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Safety differently: A case study in an Aviation Maintenance-Repair-Overhaul facility

  • Amsterdam University of Applied Sciences
  • Amsterdam University of Applied Sciences
  • SDO University of Applied Sciences.

Abstract and Figures

You This paper presents the findings from a ‘Safety Differently’ (SD) case study in aviation, and specifically in a maintenance, repair and overhaul (MRO) organisation in Southeast Asia. The goal of the case study was to apply a new method of safety intervention that is part of the Safety Differently toolkit and utilises a bottom-up approach. This research tested the extent to which these interventions could be embedded into a continuous improvement program in a highly controlled environment, namely an Aviation MRO. The interventions (called micro-experiments, ME) are considered as a flexible tool, which allows testing of process improvements in a safe to fail way, empowering the lower levels of the organisation, challenging safety related issues and revealing key areas in need of transformation. The ideas for the interventions considered in the case study were retrieved from interviews conducted with 50 mechanics, and include issues to address aviation safety and occupational health as well as quality. We elected to include all three categories in this study as the ME approach is applicable to all of these. This MRO case study showcases the benefits and limitations of the ME in aviation, revealing the conditions under which it may become useful. Future studies should further explore the role of complex and heavily controlled industries in similar bottom up approaches, so that interventions can become part of a continuous improvement plan.
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Safety differently: A case study in an Aviation
Maintenance-Repair-Overhaul facility
Anastasios Plioutsias1,
, Konstantinos Stamoulis 2, Maria Papanikou2, and Robert J. de Boer3
1Coventry University, School of Mechanical, Aerospace and Automotive Engineering, Faculty of
Engineering, Environment and Computing, UK
2Amsterdam University of Applied Sciences, Aviation Academy, Faculty of Technology, NL
3Northumbria University, Amsterdam Campus, NL
Abstract. You This paper presents the findings from a ‘Safety
Differently’ (SD) case study in aviation, and specifically in a
maintenance, repair and overhaul (MRO) organisation in Southeast
Asia. The goal of the case study was to apply a new method of safety
intervention that is part of the Safety Differently toolkit and utilises
a bottom-up approach. This research tested the extent to which these
interventions could be embedded into a continuous improvement
program in a highly controlled environment, namely an Aviation
MRO. The interventions (called micro-experiments, ME) are
considered as a flexible tool, which allows testing of process
improvements in a safe to fail way, empowering the lower levels of
the organisation, challenging safety related issues and revealing key
areas in need of transformation. The ideas for the interventions
considered in the case study were retrieved from interviews
conducted with 50 mechanics, and include issues to address aviation
safety and occupational health as well as quality. We elected to
include all three categories in this study as the ME approach is
applicable to all of these. This MRO case study showcases the
benefits and limitations of the ME in aviation, revealing the
conditions under which it may become useful. Future studies should
further explore the role of complex and heavily controlled industries
in similar bottom up approaches, so that interventions can become
part of a continuous improvement plan.
1 Introduction
Safety Differently is a new, yet under conceptualised, approach to improving safety processes
by using the experience, knowledge and creativity of the frontline employees [1]. As part of
the SD toolkit, micro-experiments (ME) have been introduced as a way to test the feasibility
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MATEC Web of Conferences 314, 01002 (2020)
of interventions in a safe-to-fail manner. Maintaining aircraft to the highest safety standards
requires skills of the mechanics within a Maintenance, Repair and Overhaul (MRO)
organisation. Aircraft mechanics perform daily tasks, in demanding working conditions and
whilst following procedures, designed to comply with safety and quality standards and
regulations. Hence, given their subject-matter expertise, MRO personnel is a valuable source
for the detection of issues experienced at the shop floor. Since it is important to continuously
improve processes, this paper focuses on interventions utilising the most valuable source of
an MRO organisation, its workforce. The MRO mechanics are key in sharing problems from
the shop floor and help locate the potential interventions required to address issues affecting
safety. Little is known about the results of the ME approaches and the added value to the
continuous improvement of safety. Following the principles of Safety Differently (SD), we,
therefore, explored bottom-up improvements through testing of the ME-based interventions.
Our motivation stemmed from the lack of applications in highly controlled and complex risk
industries, such as aviation. Aviation is an industry characterised by complexity, high
severity risks, and consequently a strong regulatory framework. Any such ME case study or
application in aviation is missing.
It was a challenge to examine the possibility of the ME application in an aviation
organisation because the study must deal with strict regulations, whereas the methodology
requires the elimination of constraints, possibly violating aviation rules. Our approach aimed
to assess the benefits of ME in high risk industries and safety critical tasks [2] in two phases.
