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