Human Factors for Aircraft Maintenance

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

Foreword
This course will benefit

you both:

professionally at workplace

&
personally in daily life

Goal
Awareness of personal behaviour

Minimise errors
Reduce the number of incidents
Improve Safety of personnel & aircraft.

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?

Introduction
Aviation: Safest forms of

travelling.
Chain of Events/human
errors
Solution / Safety Net:
If we break the chain at our
level, the accidents will not
happen.

The need to consider the human factor

Most important human factor:
Ability to learn from experience & mistakes
committed by others.
Basic Rules:

If it has gone wrong once, it will probably go

wrong again.
Safety Net:
At Design stage By manufacturer. ( e.g. Cross wires)
At user level By following written procedures.

Error in aircraft maintenance

Valujet Flight 597:
5 pax & 2 flight attendants injured.
7th Stage high compressor disk failed.
Investigated Causes:
Fatigue crack.
Poor Record-keeping.

Reasons of Safety Improvement

better aircraft
better air traffic control
better weather forecasts.

It is difficult to fix a faulty person

than to fix a faulty component.

Do you agree?

10

Human Error Estimates:

11

Error Iceburg:
A chain of minor events caused accidents.
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.
Saying :Take care of your hours and days,

months and years will take care themselves.

12

In aviation, Extremely Low Tolerance for Errors

Although we learn through mistakes, yet

cannot afford to commit mistakes ourselves

and learn. We have to:

learn from the mistakes of others.

Proactive Approach:

Taking measures, in advance, to avoid the

occurrence of any event.
13

Causes & Casts of Air Accidents ex: Boeing

14

A Simple Mistake by one Person

affects an Entire Organsiation
B767 was being brought into Hanger, 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

Cost of one Night Stop at Foreign

Station

Approximately 40,000/- USD

16

Top seven causes of inflight shutdowns :

Boeing analyzed the most common errors behind B767 inflight shutdowns; almost 70%
were caused by installation problems.

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%)

17

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

Who is right?
Both are right from their

own positions.
When you decide
anything or assign any
task to someone, place
yourself on his position
and see the things as
he perceives.

19

Aloha Airlines flight of B737

had 18 feet (5.5m) of fuselage skin ripped off.

An AD called for close inspection of 1300 rivets.

The inspector had 22 years of experience.
The chief inspector had 33 years of experience.
In the inspection prior to the incident no cracks were found.
A post incident inspection revealed that there were at least 240 cracks
present at the last inspection prior to the incident.

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Comparison of Human Errors to Machine Errors

21

Murphys Law:
Anything that can go wrong will go wrong.
Manufacturers

design changes-make it impossibility to use in

wrong way. e.g. computer connectors.
Procedures misunderstood

Users improve procedures e.g. Dual

inspection.

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Types of Errors
Active error - immediate effect

Height of aircraft not read correctly crash immediate

effect

Latent error - delayed effect

Bolt was corroded not seen so not replaced will
ultimately break.
Delay between the mistake and consequence.
e.g. Smoking.

23

Conclusions from brief introduction of human Errors

Errors affect both lives and profit.

Many errors are made, but it usually requires a chain of

events for a serious incident to occur.

Although only a few errors will be the cause of an
accident, it is impossible to predict which one this will be.
AMTs must be aware of the different kinds of mistake
they make and the possible consequences.
AMTs must know the company's procedures for avoiding
errors and the benefit of following those procedures.

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9.2 HUMAN PERFORMANCE AND LIMITATIONS

Brain the CPU of Human body.

Input devices of human body and their related

senses.
Five senses: : smell, taste, sight, hearing
and touch.
Minimum level of stimulation Threshold
values.
Health of our senses.
Potections.

25

Brain
Left half of brain thinks

rationally. Used while

dealing with problems.
Right half of brain thinks
emotionally. Related to
creativity and clever ideas.
Which one is correct to use?

Both should be used.

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Strategies

27

Information Awareness
Five senses - the sources of information.
Smell can warn us of dangers.
Sense of temperature through touch.
Extreme of touch is pain. sense of touch.
Taste very rarely used.
The two most used senses: Sight and

hearing.

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Detection & Awareness

Sight sense eyes.
Minimum level of

stimulation / threshold
level with naked eye :
60 micron.
Inspection involves:
search and decision
making.

29

Use of eyes:

Inspections: 80% of inspections are visual inspection

Written documents: Different manuals.
Job-cards
Writing what you have done.
Written Communication:

Legible
Accurate
Complete
Order of sentences.

30

Hearing
Use ears.
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.
50% to 80% waking time spent in
listening.
Two ears and one tongue.

