Training Centre

Module 9 HUMAN FACTORS

Category Aerospace/Avionics

Sub Module 9.9 - Hazards in The Workplace

MODULE 9
Sub Module 9.9

HAZARDS IN THE WORKPLACE

For Training Purpose Only

ISO 9001:2008 Certified

9.9

CAA Approval No: HQCAA/2231/44/AW Dated: 11th Sept, 09

Rev. 00
Nov 2009

Training Centre

Module 9 HUMAN FACTORS

Category Aerospace/Avionics

Sub Module 9.9 - Hazards in The Workplace

Contents
SECTION 1: HAZARDS IN THE WORKPLACE ------------------------------ 1
DEALING WITH EMERGENCIES----------------------------------------------- 1
THE BASIC ACTIONS IN AN EMERGENCY ARE TO: ----------------------- 1
CASE 1 ----------------------------------------------------------------------------- 2
CASE 2 ----------------------------------------------------------------------------- 3
CASE 3 ----------------------------------------------------------------------------- 4
CASE 4 ----------------------------------------------------------------------------- 5

For Training Purpose Only

ISO 9001:2008 Certified

9.9 - i

CAA Approval No: HQCAA/2231/44/AW Dated: 11th Sept, 09

Rev. 00
Nov 2009

Training Centre

Module 9 HUMAN FACTORS

Category Aerospace/Avionics

Sub Module 9.9 - Hazards in The Workplace

SECTION 1: HAZARDS IN THE WORKPLACE

THE BASIC ACTIONS IN AN EMERGENCY ARE TO:

Hazards in the workplace tend to be a health and safety issue,

relating to the protection of individuals at work. All workplaces
have hazards and aircraft maintenance engineering is no
exception. Health and safety is somewhat separate from human
factors and this chapter therefore gives only a very brief
overview of the issues relating the aircraft maintenance
engineering.

Stay calm and assess the situation

DEALING WITH EMERGENCIES

Make the area safe

Careful handling of health and safety in the maintenance

environment should serve to minimize risks. However, should
health and safety problems occur, all personnel should know as
far as reasonably practical how to deal with emergency
situations. Emergencies may include:

Protect any casualties from further danger

Observe what has happened

Look for dangers to oneself and others
Never put oneself at risk

Remove the danger if it is safe to do so (i.e. switching off

an electrical current if an electrocution has occurred)

An injury to oneself or to a colleague

Be aware of ones own limitations (e.g. do not fight a fire

unless it is practical to do so)

A situation that is inherently dangerous, which has the

potential to cause injury (such as the escape of a
noxious substance, or a fire)

Assess all casualties to the best of ones abilities

(especially if one is a qualified first aider)

Appropriate guidance and training should be provided by the

maintenance organization. The organization should also provide
procedures and facilities for dealing with emergency situations
and these must be adequately communicated to all personnel.
Maintenance organizations should appoint and train one or
more first aiders.
Emergency drills are of great value in potentially dangerous
environments. Aircraft maintenance engineers should take part
in these wherever possible. Knowledge of what to do in an
emergency can save lives.

Call for help

Summon help from those nearby if it is safe for them to
become involved
Call for local
extinguisher)

equipment

(e.g.

fire

Call emergency services (ambulance or fire brigade, etc)

Provide assistance as far as one feels competent to.
For Training Purpose Only

ISO 9001:2008 Certified

9.9 - 1

emergency

CAA Approval No: HQCAA/2231/44/AW Dated: 11th Sept, 09

Rev. 00
Nov 2009

Training Centre

Module 9 HUMAN FACTORS

Category Aerospace/Avionics

Sub Module 9.9 - Hazards in The Workplace

CASE 1
PATIENT DIED PROBABLY DUE LACK OF OXYGEN
SUPPLY

Upon arrival it was noted that oxygen flow of the aircraft

installed bottle was set to max (fully open, 10 liter per minute)
and the regulator connection was extremely tight.
ANALYSIS

BACKGROUND
As requested for a supply of medical Oxygen, a bottle was
installed in the aircraft for the use of a meda case. The oxygen
requirement was a continuous flow rate of 2 liters per minute.
As per the certifying staff oxygen bottle was checked and found
satisfactory.
Prior to flight once the passenger was in the aircraft the Doctor
checked the oxygen bottle and found in satisfactory condition.
Once the patient was connected to the oxygen bottle installed in
the aircraft, it was noticed that bottle was leaking around its
connection to the regulator and it was noted that pressure has
decreased from 2200 to 1500 psi. A little while later as per the
flight crew the leak had stopped. The oxygen bottle brought
from the hospital was also carried on board.

Reason for the bottle leak could not be established although it

should have been declared unserviceable once found leaking.
Crew did not check the hospital oxygen bottle and relied on the
information provided by the doctor.
Oxygen bottles were serviced and supplied by a third party.
Poor handling by a person who is not conversant with the
operation led to leak and wrong setting of the regulator.

