AS9100 Rev D – How to prevent Operator Error
The 737 is made up of 367,000 parts. AS9100 Rev D is the internationally recognized standard that provides the requirements for Aerospace Quality Management Systems. It is used by major aircraft manufacturers and all their key suppliers downstream to ensure that each of the 367,000 parts are conforming prior being assembled on the aircraft. The airline industry safety record speaks for itself.
However, even with the high level of quality systems and regulation there are still accidents that occur in the aviation industry. Often operator error is identified as one of the causes. This cause is however, not limited to accidents/incidents/non-conformities within the aviation industry only but also to other industries. The issue with identifying the problem as operator error is that the person is blamed, and organizations failed to look at how the system failed the individual. AS9100 Rev D asks organizations to identity the potential risks to the process at the planning stage and to take action to mitigate these risks.
However, a new concept of risk-based thinking introduced in the 2016 AS9100 Rev D, asks organizations to constantly be assessing risks (as a culture) even after the planning stage. In the actual manufacturing process, the AS9100 Rev D asks organization to consider the possibility of mistake-proofing the system in order to minimize risks. So when it actually is an operator error is it possible that the system did not adequately assess the risks associated with the process or did not opt to mistake proof the process.
The AS9100 Rev D further asks organizations to ensure that action taken to address non-conformities prevent recurrence. If Root Cause Analysis is operator error, then is the corrective action of training or replacing the operator sufficient? If too often we are evidencing operator errors, should that not be indicative of a larger cultural problem?
Management system standards such as the AS9100 Rev D built upon the Plan-Do-Check-Act (PDCA) cycle encourage organizations to identify and address issues from a system perspective. That is when things go wrong we need to go back to the drawing board and assess how did our plan fail. If there is a major aircraft accident just blaming it on operator error would not reveal the underlying issues that may lie in regulatory oversight, pilot training programs, or aircraft maintenance as examples.
AS9100 Rev D does not provide the answer to preventing operator error. What is does do is provide a framework for quality management systems. The organization uses the framework to identify the risks in its business and operating environment and then takes action to address these risks. Implementing a robust aerospace quality management system based on AS9100 Rev D and continually improved should enable companies to with time implement measures that will reduce operator errors to a minimum.