODULE 8 Effective Communication (Shift Turnover & Feedback)

Training Objectives:

1. To understand how written communication can lead to the reduction of human errors.

2. To understand the importance of written communication.

3. To recognize examples of poor written communication.

4. To understand how we communicate.

5. How to write effectively.

6. To understand the importance of a written shift turnover document.

7. To recognize the value of feedback.

OVERHEAD:

Maintenance Resource Management; Human Factors Awareness Training Robertson & Sian 1

MRM Training

Effective Communication

Q What we are going to learn next is:

– What is effective communication?

– Written communication

– Listening skills

– Speaking skills

– Shift turnover

– Feedback

TRAINING OBJECTIVES

Here is what we are going to do next.

CLASS or GROUP EXERCISE

Communicating Decisions

n Say What to Do

– 3 a.m.: Engine is disassembled and in

trouble-shooting. Diagnosis is made.

– Maintenance Control says send plane to

CLE for scheduled maintenance

– Result: AMTs can’t finish job even though

they know the problem and can fix it.

< Issue MEL.

< Lost 3 hours of work.

Typically communications between groups or

individuals simply involves passing a statement

of what needs to be done. For example, an

actual problem situation was as follows.

Very often what doesn’t get passed in

communications is saying WHY something

must be (or was) done. It is very important to

say not just what to do but also your reasons

behind that decision. For example, what if we

take the same problem situation but in this case

maintenance control says why the plane needs

to be sent to Cleveland. The scheduled

maintenance is for a carpet change out. The

result may have been quite different.
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Communicating Decisions

n Say Why to Do it

– 3 a.m.: Engine is disassembled and in

trouble-shooting. Diagnosis is made.

– Maintenance Control says send plane to

CLE for scheduled maintenance

– Scheduled maintenance

change-out

– Result: Why don’t we do carpet change-out

here so that we can finish the job?

< No MEL is needed

< Work is completed without lost time

Communicating Decisions

n Say What to Do

– Problem diagnosis entered into

maintenance computer for next shift or

station

– Next shift replaces part indicated, but that

doesn’t fix problem

– Result: AMT must trouble-shoot again,

repeating many steps taken on first shift

< Aircraft delay

The extra piece of information about the reason

for the decision allowed the line station to

instead suggest that they could do the carpet

change out themselves and finish the repair

thereby avoiding the MEL entry and

completing the repair without losing additional

time. With this piece of information, they

completed the job on time and got the aircraft

on the gate on time.

Let’s look at another example of

communicating decisions and the importance

of communication.

IF in the same situation, the person performing

the maintenance also entered why he had

arrived at that diagnosis and the options that

had been tried and the information regarding

the diagnosis activities, the next shift would

have been much better able to deal with this

problem and arrive at a new diagnosis.

Effective communication is critical for many

types of job functions in order to have safe

operations.

When you communicate decisions between

groups or shifts, it is important to not only

communicate the decision but also why you

made that decision. This provides a better

understanding of the situation and allows

people to better interpret the information

relevant to the situation. It also allows the

knowledge and ideas of a wider group of

people to come into play. Other people may

have information that you don’t have.
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Communicating Decisions

n Say Why to Do it

– Problem diagnosis entered into

maintenance computer for next shift or

station

– Also enter options already tried and

information that was used to arrive at

that diagnosis

– Next shift replaces part indicated, but

that doesn’t fix problem

– Result: AMT can quickly determine

new diagnosis

Importance of Communicating

Reasons for Decisions

n Communicate decision

– Do this action

n Communicate Why you made that

decision

– Provides better understanding &

interpretation of information

– Allows knowledge & ideas of everyone to

come into play

– Leads to better solutions than one person

acting alone

By drawing on the information of the wider

group, you may be able to get better solutions

than any one person acting alone. Use our

valuable and experienced resources within our

company.

We are going to do a teamwork exercise where

this idea will really become valuable.

