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Dirty Dozen Federal Aviation

Administration

Human Error In Aircraft


Maintenance

Presented to: National Safety Council


By: Richard Travis, FAA Safety Team
Date: May 20, 2018
The Best People Make
the Worst Mistakes

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Delta Flight 1288 MD-88

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The Dirty Dozen

• Communication • Lack of Resources


• Complacency • Pressure
• Lack of Knowledge • Assertiveness
• Distraction • Stress
• Teamwork • Lack of Awareness
• Fatigue • Norms

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“The Dirty Dozen”
1. Lack of Communication 7. Lack of Resources
2. Complacency 8. Pressure
3. Lack of Knowledge 9. Lack of Assertiveness
4. Distraction 10. Stress
5. Lack of Teamwork 11. Lack of Awareness
6. Fatigue 12. Norms

Safety Nets
Use logbooks, worksheets etc. to
communicate and remove doubt.

Discuss work to be done or what has been completed.

Never assume anything.

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Continental Express, 14 Fatalities, 9-11-91
Safety Nets
Use logbooks, worksheets etc. to communicate and remove doubt.
Discuss work to be done or what has been completed.
Never assume anything.
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“The Dirty Dozen”
1. Lack of Communication 7. Lack of Resources
2. Complacency 8. Pressure
3. Lack of Knowledge 9. Lack of Assertiveness
4. Distraction 10. Stress
5. Lack of Teamwork 11. Lack of Awareness
6. Fatigue 12. Norms

Safety Nets
Train yourself to expect to find a fault.

Never sign for anything you didn’t do.

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Therefore the Safety Board concludes
that a low expectation of finding a
crack in a –219 series fan hub might
have caused the inspector to overlook
or minimize the significance of an
indication.

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Jackscrew

88

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Italian Air Force, Keflavik
• No lineman present for start-up
• Crew asked LM to verify battery door
closed (near left landing gear) after
engines were started
• LM walked thru prop, killing him instantly
• First such case in Italian AF in over 50
years

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Loadmaster exits crew door to check battery door.
Engines were running
Italian Air Force, Keflavik
CREW DOOR

BATT. DOOR

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Loadmaster killed as he walks into prop.
Body and remains scattered over 100 feet.

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Accident cleanup by “Fire Department”

Carelessness and overconfidence are more dangerous than


deliberately accepted risk.
- Wilbur Wright, 1901.
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Safety Nets
Face Reality
Physical Fitness
Create Challenges for yourself
Train yourself to expect to find a fault.
Never sign for anything you didn’t do
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B737-500
Continental Flight 1515 January 16,2006
El Paso International Airport

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“The Dirty Dozen”
1. Lack of Communication 7. Lack of Resources
2. Complacency 8. Pressure
3. Lack of Knowledge 9. Lack of Assertiveness
4. Distraction 10. Stress
5. Lack of Teamwork 11. Lack of Awareness
6. Fatigue 12. Norms

Safety Nets
Get training on type.

Use up to date manuals.

Ask a Tech. Rep. or someone who knows.

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Lack Of Knowledge

Safety Nets
Get training on type.
Stay Current
-Read, Read, Read
Use up to date manuals.
Ask a Tech. Rep.
-or someone who knows

Communicate September 2, 1998


Douglas MD-11 in the sea
No Pride! 9KM Off Nova Scotia
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“The Dirty Dozen”
1. Lack of Communication 7. Lack of Resources
2. Complacency 8. Pressure
3. Lack of Knowledge 9. Lack of Assertiveness
4. Distraction 10. Stress
5. Lack of Teamwork 11. Lack of Awareness
6. Fatigue 12. Norms

Safety Nets
Always finish the job or unfasten the connection

Mark the uncompleted work.

Lock wire where possible or use torque seal.

Double inspect by another or self.

When you return to the job always go back three steps.

Use a detailed check sheet.

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Safety Nets
Always finish the job or unfasten the connection.
Mark the uncompleted work.
Lock wire where possible or use torque seal.
Double inspect by another or self.
When you return to the job always go back three steps.
Use a detailed check sheet.

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“The Dirty Dozen”
1. Lack of Communication 7. Lack of Resources
2. Complacency 8. Pressure
3. Lack of Knowledge 9. Lack of Assertiveness
4. Distraction 10. Stress
5. Lack of Teamwork 11. Lack of Awareness
6. Fatigue 12. Norms

Safety Nets
“Reconfirm duties among team members.”

“Team tasks require a full team.”

“Communicate!”

“FOLLOW THE CORRECT PROCEDURES.”

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Lack of Teamwork

Safety Nets
“Communicate!”

“Team tasks require


a full team.”

“Reconfirm duties
among team members.”

“FOLLOW THE CORRECT PROCEDURES.”

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“The Dirty Dozen”
1. Lack of Communication 7. Lack of Resources
2. Complacency 8. Pressure
3. Lack of Knowledge 9. Lack of Assertiveness
4. Distraction 10. Stress
5. Lack of Teamwork 11. Lack of Awareness
6. Fatigue 12. Norms

Safety Nets
Be aware of the symptoms and Sleep and exercise
look for them in yourself and regularly.
others.

Plan to avoid complex tasks at Ask others to


the bottom of your circadian check your work
rhythm.

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Fatigue
ACUTE FATIGUE
➢Produced by physical exertion or sleep loss
➢Alleviated by a single rest period

CHRONIC FATIGUE
➢Medical or psychological problem
➢Depression or “chronic fatigue syndrome”

OPERATIONAL FATIGUE
➢Most commonly seen after 3-4 days of heavy tasking
➢Not relieved by a single sleep period

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SYMPTOMS OF FATIGUE
Attention reduced
Memory diminished
Mood becomes withdrawn
Low situational awareness
Long hours of labor (any type).
High intensity stress.

