Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
ENG752
Initial Report
A scheduled engine change was planned for outside the hangar. Weeks in advance I stated I was not comfortable with this due to relative inexperience on that critical task and there were no experienced staff available to support me. I was told it was OK, they would get a different team to run it. The day of the aircraft arrival I was told I am doing it and they have got another contractor to assist but he doesn’t have engine change experience. The aircraft was in work for approximately 12 hours when the customer had an AOG in their fleet and asked to return the a/c back to service (no critical tasks had been performed, mainly access and it was all documented). Company management told me to continue. They then told me to tell the customer we would meet the agreed downtime (5 days) even though management knew it would be at least 7 days or possibly more due to work stoppages (working outside in the winter). The pressure put on me was incredible, so I stopped all work until management told the customer what was actually happening. There is another engine change scheduled for outside again next week and, after expressing my concerns, I’ve been told I’ve got no choice, there is no one else.
In the hangar in general there is a massive shortage of engineers. Down to as few as 2 B1s per C-check and up to 30 mechanics. Currently running 3 lines of maintenance in the hangar and one line outside. Many engineers are feeling under pressure and there have been many IORs and MORs raised for missed inspections, missed independent inspections, and even mechanics doing inspections with engineers having to just over-sign.
CHIRP Comment
After initial contact, the organisation did not comment further and the reporter was uncomfortable in allowing CHIRP to contact the CAA. It is worth noting that CHIRP reports passed to the CAA with the reporter’s permission often become whistleblower reports and as such are subject to strict CAA confidentiality procedures.
Mechanics carrying out inspection tasks was covered in CHIRP Air Transport FEEDBACK Ed 150 (April 2024) and this report highlights three further aspects of risk, driven by Human Factors issues.
Staff shortages have become a recurring theme in recent CHIRP engineering reports. Two B1s for a C-check sounds very concerning and one can only wonder if the man-management of thirty mechanics would undermine the time available for licenced staff to address their technical duties.
We have all worked outside in inclement weather, especially for AOG situations. We all know the mitigations required for the weather when working outside such as additional blanking of tubes and connectors, covering exposed areas of the aircraft that we perhaps would not need to do for short periods inside the hangar. We also know that our performance is affected under outside cold conditions from things like cold hands and toes, streaming eyes and nose etc. Carrying out tasks within the bypass duct might appear to be the ideal shelter, until the cold wind blowing across a flat airfield starts whistling through. Apart from a natural desire to hurry the job and get back inside, our attention span is reduced and even our communications are at risk of being curtailed, misunderstood or just missed. It was not possible to establish if the maintenance organisation knew in the beginning that the work would have to take place outside or not. Did the Operator and it’s Continuing Airworthiness Organisation think an engine-change outside was acceptable? Did they just contract out the work and forget it was taking place? Did the Operator provide an onsite representative? Did any party consider the implications of multiple organisations working together?
Another concerning question raised by this report is that of competence to conduct work. An organisation can have a very effective competence assessment procedure but the second a staff member says they are concerned that they do not have the correct experience, the work should stop until a safe solution is found. It shouldn’t be necessary to repeat this, especially in CHIRP Air Transport FEEDBACK but, to be clear, if there’s no approved data, you stop; if there’s no approved tooling, you stop; if there’s no authorised components, you stop; if there’s no staff, you stop; if there’s no ground equipment, you stop; and last, but in no way least, if you don’t have confidence in your competence, you stop.