EASA 145 & 66 Human factor Training

7/24/2019 EASA 145 & 66 Human factor Training

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Maintenance

Human Factors TrainingEASA 145 & 66


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Maintenance Human Factors

This training is based on EASA 145, whichrequires

That maintenance organizations put in place amaintenance Human Factors program thataddresses ten (10) maintenance Human Factorsissues, and where

One (1) of the issues is the need to trainmaintenance staff to be competent inmaintenance Human Factors knowledge andskills


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EASA 145 Maintenance Human FactorsTraining Requirements

1. General / Introduction to human factors

2. Safety Culture

3. Human Error4. Human Performance & Limitations

5. Environment

6. Procedures, Information, Tools and Practices

7. Communication8. Teamwork

9. Professionalism and integrity

10.Organizations HF Program


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I. General

Introduction toHuman Factors


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Definition

Human Factors is a technical discipline aimed atoptimizing human performance within a system bycontributing to the planning, design, and evaluation of

tasks, jobs, products, organizations, environmentsand systems in order to make them compatible withthe needs, abilities, and limitations ofpeople.

This Not This


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Where Can Human FactorsBe Applied in Maintenance?

Manuals &Procedures

Training

OperationalControls & Displays

Design forMaintainability

Human/ComputerInteraction

Work GroupProcedures


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SHELL Model


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Variations in Performance & limitations

Physical size & shape

Physical needs (sustenance, sleep etc)

Input/Output Characteristics Information processing

Environmental tolerances (temp, pressure,humidity, enclosed space, stress & boredom)

Liveware


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Ergonomics Tool design & operation

Instrument interpretation

Work space & access

GSE reliability

Liveware Hardware


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Non-physical aspects of systems such as:

Document design & layoute.g. maintenance manual

Symbology and computer programmes

Procedures

Training manualsi.e. content and design

Rules and regulationsi.e. company and authority

Liveware Software


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Extremes of temperature affects thoughtprocesses

Excess noise and vibration affectsconcentration

Shift work causes fatigue making error prone

Liveware Environment


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Leadership, co-operation,teamwork, personality

interactions Staff/management relationships,

corporate culture & climate,company operating pressures

Domestic Pressure

Liveware Liveware


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Causes of Accidents

Source : FSF , 2000


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Causes of Accidents

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

1903 TodayTIME

~80% of accidents are now

due to human error

~20% of accidents are now

due to machine causes


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Maintenance-Related Accidents

Maintenance system failures, due to errorsand/or violations, can affect safety of flight in twodifferent ways:

1. Primary Cause of an accident. Accident is due tothe maintenance/inspection failure. Accident is not inany way due to flight crew action.

2. Contributing Factorto an accident. Accident

chain begins with a maintenance/inspection failure thatis incorrectly handled by the flight crew, ultimatelyending up as an accident (Primary Cause is pilot error).


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Accident Where Maintenance Isthe Primary Cause

Kahului, Hawaii, U.S.A. 1988 Upper fuselage separation 737-200


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Kahului 737 Event

Post incident inspection revealed that there were atleast 240 cracks present at the last inspection prior

to incident.Among the contributing factors to the error of notseeing the cracksLack of resourcesNo proper platform or inspection lights.

FatigueInspection carried out late at night.

Lack of technical knowledgeNot enough inspectiontraining.

ComplacencyDone other aircraft and had not find anycracks.


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Maintenance as a Primary Cause

Data provided in a recent Advance-Notice ofProposed Amendment No xx/2007 from EASA*.

Primary Cause of HF-Related Accidents # of Accidents % of Total

Design 135 3%Production 101 2

Operations (flight crew related) 3038 58

Maintenance 416 8

ATM 66 1

Dispatch 18 0

Loading 129 2

TOTAL HF-Related Accidents 3903 75

Non-HF-Related Accidents 1320 25

TOTAL 5223 100*Data obtained from EASA Safety Analysis & Research. It is based on airliner accidents only, covering the period

1990 to January 2006. Only reports where causal factors have been positively identified are included in the analysis.


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Accident Where Maintenance Is aContributing Factor

Lima, Peru 1996 Tape left on static ports 757-200


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Lima 757 Event

The aircraft's three static ports on the left side wereobstructed by masking tape. The tape had beenapplied before washing and polishing of the aircraft

the day before the accident flight.Work was begun on one shift and handed over tonext mornings shift.

Poor shift handover log was a contributing factor.

Mechanics and pilots both missed tape during walkaround.


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Safety Costs ofMaintenance Events 2003

The International Air Transport Association (IATA)Safety Report 2003 found that in 26% of theaccidents a maintenance-caused event started the

accident chain.

IATA Safety Report 200640%



Note: IATA did not distinguish between maintenance asa Primary Cause vs. a Contributing Factor.


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Monetary Costs of Maintenance Error

Maintenance error caused

20% to 30% of in-flight shutdowns (IFSDs) at a

cost of US $500,000 per IFSD50% of flight delays due to engine problems at acost of US $9,000 per hour.

50% of flight cancellations due to engine problems

at a cost of US $66,000 per cancellation.


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Murphys Law


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Summary

About 80% of aircraft accidents today are caused by humanerrors.

Maintenance and inspection errors are the primary cause of

8% of the accidents.Maintenance and inspection errors are a link in the accident

chain in an additional 20% - 30% of the accidents.

Maintenance and inspection errors can also be very costly.

The whole industry (manufacturers, vendors, aviationauthorities, airlines, and maintenance providers) must worktogether to reduce the risk from these errors.


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II. Safety Culture/Organisational factors


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Safety Culture

EASA 145 requires that a maintenanceorganization develop a Safety Culture

within the organization.One way to begin development of aSafety Culture is to put the elements of

a Safety Management System intoplace.


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Safety CultureSafety Management System

Definition of culture/safety culture

Importance of a good safety culture

Elements of a good safety culture

Safety Management System (SMS)

International Civil Aviation Organization

(ICAO)

General characteristics and functions ofan SMS


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Definition of Culture

Culture = Customary beliefs, behaviorpatterns, and traits of a racial, religious, orsocial group

Any organization has a culture of its own

Management style

Morale

Acceptable behaviors

Norms


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Definition of Safety Culture

What is a safety culture as it applies to anaircraft maintenance organization?

A safety culture is a (maintenanceorganization) culture in which safety plays amajor role.


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Importance of a Good Safety Culture

Safety, as it applies to maintenance, hasthree components1. Maintenance actions (e.g., an installation error) can

lead to safety of flight issues2. Mechanic actions can lead to personal safety issues

(e.g., cuts, puncture wounds, and broken bones)

3. Maintenance actions can lead to environmentaldegradation.

A good safety culture will reduce theinstances of all three of these events,reducing the accident rate and, thus,saving lives and money.


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J. ReasonThe Elementsof a Good Safety Culture

Informed CultureA culture in which those whomanage and operate the system have currentknowledge about the human, technical,

organizational and environmental factors thatdetermine the safety of the system as a whole.

Reporting CultureA culture in which people arewilling to report errors and near misses.

