LEARNING ACHIEVED FROM SHADOWING OPPORTUNITY

Non Technical skills / Crew Resource Management – General Definition:

Non Technical Skills / Crew Resource Management can be defined as (and is understood to be) a management system which makes optimum use of all available resources: i.e. People / Procedures / Equipment to promote safety and to enhance the efficiency of Flight Systems.

Base: MEL

Date of visit: 21OCT2011

Cabin Crew Instructor’s name:Mark Langtry

Dept. where Shadowing occurred:ENGINEERING / Virgin Tech

Simon Fletcher

Non Technical Skills:– Core Elements (defined)

Cabin Crew Instructor’s;Observation / Learning from visit

1. Information Acquisition & Processing

Involves understanding how humans acquire and process information. Items covered include short and long term memory and its limitations and information processing models.

Communicating with Senior Engineer – Steve Adams Movements sheets / Morning afternoon (See attached - Annex B) Flexibility/Confirmation; Simon is allocated aircraft to carry out

“Flight Readiness Checks”(“F R C’s”), things then change, must be able to attend to another aircraft if need be

F R C’s - Simon checks sheets in Log First aircraft checked was VH-BZG. Every night Aircraft receives

“Daily Inspection” (See attached - Annex C) recorded in Maintenance Log – A COMPLETE HISTORY for the last month, this info is still required to be stored also away from log, (on line) for life of aircraft + 7 years afterwards, (even if is broken up for parts)

Work allocation & hence appropriate information received dependant upon whether task lies within / not within “Limits”

e.g. attention to a dent may require a more senior appraisal, (university qualified engineer) MEL (Minimum Equipment List) reviewed. E.g. when Decal had to be replaced on Embraer FO’s steering

column (had to be brought “Safe Hand” from Perth “Reflectively” employ Questions / “Cross Checks”- This relates to:

INDEPENDENT INSPECTIONS which Require: ( i.e. anything to do with : Flight Controls Engine Control Installation of Escape Slides Torques on Engine Installations –Bolts )

- ALL REQUIRE; 1 to do the job / 1 to check the job- On safety Critical tasks ; require 2 signatures on sign off

Another interesting fact is that Virgin follows Boeing’s Maintenance approach, QANTAS has their own, another layer of bureaucracy that must be administered and worked through.

2. Workload management

Covers prioritization, distraction management and tactical interrelated decision making associated with workload management.

Generally busy till 10 am dies down a bit till 2pm then defects generally present requiring attention

Again, Senior Engineer – Steve Adams seeks to manage Simon’s workload. Saturdays Aircraft Terminate Earlier / Sundays aircraft Terminate later keep this in mind when allocating tasks.

Different Engineers have different areas of expertise. Simon’s is Airframes & Engines. / Some may be avionics, electrical etc.

(See Annex D re; Crew Listings / Qualifications) Any decision-making related back to Maintenance manual. Imperative need to Prioritise, ESPECIALLY when called to carry out

maintenance at short notice. Captain contacts AMCO Senior Engineer Simon

MAINTENANCE STRUCTURE : HEAVY MAINTENANCE 3 months (Virgin calls it a “H” Check, a BIG service / RAAF call them a “D” Check, essentially Aircraft apart all over Hangar)

BASE MAINTENANCE Over night in the hangar

LINE MAINTENANCE Overnight – Online “Scheduled call ups” (Virgin calls them “V1” Check, “V2” checks etc. )

All aircraft require “Daily Tasks” also. These have a 48 hr life span. This to allow for an overnight in a non major service port,

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e.g. LST / CBR / MKY. Actually carried in 24 hours if overnight in a major port. This has to be allowed for and “Managed” Holistic view always !

3. Threat and Error management

Provides the cognitive and social skills to identify and mitigate environmental and organisation threats and avoid and manage human errors.

Always Procedures / the Manuals to follow Cognitive & social Skills displayed by positive interaction with

Flight – Cabin Crews / AMCO / Pit Crews / Caterers / Refuellers - All have “Problems requiring solutions”

Utilisation of M.E.D.A. Process, (Maintenance Error Decision Aid ) A Boeing process. It’s about not just looking to blame the person who made the error, consider all aspects and contributing factors, (e.g. bad light, fatigue, supervision etc.) A “Holistic” approach

Towing, adherence to safety protocols re manpower etc. Low Visibility, safety car etc. (I rode with another ENGINEER who was the “Brake Rider” in a 737 cockpit from the hangar right across to the gate – Fascinating !!!)

