8/3/2019 AMHF CAP716

1/34

Click to edit Master subtitle style

4/29/12

AVIATION MAINTENANCEHUMAN FACTORS

(JAA JAR145)

CAP 716

8/3/2019 AMHF CAP716

2/34

4/29/12

Good Safety Culture

Successfully institutionalize safety

All personnel committed to safety

Implement SMS (CAP 712)

8/3/2019 AMHF CAP716

3/34

4/29/12

Good Safety Culture KeyElements

Support from the top

A formal safety policy statement

Awareness of the safety policystatements and buy-in from all levelswithin the organisation

Practical support to enable theworkforce to do their jobs safely, e.g.in terms of training, planning,

resources, workable procedures, etc.

8/3/2019 AMHF CAP716

4/34

4/29/12

MOE SMS

Safety Policy

Manpower resources

Control of man-hour planning versusscheduled maintenance work

Procedures to detect and rectify

maintenance errors Shift/task handover procedures

Procedures for notification ofmaintenance data inaccuracies and

8/3/2019 AMHF CAP716

5/34

4/29/12

n n egra e pproac o umanFactors and

Safety

8/3/2019 AMHF CAP716

6/34

4/29/12

Factors Associated withthe individual

a) Physical fitness.

b) Physiological characteristics such as

visual acuity, colour vision, hearing,etc.

c) Personality.

d) Attitude, professional integrity,motivation.

e) Arousal level, low arousal

(boredom), excessively high arousal

8/3/2019 AMHF CAP716

7/34

4/29/12

Fitness for Work

Certifying staff working on a JAR66license must not exercise theprivileges of their certification

authorisation if they know or suspectthat their physical or mentalcondition renders them unfit to

exercise such privileges. Thisincludes blood-alcohol level, drugs &medication, eyesight, colour visionand psychological integrity.

8/3/2019 AMHF CAP716

8/34

4/29/12

Shift work and Fatigue

Shift personnel fatigue may beminimised by:

Avoiding excessive working hours Allowing as much regular night sleep

as possible;

Minimising sleep loss; Giving the opportunity for extended

rest when night sleep has been

disrupted;

8/3/2019 AMHF CAP716

9/34

4/29/12

Shift personnel fatigue may beminimised by:

Minimising night shifts throughcreative scheduling

Providing longer rest periodsfollowing night shifts

Within a week providing longer

continuous rest periods when theweek includes more than 2 nightshifts

The impact of fatigue may beminimised b :

8/3/2019 AMHF CAP716

10/34

4/29/12

Competence, Knowledge,Experience and Competency

There is no formal restriction on thenumber of aircraft types which anengineer may have on his license,

although large organisations tend torestrict authorisations to two or threecomplex aircraft types (indeed, some

NAAs have this as a legal restriction).

JAR145 recognises that technicians

must remain reasonably current on

8/3/2019 AMHF CAP716

11/34

4/29/12

Errors, Violations and Non-compliance with

Procedures

8/3/2019 AMHF CAP716

12/34

4/29/12

Human Error

human error (including violations) isthose occasions in which a plannedsequence of mental or physical

activities fails to achieve its intendedoutcome, and when these failurescannot be attributed to the

intervention of some chance agency

8/3/2019 AMHF CAP716

13/34

4/29/12

"human error and "systemerror"

There are two approaches to looking aterror:

(i) from the point of view of theindividual and

(ii) from the point of view of the wholesystem, of which the individual

technician is only one part. The" "

8/3/2019 AMHF CAP716

14/34

4/29/12

Important to understand the rootcauses behind errors and violations,and whether an error is a one off or a

more systemic problem which may re-occur, and whether it is a problem withan individual technician or with the

system.

8/3/2019 AMHF CAP716

15/34

4/29/12

Non-compliance withProcedures

Why people dont follow procedures.Source: Human Reliability AssociatesLtd.

8/3/2019 AMHF CAP716

16/34

4/29/12

Why people dont followprocedures. Source: Human

Reliability Associates Ltd

8/3/2019 AMHF CAP716

17/34

4/29/12

Procedures, Documentation andMaintenance

Data

Procedures fall into two categories:

Maintenance Data- produced by themanufacturer and

Procedures and work instructions-produced by, and within the controlof, the maintenance organisation oraircraft operator.

8/3/2019 AMHF CAP716

18/34

4/29/12

Maintenance Data

Access and Availability

JAR145 requires that maintenancedata is readily available for use,available in close proximity to theaircraft being maintained, and thatthere should be an adequate number

of computer terminals, microfilm/microfiche readers, and printers.

