Human Factors Presentation on Maintenance Safety

Maintenance Human Federal Aviation
Administration
Factors Presentation
System
Prepared by
Aviation Safety Organization
Flight Standards Service
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Welcome
Human Factors in Aviation Maintenance Federal Aviation 2

Administration
Presentation Plans
• Speak in straightforward terms
• Reinforce your current knowledge
• Offer new concepts and/or new ways to explain old

concepts
• Provide links for more information
• Have a few laughs?

Administration
Presentation Content
1. What is human factors?
2. History of human factors
3. Human factors spectacles
4. The PEAR model
5. Human error
6. Maintenance accidents
7. Where to get information
8. Summary

Administration
1 What is Human Factors?

Administration
What is Human Factors?
This section shall:
• Define human factors as it relates to

maintenance
• Show specific examples of maintenance

human factors
• Show why the topic is important to you

Administration
List “Human Factors” Related to
Maintenance

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What is Human Factors?
• Designing workplaces, tools,
procedures, and policies so people
can use them easily and safely
• Primary concern is for people in the

organization
• Combines elements from many

disciplines
• Critical to the overall flight safety

and personal safety

Administration
Human Factors Goal — A Summary
Ensure continuing safety and efficiency by paying

attention to issues that affect human performance.

Administration
The Elements of Human Factors

Administration
Human Factors Goal for Review
Ensure continuing safety and efficiency by paying

attention to issues that affect human performance.

Administration
2 History of Human Factors

Administration
The History of Human Factors
• Early military work on designing
weapons and uniforms
• Time and motion studies (Frank

and Lillian Gilbreth)
• World War II aircraft cockpit

controls and displays
• Establishment of Human Factors

Society (1957)
• Military systems and

consumer products

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Maintenance Human Factors has
Evolved in 20 Years!

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Human Factors Timeline

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3 Human Factors Spectacles

Administration
Put on your “Human Factors
Spectacles”
• Examples of the human factors
perspective
• You can see human performance

issues if you look
• The remainder of this presentation

will show you what to look for
• Look at others
• Look at yourself
• Look at the environment that

surrounds you

Administration
Put on your “Human Factors
Spectacles”
• Sensitivity to human factors
• Knowledge of how human factors affect work and

safety
• Objectively examine your world
• Be willing to make suggestions and comments

Administration
What did you Learn about Human Factors
Spectacles from the Introductory Video?
• What was the premise of the human factors spectacles video?
• List 10 things that you see while driving with your human factors
spectacles
• List 10 things that you see in this class with your human factors
spectacles
• List 10 things that you see at work with your human factors
spectacles
• What do you see at home with the human factors spectacles?
• In the mirror?

Administration
A Reminder to Apply Human Factors
Principles 24 x 7

Administration
4 The PEAR Model

Administration
Why Use Models?
• Models make it easier

to understand complex
things
• Easy to remember
• Models can be 2-D, 3-

D, or mental

Administration
The SHELL Model
• Originally used for

pilot’s crew resource
management (CRM)
• Has served human

factors training well –
worldwide
• A bit abstract

Administration
The SHELL Model Explained
• S includes all
documentation
• H is physical stuff, like

tools and equipment
• E is for the physical

and social environment
• L-1 is for individuals
• L-2 is for groups

Administration
The PEAR Model
• PEAR is easy to remember
• It works for maintenance
• It is matched with the SHELL

model

Administration
PEAR
• People who perform the job
• Organizational and physical environment
• Actions (tasks) performed as part of the job
• Tools, procedures, and other resources

Administration
People
Physical Psychological
• Size • Experience
• Gender • Knowledge
• Age • Training
• Strength • Attitude
• The five senses • Emotional state
Physiological Psychosocial
• Health • Interpersonal relations
• Nutrition • Ability to communicate
• Lifestyle • Empathy
• Alertness/fatigue • Leadership
• Chemical dependency

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What Does This Mean?
• We live in 24x7x365
world
• Aviation does not

rest
• Humans need rest!

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Overview of Fatigue

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People — Vision and Hearing
Physical Psychological
• Size • Experience
• Gender • Knowledge
• Age • Training
• Strength • Attitude
The Five Senses • The five senses • Emotional state
Physiological Psychosocial
• Health • Interpersonal relations
• Nutrition • Ability to communicate
• Lifestyle • Empathy
• Alertness/fatigue • Leadership
• Chemical dependency

Administration
How to Remember the Five Senses
When you toast you:
See
Smell
Taste
Feel
Hear

Administration
A Test / Example of…
Volunteer Needed
As quickly as possible,
say the color of each word on the screen.

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Sensing and Perception
desk
rock
cat
spoon
book

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Sensing and Perception
red
blue
gray
purple
green
Administration
What is This?