Learning CultureA culture in which people havethe willingness and competence to draw the rightconclusions from its safety information system, andthe will to implement major reforms when the need isindicated.


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J. ReasonThe Elementsof a Good Safety Culture

Just CultureA just culture where anatmosphere of trust is present and people areencouraged or even rewarded for providing

essential safety-related information, but wherethere is also a clear line between acceptableand unacceptable behavior.

Flexible CultureA culture that has

organizational flexibility typically characterizedas shifting from the conventional hierarchicalstructure to a flatter professional structure.


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Achieving a Safety Culture

A Safety Culture is achieved over time,requiring:

A commitment to safety from the SeniorManagement down through every worker in theorganization.

A process for achieving safety. This process

often is called a Safety Management System.


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III. HumanPerformance

& Limitations


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Human Performance &Limitations

Normal curve

Human strengths andweaknesses

VisionHearing

Information processing

Attention and

perceptionMemory

Speed/accuracy trade-off

Physical work

Fatigue and sleep

Claustrophobia and

physical accessFitness and health

Alcohol, medication, anddrugs

Repetitive tasks/complacency


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Introduction to Human Performance

Human beings have strengthsand weaknesses

Tasks that do not account forhuman limitations result in: Errors Injuries

If you review a task or workstation, do not ask:

Can it be done?

Ask:

Can it be done safely andcorrectly by the people whodo the job?

Vision

Hearing

Cognition

Strength

Reach


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Humans Are Betterthan Machines in

Detecting small amount of visual and acoustic energy.

Perceiving patterns of light or sound.

Improvising and using flexible procedures.

Reacting to unusual or unexpected events.

Storing very large amounts of information for long periods and recallingrelevant facts at the appropriate time.

Applying originality at solving problems.

Reasoning inductively.

Exercising judgment.

Learning from experience.Use a human operator when a system componentis needed that can think on its feet, process information

in ways that could not be predicted, and can then acteffectively using the result.


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Machines Are Betterthan Humans in

Responding quickly to control signals.

Applying great force smoothly and precisely.

Performing repetitive, routine tasks.

Storing information briefly and then erasing itcompletely.

Reasoning deductively, including computational

ability.Handling highly complex operationsdoing manydifferent things at once.


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Other Major Differences

Machines can be modified, redesigned, andretrofithumans cannot.Humans are born with innate, genetically determined

differences that are shaped by the environment. Innate aptitudes or abilities are developed througheducation and training.

Machines can be manufactured to be identicalwith (nearly) identical output or performance.Humans are not identical and vary across all sensory,cognitive, physical, and performance characteristics.

Specific aspects of human performance can be mademore equal through education and training.


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Vision Performance Issues

Being able to see clearly is vitalin aircraft maintenance andinspection.

Vision requirements are taskbased.

Illumination requirements are

task based.Technicians must recognizetheir individual visuallimitations and capabilities.


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The Normal Visual Field

Provide visual access to workarea... Without excessive bending

For both short and tall peopleVisual access is critical to...

Doing the task

Visual validation of the task

Examples of problems due topoor visual access: Incorrect attachment

Inspection errors

Increased task time


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Colorblindness

Complete color blindness is quiterare.

Most people are actually colordeficient and have problems

seeing red and green.About 10%-15% of males and 1%

of females are color deficient.

Most do not even know.

They learn to compensate with

degrees of brightness andtexture.

If you find you have it, avoiderrors by asking other peoplewhen you are unsure.

An estimation of what the spectrum lookslike for different types of colorblindness.

No Red receptors

No Green receptors

No Blue receptors


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A Quick Colorblindness Test

This is a demonstration.You should see the number 12.


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What Numbers Do You See?


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Recommended Illumination Levels*

Tasks

Illumination Levels in Lux Light

SourceRecommend Minimum

Perceiving small details with low contrast for

prolonged times, or where speed and accuracy are

essential, such as repairing small components,

inspecting dark materials

1650 1075 General service

plus

supplementary

Perceiving small details with fair contrast where speed

and accuracy are not so essential, such as electronic

assembly


and/or

supplementary

Prolonged reading, desk or bench work, general office

and laboratory work, such as assembly work and filing

records


and/or

supplementary

Occasional reading, recreation, reading signs where

visual tasks are not prolonged, such as reading abulletin board


and/orsupplementary

Perceiving large objects with good contrast, such as

locating objects in a bulk supply warehouse


Passing through walkways and handling large objects,

such as loading from a platform


*Illumination requirements for representative tasks (MIL-HDBK-759A)


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The Human Auditory System

The outer ear collects sound

The middle ear channels sound to theear drum

The inner ear converts sound to nerveimpulses

Tiny hair cells (cilia) in the Cochleavibrate with different sounds

Excessively loud noise can result inthe hair cells stretching too far andbreaking

Listening to the same frequency orpitch for a long time can also damagethe hair cells

Listening to loud noise for a longperiod can also cause fatigue

Outer Ear Middle Ear Inner Ear

Ear Drum

Cochlea


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Protect Your Hearing!!

Types of Hearing ProtectionDisposable plugs

Reusable plugs

Custom-fitted plugsEar muffs

Wearing Hearing Protection ProperlyFollow package directions when putting protection on.

Make sure the selected protection fits properly.Maintain hearing protective devices in a sanitary condition.

Make sure nothing interferes with the use of hearingprotectors (e.g., eyeglass frames).


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Sound Intensity Levels

Db Level Example Dangerous Time Exposure

0 Lowest sound audible to ear None

30 Quiet library, soft whisper None

40 Quiet office, living room None

50 Light traffic at a distance, refrigerator None60 Air conditioner at 6 m., conversation None

70 Busy traffic, noisy restaurant Critical level begins

80 Subway, heavy city traffic, alarm clock More than 8 hours

90 Truck traffic, lawn mower, shop tools Less than 8 hours

100 Chain saw, boiler shop, pneumatic drill Less than 2 hours

120 Rock concert in front of speakers, Immediate danger

sandblasting, thunderclap

140 Gunshot blast, jet plane @ 15 m. Any exposure is bad

180 Rocket launching pad Hearing loss inevitable

American Academy of Otolaryngology, Washington, DC


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Information

Processing/Attention and

Perception/Memory


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A Model ofHuman Information Processing.

(Adapted from Wickens, C.D. Engineering Psychology and Human Performance. Columbus, Ohio: Charles E. Merrill Publishing Co., 1984.)

Three types of memory Sensory memory

Working or short-term memory

Long-term memory

Attention (concentration) is a limitedresource, which must be shared between

Observing the situation

Deciding on a response

Executing the response


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Attention and Selection

The first process of memory is attention.

There is much more information in your environmentthan you can process at any one time.

You must make choices (conscious & unconscious)regarding the stimuli to which you will attend.

Early theory was that we could only attend to onething at a time.

That theory is still believed to be true. However, wecan switch our attention quickly, especially if theinformation comes from different channels (e.g.,hearing and vision).


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Working (Short-Term) Memory

This is the memory that we use, for example, whensome one gives us a phone number to call or givesus directions on how to find an office in a building

Working memory lasts only about 20 seconds,although you can make the memory last longer byrepeating the information to yourself in your head

Working memory can hold about 7 + 2 (5 to 9)

chunks of information. For example, you willremember the name

Steven as one chunk of information, not as sixseparate letters.


