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Human Factors in Aviation Maintenance.

An Introduction to Human Factors andMaintenance Error Management.

Presented by: Roger Hughes Human Factors/MEDA

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CHA IN OF EVENTS

Multiple contributing factors (causes) that canlink up and lead to an accident.

Contributing factors is anything that affects howa human does his/her job.

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CHA IN OF EVENTS

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B REA K THE CHA IN OFEVENTS o r PREVENT THEM

FROM FORMING

SAFETY NET

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S FETY N ETS Wheres my net?

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Human Error Photo Gallery

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Larger Commercial Jet Aircraft Fatal AccidentsFrom August through December 2005

August 02, 2005 Air France - A340 Toronto 0 fatalities August 06, 2005 - Tuninter - ATR72 Sicily 16 fatalities August 14, 2005 - Helios Airways B737 Athens 122 fatalities August 16, 2005 - W. Caribbean MD80 Caracas - 160 fatalities August 23, 2005 Trans Peru B737 Peru 43 fatalitiesSept. 05, 2005 Mandala Airlines B737- Medan 101 fatalitiesOctober 25, 2005 Bellview Airlines B737 Lagos 117 fatalitiesDecember 08, 2005 Southwest Airlines B737 - Chicago 1 fatalityDecember 10, 2005 Sosoliso Airlines DC-9 Nigeria 103 fatalities

Dec. 19, 2005 Chalks Airways Grumman G-73 Miami - 20 fatalities

Total # of fatalities = 683

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Attention Falls on Human Error in Fatal Helios Airways Crash

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Probable Cause: Human Error = Wrong Fuel Gauge

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Structural Failure May Have Led to Chalks AirCrash

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United Airlines Flt 173

Portland , OregonDecember 28, 1978

Histo ry o f Hum an Facto rs Train ing

The information below represents events that led to thedevelopment of Human Factors in the airline industry .

Aloha Airlines Flt 243Maui, Hawaii

April 28, 1988

Air Ontario Flt 1363Dryden, OntarioMarch 10, 1989

Cockpit Resource Management

CRMCrew Resource Management

LOFTLine Oriented Flight Training

CCCCrew Coordination Concept

HPIMHuman Performance in Maintenance

MRM

Maintenance Resource Management

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DC-8 Main Landing Gear

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United Flight 173

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United Flight 173

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Aloha Flight 243

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Maintenance Resource Management Programs

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Human Factors Working Group Delegates

FLL: Steve Wahab, IAD: Scott Shipman, BOS: John Cross, LGB: John Byner

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Human Factors Working Group Delegates OAK: Shirish Karnik (Chewy), BUF: Jon Ross, LGA: Joshua Pais,

PBI: Adrian Wintsch

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Contributing Factors to Maintenance Error.What we usually call human error is really system error. People are onlyone part of a system that includes all of the other parts of the organization.

Immediate Environment Organization Facilities Philosophy

Technician Weather Supervision PolicyKnowledge A/C design/config. Planning ProceduresSkills Equipment/tool/parts Organization Training

Ability Maintenance manuals Prioritizing Corp. CulturePersonal Issues Tasks Instructing MEMS

Time pressure FeedbackTeamwork PerformanceOJT Training ManagementCommunication Team Building

70 Percent of Maintenance Errors are attributed to these contributing factors30 Percent of Maintenance Errors are attributed to these contributing factors

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Aircraft Maintenance

Human FactorsStatistics70 to 80 Percent of aviation accidents are caused by

human errors and violations . (Flight/ATC/A/CMaintenance)

A maintenance event started the accident chain in26% of the worldwide accidents in 2003 forWestern/Eastern-built jets and turboprops.

It is estimated that every 9 days there will be acommercial hull loss by 2020

12 to 15 percent are directly attributable to AircraftMaintenance

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Aircraft Maintenance

Human FactorsCost To The Bottom Line

>A/C Maintenance responsible for :

20-30 % of all in-flight engine shutdowns at $500,000 perevent.

