Human Factors For Maintainers - signalcharlie - home Human Factors.pd… · · 2013-07-31Human...

Bell Helicopter Proprietary Information

Bell Helicopter Textron Inc. is a wholly owned subsidiary of Textron Inc. Bell Helicopter Textron Canada Limited is a wholly owned subsidiary of Textron International Holding S.L, a wholly owned subsidiary of Textron Inc. Each company is a separate legal entity and a member of the Textron family of companies. © 2013 Bell Helicopter Textron Inc. All registered trademarks are the property of their respective owners.


5th Annual 2013 Aviation Human Factors and SMS Wings Seminar 2013

Human Factors for Maintainers

Charles Fisher Director, Bell Helicopter Training Academy


Copyright 2013 Bell Helicopter Textron Inc.


What is “Human Factors”?

• Designing workplaces, tools, procedures, and policies

so people can use them easily and safely

• Primary concern is for people in the organization

• Combines elements from many disciplines

• Critical to the overall flight safety and personal

safety




About 80 percent of maintenance mistakes involve human factors, according to the Federal Aviation Administration.

“As aircraft became more reliable and less prone to mechanical failure, the percentage of accidents related to human factors (human causes) increased.”

Human Factors Other Factors

3

What is “Human Factors”?




Inte

rnal •Boring

repetitive jobs

•Personal life problems

•Substance abuse

•Fatigue

•Stress

•Poor communication

Exte

rnal •Smelly fumes

•Loud noises

•Snow

•Lack of spare parts

•Poor tool control

•Slippery floors

•Lack of tools and equipment

Tra

inin

g

•Poorly designed testing for skill and knowledge

•Poor instruction

•Incomplete or incorrect documentation

•Poor training

4

Elements of Human Factors




Internal Elements

Boring repetitive jobs

Personal life problems

Substance abuse

Fatigue

Stress

Poor communication

5




Contributes to maintenance errors

No limitations on duty hours for maintainers

Part 145 operators must account for human performance limitations when organizing shifts

Fatigue management:

Avoid excessive working hours

Allow as much regular sleep as possible

Take into account reduced physical and mental capacity at night

Provide longer rest periods following night shifts

Fatigue

6




MARUFF, P., FALLETI, M. G., COLLIE, A., DARBY, D. and MCSTEPHEN, M. (2005), Fatigue‐related impairment in the speed, accuracy and variability of psychomotor performance: comparison with blood alcohol levels. Journal of Sleep Research, 14:21–27.

Fatigue can impair speed and accuracy of cognitive performance equal to or greater than blood alcohol concentrations (BAC).

7

Effects of Fatigue




Allocate more critical tasks during day shifts when staff are likely to be more alert.

Carry out appropriate checks after night shift work.

Break up lengthy repetitive tasks into smaller tasks, with breaks in between.

8

Mitigate the Effects of Fatigue




Predictable, universal, human reaction to:

Fatigue

Time Pressure

Difficult or unexpected situations

Personal Problems

Component of any human work

Stimulus that results in a change in arousal of the nervous system and focuses our attention process

Stress hormones released which changes heart rate

9

Stress




Acute Stress

Rapid build up

Shocks the nervous system

Easy to detect – heart rate, pulse, etc.

Can trigger “fight or flight” response

Body chemicals help cope

Chronic Stress

Gradual build up over a long period of time

Difficult to detect

Does not trigger “fight or flight” response

Can lead to medical problems – ulcers, heart problems, depression, etc.

10

Types of Stress


About ___% of accidents involve human factors.

1.25%

2.77%

3.80%

4.90%


Which of these is one of the internal human factors?

1.Internal distractions

2.Stress

3.Fatigue

4.Substance Abuse

5.All of the Above




Hazardous Environment Smelly fumes

Loud noises

Snow

Lack of spare parts

Poor tool control

Slippery floors

Lack of tools and equipment

13

External Elements




Demands:

Physical strength

Coordination

Meticulous attention to detail

Reading

Recording data

14

Hazardous Environment




Poorly designed testing for skill and knowledge

Poor instruction

Incomplete or incorrect Documentation

Poor training

15

Training Elements




The Dirty Dozen




The Dirty Dozen

Lack of Communication

Complacency

Lack of Knowledge

Distraction

Lack of Teamwork

Fatigue

Lack of Resources

Pressure

Lack of Assertiveness

Stress

Lack of Awareness

Norm





When changing shifts, maintainers must communicate with one another, explaining what work has and has not been completed.





Only 30% of verbal communication is received and understood.