Administration
What is This Now?
Both the letter “B” and the number “13” are the same figure. However,
the context determines how you perceive it.
(Coren, et al, (1994), Sensation and Perception, Harcourt Brace College Publishers)

Administration
Environment
Physical Organizational
• Weather extremes • Personnel
• Location (in/out) • Supervision
• Workspace • Labor - management
• Lighting • Size of company
• Sound levels • Profitability
• Housekeeping • Job security
• Safety issues • Morale
• Corporate culture
• Safety culture

Administration
Actions
• What do you need to know?

• What skills are necessary?
• Steps to perform a task
• Sequence of actions
• Communication requirements
• Information requirements
• Inspection requirements
• Certification requirements

Administration
Actions — What Can You Do Today?
• How do you communicate error

events?
• Are there enough people to do the

job?
• Do personnel understand the cost of

aircraft damage?
• How can you motivate one another to

care more?
• Are you responsible for the things

that others do?

Administration
Resources
• Technical documentation systems

• Test equipment
• Enough time
• Enough people
• Lifts, ladders, stands, seats
• Materials
• Portable lighting, heating, cooling
• Training

Administration
Resources — Please Offer Your
Examples
• Are resources ever a problem?
• What are the solutions?
• Can you give an example?
• What advice can you offer?

Administration
5 Human Error

Administration
Human Error
• Definition of human error
• Types of errors
• The “dirty dozen”
• Examples of errors
• Event investigations –
Maintenance Error
Decision Aid (MEDA)

Administration
The Greatest Hazard to Aircraft is…?
Gravity
Humans

Administration
80% of Events are Caused by Human
Error

Administration
The Odds are Against Doing it Right!
Only one way to

disassemble
40,000+ ways to
incorrectly
reassemble!

Administration
Definition of Human Error
A human action with

unintended consequences

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Types of Human Error

Administration
Active and Latent Errors

Administration
Why Things Go Wrong
• Incomplete installation (33%)
• Damage on installation (14.5%)
• Improper installation (11%)
• Equipment not installed or
missing (11%)
• Foreign object damage (6.5%)
• Improper troubleshooting,
inspection, test (6%)
• Equipment not activated or
deactivated (4%)
Data from Boeing study of 276 in-flight
engine shutdowns (1994)

Administration
The Civil Aviation Authority’s List of
Errors

Administration
The 12 Most Common Causes for
Human Errors
• Eliminate these causes and

you have conquered most
human errors
• Talk about each of these
• What are the causes in your

company?
• What are the corrective

actions?

Administration
Iceberg Model

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Event Investigation — MEDA
• Boeing’s event investigation

system
• Used by 500 airlines

worldwide
• Finds the contributing factors

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Performance Shaping Factors
Anything that can increase or decrease the likelihood of human error.

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6 Maintenance Accidents

Administration
Fatal Accidents: Intl – 1998 to 2007
60 2000
1800
50
1600
1400
40
Fatal Accidents
1200
Fatalities
30 1000
800
20
600
400
10
200
0 0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
World Accidents World Fatalities
Source: US NTSB and Flight International, 8-14 January 2008

Administration
Fatal Accidents: US/Intl – 1998 to 2007
60 2000
1800
50
1600
1400
40
Fatal Accidents
1200
Fatalities
30 1000
800
20
600
400
10
200
0 0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
US Accidents World Accidents US Fatalities World Fatalities
Source: US NTSB and Flight International, 8-14 January 2008

Administration
Intl Accident Cause Factors 2007
Other
27%
Human Factors
45%
Controlled Flight Into
Terrain
1%
Technical/
Maintenance
27%
Source: Flight International, 8-14 January 2008

Administration
Causes of Helicopter Accidents
(1985 - 2006)
Published March 2006
21 Human factors
10 Engine failure
1 Mechanical failure
9 Probable cause unknown or
undetermined (NTSB
investigation not completed)
7 Weather
3 Structural failure

Administration
Implications of the Safety Statistics
for Maintenance Human Factors
• There are “opportunities for improvement”
• Maintenance and technical issues are areas of concern
• Technical documentation systems!!
• Human factors challenges are ever present

– Alertness/fatigue
– Communication (flight crew to maintenance)
– Inadequate use of lessons learned (event reporting)
• Challenges are similar for all aviation segments!

Administration
Maintenance Accidents
• Maintenance errors cause
accidents
• Accident statistics
• Common maintenance
errors
• Examples of maintenance-
related accidents
• Specific accidents

Administration
Historic Maintenance-Related
Accidents

Administration
Recent Maintenance-Related
Accidents
Jan 2000 Alaska Airlines MD-80 Jackscrew for elevator control
Mar 2001 Lufthansa A320 Mis-wired side stick

Apr 2001 Emery Worldwide DC-8 Reversed hydraulic check-valve
Aug 2001 Air Transat A330 Fuel exhaustion over Atlantic
May 2002 China Airlines B747-200 In-flight break-up at 35K feet

Jan 2003 Air Midwest Beech 1900D Trim rigging
Aug 2003 Colgan Air Beech 1900D Trim rigging
Jan 2006 Continental B737-500 Engine run-up

