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Human Factors 2

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Primary Causes of Aircraft Accidents *

Flight Crew

Airplane

Maintenance

Weather

Airport/ATC

Other

Percentage of Total Accidents with Known Causes

20 40 60Primary Factor 70503010

Excludes:

Sabotage

Military Action

Turbulence Injury

Evacuation Injury

Servicing Injury

Pilots are human

and humans make errors!(Note: this does not mean that errors are OK!)

The Crew usually makes the last mistake!* Copyright 2004 by the Boeing Commercial Airplane Group. Adapted with permission.Human Factors 3

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TEM Objectives:The objective :

understanding how to assess various risklevels of threats

logical approaches (strategies) to deal withthem

reduce human error in dynamic dailymaintenance operations.

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TEM Model

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Human Factors 6

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THREATS IN MAINTENANCE

Threats -events occur outside the influence ofthe maintenance crew, require crew attentionand management to maintain safety margins

Threats increase complexityof maintenanceoperation andweaken barriers against error

ObservableThreats

Known e.g. Poor training , Incomplete orincorrect documentation

Unexpected e. g, Engine on fire during ground

run

Threats = Red Flags!

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Latent Threat

inherent in system, organization, or individualthat increases risks.- not directly observable at the sharp end ofoperations.

- usually uncovered e.g.,Equipment design issue

Optical illusions

Training philosophy and practices

Organizational culture (Positive or Negative)

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Typical Latent Threat

Poor planning or scheduling Inadequate design/poor equipment

Improper allocation/lack of resources

Flawed procedures

Defective communications Training deficiencies

Inadequate selection procedures

Inspection and oversight flaws

Neglect of known hazards Lack of motivation

Note that these are all management problems!Flight Safety Foundation, 2006; Adapted with permission.

Human Factors 10

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(Threats)

Fatigue

Boring repetitive jobs

Lack of spare parts andtools

Personal life problems Substance abuse

Loud noises

Poor communication

Poor language

What are the types of things that negatively effect humanperformance and may lead to human error?

Your answers:

Our answers how many match?

Poor instructions

Unrealistic deadlines

Smelly fumes

Poor training

Incomplete or incorrectdocumentation

Poorly designed testingfor skill and knowledge

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What are the contributing factors?

(Threats)

Lets target the 12 most common

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Lack of CommunicationComplacency *

Lack of Resources

Distraction *

Lack ofKnowledge *

Fatigue

Lack ofTeamwork

Lack ofAwareness

Stress

Norms *

Lack ofAssertiveness

Pressure

The Dirty Dozen The 12 Most CommonCauses for for Maintenance Errors

Human Factors 13
http://complacency.ppt/http://distraction.ppt/http://lack%20of%20knowledge.ppt/http://norms.ppt/http://norms.ppt/http://lack%20of%20knowledge.ppt/http://distraction.ppt/http://complacency.ppt/

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Actions or inactions that lead to deviations from intention

Traditional thinking eliminate error i.e., Zero Error!

Contemporary thinking error a part of life, i.e.,humansmake mistakes!

Intentional non-compliance not an error VIOLATION! Types of errors:

Maintenance errors (e.g., fitment of wrong bolts or fasteners)

Procedural errors (e.g., performing checklist items from

memory) Communications errors (e.g., instruction from supervisor

misunderstood)

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Maintenance ErrorA performance failure of the maintenance system

where the system did not perform the correct way or asexpected.

Examples:

1. foreign objects or tooling lost in an aircraft duringmaintenance

2. contamination of a fuel system due to poor procedures orpractices

3. failure to correctly install components.

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Common Maintenance Errors?

1. Incorrect installation of components

2. The fitting of wrong parts3. Electrical wiring discrepancies (including

cross-connections)

4. Loose objects (tools, etc.....) left in aircraft

5. Inadequate lubrication

6. Cowlings, access panels and fairings notsecured

7. Fuel/oil caps and refuel panels not secured

8. Landing gear ground lock pins not removed

Your answers:

Civil Aviation Authoritys List of Maintenance Errors

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Human Factors 17

Incomplete installation (33%)

Damage on installation (14.5%)

Improper installation (11%)

Equipment not installed ormissing (11%)

Foreign object damage (6.5%)

Improper troubleshooting,

inspection, test (6%) Equipment not activated or

deactivated (4%)

What errors cause engine failures?

Your answers:Boeing Study

Data from Boeing study of 276 in-flightengine shutdowns (1994)

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Human Factors 18

Fortunately, not all events become accidents

Serious incident

Routine occurrence

Accident

Statistical event

Significant event

1

10

30

200

600

Flight Safety Foundation, 2006; Adapted with permission.

but events/occurrences can lead to incidents and

accidents

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There are typically far more latent failuresthan active failures in the system

System Failures Contribute toAccidents

(ACTIVE)

(LATENT)

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ExacerbateErrors

Miss ErrorsMitigate

ErrorsTrap Errors

Error Outcomes

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Strategies/Countermeasures:

Strategies/Countermeasuresto reduce number of threats and errors

to increase awareness of potential threats anderrors

Errors must be recognized and corrected beforenegative consequences occur!

Focus on managing your future!

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Good TEM - plan and use countermeasures to prevent threatsand errors leading to an undesired aircraft/equipment state.

Planning countermeasures

Execution countermeasures

Review countermeasures

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Countermeasures used in TEM include :

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Safeguards:

TEM

SMS FLIGHT SAFETY MRM

MANUALS

SOPs

CHECKLISTSAUTOMATION

TAMM

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Safeguardsare the hardware & software thatserve as additional barriers to problems *:

* Note: Because these are also developed by humans,the potential still exists for latent defects and errors.

