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Dr. Bill Johnson Chief Scientific and Technical Advisor Maintenance Human Factors [email protected] 678.777.3873 Federal Aviation Administration Categorizing Human Performance Hazards for Safety Management Systems

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  • Dr. Bill Johnson

    Chief Scientific and Technical Advisor

    Maintenance Human Factors

    [email protected]

    678.777.3873

    Federal AviationAdministration

    Categorizing Human Performance

    Hazards for Safety Management

    Systems

  • 2 of 44

    Presentation Plan

    HF Challenges in Flt. Operations?

    SMS to the Rescue?

    PEAR : A way to consider HF Hazards

    New Thoughts and Actions

    Q&A

  • Top 10 Challenges - ALL

    Category Name % Vote # Score

    Culture/Leadership 24 524

    Tech Documentation 16 356

    Fatigue 11 248

    Voluntary Reporting 6 134

    ROI 5 120

    HF Training 5 108

    Pressure/Stress 4 99

    Oversight & Regulations 4 95

    Professionalism 3 64

    Other 3 61

  • 4 of 44www.humanfactorsinfo.com

    www.humanfactorsinfo.com

  • 5 of 44

    Presentation Plan

    HF Challenges in Flt. Operations?

    SMS to the Rescue?

    PEAR : A way to consider HF Hazards

    New Thoughts and Actions

    Q&A

  • 6 of 44

    Safety Management Systems Should:

    Formalize data collection

    Prompt deeper root cause analysis

    Identify hazards and opportunities for continuing safety

    Keep a focus on human factors. (PEAR) Measure HF!

    Allocate new resources to HF hazards

    Show how HF interventions return the investment(Safety & Money)

    Federal AviationAdministration

  • 7 of 44

    Presentation Plan

    HF Challenges in Flt. Operations?

    SMS to the Rescue?

    PEAR : A way to consider HF Hazards

    New Thoughts and Actions

    Q&A

  • 8 of 44

    Whatever Works for You: The Models

  • 9 of 4499

    People who perform the job

    Environment for work - Organizational and physical

    Actions (tasks) performed as part of the job

    Resources like equipment, tools, procedures, and more

    Pear.wmvPear.wmv

  • 10 of 4410

  • 11 of 441111

    Physiological

    Health

    Nutrition

    Lifestyle

    Alertness/fatigue

    Chemical dependency

    Physical

    Size

    Gender

    Age

    Strength

    The five senses

    Psychological

    Experience

    Knowledge

    Training

    Attitude

    Emotional state

    Psychosocial

    Interpersonal relations

    Ability to communicate

    Empathy

    Leadership

    People Example factors

  • 12 of 4412

    PEAR Can Address a Lot of Issues!

  • 13 of 44

  • 14 of 44

    People Examples

  • Ryanair 737-800 (September, 2005)

    B-737 made three un-stabilized approaches, in thunder storms, to separate Italian airports. Final landing was saved by low-time 1st Officer.

    Captain did not report that infant son had died that week.

  • Fatigued & Cold Medicine = Bad Day

  • 17 of 44

    Environment Examples

  • Aloha Airlines B737-200Kahului, Hawaii, U.S.A. 1988 Upper fuselage separation

  • 19 of 54

    Alaska Airlines MD-83Port Hueneme, CA, US 2000 Horizontal Stabilizer Jackscrew Failure

  • 20 of 44

    Action Examples

  • AeroPeruLima, Peru 1996 Tape left on static ports 757-200

  • 22 of 54

    Hilos B-737Grammatiko, Greece 2005 Flight crew incapacitation/Fuel starvation 737-300

  • A320-200 at Perpignan, France (November 2008) Pilots from XL Airways and Air New Zealand

    XL was returning A/C after 2 year lease

    Acceptance check ride

    Did not adhere to pre-agreed flight schedule

    Did not reserve airspace for necessary testing

    2 of 3 AOA sensors were inop due to improper cleaning

    Crew were not trained for acceptance test missions.

  • BA 319 Heathrow 2013

    24

  • Be the Passenger

    25

  • The Good News

  • Post Mx and Preflight Checks??

    27

  • 28 of 44

    Resource Examples

  • American Airlines DC-10Chicago, Illinois, U.S.A 1979 Engine fell after take-off

  • 30 of 44

    Charlotte, NC: Air Midwest Flight 5481, Jan 2003

    Resource Issues: technical documentation, training, personnel resources, busy schedules, fatigue training

  • 31

  • Are the challenges real?

    32

  • December 07, 2011

    AeroStar 350-B2

    Tour of the Hover Dam

  • Additional Information

    Following 100 Hr. Inspection

    Fore/aft Servo was replaced

    Post maintenance check flight flown

    2 revenue tour flights flown

    Flight time since maintenance was 3.5 hours

  • Cause

    35

    The main rotor fore/aft servo flight control

    input rod was not connected.

    Bolt, washer, locking nut, and cotter pin

    were missing.

  • Fatigue Issues

    Mechanic claimed 5 hours of sleep

    Inspector claimed 7 hours of sleep

  • 38 of 44

    Presentation Plan

    HF Challenges in Flt. Operations?

    SMS to the Rescue?

    PEAR : A way to consider HF Hazards

    New Thoughts and Actions

    Q&A

  • 39 of 44

    Compliance Philosophy ?

    . When deviations from regulatory standards do occur, the FAAs goal is to use the most effective means to return an individual or entity..to full compliance and to prevent recurrence.

    .FAA recognizes that some deviations arise fromfactors such as flawed procedures, simple mistakes,lack of understanding, or diminished skills. The agencybelieves that deviations of this nature can mosteffectively be corrected root cause analysis andtraining, education or other appropriateimprovements to procedures

    FAA Order 8000.373, June, 15

    Federal AviationAdministration

  • 40 of 44

    Compliance Philosophy for Inspectors

    FAA Order 8900.323.

    the Aircraft Flight Standards approach to oversight and compliance is evolving to stress an engaged, solution-oriented, outcomes-based approach. The goal is to identify deviations from standards and correct them as effectively, quickly, and efficiently as possible.This approach will more effectively address inadvertent deviations and conserve FAA enforcement for intentional, reckless, criminal, and uncooperative behavior.

    ...Accordingly, AFS leaders, managers, and supervisors will support inspectors when they use critical thinking to exercise sound professional judgment and take actions in accordance with this notice.

    Federal AviationAdministration

  • Compliance Philosophy: Components

  • Not unanimous but without blame

    Panel includes: Mgmt., Labor, and FAA

    No-Nos are: (Criminal Activity, drugs/alcohol, intentional falsification)

    See FAA AC120-66B

    Aviation Safety Action Program (ASAP)

    Formalized Voluntary Reporting System

  • 43 of 43

    Employee Groups Represented

  • 44 of 44

    Presentation Summary

    HF Challenges in Flt. Operations?

    SMS to the Rescue?

    PEAR : A way to consider HF Hazards

    New Thoughts and Actions

    Q&A Google: Aviation Pros Johnson