FRC’s (Flight Readiness Checks ) – Shadowed Simon while he carried these out in the dark down at gate 10. Initially within flight deck while he checked paperwork pertinent to the completion of “Daily Maintenance Checks” Then outside where he carried out the “walk around encompassing checks & removals of the following:- Engine cowling straps removed, (anti rotation)- Pito probe covers- Assessment within “E & E” bays x2 (Electrical equipment);

o One pertinent to avionics, behind fwd undercarriage bay, (anti rotational straps live in here)

o The other pertinent to flight deck controlsThen continued walk around, removing safety strapped pins, checking oil caps within engine cowlings, checking within undercarriage wells, under wings looking for hydraulic leaks and along fuselage checking for catering truck bumps. The landing gear downlock pins were then placed within the flight deck. This was then signed off. - ALL EXTREMELY THOROUGH!!!!!

After any maintenance FOD consideration, (foreign object damage) – tools left on board, Investigation if this occurs !

Also as mentioned prior, INDEPENDENT INSPECTIONS require: ( i.e. anything to do with : Flight Controls Engine Control Installation of Escape Slides Torques on Engine Installations –Bolts )

- ALL REQUIRE; 1 to do the job / 1 to check the job- On safety Critical tasks ; require 2 signatures on sign off

Radio on Engineer Wired to all areas , (Changes! ) A very challenging work environs with A/craft Noise, Hearing

protection although vital, certainly compromise communication process.

I discovered that ENGINEERS DON’T Check Emergency Lights !!!! they still think we do !!! This needs to be addressed!!!!

4. Leadership and Team behaviour

Identifies and develops the skills required to become and effective leader or follower. Also to understand team behaviour.

The FRC essentially a courtesy, Engineers carry this out to assist Flight Crew & to have it ready for them, enable faster departure

Steve fosters an environment that’s conducive to good work. He’s friendly but all know that when he requests something to occur, it need to happen pretty well immediately

Very cold in Winter / Up to 67 on Tarmac in Summer - Dehydration Engineers rotate through roles out on line in the hangar, as per

“Workload Management” BRAKE ROTOR PAD - LHS Undercarriage, inboard wheel, – “Disc Let

go” - Be prepared to “Give/ Support” – when undertaking the Brake change on the 737-800 Simon was assisting Jeff. Glenn came over to assist, essentially to enhance OTP prospects. Great teamwork & awareness of commercial considerations. - See photos

This task was carried out in the rain & in an extremely noisy environment. Also the brakes were extremely hot and quite dangerous. Amazing synchronicities observed here!!!

I asked Simon if there was anything Cabin Crew could do to promote better team working & interaction between Engineer & Cabin Crew, he remarked politely that it would be nice to at least be acknowledged with a smile when he is required to come on board. – Something for us to definitely consider!!!

5. Stress & Stress Management

Understand the nature of stress, the types of stressors, understand the human limitation that result from excessive stress and develop

Naturally there are OTP pressures, but cannot allow this to compromise safe practice. “ Brisk without Risk “ !!!

AMCO used to be in direct contact with individual Engineers, not now; all communication goes through Senior Engineer - Steve.

This strategy to allow Steve to “Control - Information Flow”

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stress management strategies. When an Engineer is onboard, we as Cabin Crew need to be respectful of their “Sterile time” i.e. time they need to be concentrating.

As before with Pit Crew, rotation of roles, - breaks both physically & mentally

Situation ever changing & at time very stressful. (Brakes change) Again, “No one will put their Licence on the line by risking an

unsafe outcome”

6. Cultural Factors

Understand the nature of culture, the layers and types of culture, the Hofstede cultural model; (HUMAN NATURE / CULTURE/ PERSONALITY) and cultural dimensions; (POWER DISTANCE / INDIVIDUALISM / MASCULINITY / UNCERTAINTY AVOIDANCE) and develop culture management strategies.

