Aloha Airline’s Flight of B737

In the inspection 
p
prior to the incident 
no cracks were 
found.  A post 
incident inspection 
revealed that there 
were at least 240 
l 18 feet of 
cracks present at the  fuselage skin 
use age s
last inspection prior  ripped off.
to t e c de t.
to the incident. 
Types of Errors
John drives into water & the car begins
g to hydroplane.
y p
Slip - having a good plan, but bad execution: John's plan is
to pump his brakes,
brakes but he misses the brake pedal & steps
on the accelerator instead.
Mistake - a bad plan is selected: John thinks that speeding
up will give him control over his car so he accelerates.
Violation - the wrong procedure is performed
intentionally: John learned from his driving teacher that he
should pump his brakes in this situation, but his brother
said that acceleration is best,, so John steps
p on the
accelerator.
Active & Latent Errors
A i
Active error ‐ i
immediate
di t effect 
ff
Height of aircraft not read correctly – crash –
immediate effect
Latent error delayed effect
Latent error ‐
Delay between the mistake & consequence. e.g. 
smoking. Bolt was corroded –
k l d d not seen so not 
replaced  will ultimately break.
Error Ice‐burg
Heinrich Ratio:
H i i hR i
à Fatal Accidents 1
à Non Fatal
N F l 10
à Reportable accidents 30
à Unsafe Acts‐
U f A t Not reported
N t t d 600

Take care of your hours & days, 
Take care of your hours & days
months & years will take care themselves
Top seven causes of in‐flight shutdowns
ƒ Incomplete installation (33%)
ƒ Damage on installation (14.5%)
ƒ Improper installation (11%)
ƒ Equipment not installed or missing (11%)
ƒ F i object
Foreign bj t ddamage (6 5%)
(6.5%)
ƒ Improper troubleshooting, inspection, test (6%)
ƒ E i
Equipment not activated
i d or d
deactivated
i d (4%)
Top eight common maintenance errors
ƒ Incorrect installation of components 
p
ƒ Fitting of wrong parts
ƒ Wrong electrical wiring of parts (including
Wrong electrical wiring of parts (including 
cross connections) 
ƒ Loose objects left in the aircraft 
Loose objects left in the aircraft
ƒ Not enough lubrication 
ƒ Cowling &/or access panels not secured 
ƒ Fuel/oil caps &/or refuel panel not secured
Fuel/oil caps &/or refuel panel not secured 
ƒ Landing gear ground lock pins not removed 
before departure
before departure 
The need to consider the human factor
Most important human factor:
Most important human factor:
ƒ Ability to learn from experience & mistakes 
committed by others
committed by others.
ƒ Basic Rules:
If it has gone wrong once, it will probably go 
wrong again.
ƒ Safety Net:
At Design stage –
At Design stage – By manufacturer. ( e.g. Cross wires)
By manufacturer ( e g Cross wires)
At user level – By following written procedures.
ƒ Manufacturers –
à design changes‐make it impossibility to use in 
wrong way. e.g. computer connectors. 
wrong way e g computer connectors
à Procedures misunderstood 
ƒ Users –
U i
improve procedures e.g. dual 
d d l
inspection.
The human brain …
… tricks us......
whenever it can!
The phenomenal power of the human mind
What do you see? 
Research has shown that young
children cannot identify the
intimate couple because they do
not have prior memory associated
with such a scenario.

Child
Children see nine
i dolphins.
d l hi

This is a test to determine if you

already have a corrupted mind. If
it is hard for you to find the
dolphins within six seconds, your
mind is indeed corrupted.
What do you see, now!!!
 t t th 4 littl d t th
stare at the 4 little dots on the 
middle of the picture for 30 
seconds 
then look at a wall near you 

a bright spot will appear 

twinkle a few times & you‘ll 
see a figure 
Who is right? 
ƒ Both are right from their 
ot a e g t o t e
own positions.

ƒ When you decide 
anything or assign any 
task to someone, place 
k l
yourself on his position 
&
& see the things as he 
th thi h
perceives.
Ways of Information Transfer
y Person to Person:
ÙVia verbal communication
ÙVia written communication
y Display / Product to person:
ÙJob
Job cards
cards
ÙManuals
ÙDisplays
ÙIndicators
y Person to Product:
e so to oduct
ÙKey board of computer
ÙControls in aircraft
Information :‐ Hard to See or Hear
ƒ Noisy environment 
Noisy environment
à Makes it hard to hear what people say.

