SAE R-192-1998 Airline Maintenance Resource Management Improving Communication (To Purchase Call 1-800-854-7179 USA Canada or 303-397-7956 Worldwide).pdf

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1、Airline Maintenance Resource Management Improving communication J.C. Taylor T.D. ChristensenAirline Maintenance Resource Management: Improving Communication J.C. Taylor and T.D. Christensen Society of Automotive Engineers, Inc. Warrendale, Pa. Copyright 1998 Society of Automotive Engineers, Inc. eIS

2、BN: 978-0-7680-6290-8Library of Congress Cataloging-in-Publication Data Taylor, James C. (James Chapman), 1937 Airline maintenance resource management : improving communication / J.C. Taylor and T.D. Christensen. p. cm. “SAE order no. R192“T.p. verso. Includes bibliographical references and index. I

3、SBN 0-7680-0231-1 1. Transport planesMaintenance and repairQuality control. 2. AeronauticsSafety measures. 3. AirlinesManagement. 4. Business communication. I. Christensen. T.D. (Tom D.) II. Title. TL671.9.T37 1998 98-36672 387.73340423dc21 CIP Copyright 1998 Society of Automotive Engineers, Inc. 40

4、0 Commonwealth Drive Warrendale, PA 15096-0001 U.S.A. Phone: (724) 776-4841 Fax: (724) 776-5760 E-mail: publicationssae.org http:/www.sae.org ISBN 0-7680-0231-1 All rights reserved. Printed in the United States of America. Permission to photocopy for internal or personal use, or the internal or pers

5、onal use of spe- cific clients, is granted by SAE for libraries and other users registered with the Copyright Clearance Center (CCC), provided that the base fee of $.50 per page is paid directly to CCC, 222 Rosewood Dr., Danvers, MA 01923. Special requests should be addressed to the SAE Publications

6、 Group. 0-7680-0231-1/98-$.50. SAE Order No. R-192Dedicated to the airline mechanics, engineers, and maintenance managers those proud professionals who keep the commercial fleet flying safely.Acknowledgments We owe a great deal to several friends and benefactors, Bruce Aubin and John Goglia (NTSB),

7、for the support and patience they offered while our ideas were turning into a readable work. Thanks go to all of themwithout their guidance and foresight we would have had a very different product. We wish to extend our appreciation to the many people who read vari- ous sections of the book during i

8、ts creation. Among these are Jerry Allen, Phil Chartrand, Steve Erickson, Leslie Eveland, Wayne Gallimore, Jon Glynn, Jim Haarbauer, Jack Hessburg, Joe Kania, Jeff Leeds, Steve Miller, Manoj Patankar, Sam Sexhus, John Stelly Jr., and Larry Strouse. We also want to thank Gordon Dupont, Steve Predmore

9、, Giselle Richardson, and William Whitley for generously allowing us to use their material, which we adapted and used in Chapters 2 and 11. The book is based on research that began in 1990 and is ongoing. This work has been given financial and/or moral support by many people: Bar- bara Kanki (NASA A

10、mes Research Center), Jean Watson (FAA Office of Aviation Medicine), Fred Leonelli (FAA Flights Standards), Chris Seher (FAA Technical Center), Frank Tullo, Ray Valeika, John Stelly Jr. (Conti- nental Airlines); John Goglia, Joe Kania, and Dave Driscoll (USAirways); Joan Kuenzi (Northwest Air Lines)

11、, Bob Doll, Lou Mancini, Yesso Tekeri- an, Jeff Leeds, Lenny Page, and Jim Griffiths (United Airlines); Richard Kormaniski (Grey Owl Aviation), Art Columb (Air Transport Assn), Dave Cann, Jim Ballough, Vince Lepera and Al Zito (FAA FSDO19); Dean Bill Petek; Professors Naj Meshkati and Mike Barr (USC

12、 Institute of Safety and Systems Management); and Dean Terry Stroup (Santa Clara University School of Engineering). Michelle Robertson was an energetic and produc- tive partner in much of this research. And finally there are the othersthe thousands of airline maintenance technicians, members and rep

13、resentatives of the IAM-AW, foremen, vAcknowledgments managers, and staff support peoplewho are willing participants in the re- search and who have given so freely of their time and experience. It is to them that this book is dedicated. Despite all this help we, of course, remain entirely responsibl

14、e for mistakes or inaccuracies that remain. Jim Taylor Palo Alto, California Tom Christensen South Bend, Indiana July, 1998 viContents Foreword xi Introduction xiii Chapter 1 What Do We Mean When We Say “Communication“? 1 OVERVIEW: The Subject Is Workaday Communication, Not “Feelings“ 1 Safety Depen

15、ds on It 1 What You Need to Know Right Now 3 Heres the Logic 4 More Logic 7 And More 7 Chapter 2 Must AMTs Be Skilled Communicators? 11 OVERVIEW: Better Communication Skills Are Required Today 11 Traditional Selection Criteria 11 What Are AMTs Really Like on the Job? 12 What About the Lead Mechanics

