Human Factors in

Aviation Maintenance.
An Introduction to Human Factors and
Maintenance Error Management.

Presented by: Roger Hughes Human Factors/MEDA

What is Human Error ?
An error is a human action (or human behavior) that
unintentionally deviates from the expected action (or
behavior).

Some situations encourages humans to commit errors.
Can you name a situation?

Human error happens when people:

Plan to do the right thing but with the wrong outcome.
Do the wrong thing for the situation
Fail to do anything when action is required.
CHAIN OF EVENTS
Multiple contributing factors (causes) that can
link up and lead to an accident.
Contributing factors is anything that affects how
a human does his/her job.

CHAIN OF EVENTS
BREAK THE CHAIN OF
EVENTS or PREVENT THEM
FROM FORMING
SAFETY NET

Wheres my net?
Human Error Photo Gallery
Larger Commercial Jet Aircraft Fatal Accidents
From August through December 2005

August 02, 2005 Air France - A340 Toronto 0 fatalities
August 06, 2005 - Tuninter - ATR72 Sicily 16 fatalities
August 14, 2005 - Helios Airways B737 Athens 122 fatalities
August 16, 2005 - W. Caribbean MD80 Caracas -160 fatalities
August 23, 2005 Trans Peru B737 Peru 43 fatalities
Sept. 05, 2005 Mandala Airlines B737- Medan 101 fatalities
October 25, 2005 Bellview Airlines B737 Lagos 117 fatalities
December 08, 2005 Southwest Airlines B737 - Chicago 1 fatality
December 10, 2005 Sosoliso Airlines DC-9 Nigeria 103 fatalities
Dec. 19, 2005 Chalks Airways Grumman G-73 Miami - 20 fatalities

Total # of fatalities = 683
Attention Falls on Human Error in Fatal Helios Airways Crash
Probable Cause: Human Error = Wrong Fuel Gauge

Structural Failure May Have Led to Chalks Air
Crash
United Airlines Flt 173
Portland , Oregon
December 28, 1978
History of Human Factors Training
The information below represents events that led to the
development of Human Factors in the airline industry.
Aloha Airlines Flt 243
Maui, Hawaii
April 28, 1988
Air Ontario Flt 1363
Dryden, Ontario
March 10, 1989


Cockpit Resource Management

CRM
Crew Resource Management
LOFT
Line Oriented Flight Training
CCC
Crew Coordination Concept


HPIM
Human Performance in Maintenance

MRM
Maintenance Resource Management

DC-8 Main Landing Gear
United Flight 173
United Flight 173
Aloha Flight 243
Maintenance Resource Management Programs
Human Factors Working Group Delegates
JFK: Jazmin Galarza, JFK: Herbert Hassell, JFK: Vincent Migliori,
TPA: Stephen Washenko
Human Factors Working Group Delegates

FLL: Steve Wahab, IAD: Scott Shipman, BOS: John Cross, LGB: John Byner
Human Factors Working Group Delegates
OAK: Shirish Karnik (Chewy), BUF: Jon Ross, LGA: Joshua Pais,
PBI: Adrian Wintsch
Contributing Factors to Maintenance Error.
What we usually call human error is really system error. People are only
one part of a system that includes all of the other parts of the organization.
Immediate Environment Organization
Facilities Philosophy
Technician Weather Supervision Policy
Knowledge A/C design/config. Planning Procedures
Skills Equipment/tool/parts Organization Training
Ability Maintenance manuals Prioritizing Corp. Culture
Personal Issues Tasks Instructing MEMS
Time pressure Feedback
Teamwork Performance
OJT Training Management
Communication Team Building


70 Percent of Maintenance Errors are attributed to these contributing factors
30 Percent of Maintenance Errors are attributed to these contributing factors

Aircraft Maintenance
Human Factors
Statistics
70 to 80 Percent of aviation accidents are caused by
human errors and violations. (Flight/ATC/A/C
Maintenance)

A maintenance event started the accident chain in
26% of the worldwide accidents in 2003 for
Western/Eastern-built jets and turboprops.

