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Compiled by Shahzad Khalil Aug2007
Contents of Course
1. 2. 3. 4. 5. 6. 7. 8. 9.
General Human Performance and Limitations Social Psychology Factors affecting Performance Physical Environment Tasks Communication Human Error Hazards in the Work Place
This course will benefit
professionally – at workplace
& personally – in daily life
Goal Awareness of personal behaviour Minimise errors Reduce the number of incidents Improve Safety – of personnel & aircraft. 4 .
Quotation: To err is human. Quiz Do human make mistakes? Are we human? Will we make mistakes? Would we like to reduce the possibility of mistakes? 5 .
6 . Chain of Events/human errors Solution / Safety Net: If we break the chain at our level.Introduction Aviation: Safest forms of travelling. the accidents will not happen.
Basic Rules: If it has gone wrong once. 7 . it will probably go wrong again. ( e. Safety Net: At Design stage – By manufacturer.The need to consider the human factor Most important human factor: Ability to learn from experience & mistakes committed by others.g. Cross wires) At user level – By following written procedures.
Error in aircraft maintenance Valujet Flight 597: 5 pax & 2 flight attendants injured. 8 . 7th Stage high compressor disk failed. Poor Record-keeping. Investigated Causes: Fatigue crack.
9 .Reasons of Safety Improvement better aircraft better air traffic control better weather forecasts.
Do you agree? 10 .It is difficult to fix a faulty person than to fix a faulty component.
Human Error Estimates: 11 .
12 .Error Iceburg: A chain of minor events caused accidents. Saying :Take care of your hours and days. months and years will take care themselves. Heinrich Ratio: Fatal Accidents Non Fatal Reportable accidents Unsafe Acts (Not reported 1 10 30 600 Safety Net: Look below the surface for minor mistakes and never leave anything unreported.
in advance. Extremely Low Tolerance for Errors Although we learn through mistakes. to avoid the occurrence of any event.In aviation. yet cannot afford to commit mistakes ourselves and learn. Proactive Approach: Taking measures. 13 . We have to: learn from the mistakes of others.
Causes & Casts of Air Accidents ex: Boeing 14 .
collided with workstands. Resulting Damage:The following equipment was damaged: Left-hand horizontal stabilizer Rudder Rear dock stands Hangar wall Cost factors: The following cost factors resulted from this one mistake: Material Regular and overtime labour Repairs to dock stands and hangar wall Loss of bay facility during additional repair Delayed or third party maintenance for other aircraft Operational complications due to aircraft unavailability Investigation and corrective action 15 .A Simple Mistake by one Person affects an Entire Organsiation B767 was being brought into Hanger.
000/.USD 16 .Cost of one Night Stop at Foreign Station Approximately 40.
test (6%) Equipment not activated or deactivated (4%) 17 .5%) Improper installation (11 %) Equipment not installed or missing (11%) Foreign object damage (6. inspection. Incomplete installation (33%) Damage on installation (14.5%) Improper troubleshooting.Top seven causes of inflight shutdowns : Boeing analyzed the most common errors behind B767 inflight shutdowns. almost 70% were caused by installation problems.
Top eight common maintenance errors Incorrect installation of components Fitting of wrong parts Wrong electrical wiring of parts (including cross connections) Loose objects left in the aircraft Not enough lubrication Cowling and/or access panels not secured Fuel/oil caps and/or refuel panel not secured Landing gear ground lock pins not removed before departure 18 .
19 .Who is right? Both are right from their own positions. place yourself on his position and see the things as he perceives. When you decide anything or assign any task to someone.
An AD called for close inspection of 1300 rivets.Aloha Airline’s flight of B737 had 18 feet (5. The chief inspector had 33 years of experience. 20 . A post incident inspection revealed that there were at least 240 cracks present at the last inspection prior to the incident. The inspector had 22 years of experience. In the inspection prior to the incident no cracks were found.5m) of fuselage skin ripped off.
Comparison of Human Errors to Machine Errors 21 .
g.g.Murphy’s Law: “Anything that can go wrong will go wrong. 22 . Dual inspection. Procedures misunderstood –Users – improve procedures e. computer connectors. e.” Manufacturers – design changes-make it impossibility to use in wrong way.