8/3/2019 AMHF CAP716

19/34

4/29/12

Inaccuracies,ambiguities and gaps

OEM Manuals scope for improvement

MRO must have in place a procedurewhereby such inaccuracies,ambiguities or missing informationare recorded and reported to thetype certificate holder.

Type certificate holders should actupon reported defects, and updatethe manuals quickly.

There is currentl no re uirement for

8/3/2019 AMHF CAP716

20/34

4/29/12

Procedures and WorkInstructions

Work instruction is what you shoulddo. Job cards are usually workinstructions;

Procedure is how you should do it.Procedures generally originate fromthe Maintenance Manual.

8/3/2019 AMHF CAP716

21/34

4/29/12

Guidelines for designingprocedures.

8/3/2019 AMHF CAP716

22/34

4/29/12

Reporting discrepancies

There should be an internaloccurrence/discrepancy reportingsystem whereby staff can report

inaccuracies or ambiguities inprocedures, or, indeed, suggest betterways of doing particular tasks, such

that procedures can be frequentlyupdated and improved.

8/3/2019 AMHF CAP716

23/34

4/29/12

Error capturing

Error capturing mechanisms:

functional checks, leak checks,inspection of tasks before signing forwork done by others, independentDuplicate Inspections (DIs), pilot pre-flight checks, etc.

8/3/2019 AMHF CAP716

24/34

4/29/12

Functional Checks

Functional checks are error capturingmechanisms in some instances sincethey will detect, if properly action, if

something is not installed, securedproperly, adjusted correctly or meetsspecified criteria in the manuals. This

is true for most systems and is aninherent part of the maintenanceprocess. It is, in the majority ofcases, impossible to carry out aduplicate inspection on a flying

8/3/2019 AMHF CAP716

25/34

4/29/12

Duplicate Inspections

Duplicate Inspections areinspections where the task or processis performed by one person, a first

check carried out by that person (ifqualified to self-certify) or by asupervising certifying engineer, and

then independent checks carried outby a second suitably qualified person.Both the first and second checksshould be thorough and, in the case ofcontrol systems, ensure that they

8/3/2019 AMHF CAP716

26/34

4/29/12

Tasks which may warrantDuplicate Inspections:

Installation, rigging and adjustmentsof flight controls

Installation of aircraft engines,propellers and rotors

Overhaul, calibration or rigging ofcomponents such as engines,propellers, transmissions andgearboxes

8/3/2019 AMHF CAP716

27/34

4/29/12

Duplicate Inspection bestpractice

8/3/2019 AMHF CAP716

28/34

4/29/12

Pilot Pre-flight Checks

Whilst not specifically intended as amechanism for capturing maintenanceerrors, nevertheless pilot pre-flight

checks should act as another barrier toprevent such an error from resulting inan accident.

8/3/2019 AMHF CAP716

29/34

4/29/12

Design for ErrorResistance

designing out cross-connectability,e.g. by having parts which cannotphysically fit incorrectly, colour

coded parts, part numbers welllabelled, staggered position of similarparts, leads that are too short to fit to

the wrong connector, etc.

cockpit warning lights for unlatched

cowlings

8/3/2019 AMHF CAP716

30/34

4/29/12

Planning andPreparation

The production planning functionincludes two complimentary elements:

scheduling the maintenance workahead, to ensure that it will notadversely interfere with othermaintenance work as regards the

availability of all necessarypersonnel, tools, equipment,material, maintenance data and

facilities;

8/3/2019 AMHF CAP716

31/34

4/29/12

When establishing the production planningprocedure, consideration should be given tothe following:

logistics,

inventory control,

square meters of accommodation, hangar availability

man-hours estimation,

man-hours availability,

preparation of work,

co-ordination with internal and

8/3/2019 AMHF CAP716

32/34

4/29/12

Teamwork, Communication, Handoversand

Sign-offs It concentrates instead on task andshift handovers, and on writtencommunication of information.

Sign-offs are discussed within thischapter since they are particularlyimportant when tasks are handed

over from one person to another,particularly when this was unplannedand there is no formal handover.

8/3/2019 AMHF CAP716

33/34

4/29/12

Task and Shift Handover

Effective task and shift handoverdepends on three basic elements:

The outgoing persons ability tounderstand and communicate theimportant elements of the job or taskbeing passed over to the incoming

person. The incoming persons ability to

understand and assimilate the

information being provided by the

8/3/2019 AMHF CAP716

34/34

4/29/12

Sign-offs

prevent omissions, mis-installations,etc., every maintenance task orgroup of tasks should be signed-off.

To ensure the task or group of tasksis completed, sign-off should onlytake place after completion and

appropriate checks. Work by noncompetent personnel (i.e. temporarystaff, trainee,) should be checked

b a thorised personnel before the