ƒ Poor lighting 
à Can
Can'tt see cracks, loose tools or parts.
see cracks loose tools or parts

ƒ Poor communication 
à Not speaking clearly 
à Bad handwriting 
g
Information Present but Missed
ƒ Awareness Problem
A P bl
à Completely focused on one task & miss 
other things around.
à Distractions: e.g. During walk‐around, a hole 
g g ,
on ground is a distracter.
‚ Conversations
‚ Interruptions
 Attention  & Awareness
ƒ Selective Attention:
Selective Attention:
à Monitoring several sources of information to decide 
whether particular event has occurred e.g. deviant 
whether particular event has occurred e g deviant
reading on several indicators in cockpit. 
ƒ Focused Attention:
à Being task focused. Concentrating to one source.
à e.g. Mechanic reading in noisy environment. 
g g y
ƒ Divided Attention
ƒ Sustained Attention
Sustained Attention
à Security Guards viewing a TV monitor.
Brain
y Left half of brain thinks 
Left half of brain thinks
rationally. Used while 
dealing with problems
dealing with problems.

y Right half of brain thinks 
g
emotionally. Related to 
y
creativity & clever ideas.

y Which one is correct to 
use?
{Both should be used.
Information Awareness
ƒ Five senses ‐ the sources of information.

ƒ Smell can warn us of dangers.
can warn us of dangers

ƒ Sense of temperature through touch.
p g

ƒ Taste – very rarely used.

ƒ The two most used senses: Sight & hearing.
Use of eyes
ƒ Inspections:
p 80% of inspections
p are visual
inspection
ƒ Written documents: Different manuals.
manuals
ƒ Job-cards
ƒ Writing what you have done.
ƒ Written Communication:
à Legible
à Accurate
à Complete
à Order of sentences
Hearing
Deteriorate with age & also suffers 
from non‐reversible permanent 
damage when exposed to high level 
of noise. 
Ear Protections
ƒ When sound volume > 90 dB
Wh d l 90 dB Use: Ears. 
Use: Ears.
AF : 20 Hz – 20 kHz
ƒ Even at 85 dB if remain exposed 
for > 4 hours
for > 4 hours
ƒ Earmuffs / Earplugs.
ƒ Treatment of ears
T t t f t k
take years.
Difference: Hearing & Listening 
ƒ Hearing
à is just the process of taking in sounds.
à not selective.
t l ti
à Passive.
à Sound of fan, air‐conditioner etc.
Sound of fan air conditioner etc
ƒ Listening
à hearing with selective attention
l i i .
à Involves interpreting the sounds.
à Active.
à To each other.
Listening
y Interest in topic.
I t ti t i
y Distraction tolerance
y Appropriate time & place.
y Eye contact
y What is said & what is not said? 
y Prejudices : decision already made.
Sometimes more 
information in 
what is not said.
hat is not said
Claustrophobia & Physical Access
ƒ Claustrophobia: 
Claustrophobia:
à Definition: An irrational fear of being in a 
confined or enclosed space.
confined or enclosed space
à e.g. Maintenance in Fuel Tank.

ƒ Space Availability:
à More space improves performance.
More space improves performance.
ƒ Controllability:
à Minimum restrictions due to clothes & 
Minimum restrictions due to clothes &
shoes.
Ways to Learn & Remembered
ƒ Hear 25%
ƒ See 30‐35%
30 35%
ƒ See & Hear 50%
ƒ S &R
Say & Repeat 75%
ƒ Do 90%
Team Work
ƒ Planning, Co‐ordination & Communication.
Pl i C di ti & C i ti
ƒ Team: a group of inter‐dependent individuals 
working together to complete a specific task. 
ƒ Example: Football
Example: Football Team
ƒ In maintenance, working as a team improves 
productivity & reduces injury & equipment
productivity & reduces injury & equipment 
damage.
Characteristics of an Effective Team
A clear purpose:  accepted by all members. 

R l d
Relaxed:  no  tensions among the members. 
t i th b

Participation: in decisions making &/or activities

Participation:  in decisions making &/or activities. 

g
Listening:  listens to the others. 

Disagreement: agree to  disagree with each other. 
Characteristics of an Effective Team  …….contd.
Openness: full & open communication.
Clear expectations: about the roles each member
& assignments fairly distributed
Sh
Shared
d leadership:
l d hi Delegation
D l ti off P
Power.

Relations with others: With other teams

teams.
Team maintenance: focus on their primary goal
b t also
but l spend d ti
time recognising
i i & maintaining
i t i i ththe
functions of the team.
 Leadership
ƒ The ability to direct & co‐ordinate the activities 
of group members & stimulate / inspire them to 
work together to complete a specific task, lead 
by example.
 Responsibilities of Leaders
ƒ Direct & co
Direct & co‐ordinate
ordinate team activity 
team activity
ƒ Delegate tasks to appropriate team members 
ƒ Make sure team members know what is expected of them 
M k t b k h ti t d f th
ƒ Focus attention on important aspects of the situation 
ƒ Adapt to internal & external changes to the environment 
ƒ Keep team members up to date on work‐related 
information 
ƒ Ask team members for work‐relevant information
ƒ Provide feedback to team on performance 
ƒ Create & maintain a professional atmosphere
Create & maintain a professional atmosphere
Effective Leader
ƒ Make suggestions 
M k ti
ƒ Encourage the team to perform 
ƒ Lead by inspiration 
ƒ Provide feedback 
How well you lead, depends on 
how well you communicate!!
how well you communicate!!
 Types of Leaders
ƒ Authoritative
A th it ti Leader
L d
à Runs the show alone. Sole decision maker.
à Controls all the resources.
resources
à Dictates actions with little input from team
members.