The first phase involved data collection to a) identify gaps in the safety of the work processes
and b) to design the subsequent potential interventions. The qualitative data was collected
through a change-oriented research design, achieved by interviewing 50 mechanics who were
the primary source according to the bottom-up approach of ME [3]. The second phase was
the experimentation of a limited number of appropriate interventions, in line with previous
applications of the concept outside aviation. The interventions were designed for their small-
scale application by using the organisation’s active work area and employees as an in-situ
laboratory [4]. The project began in the base of the organisation with two university
representatives who stayed in the MRO’s base for months. The university agreed with the
organisation about the project constraints, described in detail in 2.3, and the working progress
of the project in the organisation’s area and bays. In the following sections, we report the
extent to which the SD-based methodology through the execution of ME could be used as
part of a continuous improvement program within MRO organisations.
2 Safety Differently: concept and methodology
Sidney Dekker defines the Safety Differently (SD) concept as following: “Imagine a space,
a space in which there are no rules, a space in which people can themselves determine the
best course of action, a space in which people spontaneously negotiate and collaborate in
order to create the safest outcomes for everyone, in this space a new type of humanity
emerges, nobody is telling them, they figure it out on the spot, we call this emergent
behaviour” [5]. In a complex environment, where behaviour is difficult to predict, we cannot
be sure that the interventions that we devise actually bring the results that we envisage, or
that unintended effects are avoided. We need an approach that allows us to try different
things, does not cause peril, and can be stopped if we don’t get the results that we want. This
is where the micro-experiments (ME) come in.
In an MRO organisation, ME can be applied if the organisational safety constraints are
removed in order to accommodate the bottom-up research design, examining how the
mechanics have to maintain safety in their tasks and operations. Typical constraints in an
MRO setting mean that wide-scale interventions are not suitable, mainly due to the number
of stakeholders involved, such as airlines and regulatory bodies. An intervention can act as a
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safe-to-fail, small scale project, which uses the organisation’s workplaces and workforce [6].
The subsections that follow discuss how the micro experiments are selected and how they
were applied in the MRO organisation.
2.1 The ME concept
Captions Traditionally, aviation safety management is considered as a hard, positivist field
of research [7]. Safety Differently involves taking a more collaborative approach to safety. It
involves getting the people who do the work to decide on rules and safe working practices.
This is different from the traditional approach to safety where rules and policies are set by
managers and other third parties before being communicated to (or imposed on) the people
doing the job. ME fit into this approach as they are safe-to-fail interventions that are
monitored for success or failure, and that have been generated by the work-floor. ME are
different to ad-hoc trial-and-error interventions in that they are planned before they are
executed, and carefully monitored to see whether the intended results are realised. ME are
different to projects in that projects are not supposed to fail, whereas in micro-experiments
are temporary and we allow for unexpected, even disappointing results. In a complex
environment we cannot have the (misplaced) confidence that any intervention will surely
deliver the predefined results as expected. We need to allow for the possibility for the
intervention not to work without causing undue damage. In fact the experiment can be
considered a success if we realize an intervention “fails” and that some other solution is
required. We therefore need to be able to stop or slow the experiments. On the other hand, if
all goes well the intervention is ready to be formally implemented and possibly enlarged on
a wider (geographic or organisational) scale. Naturally we will create the ideas for the micro-
experiments in close collaboration with the task executors; many ideas will derive from them.
Micro-experiments generally require temporary safeguards because we will be deviating
from existing processes, perhaps violating the constraints that are usually in place. Care needs
to be taken to identify and only maintain those constraints that are absolutely vital to
safeguard against unacceptable risks we value the input of safety experts here. The criteria
by which we determine whether an intervention is successful (or not) need to be determined
ahead of time, although additional insights will occur as experience is gathered. Interventions
that are deemed successful need to be incorporated in the next version of Work-as-Imagined.
Even after formalisation, we remain vigilant about unintended effects, expecting the front
line to report where exceptions are necessary. Multiple micro-experiments can run in parallel,
preferably somewhat isolated from each other. Good targets for micro-experiments are
procedures that are not delivering results as expected. Many organizations that we first
engage with are susceptible to large and potentially embarrassing gaps between Work-as-
Done and Work-as-Imagined, that are not straightforward to close. This is often a good
starting point to try out micro-experiments. Other reasons to execute micro-experiments
include adapting rules to changes in processes or equipment or for innovation. To further
define the problem, we first need to identify the “job to be done”: what operators really seeks
to accomplish in the given circumstances. Successful micro-experiments help make the job
safer and easier.
2.2 Methodology
Our methodology involved a sequential research design, comprising of two data collection
phases. In the sections that follow, we initially describe the data collections phases for ME.
Following this, we showcase the utilisation of previous findings in our data analysis. Before
we present the results of the ME application, we describe the pre-coded themes and the
analysis framework. Lastly, we discuss the limitations of these choices.
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2.2.1 Research design phases
As outlined previously (cf. Section 1), the first phase involved the collection of data and the
second phase regarded the interventions. The first phase included identifying and
interviewing mechanics in semi-structured interviews. In order to identify the interviewees,
the team requested to be present at the organisation’s bays and observe the mechanics.
Through this process, fifty (50) mechanics were purposively sampled and were interviewed
individually. The main objective of this phase was to identify what gaps are prevalent
between WAD and WAI. This data collection phase was supplemented with archival data
from the MRO, including documentation from audits, investigations reports and safety
reports, as well as injury reports and maintenance error notifications. Following this phase,
the team identified a number of interventions, which formed the second phase of the study.
