HUMAN FACTORS

CONTINUATION TRAINING

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 Rules for this Session

● Team Participation – all work together

● Confidentiality
● Respect each other’s view points
● No Mobiles/pagers
● Opportunities for Questions

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Objectives of this short session
● To find out what you remember about HF
● To remind you of things you should know
● To remind you of information sources
● To update you on new legislation and procedures
● To talk about how we can all learn from mistakes.
● Your actions are critical for safety
● Human Factors are relevant to you

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 Why do you need this
Refresher training?

Regulatory requirement:
EASA AMC 145.A.30(e)

Company requirement:
Maintenance Organisation Exposition (MOE)
Part 3 Procedure 3.13

easyTech values HF

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 What Is Human Factors (HF)?
It’s the variable performance of humans, based on the
working environment, equipment used and the
procedures and regulations followed.

What is the aim of this training?

To increase safety, quality and efficiency by
reducing human error and its impact in
maintenance operations

Error / incident reduction

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 MOE

 Accessed: Via iNet

 Issued with the authority of the Accountable Manager.

 It is incumbent on all company personnel to periodically

familiarise themselves with the contents of this manual.
together with the supporting procedures.

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 Error Management System
Aims and Objectives.
Identify the factors contributing to incidents or potential
incidents, and to make the easyTech system resistant to such
errors.

Encouraging Reporting
All Members of staff are actively encouraged to submit
reports using the easyTech internal reporting system i.a.w
MOE Procedure 2-30

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 Managing & Investigating
Maintenance Error Occurrences

MOE Procedure 2-25

The Quality Assurance Department will
manage the occurrence reporting system and
they will process all reported incidents where
easyTech are involved or implicated.

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 Incident Reporting
Mechanisms Of Feedback
Once an investigation of an incident/error has been concluded.
• The root cause will have been defined.
• The relevant corrective and preventive action will have been
applied.
Feedback to staff will be carried out via a combination of the
following:-
• Change to a procedure/s
• Issuing a Quality Advisory Notices
• Continuation training

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But because a picture is worth
a thousand words………..

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 CHIPS MODEL Quiz

C_u _l _t u_ _r e
_ It can be best described as “The way we do
things around here”

Ha_ _r d
_w a _r e
__ _ Refers to tools, vehicles, office equipment, GSE
and everything needed to do the job

I n_ _s _t r_ u_ c_ t_ _i o_ n_ s_ These are things to be followed: company

procedures, work cards and AMMs

P_h _y _s _i c
__a _l This is weather, noise, lighting heating: the
working environment

So
__c _i a
_ _l Interaction, differing personalities, team
work, leadership skills

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 Case Study One

Left Hand Altimeter slides out

of its retainer on take-off.

Defect reported by flight crew :

1. “Info from crew was differential reading between Pilot and Co-
Pilot’s altimeters.”

2. Defect rectification carried out between flights.

3. Aircraft went straight back into service after rectification.

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 Case Study One

What happened next?

Read incident details, on sheet provided,

and discuss in groups what you think
happened.

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Conclusion.

The engineer confirmed he omitted to tighten the locating

screws, causal factors:-
• Under extreme pressure
• Repeated interruptions

The engineer was reminded of his responsibilities and the

need to be particularly vigilant whilst conducting and
certifying maintenance within restricted time frames.

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 Knowledge Test

1. What is the Dirty Dozen?

A? The 12 most time consuming jobs on an aircraft.
B? 12 items that feature singularly or in combination when the circumstances
surrounding an incident are investigated
C? The 12 most important Company Procedures

2. What does the "Reason Model" in the HF course illustrate?

A? Factors can line up to cause accidents/errors
B? There is no reason for any staff, other than Engineers to worry about HF
C? Incidents happen for a reason

3. What is one method of managing attentional capture

A? With personal worries
B? By taking only a quick look
C? Use detailed check sheets

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 Reason Model

Organisational
problems
Local problems
Unsafe acts

Safeguards

Picture adapted from: MRM Web Based Training, Lesson: Human Factors Fundamentals:
‘The Swiss Cheese Model. FAA/AAM, http://www.hfskyway.com/training_toc.htm.

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 The Swiss cheese model

Organisations have many defensive layers.

• Some are physical barriers (alarms, automatic
shutdowns, etc),

• Some rely on individuals being able to recognise and

counteract performance limiting elements.

• Some are dependent on procedures and

administrative controls.

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 The Dirty Dozen
After investigations of numerous incidents
these are the human fallibilities that can
be individually, or in combinations, identified
as contributing to incidents.

Can you remember what the 12 are?

