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Maintenance Human Federal Aviation

Administration
Factors Presentation
System

Prepared by
Aviation Safety Organization
Flight Standards Service

Video Instructions for


Animations provided by Presenter – Click here
Welcome

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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?

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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

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1 What is Human Factors?

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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

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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

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Human Factors Goal — A Summary

Ensure continuing safety and efficiency by paying


attention to issues that affect human performance.

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The Elements of Human Factors

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Human Factors Goal for Review

Ensure continuing safety and efficiency by paying


attention to issues that affect human performance.

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2 History of Human Factors

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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

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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

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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

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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?

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A Reminder to Apply Human Factors
Principles 24 x 7

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4 The PEAR Model

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Why Use Models?

• Models make it easier


to understand complex
things

• Easy to remember

• Models can be 2-D, 3-


D, or mental

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The SHELL Model

• Originally used for


pilot’s crew resource
management (CRM)

• Has served human


factors training well –
worldwide

• A bit abstract

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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

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The PEAR Model

• PEAR is easy to remember

• It works for maintenance

• It is matched with the SHELL


model

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PEAR

• People who perform the job

• Organizational and physical environment

• Actions (tasks) performed as part of the job

• Tools, procedures, and other resources

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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

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How to Remember the Five Senses

When you toast you:

See
Smell
Taste
Feel
Hear

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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
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What is This?

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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)

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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

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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

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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?

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Resources

• Technical documentation systems


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

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Resources — Please Offer Your
Examples

• Are resources ever a problem?

• What are the solutions?

• Can you give an example?

• What advice can you offer?

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5 Human Error

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Human Error

• Definition of human error

• Types of errors

• The “dirty dozen”

• Examples of errors

• Event investigations –
Maintenance Error
Decision Aid (MEDA)

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The Greatest Hazard to Aircraft is…?

Gravity

Humans

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80% of Events are Caused by Human
Error

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The Odds are Against Doing it Right!

Only one way to


disassemble

40,000+ ways to
incorrectly
reassemble!

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Definition of Human Error

A human action with


unintended consequences

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Types of Human Error

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Active and Latent Errors

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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)

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The Civil Aviation Authority’s List of
Errors

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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?

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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

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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

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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

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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

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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

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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!

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Maintenance Accidents
• Maintenance errors cause
accidents

• Accident statistics

• Common maintenance
errors

• Examples of maintenance-
related accidents

• Specific accidents

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Historic Maintenance-Related
Accidents

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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

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7 Where to Get Information

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Three Reference Manuals

www.hfskyway.com

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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

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For More Information — Publications

www.hfskyway.com

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For More Information —
www.hf.faa.gov

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FAA Human Factors Resources:
www.hfskyway.com

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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

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8 Summary

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