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Moving Information from Short-TermMemory into Long-Term Memory

All verbal information goes first into the short-termmemory.

When it is rehearsed (recited), part of it goes into

long-term memory.

The rest of it, usually the part we are leastinterested in, returns to short-term memory and isthen forgotten.

Whether new information is "stored" or "dumped"depends, then, on our reciting it out loud and onour interest in the information.


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Accessing Long-Term Memory

Two ways to access your memory:Recallcoming up with the information from memory

Fill-in-the-blank exams

Coming up with a persons name.

Recognitionrecognizing the correct information Multiple choice tests

True/false tests

Recognizing someone that you know.

Recognition is easier than Recall.

Often need to recall information we learned longago. How quickly/reliably we recall it depends on:Activation: How long since we last used the information.

Strength: How well we have practiced it.


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Negative Transfer of Training

When you learn new material, old material that youlearned before is still in long-term memory.

If the new material is similar to the old material but

with some small differences, you can becomeconfused. Example: Mechanic knows how to replace a hydraulic pump on airplaneA. The airline buys a newer model--airplane B.

The pump bolts on airplane A must be torqued to 50 ft lbs

The pump bolts on airplane B must be torqued to 60 ft lbs

Later, the mechanic makes an error by:

Replacing a pump on airplane A and tightening the bolts to 60 ft lbs, or

Replacing a pump on airplane B and tightening the bolts to 50 ft lbs.

MESSAGE: Be sure to check details when things

are almost, but not quite the same.


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Physical Work


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Bio-Mechanics

Human Force

Application

Spine Geometry

Work Posture

Thisimagecannot currently bedisplayed.


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Occupational Risk Factors forCumulative Trauma Disorders

Force

Frequency

Vibration

Posture


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Neutral Position ofHand and Wrist


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OK Avoid

Work Posture - Hand and Wrist


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OK

Avoid

Work Posture - Arm and Shoulder


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OK Avoid

Work Posture - Arm and Shoulder


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Neck Flexion

Neck flexion greater than 30 degrees


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Back Flexion

Back flexion greater than 30 degrees


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Squatting

> 2 Hours per Shift


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Kneeling

> 2 Hours per Shift

Hands Above Head or


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Hands Above Head orElbows Above Shoulders

> 2 Hours per Shift

Repetitively Raise Hands Above


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Repetitively Raise Hands AboveHead or Elbows Above Shoulders

> 4 Times/Minute


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Highly Repetitive Motion Neck, Shoulders, Elbows, Hands

> 4 Times/Minute


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Highly Repetitive Motion andForceful Exertions with Hands

30o

Greater than 30 degrees


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Pinch Grip

Objects weighing > 1 kg per hand

or force > 2 kg per hand


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Pinch Grip Plus Repetitive Motion

> 4 times/minute


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Pinch Grip Plus Wrist Deviation

30o



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Power Grip

Objects weighing > 5 kg per hand

or force > 5 kg per hand


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Power Grip Plus Repetitive Motion

> 4 times/minute


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Power Grip Plus Wrist Deviation



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Repeated Impact - Hands

> 10 times/hour


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Repeated Impact - Knees

> 10 times/hour


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Intensive Keying and Mousing

> 40 words per minute


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Lifting

> 11 kg or > 5 kg more than

two times/minute


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Pushing/Pulling

> 16 kg of initial force


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Use of Vibratory Tools


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Workstation Design

Design work stations for a range ofpeople, not for the average person

Permit several different workingpositions

Design should start from the pointwhere the hands spend most oftheir time

Work should be conductedbetween shoulder and waist height

Raise the work surface for workthat requires precision, so it iscloser to your eyes

Lower the work surface for workthat requires more force so yourarms are in a more neutral position

Boeing airplanes are designed forpeople from 157 cm to 193 cm

A drill which allows the user tochange grip positions

A component work bench whichholds the component in the centerand the tools around it

Getting a ladder so that you arenot working over your head

Raising a manual to see detailor a component work bench whichmoves up and down.

A component work bench whichholds a hydraulic pump at aboutwaist high

Principle Example


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Fatigue

andSleep


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Fatigue

EASA-145 requires the organisationsplanning procedures to take into

account the limitations of humanperformance, focusing on fatigue.


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Definitions

FatigueA feeling of lack of energy,weariness or tiredness. Also calledtiredness, weariness, exhaustion, or

lethargy. Fatigue is a normal response tophysical exertion, emotional stress, andlack of sleep.

AlertnessVigilantly attentive andwatchful; mentally responsive andperceptive.


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Effects of Fatigue

More than 100,000 car accidents annually inthe US are fatigue-related

Disasters such as:

Chernobyl (Russian nuclear power plant)Three Mile Island (US nuclear power plant)

Bhopal (chemical release in India)

Exxon Valdez (oil supertanker accident in

Alaska)were officially attributed to errors in

judgment induced by fatigue.


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Effects of Fatigue

Overall performancegets worse

Loss of motivation

Slowed reactions

Forgetful

Poor cognitivefunctioning

Thinking

Reasoning/judgment

Problem solving/decision making

Loss of creativity

Withdrawal from socialsituations

Mood changes

Increase alcohol use

Long term health candegrade

Quality of life degrades


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Our Circadian Sleep Wake Clock

Alertn

ess

Low

High

6 am Noon 6 pm Midnight 6 am

Time of Day3-5 am and pm = sleepy9-11 am and pm = alert


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Sleep

Sleep is defined as a state of partial or fullunconsciousness during which voluntaryfunctions are suspended and the body rests

and restores itself.Lying down

Little movement

Do not respond as readily to disturbances

Reversiblecan wake up

Observed in all mammals, all birds, and manyreptiles, amphibians, and fish.


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Sleep

Still not totally sure why we need sleep, but thereare two theoriesEnergy conservationsleep to conserve energy (old theory)

Restoration(new theory)

Neural circuits in the brain are rewired

Memory is consolidated and strengthened

Short-term memory items move into long-term memory

Growth hormone levels are restored

Blood pressure drops

The cells in your organs are strengthened by protein synthesis Sleep breaks your stress pattern.

Also, we know that bad things happen if we donot sleep.


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Effects of Missing Sleep

A person who loses one nights sleep will generallybe irritable and clumsy during the next day and willeither become tired easily or speed up because of

adrenalin.After missing two nights sleep, a person will haveproblems concentrating and will begin to makemistakes on normal tasks.

Three missed nights and a person will start tovisually hallucinate and lose grasp of reality.


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How Much Sleep Do You Need?

Depends onAgeHealthCircadian rhythmBody metabolismPhysical exercise levelThe quality of the sleepAmount of recent sleepBody temperaturePersonal differences.

Magic number of 8

hours of sleep is an

average.

Short sleepersNeedaround 6 hrs of sleep.

Long sleepersNeedaround 9 hrs of sleep.

1 in 25 people needmore than 10 or lessthan 5 hrs of sleep.

