human factors for new indoc cl ass

Human FactorsHuman Factors in in Aviation Maintenance.Aviation Maintenance.

An Introduction to Human Factors and An Introduction to Human Factors and Maintenance Error Management.Maintenance Error Management.

Presented by: Roger Hughes –Human Factors/MEDAPresented by: Roger Hughes –Human Factors/MEDA

What is Human Error ?What is Human Error ?An error is a human action (or human behavior) that An error is a human action (or human behavior) that unintentionallyunintentionally deviates from the expected action (or deviates from the expected action (or behavior).behavior).

Some situations encourages humans to commit errors. Some situations encourages humans to commit errors. Can you name a situation? Can you name a situation?

Human error happens when people:Human error happens when people:

Plan to do the right thing but with the wrong outcome.Plan to do the right thing but with the wrong outcome. Do the wrong thing for the situationDo the wrong thing for the situation Fail to do anything when action is required.Fail to do anything when action is required.

CHAIN OF EVENTSCHAIN OF EVENTS

Multiple contributing factors (causes) that can Multiple contributing factors (causes) that can link up and lead to an accident.link up and lead to an accident.

ContributingContributing factors is anything that affects how factors is anything that affects how a human does his/her job. a human does his/her job.

CHAIN OF EVENTSCHAIN OF EVENTS

BREAK THE CHAIN OF BREAK THE CHAIN OF EVENTS or PREVENT THEM EVENTS or PREVENT THEM

FROM FORMINGFROM FORMING

SAFETY NET

SAFETY NETSSAFETY NETS Where’s my net?Where’s my net?

Human Error Photo Gallery Human Error Photo Gallery

Larger Commercial Jet Aircraft Fatal Accidents Larger Commercial Jet Aircraft Fatal Accidents From August through December 2005From August through December 2005

August 02, 2005August 02, 2005 – Air France - A340 – Toronto – – Air France - A340 – Toronto – 0 fatalities0 fatalitiesAugust 06, 2005August 06, 2005 - Tuninter - ATR72 – Sicily – - Tuninter - ATR72 – Sicily – 16 fatalities16 fatalitiesAugust 14, 2005August 14, 2005 - Helios Airways B737 –Athens – - Helios Airways B737 –Athens – 122 fatalities122 fatalitiesAugust 16, 2005August 16, 2005 - W. Caribbean – MD80 – Caracas - - W. Caribbean – MD80 – Caracas -160 fatalities160 fatalitiesAugust 23, 2005August 23, 2005 – Trans Peru – B737 – Peru – – Trans Peru – B737 – Peru – 43 fatalities43 fatalitiesSept. 05, 2005Sept. 05, 2005 – Mandala Airlines – B737- Medan – – Mandala Airlines – B737- Medan – 101 fatalities101 fatalitiesOctober 25, 2005October 25, 2005 – Bellview Airlines – B737 – Lagos – – Bellview Airlines – B737 – Lagos – 117 fatalities117 fatalitiesDecember 08, 2005December 08, 2005 – Southwest Airlines – B737 - Chicago –– Southwest Airlines – B737 - Chicago – 1 fatality1 fatalityDecember 10, 2005December 10, 2005 – Sosoliso Airlines – DC-9 – Nigeria –– Sosoliso Airlines – DC-9 – Nigeria – 103 fatalities103 fatalitiesDec. 19, 2005 Dec. 19, 2005 – Chalk’s Airways – Grumman G-73 – Miami - – Chalk’s Airways – Grumman G-73 – Miami - 20 fatalities20 fatalities

Total # of fatalities = 683Total # of fatalities = 683

Attention Falls on Human Error in Fatal Helios Airways CrashAttention Falls on Human Error in Fatal Helios Airways Crash

Probable Cause: Human Error = Wrong Fuel GaugeProbable Cause: Human Error = Wrong Fuel Gauge

Structural Failure May Have Led to Chalk’s Air Structural Failure May Have Led to Chalk’s Air CrashCrash

United Airlines Flt 173Portland , Oregon

December 28, 1978

History of Human Factors TrainingHistory of Human Factors Training

The information below represents events that led to the The information below represents events that led to the development of Human Factors in the airline industrydevelopment of Human Factors in the airline industry..

Aloha Airlines Flt 243Maui, HawaiiApril 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

MRMMaintenance Resource Management

DC-8 Main Landing GearDC-8 Main Landing Gear

United Flight 173United Flight 173

United Flight 173United Flight 173

Probable Cause: Failure of the Captain to monitor and

respond to the low fuel state. Focus was on landing gear

abnormal indication and preparing the cabin for an

emergency landing.

Aloha Flight 243Aloha Flight 243

Probable Cause: Failure of Aloha

Maintenance Program to detect

the presence of significant disbonding

and fatigue cracks of lap joints @ S-10L.

