Debriefing

2012 - April - Aviation Life Support Equipment – Will it? Should there be any doubt?

In 2011, there were 123 Aviation Life Support Equipment (ALSE) related occurrences reported in the Flight Safety Occurrence Management System (FSOMS).  The chart below breaks down the nature of these occurrences and highlights why ALSE have not functioned properly when needed.

Many of the cause factors identified involved non-compliance with technical orders and checklists. Correctly inspecting, maintaining and documenting the serviceability of ALSE are critical steps due to the equipment’s unique function in sustaining life. Most preventive measures were “Personnel and Supervisors were briefed.” This preventive measure must be conscientiously carried out to be effective in preventing re-occurrence. While briefing people is a good thing, it is human nature to forget. We must rely on our technical orders and checklists to get the job done right.

What provokes error? The practical guide in Managing Maintenance Error by James Reason and Alan Hobbs states that: “It’s better to assume that you will forget, and take precautions, then to hope that you will remember.” It suggests that “memory lapse” is the most common causal factor in aircrew and maintenance errors followed by:

• interruptions
• pressure
• fatigue
• inadequate coordination between maintainers
• unfamiliar jobs
• ambiguity and highly routine procedures

LEARNING TO RECOGNIZE THESE VULNERABILITIES OR RED FLAGS IS IN ITSELF A SELF-PROTECTING SKILL WORTH DEVELOPING.