DCAM Human Factor Topic 1

INTRODUCTION
TO
HUMAN FACTOR
Prepared By: Abdul Ghani Abdul Samad 1

07/02/2017
Human Factors
Putting yoU In Human Factors !!!
Lessons learned
Prepared By: Abdul Ghani bin Abdul Samad 3

Air India A319
Parked on bay28L was push back for departure to Hyderabad. After push back,
The technician instructed the helper to remove the tow bar. The helper removed the
Tow bar, and in all this time the technician was facing the tow truck with his back
towards the engine.
In the meanwhile the captain got the taxi clearance from the ATC, inform the co-pilot
the a/c is clear. The technician still on headset and with his back facing the engines,
Aircraft started to move with both engines on. With no chocks placed the a/c started
Moving and sucked the technician still on headset. The helper who was the prime facia
To this incident immediately sat down and saved.
Finding
During pushback No AME available

No chock were place after the pushback
No clearance signal taken from ENGG before taxi out
Lack of proper coordination between P1,P2 and ground
HF playing important role to have patience, avoid hurrying and to follow SOP
SO, WHAT WILL LEARN ?
How mistakes are made and how they can be avoided, we can go a
long way to reducing the number of accidents.
How the human body works,
How the brain processes information received, a little psychology,
How we interact with others through effective communication
Learn the types of human error and ways of avoiding these errors.

Why?
To achieve the ultimate goal safe and efficient flight

operations,
To minimise accidents and incidents
To investigate the causes (including the underlying hidden

causes) and put in place Procedures to minimise the risk of the
accident or incident happening again.

Chapter 1
Introduction
The Need to Take Human Factors Into

Account
Incidents Attributable to Human Factors

/Human Errors
Murphys Law

Learning Outcomes
Upon completion of this subject, the participants should be able

to:
Demonstrate the understanding of human performance and

limitations in themselves and others.

The Term 'Human Factor'
United States - Human factor, human factors engineering
or human engineering
Europe - Ergonomics or Cognitive ergonomics
Research - human performance, technology, design

and human/computer interaction.
Focuses on how people interact with products, tools, procedures

and any processes
07/02/2017
The Term 'Human Factor'
Human factors practitioners
Psychologists (cognitive, perceptual and experimental) and

engineers. Designers (industrial, interaction and graphic),
anthropologists, technical communication scholars and computer
scientists also contribute.
Ergonomics focus on anthropometrics for optimum human/machine

interaction
Human factors focused on Cognitive and perceptual factors.
07/02/2017 Prepared By: Abdul Ghani Abdul Samad 13

workload fatigue situational
safety
accessibility awareness
shiftwork
usability
aging
user interface
individual
work in extreme
differences Area of environments
visualisation of data Research including
learnability
stress
control and display attention

design
vigilance
human/computer
interaction human performance
human attention
reliability virtual environments
human error decision
making.
1.1 The Need To Take Human Factors Into Account
Basically definition describes Human Factor as relation between.
Humans and humans.

Humans and machines.
Humans and working processes
Humans and their environment.
Also describes as:
Human capabilities and limitation

Interaction between human entity and the systems
Objectives of this training

EASA Part 145
In order to fulfill the organization commitment, it needs to
constantly develop the safety awareness and alertness. All
employees must permanently question themselves with a view to
enhancing safety at all times.
In terms of safety, all domains are interrelated. Therefore, all

employees are expected to look beyond their own field of activity
with a challenging spirit in order to anticipate all potential safety
consequences of their acts.
(EASA Part 145.A.3Od) Personnel Requirements
Human factors continuation training should be of an appropriate

duration in each two year period in relation to relevant quality
audit findings and other internal/external sources of information
available to the organisation on
Prepared By: human
Abdul errors
Ghani bin Abdul Samad in maintenance. 17
Para 145.A.30[e] :
The organization shall establish and control the competence of
personnel involved in any maintenance, management and/or quality
audits in accordance with a procedure and to a standard agreed by
the competent authority. In addition the necessary expertise related
to the job function, competence must include an understanding of
the application of human factors and human performance issues
appropriate to that person's function in the organization.
Human factors' means principles which apply to aeronautical

design, certification, training, operations and maintenance and
which seek safe interface between the human and other system
components by proper consideration of human performance.
Human performance means human capabilities and limitations
which have an impact on the safety and efficiency of aeronautical
operations.
Course objectives
Satisfy a regulatory requirement (EASA Part 145) to;
Provide initial Human Factors training
Improve a return of experience system (i.e. learning from errors)
Provide continuation training on Human Factors
Improve people and product safety in maintenance