( + Generational Culture differences)

Engineering is certainly a predominantly “Male” environment, although not particularly “Testosterone ” driven. Simon mentioned how some females work as Rostering Clerks, Resource Officers & are returning to work while on Work Cover. All whom are treated with respect & whose dignity is acknowledged at all times. Simon also re-iterated adherence of KOWF practice by all within the department. Actually, I observed some limited interaction with female Cabin Crew members carried out in a professional, friendly & courteous manner.

HOFSTEDE’S CULTURAL DIMENSIONS Although Hofstede’s dimensions refer to cultural diversity within National / Regional population groups, some brief description / analysis / observation & hence “Opinion”, may be of interest here; (NB: Allocated nos, not “Scores”, relate to perceived “Importance”)

POWER DISTANCE: (Hierarchical Gradient, strict seniority protocols)

- Seniority certainly considered important and respected, (Captain / Senior Engineer Engineers with Cabin Crew & vice versa). However, dealings carried out in a “relaxed fashion” but ever mindful of the responsibility each person held.

- Steve Adams – Senior Engineer, he runs the line “Like a Captain” but has an Electrical background. In the past much of his work was admin, (manning for shift construction etc.) These days there are more management layers but the upshot this allows for him to allow “more Engineering to happen !”

- Simon thought rather than a respect “gradient” a better analogy was that of a parabola. (Interesting as expertise varies across personnel ?)

- Professional at all times!- On a scale of 1 100, Simon suggested that “Day to Day”,

possibly possibly in the 60’s ? / If a “Jet was broken”, maybe in the 80’s 90’s !!!

INDIVIDUALISM: (Extent to which people feel they are supposed to take care of themselves /- Individual is “Integrated” into the group)

- Dealings carried out in a “relaxed fashion” & often working quite autonomously as individuals out on line. However, certainly ever mindful of the responsibilities each person encountered, (Flight Crew / Cabin Crew).

- On the other hand out on line an issue such a requirement to replace brakes needs to be achieved quickly & efficiently. (As I witnessed !!!!) This required incredible team working skills with 2 engineers working in extreme conditions, (rain, noise) to achieve this task safely & quickly.

- Certainly “Tight Nit” within Engineering department- They “Look out for each other”, (re aircraft maintenance

histories / defects)- There appeared to be a “Holistic” appreciation of where

the individual Engineer fits within the organisation, their role & if required, their authority to ground an aircraft & the consequences that would ensue.

- Certainly Professional at all times!

- INTERESTING ANOMALY Not all Engineers have the same qualifications. Some are Licensed (LAME - “Licensed” Aircraft Maintenance Engineers) & some are Un Licensed, (AME – Aircraft Maintenance Engineers). Essentially: Licensed Person

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Can make their own decisions (obviously manual compliant) Un-Licensed Person Follow the “Sheparding” of a senior

- Also Engineers have different “Specialities”, (Simon’s is “Airframes & Engines”, others may have for example, Avionics / Electrical etc.) The upshot of this is that a relatively speaking “More Junior” Engineer with a particular area of expertise can overrule the authority of a more Senior Engineer. This would always be done with professionalism & in accordance with the appropriate manuals.

- Certainly observed Engineers displaying positive

responsibility for their own actions / Health / Safety etc.- Informed that they definitely display “Shepherding” roles

but probably more when working in larger teams, (5 people required to change an engine when in the hangar)

- The group provides support and a sense of identity is apparent when fellow team members are integrated within the group. This displayed by light-hearted fun in the crew room and displays of positive morale. All within KOWF boundaries

- On a scale of 1 100, possibly around 80 - 85 ?

MASCULINITY(Dominance, Assertiveness, - Acquisition of things?)

- Assertiveness not so much within crew environment, all do what needs to be done., More interdepartmentally e.g. with AMCO re availability of an aircraft or OTP concerns.

- Dominant is not really a word / definition appropriate in this environment. Unquestionably, Engineers understand the importance of their roles and carry them out accordingly. There is never a“Stands Over” approach, only strict adherence to safety protocols and manual procedures.

- However, Assertiveness is certainly a trait displayed. From a safety perspective all must be sure of what needs to be done.

- Mutual respect was at all times observed. This to ensue a safe, positive result On time if possible !

- OTP Consistent, conscientious awareness, but never intimidated by it.

- “No one will put their Licence on the line by risking an unsafe outcome”

- Certainly necessary in an environment where priorities appear to “Evolve” before one’s eyes!

