Hmm...Blackie I hope your not peddling that vintage of pony pooh to your clients??
Since your a guru on LAME issues take a look at this quote from a
very good (yeah I know....well at least in some areas of the ATSB remit they still set a benchmark) ATSB report:
The errors of maintenance personnel can be the most visible aspects of maintenance human factors, but to understand how and why maintenance errors occur, we need to understand the organisational context in which they occur.
Figure 5 below shows the main causal elements involved in accidents and incidents. It is an adaptation of the ‘Swiss Cheese’ model originally developed by James Reason.
According to this model, accidents or incidents are usually triggered by the actions
of operational personnel, such as pilots or maintenance engineers. However, these
actions occur in the context of local conditions, such as communication, workplace
conditions, and equipment. The task environment also includes risk controls.
These are features such as procedures, checks or precautions designed to manage hazards that threaten safety. Risk controls, local conditions and individual actions can, in turn, be influenced by organisational factors such as company policies, resource allocation, and management decisions.
In order to understand and ultimately prevent accidents, it is necessary to trace the
chain of causes back through all the elements of the system including organisational
influences. This is often referred to as root cause analysis.
And since you are a guru of the '
blackhand world' you should be able to tell me what report that came from because it should be included in any LAME Human Factors course i.e. required reading??
ps Oh in case your stumped here's the link!
http://www.atsb.gov.au/media/27818/ar2008055.pdf