Writing Maintenance Procedures and Determining Factors that Reduce Human Error
The success of maintenance is not achievable without the efficient transfer of information through writing maintenance procedures. Undoubtedly, maintenance procedures provide an effective way to train, inform and protect personnel. However, writing maintenance procedures can also become a liability if they are not fit for purpose.
When maintenance procedures are inadequate personnel will tend to resist or move away from the intent of the maintenance procedure. This natural tendency will render maintenance procedures ineffective and possibly even a hazard. Research into the aviation, nuclear, and railway industries identify both the benefits and hazards of writing maintenance procedures. In the end the strategies to overcome the complexities involved with writing maintenance procedures and continued use of maintenance procedures is essential to their success.
In the end the strategies to overcome the complexities involved with writing maintenance procedures and continued use of maintenance procedures is essential to their success.
Table of Contents
- Maintenance Procedure Failure
- Writing Maintenance Procedures
Maintenance strategies and life plans are relayed to personnel through writing maintenance procedures. While often substantial time is invested in the development of the maintenance strategies and life plans, the documentation that follows is often not given the same priority. Ultimately the maintenance strategy’s success depends on the understanding and guidance of maintenance procedures. On one hand, writing maintenance procedures provides many benefits, some of which include inspection requirements, part replacement details and machinery setup. Moreover, writing maintenance procedures provides a barrier to damage causation, provides training, safety and maintenance guidelines, and acts as a memory aid. Failure to comply with maintenance procedures can contribute to damage escalation, injuries, lower plant availability, and lost revenue. While on the other hand, writing maintenance procedures that have little room for independent thinking or do not reflect the realities of how work is preformed can in fact, contribute to accidents, delays and lost revenue. These conflicting facts make writing maintenance procedures and implementing maintenance procedures complex and important.
These conflicting facts make writing maintenance procedures and implementing maintenance procedures complex and important.
Maintenance Procedure Failure
A procedure can be defined as: ‘[a] particular course of action intended to achieve a result.’ (Merriam Webster 2010). In particular, writing a maintenance procedure is the final step in the development of maintenance actions and is part of a comprehensive maintenance strategy (Standards Association of Australia 2005 & Kelly 2006). Maintenance actions are intended to preserve or restore asset functionality in order to meet production or regulatory requirements. Moreover, writing maintenance procedures acts as a barrier to fault escalation and can be illustrated through the Damage Escalation Model shown in Figure 1, below.
Figure 1: Damage Escalation Model:
(Source: Narayan 2004, p. 142)
In this case the model illustrates how a component failure escalates to effect plant output. The three layers between the component failure and the loss of plant availability are referred to as barriers and their main aim is to reduce or prevent the effects of component failure (Narayan 2004). Ultimately, writing maintenance procedures provides barrier protection through the information they provide about the task, hazards, and the improved repeatability through its function as a memory aid.
However, writing maintenance procedures does not always guarantee protection and damage escalation can and has not only resulted in reduced plant output but has caused environmental damage, serious injuries and death. As indicated above, the primary reason that damage escalation occurs is because barriers are not 100% effective. The reduced reliability of each layer is referred to as holes. Furthermore, all incidents are a result of the defects (holes) in each layer aligning. The alignment of holes illustrates how deficiencies in each layer, when combined, will lead to damage, injury or loss of plant availability (Parliamentary Office 2001). These defects are known as the Swiss cheese model of causation and can be attributed to any event that has escalated to the point of damage (Parliamentary Office 2001).
Writing Maintenance Procedures
Writing maintenance procedures provides a number of important elements to an effective barrier against damage escalation. On one hand, writing maintenance procedures provides advantages such as: gathering and transferring knowledge to other workers, allowing for set standards and criteria to be met, increased personnel reliability, and improved scheduling and planning. On the other hand, if a maintenance procedure is not clear, or does not include the appropriate elements or guidelines or information they can offer little help in event detection. In fact, poorly developed maintenance procedures are often not utilised by staff at all or if used can in some cases contribute to an incident. In the end, for a maintenance procedure to reduce damage causation it should meet certain requirements.
The problem is that, all too often maintenance procedure development and requirements are not standardized within organizations. In most cases both elements and guidelines, with which to write maintenance procedures, are not defined or clearly understood. While human factor’s such as moral, stress, age and gender do play a role in procedure compliance (Lawton 1998). Ultimately, procedure complexity, accuracy, and relevance will determine employee utilization levels (Lawton 1998). Likewise, a study investigating human error in aviation maintenance, found maintenance procedure related errors were often a contributing factor to accidents (Gramopadhye 2000). In fact, the same study found that out of the 75% of accidents attributed to human error, 18% were related to maintenance (Gramopadhye 2000). While, another study into maintenance related losses in the Swedish railway, found that 30% of track related accidents could be attributed to maintenance failings. Of which the vast majority, 60%, was due to poor or incorrect information provided to maintenance personnel (Holdgren 2005). Additionally, it was established that in the Swedish railway, poorly written maintenance procedures were a contributing factor to losses and under utilization of the work force (Gramopadhye 2000). In the end, the ability to carry out maintenance actions depends on the effective communication of information through writing maintenance procedures. Writing maintenance procedures is therefore essential to a successful maintenance program.
Writing maintenance procedures is therefore essential to a successful maintenance program.
