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2) working in limited (often height-restricted) space in the midst of congestion of other servicing
vehicles, personnel and adjoining aircraft movements;
18-APP 2-2 Safety Management Manual (SMM)
3) time pressures for on-time departures (or to make up for late running);
4) cyclical workload with peak demands followed by lulls between transiting aircraft;
5) frequent shift work;
6) requirement to operate a variety of expensive, specialized servicing equipment;
7) workforce (especially for loaders) often comprises casual unskilled labour;
8) apron workers are often employed by organizations other than the aerodrome authority
(e.g. airlines, service providers and catering companies); and
9) organizational factors deriving from management’s failure to provide a similar level of attention
to ground safety as it does to flight safety.
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19-1
Chapter 19
AIRCRAFT MAINTENANCE
19.1 MAINTENANCE SAFETY — GENERAL
19.1.1 Until recently, less attention had been paid to systematically reducing risks arising from aircraft
maintenance activities than from flight operations. Yet, maintenance and inspection errors are cited as a
factor in a number of accidents and serious incidents worldwide each year.
19.1.2 The safety of flight is dependent on the airworthiness of the aircraft. Safety management in the
areas of maintenance, inspection, repair and overhaul are therefore vital to flight safety. Maintenance
organizations need to follow the same disciplined approach to safety management as is required for flight
operations. Adhering to such a discipline in maintenance can be difficult. Maintenance activities may be
conducted by the airline itself, or they may be contracted out to approved maintenance organizations, and
as a result, these activities may take place well away from the airline’s home base.
19.1.3 Conditions for maintenance-related failures may be set in place long before an eventual failure.
For example, an undetected fatigue crack may take years to progress to the point of failure. Unlike flight
crews who have near real-time feedback on their errors, maintenance personnel usually receive little
feedback on their work until a failure occurs. During this time lag, maintenance workers may continue to
create the same latent unsafe conditions. As a consequence, the maintenance world incorporates a
combination of safety defences, including multiple redundancies of aircraft systems, to strengthen the
system. These defences also include such things as certification of maintenance organizations, licensing of
AMEs, airworthiness directives, detailed SOPs, job cards, inspection of work, and sign-offs and records of
work completed.
19.1.4 Risk potential may be created by the conditions under which maintenance is often conducted,
including such variables as organizational issues, work site conditions and human performance issues
pertinent to aircraft maintenance. Some of the broader issues in maintenance potentially affecting safety are
outlined in Appendix 1 to this chapter.
19.1.5 The term “safety” in an aircraft maintenance context is often considered to have two
connotations. One is an emphasis on industrial safety and hygiene for the protection of AMEs, facilities and
equipment. The second is the process for ensuring that AMEs provide airworthy aircraft for flight operations.
Although the two may be inextricably linked, this chapter concentrates on the latter, with little reference to
Occupational Safety and Health (OSH) issues.
19.2 MANAGING SAFETY IN MAINTENANCE
19.2.1 Given the nature of the maintenance function, the working environment for AMEs, and the
many Human Factors issues which may compromise their expected performance, a systematic approach to
safety is called for, i.e. a safety management system (SMS). Chapter 5 describes how system-wide safety
management recognizes organizational interdependencies and interactions, with the need to integrate safety
efforts across the entire operation. Successful SMS are built upon the following three cornerstones:
19-2 Safety Management Manual (SMM)
a) corporate approach to safety;
b) effective tools for programme delivery; and
c) formal system for safety oversight and programme evaluation.
19.2.2 Each of these aspects of an SMS is discussed below.
Corporate approach to safety
19.2.3 The corporate approach to safety sets the tone for how the organization develops its safety
philosophy and its safety culture. In deciding on the approach the organization wishes to take towards safety
management, the following factors may be relevant:
a) size of the maintenance organization (large operators tend to require more structure);
b) nature of the operations (e.g. around-the-clock, international or scheduled operations versus
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