by: faa safety team date: federal aviation administration airworthiness human factors r1 human error...

By: FAA Safety Team

Date:

Federal AviationAdministration

AirworthinessHuman Factors

R1

Human Error = System Failure


2

Objectives

1. Reveal that existing aircraft accident & incident data shows human error contributes to many LG failures.

2. Discuss how human error may have resulted in several LG failures on a specific aircraft .

3. Emphasize how you can reduce or mitigate human error when performing inspection or maintenance


3

•September 21, 2005


4


5

Question

• Is “Improper Maintenance” failure to follow procedures?– Yes

• Is “Inadequate Maintenance” failure to follow procedures?– Yes

• What are these numbers telling us?– Virtually ALL maintenance failures can be

associated with “Failure to Follow Procedures”!!!


6

Improper Maintenance

• Where do you find the definition for improper maintenance?

• Answer – There is no definition found in any FAR, FAA Guidance, Order, or in Title 49.

• So how do we understand or apply the term Improper Maintenance?

• Answer – Maintenance Error


7

Improper Inspection

• Where would you find the definition of inspection?

• Answer – Part 43• Where do find the definition of improper

inspection?• Answer – Again, this is not defined by FAR,

FAA Guidance/Order or in Title 49.• Lets think in terms of Inspection Error


8

Improper Installation

• Where do you find the instructions to install components?

• Manufacture Maintenance Manuals and/or other Methods and Techniques Acceptable to the Administrator.

• There is no definition for Improper Installation so lets think in terms of Installation Error


9


• The very sharpest technician on the crew can make a mistake if he/she sleeps poorly or becomes distracted by a cell phone call.

• Dirty Dozen ?


10

The Dirty Dozen

• Communication

• Complacency

• Lack of Knowledge

• Distraction

• Teamwork

• Fatigue

• Lack of Resources

• Pressure

• Assertiveness

• Stress

• Lack of Awareness

• Norms


11

SAFETY TOOL


12

SAFETY TOOL


13

April 08, 2008 – Nose Gear Failure


14



15

Human Factors Teamwork – Resources - Communication


16

Maintenance Personal Minimums Checklist


17

Situational Awareness

•2


18

Lack of Awareness & Distraction


19


20

Situational AwarenessNose Gear Down Lock Link Assembly

1

•3

•2


21

AD 2005-13-16 & Piper Service Bulletin No 1123A


22

AD 2005-13-16


23

AD 2005-13-16


24

Failure to Follow Procedures

• What are the procedures we are referring to?– Procedures contained in data approved/accepted by

the FAA.

• What is “Failure to Follow Procedures”?– Deviations from data approved/accepted by the

FAA.

• What do we need to learn from this?• Where do we need to go from here?


25

Mental Limits: Disassembly

There is only one way to disassemble the nuts, but over 40,000 wrong ways to reassemble.

Your task here is to remove these nuts from the bolt. Now reassemble them back into alphabetical order.


26

Human Factors and Failure to Follow Procedures

• Learning from all the mistakes we have made or can make is not practical.

• We must learn to associate the mistakes we make with the human factor and environmental circumstance that spawned that mistake.

• This challenge of association is vital to learning!!!


27

Situation Awareness Situation Awareness

• Knowing what is going on around you– The perception of important elements

• Seeing: loose bolts, missing parts• Hearing: verbal communications

– The comprehension of their meaning• How this affects your job• Compliance with procedures

– The projection of their status in the future• Future effects on safety, schedule, air worthiness


28

Why is Situational Awareness Important?Why is Situational Awareness Important?

SITUATIONAWARENESS

DECISIONMAKING

PERFORMANCE

Situation Awareness Drives PerformanceSituation Awareness Drives Performance


29

Poor Situational AwarenessPoor Situational Awareness

• People doing the right thing for the situation that they believed they were in but their action was incorrect due to misunderstanding not comprehending the actual situation.


30

Summary

1. FFP happens when we deviate from FAA approved/acceptable data.

2. Virtually all maintenance errors can be attributed to FFP.

3. Human Factors are at the root cause of FFP mistakes.

4. Human Factors contribute to virtually all maintenance failures.


31

Summary

5. Situational awareness.

6. We must learn to associate the mistakes we make with the human factor and environmental circumstance that spawned that mistake.

7. This challenge of association is vital to learning!!!

8. Learning paves the road to understanding!


32

Conclusion

• FAA Safety Team website: FAASafety.gov • AMT Award program• GA Award Program• WINGS• FEEDBACK Wanted at this web site:• http://www.faa.gov/about/office_org/

headquarters_offices/avs/stakeholder_feedback/afs/field/sf_faasteam/

by: faa safety team date: federal aviation administration airworthiness human factors r1 human error...

Documents