We all need to communicate.
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Who Needs to Communicate

Decisions?

n Supervisors

n Leads

n Maintenance Personnel

n All Tech Ops Organizations

OVERHEAD: DEFINITION

Communication

Process Whereby Information is

Exchanged Between Individuals

Through a Common System of

Symbols, Signs or Behavior

Maintenance Resource Management ; Human Factors Awareness Training Robertson & Sian, 1988 2

Effective Communication

– The exchange of information that conveys

meaning between two or more people

A definition of communication.

What is communication?

Ask the class what effective communication is.
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OVERHEAD: COMPONENTS

Maintenance Resource Management ; Human Factors Awareness Training Robertson & Sian, 1988 3

Effective Communication

Q Communication:

– Has both a sender and receiver

– Verbal or written

These are the basic components of

communication.

OVERHEAD: METHODS OF

COMMUNICATION

Methods of Communication

l Verbal

l Non-verbal

l Written

There are several methods of communication;

verbal, non-verbal, and written. We will

discuss each of these and provide examples in

our maintenance operations.

NOTE: It is important to have several examples

of written, and verbal communication. Have

these as handouts, overheads, or a video

vignette that demonstrate the methods of

communicating.
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Maintenance Resource Management ; Human Factors Awareness Training Robertson & Sian, 1988 4

Effective Communication

Q How do we communicate?

– Verbal:

• Two way (face to face): body language,

tonality, eye contact, facial expressions,

immediate feedback

• Two way (not face to face): e.g., on telephone,

only tonality, immediate feedback

Requirements of Good

Verbal Communication

l We Must Think Before We Speak

l Think About How the Message will be Accepted

l Be Non-Accusatory (Watch Our Tone of Voice)

l Communicate Why We Made the Decision

l Give Positive Feed Back

l Establish Eye Contact

l Allow for the Other to Respond

l Do not Interrupt the Other Person

l Be an Active Listener

Learn to Listen

l Don’t:

– Debate what is being said in your mind

– Detour (i.e., look for a key word to change the subject)

– Finish the other persons sentences

– Pre-Plan (figure out what you’re going to say next)

– Tune-out

l Do:

– Ask questions

– Paraphrase

– Make eye contact

– Use positive body language

Here are some important requirements of good

verbal communication that we should consider

very carefully. You may want to refer to these

later when you go back to your work area. We

need to remind ourselves of these important

ideas constantly. Be assertive in helping others

and yourself in using these skills. Provide

feedback to others.

Active listening is a very important skill. It

takes time to become an active listener. We

will always be practicing. Use the assertive

model to practice your listening skills.

Note: facilitator provides some listening

examples. For example, reading off a list of

bedroom items (10-15), but never stating the

word bedroom. This shows individual we have

the tendency to not actively listen and we fill in

the gaps of information with our own

perceptions and thoughts.

Note: Provide examples of non-verbal methods

of communication , if possible, by pictures or

video.
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OVERHEAD: NON-VERBAL

Non-Verbal

l Hand Signals

l Visual Signals

l Body Gestures

l Facial Expressions

GROUP EXERCISE

Maintenance Resource Management ; Human Factors Awareness Training Robertson & Sian, 1988 5

Effective Communication

• Written: most difficult, limited feedback,

no body language or tonal clues

–The reader cannot ask questions

about the meaning or the message

{Eliminate or ensure proper sequence numbers

on overheads.}

Maintenance Resource Management ; Human Factors Awareness Training Robertson & Sian, 1988 6

Effective Communication

Q Why are we concerned about effective

written communication?

– Logbook write-ups and/or signoff can result

in an incident

– Vague/unclear/incomplete EA/CD resulting

in an incident

– Shift Turnover

Note: Show examples of written

communication and how we can misinterpret

them. These misinterpretations lead to errors.

Group Exercise: Follow directions exercise:

Pass out directions for a task. Interrupt the

group at the beginning while they are reading

the instructions. Devise the instructions that tell

them to stop early in the process. Those who do

not read the instructions carefully and

thoroughly will complete all of the unnecessary

tasks.

Debrief: Why did you not read the instructions

clearly?

Why is written communication difficult?

Is this important in shift turnovers?

Why do we need to be so concerned about

effective communication?

When do we need to communicate the most?

How important is it that we communicate?