organisations

Target audience - EASA AMC 145.A.30 (e)
All maintenance, management and quality audit personnel:
post-holders, managers, supervisors
certifying staff, support staff and mechanics
technical support such as planners, engineers technician/
record staff
Quality control/assurance staff
specialised services staff
human factors staff/human factors trainers
store department staff, purchaser department staff
ground equipment operators
contract staff in the above categories
What are human factors?
inadequate poor communication
poor lighting spares and tools Fatigue
boring,
personnel problems
poor tool inspection
poor verification of time pressure

skills and knowledge Human factors that
may influence poor air quality
inadequate training work performance noise
drug and medication
abuse slippery floor
inadequate
instructions temperature
poor documentation
repetitive tasks
high pressure to
complete a task.
Human Factors In Aviation
During the Second World War many countries launched a mass
production of military aircraft. Engineers began to consider factors
like the design of control panels that were aligned with the needs
and skills of the pilots.
During the 1950s the US Air Force initiated experiments to

evaluate human personality and to optimize the interaction
between man and work flow.

In 1988 the US Government
passed the Aviation Safety
Act. demand the FAA to
perform human factors
research.
That same year, a Boeing

B737 disintegrated in flight
above Hawaii. The causes
were mainly found in the
human factors sector.

This accident did provoke high public concerns in terms of human

factors related to aircraft maintenance.
During the 1990s the FAA invested in extensive research programs

related to human factors in maintenance. Many results from these
studies were converted into mandatory guidelines for human
factors training and therefore became valid also for this course
program.

illustration shows at least three facts:
Flying is very safe
The increase of the safety rate is very small
If safety remains the same while more flights are performed per day, the
number of accidents must increase.
Accident statistics Boeing study

Main Causes For Flying Accidents
The data provided by Boeing shows the following main causes for
flying accidents:
Cockpit Crew
Aircraft
Weather
Maintenance

Who causes these mistakes?
Approx. 80% of accidents are consequences of human errors.
Therefore we have to deal intensively with human factors if we
want to improve worldwide airline safety comprehensively.

Influence of maintenance on incidents and
accidents
In the early 1990s Boeing did complete a study about the 7 major
faults that led to an engine in-flight shutdown. 276 in-flight
shutdowns were recorded for this study.
The causes were:
Incomplete installation 33%
Component damage (during installation) 14.5%
Inaccurate installation 11%
Missing equipment 11%

7 Major Errors

Pratt & Whitney did examine the reasons for 120 engine in-flight
shutdowns on Boeing B747 airplanes.

The result is almost equal to Boeing and British Civil Aviation
Authority (CAA) :
Missing components, wrong components, inaccurate installation
False installation, inadequate components, false connection of
electrical wiring and many more.

Incidents In The Aviation Sector
Aloha flight 243 ( April 1988 )

1.2.1 American Airlines DC10 Chicago OHare, 1979
In 1979 an engine separated from the wing of a DC10 shortly after
take-off. Due to its low altitude the aircraft could not be recovered
and crashed into the ground approx. 1 mile from the airport.
Investigations found out that unconventional work flows during an

engine exchange did contribute to this failure and caused the
engine separation.
In addition, other DC10 operators were aware of this acutely

dangerous situation, but did not provide sufficient with emphasis
information to the manufacturer.
Today, new industrial reporting and quicker data exchange

counteract these human communication problems.
1.2.1 American Airlines DC10 Chicago OHare, 1979

1.2.2 Continental Express EMB120
The Continental Express accident is a typical human factors example
with fatal ending. The aircraft was a Regional Turboprop Embraer
120.
The incomplete installation of a deicing system caused the

separation of the leading edge from the RH horizontal stabilizer in
flight.
The crew was helpless and could not regain control over the aircraft.
A multiplicity of human factors did play a major role in this accident.
The major reasons were poorly written reports and a mainly oral
communication during shift change.

1.2.2 Continental Express EMB120

1.2.3 Eastern Airlines L1011 Miami 1981
Another example is the accident of former Eastern Airlines during the early 1980s.
A Lockheed L1011, equipped with three engines, left Miami with 175 people on
board heading for Nassau on the Bahamas, a quite short charter flight.
Approximately 15 minutes into the flight, the pilots noted low oil pressure levels
and high oil temperatures on all three engines. Upon failure of two engines, the
aircraft returned safely on the remaining engine to Miami.
The reason was missing sealing O-rings on the Primary Chip Detectors that had
been exchanged prior to the flight. The National Transportation Safety Board
Organization identified that the possible cause was the absence of all O-rings on
the Master Chip Detectors.
This caused an insufficient lubrication and thereafter a damage of all three

engines.

The reasons for this incident were on
one hand the failure of a technician
to perform the correct and approved
procedure for the Master Chip
Detector installation on the engine
oil circuit.
On the other hand, quality control

failed to instruct the technicians to
comply strictly with the stipulated
installation instructions.
Furthermore the Eastern Airlines

management misjudged the
importance of similar incidents that
had appeared recently and failed to
initiate respective corrective actions.
An additional, fourth reason for the

accident was, that maintenance
inspectors from the FAA did misjudge
the importance of the incidents
related to the Master Chip Detector
installation and did also not take any
corrective action to prevent a
recurrence of the accident.
In fact, this event did not cause any

fatalities, but a million dollar damage
for Eastern Airlines. It simply should
not have happened!