- As with the Pit Crew Dept, the only “Acquisition” I witnessed here was the desire to acquire a positive, safe outcome / result for the business !

- With assertiveness being the most defining aspect of this, on a scale of 1 100, possibly around 80 ?

UNCERTAINTY AVOIDANCE(Degree to which people prefer “structured” over “Unstructured” situations / -Extent people seek to avoid “Uncertain” and “Ambiguous” situations.)

- STRUCTURE A MAJOR CONSIDERATION ! MANUALS !!!!- “Without structure, I don’t think anything would fly !!!

- Engineers FEAR change” !!!!! - Simon- As within the Pit Crew, a structured day is the most sought

after aspect of all these dimensions, however the likelihood of that occurring is dependant upon just so many factors beyond the control of the Members of this work group.

- Steve plans Simon’s day but so easily changed ! He allocates great importance to planning his Engineers day’s, this to allow for flexibility if need be.

- Only ONE aircraft has to go “AOG” (Aircraft On Ground) / “Tech” / “U-S” Whole “Movements” sheet is then affected Manpower is reallocated worse comes to worse, aircraft sits at the gate waiting for manpower recourses to become available.

- When “Delay Codes” appear around 3-5 pm it becomes “Pretty Hairy” - Defects appear to add up with ½ the no. of crew available to attend to them

- SAT evenings used to be bad, but more consistent these

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days, better planning in BNE (re “V” checks)- Most nights there are 19 terminating aircraft, all need

maintenance. – “Daily” inspection. (i.e. the 48 hour mandatory inspection that must be carried out if aircraft overnights in a major port hence the 48 hours to provide lee way if over-nighting a non Maintenance port.) “S.H.E.L Model” particularly relevant, (Software / Hardware / Live ware (people) & Environment – how all are connected & relate to each other) certainly at play. - NEVER A SMOOTH INTERFACE!!!!!

- Ambiguity is something that cannot be allowed to prevail in this work environment. Concise, clear and positive directions are vital !

- On a scale of 1 100, possibly around 95 - 99 ?

Generational Issues ?At Virgin Australia, average experience around 20 years Industry experience. At QANTAS around 40 years !!!

7. Situational Awareness

Understand the components that make up situation awareness, what leads to loss of SA and how to regain SA when it is lost.

Things that affect SA inclusive of the following:- Weather / Time of day / Fatigue / Working in and around Pit

Crew, (not being offensive, just there is much activity occurring) / OTP pressures

Vitally important when towing aircraft !!!! I rode in the cockpit on 2 occasions, once towing an Embraer 190 (from agacant to gate 13 to gate 13) + once in Flight deck of a 737 from maintenance hanger right over to gate 4.

Melbourne Airport Escort vehicle had to accompany us due to poor visibility

Vital importance of communications with ATC tower !!!!! Ground Frequency 121.7 – All surface Movements I was amazed at the “synchronicity” achieved between Simon, Jeff

& Glenn while undertaking Brake Change on 737 -800 !!! Like watching a team of top level elite sportsmen, each knew where to be to be of assistance to each other and worked quickly, efficiently & safely throughout the duration of this !!!! AMAZING TO WITNESS!!!

In and around the aircraft in an extremely noisy environment, moving in and around Ground Equipment in the rain! There was also a synchronicity in the manner all Pit Crew & Engineers worked in and around each other. One again, almost like footballers, “knowing where to be”.

During FRC’s Simon checked in and around some extremely “tight spots” (“E & E” bays / hatches for Aircraft)

Once again, I noticed personally that VERY INTERESTINGLY the environment appeared alien to me ! I was walking along similar routes but in different directions to that which normally I would be. I had to “Adjust” my “Situational Awareness” !

.8. Human Error, Reliability & Vigilance

Understand human limitations and what occurs when we reach our operational limit. Vigilance is also discussed and vigilance and alertness decrement issues covered.

Aircraft terminating schedule plays more of a part these days. When the company started up, until around 2004, an aircraft would terminate at up to 6 gates. These days can be up to 19 aircraft overnighting in MEL !!

Vigilance and alertness decrement issues covered by “Cross checking colleagues work as per mentioned in Information Acquisition & Processing;

i.e. INDEPENDENT INSPECTIONS of : Flight Control / Engine Control / Installation of Escape Slides Torques on Engine Installations

- ALL REQUIRE; 1 to do the job / 1 to check the job- On safety Critical tasks ; require 2 signatures on sign off

Licensed Engineer (“L.A.M.E.”) Un-Licensed Engineer (“A.M.E.)