What are the consequences and what types of

human errors could be committed? Error of

omission, commission?

We are going to talk more about written

communication. Then we will talk about the

importance of shift turnovers and

communication.
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OVERHEAD: WRITTEN

COMMUNICATION

Good Written

Communication

Should:

l Convey the complete message

l Be easy to understand

l Relate accurately to the problem

l Be readable

l Be free of any emotional or hidden messages

These are some very important rules about

good written communication.

Written communication tends to be the most

difficult kind of communication. Immediate

feedback is limited. There is no body language

or tonal clues. The reader cannot ask questions

about the meaning or the message. It has one

major advantage: there is a permanent record of

the message.

Written communication therefore is the most

difficult means of effectively completing the

communication process.

Let’s look at some examples.

OVERHEAD: FOUR C’S

Four C’s In Written

Communication

l Clear

l Correct

l Complete

l Concise

For a message to be understood and not

misinterpreted it must be clear, correct,

complete, and concise.
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OVERHEAD: CLARITY

Maintenance Resource Management ; Human Factors Awareness Training Robertson & Sian, 1988 8

Effective Communication

Q For the message to be clear:

– Say what you mean

– State the point

– Use Short sentences

– Be careful of acronyms and abbreviations

Show an example of a written message that is

NOT clear--but very confusing. Show an

example of a well-written, clear message.

OVERHEAD: CORRECTNESS

Maintenance Resource Management ; Human Factors Awareness Training Robertson & Sian, 1988 9

Effective Communication

Q For the message to be correct:

– Technically accurate

– Proper reference to the maintenance

manual

Remember to use your technical and company

resources.

OVERHEAD: COMPLETENESS

Maintenance Resource Management ; Human Factors Awareness Training Robertson & Sian, 1988 10

Effective Communication

Q For the message to be complete:

– Provide enough information

– One action per step

– Proper sequence

– Be careful of errors of omission

For the message to be complete, remember to

state first safety issues and warnings and

ALWAYS try out your message on someone

else. They should provide you with some

valuable feedback.
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OVERHEAD: EXAMPLES

Maintenance Resource Management ; Human Factors Awareness Training Robertson & Sian, 1988 13

Effective Communication

Q Written communication

– “The less I write, the less trouble I can get into in

the future”

– “Just scribble anything because no one reads all

that stuff anyway”

– “Paperwork never made any airplane fly better”

– “I don’t have time for all that paperwork

Watch out for these statements!

Written Communication

is Critical for Air Safety

n KISS principle for written

communication

– Keep It Simple Stupid (KISS)

n Two sets of tools

ñ Toolbox

ñ Pen in pocket

n BOTH are important to use correctly

and BOTH help make an aircraft safe

OVERHEAD:

Critical Times for

Communicating

l Shift Turnovers

l Maintenance Station Changes

l Problem Solving & Troubleshooting

– Within a crew & between crewmembers

l Written Logs

– Maintenance computer

– Maintenance Log Book

l Hazardous Procedure or Materials Used

– MX Taxi/run-up

– Xray inspection

 Practice your writing skills and try them out on

someone who needs to understand what you

want someone else to do—.

Good communication is always important. But

there are certain times when we have found

that you need to be especially careful that you

communicate fully. (1) Communicating the

status of on-going work at the shift change is of

course extremely important. Many accidents

have been linked to information not being

passed to the next shift. (2) The same is true as

a plane transitions to the next maintenance

station. We frequently do a poor job of

communicating the results of all the work and

troubleshooting we have done when a plane

needs to go on to the next station. (3) The

problem-solving insights we have gained need

to be shared within the maintenance team and

to others that become involved. (4) Written

logs are a major way of communicating in the

maintenance domain: both through the

maintenance computer and the maintenance log

book. (5) Whenever you work with others.
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OVERHEAD: SHIFT TURNOVERS

Shift Turnovers

l Pass On Needed Information

– Status of aircraft

– Special problems

l Serve to Establish Expectations

– What is my job?

– What will others be doing?

– How will the jobs relate to each

other?

– What is my role in working with

others?