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 Dirty Dozen by MARSS

Fill in the picture titles, using the following:-

Communication Stress
Awareness Pressure
Resources Teamwork
Distraction Knowledge
Fatigue Norms
Complacency Assertiveness

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 Dirty Dozen by MARSS

The answers……..

1. Lack of communication
Use log books, discuss work, never assume, use
written and verbal handover.
2. Complacency
Never sign for anything you didn’t do, train
yourself to expect to find a fualt
3. Lack of Knowledge
Get training on type, use up to date manuals

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 Dirty Dozen by MARSS

The answers……..
4. Distractions
Always finish job first, mark uncompleted work,
double inspect, use detailed check sheets
5. Lack of Teamwork
Discuss how a job is to be done, be sure all
involved understand
6. Fatigue
Be aware of your circadian rhythm, be aware of the
symptoms in yourself and others, sleep and
exercise regularly

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 Dirty Dozen by MARSS

The answers……..

7. Pressure
Be sure not self induced, communicate concerns,
ask for extra help, just say no!
8. Lack of Resources
Order and stock anticipated parts before required,
know available parts sources, maintain a standard
9. Lack of Assertiveness
Refuse to compromise your standards, if it’s not
critical record it in log.

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 Dirty Dozen by MARSS

The answers……..

10. Stress
Be aware of how it can effect you, take breaks,
discuss it with someone, exercise your body
11. Lack of Awareness
Will your work conflict with other work, consult others,
think about the consequences of your actions
12. Norms
Be aware “norm’s” doesn’t make it right, remember
procedures are there for a reason, follow them

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 CASE STUDY TWO

An Air Data Computer

worth $500,000 is scrapped
by mistake

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Meet our office worker Mr. Smith….

…He’s having a bad day,

slept through alarm,
missed the bus, paid for
taxi to work

….only 4 weeks in job, late twice

last week….

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 Mr Smith
No technical aircraft training
No previous experience

…..he has an Air Data Computer worth $500,000

which needs a repair. He sends it out to an
external vendor as SRT have no capability…..

ADC received by vendor

Initial investigation
Quote prepared $8,000, and faxed to Mr Smith.
Mr Smith faxed copy to customer as this was a
customer owned unit

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….he wondered if the unit might be BER
(beyond economical repair), tried to find the
cost of an ADC……

….work pressures
were building up and
he couldn’t find the
cost of the ADC
anywhere…..

…no more work please…….

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It’s only a computer it can’t be
worth that much.
The customer has accepted the
quote.
If only my manager wasn’t cross at
me for being late, I could ask for
some advice”

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…….instructions sent to the vendor to scrap the unit.
The customer had agreed to the unit being scrapped so
no bill of $500,000 to SRT luckily!!

So What went wrong?

• Not fully trained- lack of experience
• Didn’t follow Company Procedures
• Quote approved above authorisation levels
– work around
• Pressure of workload
• Lack of supervision

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 Knowledge Test
4. What will push arousal levels to high, thus effecting
performance?
A? High stress levels, excessive intake of caffeine
B? High temperature, alcohol
C? Repetitive tasks, large meals

5. Who is responsible for familiarizing themselves with company

procedures and high level documents?
A? Members of senior management
B? Line managers and Engineers only
C? All staff regardless of role or seniority

6. Who is responsible for controlling the hours worked by

employees?
A? Managers
B? The employee
C? The regulatory authority (CAA)

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 Performance variability

Human performance is intrinsically variable.

● Linked to your level of arousal (energising of nervous system)
● All have variations in arousal based on our Circadian
Rhythm.
● Typical low at 4:00am. Natural body clock is 25 hour
Cycle.
● Individual differences, such as age & experience, must
be taken into account.

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 Performance limitations
Information processing by our senses and by
memory can be degraded by human factors such
as:
alcohol, fatigue, stress, poor motivation, too high
or low arousal, insufficient attention.

Also, our brain may make a biased

interpretation of things we see…

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The two planes appear to be touching! The 757 is on final for 28L while the 747 is for 28R. The
runways are 750 ft apart, so there is still plenty of room between them. Incidentally, Lufthansa 455
is seen here returning to SFO due to an oil leak and eventual shutdown of the number 2 engine.
Note rudder is deflected to the right compensating for the failed engine on the left side.

