Ground Support Worldwide

OCT 2012

The ground support industry's source for news, articles, events, product and services information.

Issue link:

Contents of this Issue


Page 19 of 35

RAMP SAFETY manufacturers must make a renewed commitment to expedite the process to address issues with documentation. Industry Actions r Revisit (with airlines, in particular) the process for timeliness of docu- ment revision. Government Actions r Hold manufacturers, airlines, maintenance organizations and individuals responsible for inferior documents that they knowingly cre- ate and/or continue to use. Individual Actions r Report bad documentation when you see it. Request that it be addressed. Actively change the culture! EXPAND INCIDENT INVESTIGATIONS Guidelines for incident/accident investigations must require a complete root cause analysis (RCA) when it appears a procedure was not followed. The cause may be an error, where a well-documented procedure was not properly executed. Or the cause may be a document-related issue where the instruction was not clear, com- plete or correct. Although sufficient for an investi- gation, the categories are too broad from the standpoint of actionable change to mitigate future risk. Also, existing reporting systems may contain information relevant to an investigation, but that does not explic- itly state what the precursor was to the error. As an industry, we must focus on improving outcomes of formal and informal investigations of errors and document-related issues by improv- ing the data quality and developing analysis tools. We must determine what the "right" questions are for a reporting system during a formal investigation. Industry Actions r Change current event and accident investigation forms to have a section dedicated to the use of technical documentation. If technical documentation is suspect, then ensure sufficient root cause analyses. r Create internal procedures for immediate correction of technical documentation any time it may be a small (or large) contributing fac- tor to a safety event. Government Actions r Create procedures and training to help event investigators recognize the manner in which technical documentation may have been a contributing factor to an event. r Ensure that all FAA accident inves- tigations that identify procedures or documentation as contributing factors also ensure that a proper root cause analysis is conducted. Individual Actions r Report all detailed information We Lead the Industry in Innovation Orion Deicer 880 gallons 47 Foot working height 10 minute heat time New! New! about documentation issues that contributed to an error/ event/accident. GRV Glycol Recovery Vehicle 750, 1300, 2100 gallon options Learn about the latest from Global Ground Support, and how these new products save you time and money. Training Simulator - Deicing Grades Students on Performance 2200 XR 57 Foot working height NO stabilizers New! r Use voluntary reporting to describe when and why a job card or proce- dure was not used properly or at all. To summarize, there are a num- ber of ways to change a culture of noncompliance, and we've mentioned two that should take priority. Programs and leadership commitment are necessary, but not enough. Change requires personal action and a commitment to safety. Programs and processes are only successful if followed. Are you ready to change the culture in your organization? It begins with you, the aviation professional. Dr. Katrina Avers is a Research 540 East 56 HWY Olathe, KS 66061-4640 USA (913) 780-0300 20 GROUND SUPPORT WORLDWIDE r 0DUPCFS ISO 9001:2008- certifi ed quality management system Scientist at the Federal Aviation Administration in the Civil Aerospace Medical Institute Human Factors Research Lab. Dr. Avers takes a practi- cal, science-based approach and has worked to develop applied solutions that can be used across the industry.

Articles in this issue

Links on this page

Archives of this issue

view archives of Ground Support Worldwide - OCT 2012