Jul 2006 Spectrum Aircraft Spectrum 33 Mis-rigging

Administration
7 Where to Get Information

Administration
Three Reference Manuals
www.hfskyway.com

Administration
Where to Get Information: Sample Page from
Operator’s Manual for Human Factors in
Aviation Maintenance
• Training
• Human Factors Guide for

Aviation Maintenance and
Inspection
• Human Factors Operator’s

Manuals (one for aviation
maintenance and one for
airport operations)
• www.hfskyway.com
• FAA human factors resources

Administration
For More Information — Publications
www.hfskyway.com

Administration
For More Information —
www.hf.faa.gov

Administration
FAA Human Factors Resources:
www.hfskyway.com

Administration
References
FAA (2005), Human Factors Policy, FAA Order 9550.8A, available at
http://www.hf.faa.gov/docs/508/docs/HForder.pdf#search=%22faa%20order%209550.8%22
FAA (2005), The Operator’s Manual for Human Factors in Aviation Maintenance, Washington, DC,
available at http://www.hf.faa.gov/opsmanual
FAA (2007), The Operator’s Manual for Human Factors in Airport Operations, Washington, DC,
available at http://hfskyway.faa.gov/2007/OpsMan_Ramp_Final.pdf
FAA (1996), Human Factors Guide for Aviation Maintenance and Inspection, available at
http://hfskyway.faa.gov
FAA (2007), Maintenance Human Factors Training Program, Evaluate and Accept, FAA Order 8900.1,
available at:
http://fsims.faa.gov/wdocs/8900.1/V03%20Tech%20Admin/Chapter%2024/03_024_002.htm?opendoc
ument
Hackworth, H., Holcomb, K., Dennis, M., Goldman, S., Bates, C., Schroeder, D., Johnson, W. (2007).
An International Survey of Maintenance Human Factors Programs (Report No. 07/25). Oklahoma City,
OK: FAA Civil Aerospace Medical Institute.
Hall, S., Johnson, W.B. and Watson, J. (2001). Evaluation of Aviation Maintenance Working
Environments, Fatigue, and Human Performance: Phase III. Washington, DC: Federal Aviation
Administration Office of Aviation Medicine. http://hfskyway.faa.gov

Administration
8 Summary

Administration

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Maintenance Human Federal Aviation

Video Instructions for

Human Factors in Aviation Maintenance Federal Aviation 2

• Speak in straightforward terms

• Reinforce your current knowledge

• Offer new concepts and/or new ways to explain old

• Provide links for more information

• Have a few laughs?

Human Factors in Aviation Maintenance Federal Aviation 3

2. History of human factors

3. Human factors spectacles

4. The PEAR model

7. Where to get information

Human Factors in Aviation Maintenance Federal Aviation 4

Human Factors in Aviation Maintenance Federal Aviation 5

This section shall:

• Define human factors as it relates to

• Show specific examples of maintenance

• Show why the topic is important to you

Human Factors in Aviation Maintenance Federal Aviation 6

Human Factors in Aviation Maintenance Federal Aviation 7

• Primary concern is for people in the

• Combines elements from many

• Critical to the overall flight safety

Human Factors in Aviation Maintenance Federal Aviation 9

Ensure continuing safety and efficiency by paying

Human Factors in Aviation Maintenance Federal Aviation 10

Human Factors in Aviation Maintenance Federal Aviation 11

Ensure continuing safety and efficiency by paying

Human Factors in Aviation Maintenance Federal Aviation 13

Human Factors in Aviation Maintenance Federal Aviation 14

• Time and motion studies (Frank

• World War II aircraft cockpit

• Establishment of Human Factors

• Military systems and

Human Factors in Aviation Maintenance Federal Aviation 15

Human Factors in Aviation Maintenance Federal Aviation 16

Human Factors in Aviation Maintenance Federal Aviation 17

Human Factors in Aviation Maintenance Federal Aviation 19

• You can see human performance

• The remainder of this presentation

• Look at the environment that

Human Factors in Aviation Maintenance Federal Aviation 20

• Sensitivity to human factors

• Knowledge of how human factors affect work and

• Objectively examine your world

• Be willing to make suggestions and comments

Human Factors in Aviation Maintenance Federal Aviation 21

• What do you see at home with the human factors spectacles?

Human Factors in Aviation Maintenance Federal Aviation 22

Human Factors in Aviation Maintenance Federal Aviation 23

Human Factors in Aviation Maintenance Federal Aviation 24

• Models make it easier

• Models can be 2-D, 3-

Human Factors in Aviation Maintenance Federal Aviation 25

• Originally used for

• Has served human

Human Factors in Aviation Maintenance Federal Aviation 27

• H is physical stuff, like

• E is for the physical

• L-1 is for individuals

• L-2 is for groups

Human Factors in Aviation Maintenance Federal Aviation 29