Undoubtedly, improving maintenance procedure outcomes will lead to improved maintenance results. Both public and private companies and government agencies have found that maintenance procedure use improves human performance. For example, the US Navy found that maintenance procedure use in their submarine fleet led to improved maintenance and a notable reduction in infant morality (Nicholas 2005). Ultimately the goal of the research will be to enable maintenance procedure developers to assess the elements and guidelines within the bounds of the maintenance procedure that will improve barrier reliability and thus outcomes. As a result a reduction in human error due to maintenance procedure problems should be notable.
While there has been a substantial volume of literature on procedure use; most of the focus is on operational procedures. Authors have focused on industries such as the aviation, nuclear, and railway industries were non compliance and procedural gaps can result in catastrophic disasters. For example, Degani (1997) examined procedure developed in an effort to reduce procedural errors in aircraft cockpits. Additionally, research by Lautman & Gallimore (1987, sited by Degani 1997) found that: ‘[of] 93 crew error accidents that occurred from 1977 to 1984, the leading crew-caused factor in their study was ”pilot deviation from basic operating procedures” ’. Further studies by Holemgren (2005) and Lawton (1998) examined the importance of information and procedural deviations in railway related losses. Authors such as Marsden and Green (1994), Optimising procedures in manufacturing systems, illustrate the benefits and models that could be adopted for procedural development. In Lawton’s research he also examined the reasons for procedure violation. Although his research focused on human factors in procedure violation, there are some common elements that are worth noting.
Lawton’s (1998) research found that there are two types of procedure violations, intentional and unintentional. Intentional violations are related to a number of factors ranging from age, sex, and organisational culture and norms. It was determined that the psychology of most people is to conserve time and energy and since following procedures requires both time and energy there is a potential for noncompliance built into most people. Therefore, Lawton (1998) concluded that intentional violation of procedures is natural when there is a perceived saving of time, or energy, and a perceived lower risk. The second reason for violation is unintentional and occurs when the procedure is not clear, or understood by the person utilizing the procedure. Lawton believes that in both cases procedures may be constructed to reduce the likelihood of violation. Maintenance procedures should be accurate, clear, and logical in presentation to minimize misunderstanding. Additionally, the maintenance procedure should explain not only what needs to be completed but why the task is required. Likewise, increasing the understanding and perceived risk through training and monitoring of a maintenance procedure will assist in compliance. If in the end, misunderstandings are minimized and the perceived risk increased greater maintenance procedure adherence will be achieved.
A maintenance procedure should explain:
- What maintenance action needs to be completed.
- Why the maintenance action is required.
- Where the maintenance action is to be performed.
- When online/offline, maintenance interval and scheduling requirements.
- Who should complete the maintenance action and qualification/training required.
- How to safely perform the maintenance action, see below for considerations.
Furthermore, Dekker’s (2002) conducted research into contrasting models on procedures and safety. Dekker noted that there are many examples where procedures are not adequate for the reality of working situations. In fact, in some instances strict adherence to a procedure has led to accidents or unsafe situations. Where in reality maintenance procedures do not dictate how work is accomplished only provide information on what is required. Accordingly, maintenance procedures should mirror the realities of work and not dictate how work is accomplished. Furthermore, the gap that is created over time is a result of how work is actually accomplished and is a natural occurrence. Suchman’s (1987, cited by Dekker 1997) definition of a checklist to conclude that procedures are a: ‘resource for action. Procedures do not specify all circumstances to which they apply. Procedures can, in themselves not guarantee safety’ (Dekker 2002, p.235). It is then essential that review and monitoring of maintenance procedures occur and updates take place to reduce the gaps that naturally occur. The development of a maintenance procedure does not end with writing the first release version. Continuous improvement and feedback must be built into maintenance procedure management. Additionally, maintenance procedures should reflect the porous nature of the working environment and allow for variations, adaptation, and innovation (Dekker 2002).
On the whole, writing maintenance procedures acts as a barrier to damage causation and helps to deliver operationally in terms of lower injuries, cost and higher equipment availability. However, maintenance procedures are not 100% effective and do not guarantee positive outcomes by their existence alone. On the contrary, a poorly written or inaccurate maintenance procedure will lead to confusion, noncompliance and increase the likelihood of damage causation occurrence. Research confirms that maintenance procedure noncompliance is common and may even be natural. Furthermore, important maintenance procedure writing considerations that were detailed as necessities are:
- Ease of reading the maintenance procedure.
- Accuracy of the maintenance procedure.
- Training to the maintenance procedure, and
- Monitoring and updating of the maintenance procedure.
A good computerized maintenance management system (CMMS) will assist in the process of writing maintenance procedures and effectively implement and manage maintenance procedures. Since in the end the strategies to overcome the complexities involved with writing maintenance procedures and continued use of maintenance procedures is essential to their success.
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Standards Association of Australia 2005, Dependability management Part 3.14: Application guide-Maintenance and maintenance support, (AS60300.3.14-2005), Standards Australia, North Sydney.
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Vesper L J, n.d. ‘Writing procedures that contribute to performance’, LearnPlus.com, viewed on 28 January 2010,
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Paper first written in December 2009.
Smith Raymond J, 2009. ‘Determining factors that reduce human error in maintenance procedures?’
Read this again today, it’s still very pertinent and very good!