Human Factors In Aircraft Maintenance

Jon Byrd

Director of Aviation
Coosa Valley Technical College
Rome, Georgia

What is Human Factors?

M70-80% of aircraft accidents are due
to human factors JAA, May 2001
MMaintenance contributed to 15% of
commercial jet accidents Boeing,
1995

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Maintenance Human Factors

M20-30% of in-flight engine shutdowns
& 50% of delays/cancellations are
caused by human error Boeing, 1997
M48,800 non-airworthy aircraft are
dispatched each year as a result of
maintenance error Marx, 1998
MRamp accidents cost over $2 billion
annually Ramp Safety Vol.11:3
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Dollars & Sense

MAvg. cost of an in-flight engine shutdown is
$500,000
MAvg. cost of a flight cancellation is $50,000
MAvg. cost of a return to gate is $15,000
MAvg. ground damage incident costs $70,000
MOne airline estimates $75-$100 million/year
is lost
MAirline Transport Association estimates that
ground damage costs $850 million/yr
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Accidents w/ Maintenance Error

MAmerican Airlines Flight 191 1979
MAloha Airlines Flight 243 1988
MUnited Flight 232 1989
MAtlantic Southeast Airlines (ASA) Flight
532 1995
MAir Alaska Flight 261 2000
MPaul Wellstone (B100) crash 2002
MSpectrum Aeronautical LLC - 2006
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General & Corporate Aviation

Little to no data is available
Huge industry push yet we get pushed
aside

With little focus we have to work

harder
Safety Managers will have to adapt and
adopt

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The Human Element (Hu)

MWere only human...
MWe *will* make mistakes...
MThe key is to minimize errors, but
how?

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The Dirty Dozen

M Complacency

M Lack of Assertiveness

M Distraction

M Lack of Awareness

M Fatigue

M Lack of Communication

M Norms

M Lack of Knowledge

M Pressure

M Lack of Resources

M Stress

M Lack of Teamwork
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Dirty Dozen - Complacency

MI dont need to go get the tech data;
Ive done this a hundred times...
MNo need to pull that panel. Last time
I checked that linkage had plenty of
grease...
MIve been an aircraft mechanic for over
25 years; I know what Im doing...
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Dirty Dozen - Complacency

MSafety Nets
MAlways follow checklist(s) &/or squawk
cards
MNever work from memory
MBe sure to vary your routine periodically
MBe aware of the dangers of complacency

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Dirty Dozen - Distraction

MPhone calls
MPersonal Issues
MWater Cooler Talk

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Dirty Dozen - Distraction

MSafety Nets
MUse a detailed checklist
MAlways finish the task
MDouble-inspect the work
MUse torque seal &/or safety wire
MRecord or tag uncompleted work
MWhen you return to the task, always go
back three (3) steps

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Dirty Dozen Fatigue

MWhat is Fatigue?
MThe bodys normal reaction to a physical
or mental stress of a prolonged duration
MThere are two types
MAcute short duration; cured with good
nights sleep
MChronic occurs over a long period of
time; long recovery

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Dirty Dozen Fatigue

MCauses of Fatigue
MLong hours of labor (any type)
MHigh-intensity stress
MLarge temperature variations
MNoise above 80db for long duration
MSufficient intensity vibration for long
periods
MSTRONG lighting

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Dirty Dozen Fatigue

MSymptoms of Fatigue
MEnhanced stimulus required in order to
respond
MAttention reduced
MMemory diminished
MWithdrawn mood
MCircadian Rhythm inconsistencies

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Dirty Dozen - Norms

MI dont care how you did it there,
weve done it this way for years!
MOutdated/inadequate company policies

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Dirty Dozen Norms

MWhat are Norms exactly?
MThe way of doing business thats not
approved, but its been done locally for so
long that its now a Norm
MALWAYS work IAW the appropriate tech
data, or if needed, have the manual
revised
MBe aware that Norms do not make it
right
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Dirty Dozen Pressure

MGet it to the gate!!!
MToo tightly scheduled deadlines
MFlat-rated Work Orders that maybe
should have been rated

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Dirty Dozen Pressure

MSafety Nets
MStop! Assess the situation
MLook at the situation rationally
MCan I safely do the job on time?
MHave I voiced my concerns clearly?
MWhat is the worst thing that can happen to
me?