The aim of the interventions as interventions was to close the gap(s) found through the
findings from the first phase. During this phase, it was decided that the term interventions
was changed to micro-projects following the organisation’s requirement and in order to limit
possible defensive behaviours that would affect results.
2.2.2 Coding and analysis framework
MRO organisations are typically optimised by lean approaches in order to create more value
for their customers by utilising fewer resources [8]. Our approach hence initially required an
assessment of the MRO environment. Before our study commenced, the quality (and safety)
department at the MRO, had initiated a safety project to assess their safety performance.
Elements of the latter are observed in the organisation’s vision for the safety project itself,
striving for innovation and evolution, and finally, Genchi Genbutsu, going down to the shop
floor to fact check one’s ideas in the ‘real world’ [8]. The findings of the project led to the
establishment of a Safety Group (SG), encompassing the following pillars:
Technical Systems: includes all the tools, equipment, and all the physical items in the
organisation, necessary to create value for the customer.
Management Infrastructure: includes the formal structures, the processes and the systems
for controlling the resources, in association with the technical systems.
Mindset and Behaviour: include the employees’ thoughts and feelings as well as
individual and group behaviour at the workplace.
These three pillars formed our initial classification that we used to compare the SD results
with the organisation’s SG project, and hence led to a pre-coding of the issues found at the
shop floor. All the sources used from the organisation’s safety project was provided to the
team by the SG. The coded shops, which were chosen for phase one observations and
consequent sampling and data collection (Table 1).
Table 1. Shop coding.
Avionics shop
Structures shop
Cabin shop
Cargo shop
Flight control shop
Landing gear shop
Engine shop
Seat shop
Paint shop
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In the second phase, the researchers collected data, mainly from the interviews in which
the front-line mechanics assigned. These technicians answered the questions posed to them
and communicated their ideas for possible interventions. The findings from the interviews
and observations led us to a master coding according to shop floor and their bays. In addition,
the MRO’s project used numerical values to score and classify findings following the Safety
Risk Management (SRM) manual, which meets the compliance requirements according to
ICAO’s Safety Management Manual (SMM) and the data driven systems to proactively
manage safety, Safety Management Systems (SMS). The MRO uses numerical values for the
risk and taxonomies according to SMM standards [9], based on the Severity (minor to
hazardous) and the Probability (extremely improbable to frequent). The Risk Indicator (R is
calculated by multiplying the probability (P) with the Severity (S) of an occurrence (S),
forming the R = P x S equation. The result of this equation rated from low to high risk and
the values for the possibility and the severity explained detailed. The SRM was used during
the project to score and classify the findings.
2.2.3 Research rigour
The team took a series of steps to minimise bias, gain access, and to overall ensure rigour in
the research process. The mechanics were interviewed to gain information based on their
expertise and bypass the organisational-level hurdles. By doing so, the feeling of
empowerment of the mechanics increased, placing emphasis on the value of the technical and
operational experience of the mechanics. In addition, we described the interventions to the
organisation management to gain internal approval, allow execution of the interventions and
to peer-review the results. Following this, and regarding the micro-projects, acceptance by
management was ensured to reach consensus on the interventions proposed by the mechanics.
After suitable interventions were collected, the gathered intel has to be verified by the rest of
the mechanics, since implementing an idea that only suits one mechanic is not a valid micro-
experiment. Besides validating with the mechanics, it is also important to validate the
opportunities of improvement with the quality management representatives to make sure they
agree on the findings and see the same promising interventions for current tasks or processes.
In case there were multiple possible interventions, the mechanics scored them on an effort-
effect diagram (Figure 1) together with the Quality Manager. All the proposed interventions
were compared with each other in assuming the effort required to achieve each intervention
and its expected effectiveness. An example is shown in Figure 1, where intervention “1” was
preferred because it could yield the most effective result with the least amount of effort when
compared to intervention “2”. In general, interventions mapped on the top-right area of the
matrix were preferred over the rest.
Figure. 1. Effect - Effort Matrix [10]
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To gain further approval, the micro-experiment approach was described to management
in detail, covering points such as the process, success criteria, constraints and anticipated
interventions as well as the area and possibilities of amplification. Regarding the execution
of the interventions, each micro-experiment had a customised period. The main factor was
the duration of the task each intervention targeted. One researcher was continuously present
during the execution of each experiment to observe the intervention, function as the point of
contact for concerns, questions, ideas, and, most importantly, collect the views of the
mechanics on each intervention. When the predetermined timeframe expired, the experiment
was concluded by the researcher, the intervention was suspended, and the task was brought
to its previous state (e.g. tools, procedures). A final template was created with the approval
intervention when it validated from the quality management department. The decision on
whether to amplify each successful intervention into an improvement plan laid with the
organisation’s management team.
