Human Factor

Federal AviationAdministration

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Maintenance Human Factors Presentation System

Prepared by Aviation Safety OrganizationFlight Standards Service

2Federal AviationAdministration

Human Factors in Aviation Maintenance

Welcome



• 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?

Presentation Plans



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

Presentation Content



1

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



List “Human Factors” Related to Maintenance



• 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




Ensure continuing safety and efficiency by payingattention to issues that affect human performance.

Human Factors Goal — A Summary



The Elements of Human Factors



Ensure continuing safety and efficiency by payingattention to issues that affect human performance.

Human Factors Goal for Review



2History 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

The History of Human Factors



Maintenance Human Factors has Evolved in 20 Years!



Human Factors Timeline



Human Factors Spectacles3



• 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

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

Put on your “Human Factors Spectacles”



• 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?

What did you Learn about Human Factors Spectacles from the Introductory Video?



A Reminder to Apply Human Factors Principles 24 x 7



The PEAR Model4



• Models make it easier to understand complex things

• Easy to remember

• Models can be 2-D, 3-D, or mental

Why Use Models?



• Originally used for pilot’s crew resource management (CRM)

• Has served human factors training well – worldwide

• A bit abstract

The SHELL Model



• 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

The SHELL Model Explained



• PEAR is easy to remember

• It works for maintenance

• It is matched with the SHELL model

The PEAR Model



• People who perform the job

• Organizational and physical environment

• Actions (tasks) performed as part of the job

• Tools, procedures, and other resources

PEAR



Physical • Size

• Gender

• Age

• Strength

• The five senses

Physiological • Health

• Nutrition

• Lifestyle

• Alertness/fatigue

• Chemical dependency

Psychological • Experience

• Knowledge

• Training

• Attitude

• Emotional state Psychosocial

• Interpersonal relations

• Ability to communicate

• Empathy

• Leadership

People



• We live in 24x7x365 world

• Aviation does not rest

• Humans need rest!

What Does This Mean?



Overview of Fatigue



Physiological • Health

• Nutrition

• Lifestyle

• Alertness/fatigue

• Chemical dependency

Physical • Size

• Gender

• Age

• Strength

• The five senses

Psychological • Experience

• Knowledge

• Training

• Attitude

• Emotional state Psychosocial

• Interpersonal relations

• Ability to communicate

• Empathy• Leadership

The Five Senses

People — Vision and Hearing



When you toast you:

See

Smell

Taste

Feel

Hear

How to Remember the Five Senses



As quickly as possible, say the color of each word on the screen.

A Test / Example of…Volunteer Needed



deskrockcat

spoonbook

Sensing and Perception



red

blue

gray

purple

green

Sensing and Perception



What is This?



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)

What is This Now?



Physical

• Weather extremes

• Location (in/out)

• Workspace

• Lighting

• Sound levels

• Housekeeping

• Safety issues

Organizational

• Personnel

• Supervision

• Labor - management

• Size of company

• Profitability

• Job security

• Morale

• Corporate culture

• Safety culture

Environment



• 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

Actions



• 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?

Actions — What Can You Do Today?



• Technical documentation systems

• Test equipment

• Enough time

• Enough people

• Lifts, ladders, stands, seats

• Materials

• Portable lighting, heating, cooling

• Training

Resources



• Are resources ever a problem?

• What are the solutions?

• Can you give an example?

• What advice can you offer?

Resources — Please Offer Your Examples



Human Error5



• Definition of human error

• Types of errors

• The “dirty dozen”

• Examples of errors

• Event investigations – Maintenance Error Decision Aid (MEDA)

Human Error



Gravity

Humans

The Greatest Hazard to Aircraft is…?



80% of Events are Caused by Human Error



Only one way to disassemble

40,000+ ways to incorrectly reassemble!

The Odds are Against Doing it Right!



A human action with unintended consequences

Definition of Human Error



Types of Human Error



Active and Latent Errors



• 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)

Why Things Go Wrong



The Civil Aviation Authority’s List of 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?

The 12 Most Common Causes for Human Errors



Iceberg Model



• Boeing’s event investigation system

• Used by 500 airlines worldwide

• Finds the contributing factors

Event Investigation — MEDA



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

Performance Shaping Factors



Maintenance Accidents6



Fatal Accidents: Intl – 1998 to 2007

World Accidents World Fatalities

0

10

20

30

40

50

60

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

Fata

l Acc

iden

ts

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Fata

litie

s

Source: US NTSB and Flight International, 8-14 January 2008



Source: US NTSB and Flight International, 8-14 January 2008

Fatal Accidents: US/Intl – 1998 to 2007

US Accidents World Accidents US Fatalities World Fatalities

0

10

20

30

40

50

60

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

Fata

l Acc

iden

ts

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Fata

litie

s



Other27%

Controlled Flight Into Terrain

1%

Human Factors45%

Technical/Maintenance

27%

Intl Accident Cause Factors 2007

Source: Flight International, 8-14 January 2008



21 Human factors10 Engine failure 1 Mechanical failure 9 Probable cause unknown

or undetermined (NTSB investigation not

completed) 7 Weather 3 Structural failure

Published March 2006

Causes of Helicopter Accidents (1985 - 2006)



• 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!

Implications of the Safety Statistics for Maintenance Human Factors



• Maintenance errors cause accidents

• Accident statistics

• Common maintenance errors

• Examples of maintenance-related accidents

• Specific accidents

Maintenance Accidents



Historic 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

Recent Maintenance-Related Accidents



7 Where to Get Information



www.hfskyway.com

Three Reference Manuals



• 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

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



www.hfskyway.com

For More Information — Publications



For More Information — www.hf.faa.gov



FAA Human Factors Resources: www.hfskyway.com



ReferencesFAA (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?opendocument

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



Summary8

Human Factor

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