Avoiding FatigueNo Shift Rotation


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Avoiding Fatigue No Shift RotationGetting a Good Nights Sleep

Get up and go to bed at the same time.

If you are tired, go to bed early.

Use your bed only to sleepno reading, eating, etc.

Keep the bedroom dark, quiet, and cool (58F/15C).Exercise in the morning or early afternoon, not evening.

Do not eat a heavy meal before bed--a light snack at most.

No alcohol before bedtime, no caffeine after early afternoon,and avoid nicotine.

Quit worrying about falling asleepit keeps you from fallingasleep!

Stop looking at that clock! Get up if you are not sleeping.


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Avoiding Errors While Fatigued

Admit you are tired!

Remain physical to remain alert.

Exercise/stretch at frequent intervals.

Talk to people.Drink plenty of liquids.

Take a nap.

Avoid tedious, boring work.Work with somebody else so you can catcheach others errors.

Go back over and check your work.


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Drugs and Diet

Using drugs to get to sleep should be a last resort, because these drugsdecrease REM and deep sleep.

But, remember, there are drugs in food, also (like caffeine in coffee, tea,soft drinks, and chocolate).

Thus, it makes sense to approach food and drugs together.

Food and drugs release chemical that interact with our basic body rhythms.This interaction is one cause of the varied effects they produce.

One step in controlling the bad effects of foods and certain drugs is tocontrol when we consume them. If you are a morning person, the use of uppers like coffee and sugar-coated

cereal in the morning makes no sense.

Another control strategy is to avoid the combined consumption of food anddrugs that have similar effects. For example, combining downers, such as alcohol, sleeping pills, and pain

medication can be particularly dangerous.


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Drugs and Diet

Food in the stomach causes the stomach walls to stretch.The more the stretch, the stronger the signal to the body tosend blood to the stomach to aid digestion.

Diverting too much blood to the stomach by overeating cancreate a shortage of blood elsewhere, like your brain, whichcauses you to feel sluggish following a big meal.

Eating frequent, smaller meals is preferable to eating a fewlarge meals before and during work.

Eating smaller meals in the hours prior to heavyphysical work is a key dietary strategy for shift

workers.


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Physical Fitness

The Drug and Diet control strategies that we have discussedare meant to decrease the build up of stress resulting fromshift work.

However, some stress will still occur.

One factor that clearly improves our ability to cope withstress is physical fitness.

Shift work tends to drain your energy levels; fitness tends to build upyour energy levels.

Physical activity can burn off excess energy and start the cycleleading to a relaxed state that leads to good deep (non-REM) sleep.

Regular physical activity can help stabilize body rhythms and ishelpful in speeding the resettling of body rhythms in the first few daysof a shift change.

Putting It All Together to Get a


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Putting It All Together to Get aGood Sleep after Your Night Shift

Determine how much sleep you need and try to get it everyday. Use naps, as necessary.

Mental relaxation before bedPhysical relaxation before bedControl your drugs and dietGet physically fitDeal with any sleep-related medical problemsKeep the bedroom dark, quiet, and cool (15C)

Use sun-blocking shades

Work with family and neighbors for bedroom quiet

Wear sunglasses on the drive home to fool your brainTake a nap before the night shift starts in addition to your

after-shift sleep.


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Repetitive Tasks

Complacency


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Complacency

Complacency = Self-satisfactionaccompanied by unawareness of actual dangersor deficiencies.

Mechanics can become complacent when theyhave done a task over and over again withoutmaking an error.

Inspectors can become complacent when they

have done an inspection many times beforewithout finding a problem.

We must fight complacency!

Complacency


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p yOne of the Dirty Dozen


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Environment

Stress and anxiety

Definition

Why worry?

Symptoms

Stressors

Physical

Psychological

Conditions of thework environment

Cold

Heat

Illumination

Noise level


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What Are Stress and Anxiety?

Stress is a physiological reaction to physical and psychological factors(stressors) in our environment.

Anxiety (also called angst or worry) Is a psychological and physiological state characterized by somatic,

emotional, cognitive, and behavioral components. It is the displeasing feeling of fear and concern in either presence or absence

of psychological stress.Anxiety can create feelings of fear, worry, uneasiness, and dread.Anxiety is also considered to be a normal reaction to a stressor.

In other words, stress and anxiety are about the same thing.

Stress/anxietyStressors Adaptations

Positive

Negative


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Stress/Anxiety and Performance

Time Magazine December 5, 2011


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Physical & Psychological Stressors

Physical stressors Illness

Acute

Chronic

Environment Temperature

Vibration

Noise

Fumes

Fatigue Shift work

High work load.

Psychological stressorsUnpredictability

Uncertainty

Uncontrollability

Bereavement/tragedy

Daily annoyances Time pressure

Peer pressure

Management pressure

Chronic stressors Home environment

Work place pressures.

Why Worry About Threat


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Why Worry About ThreatStress/Anxiety?

Human Error

Injury

Illness

Reduced

Productivity


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Conditions of the

Work Environment

Another Effect of Heat and Cold


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Another Effect of Heat and Coldon Work Performance

Some airlines have noted an increase inmaintenance errors in line maintenance during thesummer. Why? It is so hot outside or on the aircraft that the mechanicworks quickly so that he can get back to the air-conditioned building.

Speed/accuracy trade-off applies, so errors increase.

Similar thing happens during winterWork quickly to get in out of cold.

Have to wear heavy gloves and clothing, so that it isharder to do the work. Thus, errors increase.


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V. Procedures,Information, Tools, and

Practices

Procedures, Information,


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Procedures, Information,Tools, and Practices

Visual inspection

Task inspections/duplicate inspections

PlanningWork logging and recording

Procedurepractice mismatch

Technical documentationaccessand quality.


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Visual Inspection Outline

Definitions

Visual inspectionsearch and decision

Factors affecting visual inspection

Task Factors

Subject Factors

Equipment Factors

Environment Factors

Social Factors

Concept of Damage Tolerance

Systems, Structural, and Zonal Inspections


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Visual Inspection

Over 80% of inspections on aircraft are visualinspections.

Visual inspection is often the most economical and

fastest way to find defects on an aircraft.Airframe manufacturers and airlines depend onregular visual inspections to ensure the continuedairworthiness of their aircraft.


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Definition of Visual Inspection

Visual Inspection means inspection using either orall of human senses such as vision, hearing, touchand smell.

Visual Inspection typically means inspection usingraw human senses and/or any non-specializedinspection equipment.


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Types of Inspection

General visual inspection (GVI)

Detailed inspection (DET)

Special detailed inspection (SDI)

Definition of General Visual


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Definition of General VisualInspection (GVI)

A visual examination of an interior or exterior area,installation or assembly to detect obvious damage,failure or irregularity. This level of inspection ismade from within touching distance unless

otherwise specified. A mirrormay be necessary toenhance visual access to all exposed surfaces inthe inspection area. This level of inspection ismade under normally available lighting conditionssuch as daylight, hangar lighting, flashlight or

drop-light and may require removal or opening ofaccess panels or doors. Stands, ladders orplatforms may be required to gain proximity to thearea being checked.