50 % of all flight delays at $10,000 per hour.

50 % of all flight cancellations at $50,000 per event.

Avg. ground damage incidents cost $70,000 per event.

ATA estimates that ground damage cost $ 5 Billion peryear.

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Johns Definition of HF

Per John Goglia (former NTSB member) HumanFactors is mainly about teaching people how to

communicate. In the maintenance environmentcommunication doesnt mean you and I conversing whilewere turning wrenches. It means learning how toaccurately pass job information to the guy/gal on thenext shift.

Aviation Week and Space Technology

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A d i Di i li i H

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Academic Disciplines in HumanFactors

Organizational Psychology

Courtesy of Galaxy Scientific Corporation

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ERROR CA USES

Dirty Dozen: ( Developed by Gordon Dupont )

1. Lack of Communication 7. Lack of Resources2. Complacency 8. Pressure3. Lack of Knowledge 9. Lack of Assertiveness4. Distraction 10. Stress5. Lack of Teamwork 11. Lack of Awareness6. Fatigue 12. Norms

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Errors: Could It Be That The Purp os e Of You r Life IsOnly To Serve

As A Warning To Others!

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Human Error

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Human Error

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Human Error

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Human Error

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$$$$$$$$$$$$

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Abird

In thethe hand

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Once In A A Lifetime

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Once In A A Lifetime

Seeing what you expect to see and not what isactually there

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Our Amzanig BiarnI cdnuolt blveiee that I cluod aulaclty uesdnatnrd what Iwas rdanieg. The phaonmneal pweor of the hmuanmnid. Aoccdrnig to a rscheearch at CmabridgeUinervtisy , it deosnt mttaer in what oredr the ltteers in a

word are, the olny iprmoatnt tihng is that the frist and lsatltteer be in the rghit pclae. This is bcuseae the huamnmnid deos not raed ervey lteter by istlef, but the word asa wlohe. Amzanig huh? And I awlyas thghout slpeling

was ipmorantt!

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An Accident Trajectory

Some holes due to active failures

Some holes due to latent conditions

HAZARDS

Losses

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When All Our Defenses Fail!

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NTSB Report of AA Flight 191

Pylon design too vulnerable to maintenance induceddamage.Failure of engineering dept. to ascertain the damageinducing potential of the procedure.

Failure of adequately evaluating the performance andcondition of the forklift to assure its capability for thetask.

Absence of communication between a/c maintenanceand engineering regarding difficulty encountered duringthe procedure.Failure to establish an adequate inspection program todetect maintenance induced damage.

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Violations

Violations differ from errors in that errors areunintentional, whereas violations are deliberate.Deviating from rules, procedures, instructions,and regulations.

Violations are shaped mainly by attitudes,beliefs, group norms, and safety culture.

Most stem from a genuine desire to do a good job, seldom are they acts of vandalism orsabotage.

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Aircraft MaintenanceHuman Factors

Aircraft Maintenance is a highlyerror prone activity. Any

maintenance task performed on

an aircraft is an opportunity forhuman error to be introduced.

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NORMS

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Aircraft MaintenanceHuman Factors

Our Human Factors Culture(principles) must be adopted in apositive and continuous fashion,such that it becomes an integral

part of everyday thinking ratherthan being something special.

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GLAD To Be HERE!

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THE END

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Reference MaterialKey websites using Google search engine:

http://hfskyway.faa.govhttp://www.caa.co.ukhttp://ntsb.govhttp://www.grayowl.comhttp://icao.inthttp://www.marss.orghttp://www.boeing.com

HF BooksHuman Factors in Aviation Maintenance David TaylorManaging Maintenance Error J. Reason and Alan HobbsHuman Error James ReasonA Human Error Approach to Aviation Accident Analysis D. Weigmann & S.Shappell

Advisory Circulars

AC 120-72 Human Factors training guidance