There are a number of potential hazards which fuel-tank maintenance personnel may experience whilst engaged in Fuel Tank Work however the 2 primary hazards are:
a) Chemical b) Physical
Considering Chemical Hazards and their Consequences - Fuel
Off course the most commonly recognized hazard is the jet fuel itself which is a flammable liquid and will ignite if the temperature of the fuel is such that vapour is created. (The temperature at which the vapours of a flammable liquid can ignite is known as the "flash point".)
www.sassofia.com considers the complexities of Root Cause Analysis (RCA)
To be effective in reducing negative events we need to understand how we can use various analytical techniques to first understand and then to mitigate the actual as well as potential exposure.
The root cause analysis (RCA) method uses a cause and effect approach by asking (For example) multiple "why" questions as an effective way to identify one or more low level elements which contributed in some way to a subsequent failure.
With sufficient information available we are able to develop a number of corrective actions which should directly impact the exposure and which if taken correctly should prevent failure in the future.
Direct cause is defined as “the cause that directly resulted in the occurrence.” This would be like the person who whilst following a standard operating procedure (SOP) makes an “error” which results in an adverse outcome.
So therefore we can say that the person’s error is the direct cause of the problem that occurred.
Aviation Human Factors training has only been mandatory for the last 10 years with the EASA compliant maintenance environment.
Why Aviation Human Factors Training?
Well currently some 80% of aircraft accidents are attributable to human error, shared between pilots, maintenance staff and Air Traffic Control, Ground Operations and a very small percentage to other factors.
In the main it should be understood that this is a situation which is recognized as rectifiable through the process of raising awareness, training including the associated management of competence and implementation of effective process and procedure and effective communication within the workplace.
When we talk about Human Factor (HF) related issues within the Maintenance Planning environment we need to consider also that often visibility of the outcome is moved to another area of the business. For example if due to planning considerations work is loaded onto the check in an uneven way then it is possible to create an environment where we see commercial pressure, which as we know may directly lead to stress and the possibility of an unwanted HF event.
Another issue also relating to visibility may be connected with the iceberg theory of accidents and incidents. We know that for every significant incident or accidents which occur there are maybe 10 externally report able events (to the regulator) and 30 internally report able events, (to the quality or safety system) however there are additionally in region of 300 unreported transgressions which not only go unreported, but may in fact when considered in isolation appear to have minimum direct consequence, nevertheless may in fact become either precursors or contributors to a more serious event.