Definition of a Detailed Inspection


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e t o o a eta ed spect o(DET)

An intensive visual examination of a specificstructural area, system, installation or assembly todetect damage, failure or irregularity. Available

lighting is normally supplemented with a directsource of good lighting at an intensity deemedappropriate by the inspector. Inspection aids, suchas mirrors, magnifying lenses, etc. may be used.

Surface cleaning and elaborate access proceduresmay be required.

S f O


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Some of the Operating Rules

Normal cleanup procedures are to be used prior toconducting general visual or detailed inspections. Specifiedcleanup procedures are to be used for special detailedinspections, if necessary. Sealant and corrosion protection

finishes should only be removed when specified andrestored in accordance with the Corrosion PreventionManual after the task is completed.

Excessive dust, debris, or overspray of corrosion inhibitingcompounds found during any inspection are considered tobe an unsatisfactory condition possibly reducing the fireresistance of the airplane design. Cleanup of thesematerials should be a standard part of maintenance activity.

Definition of a Special


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pDetailed Inspection (SDI)

An intensive examination of a specific item(s),installation or assembly to detect damage, failure orirregularity. The examination is likely to make

extensive use of specialized inspection techniquesand/or equipment.

Special detailed inspections are to be used whenspecified for inspecting hidden details or may be used asalternatives to detailed inspections.

NDT

Borescope

Typical Aircraft Defects Found by


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Visual Inspection

Typical airframe defects that can be found by visualinspection includeCracks

Corrosion

Disbonding

Other defects that can be found by visualinspection includeSystem and component wear

Accidental damageEnvironmental damage from long-term storage, sunlight,etc.

Factors InfluencingVi l I ti


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Visual Inspection

Task Factors

Subject Factors

Equipment Factors

Environment Factors

Social Factors

T k F t


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Task Factors

Size/complexity of the object searchedingeneral, search time is linearly related to eithersearch field area or number of inspectable items inthe field.

Number of different types of defectsthegreater the number of types of defects, the slowerthe search performance and/or the lower the hitrate.

Defect/background contrasthigherdefect/background contrast produces faster andmore accurate searches.


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Task FactorCompanyInspection Instructions


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Inspection Instructions

Before certifying any work, you must be satisfied that allcomponents, parts and materials utilized have been obtainedfrom approved sources, are of the correct specification, and arecompletely serviceable. You must also ensure that all work are

performed in accordance with current and approved MaintenanceSchedules, Maintenance Manuals, Overhauls Manuals, RepairTest Schedules/Capabilities List, Drawings or any other relevanttechnical publications, and that all applicable MandatoryModifications, Inspections or any other special requirements havebeen duly carried out. In the case of repairs not covered by theapproved technical publication, all work performed must be inaccordance with the approved instructions of the equipmentowner, e.g., Engineering Notes issued by the EngineeringDepartment.

S bj t F t


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Subject Factors

Inspector demographicsage, experience, and gender (noaffect)

Trainingnot the same as experience. Even experienced inspectorscan improve their performance (often dramatically) with a well-designedtraining program, which is based on a task analysis and which providesKnowledge of Results to the trainees.

Visual performancenot related to visual acuityas measured by a Snellen Chart. The size of the visuallobe is a predictor of inspector performance. However, studies done by the US FAA found that 20/20

vision or correctable to 20/20 should be requiredfor inspectors.

Cognitive performancepeople with the ability to dis-embedobjects from a complex/confusing background make better inspectors.

Hidd Fi E l


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Hidden Figure Example

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Hidd Fi E l


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Hidden Figure Example

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Inattentional Blindness and


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Human Errors/Accidents

Someone performing a task simply fails to see what shouldhave been plainly visible and cannot explain the lapseafterwards.

Inattentional blindness causes accidents when attention

mistakenly filters away important information, due to acombination of factors: low conspicuity, divided attention, highexpectation, low arousal.

People are unaware of the blindness. Training mainly affect

conscious, voluntary behavior.

Equipment Factors


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Equipment Factors

Magnificationincreasing magnification may onlychange the speed-accuracy trade-off with highermagnification improving target detection at theexpense of speed.

Field integrationusing a known perfect itemfor comparison during the inspection.

Visual enhancementspecific to NDI.

Human/machine function allocationspecificto NDI. Typically shows that a hybrid of human andmachine functions work better than either alone.

Environment Factors


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Environment Factors

Visual environmentcorrect lighting is important both forphysical inspection and to avoid glare in computer-basedinspection.

Auditory environmentno necessarily clear affects,although some studies show that noise >90 Db worsenedinspection performance.

Thermal environmentsome data to suggest that reallyhot and really cold environments have a negative affect on

inspection.Workplace comfortno data. However, the myth that

comfortable inspectors lose vigilance has been refuted.

Social Factors


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Social Factors

Working perioddetection performance decreases rapidlyover the first 20-30 minutes of a vigilance task (e.g., watchingradar), although this phenomenon is hard to replicate in typicalvisual inspection tasks.

Job designrest periods have been shown to improveperformance.

Supervision, instruction and other pressuresfromsignal detection theory, we know that criterion used by an inspectorfor reporting defects is influenced by the sum of all biases on theinspector. These biases are affected by a priori probability of adefect and also by the perceived costs of misses and false alarms,

which can be affected by supervisory instructions/reprimands.Information environmentboth feedback of inspection

performance (knowledge of results) and feed forward information(where to look for a defect) have been shown to improve inspectionperformance.

Summary


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Summary

Over 80% of inspections on aircraft are visualinspections, which are often the most economicaland fastest way to find defects on an aircraft.

Visual Inspection means inspection using either orall of human senses such as vision, hearing, touchand smell.

A visual inspection includes a search and adecision. The decision criteria can be influenced

by outside factors, such as management pressure.Common aircraft visual inspections include systeminspections, structural inspections, and zonalinspections.


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Error Capturing/

Task Inspectionsand Duplicate

Inspections

Error Capturing


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Error Capturing

Error capturing = Adding a task to find amistake.

Common error capturing tasks

Operational/functional checks

Mechanic/pilot pre-flight walk around checks

Task inspections/duplicate inspections.

Task Inspection


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Task Inspection

Task (Job) cards typically have two types of signoff:

Worked by (Discussed later under Norms.)

Checked by

What does SIAECs GMM say the checked byperson is supposed to do in order to feelcomfortable in signing off the task or sub-task?

Supposed to watch the whole task, or the critical parts of

the task, being performed?Must have a high degree of confidence that the work hasbeen carried out correctly.

What Standard Do You Inspect To?


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What Standard Do You Inspect To?

Many are found in the Aircraft Maintenance Manual(AMM)

Chapter 20 Airframe Standard Practices

Chapter 51 Standard Practices and StructuresChapter 70 Engine Standard Practices


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Planning of Tasks,

Equipment, andSpares

Planning of Tasks,E i t d S


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Equipment, and Spares

Planning of Tasks, Equipment and Spares

EASA 145 does not require a procedureon the planning of work.

EASA 145 and AMC material clarifies theobjective of good planning and includesthe elements to consider when

establishing the planning procedure.

