Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
ENG712
Initial Report
We are using Mobile Elevating Work Platforms (MEWP) for access against engines at great heights, leaning over the engines with only our feet on the lower floor of the MEWP whilst sprawled onto the engine. Very easy to fall Left or Right. Numerous times on a 4-day shift this can be observed. Safety boots are not being used by certain people for the entire shift and no use of high-vis jackets on the apron at any time despite being mandatory. Critical Tasks such as lifting [aircraft] pylons by hand and fitting them are occurring at the end of a 12-hour shift, with a heavy push to have them up and fitted before end of shift with a lack of a tea break.
My local area management are simply not overly worried about the use of high lifters in dangerous positions as long as they do not have to witness it. I was stood witnessing work carried out to an aircraft D-duct and my manager deemed it safe and accessible for my LAE to lean from the MEWP with only heels on the basket and the rest of his torso exterior of the basket.
Working through break times is more than acceptable to me – I understand flexibility – however the culture is shifting in a way that too much is expected in too short a timeframe with rushing and using incorrect equipment. Our man hours are not adequate for the work being pushed for and I can see standards slipping and I do not want to be on the receiving end of it. We have less than 3 people working for sometimes 8 hours solid with no break, trying to fulfil 12 peoplesā work in the shortest timeframe possible due to our lack of personnel. This in my eyes is recipe for disaster. Finally Iām just totally in disbelief that more and more people are not wearing PPE such as safety boots, and itās just shrugged off when pointed out. High-vis jackets are not being worn in pitch black on the apron; this is even more ludicrous when not 2 weeks ago a member of engineering was taken downstream from an [aircraft] engine exhaust blast. Iām overly done with health and safety becoming second to aircraft delivery, and my own wellbeing put behind the wrath of a [Management Position] phone call demanding aircraft be finished earlier.
Company Comment
Working at height is a focus for us and we are working on developing and improving our Safe Systems of Work, especially around engine changes, and training on the use of MEWPS. Regarding line managersā attitudes to H&S, since the start of the year we have been running āH&S Managementā courses. We plan to cycle all Line Managers through this course, currently [##] have completed this training. The scope of this training is to highlight H&S law and specific responsibilities of management personnel and is part of our Safety Plan to improve H&S competence in Engineering.
I donāt recognise the issue of PPE not being worn, and I have spoken to my Quality Engineers who do not recognise this statement either; I have asked my Quality Engineer to monitor this and they have not identified any shortfalls. I donāt concur with the reporter on PPE. I have had no internal reports, or from the airport authorities, and my Quality Engineers, who conduct weekly checks of all areas, have not found any issues of PPE not being worn.
Regarding working time, thereās no doubt that [Operator], similar to the rest of our industry, is in the process of recruiting various levels of maintenance staff, which has left some shifts below the expected levels. We have been monitoring this and deferring work to maintenance lines away from the reporterās location. We continue to work hard to increase recruitment and are now seeing new Licenced Engineers and Mechanics being deployed into the maintenance areas.
However, I donāt recognise the issue of engineers being forced to routinely work through their tea breaks. There is a potential that there is a quid pro quo between staff and local management allowing staff to leave early in exchange for working through breaks. I donāt agree with this practice and will follow up, but this is an age-old issue.
The jet blast event mentioned in the report happened about three weeks prior to this report and was during a [different aircraft to reporter] engine run. We are still in the process of the investigation, which is highlighting some interesting behaviours. When complete, I have no objection to sharing with you the learning from this event. Having reviewed our internal reporting system, we already have actions for the Engine Change risk assessment and the Jet blast event, but I cannot find any reports for non-adherence to PPE requirements.
We can Categorically state that no staff member has died falling from height. To hear that a staff member has a concern of repercussions for raising an internal report is always disappointing but I know the perception is out there, based on rumours and myths, and itās something we continue to communicate. I receive a [very large number] of occurrence reports raised per week. Throughout [considerable yearsā service], I cannot recall anyone being disciplined for raising a report. To make the system even more robust, earlier this year we implemented a change so only select people are able to view the reporterās name.Ā The reporterās name can only be released if it is specifically required to aid the investigation and we centrally record each time we release a name and the reason why. We have communicated this to all areas.
I understand his opinion, [in working through breaks] but looking through the time data will give us the facts. When I have checked recently, I find many people leave earlier than their shift finish time.
I accept, less managers tend to be on nights, and will send a note out to managers to speak to their night shifts. I will ask my teams to focus on this when on nights, but I know they are doing this already. Being super-critical, I would agree that sometime engineers donāt use task specific PPE (like eye protection, ear protection and gloves etc.) but this is the continual journey our people are on.
CHIRP Comment
The CHIRP-relevant aspects of this report are that work and inspections carried out whilst a risk of injury is evident, affects concentration and propagates hurried actions. Additionally, HF concerns associated with staff shortages, long periods without rest and a dilution of standards on night shift are obvious. Many of us have experienced nights, and any āslackā afforded by management is gratefully received, but we also know our performance is reduced on nights and any lowering of standards may be more of an exposure to error than we realise. The Quality Manager and the Health and Safety officer of the operator were contacted with the reporterās permission. The Operator disputes many of the statements made, and the jet blast incident was adequately investigated and resulted in seven recommendations.
Your employerās Safety Management System should be sophisticated enough to integrate both airworthiness and H&S hazards, or any issues that present a risk. Compliance auditing can cover both areas. However, although H&S permeates SMS, the differences between them need to be understood. Changing an engine comes under Part 145 (therefore requiring an SMS). Working at height to carry out the engine change comes under H&S. Hazards associated with either subject should be considered as a part of the overall activity. All staff and management should adopt safe working measures and strive for a safe working environment. There has been considerable dialog in CHIRP publications in respect of potential risks of inexperienced people new to the role, being recruited to fill recent gaps. These staff need to be brought up to speed on how they fit in with the organisationās safety culture as a matter of priority.
Despite the fact that the PPE issue was unconfirmed when surveyed by Quality, everyone should comply with the Health and Safety at Work Act 1974, enforced by the Health and Safety Executive (HSE). These responsibilities cannot be delegated or failure to comply āblamedā on others. You are responsible for your own safety and the safety of others. Managers need to be alert to deviations from the required standards and be prepared to enforce the correct practice. The HSE have their own reporting vehicle on their web site. https://www.hse.gov.uk/contact/. However, it is probably more straight forward to submit an internal report to your organisation first, provided of course you are confident with the system. Organisations need to work with their staff to ensure reporting systems are open, objective and viewed as non-punitive.