Human Factors for New Indoc Class
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Transcript of Human Factors for New Indoc Class
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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