Planning of Tasks, Equipment,and Spares


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and Spares

Planning is critical to ensure that there areadequateAppropriately qualified and alert maintenance staff

Tools

Equipment

Material

Maintenance data

Facilities

for scheduled and un-scheduled maintenance.Long-term planning.

Short-term planning.

Planning of Tasks,Equipment & Spares


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Equipment & Spares

Planning consideration should be given to

Logistics.

Inventory control.

Space availability (hangar and floor space).

Man-hours estimation.

Man-hours availability.

Preparation of work.

Co-ordination with internal and external suppliers.

Scheduling of safety-critical tasks during periods when staffare likely to be most alert, and avoiding periods whenalertness is likely to very low, such as early morning ornight shift.

Work Logging and Recording


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Work Logging and Recording

Importance of proper work logging/recording

All work on an aircraft should be documented.

Work sign-offs should occur soon after the sub-

task is completed. Do not wait until the end ofthe task to sign off all worked by blocks.

Any work done on the aircraft that is notcovered in the maintenance manual (e.g.,loosening a clamp on a wire bundle in order toget access to a part) should be recorded,typically with a non-routine card.

Technical Documentation


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EASA 145 addresses technicaldocumentation (poor maintenance data)

Inaccurate, ambiguous, incomplete

maintenance procedures, practices,information or maintenance instructionscontained in the maintenance data used by

personnel must be reported to the author ofthe data.



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The US Federal Aviation Administrationrecently did a study of aircraft maintenancemanuals (AMMs). They found that:

The manuals rarely had technical errors in them,but

The manuals were not written by mechanics,meaning that the order of the tasks typically doesnot follow the way in which a mechanic wouldactually do the task.

Documentation andMaintenance Errors


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Maintenance Errors

MEDA investigations have found thatdocumentation is the most frequent contributingfactor to maintenance error.

Problems includeNot used (50% in MEDA investigations)

Not understandable

Incorrect step

Conflicting information

No illustration.

Poor illustration


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VI. Teamwork

Team Behavior


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Team Behavior

Team Behavior- The way people behavewhen part of a team.

Overview


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Overview

What AffectsTeam Behavior?

Responsibility

Motivation

Norms

Culture

Effective TeamBehaviors

Communication

Assertiveness

SituationAwareness

Leadership

Responsibility


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Responsibility

Responsibility is...Recognizing that you can affect the teams success.

Choosing to act to help that success.

In a team, we tend to feel lessresponsible.Someone else will do it.

The whole team agreed.Nobody saw me, it could be anyone.

Social Influence


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Social Influence

How behavior is influenced by thesocial environment and the presence ofother people

Obedience to authority

Conformity to group/team.

Examples of TakingResponsibility


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Responsibility

Admitting and fixing errors.

Saying something about a situation whenyou know there is something wrong.

Addressing non-critical problems Picking up debris from the ramp

Finding the safety wire you dropped.

Maintaining professional responsibility. Maintaining technical currency.

ProfessionalismSome Examples ofUnprofessional Behaviors in Maintenance


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Unprofessional Behaviors in Maintenance

Memorizing tasks instead of using manuals/cards.

Not using torque wrenches or other calibrated tooling.

Troubleshooting through experience, instead of using theFault Isolation Manual (FIM).

Deviating from maintenance manual procedures.Failing to attach Do Not Use tags when pulling

circuit breakers and switches.

Skipping operational or functional tests.

Signing off for tasks neither seen nor checked.Providing minimum information in task handover log.

Failing to document work not specified in the manual (e.g.,loosening a clamp on a wire bundle).

Why Do We SeeUnprofessional Behavior?


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Unprofessional Behavior?

Behavior starts to stray from the professionalstandard for various reasons (uncomfortable, timeconstraints, calibrated equipment unavailable).

Supervisor does not intervene.Staff believe that supervisor does not care.

Behavior is seen as low risk.

Unprofessional behavior becomes the norm.

Existing workers put peer pressure on new hires toconform to these behaviors.

Why Do We SeeUnprofessional Behavior?


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Unprofessional Behavior?

Supervisor actually rewards unprofessionalbehavior.

Weve got 4 days of work to do in 2 days. I dont carewhat you do, just get it done. I am going into my officeand closing the door. [After meeting the 2-day deadline.]Way to go guys!! Pizza for everybody.

Supervisor threatens punishment for carrying outprofessional behavior.

What do you mean you dont feel qualified to do the job?Youre trained. Youre certified. Go out there and do thatwork. You want to keep your job, dont you?

Then How Do We Move Back toProfessional Behaviors?


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Professional Behaviors?

What not to do

Pick out an offender and punish him/her in frontof their work group.

Threaten staff.

Then How Do We Move Back toProfessional Behaviors?


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Professional Behaviors?

What you should doManagement decides what behaviors are desired.Management and labor meet to agree on the newbehaviors. Address issues brought up by labor, e.g.,

Time it will takeAvailability of equipment, calibrated tools, parts, etc.

Supervisors are provided training on new expectations No threats to staff if they are doing correct behavior. Reward correct behavior and model correct behavior.

Labor told of progressive punishment for failure to exhibitnew behaviors Verbal warning Letter to file Time off without pay.

Motivation


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ot at o

Motivation = A process within a person thatcauses the person to move toward a goalthat is rewarding.

Two types of motivation:IntrinsicWe move toward a goal because ofrewards that are internal to ourselves (e.g.,feelings of satisfaction or accomplishment).

ExtrinsicWe move toward a goal because ofrewards that are external to ourselves (e.g.,praise, a good grade on a test, or money).

Motivation Affected by Beliefs


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y

Motivation is determined both by

The intrinsic orextrinsic reward, and

The beliefthat effort will result in achieving the

reward.Example: Someone who does not believe they canwin a race will not be motivated to try hardto prepare for and win the race,

no matter how badly they wantthe $100K prize money.

Performance = Skill X Motivation


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Performance is determined by BOTH:

Skill

&

Motivation

Example: Someone with medium skills

and high motivation can out performsomeone of high skills and no motivation.

Implications for Management


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p g

Management must not only provide hygiene factorsto avoid employee dissatisfaction, but must providemotivation factors intrinsic to the work itself in orderfor employees to be satisfied with their jobs.The job should have sufficient challenge to use the fullabilities/skills of the employee.

Employees who demonstrate increasing levels of ability/skill should be given increasing levels of responsibility.

If a job cannot be designed to use an employees full

abilities/skills, then the organization should considerreplacing the employee with one who has fewerabilities/skills. If an employees abilities/skills cannot befully used, then there will be a motivation problem.

Norms


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Definition: Typical behavior in a social group ororganization.

