The "Dirty Dozen" in Aviation Maintenance

Fold

Table of Contents

Introduction

Why human factors in maintenance?

Cost of not adhering to proper maintenance guidelines

Table of "Dirty Dozen" Human Factors

Accidents in which Dirty Dozen have contributed

Overview

Introduction

Due to a spate of maintenance-related aviation incidents and accidents in the late 1980s and early
1990s, Transport Canada, together with the aviation industry identified 12 human factors, christened
the dirty dozen which were human factors elements that degrade peoples ability to perform
effectively and safely which could lead to maintenance errors. In 1994, dirty dozen posters were
developed which provided information and guidance to maintenance personnel all over the world to
identify and prevent these dirty dozen factors. Safety nets were also introduced so that the
appropriate mechanisms can be put into place to prevent human errors. [1]

Why human factors in maintenance?

Studies and analysis have shown that maintenance is a large contributing factor in accidents. For
example:

Sears conducted a detailed study of 93 major world-wide accidents between 1959 and 1983
and found that 12% of the accidents were attributed to maintenance and inspection factors
(4th on the list). [2]

In an analysis done by Boeing in 1995, 15% of commercial accidents between 1982 and 1991
had maintenance as a large contributing factor. [3]

In an aircraft hangar, a typical maintenance environment would involve a myriad of different and
difficult tasks simultaneously going on whilst the personnel are working on an aircraft. Numerous HF
issues involved would include maintenance personnel having to work on aircraft structures in
confined spaces or at high heights with coordination needed amongst various team members
essential. These factors coupled with a high noise environment in the late hours of the night whilst
having to make sure their jobs are meticulously done contribute to a high probability of mistakes and
hence accidents.

Cost of not adhering to proper maintenance guidelines

The cost of not adhering to proper maintenance guidelines is heavy and avoidable and three findings
in an article titled "Human Factors: "Beyond the Dirty Dozen" [4] can attest to that;

According to FAA, about 80 percent of maintenance mistakes involve human factors (HF) and
if not detected, would lead to accidents.

According to researcher Alan Hobbs, in an Australian Transport Safety Bureau report, the
cost of canceling a Boeing 747-400 flight can cost an airline $140,000, with delays at the gate
costing $17,000 per hour off companys revenues thus depicting the high costs of delays and
flight cancellations.

The FAA manual also states that ramp incidents wreaked $5-billion-worth of damage
worldwide in 2004.

Table of "Dirty Dozen" Human Factors

The table below provides a comprehensive description of the 12 Dirty Dozen Factors through the
posters as well as providing the relevant safety nets that should be subscribed to.

