evolving human factors recurrent training for maintenance 2009... · · 2009-05-141 evolving...
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Evolving Human Factors Recurrent Evolving Human Factors Recurrent TrainingTraining for Maintenancefor Maintenance
““Paper Shredder Paper Shredder Guarantees New MaterialGuarantees New Material““
JJ MilanoJJ Milano
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Aren’t Computers Great!
Here, Dr. Bill explains how in the future, technicians will fix aircraft without leaving their office.
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Quick History of Horizon Air
• Northwest Regional Airline• Established 1981• Two leased Fairchild F-27• 36 employees• Seattle – Yakima, WA
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Horizon Air Today
• 4,000+ employees• Serve more than 45 cities• Regional Airline of the
Year 2007
• Today:
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Aircraft In fleet On order Options
Bombardier Q400 37 11 20Bombardier CRJ-700 18 0 0Total 55 11 20
Today’s “Equipment”
Q-400 CRJ-700
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Human Factors History
• 400+ Mechanics and Supervisors attended two-day seminar
• Classes later included fleet services• Two-day workshop continues inside a
two week “New Hire” orientation course
• Human Performance In Aviation Maintenance Workshop (HPIAM)• Spring 2001
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• Do we have a “climate” of safety?
• Do we have a “culture” of safety?OR
Climate vs. Culture
* Patankar, M (2005). A Comparative Review of Safety Cultures.
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Nothing Lasts Forever
* Patankar, M. & Taylor, J. (2000). Targeted MRM Programs: Setting ROI Goals and Measuring the Results.
• Positive effects of training last no more than a year and likely less (6-9 months)*
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Recurrent Human Factors
• MTX training took 6 months develop• FAA Letters of Investigation (LOI)• ASAP self-disclosure reports• QA audit findings
• Built a one day (eight-hour) course• Launched in January 2006
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Trends Identified4th Qtr QA Audit 2008
3 2
11
27
1 10
5
10
15
20
25
30
EQP MAT PRC HF TRG MGT
Root Causes
Occ
uran
ces
Equipment – Materials – Procedures – Human Factors – Training – Management
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• Rooted in HF philosophy• Address current Horizon Air issues• Evolve and change as company changes
What would recurrent training look like?
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1. Quick review of the Dirty Dozen2. “Sell” Horizon’s Safety Culture3. Actual Horizon Air events –
(ASAP Reports, QA Audit Findings & FAA Letters of Investigation)
4. Feedback collection process for next year’s MRM content
Recurrent Human Factors
Four Main Characteristics
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Recurrent Human Factors
Feedback collection process
MRMCourse
StudentFeedback
(Surveys &Critiques)
Error Data/Analysis
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MORNING SESSIONIntroduction & Rules of the Road
Participant IntroductionsStatement of Objectives
The “Dirty Dozen” RevisitedCase Studies: “When Rags become FOD”
Case Studies: “Going Nuts over Nut-plates”FAA Human Factors Manual
Case Studies: “Runaway Run-Taxi”Human Error at Horizon Air
Roundtable Discussion: Are We at Risk?
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Murphy’s LawManagement Greeting
Case Studies: “Pre-Mod/Post-Mod PSU”Norms: The Silent Enemy
Exercise: “Shortcut or Safety Shortfall?”Safety Reporting Systems
ASAP Program Case Studies: “Certs turning into Pumpkins”
Last Year’s Survey ResultsMRM in the Future
Workshop Review & Critique
AFTERNOON SESSION
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1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue7. Lack of Resources8. Pressure9. Lack of Assertiveness10. Stress11. Lack of Awareness12. Norms
“DIRTY DOZEN” REVIEW
Adapted from Gordon DuPont
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CASE STUDY: Chronology of Events
• During tear down of #2 MLG a three hour interruption was experienced to locate parts
• Frustration was felt to leave a job in such a state while proper parts were located
• MTX Techs were reassigned to other tasks• No one could remember putting “shop rag”
into strut assembly• Parts were eventually located and the task
was completed• While in service, problems with #2 MLG
caused complete tear down, rag found in strut
• N353PH #2 MLG repack was performed by graveyard tech on 10/24/2006
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• What safety nets would prevent this from happening again?
• Was incident preventable?• What were links in the chain of events?”
ROUND TABLE DISCUSSION: (After each case study.)
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• Landing Gear strut repack / restoration Work Cards (EC) revised for all fleet types
• All fleet types to incorporate QC inspection step for FOD inspection and correct assembly in the build up.
• FAA Liaison office to monitor promised actions• QA to conduct audits of promised actions to
ensure they are effectively implemented
CASE STUDY: ERC ACTION ITEMS
• Event Review Committee recommends (per ASAP report) creation of MTC for Main Landing Gear shock strut repack
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James Reason’s Swiss Cheese Model
Threat
Adapted from J. Reason
Task Card
Planning
Stress &Distraction
RII / QCCom
pany
C
omm
unic
atio
n
Em
ploy
ee
QX
O
rgan
izat
ion
Insp
ectio
n
Fixing the Task Card, may prevent this type of error.
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• All Participants Sampled• 48 Questions• Course Objectives
• Human Error• QX Resources• MRM Case Studies• Effecting Change• Safety Reporting• MRM Training
Maintenance Resource Management(MRM) Questionnaire
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Effecting positive change is both an obligation AND a right of the certificated mechanic.
3.50
3.70
3.90
4.10
4.30
4.50
4.70
4.90
All
PDX
Station
s1-
10 Y
ears
11-20
Yea
rs
21+ Y
ears
Mecha
nicSup
ervis
orsOthe
r MTX
Maintenance Resource Management(MRM) Questionnaire
Like
rt S
cale
1-5
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FAA HF Cookbook
Horizon Air’s secret recipe for a delicious RECURRENT HF TRAINING COURSE?
Get out a sheet of paper and
pencil.
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Horizon Air’s secret recipe for a delicious RECURRENT HF COURSE?
3 fresh ASAP reports4 quarters QA Audit Data1 juicy FAA LOIDash of Missed RII’s
Fold in the Dirty Dozen
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Horizon Air’s secret receipt for a delicious RECURRENT HF COURSE?
Bake at AC120-92 for 4 – 8 hours.
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Horizon Air’s secret receipt for a delicious RECURRENT HF COURSE?
Best served up seminar style
10 – 12 mechanics, supervisors, and inspectors (keep it mixed)
Repeat once a year
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