1 SWISS Safety, 30 March 2006 SVFB Welcome! Operational Safety – Technical Safety.

1SWISS Safety, 30 March 2006 SVFB

Welcome!

Operational Safety – Technical Safety


3.4

8.1

0.4

1.82.2

0.2

World 1.2

Hull Losses per Million Departures. Western Built J ets 1990 - 1999

2.00.6

4.00.4

ACCIDENT RATES VARYACCIDENT RATES VARY



Human Factor

– Intentional non - compliance– Proficiency– Operational Decision– Communication– Procedural– Incapacitation


LOSA results: Errors committed and consequences (per 100 flights)

0 10 20 30 40 50 60

Violation(intentional)

Procedural(un-intentional)

Communication

Proficiency / Skill

OperationalDecision-making

number of errors which became consequential

number of flights with errors

Source: UT; Dr. R. Helmreich

Note:

Crews which committed violations

where twice as likely

to encounter an additional error!



Without the whole hearted commitment of management, any safety program will be ineffective

Safety is good for business

Question: Who is producing Safety?

Safety Culture

Senior Management Commitment


ReactiveFocus

Normal Operations

Exceedences

ProactiveFocus

Incidents

Accidents

Accident Precursors

Incident Precursors




Data provided by Quick Access Recorder

B - 747 - 500 Parameters

MD - 11 - 1’500 Parameters

A320 - 2’500 Parameters

A330 - 4’000 Parameters out of 10’000



“Stop shaking, man! Just tell me what happened?”

12

Flight Data Monitoring

12SWISS Safety, 19 May 2005 WANO



0% 5% 10% 15% 20% 25%

Percentage of Occurences

Time Pressure

Equipment Deficiencies

Inadequate Training

Fatigue

Co-ordination difficulties

Procedures

Supervision

Environment

Previous error

Co

ntr

ibu

tin

g F

ac

tors


Contributing factors to maintenance errors


We must not aim to eliminate human error

Error is a useful mechanism to allow humans to learn

However, we must manage error where it can have a significant impact on:

– Aircraft Safety– Health and Safety– Economics


Managing maintenance errors


In Europe, EASA have identified maintenance human factor issues

Currently have plans to develop regulations governing all areas of the industry between 2005 and 2007:– Design organisations, (Part21-P-NPA)– Airframe manufacturers, (Part25- P- NPA 25-310)– Powerplant manufacturers (Part E- NPA-E-38)– Maintenance organisations: (Part 145 Amendment 5)


Regulators approach


– Error reporting system– Efficient shift and task handover

procedures– Organisation of shifts– Effective planning of maintenance tasks– HF training– etc

EASA PART Part 145 Amendtment 5 requires


Regulators approach


Maintenance organizations are faced with the practical questions of Human Factors, including:– Minimizing the number of errors and their consequences

Error detection (e.g. reporting) Event analysis and improvement actions Training

– Dealing with violations Understanding violations and removing the need to violate Violation management




The Challenge– The conflict of maintenance professionalism– Maintenance personnel in some organisations are unable to

openly report for fear of disciplinary action

The Solution– These issues cannot be solved by one measure alone, but in the

development of a “Just and Learning Safety Culture”

Blame Just and Learning No Blame

Styles of Safety Culture





Airbus maintenance error study



Top Six Error Types:– 13% Installation incomplete, component installed but not

secured– 10% Installation incorrect, incorrect torque applied – 9% Installation incomplete, component/ fluid/ material

missing – 8% Installation incomplete, access panel not closed/ secured– 6% Installation incorrect, system/ equipment incorrectly set

or reset– 5% Installation incorrect, incorrect component/ part/ fluid/

gas/ material installed

Airbus maintenance error study


A B C D E F G H

Goal

F HA B C D E G

Removal: 1 way

C

FB

E

D

G

H

A

Installation: 40,000 combinations - not including omissions

[Adapted from Hall, Human Factors Training Module 1


“Reducing Errors to Make Flights Safer”The Wall Street Journal Europe


Conclusion

• Reducing seemingly minor errors is only going to become more critical

• As skies and airport get more crowded, mistakes can have more serious consequences

• What is safe today is not going to be safe enough tomorrow



Thank you!

Questions? and Answers!

1 SWISS Safety, 30 March 2006 SVFB Welcome! Operational Safety – Technical Safety.

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