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 How alcohol
affects performance
Drinking in 1 hour on an empty stomach:
Note 2 bottles of beer =1.2 pints=2 measures of spirit
.
● 2 bottles of beer - loss of inhibition; some loss of co-ordination; safety
of work affected for 1 hour

● 4 bottles of beer - faulty decision-making; further loss of co-ordination;

drowsiness; safety of work affected for 3 hours

● 6 bottles of beer - reactions significantly slowed; safety of work

affected for 5 hours

● 8 bottles of beer - all reactions depressed; safety of work affected for

7 hours

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 How to handle drugs
● if drug information advises not to, do not operate equipment
 follow prescribed dosage exactly
 do not take drugs in combination except under medical
supervision
 do not take drugs prescribed for others
 do not use “recreational” drugs (e.g. LSD, marijuana, cocaine,
ecstasy etc.)

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 Performance and human factors

What is stress?
HSE defines it as "the adverse reaction people have to
excessive pressure or other types of demand placed on them".

Why do we need to tackle stress?

• up to 5 million people in the UK feel "very" or "extremely" stressed
by their work
• a total of 12.8 million working days were lost to stress, depression
and anxiety in 2004/5.*

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*HSE website www.hse.gov.uk/falls/wahr.htm
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Dealing with stress

● a plan to tackle the stressors/pressures

● regular physical exercise
● healthy eating and adequate sleep
● talk to someone

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Speaker- Transfer Decoding-
Encoding Mode Listener

Feedback
Communication Process

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“Rights” for Assertive Behaviour

 The right to state your ideas

 The right to ask for clarification
 The right to be listened to
 The right to question decisions
 The right to say “NO”
 The right to freely disagree

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 The Double Standard
What is your understanding of the term?

Examples:-
• Black books
• Work arounds

Why?
• Easier
• Quicker

What are the limitations?

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 A T ’ S
WH
W ?
NE

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 AWN 47- Personal Responsibility
Of Licensed Aircraft Engineers

New Legislation came into effect late 2003.

Police have been given the powers to test maintenance

engineers for drink or drugs should they have concerns that
the task performance of an individual associated with an
incident has been impaired due to the consumption of
alcohol or controlled substances.

The acceptable blood/ alcohol limit has now been reduced

to 80 milligrams of alcohol per 100 millilitres of blood.

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 WHAT’S NEW? “In 2004/2005 in the
UK 53 people died
and nearly 3800
The Work at Height Regulations 2005 came suffered a serious
into effect on 6 April 2005. The Regulations injury as a result of a
will apply to all work at height where there is fall from height in the
a risk of a fall liable to cause personal injury. workplace.”

If you are an employee or under someone else’s control, regulation 14

says you must:
● Report any safety hazard
● Use the equipment supplied properly, follow any training and instructions

As part of the Regulations, duty holders must ensure:

● all work at height is properly planned and organised;
● those involved in work at height are competent;
● the risks from work at height are assessed and appropriate work equipment is
selected and used;
● the risks from fragile surfaces are properly controlled; and
● equipment for work at height is properly inspected and maintained.

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 WHAT’S NEW?
From February 2006 the new Noise at work
regulations come into force
170,000 people in the UK
suffer deafness, tinnitus
or other ear conditions as
a result of exposure to
excessive noise at work*

Regular exposure to noise at or above 85 dB(A)

(previously 90 dB(A)) is likely to cause
permanent hearing loss.

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*HSE website www.hse.gov.uk/falls/wahr.htm
 A N D
A R Y
MM O N S
SU L U S I
N C
CO

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 M A RY
SU M D
AN O NS SAFETY
C LUS I
CO N
 The first law of all operations is SAFETY.

 Where you feel safety may be compromised, just say No!

 Adopt the principle that safety is of paramount importance

regardless.

 Follow the standard procedure.

 If there is a gap between the procedure and the current working

practice take steps to update the procedure.

 What is the safety consequences of not doing the job correctly?

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 M A RY
SU M D
AN O NS
LU SI
C
CO N

Incidents share similar characteristics:

● Unclear or poor procedures
● Lack of equipment, tools, spares
● Communication breakdowns
● Time pressure
● commercial motives Vs airworthiness
● Fatigue

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 M A RY
SU M D
AN O NS
C LUS I
CO N

performance is also vulnerable to a

range of external factors such as:
● the organisational culture
● the design of hardware
● the accessibility of appropriate instructional guidance
● the physical environment
● the social environment

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 M A RY
SUM D
AN O NS
C LU SI
CO N

thus the professional needs to:

● be AWARE of their limits and variability

● be AWARE of external factors which can challenge their

performance

● FOLLOW PROCEDURES to eliminate or minimise the detrimental

effects on performance of these human factors

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 Evaluation Feed Sheets
● Please fill out evaluation form

● Very important for the course

● Be critical

● Be honest

● This is essential to improve for the future

● Any other comments

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