Maintenance Resource Management Programs

Human Factors Working Group DelegatesHuman Factors Working Group DelegatesJFK: Jazmin Galarza, JFK: Herbert Hassell, JFK: Vincent Migliori, JFK: Jazmin Galarza, JFK: Herbert Hassell, JFK: Vincent Migliori,

TPA: Stephen WashenkoTPA: Stephen Washenko

Human Factors Working Group DelegatesHuman Factors Working Group Delegates

FLL: Steve Wahab, IAD: Scott Shipman, BOS: John Cross, LGB: John BynerFLL: Steve Wahab, IAD: Scott Shipman, BOS: John Cross, LGB: John Byner

Human Factors Working Group DelegatesHuman Factors Working Group DelegatesOAK: Shirish Karnik (Chewy), BUF: Jon Ross, LGA: Joshua Pais,OAK: Shirish Karnik (Chewy), BUF: Jon Ross, LGA: Joshua Pais,

PBI: Adrian WintschPBI: Adrian Wintsch

Contributing Factors to Maintenance Error.Contributing Factors to Maintenance Error.What we usually call ‘human error’ is really ‘system error’. People are only What we usually call ‘human error’ is really ‘system error’. People are only one part of a system that includes all of the other parts of the organization.one part of a system that includes all of the other parts of the organization.

Immediate EnvironmentImmediate Environment OrganizationOrganization Facilities PhilosophyFacilities PhilosophyTechnicianTechnician Weather Weather SupervisionSupervision Policy Policy Knowledge A/C design/config. Planning ProceduresKnowledge A/C design/config. Planning ProceduresSkills Equipment/tool/parts Organization TrainingSkills Equipment/tool/parts Organization TrainingAbility Maintenance manuals Prioritizing Corp. Culture Ability Maintenance manuals Prioritizing Corp. Culture Personal Issues Tasks Instructing MEMSPersonal Issues Tasks Instructing MEMS Time pressure FeedbackTime pressure Feedback Teamwork PerformanceTeamwork Performance OJT Training ManagementOJT Training Management Communication Team Building Communication Team Building

70 Percent of Maintenance Errors are attributed to these contributing factors70 Percent of Maintenance Errors are attributed to these contributing factors 30 Percent of Maintenance Errors are attributed to these contributing factors30 Percent of Maintenance Errors are attributed to these contributing factors

Aircraft Maintenance Aircraft Maintenance Human FactorsHuman Factors

StatisticsStatistics70 to 80 Percent of aviation accidents are caused by 70 to 80 Percent of aviation accidents are caused by

human errors and human errors and violationsviolations.. (Flight/ATC/A/C (Flight/ATC/A/C Maintenance)Maintenance)

A maintenance event started the accident chain in A maintenance event started the accident chain in 26% of the worldwide accidents in 2003 for 26% of the worldwide accidents in 2003 for Western/Eastern-built jets and turboprops. Western/Eastern-built jets and turboprops.

It is estimated that every 9 days there will be a It is estimated that every 9 days there will be a commercial hull loss by 2020commercial hull loss by 2020

12 to 15 percent are directly attributable to Aircraft 12 to 15 percent are directly attributable to Aircraft MaintenanceMaintenance


Cost To The Bottom LineCost To The Bottom Line

>A/C Maintenance responsible for :

20-30 % of all in-flight engine shutdowns at $500,000 per event.

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 per year.

John’s Definition of HF John’s Definition of HF

Per John Goglia (former NTSB member) “Human Factors is mainly about Per John Goglia (former NTSB member) “Human Factors is mainly about teaching people how to communicate. In the maintenance environment teaching people how to communicate. In the maintenance environment communication doesn’t mean you and I conversing while we’re turning communication doesn’t mean you and I conversing while we’re turning wrenches. It means learning how to accurately pass job information to the wrenches. It means learning how to accurately pass job information to the guy/gal on the next shift”.guy/gal on the next shift”.

Aviation Week and Space TechnologyAviation Week and Space Technology

Academic Disciplines in Human Academic Disciplines in Human FactorsFactors

Organizational Psychology

Courtesy of Galaxy Scientific Corporation

ERROR CAUSESERROR CAUSES

Dirty Dozen: Dirty Dozen: ( ( Developed by Gordon Dupont Developed by Gordon Dupont ))

1. Lack of Communication 7. Lack of Resources1. Lack of Communication 7. Lack of Resources2. Complacency 8. Pressure2. Complacency 8. Pressure3. Lack of Knowledge 9. Lack of Assertiveness3. Lack of Knowledge 9. Lack of Assertiveness4. Distraction 4. Distraction 10. Stress10. Stress5. Lack of Teamwork 5. Lack of Teamwork 11. Lack of Awareness11. Lack of Awareness6. Fatigue 6. Fatigue 12. Norms12. Norms

Errors: Errors: Could It Be That The Purpose Of Your Life Is Could It Be That The Purpose Of Your Life Is Only To Serve Only To Serve

As A Warning To Others!As A Warning To Others!