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Desired OUTCOMESorUndesired CONSEQUENCES ?

Successful TEM results in outcomes that are desirable,i.e., safe aircraft

Consequences oferrors not corrected/contained

result in an undesired aircraft /equipment state(US)Anundesiredstate is an aircraft/equipment deviation

or incorrect configuration associated with a clearreduction in safety margins

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TEM Principles:TEM is central to all safety processes and

provides defences against hazards inoperational situations; it involves

Identifying hazards to safety, i.e., threats,

errors, or undesired states (deviations) Assessing the risks of these hazards (the

consequence of accepting hazards)

Avoiding or trapping threats and errors Containing the end result (mitigation)

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TEM Concepts: The mission (i.e., safe, effective mission/objective)

may be a pre-flight check, an aircraft repair, a tripplan, or even an ops manual or company procedure

i.e., TEM can be applied to all aviationorganizational entities.

The maintenance crew is only one resource to theoperator or systems manager who must makeaccurate and timely decisions for successful results.

The operator is only as effective as the information heor she receives from all resources (The TEAM).

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TEM Concepts Individuals are humans, and humans (all humans!)

make mistakes.

The aviation mission or objective is dynamic.

TEM is not a sequential system! Because all

organizational entities are made up of individuals,threats (hopefully with innovative threat solutions!)and human error (with error resolutions!) areintroduced throughout the timeline of the

particular mission. External threats also continuously occur and must

be dealt with utilizing all appropriate resourcesavailable.

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Accurate Decision-Making

The primary key to a successful mission outcome isaccurate decision-making by the individual orindividuals who are involved in aircraftmaintenance

Accurate Decision-Making = Successful Outcome!

In the maintenance set up, a crew is only as effectiveas the information (not data!) he or she receivesthrough proper teamwork and resourcemanagement.

The crew is the one of the authority regarding thesafety of the aircraft; e.g., a technician can alwayselect to snap a dangerous defect.

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Techniques for Managing Errors: Identify behaviors in the maintenance organization

which are unacceptable, inappropriate, orundesirable. E.g. poor documentation or the perceived

requirement/pressure to work long hours to complete atask.

Replace unacceptable behavior with correct behavior.Establish boundaries and framework for maintenance

organizations to operate under. An example would be toestablish rules on work hours and overtime.

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Techniques for Managing Errors cont If something is not correct in the maintenance

organization and system, get it corrected for thefuture..

Maintenance incidents, near misses and accidentsmust be reported to allow the organization to learnfrom error and to put mitigation strategies in place.

An easily accessible, non-punitive, and anonymousreporting system can be very valuable.

Investigating and reporting maintenance errorgenerates understanding as to why an incident

occurred.Expand investigations wider to include latent

errors and defects, not just the active errors and physicalcauses

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Human Factors 93

Error ChainAn accident is what?

An unplanned and unfortunate event that resultsin damage, injury, or upset of some kind.

An error chain is what?

Multiple contributing causes that lead to anaccident.

StressNorms

PoorCommunication

Distraction ComplacencyLack of

Awareness

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Human Factors 95

Hardware and software that existbefore the human enters:

Policies andSOPs

MaintenanceManuals

Training

Job Cards

Inspections

Service Bulletins Test Equipment

Regulations

Shift Turnover

Chain Breaking - Resistive

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Human Factors 96

Breaking the Error ChainWhat happens when we use StandardOperating Procedures?

Stress

Norms

PoorCommunication

Distraction Complacency

Lack ofAwareness

UseSOP

Completion of operational goals..

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Proficiency

Vigilance Assertiveness

Procedural Compliance

Effective Communication Teamwork Effective Communication

Decision Making

Experience Leadership

Situational Awareness

Company Safety Culture Workload Management

Chain Breaking - Resolve

Human Factors 97

What the human brings to the system - our TEM skills:

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Threat and Error Management

A barrier represents resourcesavailable to the maintenance crewto improve safety by mitigatingthreats and errors.

We use multiple layers of barriersto improve our safety margin.

The holes represent errorsinherent or created in each barrier.

An arrow is a threat to completionof the operational goal.

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Regulations

Shift Turnover & Other Resources

Tools & Test Equipment

Job Cards

Policies & SOPs

Barriers - Resistive

Human Factors 100

Inspections

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Teamwork

Situational Awareness

Decision Making

Communication

Vigilance

Barriers - Resolve

Human Factors 101

Workload Management

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TeamworkRegulations

Situational AwarenessTurnover & Resources

Decision Making


CommunicationJob Cards

VigilanceInspections

Workload ManagementPolicies & SOPs


Human Factors 102

Resistive and

Resolve Barriers

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TeamworkRegulations


Decision MakingTools & Test Equipment



Workload Management

Policies & SOPs

Human Factors 103


When the holesline up

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TeamworkRegulations


Decision Making





Human Factors 104


When we use our

MRM skills

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TeamworkRegulations


Decision Making





Human Factors 105

Management

When we are

vigilant

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YOU are the one of the line of DEFENSE!

Human Factors 106

Vigilance

YOUR vigilance will save lives - The buck STOPS here!

Th t E M t

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Threat Error Management

Picture of two maint dudes talking

Human Factors 107

TEM Skill R l

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What the human brings to the system - our MRM skills:

Proficiency

Vigilance Assertiveness Procedural Compliance Effective Communication Teamwork

Decision Making Experience Leadership Situational Awareness Company Safety Culture Workload Management

TEM Skills - Resolve

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