MListen to your rational mind

MHas this happened before?

MAct
MSpeak up ask for help or more time
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Dirty Dozen - Stress

MPersonal issues
MWeather concerns
MWanting that atta-boy for the boss

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Dirty Dozen - Stress

MHow to Manage
MIf you do not manage stress, it will gladly
manage you
MStop burning up emotional energy
MLook rationally at the problem
MCure the cause, not the symptom

MListen to your rational, not your

emotional, mind
MAct once you have a plan, go for it
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Dirty Dozen - Stress

MOther Stress Helpers
MBe sure the solution starts with I
MBe realistic and practical
MTake a break
MTalk to someone who is not emotionally
involved with the situation
MDont expect miracles, just keep trying

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Dirty Dozen Lack of Assertiveness

MOnly do whats expected of me and
thats it... Not a movement more.
MNot researching all applicable technical
data
MNot following technical data to the t.

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Dirty Dozen Lack of Assertiveness

MSafety Nets
MRecord all the work you do in the logbook,
but only sign for that which is serviceable
MRefuse to compromise your standards

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Dirty Dozen Lack of Awareness

MNot aware of technical data revision
MNot aware of surroundings

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Dirty Dozen Lack of Awareness

MSafety Nets
MTHINK
MWhat could occur in the event of an accident?

MCHECK
MWill your work conflict with a previous or
existing repair &/or modification?

MASK
MSee if anyone else can spot a problem you
overlooked

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Dirty Dozen Lack of Communication

MEither technician to technician
MManagement to hangar
MInspection Department to Maintenance
crew(s)

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Dirty Dozen Lack of Communication

MGood Communication Tips
MYou have:
MTwo ears
MTwo eyes
MOne mouth

MUse them in that order!

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Dirty Dozen Lack of Communication

MTo Improve Communication
MLearn to Listen

MDo NOT

MDebate
MDetour
MPre-plan
MTune-out

MDo

MAsk questions
MParaphrase
MMake eye contact
MUse positive body language
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Dirty Dozen Lack of Knowledge

MAm I experienced for this task?
MDo I have all of the appropriate tech
data?
MAware of FARs

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Dirty Dozen Lack of Knowledge

MSafety Nets
MObtain school training on type, model, etc
MGet supervised on-the-job training
MUse current technical manuals
MTech Reps &/or Manufacturer Reps are
there for a purpose use them!

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Dirty Dozen Lack of Resources

MIs the appropriate tech data available?
MDo I have the proper tools and
equipment to perform the task?

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Dirty Dozen Lack of Resources

MSafety Nets
MCheck all suspect areas at the beginning
of all inspections and AOG the required
parts
MOrder & stock parts before theyre
required
MKnow your sources
MArrange for pooling &/or loaning
MMaintain aircraft to highest standard
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Dirty Dozen Lack of Teamwork

MIs this a task that really two
technicians should do?
MNo, I dont need any help; I know
what Im doing!

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Dirty Dozen Lack of Teamwork

MSafety Nets
MAlways discuss and plan the Who, What,
When, Where, and How of the task to be
done
MInsure that everyone understands and
agrees

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Accident Model

Co
nd
iti
on
sa
fe
Un

Superv
ision/O
rg

anizati
on

The Domino Theory

ct
A
fe
nt
a
e
s
v
pE
a
Un
h
Mis

Damage/Injury

3
4
Dominos

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Reasons Swiss Cheese Model

Organizational
Factors

Latent Condition

Unsafe
Supervision

Latent Condition

Unsafe Act
Preconditions

HFACSHuman Factors Analysis

& Classification System

Latent Condition
Unsafe
Acts

Active Failure

Accident

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Human Factors Prevention

Recap
Were all human and we will make
mistakes
Know your own limits
Learn to recognize it in others

Cure the cause and not the symptom

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My Thanks
FAA
Lou Lerda Safety Program Manager,
Seattle, WA FSDO
Atlanta FSDO-11

Jim Lumley & GWBAA

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Human Factors in Aviation Maintenance

Questions?
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