consequences of errors in aviation

CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE

WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL

HF ACCIDENT SCENARIO

ORG & LOCAL FACTORS

CONCLUSION

Q & A

TOP SIX MAINT. ERRORS


WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


CONSEQUENCES OF CONSEQUENCES OF ERRORS ERRORS

IN IN AVIATION MAINTENANCEAVIATION MAINTENANCE

PREPARED BY:PREPARED BY:

SQN LDR SQN LDR

OMAR HAYAT KHAN OMAR HAYAT KHAN

PAF BASE PAF BASE MIANWALIMIANWALI


WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


WHAT ARE ERRORS?WHAT ARE ERRORS?

• A failure arising from – an action that was not completed as intended

– a plan for action that was inadequate to begin with

• Slips & Lapses (skill-based)Slips & Lapses (skill-based)– occur at execution stage (memory and attention errors)

• Mistakes (rule- and knowledge-based)Mistakes (rule- and knowledge-based)– occur at judging or inference stage (planning errors)

(Reason, 1990)

Ultimate outcome (detected or undetected, mitigated or leading to further errors, catastrophic or inconsequential) is not part of

the definition


WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


MAINTENANCE ERRORMAINTENANCE ERROR

“A maintenance error is considered to have occurred when the maintenance system, which includes the human element, fails to perform in the manner expected in order to achieve its safety objectives.”


WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


TO ERR IS HUMAN!TO ERR IS HUMAN!

• Aviation (U.S. air carriers)Aviation (U.S. air carriers)– 2 errors per flight (LOSA data, 2001)

– <0.3 fatal accidents/ 100,000 flight hours annually– 60-80% of accidents involve human error (Foushee 1984)

• Hospital admissionsHospital admissions– 1,000,000 people injured/yr by errors in treatment at hospitals

in US (Marx,2001) – 44,000-98,000 errors are fatal (= 1 jumbo jet crash per day) (IOM

report 1999, Leape, 1999)

– UK: 40,000 errors are fatal (QuIC report, 2000)

• Drug administration Drug administration – 1 in 5 injuries or deaths annually in hospitals (AHRQ 1991)

– 7,000 deaths annually (QuIC report, 2000)

AND THE LIST GOES ON……….


WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


ACCIDENTS

INCIDENTS

ERRORS (UNREPORTEDOCCURRENCES)


WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


Old View New View Revised

• Human error is the cause of accidents

• Human is the most unreliable component

• Improve safety by restricting human action

• Human error is the effect of deeper issues

• Human is necessary to create safety

• Get away from blame and ask “why”?

• Improve safety by understanding (and leveraging) human and organizational performance

Human Error & Aviation SafetyHuman Error & Aviation Safety


WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


• Human Factors Directorate established in 2002

• Stage I - Initially focused to address HF issues amongst aircrew by launching a CRM (Crew Resource Management) Course later made mandatory for all aircrew.

• Stage II - To address HF issues amongst Ground Crew, an MRM (Maintenance Resource Management) program is under development.

Human Factors & PAFHuman Factors & PAF


WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


Maintenance Resource Maintenance Resource ManagementManagement

The The

dirty

dirty

dozendozen

Complacency

Distraction

Fatigue

Norms

Pressure

Stress

Lack of Assertiveness

Lack of Awareness

Lack of Communication

Lack of Knowledge

Lack of Resources

Lack of Teamwork


WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


A technician over torqued the outlet union nut damaging internal threads of the hydraulic filter cover and de-shaping the sealing ring of the assembly (F-7P)

Error – 1Error – 1

UNION AND SEAL OF THE HYDRAULIC FILTER COVER ASSEMBLY


WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


After 10 minutes of Flight (F-7P), once gears were lowered for a touch and go landing, main hydraulic warning light came steady on with pressure dropping to below normal limit due to hydraulic leak!

Error – 1 (Consequence)Error – 1 (Consequence)


WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


A technician adopted incorrect posture for locking fasteners of the electronic nose compartment (F-7P) using a T-handle.



WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


While applying force upon the T-handle to tighten the fasteners, the tool slipped and impacted the front wind shield of the aircraft inducing a crack!



WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


Maintenance team worked inside the gas path to rectify an engine anomaly (F-7P). A tool was left behind which went undetected through all supervisory checks and the aircraft was given a full power ground run!



WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


The undetected tool inside the gas path was ingested during Funco run and induced damage to compressor blades (all six stages)!



WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


BA maintenance technician on night shift installed the incorrect bolts during windscreen replacement and did not consult the applicable IPB/Tech Manual.



WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


The incorrect bolts could not hold the left windscreen in flight due to cabin pressure resulting in the wind screen blowing off in air. The pilot was jerked out of his seat by the rushing air and was forced out of the cockpit with his knees snagging onto the flight controls!



WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


To save on engine change time, AA maintenance bypassed TO procedure (DC-10 Aircraft) of step-wise removal of engine + pylon and started removing them as a set for the plea of saving 200 man-hours and reducing the number of disconnects (i.e., hydraulic and fuel lines, electrical cables, and wiring) from 72 to 27.



WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


The self evolved maintenance procedure for engine change resulted in damage to the left wing engine pylon during engine change on aircraft DC-10 (Tail No. N110AA) at AA aircraft maintenance facility on March 29, 1979. Eight Weeks later, the aircraft when scheduled as Flight 191, crashed just after take-off due to No.1 engine/pylon separation from the left wing.



WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


HUMAN FACTORS HUMAN FACTORS ACCIDENT SCENARIOACCIDENT SCENARIO

Defenses

Gaps

Teamwork

Reliable Maintenance

Good Management

Ambiguous instruction(goes unchallenged)

Pilot lets it go / fails to check

Mis-judgment by Supervisor

Error by Worker

Operational pressureHigh work load.

Reason’s Swiss Cheese ModelReason’s Swiss Cheese Model


WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


TOP SIX TOP SIX MAINTENANCE ERRORSMAINTENANCE ERRORS

1. Incorrect installation of components.2. The fitting of wrong parts.3. Electrical wiring discrepancies

(including cross-connection).4. Loose objects (tools, etc.) left in

aircraft.5. Inadequate lubrication.6. Cowlings, access panels and fairings

not secured.


WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


ORGANIZATIONAL & LOCAL ORGANIZATIONAL & LOCAL FACTORS CRITICAL TO DEVELOPING FACTORS CRITICAL TO DEVELOPING

A SAFETY CULTUREA SAFETY CULTURE

Organizational Local

Training and selection of personnel.

Knowledge and skill of personnel.

Quality of resources as distributed.

Quality of resources at Flight Lines / Shops / COE.

Organizational Structure Hangar environment.

Opportunities for career development.

Morale & personalities of Aircraft Technicians.


WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A


CONCLUSIONCONCLUSION


WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A

TOP SIX MAINT. ERRORS QUESTIONSQUESTIONS??


WHAT ARE ERRORS?

TO ERR IS HUMAN!

ERRORS & SAFETY

HUMAN FACTORS & PAF

EXAMPLES - PAF

EXAMPLES - GLOBAL


ORG & LOCAL FACTORS

CONCLUSION

Q & A

TOP SIX MAINT. ERRORS THANK THANK YOUYOU!

consequences of errors in aviation

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