Aviation maintenance is a complex and demanding endeavor. Its success, which is
ultimately measured by the safety of the flying public, depends on communication and
teamwork. Aviation maintenance operations are most successful when crews function as
integrated, communicating teams -- rather than as a collection of individuals engaged in
Over the past decade, the importance of teamwork in the maintenance setting has been
widely recognized.1,2,3,4,5,6,7,8 The result has been the emergence of human factors training,
Maintenance Resource Management (MRM) programs, and other team-centered activities within
the aviation maintenance community.
Maintenance Resource Management is a general process for improving communication,
effectiveness, and safety in airline maintenance operations. Effectiveness is measured through
the reduction of maintenance errors, and improved individual and unit coordination and
performance. MRM is also used to change the "safety culture" of an organization by
establishing a pervasive, positive attitude toward safety. Such attitudes, if positively reinforced,
can lead to changed behaviors and better performance.
Safety is typically measured by occupational injuries, ground damage incidents, reliability,
and airworthiness. MRM improves safety by increasing the coordination and exchange of
information between team members, and between teams of airline maintenance crews.
The details of MRM programs vary from organization to organization. However, all MRM
programs link and integrate traditional human factors topics, such as equipment design, human
physiology, workload, and workplace safety. Likewise, the goal of any MRM program is to
improve work performance and safety. They do this by reducing maintenance errors through
improved coordination and communication.
Not surprisingly, a prerequisite for implementing successful MRM is the will to do so. As
with any program intended to be diffused throughout an organization, MRM must have the
positive, explicit, and demonstrated support of senior management.
A typical MRM training program addresses each of the following components:
1. Understanding the maintenance operation as a system
2. Identifying and understanding basic human factors issues
3. Recognizing contributing causes to human errors
4. Situation awareness
5. Decision-making; Leadership
6. Assertiveness (how to effectively speak up during critical times)
7. Peer-to-peer work performance feedback techniques
8. Stress management and fatigue
9. Coordination and planning
10. Teamwork and conflict resolution
11. Communication (written and verbal)
In this chapter, we describe the background and evolution of MRM. We discuss current
practices and describe some real-life implementation experiences. We present a systems
approach to designing and developing an MRM training program. Finally, we provide a generic
MRM course outline with examples of activities designed to promote the use of MRM skills.
There is some confusion regarding the definition of Maintenance Resource Management.
Much of this confusion is most likely the result of trying to portray MRM as a "thing," like a
training program or an organizational intervention. It is, instead, a process, a perspective, and a
philosophy. Put another way, many typically view MRM as a singular tool , such as a training
intervention, through which safety is achieved. In contrast, we view MRM more holistically by
defining MRM by what it does, rather than what it is.
MRM encompasses much more than a training program or "teamwork" skills; it involves a
change in individuals' perspectives through which safety becomes chief priority. In this context,
MRM addresses human errors and problem resolution through open and honest communication
among AMTs, managers, and the FAA.3,8,9,10,11,12,13
MRM is characterized by working together and using available resources to reduce errors
and to promote safety. There is a growing body of evidence that team coordination among
aviation crews improves safety, product quality, and system
Maintenance Resource Management, as with other human-factors-oriented processes, is
based on a systems approach. It incorporates a variety of human factors methods, such as job
and work design, and considers the overall socio-technical maintenance system (see Chapters 2
& 6).2,9 For example, the SHELL model, Figure 16-1, shows how we define human factors as
a system and illustrates the various interactions that occur between sub-systems and the human
operator. This is a modification of the SHEL model described in Chapter 1.
Figure 16-1. The SHELL model.
The interactions in this model can affect both individual and team performance. MRM
training typically focuses on the interaction between the individual AMT and other team/crew
members: liveware/liveware interactions in SHELL terminology. This person-to-person
interaction can be considered the most detailed level of communication and team-building. The
interactions among teams and departments occur at a more general level.