The Dirty Dozen (All posters embedded from MARSS on Safety nets
Explanation
1 September 2009) available
Caption says "I guess
day shift can finish Use logbooks
screwing on the to
panel." Lack of communicate,
communication is to remove
depicted as the doubt.
worker is going to Discuss work
leave the panel of an to be done
aircraft unfinished and what has
without been
communicating this completed to
to the next worker in the one taking
any written or verbal over from
form, assuming that you. Never
the next worker assume
knows which part of anything,
the aircraft is left always check.
unfinished.
Caption says "I've
looked back there
1,000 times and
never found
anything
wrong." Complacenc
y is depicted
whereby a
maintenance
personnel has
Train yourself
finished signing an
to expect to
inspection sheet
find a fault
whilst telling himself
and to
that he has checked
consistently
at the aircraft part a
look out for
thousand times
these faults or
without ever finding
hazards.
anything wrong; This
Never sign for
is despite the fact
anything you
that a component of
didn't do.
the aircraft has a
Never assume
spoilt cable. Hence,
anything,
by performing a
always check.
routine task over
and over again,
overconfidence due
to increasing
proficiency could
lead lead to
complacency setting
in and errors in
judgment can
appear.
Caption says "This is
the third one to
bend! What's going
on?" Lack of
knowledge is
depicted in which a
maintenance
personnel cannot
fathom how a
Don't rely on
helicopter part could
memory and
be bent for a third
consult the
time even though he
relevant up to
has kept working on
date manuals.
it, demonstrating
Always ask if
that there is a
you are in
possibility there is a
doubt. Get
lack of certain type
training on
of knowledge in how
type.
he is remedying the
helicopter part. This
could be also due
the rapid pace at
which technology is
evolving and hence
increased knowledge
is needed when
performing the task.
 Always finish
the job or
Caption says "Hey, unfasten the
Your wife is on the connection.
phone." Distraction i Document
s depicted as the and handover
personnel is the
informed of an uncompleted
urgent call from his work. When
wife, hence taking you return to
him away from the job, re-
focusing on his job inspect by
which could another or
potentially lead to always go
errors later as his back three
concentration has steps by
been affected. yourself. Use
a detailed
check sheet.
Caption says "I
thought you wanted
Discuss what,
him to turn left right
who and how
here!" Lack of
a job is to be
teamwork in which
done. Be sure
two marshallers are
that everyone
trying to guide an
understands
aircraft in opposite
and agrees
directions shows a
through good
fundamental lack of
communicatio
cooperation and
ns and co-
communication
ordination
which are essential
with team
in performing certain
members.
difficult tasks
Look out for
especially when
one another.
more people are
involved.
 Be aware of
the symptoms
and look for
Caption says "I'm
them in
glad this double
yourself and
shift is
others. Plan
over." Fatigue is
to avoid
depicted with a
complex tasks
maintenance
when you are
personnel blissfully
physically
unaware that he is
exhausted.
reaching the end of
Sleep and
the horizontal
exercise
stabilizer as he has
regularly. Ask
become fatigued
others to
after working a
check your
double shift.
work. If you
are fatigued,
take a break.
Caption says "We
Check suspect
have nil stock of left
areas at the
skids so I guess this
beginning of
will have to
the
do."Lack of
inspection.
resources is depicted
Order and
with a maintenance
stock
personnel standing
anticipated
in front of a
parts before
helicopter with two
they are
different
required.
components; a float
Know all
on the left and a skid
available
on the right;
parts sources
obviously one of the
and arrange
essential parts is
for pooling or
insufficient and he
loaning.
has fixed a totally
Maintain a
different part on and
standard and
still wants the
if in doubt
helicopter to
ground the
continue to fly.
aircraft.
Hence, there are
Preserve all
times when there a
equipment
lack of resources, a
through
decision must be
proper
made not to fly for
maintenance.
safetys sake.
Caption says "Hurry
up or we're going to
be late
again!" Pressure is Be sure the
depicted with an pressure isn't
aircraft captain who self-induced.
is averse to being Communicate
late, rushing a your
maintenance concerns.
personnel to finish Request for
closing up a panel assistance.
and whilst doing so, Just say No.
he misses seeing a
component jutting
out.
 Be assertive
Caption says "Listen, and provide
I own the aircraft clear
and I say it's not a feedback
bad leak!" Lack of when danger
assertiveness is is perceived. If
shown with the it's not
maintenance critical, record
personnel being it in the
badgered by the journey log
owner of the aircraft book and only
and not asserting sign for what
himself and backing is serviceable.
down by telling him Refuse to
that the plane is compromise
indeed suffering your
from a bad oil leak. standards.
Hence by allowing Allow team
himself to be members to
intimidated and not give their
speaking up, it could opinions and
potentially lead to accept
an accident. criticisms
positively
 Be wary of
the effects of
Caption says "We
stress on your
lost our best
performance.
aircraft! How are
Stop and look
they going to pay
rationally at
my wages? What if
the problem.
I'm sued?" Stress is
Determine a
depicted with a
rational
maintenance
course of
personnel pulling his
action and
cart of tools towards
follow it. Take
the moving propeller
time off or at
and his overstressed
least have a
at having lost his
short break.
best aircraft and the
Discuss it with
fact that he might be
someone. Ask
sued. Hence, the
fellow
stress build up has
workers to
exceeded his limits
monitor your
and he cant think
work. Exercise
rationally and
your body.
perform his task
Ensure
right.
sufficient rest
at all times
Caption says "All the
regulation said was,
'Install Where it is
Think of what
Easily
may occur in
Accessible."Lack of
the event of
awareness is
an accident.
depicted as an
Check to see
aftermath in this
if your work
incident whereby a
will conflict
passenger has hit his
with an
head against a fire
existing
extinguisher during
modification
an emergency as the
or repair. Ask
maintenance
others if they
personnel who had
can see any
installed the fire
problem with
extinguisher there
the work
showed a lack of
done by
awareness by not
checking
using common sense
periodically to
and vigilance by
ensure
putting it at a place
correct work
that though easily
procedures.
accessible could
potentially hurt
someone.
 Caption says "Never
mind the
Maintenance
Manual. Its quicker
the way we do it
here." Norms are
Always
depicted with a
comply with
forklift used to
defined work
install a jet engine
procedures.
demonstrating how
Be aware that
this procedure was
"norms" don't
conducted at this
make it right.
maintenance facility,
that even though it
is a flawed manner
has become a norm
as the majority
performs in this way.