ƒ Participatory Leader
à Encourages participation.
à Distributes resources & delegate power.
à Get maximum input from
f members
b
à Group decisions.
 Authoritative & Participatory?
Authoritative Participatory

Done quickly. Time available.

Taskk structured.
T t t d ClearCl Taskk unstructured.
T t t d Inputs
I t
Answers. required.
Conflicts Work well together
together.

Accepts decision taken by Do not accepts decision

single person. taken by single person.
Which type of leadership is better?

B l
Balance b
between the two types
h
Factors Affecting Performance ‐ Stress
y Definition: 
Definition: Physical or psychological tension caused by 
Physical or psychological tension caused by
dealing with difficult situations.

y Stressors
St
{Personal problems.
{Work related problem.
W k l t d bl
{Social problems.

y Cost of Stress
{Poor work quality –
q y Public safety jeopardised.
yj p
{Heart diseases – Sleeping problem
Components of Situation Awareness
Be aware of your surroundings. 
B f di
Use all the senses.

“ Fire , Fire, Fire”
ƒ Perceiving : e.g. listening of some sound.
ƒ Comprehending: 
Comprehending: What that sound mean?
What that sound mean?
ƒ Projecting: Thinking about possible consequences.
General Model of Human Error
The Transactional Analysis Model (Contd.)
ƒ Parent:
à Orders 
à Claims to know 
Claims to know
everything 
à Caring, encouraging, 
g, g g,
supportive & 
protective.
à Sentences:
S
‚ Let me help you.
‚ Leave it to me, I will 
L it t I ill
do this.
The Transactional Analysis Model (Contd.)
ƒ Adult: ƒ Child:
à Asks for reasons. à Emotional
à Talk on equal level.
Talk on equal level à Free & natural.
Free & natural
à Sentences: à Obey, retreat, be polite.
‚ What is your 
Wh t i à Not sure of itself.
Not sure of itself
opinion? à Sentences:
‚ I do not agree.
I do not agree ‚ I do not like you.
Id t lik
‚ I do not know, I want 
leave.
leave
 Results of poor communication
ƒ Errors 
ƒ Inefficiencies 
ƒ Duplication of effort.
ƒ Conflict
Conflict 
ƒ Reduced quality
ƒ Cost increases 
Results of good communication
ƒ Reach an understanding with one another. 
ƒ Co‐ordinate their efforts.
ƒ Agree who does what. 
ƒ Decide on actions & make decisions effectively. 
ƒ Take correct action to reach their goals. 
 Forms of communication
y Verbal communication
{ the spoken word.
{ face‐to‐face or through an electronic medium 
f f h h l d
such as a telephone, radio, loud speaker etc. 
y Non‐verbal communication 
Non verbal communication
{ as body language.  
{ Wave, smile or frown. 
Wave smile or frown
y Written communication
{ Manuals, Job
Manuals, Job‐cards,
cards,  letters, magazines, books, 
letters, magazines, books,
forms, e‐mail etc. 
 Communication Model
ƒ Communication in its simplest form involves two 
l f l
people: 
à The Sender
Th S d : the speaker or writer who is 
th k it h i
transmitting a message. 
à The Receiver
The Receiver : the person who sees, hears or reads 
: the person who sees hears or reads
the message. 
ƒ Feedback
ƒ Messages filtered through feelings, opinions & 
intentions The message includes body language
intentions. The message includes body language.
Three Cs of Communication
B correct
ƒ Be 
à Standard part names.
Standard part names

Be complete.
ƒ Be 
à Enough information.

ƒ Be clear
à Say what you mean to say.
 The impact of information technology
¾ e‐mail, voice mail, fax machines, mobile phones & pagers. 
e‐mail voice mail fax machines mobile phones & pagers
¾ Information technology (IT) improves communication in 
organisations in the following ways:
organisations in the following ways: 
¾ It cuts across time boundaries. 
¾ It cuts across geographical boundaries.
It t geographical bo ndaries
¾ It allows multiple, simultaneous reception.
¾ Bottlenecks can be avoided as electronic information channels are 
typically direct between sender & receiver. 
¾ It helps reduce paperwork.
Shift Work
Conclusions
ƒ Errors affect both lives & profit. 

ƒ Many errors are made, but it usually 
requires a chain of events for a serious 
incident to occur. 

ƒ Although only a few errors will be the 
cause of an accident, it is impossible to 
predict which one this will be. 
 It is difficult  to fix 
a faulty person than 
to fix a faulty component.

Do you agree?
Do you