2.3 Constraints
When the project was being planned, and following the principles of ME, the team observed
that there are several limitations when applying ME in an aviation organisation. The chosen
MRO organisation allowed the researchers time to organise and plan the project locally, but
the quality manager and the safety group required the following constraints to be applied to
the ME’s:
Any actions must be according to the regulations
Any intervention must be according the procedures
Any interaction cannot create new risks
Any intervention is according to the organisation’s risk assessment
Any intervention is not a permanent solution
Any intervention must comply with requirements set by organisation’s clients
Any intervention is only applied to the predetermined bay with predetermined group
Any intervention will run for fixed period of time
Any intervention can only be executed with the present of at least one of the
university’s representative on site.
Any intervention can only be executed in agreement with Quality Manager, VP, the bay
manager involved and the project team.
The limitations deriving from the application of ME in a highly controlled industry
quickly became the first important finding of the case study. It is clear that the first three
constraints (any actions must be according to the regulations, any intervention must be
according the procedures, and any interaction cannot create new risks) do not allow any
innovation to take place. These, as well as the required permission to execute the ME’s,
severely impeded progress at the site, and needed executive circumvention to allow the ME’s
to be applied. Although in the ME concept the interventions are described as a bottom up
process, the validation, approval and decision processes in aviation are a top down process
with assumptions and issues including not merely safety aspects but also extending to other
departments like security and quality. The discussion about the limitations follows the
presentation of our results.
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3 Results
This section presents the findings from phases one and two of the sequential research design
applied following the principles of the ME concept. Table 2 below provides an overview of
the amount of data and of the sources involved in phase one of the study (i.e. interviews and
archival data). Interview findings were initially categorised in single or multiple concerns.
The categories emerged from the narratives of the research as presented in Table 2.
Table 2. Number of times that concern is raised and/or observed.
Number of findings
Single Concern
One time
Few Concerns
2 5 times
Multiple Concerns
6 10 times
A Lot of Concerns
>10 times
When a finding was a single concern, it meant one mechanic only raised it; such issues
were either considered minimal, according to the QM and the SG, as general remarks or seen
as irrelevant to the organisation. Valid concerns were findings reported by multiple
mechanics, and issues on which the organisation agreed, but had its intervention planned,
processed or implemented (11 in total). In addition, findings were categorised according to
the bay coding (cf. Section 2.2.2) as presented in Table 3. As shown below, the findings were
also categorised according to in- and on- the aircraft (in A/C, on A/C), and were summarised
for each of the shops. Bay 6 is not included in the study.
Table 3. Numbers of findings per bay.
In A/C
Bay 1
Bay 2
Bay 3
Bay 4
Bay 5
Bay 7
Bay 8
The shops that are not necessarily linked to all bays. For example, the landing gear shop
(LDG), is linked only with the bay 5 and bay 8. In total, sixty-nine findings (69) were
recorded. However, ten of these findings were finally selected as interventions, through the
validation and approval process as described previously (cf. Section 2). The accepted findings
as interventions are described in detail in 3.2.
3.1 WAD WAI analysis
During the analysis of the interview data, it was observed that the mechanics were hiding the
gaps between how they should do their job (WAI) versus the way they perform their tasks
(WAD). Hence, we observed that the MRO organisation manifests signs of a problematic
safety climate. These limitations are further discussed in Section 4.
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3.1.1 Findings Characteristics
The findings initially examined and evaluated the possible interventions for the MRO
organisation. As shown in Table 4, the intervention characteristics were classified using the
three pillars of the SG, then by area of improvement and per type of method and lastly by
using the MRO’s risk assessment scaling method.
Table 4. Evaluation of Interventions
Classification of Findings
Technical Systems
Management Infrastructure
Mindset and Behaviour
Type of method
Researcher’s Observation
Risk Assessment of Findings
High (>40)
Medium High (30-39)
Medium (7-29)
Low (<5)
In detail, in the risk assessment it is observed that eleven (11) findings are in medium-
high and high risk and they have been rejected. The rest fifty-eight findings were examined
and evaluated from the project team, the quality manager and the organisation’s safety group.
From the suggested area of improvement, the twenty four of the sixty-nine findings belong
to safety area. The rest thirty-nine addressed to faciliatory and twenty-four are related with
the equipment. Fifty of the total findings are related with the process, fifteen of them are with
the WAD & WAI concept and four of them are related with the researcher’s observations.
When the team taxonomized with the same taxonomy of the previous safety group and QM
project they found thirty-four (34) findings in technical systems (48% of the findings),
twenty-one in management infrastructure (31% of the findings) and fourteen in mindset and
behaviour category (21% of the findings).
3.2 The accepted interventions
Due to the absence of findings on safety alone, most of the processes discussed were not
strictly safety-oriented but also overlapped with quality and occupational health domains.
Although mechanics were hesitant in discussing these gaps, they were eager to suggest
possible improvements and ideas. Similar to the problems of the WAD-WAI analysis, this
process manifested that trust from the mechanics was low, and that, then, there is a
problematic (safety) climate. During the process, and as the role of the researcher was
distinguished from organisation management, trust increased, and the mechanics opened up,
sharing the insights that follow in the ten (10) executed interventions, which have more
quality characteristics than safety related issues.
