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Doc 9824. Edition 1
Last modified:1/1/2003
Human Factors Guidelines for Aircraft Maintenance Manual
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iiiPREFACEExtract from an address by the President of the ICAOCouncil, Dr. Assad Kotaite, to the Plenary Meeting of theAviation Study Group at Linacre College, OxfordUniversity, United Kingdom, on 16 February 2001I suggest to you today that it is through theorganizational perspective that we will break the cur-rent safety impasse in which we find ourselves. Istrongly believe that the contribution of the aviationsystems management towards enhancing safety is para-mount. Regulators and airline management alike definethe environment within which individuals conduct theirtasks. They define the policies and procedures thatindividuals must follow and respect. They allocate thecritical resources which individuals need in order toachieve the systems safety and production goals.Lastly, when the system fails, they must thoroughlyinvestigate these failures and take all needed remedialaction to avoid repetition. Simply put, managers play afundamental role in defining and sustaining the safetyculture of their organizations.One crucial aspect of an organizations safety cultureis the ability to deal with human error. From anorganizational perspective, human error should becomea warning flag for regulators and managers, a possiblesymptom that individual workers have been unable toachieve the system goals because of difficult workingenvironments, flaws in policies and procedures, inad-equate allocation of resources, or other deficiencies inthe architecture of the system. We must face the factthat because of human error, unwanted, un-willful devi-ations from the norms will take place. However,deviations in and of themselves are not the problem.The danger lies not in experiencing operational devi-ations, but rather in not having an adequate process ofmanaging these deviations.Effective deviation management results from the freeexchange of information about operational errors whichlead to deviations. We must create, therefore, an oper-ational environment where anyone can feel secure incoming forward and sharing information concerningdeviations. In other words, humans must be part of thesolution and not part of the problem. This is a non-punitive environment, which nevertheless retains indi-vidual and organizational accountability.
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Table Of Contents
COVER PAGE
AMENDMENTS
PREFACE
TABLE OF CONTENTS
FOREWORD
ACRONYMS AND ABBREVIATIONS
GLOSSARY
INTRODUCTION
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7