Monitoring of Aircraft changes & cancellations via FID Screen + requests from Steve.

Knowing what can and cannot be achieved safely and legally. Following procedures and having an appreciation of Compliance

requirements. “Always do it by the book, no “Shotgunning” Always aware of Safety ! – VIGILANCE ! Monitoring fellow Engineers & company members, - Morale,

Fatigue, Quality of work etc. (Situational awareness) “Brisk without Risk” !!!

9. Communication and Co-operation Company frequency for Ground requirements 131.15

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Understand the communication process, where, when and how the process fails and what can be done to ensure effective efficient communication.

Good communication definitely compromised when radios fail out on line. Especially when multi tasking Delay ensues!

When towing, visual signs;“FIST” – Brakes on“OPEN HAND – Brakes off

Liaising with Tower” & communicates / cross checks with “Brake Rider” sitting in Captain’s seat in aircraft being towed

Use of “Fault Isolation Manual” – fault codes, re lists of components. These are Spot on !!! Millions of references !!!

Liaise with Pit Crew Members Re use of Tugs / transport / Vans Must be refuelled / re charged.

Proffer advice on ground but not in the air, legal boundaries PUSH BACK PROCEDURE with PPU (Push back unit):

- Walk around check leaks, bumps etc.- Close panels- Doors shut- Door handles flush

Comms into aircraft: - FO side.

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I was able to witness the following as Simon plugged me in also while he was dispatching an aircraft.

- Following is what I encountered:

7.6.6 Power Push (PPU) procedure (See Annex E )(Ground Handling – Aircraft Dispatch –B737)

FLIGHT CREW To call aircraft dispatcher back to the interphone, flash the runway turn off lights off several times.

GROUND CREW If the aircraft dispatcher requires to contact the flight deck, use the standard marshalling signal, refer section 7.2.2 – Standard Hand Signals. Confirmation of clearance to approach aircraft will be by flashing the runway turn off lights.

Captain “Flight deck to ground”Aircraft Dispatcher “Ground”Captain “Confirm steering lock-out pin NOT installed”Aircraft Dispatcher “Confirmed”Captain “Ready for push back”Aircraft Dispatcher “Release brakes”Captain “brakes released”Aircraft Dispatcher “Commencing pushback”

When clear to do so

Aircraft Dispatcher “Clear to start (2, 1 or both)”

The aircraft dispatcher will then direct the Captain with following commands, as needed, during the pushback:

- “Left / Right” – the Captain applies the applicable tiller input.- The dispatcher will repeat the command until the required amount of tiller input is achieved, and then say “Hold”

NOTE The commands “Left” or ”Right” are respective to the Aircraft direction when viewed from the flight compartment, looking forward.

- “Hold” – the Captain holds the tiller at the current position.- “Reduce” – the Captain reduces the tiller input until the dispatcher says; “Hold”.- “Centre” – the Captain turns the tiller to the centre neutral position.- “Maintain the centreline” – the aircraft is to be towed in a fwd direction & the Captain is to steer at their discretion to maintain the runway centreline.- “Left, Correction, Right” – the dispatcher will use the phrase, “Correction” followed by the actual direction to be steered, when an incorrect direction has been commanded.- “Stop, Stop, Stop” – this is the command issued by the dispatcher or the Captain in the event of an emergency stop requirement.

NOTE No read back of any command is required by the flight crew.

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At completion of pushback:- Always drive in a straight line for at least 10 metres before completing the push back operation,

NOTE If the aircraft is to be moved fwd after pushback, the nose gear steering must be centred for the first 2 metres of the new direction to allow the PPU castors to realign before turns are initiated

Aircraft Dispatcher “Park brakes”Captain “brakes parked”

At this stage the aircraft dispatcher will remotely disconnect the PPU from the main landing gear & reverse it to approximately 3.5 metres rear of the tail of the aircraft.