31

Ear Protections
When sound volume > 90 dB
Even at 85 dB if remain exposed for

> 4 hours.
Earmuffs / Earplugs.
Treatment of ears take years.

32

What is the difference between

Hearing & Listening
Hearing
is just the process of taking in sounds.
not selective.
Passive.
Sound of fan, air-conditioner etc.
Listening

hearing with selective attention.

Involves interpreting the sounds.
Active.
To each other.
33

Listening
Interest in topic.
Distraction tolerance
Appropriate time & place.
Listening instead of talking: two ears & one tongue.
Preparation
Eye contact
What is said and what is not said? Sometimes more
information in what is not said.
Prejudices : decision already made.

34

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

Information That is Hard to See or Hear

Noisy environment

Makes it hard to hear what people say.

Poor lighting

Can't see cracks, loose tools or parts.

Poor communication

Not speaking clearly

Bad handwriting

37

Information Present but Missed

Awareness Problem

Completely focused on one task and miss

other things around.
Distractions: e.g. During walk-around, a hole
on ground is a distractor.

Conversations
Interruptions

38

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.

39

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.

40

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.
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9.3 Social Psychology

The area of psychology that deal with how
groups behave and how individuals are affected
by the group.

42

Different Ways to Learn & %age Remembered:

Hear
See

25%
30-35%
See & Hear
50%
Say & Repeat
75%
Do
90%

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Motivation
Willingness to put effort into

achieving a goal.

44

Alfred Adlers Motivation Theory

All human behaviour is goal-directed.

When given the chance to contribute, they become

productive, task-oriented employees and in result feel
significant.
People are creative decision-makers.

An active role in solving problems and decision making.

Humanity is socially embedded.

Problems cannot be solved by one person in isolation.

They are solved by co-operation and contribution.
Use is more important than possession.

A person's knowledge and skills are of no value if they are

not used.
People (and organisations) function holistically.

The whole is greater than the sum of the individual parts.

A group effort be encouraged.

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Maslows Theory of Hierarchy of Needs

46

Culture Issues
Corporate Culture:
Develop a desirable corporate culture.
Pleasant workplace and effective maintenance.
Philosophy:

Mission Statement: Clearly worded and communicated.

Guidelines stating what is and is not acceptable.

Ceremonies for appropriate recognition.
Hearfelt concerns for employees.
Open communication.

47

Teamwork
Planning, co-ordination and communication.

Team: a group of inter-dependent individuals

working together to complete a specific task.
Example: Football Team
In maintenance, working as a team improves

productivity and reduces injury and equipment

damage.

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Characteristics of an Effective Team

n
n
n
n
n
n
n
n
n
n

A clear purpose: accepted by all members.

Relaxed: no tensions among the members.
Participation: in decisions making and/or activities.
Listening: listens to the others.
Disagreement: Agree to disagree with each other.
Openness: full and open communication.
Clear expectations: about the roles each member &
assignments fairly distributed
Shared leadership: Delegation of Power.
Relations with others: With other teams.
Team maintenance: focus on their primary goal but also spend
time recognising and maintaining the functions of the team.

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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.

Lead by example.

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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
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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

Types of Leaders
Authoritative Leader:
Runs the show alone. Sole decision maker.
Controls all the resources.
Dictates actions with little input from team members.
Participatory Leader:

Encourages participation.
Distributes resources and delegate power.
Get maximum input from members
Group decisions.

53

 Which type of leadership is better?

Balance between the two types.

54

When to use Authoritative and when

Participatory?
Authoritative

Participatory

Done quickly.

Time available.

Task structured. Clear

Answers.

Task unstructured. Inputs

required.

Conflicts

Work well together.

Accepts decision taken by

single person.

Do not accepts decision

taken by single person.
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9.4. Factors Affecting Performance

Stress
Definition:
Physical or psychological tension caused by dealing
with difficult situations.
Stressors

Personal problems.
Work related problem.
Social problems.

Cost of Stress
Poor work quality Public safety jeopardised.
Heart diseases Sleeping problem
56

Stress and performance

Stress in itself is not

necessarily bad.
Positive level of stress:
Best Performance.
Negative level of stress:
Poor performance.

57

Time Pressures & Deadlines

Time pressure sets the pace of work.
Stressful Situations:

Overload
Under-load

Fire Fighters:

Under-loaded & Overloaded

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Varying the Task

Alternate / swap tasks:

Physical demanding with mentally demanding

High awareness with low awareness
Long duration with short duration

Frequent Breaks

Break can be a change of work.

59

Components of Situation Awareness

Be aware of your surroundings.
Use all the senses.

