Diminishing the ‘human factor’ one Airman at a time

Published March 28, 2011
By Maj. Gabe Johnson
162nd Fighter Wing Public Affairs

TUCSON, Ariz. -- The concerted efforts of Air Force safety officials and aircraft maintainers to remove the human element from preventable mishaps are deeply rooted in a humanitarian ethos - the idea that every Airman deserves to go home safe at night.

Maintenance Resource Management, or MRM, is the safety movement sweeping across the Total Force picking up disciples along the way. Recently, 59 maintainers representing a spectrum of ranks and weapon system specialties visited the 162nd Fighter Wing here to become certified MRM instructors enabling them to spread the word and change the service's safety culture - one Airman at a time.

The program, which is derived from the established cockpit resource management concept used by aircrews, abolishes the authoritarian approach to safety and empowers the most junior Airman to speak up about possible risks. Under MRM, all tasks are evaluated by a team of maintainers who are taught to rely on planning and preparation, decision making, communication, mutual support, task management and lessons learned.

Although the Air Force operates safer than it ever has during its history, proponents of MRM are working to bring the margin to zero - or close to it.

Following a study of aviation mishaps between 1992 and 2002, the Air Force determined that about 18 percent of its aircraft mishaps were attributable to maintenance human error. The study cited such mistakes as failure to follow published aircraft manuals, lack of assertive communication among maintenance technicians, and improper assembly practices.

In 2005, the Air National Guard Aviation Safety Division, made the MRM program available to the Guard's 88 flying wings. In 2006, the Department of Defense recognized the value of the program by adopting a variant of ANG MRM for training throughout the Air Force and is now widely used with substantial results.

Organizations that fully employ MRM experience up to a 67 percent reduction in preventable mishaps, injuries, lost workdays and lost equipment.

Col. Doug Slocum, the Air National Guard director of safety and the author of the MRM curriculum, saw the sites of his hometown as a boy from a beanbag chair in the back of this parent's pick up.

"If you saw someone doing that today you'd call 9-1-1," he said.

He uses this anecdote from his personal past to highlight how safety behavior evolves in a given culture, and he raises the question of what will be the safety norms - attitudes and behaviors - of 2025.

Slocum, an F-16 pilot by trade, is a student of history, statistics and human behavior - all of which are keys to his program. He notes that over time many of the mechanical traps in aviation were engineered out of the equation, yet mishaps still occur because of the human factor.

"In the human being aspect of getting work done, how do we work better together? We have to move to a level of excellence that has not been thought of before. We can be proud of our heritage, but from a safety stand point we can't look back in time and say that's where we'd ever want to go again," said Colonel Slocum. "Instead we want to look at where we are now and, more importantly, where will we be in 20 years. What will be our acceptable safety behavior then?"

Lt. Col. Dave LaTour, chief of safety for the 150th Special Operations Squadron at McGuire Air Force Base, N.J., is one of the converted who now trains other MRM instructors.

"People are so afraid of failure that they rush toward success and inadvertently introduce failure. Rushing is all thrust with no vector. Instead of being in a hurry we want to be quick because quick is intentional and precise about where you are going," said Colonel LaTour.

"Assumptions are also a challenge we have to overcome," he added. "We assume that because we are intelligent and proficient at our job that we don't need someone to check our work, and we assume that rank either inhibits or empowers us when the reality is that we are equals when it comes to keeping each other safe."

Lt. Col. Dom Sarnataro, a C-130 pilot and chief of safety for the 189th Airlift Wing at Little Rock Air Force Base, Ark., is a newly minted instructor from the Tucson course. He said MRM incorporates many of the safety practices he uses in the cockpit.

"MRM encourages members to read about safety mishaps from around the service," he said. "I am safest at my job after I hear a safety brief about a pilot who got hurt. You naturally think, 'That could happen to me.'"

Lessons learned factor into an overall MRM approach that helps maintainers assess risk.

"Take an engine change for example," said Sarnataro, "there's lighting within five miles, we have a younger guy on the job and it's windy. All of these factors can add up to an unacceptable risk to get the job done. All it takes is one individual to speak up."

And more teamwork for every task creates more opportunity to speak up.

"One Airman might be a 90 percent kind of worker," he said, "meaning that nine out of 10 times his work is error free. But if he works alongside another 90 percent kind of worker he'll get the benefit of another perspective and together they've cut their possibility of error from one in 10 to one in 100. If you have a 90 percent kind of supervisor check the team's work, suddenly you have an overall error rate that's all the way down to one in 1,000."

According to Colonel Slocum the future of Air Force maintenance safety could become automated to insulate people from preventable errors. He proposes a system of checks and balances that ensures real-time compliance with safety measures; a system that automatically verifies all steps involved in a certain task including the qualification of the maintainer and the supervisor's inspection of the work.

He openly claims he's no public speaker, yet to date he's personally trained 60,000 Airmen in MRM.

"Safety is all about family, so I'll call it a passion. At the end of every course I show a picture of my daughter Keira. Every day after work, each one of us deserves to go home safe to our family, and that's our main objective in safety."