23 . Smoking.Types of Errors Active error .g. e.delayed effect Bolt was corroded – not seen so not replaced will ultimately break.immediate effect Height of aircraft not read correctly – crash – immediate effect Latent error . Delay between the mistake and consequence.
Although only a few errors will be the cause of an accident. AMTs must be aware of the different kinds of mistake they make and the possible consequences. Many errors are made.Conclusions from brief introduction of human Errors Errors affect both lives and profit. 24 . it is impossible to predict which one this will be. but it usually requires a chain of events for a serious incident to occur. AMTs must know the company's procedures for avoiding errors and the benefit of following those procedures.
Five senses: : smell. Potections. Minimum level of stimulation – Threshold values. Input devices of human body and their related senses. sight. 25 . taste. Health of our senses.2 HUMAN PERFORMANCE AND LIMITATIONS Brain – the CPU of Human body.9. hearing and touch.
Brain Left half of brain thinks rationally. Right half of brain thinks emotionally. Which one is correct to use? Both should be used. 26 . Related to creativity and clever ideas. Used while dealing with problems.
Strategies 27 .
Taste – very rarely used. Extreme of touch is pain. Sense of temperature through touch. Smell can warn us of dangers. The two most used senses: Sight and hearing.the sources of information.Information Awareness Five senses . 28 . – sense of touch.
Detection & Awareness Sight sense – eyes. 29 . Inspection involves: search and decision making. Minimum level of stimulation / threshold level with naked eye : 60 micron.
Written Communication: Legible Accurate Complete Order of sentences.Use of eyes: Inspections: 80% of inspections are visual inspection Written documents: Different manuals. Job-cards Writing what you have done. 30 .
50% to 80% waking time spent in listening. 31 .Hearing Use ears. Two ears and one tongue. AF : 20 Hz – 20 KHz Volume / Audio level in decibel (dB) Awareness threshold: 0 dB Deteriorate with age and also suffers from non-reversible permanent damage when exposed to high level of noise.
Earmuffs / Earplugs.Ear Protections When sound volume > 90 dB Even at 85 dB if remain exposed for > 4 hours. 32 . Treatment of ears take years.
not selective. Active. Involves interpreting the sounds. Listening hearing with selective attention. 33 .What is the difference between Hearing & Listening Hearing is just the process of taking in sounds. To each other. Passive. Sound of fan. air-conditioner etc.
Preparation Eye contact What is said and what is not said? Sometimes more information in what is not said. Distraction tolerance Appropriate time & place. Listening instead of talking: two ears & one tongue.Listening Interest in topic. 34 . Prejudices : decision already made.
Hearing Damage 35 .
Different Ways of Information Transfer: Person to Person: Via verbal communication Via written communication Display / Product to person: Job cards Manuals Displays Indicators Person to Product: Key board of computer Controls in aircraft 36 .
Not speaking clearly Bad handwriting Poor lighting Poor communication 37 . loose tools or parts.Information That is Hard to See or Hear Noisy environment Makes it hard to hear what people say. Can't see cracks.
a hole on ground is a distractor. Conversations Interruptions 38 .Information Present but Missed Awareness Problem Completely focused on one task and miss other things around. Distractions: e. During walk-around.g.
Attention and Awareness
Selective Attention: Monitoring several sources of information to decide whether particular event has occurred e.g. deviant reading on several indicators in cockpit. Focused Attention: Being task focused. Concentrating to one source. e.g. Mechanic reading in noisy environment. Divided Attention Sustained Attention Security Guards viewing a TV monitor.
Mental limits: Disassembly and Re-assembly
There is only one way to disassemble the nuts, but there are
40, 000 wrong ways to re-assemble them. Knowledge and experience will help to prevent mistakes, but nobody can know everything (Human limitations) Use of Written instructions and Experience of colleagues can compensate for these limitations.
Claustrophobia and Physical Access
Claustrophobia: Definition: An irrational fear of being in a confined or enclosed space. e.g. Maintenance in Fuel Tank. Use Life-Line Space Availability: More space improves performance. Controllability: Minimum restrictions due to clothes & shoes.