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Table 5. The accepted interventions
Problem description
Intervention description
The mechanics are not allowed to wear their
safety shoes during final maintenance in a
cleaned cabin, prepared for delivery to the
customer. However, mechanics often make
last-minute repairs in the cabin, in which
the use of safety shoes is recommended.
Three types of covers were tested and a
silicon, flexible shoe cover was selected
due to ease of use, grip provided and anti-
static properties. The experiment proved
useful and QM extended the shoes
throughout the organisation by adding them
to the personal protection equipment (PPE).
Following installation the seat covers are
often damaged and repairing them usually
means delays in customer acceptance and is
For the business class seat covers, the
intervention is a fabric, reusable seat cover.
For small tools, such as a drill bit, a
expendables form needs to be filled in at the
tool room booth, making the tool keeper
wait for the completion of the form.
The filling in of the form elsewhere can
increase the throughput of the booth and
therefore reduce the current queue time.
Under the wing of Airbus aircrafts, a strong
presence of kerosene fumes can be noticed.
Fume-removing fans could be used to
circulate the air. A risk, however, is that the
fumes move to other work areas.
Current methods of working on the fuselage
or wings of the aircraft can be dangerous to
mechanics and can damage the aircraft.
Butterfly Suction Cups: A new system, in
the shape of a butterfly, was proposed as an
improved and safe alternative.
The safety shoes at are currently used by
mechanics are uncomfortable and are of
low quality.
The introduction of a new type/brand of
safety shoes has been proposed.
The extreme hot climate working
conditions in Southeast Asia.
To address the tropical working conditions,
lighter shirts made from a dry-fit fabric,
have been proposed for the mechanics.
When a tool is missing from one toolroom
mechanics often walk to the other toolroom
a few 100 meters away with time-
A transportation means such as a bicycle
can significantly reduce the time needed to
get a tool from a different tool room.
Everyday mechanics have to retrieve their
standard toolboxes from the toolroom,
which creates long queues at the start and
finish of the shifts.
The Relocation of the toolboxes back in the
shop area was suggested, and only using the
toolroom as for original and limited
Inside the cabin, mechanics use stairs made
from foam and tape, these are unstable.
A more firm and secure stair was proposed
as a safer equipment for the mechanics.
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4 Discussion and Recommendations
The SD principles guided the application of the Micro Experiments in a bottom up process
to identify the problems and the solutions for safety related issues. The research objectives
focused on exploring whether the application of the ME approach could trigger interventions
for improved safety processes in an aviation organisation. Our two- phases methodology
following the principles of the ME in an aviation organisation, revealed the benefits and the
limitations of the approach in a high controlled and operationally risky environment. Below
we discuss the key findings from the ME case study at the MRO organisation noting our
4.1 Occupational Health, Process Safety and Quality overlaps
One of the critical realisations during the project was the relationship between safety and
quality management. Through the research, the team realised that the constraints and the
limitations in an aviation organisation are strong barriers for the ME application as described
and applied elsewhere. The lack of case studies in aviation meant that the research would
enter an under-explored field, which created challenges and sometimes misunderstandings
between the researchers and the management of the organisation. We therefore report that
the ME assumptions are challenged by the organisation’s quality and safety department,
which descriptions of ME do not account for. For example, the MRO’s quality department
attempted to assess the safety findings and observations as quality markers. Our findings here
highlight the problems in the quality vs safety and occupational health misperceptions, and
how these create confusion in the safety management process and the identification of
suitable interventions for the organisation. Secondly, the safety department initially raised
constraints that paralysed the ME and needed to be lifted by top-level intervention for
progress to be made
Albeit, the revelation shows that the ME approach can reveal deeper organisational issues
intervening in the safety processes, whether managed or performed, and supports the benefits
deriving from bottom-up approaches [3]. Because of these benefits, mid-project interventions
were able to take place. Initially, the team was able to recognise the lack of ME fundamental
knowledge and thinking in the MRO organisation. Secondly, the team was able to address
this issue by filling the knowledge gap with ME workshops and additional visits on-site the
MRO. The intermediate actions aided to have most of the interventions accepted from the
organisation, yet, as reported in Section 3, with quality and occupational health aspects, and
not a clear safety orientation. The same misconception was identified in the interviews where
the participants wanted to discuss and proposed quality and not safety interventions like the
cover of the cabin seats during the work of the technicians in the aircrafts’ cabin. This finding
and change process underpins the added value of ME and the intervention possibilities in
aviation organisations.
