Investigate a maintenance error and analyse the error trend

You are the assistant quality and safety officer.

Simulated workplaceAdvanced missionCAQA AeroTech Maintenance

What is going on

A pitot cover was left fitted on a helicopter after a daily inspection at Sunshine Coast and found by the pilot on the walk around, self reported as SR-26-087. It is the third close up related error this quarter, after a fuel drain valve reinstalled without safety wire and a spanner unaccounted for in an engine bay. Daniel Okoro wants a maintenance error management investigation of the pitot cover event: interview the reporter under just culture principles, identify the contributing factors, and recommend controls. He then wants the three events analysed for common factors and a short report and human factors briefing prepared for the safety committee on 23 September.

Daniel Okoro, Quality and Safety Manager
Subject: Investigate the pitot cover occurrence and review the error trend

The pitot cover left fitted at Sunshine Coast (SR-26-087) is the third close up error this quarter alongside the fuel drain safety wire and the spanner. I want a proper investigation of the pitot cover event using the maintenance error management approach: interview the reporter, identify the contributing factors, and recommend controls. Then look across the three events for common factors and prepare a short report and a human factors briefing for the safety committee on 23 September. Update the safety reports register as you go.

Your brief

Investigate the pitot cover occurrence using the maintenance error management approach, identify contributing factors and controls, analyse the three recent events for common factors, update the safety register and prepare a committee report and a human factors briefing.

Work through it

You do not need to do it all. Doing a few of these will show you what the work is like. Your ticks and notes stay on this device.

Read the Safety Policy just culture section, the Human Factors and Fatigue Management Policy and the occurrence report guidance and plan an interview that is open and non-punitive.
Review SR-26-087, the work order for the daily inspection and the roster for that shift to establish the timeline, the interruptions and the duty hours of the reporter.
Interview the reporter and the certifying engineer, recording the sequence of events and the contributing conditions such as interruption, time pressure, lighting and handover.
Classify the contributing factors using the maintenance error management model and identify the control that failed or was missing at close up.
Recommend controls following the hierarchy of controls, such as recording covers and blanks on the work order, a close up checklist and a final walk around by the certifier, with owners and dates.
Analyse SR-26-083, SR-26-087 and SR-26-088 together for common factors such as shift timing, interruptions, apprentice supervision and tool and equipment control, and record the trend.
Update the three entries in the Safety and Occurrence Reports system with findings, actions and status, and confirm the regulator reporting status of each.
Prepare a two page report for the safety committee and a fifteen minute human factors briefing on close up errors for delivery on 23 September.

My notes: what did I enjoy, and what surprised me?

What someone in this role would produce

Investigation record with timeline and contributing factors
Control recommendations with owners and dates
Trend analysis across the three events
Updated safety register entries
Committee report and human factors briefing

Printing this is a record of what you explored. It is not a certificate or a qualification.