3 Social Psychology The area of psychology that deal with how groups behave and how individuals are affected by the group. 42 .9.
Different Ways to Learn & %age Remembered: Hear 25% See 30-35% See & Hear 50% Say & Repeat 75% Do 90% 43 .
44 .Motivation Willingness to put effort into achieving a goal.
When given the chance to contribute. they become productive. 45 . The whole is greater than the sum of the individual parts. A group effort be encouraged. task-oriented employees and in result feel significant. An active role in solving problems and decision making. Humanity is socially embedded. People (and organisations) function holistically.Alfred Adler’s Motivation Theory All human behaviour is goal-directed. Problems cannot be solved by one person in isolation. A person's knowledge and skills are of no value if they are not used. People are creative decision-makers. Use is more important than possession. They are solved by co-operation and contribution.
Maslow’s Theory of Hierarchy of Needs 46 .
Pleasant workplace and effective maintenance. Hearfelt concerns for employees. Open communication. Philosophy: Mission Statement: Clearly worded and communicated. Guidelines stating what is and is not acceptable. Ceremonies for appropriate recognition.Culture Issues Corporate Culture: Develop a desirable corporate culture. 47 .
co-ordination and communication. Team: a group of inter-dependent individuals working together to complete a specific task. 48 . Example: Football Team In maintenance.Teamwork Planning. working as a team improves productivity and reduces injury and equipment damage.
Openness: full and open communication. 4. 9. Participation: in decisions making and/or activities. 2.Characteristics of an Effective Team 1. 10. Clear expectations: about the roles each member & assignments fairly distributed Shared leadership: Delegation of Power. Disagreement: Agree to disagree with each other. Listening: listens to the others. 7. A clear purpose: accepted by all members. 49 . Team maintenance: focus on their primary goal but also spend time recognising and maintaining the functions of the team. 5. 8. Relations with others: With other teams. Relaxed: no tensions among the members. 6. 3.
Lead by example. 50 .Leadership The ability to direct and co-ordinate the activities of group members and stimulate / inspire them to work together to complete a specific task.
Responsibilities of Leaders Direct and co-ordinate team activity Delegate tasks to appropriate team members Make sure team members know what is expected of them Focus attention on important aspects of the situation Adapt to internal and external changes to the environment Keep team members up to date on work-related information Ask team members for work-relevant information Provide feedback to team on performance Create and maintain a professional atmosphere 51 .
Effective Leader Make suggestions Encourage the team to perform Lead by inspiration Provide feedback How well you lead depends on how well you communicate. 52 .
Participatory Leader: Encourages participation. Get maximum input from members Group decisions. Dictates actions with little input from team members. 53 . Sole decision maker. Distributes resources and delegate power. Controls all the resources.Types of Leaders Authoritative Leader: Runs the show alone.
54 . Which type of leadership is better? Balance between the two types.
Work well together. Task unstructured. 55 . Inputs required. Participatory Time available. Do not accepts decision taken by single person. Conflicts Accepts decision taken by single person.When to use Authoritative and when Participatory? Authoritative Done quickly. Task structured. Clear Answers.
Factors Affecting Performance Stress Definition: Physical or psychological tension caused by dealing with difficult situations. Work related problem. Stressors Personal problems.4. Social problems.9. Heart diseases – Sleeping problem 56 . Cost of Stress Poor work quality – Public safety jeopardised.
Positive level of stress: Best Performance. Negative level of stress: Poor performance.Stress and performance Stress in itself is not necessarily bad. 57 .
Stressful Situations: Overload Under-load Fire Fighters: Under-loaded & Overloaded 58 .Time Pressures & Deadlines Time pressure sets the pace of work.
Frequent Breaks 59 .Varying the Task Alternate / swap tasks: Physical demanding with mentally demanding High awareness with low awareness Long duration with short duration Break can be a change of work.
listening of some sound. Use all the senses.g. Fire” Perceiving : e. Fire. 60 . Comprehending: What that sound mean? Projecting: Thinking about possible consequences.Components of Situation Awareness Be aware of your surroundings. “ Fire .
