STATED INTENT OF THIS SITE
Cummins N14M
A forty thousand dollar engine failure.  Above is a Cummins N14M that I built in the engine room of F/V Triple Star with all new parts including the new cylinder block and new crank shaft. This was a repair following a disastrous human error failure by the vessel captain.  It was an oil starvation failure caused by leaving the oil pan drain plug loose and untorqued after a pre-installation oil change during complete engine room refitting and repowering with the N14.  The engine siezed the crankshaft on the first trip out from the two month refit.  Pictured is the engine repair in progress that replaced it after the oil starvation.  The job took 3 weeks because the parts had to go in and out of the engine room through the entry hatch in the roof including the cylinder block. The crank was hoisted from below the engine into it's saddles with two chain come alongs while the block hung from two other chain come alongs. This is a brand new 20,000 dollar block for a job that cost 40,000 dollars because a single plug was not tightened.  There was an engine install checklist being used during the refit, and it did not have an item check off for "all drain plugs torqued to spec".  Three things had to happen for this to slip by.  1) The changer had to forget to torque the plug, 2) nobody double check inspected for loose torques, and 3) the checklist did not have it itemized.  When a mistake like this is made on an airline class of high bypass turbofan engine, the cost can be in the multiple millions of dollars even if only the engine is damaged.  Being an engine wrench is very unforgiving.  Photo by Robert Reed

INTENT
The intent of these pages is simple.  I want to plant a cultural seed that will make us want to use the best methods available to lead our industry in human performance. This includes safety performance.  

Leading companies like Boeing Commercial Airplanes have spent the last two decades studying human performance issues.  They've undertaken a leading role in building programs to improve pilot and technician performance.  They've zeroed in on why humans make mistakes, and they've come up with answers.  There is a system in place to deal with it, and it works with a caveat or two.

The lion's share of research and program formulation has gone into airline and military aviation operations.  The reason is obvious:  big airplanes are VERY expensive.  The mistakes made while maintaining them are very expensive, so that motivated the industry to understand and attempt to improve performance of the maintainers.  The bulk of research went into pilot performance, but much of the subject matter also applies to maintenance technicians and in many cases all work places.   

Having been part of the aviation culture for many years, the subject of human error came up often.  While in training as an aircraft accident investigator, the psychology of pilot error was looked at in detail.  This was in 1988, so I started asking "why haven't efforts to mitigate human error in aviation wrenching been tried?"

Well they had been, but programs to that end never made it to my level.  It was early on in the game.  They had been filtering into the airline industry only recently at that time.

DRIVERS OF THE EFFORT
Cutting edge companies like Cummins West Inc. and others in the industrial and heavy transport diesel indusries will be motivated to look into these efforts as the expense and technologies continue to move forward.  Difficulty finding experienced talented technicians will help drive the effort.

New production pressures will drive production errors that will in turn drive question asking, begging answers that will come sporadically.  Unless an effort is made to take a leap of understanding of how people make these mistakes, they will likely repeat.    

The usual types of mistakes will be understood and fixed the way that have always been.  Some issues are easy to understand and identify, and some sub par techs are also easy to identify as the source of the problem.  Some are no brainers.

It's been my observation that many repeatable errors by not only technicians but also of supervisors and managers that lead to repeat events could be identified and stemmed.  Often they are not identified properly because no coherent system is in place to analyse, make recommendations, implement them and enforce them.  In addition to technicians, management has to accept that they might be identified as a part of the process that led to the error, also accepting that they will be part of the process of reviewing the event so that it can be stemmed.

Techniques described here use investigations to arrive at event causes, to make recommendations to prevent future similar events.   Some companies don't like calling them "investigations", opting instead to use the word "review" to remove negative stigma of the word "investigation".  This will be explored further.  

Experience shows that sometimes the results of event investigations (or reviews) can lead to manual changes and procedural changes that have little effect.  More creative mitigation strategies sometimes need to be dreamed up to stop a repeat error issue.  These can be simple things like stensiling a message on the outside of a shipping box to remind a tech to make sure he or she performed a crucial step (previously identified as a "repeat error issue" before releasing the equipment for service.  In many cases strategies must be drawn up to catch the attention of techs who are "running on autopilot" due to fatigue or boredom.


THE BEST TECHNICIANS MAKE THE WORST AND MOST EXPENSIVE MISTAKES
It has been proven through study and research that the best technicians and performers make the worst mistakes.  This is because they are pushed to the sharp edge of the organization's work, troubleshooting the wierdest problems and taking on the most difficult jobs.  They know things that others don't, but those can cause a wrong turn to go really bad.  Ask me how I know.

Mistakes are expensive.  99 percent of techs don't mean to error, but all of them do it.  Studies have shown that the best most talented technicians make the most expensive mistakes.  This makes sense because they are usually challenged with the most expensive equipment with the most complex and difficult diagnostic issues. 

Systems to mitigate human errors in wrenching consist of cave man philosophies and policies of punishment and shame dating back to the stone ages. It's baffling to think that the state of the art is still languishing in stagnation this way. The results of such conventional remedial actions are lack of information to others about how they happened and defensive behavior by the tech who errored.  This type of policy is itself in error.  Years of research in aviation human performance has shown that there are better ways.

Therefore, my intent is to help these companies see what is being done in this area, and move forward with the leaders in human performance technologies.  Companies with strong safety based cultures will see the most benefit.

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