ERROR & SYSTEMS
Task analysis of maintenance activities has revealed aircraft inspection to be a complex activity requiring above average coordination, communication and cooperation between inspectors, maintenance personnel, supervisors and various other sub-systems (e.g., planning, stores, clean-up crew, shops) to be effective and efficient. A large portion of the work done by inspectors and maintenance technicians is accomplished through teamwork. The challenge is to work autonomously but still be a part of the team. In a typical maintenance environment, first, the inspector looks for defects and reports them. The maintenance personnel then repair the reported defects and work with the original inspector or the buy-back inspector to ensure that the job meets predefined standards. During the entire process, the inspectors and maintenance technicians work with their colleagues from the same shift and the next shift as well as personnel from planning, stores, etc. as part of a larger team to ensure that the task gets completed (FAA 1991). Thus, in a typical maintenance environment, the technician has to learn to be a team member, communicating, and coordinating the activities with other technicians, and inspectors. One of the areas requiring the use of effective team skills is shift change, but this procedure has been widely reported as a cause of several errors/accidents in the aircraft maintenance industry (see FAA 1991, FAA 1993, Hobbs et al. 1995 and the recent Continental Express crash). This can be attributed to a lack of well-defined shift change
procedures for use by the aircraft maintenance industry. In response to this need, industry has developed ad-hoc measures and general guidelines to assist various personnel involved in the shift change process. This has resulted in various organizations developing their own internal procedures, which vary in their level of instruction/detail. Because of this situation, shift change procedures are not standardized across the industry. Moreover, they are often not based on sound principles of human factors design. Hence, there exists a need to look at the shift change process. In response to this need, this research looked at the entire shift change process to identity human factors interventions that can be applied to develop a standardized shift change process which will minimize shift change errors.