16、? 13 Why Do AMTs Make Mistakes? 15 Remember: Workplace Communication Is About the JOB 18 Chapter 3 Communication Mistakes in Maintenance Costs Lives 21 OVERVIEW: Maui and Eagle Lake Accidents Focus Attention on Maintenance Communication 21 Outline of the Accident 23 viiAirline Maintenance Resource M

17、anagement: Improving Communication The Companys Larger System 24 Communication and Collaboration 27 The Eagle Lake Accident 28 Outline of the Accident 28 Collaboration, Communication, and the Eagle Lake Accident 31 Culture Is Hard to Change 33 A Parting Thought 34 Chapter 4 A Short History of Commun

18、ication and Human Factors Management in Aviation Maintenance 37 OVERVIEW: Human Factors Management Is a Powerful New Science in Aviation 37 What Human Factors Management Is All About 38 The Evolution of Human Factors Management 40 Culture Clash in Aviation Maintenance 45 Cultural Change in Maintenan

19、ce in the 1990s 47 Beyond Human Factors Management 48 Chapter 5 Professionalism Now Includes More Communication 53 OVERVIEW: A New Approach Is All But Inevitable 53 Big Problem: Some Mechanics Now Just “Factory Hands“ 54 Specialization Reduces Professionalism 56 Professionalism? In this Environment?

20、 60 Professionalism in Context 61 A Parting Thought 63 Chapter 6 The Quality of Communication Determines the Quality of Decision Making 65 OVERVIEW: Cost Pressures Threaten Communication Quality When Its Needed Most 65 Outside Vendors Increase Risk of Costly Communication Errors 67 Offshore Engine O

21、verhaul Leads to Serious Injury and Major Property Damage 67 Factory Workers Propeller Repairs Lead to Serious Accident 69 viiiContents The Deadly Effects of Mislabeled Cargo 71 Missing O-Rings Lead to In-Flight Shutdowns and Nearly Cause Disaster 74 A Parting Thought 78 Chapter 7 Up Your Profession

22、alism 79 OVERVIEW: Todays Mechanics Must Rise to New Levels 79 Professional AMTs Need Better Communication Than Mere Grease Monkeys Do 81 Professionalism Defined and Delivered: The 4 Cs 83 New Classifications Mean More Communication Skills 84 More Professionalism or Less? 84 Some Parting Thoughts 87

23、 Chapter 8 Mechanics Cannot Thrive on the Written Word Alone 89 OVERVIEW: Effective Communication Is Multimedia 89 Oral Communication Has Limitations 93 Written Communication Is As Important As Ever 94 The Accident at Dryden, Ontario 95 Encouraging Attempts to Improve Written Communication 100 A Par

24、ting Thought 103 Chapter 9 MRM Is Multiparty Cooperation, Open Communication, and Error Reduction 105 OVERVIEW: MRMA Strong Model for Multiparty Communication, Cooperation, and Error Reduction 105 PHASE ONE: Participative Data Collection 108 PHASE TWO: Making Changes With and Without AMT Involvement

25、 111 PHASE THREE: Broadening MRMs Scope from Paperwork Errors to All Quality 117 PHASE FOUR: Broadening MRM to Become a Culture 118 A Parting Thought: The Bases of Success 119 ixAirline Maintenance Resource Management: Improving Communication Chapter 10 Early Successes with Open Communication 123 OV

26、ERVIEW: Continental Airlines MRM Communication Program Pays Off 123 CRM and Teamwork Training in Aviation 125 Continental Introduces MRM 126 The Importance of Purposeful Systems 138 A Parting Thought: Borrow from the Best 141 Chapter 11 AMT-Oriented Communication Training Comes of Age 143 OVERVIEW:

27、The Need for Strategic Thinking and Management Follow-Through 143 Background 143 The Increasing Variety of Current MRM Programs 146 The New Age of MRM Programs 148 A Case Study in Bringing MRM to AMTs 150 Initial Training Evaluations Very High 152 Improved Attitudes 153 Performance Changes Related t

28、o MRM Training 157 Reported Changes from MRM Training 158 A Parting Thought: The Importance of Implementation 160 Chapter 12 Recommendation Number One: Change Your Mind 163 OVERVIEW: The Real Trouble with Maintenance Is Called Culture Lag 163 Achieving an Effective MRM Culture 175 A Final Thought 18

29、2 Appendix A Principles of Cultural Redesign 185 Appendix B Some New-Culture Programs Already in Place 189 Index 191 About the Authors 201 xForeword If you care about aircraft safety, this is a book you must readno matter what your connection to airline maintenance, no matter where you are in the wo

