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maintaining detailed work records;
5) variable environmental factors (for example, conditions on the ramp versus in the technical
workshop versus on the hangar floor);
6) unique operating conditions created by concurrent activities and inclement weather on the ramp;
and
7) shortcomings in the provision of timely, accurate, understandable discrepancy reports by flight
crews, etc.; and
19-APP 1-2 Safety Management Manual (SMM)
c) Human Factors in maintenance:
1) organizational and working conditions (as described above);
2) environmental factors (e.g. temperature, lighting and noise);
3) individual factors (e.g. workload, physical demands and maintenance);
4) scheduling (e.g. shift work, night work and overtime) versus adequacy of rest periods;
5) appropriateness of SOPs (e.g. correctness, understandability and usability);
6) quality of supervision;
7) proper use of job cards, etc. (i.e. do actual floor practices comply with SOPs?);
8) adequacy of formal training, on-the-job training (OJT), recurrent training and Human Factors
training;
9) adequacy of handovers at shift changes and record keeping;
10) boredom; and
11) cultural factors (e.g. AME’s professionalism and openness to report errors and hazards).
2. The Human Factors Guidelines for Aircraft Maintenance Manual (Doc 9824) provides information on
the control of human error and the development of countermeasures to error in aviation maintenance. It is
targeted at managers in maintenance organizations, aircraft operators and Civil Aviation Administrations.
— — — — — — —
19-APP 2-1
Appendix 2 to Chapter 19
MAINTENANCE ERROR DECISION AID (MEDA)
1. The Maintenance Error Decision Aid (MEDA) provides a structured framework for documenting
contributing factors to errors and for recommending suitable error prevention strategies. MEDA is founded
on the following basic tenets:
a) Maintenance errors are not made on purpose.
b) Most maintenance errors result from a series of contributing factors.
c) Many of these contributing factors are part of an operator’s processes and therefore can be
managed.
2. The traditional approach in following up on maintenance errors was all too often to identify the event
caused by a maintenance error and then to administer discipline to whoever made that error. The MEDA
process goes much further (without the disciplinary follow-up unless there has been a deliberate violation of
procedures). Having investigated the event caused by a maintenance error and identifying who made the
error, MEDA facilitates the following actions:
a) determining those factors which contributed to the error;
b) interviewing the responsible persons (and others if necessary) to obtain all the pertinent information;
c) identifying those organizational or system barriers which failed to prevent the error (and the
contributing factors as to why they failed);
d) gathering ideas for process improvement from the responsible persons (and others as applicable);
e) maintaining a maintenance error database;
f) analysing patterns in maintenance errors;
g) implementing process improvements based on error investigations and analyses; and
h) providing feedback to all employees affected by these process improvements.
3. MEDA checklists facilitate the interview process (i.e. data acquisition) and data storage in a
maintenance error database. With a view to understanding the context in which maintenance errors are
committed, listed below are ten areas where data should be collected:
a) Information. This category includes work cards, maintenance procedures manuals, service
bulletins, engineering orders, illustrated parts catalogues and any other written or computerized
information provided either internally or by the manufacturer that is considered necessary for the
fulfilment of the AME’s job. Some of the contributing factors as to why the information was
problematic or was not used include:
19-APP 2-2 Safety Management Manual (SMM)
1) understandability (including format, level of detail, use of language, clarity of illustrations and
completeness);
2) availability and accessibility;
3) accuracy, validity and currency; and
4) conflicting information.
b) Equipment/tools. This category includes all the tools and materials necessary for the correct
completion of the maintenance or inspection task. In addition to routine drills, wrenches,
screwdrivers, etc., it includes non-destructive test equipment, work-stands, test boxes and special
tools identified in the maintenance procedures. Some of the contributing factors as to how
equipment or tools can compromise the performance of the AME include:
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Safety Management Manual (SMM) 安全管理手册(151)