4.2 Insights following the SD principles
Using the ME approach to inquiry, the findings from interviews in interventions achieved a
variety of results and insights into the adoption of the boader SD principles. Concerns such
as middle management isolation, fear of change, and not wanting to take responsibility,
revealed problems of safety bureaucracy and showcased the possible issues these can induce
during a (research) project and in the safety processes of an MRO organisation without
directly impacting the ME. The mechanics also reported that there are even cases in which
they were demoted after they made critical remarks about the organisation and/or shared
innovative ideas. There are clear indicators of the presence of these types of bureaucracies
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within the organisation. Our ME findings hence support studies highlighting the importance
of safety climate underpinning aviation MRO practice [11]. Importantly, our study showed
that, when the organisation shows value and appreciation towards the work of the mechanics,
their opinions and ideas, the attitude towards responsibility changed. Specifically, the MRO
mechanics were appreciative of the responsibilities and chances are given to them to be part
of a change-based project. It showed them the importance of bottom-up suggestions and
challenging of organisation procedures. The interventions provided the flexibility required to
fit and try a wide selection of interventions. The first completed interventions showed the
amount of effort mechanics put in their ideas and the results they can achieve from this input.
The fact that the shoe cover intervention (Table 5) will be amplified organisation wide is a
first step towards the continuous improvement.
4.3 Evaluation of the MRO project
During the planning and execution phases of the project, several success factors and
limitations were revealed. Success factors include the MRO’s availability and willingness at
a high level to run the project in their working area. The decisions the team took in the latter
environment, aided in achieving research rigour and insights for the transferability of the
results [12]. In detail, the team followed the data to make decisions instead of aiming to
satisfy standards not relevant and not appropriate for the project (i.e. external and internal
validity, reliability and objectivity). In addition, the researchers’ professional background in
aviation organisations helped establish a common communication channel with the MRO
managers, gaining access into their MRO systems. Hence, familiarity with the culture of the
participants aided reflexivity [13]. As a bottom-up process underpinned the project, the
developing cooperation between managers and mechanics became evident. This success
factor showed the power of the ME approach and the advantages over traditional intervention
approaches (ad-hoc or projects).
Limitations of the project include the chosen context of the case study, hence addressing
our main objective. In detail, in the highly controlled MRO environment, the more
inexperienced members were not able to recognise possible safety-related issues, which
would have been useful for the project process. Moreover, the inexperienced members
unintentionally behaved like auditors, adding to a lack of trust already in the MRO, and
revealing problems of safety climate. Similarly, the managers were unprepared for this type
of project. Our findings hence support past aviation MRO safety studies, where safety climate
is seminal to developments. Additional limitations were the context of safety bureaucracy,
which surfaced organisational problems such as the lack of a positive safety culture, the lack
of trust and the lack of safety knowledge in the middle and the low-level employees. For
example, during interviews, it became evident that most employees are confused between the
failure analysis and incident investigation.
5 Conclusion and future directions
Safety Differently in aviation organisations is an underexplored field. Micro experiments are
not safety recommendations, but they comprise a tool to explore the perceptions of shop-
floor employees that guide actions and behaviours. In order to formulate interventions,
incident reports can be used, although it should be noted that incident reports do not trigger
them. Incident reports can be used as a tool to identify focus areas, assess the status of the
safety recommendations and close the loop. In addition, it is recommended that, although the
micro experiment is a bottom-up process, the organisation is assessed before any safety
differently project can begin. Our case study application revealed the bottle neck situation
MATEC Web of Conferences 314, 01002 (2020)
which forms our contribution to further ME applications in a similar aviation organisation.
Our recommendation is hence to initially assess the organisation’s safety climate and then to
apply the framework for the Safety differently project. The assessment of safety climate is
fundamental for the SD and therefore ME - implementation in aviation. It is a way to plan
the researcher's actions before the application of any method and tool of SD concept. The
preparation of the safety program participants is an additional necessary action, which
includes top-down training and identification of the setting the micro experiment takes place,
so that daily working load is not affected. They are no potential risks for the organisation’s
operations. Moreover, it is recommended that the organisation prioritises the organisation’s
problems, using quality tools and methods (e.g. Effect Effort, Pareto, Fishbone diagrams).
In any aviation organisation which has many working tasks, the term ‘micro experiments’
is not a familiar one and could, therefore, threaten their acceptance. It is therefore suggested
that the term changes to ‘micro-projects interventions’, which is a less threatening term to
aviators. Future research should hence focus on tactics for the smoother application of the
micro-project interventions can give opportunities in organisations to prepare, plan and
organise better large-scale projects in the future. With the use of interviews at the shop floor,
new findings and interventions can be collected, executed and possibly amplified throughout
the organisation. However, mechanics will have to be empowered to share their concerns and
ideas openly. Addressing safety bureaucracy problems will not only transform the
intervention to an improvement plan, but it can help enhance wider safety practices (e.g.
safety promotion, reporting). Safety Differently and ME can, therefore, be used to
continuously improve following a bottom-up approach.
The authors would like to thank Juno Beckers and Niek Kuilder, for their contributions.
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MATEC Web of Conferences 314, 01002 (2020)
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MATEC Web of Conferences 314, 01002 (2020)
... In aviation, Plioutsias et al. (2020) applied safety differently (SD) to a maintenance, repair and overhaul (MRO) organisation in Southeast Asia by (a) identifying WAD-WAI gaps through interviews with 50 MRO mechanics and (b) designing potential interventions to fill these gaps based on micro experiments through a bottom-up process. After identifying ten gaps, the application of micro experiments to design respective interventions met several challenges, such as compliance concerns from the quality and safety departments, fear of change, not taking responsibility, etc. and other adverse conditions showing a negative safety climate. ...