The safety nets:

Use logbooks, worksheets, etc. to communicate and remove doubt

Discuss work to be done or what has been completed

Never assume anything




Complacency

Overconfident after becoming proficient in a certain task, which can mask the awareness of dangers.

Self-satisfaction accompanied by a loss of awareness of the danger

"I've looked back there 1,000 times and never found anything wrong."

The safety nets are:

Train yourself to expect to find a fault

NEVER sign for anything you

didn't do




Lack of Knowledge

Maintainers must remain up to date on current equipment and how to fix it.

Aviation organizations have a regulatory responsibility to provide required training to their personnel.

The safety nets offered are:

Get training on type

Use up-to-date manuals

Ask a Tech. Rep. or someone who knows




Distraction

Can cause us to think we are further ahead than we actually are.

The safety nets for distractions are:

• Always finish the job or unfasten

the connection.

• Mark uncompleted work.

• Lockwire where possible or use

torque seal.

• When returning to the job, always

go back three steps.

• Use a detailed check sheet.




Lack of Teamwork

A lack of teamwork can ultimately affect the safety of maintenance work.

Not working together is tied in with lack of communication.

The safety nets for teamwork are:

Discuss what, who, and how a job is to be done

Be sure that everyone understands and agrees




Fatigue

Many human variables rise and fall daily due to natural circadian rhythm.




Fatigue

Fatigued workers tend to underestimate the problem and overestimate the ability to cope with it.

The fatigue safety nets call for:

Be aware of symptoms

Avoid complex tasks at the bottom of circadian rhythm

Sleep and exercise regularly

Ask others to check work


Which characteristic is NOT one of the Dirty Dozen?

1.Complacency

2.Fatigue

3.Stress

4.Temperance

5.Norm




Lack of Resources

When there is a lack of resources available to properly fix something, cease maintenance until the proper parts are available.

Lack of supply and support can interfere with one’s ability to complete a task.


Check suspect areas at the beginning of the inspection and AOG the required parts.

Order and stock anticipated parts before they are required.

Know all available parts sources and arrange for pooling or loaning.

Maintain a standard and if in doubt, ground the aircraft.




Pressure

Pressure to get things repaired is always present in aviation.

Do not let the pressures of time constraints get in the way with safely finishing a repair.

Urgent demands can influence performance.

The safety nets to counteract this are:

Be sure the pressure is not self-induced

Communicate concerns

Ask for extra help

Just say NO




Lack of Assertiveness

Failing to alert others when something does not seem right can result in fatal accidents.

Assertiveness is the ability to express feelings, opinions, beliefs, and needs in a positive, productive manner.

The counteracting safety nets are:

If it is not critical, record it in the journey log book and only sign for what is serviceable.

Refuse to compromise standards.




Stress

Stress is the subconscious response to the demands placed on a person. Stress can be acute or chronic.

Stress safety nets call for:

Be aware of how stress can effect work

Stop and look rationally at the problem

Determine a rational course of action and follow it

Take time off or at least have a short break

Discuss it with someone

Ask fellow workers to monitor work

Exercise your body




Lack of Awareness

Failure to recognize all the consequences of an action, or lack of foresight


Think of what may occur in the event of an accident.

Check to see if work will conflict with an existing modification or repair.

Ask others if they can see any problem with the work done.




Norms

The way things are normally done.

Unwritten rules followed or tolerated by most of the organization.

Negative norms can detract from established safety standard and cause an accident to occur.

The safety nets offered are:

Always work as per the instructions or have the instructions changed

Be aware that "norms" don't make it right




Communications

Were the words exchanged clear and meaningful?

Did you understand them?

Do you think the crew understood each other?

Were all of the individual segments of communication effective?

What factors prevented/affected effective communications by this crew ?




Cost:

Loss of money

Personal injuries

Loss of life

Consequences vary:

Major errors do not always lead to major accidents

Minor errors can lead to major accidents

35

Costs and Consequences




Traditional ways of addressing human error:

Selection of personnel

Procedures/standardization

Technology/automation

Redundancy

Training

Motivation

36

Addressing Human Error




Conduct maintenance in a way that enables the aircraft to be released to service in a safe condition.

37

Approach to Human Factors & Safety




Top level commitment to safety and human factors

Company policy on human factors

Human factors training

Clear disciplinary policy where genuine errors do not result in punishment

Policy to manage fatigue

Mechanism to report problems

Means of providing feedback on problems and fixes

38

Elements of a Safety Program




Thank you for your participation!

39

Questions

Human Factors For Maintainers - signalcharlie - home Human Factors.pd… · · 2013-07-31Human...

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