There are also external forces that can affect individual and team performance. These
include political and regulatory considerations (e.g., FAA, OSHA, NTSB) and economic factors
(e.g., global competition). Achieving the goals of MRM requires improving interactions at both
the detailed and general levels. These improvements must occur within the context of external
factors and an understanding of their effects. To this end, the SHELL model depicts the systems
approach to integrating human factors methods and principles to design an MRM program.
Evolution of MRM
MRM is the result of a series of events that drove its development. Figure 16-2 outlines the
evolution of MRM and human factors training programs. The catalyst for the development of
cockpit resource management (CRM), the United Airlines (UAL) Flight 173 DC-8 accident, is
As the DC-8 was approaching Portland, the flight crew noticed a problem with the landing
gear. The pilots kept flying while trying to resolve the problem, thus diverting their attention
from the task of monitoring other critical systems. Eventually, they ran out of fuel and crashed
short of the runway, killing 10 people. This accident resulted in United Airlines initiating
Cockpit Resource Management (CRM) training.
Figure 16-2. The evolution of MRM and human factors training programs.
The UAL CRM workshop concentrated on improving communication among pilots and
other crew members on the flight deck. This program eventually evolved into Crew Resource
Management, which pertains to utilizing resources outside the cockpit. This training is now
sometimes called Command/Leadership/Resource Management (CLR).14
In addition to CRM and CLR, airlines also created Line Oriented Flight Training (LOFT).
LOFT incorporates flight simulators to create better working relationships by employing
stressful situations in realistic scenarios. The feedback that can be given to teams after this type
of training reinforces the development of communication and coordination skills.14
Just as CRM grew from a reaction to a tragic event, another key mishap led to the
development of MRM and maintenance-based human factors training. In 1988, Aloha Airlines
Flight 243 suffered a near-catastrophic failrure.23 Eighteen feet of fuselage skin ripped off the
aircraft at an altitude of 24,000 feet, forcing an emergency landing. Following this accident, the
FAA issued an Airworthiness Directive (AD) requiring a close visual inspection of 1300 rivets
on B-737 aircraft.24
The Aloha B-737 involved in this accident had been examined by two inspectors, one with
22 years experience, the other, the chief inspector, with 33 years experience. Neither found any
cracks in their inspection. However, post-accident analysis determined there were over 240
cracks in the skin of this aircraft.23 The ensuing investigation identified many
human-factors-related problems leading to the failed inspections. These findings focused
attention onto maintenance as a potential accident causal factor, and led to the development of
MRM and human factors training.
In 1991, due in part to this new focus, Continental Airlines expanded and modified its Crew
Resource Management training to become Crew Coordination Concept (CCC) training --
designed specifically for its Maintenance Technical Operations personnel. CCC is the precursor
of what has become known as MRM.11,15,25 MRM shares certain basic features with CRM,
including addressing the issues of communication and team coordination. However, the target
audience for MRM includes AMTs, staff support personnel, inspectors, engineers, and managers
-- a much more diverse group than cockpit crews.
Since 1991, over 2,000 technical operations workers and managers have attended this
16-hour course. The objective was "To equip all technical operations personnel with the skill to
use all resources to improve safety and efficiency."11,25 Subsequent evaluation of CCC, over
the course of three years, showed positive and significant effects on safety, assertive
communication, team coordination, stress management and dependability.8,11,15,19
CCC was shown to reduce maintenance error rates, and to improve human reliability in
measurable terms based on a wide variety of objective performance data.8,15,19 Thus,
Continental Airlines was able to demonstrate successfully the positive effects of its first "MRM"
training course.8,15,19,35 This course provided, in part, the inspiration to develop other MRM
Similarly, in response to the 1989 crash of Air Ontario Flight # 1363, Transport Canada
developed the Human Performance in Maintenance workshop.18 These efforts were conducted
in parallel to CCC. Crew coordination was identified as a contributing factor to this accident.
The first workshop, held in January 1994, was successful in providing a heightened awareness of
human factors problems and solutions in the maintenance environment. One outcome was the
identification of the "Dirty Dozen": 12 human factors elements that degrade people's ability to
perform effectively and safely.27
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