What is Human Factors? 70-80% of aircraft accidents are due to human factors –
JAA, May 2001. Maintenance contributed to 15% of commercial jet accidents ...
Human Factors In Aircraft Maintenance Jon Byrd
Director of Aviation Coosa Valley Technical College Rome, Georgia
What is Human Factors? M70-80% of aircraft accidents are due to human factors – JAA, May 2001 MMaintenance contributed to 15% of commercial jet accidents – Boeing, 1995
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Maintenance Human Factors M20-30% of in-flight engine shutdowns & 50% of delays/cancellations are caused by human error – Boeing, 1997 M48,800 non-airworthy aircraft are dispatched each year as a result of maintenance error – Marx, 1998 MRamp accidents cost over $2 billion annually – Ramp Safety Vol.11:3 CVTC
Dollars & “Sense” MAvg. cost of an in-flight engine shutdown is $500,000 MAvg. cost of a flight cancellation is $50,000 MAvg. cost of a return to gate is $15,000 MAvg. ground damage incident costs $70,000 MOne airline estimates $75-$100 million/year is lost MAirline Transport Association estimates that ground damage costs $850 million/yr CVTC
Accidents w/ Maintenance Error MAmerican Airlines Flight 191 – 1979 MAloha Airlines Flight 243 – 1988 MUnited Flight 232 – 1989 MAtlantic Southeast Airlines (ASA) Flight 532 – 1995 MAir Alaska Flight 261 – 2000 MPaul Wellstone (B100) crash – 2002 MSpectrum Aeronautical LLC - 2006 CVTC
General & Corporate Aviation • Little to no data is available • Huge industry push yet we get pushed aside
• With little focus we have to work harder • Safety Managers will have to adapt and adopt
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The Human Element (“Hu”) M“We’re only human...” MWe *will* make mistakes... MThe key is to minimize errors, but how?
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The “Dirty Dozen” M Complacency
M Lack of Assertiveness
M Distraction
M Lack of Awareness
M Fatigue
M Lack of Communication
M Norms
M Lack of Knowledge
M Pressure
M Lack of Resources
M Stress
M Lack of Teamwork CVTC
Dirty Dozen - Complacency M“I don’t need to go get the tech data; I’ve done this a hundred times...” M“No need to pull that panel. Last time I checked that linkage had plenty of grease...” MI’ve been an aircraft mechanic for over 25 years; I know what I’m doing...” CVTC
Dirty Dozen - Complacency MSafety Nets MAlways follow checklist(s) &/or squawk cards MNever work from memory MBe sure to vary your routine periodically MBe aware of the dangers of complacency
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Dirty Dozen - Distraction MPhone calls MPersonal Issues MWater Cooler Talk
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Dirty Dozen - Distraction MSafety Nets MUse a detailed checklist MAlways finish the task MDouble-inspect the work MUse torque seal &/or safety wire MRecord or tag uncompleted work MWhen you return to the task, always go back three (3) steps
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Dirty Dozen – Fatigue MWhat is Fatigue? MThe body’s normal reaction to a physical or mental stress of a prolonged duration MThere are two types MAcute – short duration; cured with good night’s sleep MChronic – occurs over a long period of time; long recovery
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Dirty Dozen – Fatigue MCauses of Fatigue MLong hours of labor (any type) MHigh-intensity stress MLarge temperature variations MNoise – above 80db for long duration MSufficient intensity vibration for long periods MSTRONG lighting
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Dirty Dozen – Fatigue MSymptoms of Fatigue MEnhanced stimulus required in order to respond MAttention reduced MMemory diminished M“Withdrawn” mood MCircadian Rhythm inconsistencies
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Dirty Dozen - Norms M“I don’t care how you did it there, we’ve done it this way for years!” MOutdated/inadequate company policies
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Dirty Dozen – Norms MWhat are “Norms” exactly? MThe way of doing business that’s not approved, but it’s been done locally for so long that it’s now a “Norm” MALWAYS work IAW the appropriate tech data, or if needed, have the manual revised MBe aware that “Norms” do not make it right CVTC
Dirty Dozen – Pressure M“Get it to the gate!!!” MToo tightly scheduled deadlines MFlat-rated Work Orders that maybe should have been rated
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Dirty Dozen – Pressure MSafety Nets MStop! Assess the situation MLook at the situation rationally MCan I safely do the job on time? MHave I voiced my concerns clearly? MWhat is the worst thing that can happen to me?