Technical Report
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The last decades have seen the emergence of relatively new concepts in safety and risk management, such as Resilience Engineering (RE), Safety-II (S2), High-Reliability Organizations (HROs), and Safety Differently (SD). These concepts often question traditional safety practice and invite stakeholders (e.g., regulators, business managers, OHS practitioners and researchers) to view safety from different angles, including how safety is defined, the role of people in safety, and how organisations could improve safety. This report maps the principles of major new safety paradigms and reviews respective empirical research, mainly in the construction sector, and opinion/conceptual articles. Our review showed that most of the new safety approaches remain largely theoretical and emphasise organisational aspects, which, however, could regard any business area and not only safety. Moreover, in addition to a few contradictions between them, most of the new safety paradigms imply generalisations and assumptions that could not accommodate the dynamic and diverse organisational contexts (e.g., locations, workforce composition, operational complexity), and they lack visible connections with other related areas such as process and fire safety. Besides, our review suggests that (1) most of the new safety paradigms are not accompanied by practical implementation methods, (2) the validity of the relationships between associated variables has been tested only internally through cross-sectional perception questionnaires mainly, and (3) it is currently unknown if the application of these paradigms directly improves or indirectly contributes to safety. Certainly, the combination of the observations above suggests that implementing new safety paradigms in construction could be faced with several unknowns, further heightened by the project-based nature of construction operations, transient workforce, widespread outsourcing of labour from multiple contractors and financial and time pressures. However, such challenges already exist under current safety management practices, which do not always deliver, and should not be viewed as deterrents from considering newer approaches to safety. Instead, these challenges could comprise opportunities for more targeted and authentic investment in learning and improving based on the maximum possible and honest reconciliation of understandings, needs, expectations, experiences and practices of managers and workers at all organisational levels, including contractors. Admittedly, measuring the effectiveness of any change based on new safety paradigms can be difficult, as system and organisational outcomes are often influenced by a variety of factors beyond just the safety management practices under whatever traditional or newer safety principles. Nonetheless, it is our position that new safety paradigms deserve attention and implementing their principles could offer valuable insights into improving safety, provided these safety approaches will not be approached as one-size-fits-all solutions and deterministically. In the next project phase, we will facilitate the evaluation of those principles by company staff and contractors while considering any unique contextual characteristics before deciding about and co-designing their implementation.
... GMF Aeroasia Tbk perlu menerapkan praktekpraktek pengelolaan proyek sesuai standar dunia industri penerbangan. "Para pekerja langsung (mekanik) perlu diberikan kesempatan untuk menyampaikan pertimbangan-pertimbangannya dan juga ide-ide secara terbuka [8]." Beberapa proyek yang dikerjakan oleh PT. ...
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The air transportation industry in Indonesia is growing rapidly and is very competitive. Aircraft fleet maintenance is an important factor in supporting airlines to compete in the local and global industry. On the other hand, delays in the completion of fleet maintenance can result in delays in flight schedules and this is very detrimental to the airline and passengers. This is a challenge for business actors in the aircraft maintenance sector because of the risk of being penalized for delays that occur. Therefore, this study aims to reduce the risk of late fines faced by aircraft maintenance business actors. With project management, the company is expected to be able to produce effective and efficient maintenance activities. This is very much needed by the company in producing optimal output and has a great impact on airlines that use aircraft maintenance services. In this study, the evaluation of project management uses the Critical Path Method (CPM), Program Evaluation and Review Technique (PERT), Work Breakdown Structure (WBS) to evaluate the preparation of aircraft maintenance activities and the Crashing method if acceleration is needed in completing maintenance activities in accordance with agreed agreement. With the preparation of good project management, it is possible to estimate the time and cost needed to complete a project so as to minimize delays and losses in completion. The project management planning used in this project resulted in an accelerated completion of 3.5 days with an additional cost of $ 8,958.23.
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Strengthening the learning culture and the safeguards in organizations can enhance safety and performance in preventing incidents. The effective implementation of human performance improvement and operational learning can support the organization in achieving these goals. However, there is no streamlined implementation framework that considers the alignment of strategic and tactical actions in the management system cycle to implement human performance improvement and operational learning. This paper presents an implementation framework that fills the above gaps. It consists of four steps: (1) establish/validate a strategic objective, (2) conduct an assessment, (3) develop a plan, and (4) execute the plan. The proposed framework also includes a site tour phase during operational learning as an alternative to storytelling, which has an inherent bias. This framework was tested in the land transportation system of one of Indonesia’s biggest oil producers.