It is estimated that every 9 days there will be a
commercial hull loss by 2020

12 to 15 percent are directly attributable to Aircraft
Maintenance
Aircraft Maintenance
Human Factors
Cost To The Bottom Line

>A/C Maintenance responsible for :

20-30 % of all in-flight engine shutdowns at $500,000 per
event.

50 % of all flight delays at $10,000 per hour.

50 % of all flight cancellations at $50,000 per event.

Avg. ground damage incidents cost $70,000 per event.

ATA estimates that ground damage cost $ 5 Billion per
year.
Johns Definition of HF
Per John Goglia (former NTSB member) Human
Factors is mainly about teaching people how to
communicate. In the maintenance environment
communication doesnt mean you and I conversing while
were turning wrenches. It means learning how to
accurately pass job information to the guy/gal on the
next shift.




Aviation Week and Space Technology




Academic Disciplines in Human
Factors
Organizational Psychology
Courtesy of Galaxy Scientific Corporation
ERROR CAUSES
Dirty Dozen: ( Developed by Gordon Dupont )

1. Lack of Communication 7. Lack of Resources
2. Complacency 8. Pressure
3. Lack of Knowledge 9. Lack of Assertiveness
4. Distraction 10. Stress
5. Lack of Teamwork 11. Lack of Awareness
6. Fatigue 12. Norms
Errors: Could It Be That The Purpose Of Your Life Is
Only To Serve
As A Warning To Others!
Human Error
Human Error
Human Error
Human Error
$$$$$$$$$$$$
A
bird
In the
the hand
Once In A
A Lifetime
Once In A
A Lifetime
Seeing what you expect to see and not what is
actually there
Our Amzanig Biarn
I cdnuolt blveiee that I cluod aulaclty uesdnatnrd what I
was rdanieg. The phaonmneal pweor of the hmuan
mnid. Aoccdrnig to a rscheearch at Cmabridge
Uinervtisy , it deosnt mttaer in what oredr the ltteers in a
word are, the olny iprmoatnt tihng is that the frist and lsat
ltteer be in the rghit pclae. This is bcuseae the huamn
mnid deos not raed ervey lteter by istlef, but the word as
a wlohe. Amzanig huh? And I awlyas thghout slpeling
was ipmorantt!
An Accident Trajectory
Some holes due
to active failures
Some holes due
to latent conditions
HAZARDS
Losses
When All Our Defenses Fail!
NTSB Report of AA Flight 191
Pylon design too vulnerable to maintenance induced
damage.
Failure of engineering dept. to ascertain the damage
inducing potential of the procedure.
Failure of adequately evaluating the performance and
condition of the forklift to assure its capability for the
task.
Absence of communication between a/c maintenance
and engineering regarding difficulty encountered during
the procedure.
Failure to establish an adequate inspection program to
detect maintenance induced damage.
Violations
Violations differ from errors in that errors are
unintentional, whereas violations are deliberate.
Deviating from rules, procedures, instructions,
and regulations.

Violations are shaped mainly by attitudes,
beliefs, group norms, and safety culture.

Most stem from a genuine desire to do a good
job, seldom are they acts of vandalism or
sabotage.
Aircraft Maintenance
Human Factors
Aircraft Maintenance is a highly
error prone activity. Any
maintenance task performed on
an aircraft is an opportunity for
human error to be introduced.

Aircraft Maintenance
Human Factors
Our Human Factors Culture
(principles) must be adopted in a
positive and continuous fashion,
such that it becomes an integral
part of everyday thinking rather
than being something special.
GLAD To Be HERE!

Reference Material
Key websites using Google search engine:
http://hfskyway.faa.gov
http://www.caa.co.uk
http://ntsb.gov
http://www.grayowl.com
http://icao.int
http://www.marss.org
http://www.boeing.com
HF Books
Human Factors in Aviation Maintenance David Taylor
Managing Maintenance Error J. Reason and Alan Hobbs
Human Error James Reason
A Human Error Approach to Aviation Accident Analysis D. Weigmann & S.
Shappell
Advisory Circulars
AC 120-72 Human Factors training guidance