Captain “Clear to disconnect”Aircraft Dispatcher “Disconnecting, hand signals on left/right””

The Aircraft dispatcher will disconnect the interphone & close the interphone panel/door. They will then position themselves clear of the aircraft and in the full view of the flight crew.When the aircraft dispatcher is satisfied that all equipment is clear, the PPU is at a safe distance, headset removed, communications access panel closed & the area is clear, they will indicate to the crew, (FLIGHT) that it is clear to taxi.___________________________________________________

Communication on the tarmac during the Brake change that I witnessed was naturally made extremely difficult with the mandatory and of course important use of hearing protection.

In times of less activity, Simon liaised with Steve, (Senior Engineer) as well as his colleagues re any assistance that may be required

10. Decision Making & Conflict Resolution

Understand the types of decision making processes, when they are applicable and why they sometimes fail. Introduce the GRADE decision making model. Discuss expert decision making.

Always consultation !!! One job at a time approach An issue can be when you are working on a job & then

inadvertently are called away. Requirement for an entry to be made into the Maintenance Log This to keep communication with Flight Crew & fellow Engineers, always open.

As mentioned prior, just because someone may be in a more senior role, doesn’t mean they are “Expert” in all areas

11. Automation

Understand the issues associated with the automated flight deck such as mode confusion, automation complacency and automation calibration. Develop automation use strategies.

737 Essentially a pretty “old design” airframe wise hence most defects have occurred before at some stage !!!

There is a “Hands On” approach, naturally a technical bias Automation complacency combated by :

- Firstly, adherence to the maintenance manual- Secondly, Human factors Training- Peer group review

From my observation, Simon’s role does require the use of initiative but always with SOP’s in mind & after consultation with a colleague if necessary. His ability to think quickly and make informed decisions based on available information, determines both a positive & safe result.

Gates 9 & 10 are not ground power equipped. Recently acquired new ground power generators. Late at night, aircraft APU can burn up to around 1000 Lt of fuel. Generators are fully portable and can supply ground power, much more efficient use of resources.

During overnight checks, working safely with Tooling & hydraulic rigs

Working with the remotely controlled Aircraft Push back device – “Power Push Unit “ / PPU (See Annex F)

“S.H.E.L.” Factors certainly at play within this profession ; “Liveware” interacting with the hardware of aviation technology being almost a “Given”

12. Health

Understand the health issues associated with commercial aviation dehydration and cosmic radiation.

As with our Pit crew colleagues, the most obvious observation relates to noise, - The people it affects and the Communication Process it compromises. Of course one would be deaf very quickly with out the use of hearing protection!

Simon also related that diseases such as forms of Cancer used to

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be quite an issue. This was more with the older generation of Engineers who were not as educated re deleterious / castigenic effects of exhaust fumes, oils and lubricants.

FOLLOWING LIST OF SOME HEALTH RELATED HAZARDS:- Heavy metals / castigens (bolts coated with cadmium)- Gas turbine oil smoke- Aircraft grade hydraulic / brake fluid “Skydrol”- Toilet waste – from walk around –Hepatitis (Vaccinations)- “Honey truck” / toilet truck waste- Jet fuel / kerosene – dermatitis- Landing gear fluid / Oil for engines (“Mobil Jet 2”)- Removal / installation of air filters - Removal of Sharps from toilets- Dehydration- Sunburn / skin cancer- Back injuries & muscle strains from working within

confined spaces- MANY OTHER HIDDEN RISKS !!!

All requires constant awareness & vigilance !!!! The physical aspect of this work is also a factor, (Brake Change). Shift work, Circadian ramifications. Manual Handling awareness -Vital ! Importance of “Situational Awareness” in this regard

13. Fatigue & Fatigue Management

Understand the nature of fatigue, the degradation of human performance when fatigued and the difference between tiredness and fatigue. Understand the nature and stages of sleep and develop fatigue management strategies.

Steve, (Senior Engineer), seeks to manage / distribute work load That said, vital for Simon to manage his workload. Both from a

fatigue perspective and a concentration perspective Once again Circadian factors. Early Shifts and then a late shift,

adjusting to this change to one’s Cicadian Rhythm. Fatigue affects decision making ability

- “Things make sense on Day shift, but then same maintenance item on night shift, well, - ?????”

- Things get done quicker on day shift If Engineer attaches to LST / HBA then effectively work “Split

Shifts” – Exhausting ! Hotel rest often insufficient or of poor quality

As observed, Weather affects workload. Delays. Need to workback, (of course overtime is granted, but with overtime accumulation of fatigue will occur.