1.2.4 Aloha Airlines B737-200, Hawaii, 1988
In 1988, an Aloha Airlines Boeing B737-200 experienced a rapid
decompression and structural failure at an altitude of 24.000 ft
during a flight from Hilo to Honolulu, Hawaii.

1.2.4 Aloha Airlines B737-200, Hawaii, 1988
During the flight a structure section including outer skin of 18 ft length aft of the
FWD passenger door and above the cabin floor level separated from the aircraft.
There were 89 passengers and 6 crew members on board.
One cabin crew member was turn from the aircraft by the rapid decompression.
The flight crew initiated an emergency descend and landed safely on Kahului
airport on Maui island.
The safety topics that were mentioned in the last NTSB report included the quality
of the maintenance programs and its monitoring by the FAA as well as human
factors in aircraft maintenance and the airworthiness inspections of transport
aircraft.
Thereby human factors include repair procedures, training as well as the

certification and qualification of technicians and inspectors. Those are exactly the
factors that appear within the Dirty Dozen.

1.2.5 United Airlines DC10, Sioux City, 1989
In 1998 a critical engine failure caused a complete loss of the

aircrafts control system on a United Airlines DC10. The airplane was
enroute from Denver to Chicago and had to perform a crash landing
in Sioux City/Iowa. Due to the heroic performance of the flight crew
the landing was successful.
The NTSB accident report indicated an insufficient consideration of

human factors and limitations within the inspections and quality
insurance processes of the United Airlines engine overhaul. A fatigue
crack in the fan disc No. 1 was not detected that had been caused by
a previous unnoticed material fault.

1.2.5 United Airlines DC10, Sioux City, 1989
The separation and disintegration of fan disc No.1 caused the
failure of all three hydraulic systems that supplied the aircraft
controls with energy.
This accident did generate a much higher awareness for human
factors in terms of processes and work flow for the inspection of
rotational components of turbine engines.

1.2.6 Northwest Airlines Boeing B747-200, Narita/
Japan, 1994
In 1994 Northwest Airlines experienced a heavy engine failure

during landing at Narita/Japan. On the flight from Hong Kong to
New York/JFK the airplane performed an intermediate landing in
Narita. The airplane did stop on the Taxiway in Narita with Engine
No. 1 touching the ground.
The lower forward engine cowling had been ripped off while it was
dragged along the runway. A fire that developed close to the No 1
engine was extinguished by the fire brigade directly on site.

1.2.6 Northwest Airlines Boeing B747-200, Narita/
Japan, 1994
The reason why the engine fell off from the airplane was found in
the installation of the aft safety bolt that had been performed 30
days ago, however without the appropriate securing elements.
The investigation of the incident did show that these elements

were found in their package at the facilities in the US where the
maintenance had been performed.

1.2.7 ValueJet DC-9, Florida, 1995
During this accident the cargo of the aircraft, a DC-9 enroute from
Miami to Atlanta, caught fire. The fuels for the fire were old
aircraft tires and passenger oxygen generators.

1.2.7 ValueJet DC-9, Florida, 1995

Human factors, that contribute to the accident include, the
following aspects:
Insufficient training of the cargo dispatchers technicians
violation of the stipulated procedures
failure to secure and mark the dangerous goods correctly
insufficient monitoring by the controlling bodies.
In this example many errors were on behalf of the workers, the

company and the controlling bodies.

1.2.8 ValueJet DC-9, Atlanta
Atlanta 1995: During the take-off run, a catastrophic engine failure

occurred on a ValueJet DC-9. When the aircraft accelerated, the
occupants and the tower controllers heard a loud bang. The
engine fire warning came on and the crew of the following aircraft
informed the ValueJet pilots that their RH engine was on fire. The
take-off was aborted.
Small debris of the RH engine penetrated the aircraft fuselage and

the main fuel supply line of the RH engine, which caused a cabin
fire. The airplane did stop on the runway and all occupants were
evacuated. Nevertheless the aircraft fuselage was completed
destroyed.

1.2.8 ValueJet DC-9, Atlanta
What was the cause? Again, human factors!
The previous aircraft operator did not perform a detailed inspection

of the high pressure compressors stage No. 7. In addition, the
maintenance personnel did not have a detailed monitoring system
available to allow a step by step documentation of any inspection
procedure.
These factors are also part of the Dirty Dozen.

Accident or incident could have been avoided.
An individuals failed to
1. Recognize potential hazards,
2. Did not react as expected
3. Diversion
Incidents and accidents which involved human factors

problems could formed an error chain.