Norms are simply the state of actual conditions

They can be effective or ineffective in theperformance of quality work

Tagging connectionsWearing appropriate

safety equipmentFollowing check lists

and procedures

Some Ineffective NormsWe Have Seen at Airlines


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We Have Seen at Airlines

Memorizing tasks instead of using manuals/cards

Not using torque wrenches

Troubleshooting through experience, instead of using the FaultIsolation Manual (FIM)

Deviating from maintenance manual proceduresFailing to attach Do Not Use tags when pulling circuit breakers

and switches

Skipping functional or operational tests

Signing off for tasks not seen nor checkedProviding minimum information in shift handover log

Failing to document work not specified in the manual (e.g.,loosening a clamp on a wire bundle)

Norms


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The Asch studies suggest that new staffwill quickly pick up the existing norms intheir work group. If these are norms like

Memorizing tasks instead of usingmanuals/cards

Not using torque wrenches,

then new staff will quickly learn these

behaviors.

Procedural Non-Compliance


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p

EASA 145 requires that procedural non-compliance be addressed. Very important!There is an assumption that people will follow theprocedure as written.

When this assumption is broken, the whole basis of thesafety system is put at risk.Maintenance requirements, therefore safety, are basedalmost solely on an assumption that people will follow theprocedures.

Therefore, maintenance organizations should:Not allow procedural non-compliance to become anormal behavior (norm), and

Make sure written procedures are easy to follow so thatthey will be used.

Signing Tasks Not SeenNor Checked


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EASA 145 requirement to address thisissue.

New Alternate Means of Compliancematerial elaborates on the meaning ofsign-off and the need to check orinspect the task before signing off.

Signing Off Tasks


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g g

A sign-off is a statement by the competent personperforming or supervising the work that the task orgroup of tasks has been correctly performed. Thisis a worked by sign-off, not a QC inspection sign-

off nor a release to service sign-off.Research has shown that many maintenancetasks, which are carried out by workers who are notcompetent to sign off on their own work (e.g.,

temporary staff or trainees), are signed-off unseenby the person supervising the work.

Signing Off Tasks


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g g

Some airlines have one sign-off for each task card.Other airlines have sign-offs for each sub-task withina task card.

Signing off small groups of tasks (sub-tasks)Will help prevent situations where a technician is calledaway from a task (to do another task or at shift end), andthe person picking up the previous task has no record ofwhat has been completed on the task, and

Will encourage a mechanic to continue with the task up to

the next break point before leaving the task (e.g., either totake a break or end the shift).

Sign-off points would be determined by M&E asappropriate to the nature of the work.

Signing Off Tasks


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CAP 716 statesSign-offs should be considered as a mechanism for

ensuring that all steps in the task have been carriedout correctly

Not a method for knowing whom to blame if the taskis not done correctly.

It is expected that the person signing off anotherswork view or inspect the work before signing off.

However, CAP 716 states, It is understood that, in

some cases, the person signing-off the taskwill beunable to view or inspect, in detail, the work whichhas been carried out, but it is important that thatperson has a high degree of confidence that the workhas been carried out correctly.

Effective Team Behaviors


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Communication

Assertiveness

Situation Awareness

Leadership.

Communication


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Communication - The ability to clearly andaccurately send and acknowledge informationand to provide useful feedback.

Basic Communications Model


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Sender

Message

Receiver

Feedback

ENVIRONMENT

Communication Modelin the U.S. Nuclear Industry


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y

Sender

1. Message

Receiver

ENVIRONMENT

2. Feedback

3. Feedback

Senders Responsibility


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Communicatinginformation clearly.

Covering timelyinformation accurately.

Requesting verification of

feedback.Verbalizing plans.

Receivers Responsibility


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p y

Acknowledge communications.

Repeat information.

Paraphrase information.

Clarify information.

Provide useful feedback.

Barriers to EffectiveCommunication


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Passive listening

No feedback

Poor feedback.

Not using the rightwords.

Inappropriate method.

Vague or lateinformation.

Active Listening


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g

DO NOT

Argue about things.

Bring up things that are notimportant.

Plan out your words whilethe other person is talking.

Think about other thingswhile the other person istalking.

DO

Ask good questions.

Make eye contact.

Use positive bodylanguage.

Repeat back using yourown words to make sureyou understand.

Written Communication


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Written communication can be hard. No visual feedback to tell you if the reader

understands.

The reader cannot ask questions.

Make sure that your writing is: Correct

Complete Clear.

Use computer spell checker.

Shift and Task Handover


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EASA and the FAA require a shift and taskhandover procedure acceptable to theNational Aviation Authority.

Incident investigation data shows that taskhandovers are one of the major contributingfactors to error-caused events.



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The primary objective of handovers is to ensure that allnecessary information is communicated between the out-going and in-coming personnel.

Effective handovers depend on three basic elements:

1. The outgoing persons ability to understand andcommunicate the important elements of the job or taskbeing passed over to the incoming person.

2. The incoming persons ability to understand thisinformation.

3. A formalized process for exchanging informationbetween outgoing and incoming persons and a placeand time for such exchanges to take place.



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Organizations should have a recognizedprocedure for task and shift handovers which allstaff understand and adhere to. This procedure

should be listed in the GMM.The procedure should provide for sufficient timeto be made available by way of a shift overlap20 to 30 minutes is considered good practice.

Aids to Effective Communicationat Shift Handover


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If only one communication method is used there is arisk of erroneous transmission. For this reasoninformation should be repeated using more thanone method.

While all essential information (especially the detailedstatus of tasks) should be recorded in written form, itis also important to pass this information verbally inorder to reinforce it. Then feedback/questioning canbe used to test ones understanding of the handover,

which increases accuracy.The ability for two-way communication to take place is,therefore, important at shift handover.



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A part of the shift handover process is to helpdevelop a shared mental picture of themaintenance system, aircraft configuration, tasks inwork etc. This is particularly true when deviations

from normal working has occurred, such asHaving the aircraft in the flight mode at a point in amaintenance check when this is not normally done.

When people have returned following a lengthy absence(the state of things could have changed considerably

during this time) andWhen handovers are carried out between experiencedand inexperienced personnel.

In all these cases handovers can be expected totake longer.



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Written communication is helped by thedesign of the documents, like the handoverlog, which consider the information needs of

those people who are expected to use it.Involve the people who conduct shift handovers

Ask them what key information should be included andWhat format it should be in.

This helps accurate communication and gets theirbuy-in, which contributes to its use andacceptance of the process.

Handing Over a Task Directly toAnother Person


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When the task is being directly handed over tosomeone who is present, the task handover shouldbe done face to face using verbal and writtencommunication.

In these cases the written element is normally thetask card or non-routine process sheets. Theseshould be accurately completed and clearly identifywhere in the task the work ended.

Any deviations from normal working practices orprocedures must be clearly highlighted with thenon-routine sheets.

Handing Over a Task for Somebody toComplete Later


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It is common that a job is left incomplete during a shift.

In these cases it is often not known who will eventually pickup the job of completing and certifying the release toservice.

These situations present a far greater risk and challenge toeffectively communicate the stage of task accomplishmentand what is required to complete the job.

Face to face communication is not possible. Therefore, totalreliance has to be placed on written communication. Thisprovides no redundancy or an opportunity to question andtest a true understanding by the person expected to finishthe job.

Handing Over Non-Scheduled Tasks


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Complex or lengthy non-scheduled tasks should always bebroken down into a number of discrete steps using stage sheetsor process sheets.