Simon related an anecdote of how fatigue affected his and others judgement during a 7pm 7am night shift,

- Back in 2007 when first Embraer aircraft was in the hangar undergoing an “ Systems Integrity Test” (must be done at the end of the night as it’s quite a long and exhaustive test, Embraer company representative was in attendance also)

- The aircraft failed the test 8 times !- The first couple of times were maintenance errors & were

managed accordingly- But then the aircraft continued to fail the test, (takes

about an hour each time !)- Eventually discovered that the Embraer representative was

asleep in the Flight Deck and had his knees up against a switch !

- The Aircraft’s Systems were actually fine, just everyone’s “Situational Awareness” was not !!!

One Strategy Simon employs while on Night shift is to make accurate lists on his movement sheet, so he can be assured not to forget tasks that are allocated.

GENERAL COMMENTS

(Annex A – Photographs of Push Back + Brake Change)

Who I Observed:

Simon’s Team Senior Engineer Line Maintenance Supervisor - Barry - Steve Adams - Dale Fisher - Greg - Jeff Deputy Part Time - Glenn - Martin - Leo - Mick - Greg - Jason (+ 2 away on leave)

Activities that were of particular learning / benefit

Towing Aircraft of 2 Aircraft, one a short distance & one with visibility issues addressed (Developed appreciation of

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communication skills and Situational Awareness) The Brake Change of 737 -800 Accompanying Simon - Push back with PPU. (Again communication and Situational Awareness skills) During aircraft Readiness Checks, Investigation of E & E hatches!!! (Electrical & Equipment - Stowage of Anti

rotation straps + insight re location of Interphone electrical system amongst other Avionics)

Once again, the learning derived from this opportunity was immensely valuable. The exercise will enhance my skills & experience as both a Cabin Crew Instructor facilitating in Non Technical Skills / Crew Resource Management and again and more importantly, daily in my role as an online Cabin Crew Member !

Others undertaking a similar experience would most certainly gain insight such as I was able. Of course Operational and Commercial concerns require effective / efficient utilisation of human resources and opportunities for greater interaction between departments are often very difficult to organise. Certainly, that many “Bridges” are built when such undertakings are possible.

Some General and Specific Observations:

From an NTS / CRM Facilitator’s perspective, a holistic appraisal / appreciation & ultimately, implementation of all CASA endorsed - Non Technical Skills Core Elements, is the most effective way to safely, efficiently & hence profitably achieve synchronicities within the aviation environment.

The importance of effective Teamwork between all departments cannot be reiterated enough. The privilege of undertaking this Shadowing experience has served greatly to re-enforce my appreciation of those that contribute to our operational capability.

Yet again I restate my true appreciation of Situational Awareness being indeed vital and necessary to integrate professionally (and to ultimately empathise with), our fellow colleagues across all aspects of our business. This, an awareness to prepare us well ahead of time during times of disruption and importantly from a safety perspective, to provide insight into the protocols and Standard / Non Standard Operating Procedures of our colleagues from other departments.

Again and as with my Pit Crew Leader experience, we as Cabin Crew must to be open to the learning available from colleagues located within other departments. So much safely implemented initiative, expertise and professionalism occurs before our very eyes. With genuine appreciation and empathy, we positively develop wonderful opportunities / possibilities of greater interaction, understanding and teamwork.

In closing may I take this opportunity to again express my sincerest thanks for the opportunity to undertake this Shadowing Exercise. I fully appreciate that much liaison and co-operation between our two departments was necessary for this opportunity to occur.

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LEARNING ACHIEVED FROM NON TECHNICAL SKILLS SHADOWING OPPORTUNITY

Base: MEL

Date of Visit: 21 OCT 2011

Engineer’s name: Simon Fletcher

Cabin Crew Instructor’s name: Mark Langtry

NON TECHNICAL SKILLS / CREW RESOURCE MANAGEMENT – GENERAL DEFINITION:

Non Technical Skills / Crew Resource Management can be defined as (and is understood to be) a management system which makes optimum use of all available resources to promote safety and to enhance the efficiency of Flight Systems, i.e.:

- People- Procedures - Equipment

During Cabin Crew initial Training for Non Technical skills, we seek to discuss & impart an understanding of the following “Core Elements / Skills”

Information Acquisition & Processing Workload management Threat & Error management

Leadership & Team behaviour Stress & Stress Management Cultural Factors

Situational Awareness Human Error & Reliability Communication & Co-operation

Decision Making & Conflict Resolution Automation Fatigue & Fatigue Management

Vigilance Health

(In depth analysis of a select few skills is undertaken on a rotational basis for yearly re-currency.)