30、rld. This book is a primer about the leading-edge approach to mainte- nance operations, the partnership of manager, doer, and regulatorthe art and science of Maintenance Resource Management (MRM). As a former president of the Society of Automotive Engineers (SAE) and as the recently retired vice pre

31、sident of maintenance operations for USAirways, I have been twice blessed by having helped get this book com- missioned and by having had the privilege of getting an airline started with MRM. Our own story is told in Chapter 9, warts and all. Despite our early successes with this new approach, USAir

32、ways is continuing to learn the ins and outs of MRM. Taylor and Christensen have something important to say to all of us. In clear and compelling language, the authors tell the inside story of maintenance communication errors that led to near disasters and also to air- plane accidents that claimed h

33、undreds of lives. Although these examples are drawn from North American experience, the lessons apply to mainte- nance operations everywhere. The authors show how these sometimes simple workplace communica- tion failures could have happened at any airline, anywhere, thanks to an industrywide mainten

34、ance culture that has evolved too slowly to keep pace with the changes in our industry. This book confirms that communication skills are the lifeblood of the aviation maintenance technician; they will help us address the ever-increasing complexities in our technology, govern- ment regulations, and t

35、he marketplace, in order to produce a continuously improving safety environment. In the last three chapters of this book, the authors detail how the MRM programs at several leading carriers are reducing maintenance errors and improving the professional caliber of mechanics and managers. The authors

36、xiAirline Maintenance Resource Management: Improving Communication give you the numbers, directly from the latest research on the effectiveness of these MRM initiatives. They “make no bones“ about itthey show you how the deadly mistakes of the past are practically guaranteed to rise with- out these

37、kinds of fundamental reforms in our old, familiar workplace com- munication practices. The changes the authors are calling for are needed everywhere and at every airline. Wherever the old ways remain in use, accidents are waiting to happen accidents that do not have to happen. Such accidents are cau

38、sed by mainte- nance errors that can be prevented. Taylor and Christensen go one step further, reaching beyond the best practices beginning to take hold in our industry today. They also brief us on what lies ahead and what will be needed to bring us abreast of the high- performance work systems in t

39、he best high-tech industries around the world. In one book, the authors cannot teach us everything we need to know. However, they can show us where to startright where we areand when to startright now, today. If you did not already know why you must start moving, and keep moving, in this direction,

40、they make it painfully obvious. As for the pain, these authors have been around and know well that their prescription for change will not be easy medicine to swallow. In some ways, their prescriptions are a frontal assault on a way of working life that for us continues to feel tried and true despite

41、 having outlived its usefulness. Some of our best stuffthe things that have worked so well in the pastare now becoming the biggest obstacles in our paths. Taylor and Christensen introduce us to the enemyourselves. To achieve what we want in the future, we must begin by changing our own minds right n

42、ow. Rather not? Do it anyway, because lives are at stake. It is an urgent message clearly stated. This message must be said and heard, loudly and clearly, throughout the industry. A good place to start, or to pick up where you left off, is right here. Just turn the page. B.R. Aubin Senior Vice Presi

43、dent, Technical Operations, Air Canada (retired) Senior Vice President, Maintenance Operations, USAir (retired) xiiIntroduction The Critical Nature of Communication In 1903, Orville and Wilbur Wright completed the first successful powered flight. Although their preparations seemed complex at the tim

44、e, by our stan- dards they were very simple. When the brothers designed, flew, and repaired their own airplane, they didnt worry much about communication breakdowns, because they were involved in every operation. Over the next 95 years, as advances in technology changed every aspect of aviation, lit

45、tle attention was paid to an important element of safetycommunication in the workplace. In 1988, the industry got a wake-up call from a fatal accident involving a Boeing 737 near Maui, Hawaii. One crew member died, and a number of passengers were injured when the skin on the aircraft peeled back in

46、flight. The National Transportation Safety Board (NTSB) attributed the accident to the management of the entire maintenance system, rather than to individ- ual error Ref. 1. Although maintenance issues had come up before, this accident marked the first time the NTSB laid the blame squarely at manage

47、- ments door. After the NTSBs report on the Maui accident, it began to dawn on the aviation community that communication is an industrywide problem. Even so, communication and coordination issues have only recently been considered as important as technological advances. By definition, management is

48、responsible for the communication and coor- dination systems of their organization. However, after airline deregulation in 1978, managements focus shifted to mergers and cost reduction issues. Employee needs and organizational structures were of secondary impor- tance. Competition pressured airlines

49、 to pursue productivity improvements aggressively, to minimize “nonessential“ maintenance activity, and to reduce costs, even as they expanded operations. As technology and economics xiiiAirline Maintenance Resource Management: Improving Communication governed airline operations from 1978 into the mid-1990s, aviation acci- dents continued at a nearly constant rate. In 1996, aviation accidents worldwide accounted for over 1300 passenger fatalities, nearly twice the annual average of the previous five years Ref. 2. Today, it is estimated that air tr