Human Factors in Aviation Maintenance.

An Introduction to Human Factors and Maintenance Error Management.

Presented by: Roger Hughes Human Factors/MEDA

What is Human Error ?

An error is a human action (or human behavior) that unintentionally deviates from the expected action (or behavior). Some situations encourages humans to commit errors. Can you name a situation? Human error happens when people:

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

CHAIN OF EVENTS
Multiple contributing factors (causes) that can link up and lead to an accident. Contributing factors is anything that affects how a human does his/her job.

CHAIN OF EVENTS

BREAK THE CHAIN OF EVENTS or PREVENT THEM FROM FORMING

SAFETY NET

SAFETY NETS
Wheres my net?

Human Error

Photo Gallery

Larger Commercial Jet Aircraft Fatal Accidents From August through December 2005

August 02, 2005 Air France - A340 Toronto 0 fatalities August 06, 2005 - Tuninter - ATR72 Sicily 16 fatalities August 14, 2005 - Helios Airways B737 Athens 122 fatalities August 16, 2005 - W. Caribbean MD80 Caracas -160 fatalities August 23, 2005 Trans Peru B737 Peru 43 fatalities Sept. 05, 2005 Mandala Airlines B737- Medan 101 fatalities October 25, 2005 Bellview Airlines B737 Lagos 117 fatalities December 08, 2005 Southwest Airlines B737 - Chicago 1 fatality December 10, 2005 Sosoliso Airlines DC-9 Nigeria 103 fatalities Dec. 19, 2005 Chalks Airways Grumman G-73 Miami - 20 fatalities

Total # of fatalities = 683

Attention Falls on Human Error in Fatal Helios Airways Crash

Probable Cause: Human Error = Wrong Fuel Gauge

Structural Failure May Have Led to Chalks Air Crash

History of Human Factors Training

The information below represents events that led to the development of Human Factors in the airline industry.
United Airlines Flt 173 Portland , Oregon December 28, 1978 Cockpit Resource Management CRM Crew Resource Management LOFT Line Oriented Flight Training CCC Crew Coordination Concept HPIM Human Performance in Maintenance MRM Maintenance Resource Management

Aloha Airlines Flt 243 Maui, Hawaii April 28, 1988

Air Ontario Flt 1363 Dryden, Ontario March 10, 1989

DC-8 Main Landing Gear

United Flight 173

United Flight 173

Aloha Flight 243

Maintenance Resource Management Programs

Human Factors Working Group Delegates JFK: Jazmin Galarza, JFK: Herbert Hassell, JFK: Vincent Migliori, TPA: Stephen Washenko

Human Factors Working Group Delegates

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

Human Factors Working Group Delegates

OAK: Shirish Karnik (Chewy), BUF: Jon Ross, LGA: Joshua Pais, PBI: Adrian Wintsch

Contributing Factors to Maintenance Error.

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.
Immediate Environment Facilities Weather A/C design/config. Equipment/tool/parts Maintenance manuals Tasks Time pressure Teamwork OJT Training Communication Organization Philosophy Policy Procedures Training Corp. Culture MEMS

Technician Knowledge Skills Ability Personal Issues

Supervision Planning Organization Prioritizing Instructing Feedback Performance Management Team Building

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

Aircraft Maintenance Human Factors

Statistics
70 to 80 Percent of aviation accidents are caused by human errors and violations. (Flight/ATC/A/C Maintenance)

A maintenance event started the accident chain in 26% of the worldwide accidents in 2003 for Western/Eastern-built jets and turboprops.
It is estimated that every 9 days there will be a commercial hull loss by 2020 12 to 15 percent are directly attributable to Aircraft Maintenance

Aircraft Maintenance Human Factors

Cost 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.

Johns Definition of HF
Per John Goglia (former NTSB member) Human Factors is mainly about teaching people how to communicate. In the maintenance environment communication doesnt mean you and I conversing while were turning wrenches. It means learning how to accurately pass job information to the guy/gal on the next shift.

Aviation Week and Space Technology

Academic Disciplines in Human Factors

Organizational Psychology

Courtesy of Galaxy Scientific Corporation

ERROR CAUSES
Dirty Dozen: ( Developed by Gordon Dupont )
1. Lack of Communication 2. Complacency 3. Lack of Knowledge 4. Distraction 5. Lack of Teamwork 6. Fatigue 7. Lack of Resources 8. Pressure 9. Lack of Assertiveness 10. Stress 11. Lack of Awareness 12. Norms

Errors: Could It Be That The Purpose Of Your Life Is Only To Serve As A Warning To Others!

Human Error

Human Error

Human Error

Human Error

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

A bird In the the 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 Biarn

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

An Accident Trajectory
Some holes due to active failures
HAZARDS

Some holes due to latent conditions

Losses

When All Our Defenses Fail!

NTSB Report of AA Flight 191

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

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

Violations are shaped mainly by attitudes, beliefs, group norms, and safety culture.
Most stem from a genuine desire to do a good job, seldom are they acts of vandalism or sabotage.

Aircraft Maintenance Human Factors

Aircraft Maintenance is a highly error prone activity. Any maintenance task performed on an aircraft is an opportunity for human error to be introduced.

NORMS

Aircraft Maintenance Human Factors

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

GLAD To Be HERE!

THE END

Reference Material
Key websites using Google search engine: http://hfskyway.faa.gov http://www.caa.co.uk http://ntsb.gov http://www.grayowl.com http://icao.int http://www.marss.org http://www.boeing.com HF Books Human Factors in Aviation Maintenance David Taylor Managing Maintenance Error J. Reason and Alan Hobbs Human Error James Reason A Human Error Approach to Aviation Accident Analysis D. Weigmann & S. Shappell Advisory Circulars AC 120-72 Human Factors training guidance