Fire , Fire, Fire

Perceiving : e.g. listening of some sound.
Comprehending: What that sound mean?
Projecting: Thinking about possible consequences.

60

Models
Are in diagram form.
Drawn to understand complex systems.
For example: model of braking system of bicycle to
understand aircraft braking system.
Block Diagrams, wiring diagrams etc.

61

Why we draw models?

To identify the components of the system.
To develop the strategies to improve the

system.

62

SHELL Model
Software
Hardware
Environment
Liveware (Individual)
Liveware (Group)

63

9.7 Communication

64

Definitions of Communication
Skill of passing information from on person to

another.
Transfer of information from one place to
another.
The dynamic and irreversible process by
which we make contact and interpret
messages within a given situation or context.

65

The Transactional Analysis Model

Is an attempt to explain

human behavior,
especially
communication.
Three minds or ego
states.
No good or bad ego
state.
A healthy personality
includes all three.

66

The Transactional Analysis Model (Contd.)

Parent:
Orders
Claims to know everything
Caring, encouraging,
supportive & protective.
Sentences:
Let me help you.
Leave it to me, I will do
this.

67

The Transactional Analysis Model (Contd.)

Adult:
Asks for reasons.
Talk on equal level.
Sentences:
What is your opinion?
I do not agree.

Child:
Emotional
Free & natural.
Obey, retreat, be polite.
Not sure of itself.
Sentences:
I do not like you.
I do not know, I want
leave.

68

Dupont Model
Emotional Minds:

Responds faster.
Decisions made without
analysis.
Sentences:

Hurry up.
Forget it.

Rational Minds:

Takes more time to react.

Decisions made through
analysis.

Balance

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Results of poor communication

Errors
Inefficiencies
Duplication of effort.
Conflict
Reduced quality
Cost increases

70

Results of good communication

Reach an understanding with one another.

Co-ordinate their efforts.
Agree who does what.
Decide on actions and make decisions
effectively.
Take correct action to reach their goals.

71

Forms of communication

Verbal communication

Non-verbal communication

the spoken word.

face-to-face or through an electronic medium such as a
telephone, radio, loud speaker etc.
as body language.
Wave, smile or frown.

Written communication

Manuals, Job-cards, letters, magazines, books, forms,

e-mail etc.

72

Communication model
Communication in its simplest form involves

two people:

The Sender : the speaker or writer who is transmitting

a message.
The Receiver : the person who sees, hears or reads
the message.

Feedback
Messages filtered through feelings, opinions and

intentions. The message includes body language.

73

Three
Be

complete.

Enough information.

Be

correct

Standard part names.

Be

Cs of Communication

clear

Say what you mean to say.

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The impact of information technology

e-mail, voice mail, fax machines, mobile phones and pagers.

Information technology (IT) improves communication in

organisations in the following ways:

It cuts across time boundaries.
It cuts across geographical boundaries.
It allows multiple, simultaneous reception.
Bottlenecks can be avoided as electronic information channels
are typically direct between sender and receiver.
It helps reduce paperwork.

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9.8 Human Errors

General Model of Human Error:

76

Types of Errors
Example: John drives into water and the car begins to

hydroplane.
Slip - having a good plan, but bad execution: John's plan is to
pump his brakes, but he misses the brake pedal and steps on
the accelerator instead.
Mistake - a bad plan is selected: John thinks that speeding up
will give him control over his car so he accelerates.
Violation - the wrong procedure is performed intentionally:
John learned from his driving teacher that he should pump his
brakes in this situation, but his brother said that acceleration is
best, so John steps on the accelerator.

77

Dirty Dozen
Aviation safety specialist, Gordon Dupont,

identified 12 most common human factor

maintenance errors, known as dirty dozen
that limit peoples ability to perform effectively
and safely

78

Dirty Dozen ( continued)

Lack of communication
Lack of teamwork
Lack of assertiveness (not enough confidence).
Complacency (too relaxed)
Distraction
Pressure
Lack of resources
Lack of knowledge
Lack of awareness
Norms
Stress
Fatigue

79

1. Lack of Communication
Communication by:

the spoken words

the written words
gestures and facial
expressions
body language

80

Sender-Receiver Model of Communication

81

Compare two Log-book Entries

82

2. Lack of Team Work

83

3. Lack of Assertiveness

84

4. Complacency (Too relaxed)

85

5. Distraction

86

6. Pressure

87

7. Lack of Resources

88

8. Lack of Knowledge

89

9. Lack of Awareness

90

10. Norms

91

11. Stress

92

12. Fatigue

93

Shift Work

94

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Thank you for your Attention

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