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This paper outlines the use of both quantitative and qualitative research methodologies in organisational research as applied in the aviation environment and argues the case for both approaches in such research. Aviation safety and human performance research, with its largely observation based methodology and life critical outcomes, is an area where quality of research is more important than academic argument as to the purity of research methodology. Though the desire for high quality research should always be the underlying principle in methodology selection, it appears that one research approach is more prevalent. Quantitative research methodology has been, and continues to be, the preferred research methodology under which aviation research is conducted. With its grounding in the natural sciences, this methodology is indeed a logical choice for research in an industry based in a highly evolved technical environment. From a historical perspective, early aviation research topics revolved around subjects with a basis in physics, chemistry, engineering and medicine. These subjects naturally lend themselves to the analytical and empirical nature of quantitative research methodology; underpinned by a positivistic epistemology, stating that positive substantiation of all enquiries is essential for authentic research. While research in aviation continues unabated under the positivistic approach, the maturation of the aviation industry has resulted in an expansion of research topics to include areas related to human performance. It is in this field that numerous researchers have concluded that the use of quantitative processes may exhibit flaws due to the attempted removal of the human element in the research process. The aviation environment is complex with a myriad of cultural, organisational and technical interrelationships considered by many to be a human construct. As a human construct, it is logical that some research needs a qualitative element to add context and depth to the results. Logic dictates that there may be a legitimate role for research in this field to contain elements of both qualitative and quantitative methodologies. With this in mind perhaps it is time to consider qualitative research, as founded in social constructionist theory, as a valid component of aviation research methodology.
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Although many critics are reluctant to accept the trustworthiness of qualitative research, frameworks for ensuring rigour in this form of work have been in existence for many years. Guba's constructs, in particular, have won considerable favour and form the focus of this paper. Here researchers seek to satisfy four criteria. In addressing credibility, investigators attempt to demonstrate that a true picture of the phenomenon under scrutiny is being presented. To allow transferability, they provide sufficient detail of the context of the fieldwork for a reader to be able to decide whether the prevailing environment is similar to another situation with which he or she is familiar and whether the findings can justifiably be applied to the other setting. The meeting of the dependability criterion is difficult in qualitative work, although researchers should at least strive to enable a future investigator to repeat the study. Finally, to achieve confirmability, researchers must take steps to demonstrate that findings emerge from the data and not their own predispositions. The paper concludes by suggesting that it is the responsibility of research methods teachers to ensure that this or a comparable model for ensuring trustworthiness is followed by students undertaking a qualitative inquiry.
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The present study is concerned with the human factors that contribute to violations in aviation maintenance. Much of our previous research in this area has been based on safety climate surveys and the analysis of relations among core dimensions of climate. In this study, we tap into mainstream psychological theory to help clarify the mechanisms underlying the links between climate and behavior. Specifically, we demonstrate the usefulness of Ajzen's (1991, 2001) Theory of Planned Behavior (TPB) to understanding violation behaviors in aircraft maintenance. A questionnaire was administered to 307 aircraft maintenance workers. Constructs measured by the survey included perceptions of management attitudes to safety, own attitudes to violations, intention to violate, group norms, workplace pressures, and violations. A model based on the TPB illustrated hypothetical connections among these variables. Path analyses using AMOS suggested some theoretically justifiable modifications to the model. Fit statistics of the revised model were excellent with intentions, group norms, and personal attitudes combining to explain 50% of the variance in self-reported violations. The model highlighted the importance of management attitudes and group norms as direct and indirect predictors of violation behavior. We conclude that the TPB is a useful tool for understanding the psychological background to the procedural violations so often associated with incidents and accidents.
Current assessment practice and its models typically aspire to capture the considerable variety of airline pilots' performance across highly specific behavioural markers and highly unspecific categories. Yet research into one of the most advanced assessment models has shown large disagreement among assessors in terms of both their scoring and reasoning. Rather than further attempts to eliminate this variety in assessors' judgments, a deeper understanding is required of the source of disagreement. The aim of this study is to reflect on current assessment practice by considering opposing, yet complementary views of human error and safety. Considerable discrepancy is identified between the underlying assumptions of assessment practice and the precepts of advanced safety research. The shift that has occurred in safety thinking hardly seems to have penetrated assessment practice in aviation. This study challenges current assessment practice and sketches approaches that might be more congruent with insight from safety research.
Process Improvements with Safety Differently
  • J Beckers
Beckers, J. (2019). Process Improvements with Safety Differently. Amsterdam University of Applied Sciences.
Safety Differently A new view of safety excellence
  • R Gantt
Gantt, R. (2018). Safety Differently-A new view of safety excellence. Available online at In Dekker, S. (2018). A micro-experiment. In S. Dekker, The Safety Anarchist (pp. 180-185). Oxford: Routledge.
Safety Differently, The Movie
  • S W A Dekker
Dekker, S. W. A. (2017). Safety Differently, The Movie. Available online at
Safety Management Manual
  • Icao
ICAO (2013). Safety Management Manual. Available online at
Management of safety rules and procedures: a review of the literature
  • A Hale
  • D Borys
  • D Else
Hale, A., Borys, D., & Else, D. (2016). Management of safety rules and procedures: a review of the literature. Report submitted to the IOSH Research Committee, Report 12.3.