Human ErrorHuman Error

$$$$$$$$$$$$$$$$$$$$$$$$

A bird

In thethe hand

Once In A A Lifetime

Once In A A Lifetime

Seeing what you expect to see and not what is actually there

Our Amzanig BiarnOur Amzanig Biarn

I cdnuolt blveiee that I cluod aulaclty uesdnatnrd what I I cdnuolt blveiee that I cluod aulaclty uesdnatnrd what I was rdanieg. The phaonmneal pweor of the hmuan was rdanieg. The phaonmneal pweor of the hmuan mnid. Aoccdrnig to a rscheearch at Cmabridge mnid. Aoccdrnig to a rscheearch at Cmabridge Uinervtisy , it deosn’t mttaer in what oredr the ltteers in a Uinervtisy , it deosn’t mttaer in what oredr the ltteers in a word are, the olny iprmoatnt tihng is that the frist and lsat word are, the olny iprmoatnt tihng is that the frist and lsat ltteer be in the rghit pclae. This is bcuseae the huamn ltteer be in the rghit pclae. This is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the word as mnid deos not raed ervey lteter by istlef, but the word as a wlohe. Amzanig huh? And I awlyas thghout slpeling a wlohe. Amzanig huh? And I awlyas thghout slpeling was ipmorantt!was ipmorantt!

An Accident TrajectoryAn Accident Trajectory

Some “holes” dueto active failures

Some “holes” dueto latent conditions

HAZARDS

Losses

When All Our Defenses Fail!When All Our Defenses Fail!

NTSB Report of AA Flight 191NTSB Report of AA Flight 191

Pylon design too vulnerable to maintenance induced Pylon design too vulnerable to maintenance induced damage.damage.Failure of engineering dept. to ascertain the damage Failure of engineering dept. to ascertain the damage inducing potential of the procedure.inducing potential of the procedure.Failure of adequately evaluating the performance and Failure of adequately evaluating the performance and condition of the forklift to assure it’s capability for the condition of the forklift to assure it’s capability for the task.task.Absence of communication between a/c maintenance Absence of communication between a/c maintenance and engineering regarding difficulty encountered during and engineering regarding difficulty encountered during the procedure. the procedure. Failure to establish an adequate inspection program to Failure to establish an adequate inspection program to detect maintenance induced damage. detect maintenance induced damage.

ViolationsViolationsViolations differ from errors in that errors are Violations differ from errors in that errors are unintentional, whereas violations are deliberate. unintentional, whereas violations are deliberate. Deviating from rules, procedures, instructions, Deviating from rules, procedures, instructions, and regulations.and regulations.

Violations are shaped mainly by attitudes, Violations are shaped mainly by attitudes, beliefs, group norms, and safety culture.beliefs, group norms, and safety culture.

Most stem from a genuine desire to do a good Most stem from a genuine desire to do a good job, seldom are they acts of vandalism or job, seldom are they acts of vandalism or sabotage. sabotage.


Aircraft Maintenance is a highly Aircraft Maintenance is a highly error prone activity. Any error prone activity. Any

maintenance task performed on maintenance task performed on an aircraft is an opportunity for an aircraft is an opportunity for human error to be introduced. human error to be introduced.

NORMSNORMS


Our Human Factors Culture Our Human Factors Culture (principles) must be adopted in a (principles) must be adopted in a positive and continuous fashion, positive and continuous fashion, such that it becomes an integral such that it becomes an integral part of everyday thinking rather part of everyday thinking rather than being something special.than being something special.

GLAD To Be HERE!GLAD To Be HERE!

THE ENDTHE END

Reference MaterialReference MaterialKey websites using “Google” search engine:Key websites using “Google” search engine:

http://hfskyway.faa.govhttp://hfskyway.faa.gov http://www.caa.co.ukhttp://www.caa.co.uk http://ntsb.govhttp://ntsb.gov http://www.grayowl.comhttp://www.grayowl.com http://icao.inthttp://icao.int http://www.marss.orghttp://www.marss.org http://www.boeing.comhttp://www.boeing.com

HF BooksHF Books Human Factors in Aviation Maintenance – David TaylorHuman Factors in Aviation Maintenance – David Taylor Managing Maintenance Error – J. Reason and Alan HobbsManaging Maintenance Error – J. Reason and Alan Hobbs Human Error – James ReasonHuman Error – James Reason A Human Error Approach to Aviation Accident Analysis – D. Weigmann & S. A Human Error Approach to Aviation Accident Analysis – D. Weigmann & S.

ShappellShappellAdvisory CircularsAdvisory Circulars

AC 120-72 – Human Factors training guidanceAC 120-72 – Human Factors training guidance

human factors for new indoc cl ass

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