MListen to your rational mind MHas this happened before?
MAct MSpeak up – ask for help or more time CVTC
Dirty Dozen - Stress MPersonal issues MWeather concerns MWanting that “atta-boy” for the boss
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Dirty Dozen - Stress MHow to Manage MIf you do not manage stress, it will gladly manage you MStop burning up emotional energy MLook rationally at the problem MCure the cause, not the symptom
MListen to your rational, not your emotional, mind MAct – once you have a plan, go for it CVTC
Dirty Dozen - Stress MOther Stress Helpers MBe sure the solution starts with “I” MBe realistic and practical MTake a break MTalk to someone who is not emotionally involved with the situation MDon’t expect miracles, just keep trying
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Dirty Dozen – Lack of Assertiveness M“Only do what’s expected of me and that’s it... Not a movement more.” MNot researching all applicable technical data MNot following technical data to the “t”.
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Dirty Dozen – Lack of Assertiveness MSafety Nets MRecord all the work you do in the logbook, but only sign for that which is serviceable MRefuse to compromise your standards
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Dirty Dozen – Lack of Awareness MNot aware of technical data revision MNot aware of surroundings
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Dirty Dozen – Lack of Awareness MSafety Nets MTHINK MWhat could occur in the event of an accident?
MCHECK MWill your work conflict with a previous or existing repair &/or modification?
MASK MSee if anyone else can spot a problem you overlooked
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Dirty Dozen – Lack of Communication MEither technician to technician MManagement to hangar MInspection Department to Maintenance crew(s)
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Dirty Dozen – Lack of Communication MGood Communication Tips MYou have: MTwo ears MTwo eyes MOne mouth
MUse them in that order!
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Dirty Dozen – Lack of Communication MTo Improve Communication MLearn to Listen
MDo NOT
MDebate MDetour MPre-plan MTune-out
MDo
MAsk questions MParaphrase MMake eye contact MUse positive body language CVTC
Dirty Dozen – Lack of Knowledge M“Am I experienced for this task?” M“Do I have all of the appropriate tech data?” MAware of FAR’s
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Dirty Dozen – Lack of Knowledge MSafety Nets MObtain school training on type, model, etc MGet supervised on-the-job training MUse current technical manuals MTech Reps &/or Manufacturer Reps are there for a purpose – use them!
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Dirty Dozen – Lack of Resources MIs the appropriate tech data available? M“Do I have the proper tools and equipment to perform the task?”
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Dirty Dozen – Lack of Resources MSafety Nets MCheck all suspect areas at the beginning of all inspections and AOG the required parts MOrder & stock parts before they’re required MKnow your sources MArrange for pooling &/or loaning MMaintain aircraft to highest standard CVTC
Dirty Dozen – Lack of Teamwork MIs this a task that really two technicians should do? M“No, I don’t need any help; I know what I’m doing!”
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Dirty Dozen – Lack of Teamwork MSafety Nets MAlways discuss and plan the Who, What, When, Where, and How of the task to be done MInsure that everyone understands and agrees
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Accident Model
1
Co nd iti on sa fe Un
Superv ision/O rg
anizati on
The Domino Theory
ct A fe nt a e s v pE a Un h Mis
Damage/Injury
2
3 4 Dominos
5
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Reason’s Swiss Cheese Model Organizational Factors
Latent Condition
Unsafe Supervision
Latent Condition
Unsafe Act Preconditions
HFACSHuman Factors Analysis & Classification System
Latent Condition Unsafe Acts
Active Failure
Accident
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Human Factors Prevention • Recap • We’re all human and we will make mistakes • Know your own limits • Learn to recognize it in others
• Cure the cause and not the symptom
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My Thanks • FAA • Lou Lerda – Safety Program Manager, Seattle, WA FSDO • Atlanta FSDO-11
• Jim Lumley & GWBAA
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Human Factors in Aviation Maintenance
Questions? CVTC