Virgin Australia Engineer:

A few dot points re; how you believe the above “Non Technical Skills” relate and are appropriate in your day to day dealings would be greatly appreciated;

*Communications- verbal/visual signals required for A/C towing/marshalling.

*Co-operation- keeping people in the loop about defects and possible AOG situations (AMCO, Maintenance watch, planning, senior engineer)

* Information acquisition – knowing where to get the right information, i.e.-A/C maintenance manuals, service letters, service bulletins, Component manuals, task cards, fault isolation manuals, Illustrated parts catalogue, MCM, EMS…

*Fatigue- sleep patterns, and ensuring enough sleep to cope with night shifts.

*Decision making- deciding the best course of action for dealing with aircraft defects (MEL, EO, fix the fault)

*Workload management- ensuring enough ground time, the right amount of people and the correct parts are available to fix the defect.

*Situational Awareness – remaining aware of surroundings, when on tarmac or towing aircraft on taxi-ways. Maintaining a listening watch whilst towing A/C

*Vigilance- maintaining a high concentration level, completing the job without missing tasks, wether it’s a flight readiness check or engine change all steps must be accomplished.

*Threat & Error management- Being a safety conscious industry, all tasks are carried out with the aim to minimise errors. (Systems such as simultaneous maintenance, EDTO requirements) When errors do occur, steps are in place to find out the underlying root cause and eliminate it, to ensure it does not happen again. (MEDA investigations)

Cabin Crew Instructor: Activities that were of particular learning / benefit

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A few dot points re; what insight you felt was obtained from this learning opportunity

Towing Aircraft of 2 Aircraft, one a short distance & one with visibility issues addressed (Developed appreciation of communication skills and Situational Awareness)

The Brake Change of 737 -800 Accompanying Simon - Push back with PPU. (Again

communication and Situational Awareness skills) During aircraft Readiness Checks, Investigation of E & E

hatches!!! (Electrical & Equipment - Stowage of Anti rotation straps + insight re location of Interphone electrical system amongst other Avionics)

Some General and Specific Observations:

From an NTS / CRM Facilitator’s perspective, a holistic appraisal / appreciation & ultimately, implementation of all CASA endorsed - Non Technical Skills Core Elements, is the most effective way to safely, efficiently & hence profitably achieve synchronicities within the aviation environment.

The importance of effective Teamwork between all departments cannot be reiterated enough. The privilege of undertaking this Shadowing experience has served greatly to re-enforce my appreciation of those that contribute to our operational capability.

Yet again I restate my true appreciation of Situational Awareness being indeed vital and necessary to integrate professionally with (and to ultimately empathise with), our fellow colleagues across all aspects of our business. This, an awareness to prepare us well ahead of time during times of disruption and importantly from a safety perspective, to provide insight into the protocols and Standard / Non Standard Operating Procedures of our colleagues from other departments.

Again and as with my Pit Crew Leader experience, we as Cabin Crew must to be open to the learning available from colleagues located within other departments. So much safely implemented initiative, expertise and professionalism occurs before our very eyes. With genuine appreciation and empathy, we positively develop wonderful opportunities / possibilities of greater interaction, understanding and teamwork.

Thanks for taking the time to provide feedback and opportunity to work along side & learn from you today !

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ANNEX A

Photographs of Push back + Brake change

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Engineer VA4 Engineer VA3 Engineer VA1

Brake Change 2 Brake Change 3 Brake Change 4

Brake Change 5 Brake Change 1

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ANNEX B

Movements sheets

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ANNEX C

Manual Daily Inspection Regimens- B 737-700 / 800

- Embraer 190

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ANNEX D

CREW LISTINGS / QUALIFICATIONS

ANNEX E

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Manual Power Push (PPU) procedure(Communication & Cooperation)

ANNEX F

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Manual information re:Remotely controlled Aircraft Push back device

– “Power Push Unit (PPU)

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