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Human Factors In Aircraft MaintenanceJon ByrdDirector of AviationCoosa Valley Technical CollegeRome, 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
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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 $15,000MAvg. ground damage incident costs $70,000MOne airline estimates $75-$100 million/year
is lost MAirline Transport Association estimates that
ground damage costs $850 million/yr
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Accidents w/ Maintenance Error
MAmerican Airlines Flight 191 1979MAloha Airlines Flight 243 1988MUnited Flight 232 1989MAtlantic Southeast Airlines (ASA) Flight
532 1995MAir Alaska Flight 261 2000MPaul Wellstone (B100) crash 2002MSpectrum Aeronautical LLC - 2006
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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)
MWere only human...
MWe *will* make mistakes...
MThe key is to minimize errors, but how?
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The Dirty Dozen
MComplacency
MDistraction
MFatigue
MNorms
MPressure
MStress
MLack of Assertiveness
MLack of Awareness
MLack of Communication
MLack of Knowledge
MLack of Resources
MLack of TeamworkCVTC
Dirty Dozen - Complacency
MI dont need to go get the tech data; Ive done this a hundred times...
MNo need to pull that panel. Last time I checked that linkage had plenty of grease...
MIve been an aircraft mechanic for over 25 years; I know what Im doing...
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Dirty Dozen - Complacency
MSafety Nets
MAlways follow checklist(s) &/or squawk cardsMNever work from memoryMBe sure to vary your routine periodicallyMBe 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 NetsMUse a detailed checklistMAlways finish the taskMDouble-inspect the workMUse torque seal &/or safety wireMRecord or tag uncompleted workMWhen you return to the task, always go
back three (3) steps
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Dirty Dozen Fatigue
MWhat is Fatigue?MThe bodys normal reaction to a physical
or mental stress of a prolonged durationMThere are two typesMAcute short duration; cured with good nights sleepMChronic occurs over a long period of time; long recovery
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Dirty Dozen Fatigue
MCauses of FatigueMLong hours of labor (any type)MHigh-intensity stressMLarge temperature variationsMNoise above 80db for long durationMSufficient intensity vibration for long
periodsMSTRONG lighting
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Dirty Dozen Fatigue
MSymptoms of FatigueMEnhanced stimulus required in order to
respondMAttention reducedMMemory diminishedMWithdrawn moodMCircadian Rhythm inconsistencies
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Dirty Dozen - Norms
MI dont care how you did it there, weve 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 thats not
approved, but its been done locally for so long that its now a NormMALWAYS work IAW the appropriate tech
data, or if needed, have the manual revisedMBe aware that Norms do not make it
right
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Dirty Dozen Pressure
MGet 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 NetsMStop! Assess the situationMLook at the situation rationallyMCan 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 mindMHas this happened before?
MActMSpeak up ask for help or more time
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Dirty Dozen - Stress
MPersonal issues
MWeather concerns
MWanting that atta-boy for the boss
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Dirty Dozen - Stress
MHow to ManageMIf you do not manage stress, it will gladly
manage youMStop burning up emotional energyMLook rationally at the problemMCure the cause, not the symptom
MListen to your rational, not your emotional, mindMAct once you have a plan, go for it
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Dirty Dozen - Stress
MOther Stress HelpersMBe sure the solution starts with IMBe realistic and practicalMTake a breakMTalk to someone who is not emotionally
involved with the situationMDont expect miracles, just keep trying
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Dirty Dozen Lack of Assertiveness
MOnly do whats expected of me and thats 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 NetsMRecord all the work you do in the logbook,
but only sign for that which is serviceableMRefuse 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 NetsMTHINKMWhat could occur in the event of an accident?
MCHECKMWill your work conflict with a previous or
existing repair &/or modification?
MASKMSee 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 TipsMYou have:MTwo earsMTwo eyesMOne mouth
MUse them in that order!
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Dirty Dozen Lack of Communication
MTo Improve CommunicationMLearn to Listen
MDo NOTMDebateMDetourMPre-planMTune-out
MDoMAsk questionsMParaphraseMMake eye contactMUse positive body language
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Dirty Dozen Lack of Knowledge
MAm I experienced for this task?
MDo I have all of the appropriate tech data?
MAware of FARs
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Dirty Dozen Lack of Knowledge
MSafety NetsMObtain school training on type, model, etcMGet supervised on-the-job trainingMUse current technical manualsMTech 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?
MDo I have the proper tools and equipment to perform the task?
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Dirty Dozen Lack of Resources
MSafety NetsMCheck all suspect areas at the beginning
of all inspections and AOG the required partsMOrder & stock parts before theyre
requiredMKnow your sourcesMArrange for pooling &/or loaning
MMaintain aircraft to highest standard
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Dirty Dozen Lack of Teamwork
MIs this a task that really two technicians should do?
MNo, I dont need any help; I know what Im doing!
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Dirty Dozen Lack of Teamwork
MSafety NetsMAlways discuss and plan the Who, What,
When, Where, and How of the task to be doneMInsure that everyone understands and
agrees
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Accident Model
Damage/InjuryMish
ap Event
Unsaf
e Act
Unsa
fe Co
nditi
on
Supe
rvisi
on/O
rgan
izat
ion
1 2 3 4 5Dominos
The Domino Theory
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Reasons Swiss Cheese Model
OrganizationalFactors
UnsafeSupervision
Accident
Unsafe ActPreconditions
Latent Condition
Latent Condition
Latent Condition
Active FailureUnsafe
Acts
HFACS-Human Factors Analysis
& Classification System
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Human Factors Prevention
Recap Were 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
Human Factors In Aircraft MaintenanceWhat is Human Factors?Maintenance Human FactorsDollars & SenseAccidents w/ Maintenance ErrorGeneral & Corporate AviationThe Human Element (Hu)The Dirty DozenDirty Dozen - ComplacencyDirty Dozen - ComplacencyDirty Dozen - DistractionDirty Dozen - DistractionDirty Dozen FatigueDirty Dozen FatigueDirty Dozen FatigueDirty Dozen - NormsDirty Dozen NormsDirty Dozen PressureDirty Dozen PressureDirty Dozen - StressDirty Dozen - StressDirty Dozen - StressDirty Dozen Lack of AssertivenessDirty Dozen Lack of AssertivenessDirty Dozen Lack of AwarenessDirty Dozen Lack of AwarenessDirty Dozen Lack of CommunicationDirty Dozen Lack of CommunicationDirty Dozen Lack of CommunicationDirty Dozen Lack of KnowledgeDirty Dozen Lack of KnowledgeDirty Dozen Lack of ResourcesDirty Dozen Lack of ResourcesDirty Dozen Lack of TeamworkDirty Dozen Lack of TeamworkAccident ModelReasons Swiss Cheese ModelHuman Factors PreventionMy ThanksHuman Factors in Aviation Maintenance