Accidents in which Dirty Dozen have contributed

Crash of Alaska Airlines Flight 261

This page provides a synopsis of the crash of Alaska Airlines Flight 261 and how dirty dozen factors
have contributed to it.

Crash of Air Midwest Flight 5481

This page provides a synopsis of the crash of Air Midwest Flight 5481 and how dirty dozen factors
have contributed to it.

Overview

The dirty dozen factors have long since been identified but yet has can be seen from the examples of
accidents it has contributed above, it has still not been fully eradicated in the realm of aviation
maintenance. It is imperative that maintenance organizations inculcate a working environment that
reiterates these factors holistically so that they are ingrained in the maintenance personnel; this can
be done through human factors training workshops by reiterating these factors and showing the
aviation accidents they have caused.
It is by creating a culture in which all personnel are aware of these factors and the safety nets
involved, this would help decrease the high percentage of human factors involved in maintenance
issues.

References

1. Dupont, G. (1997). The dirty dozen errors in aviation maintenance. In Meeting Proceedings
Eleventh Federal Aviation Administration Meeting on Human Factors Issues in Aircraft Maintenance
and Inspection: Human error in aviation maintenance (pp. 45-49). Washington, DC: Federal Aviation
Administration/Office of Aviation Medicine.

2. Sears, R.L. (1986). A new look at accident contributions and the implications of operational
training programmes (unpublished report). Quoted in Graeber and Marx: Reducing Human Error in
Aviation Maintenance Operations. (presented at the Flight Safety Foundation 46th Annual
International Air Safety Seminar, Kuala Lumpur, Malaysia, 1993)

3. Graeber, R.C. and Marx, D.A. (1993).: Reducing Human Error in Aviation Maintenance Operations.
(presented at the Flight Safety Foundation 46th Annual International Air safety Seminar, Kuala
Lumpur, Malaysia, 1993)

4. Charlotte Adams. (2009). Human Factors: Beyond the "Dirty Dozen". Retrieved from the World
Wide Web on 4 Sep 2009http://www.aviationtoday.com/am/issue/cover/Human-Factors-Beyond-
the-&quotDirty-Dozen%22_33730.html

Want to know more?

Human Factors: Avoid the Dirty Dozen with Safety Nets.

This article extols the virtues of avoiding the dirty dozen through safety nets by human factors
training.

MRM Handbook

It provides a good write up on the need for human factors to be dealt with in a maintenace context
and the differences between MRM and CRM.

The "Dirty Dozen" in ASRS Maintenance Reporting

It provides good accounts of how "dirty dozen human factors play a role in maintenance incidents
reported to the ASRS.

Contributors to this page

Authors / Editors

LeoWitWiki

human-factorsmaintenance