Solutions For

Shift Turnovers & Meetings

l Give complete explanations of status

of work

l Ensure that all parties understand

the message being conveyed

l Provide a written turnover to serve

as a reference later

There are two important functions of shift

turnover meetings. 1) They make sure needed

information is passed to the incoming

maintenance crew. This includes information

on the status of the aircraft that they are going

to be working on and any special problems that

may be present. 2) Shift turnover meetings also

serve to establish your expectations for the

maintenance team and to create the big picture.

This involves describing not only what each

person has to do but also providing an

understanding of what others are going to be

doing and how their jobs interrelate. This

creates the big picture that is needed.

You also create expectations regarding

teamwork. Teamwork has to do with the degree

to which people work together to accomplish

the maintenance goal as opposed to the degree

to which they only do their specific task

assignments. Creating a sense of teamwork is

important for insuring that maintenance goals

are met most effectively. Teamwork is our next

training module and we will be involved in a

group exercise.

Here are some suggestions on how we can

improve shift turnovers and meetings.

Are we conducting our shift turnovers this way

now?

GROUP EXERCISE:

MAINTENANCE LOGBOOK

CAMPAIGN DIRECTIVE

SQUAWKS

ENGINEERING AUTHORIZATION

NOTE: Facilitator needs to provide examples

of poor, unclear, written communications that

are internal examples from the company.

Have groups identify why these examples are

confusing and unclear. Have the groups list

how they could improve these written

communications.

Remember: The lack of effective

communication is a factor that can have serious

consequences relative to flight safety and

maintenance error.
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GROUP EXERCISE: SHIFT TURNOVER

Facilitators could design a shift turnover

exercise where something as simple as recreating a pattern using dominos can be done.

For example, one shift could write a series of

written instructions about this pattern and leave

them for the next crew. The next crew will

have to follow the instructions and create the

exact pattern. Of course, physically moving

the two shifts needs to be done. De-briefing the

exercise demonstrates how difficult it is to

write clear instructions so that the next crew or

individual clearly understands exactly what to

do.

Discussion: As maintenance personnel, we

sometimes have a distrust of the written word.

Thus we sometimes do not even write a shift

turnover memo to provide the next crew with

essential information about what we have

completed and what the status of the repair is.

For written communication we do not want the

reader to misinterpret and fill in the gaps.

Many of you probably filled in the gaps when

you were completing the pattern for the domino

exercise. You may have been correct or

incorrect. The consequences of your actions

here are minimal. However, as we have pointed

out before, the consequences of your actions in

maintenance operations can lead to catastrophic

errors or physical damage.

OVERHEAD: FEEDBACK

Feedback Communication

l Without feedback you may never know if

the problem is fixed

l The system may continue to have

problems down the line

l More repairs may be needed before the

problem is finally diagnosed correctly and

fixed

Feedback is critical in creating good mental

models. You may make a repair, but unless you

have feedback you may never know if you

have correctly diagnosed the problem and fixed

it. The system may continue to have problems

and may have had several repairs down the line

before it is fixed correctly. Without feedback

you will never develop an understanding of the

problem and what works to fix it.
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GROUP EXERCISE:

Group Exercise

Eagle Lake Accident

(Appendix A)

{Where is appendix A? What is this accident

about? Can we summarize it somewhere?}

CLASS ROOM OR GROUP EXERCISE:

Feedback Exercise

l Identify problems that prevent good

feedback in the maintenance system.

l What are some potential solutions to

these problems?

l How can we provide good feedback to

others?

l Where do we go at our company to

give feedback?

Let’s review a case study for communication

problems at a shift turnover.

Let’s get our groups and have each group

identify communication problems and other

Human Factors and MRM issues.

List these issues and identify a spokesperson.

The facilitator may want to have one group list

communication problems and the other groups

to look at Human Factors elements, chains of

events or developing safety nets.

NOTE: This could be another communication

and feedback exercise. Take a communication

problem that has occurred in the company and

use it to demonstrate problems of

communication and feedback. Have the groups

develop filters, safety nets, projected changes

regarding Human Factors elements,

organizational resources, policies, etc.

This is a good opportunity to view objectively

issues in the company.
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