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CIRCADIAN RHYTHMS

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Fatigue

Safety Nets
Be aware of the symptoms and look for
them in yourself and others.
Plan to avoid complex tasks at the bottom
of your circadian rhythm.
Sleep and exercise regularly.
Ask others to check your work.
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“The Dirty Dozen”
1. Lack of Communication 7. Lack of Resources
2. Complacency 8. Pressure
3. Lack of Knowledge 9. Lack of Assertiveness
4. Distraction 10. Stress
5. Lack of Teamwork 11. Lack of Awareness
6. Fatigue 12. Norms

Safety Nets
Check suspect areas at the beginning of the inspection
and AOG the required parts.
Order and stock anticipated parts before they are
required.
Know all available parts sources and arrange for
pooling or loaning.
Maintain a standard and if in doubt ground the aircraft.

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Lack of Resources
Safety Nets
Check suspect areas at the beginning of the
inspection and AOG the required parts.
Order and stock anticipated parts before they are
required.
Know all available parts sources and arrange for
pooling or loaning.
Maintain a standard and if in doubt ground the
aircraft.
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“The Dirty Dozen”
1. Lack of Communication 7. Lack of Resources
2. Complacency 8. Pressure
3. Lack of Knowledge 9. Lack of Assertiveness
4. Distraction 10. Stress
5. Lack of Teamwork 11. Lack of Awareness
6. Fatigue 12. Norms

Safety Nets
Be sure the pressure is not self- induced.

Communicate your concerns.

Ask for extra help.

Just say NO.

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Jessica Dubroff 1988- 1996

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Chiang Kai-Shek Airport Taiwan
June 6, 2005

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Pressure

Safety Nets

Be sure the pressure is not self- induced.

Communicate your concerns.

Ask for extra help.

Just say NO.

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“The Dirty Dozen”
1. Lack of Communication 7. Lack of Resources
2. Complacency 8. Pressure
3. Lack of Knowledge 9. Lack of Assertiveness
4. Distraction 10. Stress
5. Lack of Teamwork 11. Lack of Awareness
6. Fatigue 12. Norms

Safety Nets
If it’s not critical, record it in the journey log book &
only sign for what is serviceable.

Refuse to compromise your standards.

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Assertiveness
High
Assertive Team Work
Both Party’s Rights
Performance

Synergy

Others Your
Rights Rights

Low Passive Aggressive


Acquiesce Anger
Compromise Offense
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Lack of Assertiveness
Safety Nets
If it’s not critical, record it in the journey log book
& only sign for what is serviceable.
Refuse to compromise your standards.

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“The Dirty Dozen”
1. Lack of Communication 7. Lack of Resources
2. Complacency 8. Pressure
3. Lack of Knowledge 9. Lack of Assertiveness
4. Distraction 10. Stress
5. Lack of Teamwork 11. Lack of Awareness
6. Fatigue 12. Norms

Safety Nets
Be aware of how stress Take time off or at least
can effect your work. have a short break.

Stop and look rationally Discuss it with


at the problem. someone.

Ask fellow workers to


Determine a rational monitor your work.
course of action and
follow it.
Exercise your body.

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STRESS

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Stress
Safety Nets
Be aware of how stress can effect your work.
Stop and look rationally at the problem.
Determine a rational course of action and
follow it.
Take time off or at least have a short break.
Discuss it with someone.
Ask fellow workers to monitor your work.
Exercise your body.
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“The Dirty Dozen”
1. Lack of Communication 7. Lack of Resources
2. Complacency 8. Pressure
3. Lack of Knowledge 9. Lack of Assertiveness
4. Distraction 10. Stress
5. Lack of Teamwork 11. Lack of Awareness
6. Fatigue 12. Norms

Safety Nets
Think of what may occur in the event of
an accident.

Check to see if your work will conflict


with an existing modification
or repair.

Ask others if they can see any


problem with the work done.

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Lack of Awareness

Safety Nets
Think of what may occur in the event of an
accident.
Check to see if your work will conflict with an
existing modification or repair.
Ask others if they can see any problem with the
work done.
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“The Dirty Dozen”
1. Lack of Communication 7. Lack of Resources
2. Complacency 8. Pressure
3. Lack of Knowledge 9. Lack of Assertiveness
4. Distraction 10. Stress
5. Lack of Teamwork 11. Lack of Awareness
6. Fatigue 12. Norms

Safety Nets
Always work as per the instructions or
have the instructions changed.

Be aware that ‘norms don’t make it right.

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This picture was taken by an amateur photographer
seconds before an American Airlines DC-10 crashed at
Chicago O'Hare Airport, after losing an engine during
takeoff. Below is the resulting explosion. Improper
maintenance procedures was to blame. Two-hundred-
seventy-one people aboard were killed as well as 2 on the
ground. (May 25, 1979)

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Norms

Safety Nets
Always work as per the instructions or
have the instructions changed.
Be aware that ‘norms don’t make it right.

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FATIGUE
STRESS
COMPLACENCY
COMMUNICATION
AWARENESS
DISTRACTION
LACK OF KNOWLEDGE
TEAMWORK
LACK OF RESOURCES
PRESSURE
LACK OF ASSERTIVENESS
NORMS
Lee Marvin, Ernest Borgnine, Jim Brown, Charles Bronson, John Cassavetes, Trini Lopez, Telly Savalas, Donald Sutherland, Clint Walker
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Face Reality
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• Air France Concorde Flight 4590. July 25, 2000
• 100 passengers, 9 crew, and 4 people on the ground were
killed when the aircraft hit hotel.

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