Cost
Human errors in aircraft maintenance do not only endanger safety,

they also cost a lot of money.
1. In-flight failure - USD 500.000
2. Flight cancellation - USD 50.000
3. Incident on ground - USD 100.000
Airlines losing at least $ 1.000.000 per year.

Fender Benders
Fender Bender incidents are not really noticed by public. Theses

incidents happen quite often on the runway, taxi way, apron or in
the hangar, documented only by the airlines themselves and causing
costs in the order of millions of US dollars.
1.6 MURPHYS LAW
Murphy's law is a popular adage in Western culture that most
likely originated at Edwards Air Force Base in 1948. The law
broadly states that things will go wrong in any given situation, if
you give them a chance.
'If there is more than one way to do a job, and one of those ways
will result in disaster, then somebody will do it that way.'
Tendency of human being towards complacency.
Can be regarded as notation if something can go wrong it will.
It is not true incidents or accidents ONLY happen to people who

are irresponsible or sloppy.

1.6 MURPHYS LAW
Simply means when an a/c parts can possibly be installed

incorrectly, someone will do it.
Many times these maintenance error are not discovered until

the a/c is in flight
Read as if there are two or more ways to do something, and

one of those ways can result in a catastrophe, then some one will
do it

1.6 MURPHYS LAW
If something can go wrong, it will go wrong
Some remarks to think about:
Nothing is as simple as it may appear
Everything takes longer than you assume
If there is the possibility that things may go wrong, they will go

wrong and cause the most severe damage.
Things you leave on their own will go from bad to worse.

1.6 MURPHYS LAW
You are always intervened, if you seriously want to spend time with
something.
Every solution generates two new problems.
It is impossible to design anything absolutely safe. Fools are very

inventive.
Nature always takes sides for the hidden error.

END
OF
PRESENTATION
07/02/2017

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INTRODUCTION

Prepared By: Abdul Ghani Abdul Samad 1

Prepared By: Abdul Ghani bin Abdul Samad 3

During pushback No AME available

How the human body works,

How the brain processes information received, a little psychology,

How we interact with others through effective communication

Prepared By: Abdul Ghani bin Abdul Samad 8

To achieve the ultimate goal safe and efficient flight

To minimise accidents and incidents

To investigate the causes (including the underlying hidden

Prepared By: Abdul Ghani bin Abdul Samad 9

The Need to Take Human Factors Into

Incidents Attributable to Human Factors

Prepared By: Abdul Ghani bin Abdul Samad 10

Upon completion of this subject, the participants should be able

Demonstrate the understanding of human performance and

Prepared By: Abdul Ghani bin Abdul Samad 11

Europe - Ergonomics or Cognitive ergonomics

Research - human performance, technology, design

Focuses on how people interact with products, tools, procedures

Human factors practitioners

Psychologists (cognitive, perceptual and experimental) and

Ergonomics focus on anthropometrics for optimum human/machine

Human factors focused on Cognitive and perceptual factors.

07/02/2017 Prepared By: Abdul Ghani Abdul Samad 13

control and display attention

Humans and humans.

Also describes as:

Human capabilities and limitation

Prepared By: Abdul Ghani bin Abdul Samad 16

In terms of safety, all domains are interrelated. Therefore, all

Human factors continuation training should be of an appropriate

Human factors' means principles which apply to aeronautical

Satisfy a regulatory requirement (EASA Part 145) to;

Provide initial Human Factors training

Improve a return of experience system (i.e. learning from errors)

Provide continuation training on Human Factors

Improve people and product safety in maintenance

Prepared By: Abdul Ghani bin Abdul Samad 19

poor verification of time pressure

During the 1950s the US Air Force initiated experiments to

Prepared By: Abdul Ghani bin Abdul Samad 22

That same year, a Boeing

Prepared By: Abdul Ghani bin Abdul Samad 23

This accident did provoke high public concerns in terms of human

During the 1990s the FAA invested in extensive research programs

Prepared By: Abdul Ghani bin Abdul Samad 24

Accident statistics Boeing study

Prepared By: Abdul Ghani bin Abdul Samad 26

Prepared By: Abdul Ghani bin Abdul Samad 27

The causes were:

Incomplete installation 33%

Component damage (during installation) 14.5%

Inaccurate installation 11%

Missing equipment 11%

Prepared By: Abdul Ghani bin Abdul Samad 29

Prepared By: Abdul Ghani bin Abdul Samad 30

Prepared By: Abdul Ghani bin Abdul Samad 31

Aloha flight 243 ( April 1988 )

Prepared By: Abdul Ghani bin Abdul Samad 32

Investigations found out that unconventional work flows during an

In addition, other DC10 operators were aware of this acutely

Today, new industrial reporting and quicker data exchange