61 . Block Diagrams. wiring diagrams etc. For example: model of braking system of bicycle to understand aircraft braking system.Models Are in diagram form. Drawn to understand complex systems.
To develop the strategies to improve the system.Why we draw models? To identify the components of the system. 62 .
SHELL Model Software Hardware Environment Liveware (Individual) Liveware (Group) 63 .
7 Communication 64 .9.
The dynamic and irreversible process by which we make contact and interpret messages within a given situation or context. Transfer of information from one place to another.Definitions of Communication Skill of passing information from on person to another. 65 .
No good or bad ego state. Three minds or ego states. A healthy personality includes all three.The Transactional Analysis Model Is an attempt to explain human behavior. 66 . especially communication.
) Parent: Orders Claims to know everything Caring. encouraging.The Transactional Analysis Model (Contd. I will do this. Sentences: Let me help you. supportive & protective. Leave it to me. 67 .
Child: Emotional Free & natural. 68 . Sentences: I do not like you. I want leave.The Transactional Analysis Model (Contd. Obey. I do not know. Talk on equal level. Sentences: What is your opinion? I do not agree.) Adult: Asks for reasons. Not sure of itself. be polite. retreat.
Sentences: Hurry up. Rational Minds: Takes more time to react. Decisions made without analysis. Decisions made through analysis.Dupont Model Emotional Minds: Responds faster. Forget it. Balance 69 .
Conflict Reduced quality Cost increases 70 .Results of poor communication Errors Inefficiencies Duplication of effort.
Decide on actions and make decisions effectively.Results of good communication Reach an understanding with one another. 71 . Co-ordinate their efforts. Agree who does what. Take correct action to reach their goals.
Non-verbal communication Written communication 72 . Manuals. as body language. smile or frown. forms. letters. magazines.Forms of communication Verbal communication the spoken word. Job-cards. e-mail etc. radio. loud speaker etc. face-to-face or through an electronic medium such as a telephone. Wave. books.
The Receiver : the person who sees.Communication model Communication in its simplest form involves two people: The Sender : the speaker or writer who is transmitting a message. The message includes body language. hears or reads the message. Feedback Messages filtered through feelings. opinions and intentions. 73 .
clear Standard part names. Be Say what you mean to say. 74 . Be Enough information.Three Be Cs of Communication correct complete.
Information technology (IT) improves communication in organisations in the following ways: It cuts across time boundaries. fax machines. It helps reduce paperwork. It cuts across geographical boundaries. voice mail. simultaneous reception. Bottlenecks can be avoided as electronic information channels are typically direct between sender and receiver. 75 . mobile phones and pagers.The impact of information technology e-mail. It allows multiple.
8 Human Errors General Model of Human Error: 76 .9.
Violation . Slip . but bad execution: John's plan is to pump his brakes.the wrong procedure is performed intentionally: John learned from his driving teacher that he should pump his brakes in this situation.a bad plan is selected: John thinks that speeding up will give him control over his car so he accelerates. Mistake .Types of Errors Example: John drives into water and the car begins to hydroplane.having a good plan. 77 . so John steps on the accelerator. but his brother said that acceleration is best. but he misses the brake pedal and steps on the accelerator instead.
identified 12 most common human factor maintenance errors. known as dirty dozen that limit people’s ability to perform effectively and safely 78 . Gordon Dupont.Dirty Dozen Aviation safety specialist.
Complacency (too relaxed) Distraction Pressure Lack of resources Lack of knowledge Lack of awareness Norms Stress Fatigue 79 .Dirty Dozen ( continued) Lack of communication Lack of teamwork Lack of assertiveness (not enough confidence).
Lack of Communication Communication by: the spoken words the written words gestures and facial expressions body language 80 .1.
Sender-Receiver Model of Communication 81 .
Compare two Log-book Entries 82 .
2. Lack of Team Work 83 .
Lack of Assertiveness 84 .3.
4. Complacency (Too relaxed) 85 .
5. Distraction 86 .
6. Pressure 87 .
7. Lack of Resources 88 .
Lack of Knowledge 89 .8.
Lack of Awareness 90 .9.
Norms 91 .10.
Stress 92 .11.
Fatigue 93 .12.
Thank you for your Attention 97 97 .
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