Many incidents have occurred when people have started a non-scheduled task, but had to leave before it was finished without

anybody to handover to.These situations are normally associated with time pressure or

emergency situations.

It is vital that time is taken by the person leaving the job to recordin detail what activities have taken place and what is requiredto complete the job. Record this on stage sheets andemphasize any deviations from the maintenance manual.

Management and supervisors have a responsibility to ensure thatadequate time is given to maintenance staff to record their work,if the task is not completed for any reason.

Cultural Differences in Communication


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Culture = Customary beliefs, behaviorpatterns, and material traits of a group(organization).

Some of these beliefs deal withcommunication issues.Do not admit to mistakes.

Indirect (not straightforward) communications.

Pilots will not talk to maintenance staff, etc.

Discuss how the participants national/organizational cultures affect communication.

Assertiveness


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Assertiveness - The willingness to activelyparticipate, and the ability to state and maintainindividual position.

What Is Assertiveness?


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Providing relevant information without being asked.

Making suggestions.

Asking questions as necessary.

Confronting ambiguities.

Willingness to make decisions.

Maintaining position when challenged until convincedby the facts.

Clearly stating positions on decisions and procedures.

Refusing an unreasonable request.

If a disagreement exists, take the most conservative

action until more information is available.

Situation Awareness


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Situation Awareness - The ability to maintainawareness of what is happening on the ramp or thehangar, as well as what is happening on the task.

Situation AwarenessIs the Ability to...


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See elements (e.g., people and equipment) inthe work environment.

Where they are now.

Whether they are moving or stationary.

Understand the importance of what you see,especially with regard to hazards/problems.

Project the status of the elements for the nearfuture (i.e., determine future implications) inorder to detect situations requiring action.

Barriers to Situation Awareness


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Insufficient communication

Fatigue/stress

Task overload/underload Groupthink mindset

Press-on mentality

Degraded operating conditions.

Overcoming Barriersto Situation Awareness


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Actively question/evaluate.

Use assertive behavior when necessary.

Analyze/monitor situation continuously.

Leadership


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Leadership - The use of influence to direct and

coordinate the activities of the members of a group

toward the accomplishment of group objectives.

Types of Leadership


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Designated - Leadership by authority,position, rank, or title. Formal/permanent.

Functional - Leadership by knowledgeor experience.

Informal/temporary.

Designated Leadership BehaviorsCompany Level


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Inspire a shared vision, develop a mission, and establishstandards that help the organization achieve its next stageof development.

Foster teamwork, collaboration, and ownership and motive

team members by recognizing/rewarding individual andteam contributions.

Plan and manage change efficiently and nurture thestrengths of followers to facilitate goal directive activities.

Serve as a symbol of the group and influence others beyondthe group to achieve mutually workable arrangements.

Establish an environment that is conducive to learning.

Functional Leadership BehaviorsCrew Level


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Direct and coordinate crew activities.

Delegate tasks to crew members.

Ensure crew understands expectations.

Focus attention on critical aspects of situations. Keep crew informed of task/shift information.

Ask crew members for relevant task/shiftinformation.

Provide feedback to crew on their performance.

Create and maintain a professional atmosphere.

Effective Functional Leadership


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Make suggestions; do not dictate.

Encourage crew to participate.

Lead by inspiration.

Provide feedback to the crew.

Barriers To EffectiveLeadership


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Micro-management - failure to delegate

Poor interpersonal skills

Easily frustrated Pressures crew members to perform

Unable to adapt to new situations

Rigidity.

Summary


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Factors that affect theway that people behavewhen part of a teaminclude

Obedience to authority

Conformance to team

Amount of responsibility

Motivation to do a good

jobWork group norms

Work group and nationalculture.

Effective teambehaviors includeGood communication,including active listening

AssertivenessSituation awareness

Leadership.


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VII. Human Error/Incident

Investigation

Human Error/IncidentInvestigation


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Errors and violationsTypes of errors

Error models and theoriesReasons Swiss Cheese modelBoeing Maintenance Error DecisionAid (MEDA) contributing factors model

Incident InvestigationPractice

Definitions of Error and Violation


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An erroris a human action (behavior)that unintentionally departs from theexpected action (behavior).

A violation is a human action(behavior) that intentionally departs

from the expected action (behavior).

Violations


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Violations are often made by well-intentioned staff trying to finish a job, notstaff who are trying to increase comfort or

reduce their work load.There are several types of violations

Routine

Situational

Exceptional

Violation Definitions


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RoutineThese are common practice.Often occur with such regularity that they areautomatic. Violating this rule has become a

group norm. Often occur when the existingprocedure does not lead to the intendedoutcome. Condoned by management.

Violation Definitions (contd.)


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SituationalOccur as a result of factorsdictated by the employees immediate workarea or environment. Due to such things

asTime pressure

Unavailability of equipment, tools, or parts

Insufficient staff

Lack of supervisor/degreed engineer to askquestions to.

Violation Definitions (contd.)


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ExceptionalMechanic/inspector willfullybreaks standing rules while disregarding theconsequences.

These are very rare in our business!

Errors and Violations


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Errors have been the focus of research, so we havemore theories of why errors occur than theories ofwhy violations occur.

However, errors and violations often occur together

to produce an unwanted outcome. Data from theU.S. Navy suggest that

~20% of the events are caused by a violation only~20% of the events are caused by an error and a

violation, and~60% of the events are caused by an error only.

Types of Maintenance Error


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Maintenance Error= Error by amechanic/engineer/inspector that leads toproblems on the aircraft.

Installation errorsServicing errorsRepair errorsFault isolation/inspection/testing errors

Errors causing foreign object damage (FOD)Errors causing equipment damageErrors causing personal injury.

Human Error in AircraftMaintenance: UK CAA 1992


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1. Incorrect installation of components.2. Fitting of wrong parts.

3. Electrical wiring discrepancies.

4. Loose objects left in aircraft.5. Inadequate lubrication.

6.Access panels/fairings/cowlings notsecured.

7. Fuel/oil caps and fuel panels not secured.

8. Gear pins not removed before departure.

UK Flight Safety Committee 2004Top 10 Causes of Maintenance Mishaps


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1. Failure to follow published technical data or local instructions.2. Using an unauthorized procedure not referenced in the

technical data.

3. Supervisors accepting non-use of technical data or failure tofollow maintenance instructions.

4. Failure to document maintenance properly in maintenancerecords, work package.

5. Inattention to detail/complacency.

6. Incorrectly installed hardware on an aircraft/engine.

7. Performing an unauthorized modification to the aircraft.8. Failure to conduct a tool inventory after task completion.

9. Personnel not trained or certified to perform the task.

10. Ground support equipment improperly positioned for the task.

Why Are Technicians Such a ValuableAsset in Reducing Mx Errors/Violations?


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Error Models and

Theories

Error Theories


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Now we will focus on the theoriesof error.

Reasons Swiss Cheese modelMEDA contributing factors model.


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Reasons Swiss

Cheese Model

Reasons Model of AccidentCausation

Defenses

Functional Tests

7/24/2019 EASA 145 & 66

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EASA 145 & 66 Human factor Training

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