As per the doctor the hospital oxygen bottle had enough oxygen
to cover the entire flight. The patient was connected to the
hospital oxygen bottle. However no one had checked the bottle
pressure and it was unknown how much oxygen was left in the
bottle.
During approach landing phase 30-35 miles short of the airport,
the doctor had informed that both oxygen bottles were
consumed and no oxygen was available to the patient. Upon
arrival, oxygen was supplied and patient was rushed to the
hospital. It was learned that patient died before reaching the
hospital.
For Training Purpose Only

ISO 9001:2008 Certified

9.9 - 2

CAA Approval No: HQCAA/2231/44/AW Dated: 11th Sept, 09

Rev. 00
Nov 2009

Training Centre

Module 9 HUMAN FACTORS

Category Aerospace/Avionics

Sub Module 9.9 - Hazards in The Workplace

CASE 2
AIRCRAFT WAS ABOUT TO MOVE WITH AIRCRAFT
HANDLER AT CLOSE PROXIMITY
BACKGROUND
Aircraft handler had difficulties removing the front chock on
nose wheel. After hitting the front chock, several times, the
chock moved aside about 450 and at that time aircraft handler
noticed that the aircraft wheel moving forward so he left with aft
chock and trolley, and showed the Captain that the chock was
not cleared. No one was injured in this incident.
EVENT INFORMATION
Pilot in charge has noticed during walk-around that nose wheel
was slightly off centre. Emergency brake was OFF and was
selected to PARK before start of checks. Flight crew was in a
hurry to obtain ATC clearance as one aircraft was back tracking
and other was also ready for departure. Mechanic on duty had
informed verbally that chocks have been removed and he was
disconnecting the headset. Un-feathering of propellers and this
happened to be at the same time that the aircraft handler was
trying to remove chocks. Since crew did not notice that the
chocks were not removed, selected the nose wheel steering.
The centering of the nose wheel kicked the chock forward and
the aircraft jerked. The mechanic rushed to the aircraft and
removed the chocks. First Officer alerted that a person was
close to aircraft, so propeller setting was changed to START
FEATHER. The aircraft did not physically moved forward.

For Training Purpose Only

ISO 9001:2008 Certified

9.9 - 3

CAA Approval No: HQCAA/2231/44/AW Dated: 11th Sept, 09

Rev. 00
Nov 2009

Training Centre

Module 9 HUMAN FACTORS

Category Aerospace/Avionics

Sub Module 9.9 - Hazards in The Workplace

CASE 3
IN A LAYOVER FLIGHT AT A LINE STATION A CLEANER
WAS LOCKED INSIDE THE AIRCRAFT NEARLY ONE HOUR.
BACKGROUND

None of them including ramp staff realized the cleaner was

inside. The cleaner was left alone inside the aircraft for about
one hour and the airport supervisor called the station assistant
informing that cleaner was left inside the aircraft. He rushed to
open the door to let the cleaner out after obtaining permission
from captain.

This incident occurred on a Friday close to prayer time. There

was two engineering staff on board to carry out some
maintenance work in the afternoon before departure. An elderly
employee working as laborer was doing cabin cleaning.
The flight landed close to noon and after disembarking the
passengers flight crew completed their routine checklists. The
cabin crew reported cabin clear and did the security checks to
confirm that nothing is left by the passengers. One crew
member noticed the cleaner getting in to aircraft at this time as
usual. Since it was the day shutdown at the station, they packed
their belongings and left the aircraft not confirming whether the
cabin cleaning was completed. The ramp staff was outside near
the air stair door and one of them, as requested by the
mechanic, went to collect the tool box which was loaded in the
baggage compartment. As the flight crew came out of the
aircraft, saw the mechanic installing the propeller guards.
Assuming they handed over the aircraft to the mechanic and the
engineer, crew started move away from the aircraft. The flight
attendants reminded the captain, of the door being left open.
When the captain was going to close it, the mechanic climbed
down the steps and closed the door together with the ramp
staff. He again opened the door and got his bag which was left
in the overhead compartment of raw 1. The cleaner at this time
was cleaning the last row seats. Since all the others are outside
and waiting for him, the mechanic hurried to join them, close the
door and left together with the rest of the crew.
For Training Purpose Only

ISO 9001:2008 Certified

9.9 - 4

CAA Approval No: HQCAA/2231/44/AW Dated: 11th Sept, 09

Rev. 00
Nov 2009

Training Centre

Module 9 HUMAN FACTORS

Category Aerospace/Avionics

Sub Module 9.9 - Hazards in The Workplace

CASE 4
ATC SEPARATION BREAKDOWN BACKGROUND
Island aviation aircraft departed and mistakenly followed wrong
instrument departure causing separation breakdown with
another aircraft inbound for landing.
Aircraft was taxing out and lining up on runway for departure
with a delay. When they were on the turn to line up and about to
report ready for departure, the controller asked to follow new
instructions. Since it was a new clearance, immediately the copilot took out the chart which has mentioned departure and
briefed the captain who was the pilot flying. According to the
crew, the co-pilot briefed runway heading and left turn to
establish. Without knowing what briefed was wrong the aircraft
took off and turned left towards the eastern side of the field. At
this time another aircraft was on descend and on the North East
of the airfield for landing. The controller noticed both aircraft in
same sector and advised the aircraft that they were flying a
wrong departure. The pilots were puzzled and confidently
reported that they were flying the correct departure. It took a
while for the crew to realize they were flying a wrong departure.
The controller corrected this separation break by giving
necessary instructions and later cleared for correct route.

For Training Purpose Only

ISO 9001:2008 Certified

9.9 - 5

CAA Approval No: HQCAA/2231/44/AW Dated: 11th Sept, 09

Rev. 00
Nov 2009