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Aloha Airline’s Flight of B737

In the inspection  p prior to the incident  no cracks were  found.  A post  incident inspection  revealed that there  were at least 240  l cracks present at the  last inspection prior  to t e c de t. to the incident. 

18 feet of  fuselage skin  use age s ripped off.

Types of Errors
John drives into water & the car begins to hydroplane. g y p Slip - having a good plan, but bad execution: John's plan is to pump his brakes, but he misses the brake pedal & steps brakes 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 , p said that acceleration is best, so John steps on the accelerator.

Active & Latent Errors
Active error ‐ i A i immediate effect  di t ff
Height of aircraft not read correctly – crash – immediate effect

Latent error ‐ Latent error delayed effect
Delay between the mistake & consequence. e.g.  smoking. Bolt was corroded – not seen so not  k l d d replaced  will ultimately break.

Error Ice‐burg
Heinrich Ratio: H i i hR i Fatal Accidents Non Fatal N F l Reportable accidents Unsafe Acts‐ Not reported U f A t N t t d 1 10 30 600

Take care of your hours & days,  Take care of your hours & days months & years will take care themselves

Top seven causes of in‐flight shutdowns
Incomplete installation Damage on installation Improper installation Equipment not installed or missing Foreign bj t damage F i object d Improper troubleshooting, inspection, test Equipment not activated or d E i i d deactivated i d (33%) (14.5%) (11%) (11%) (6.5%) (6 5%) (6%) (4%)

Top eight common maintenance errors
Incorrect installation of components  p Fitting of wrong parts Wrong electrical wiring of parts (including  Wrong electrical wiring of parts (including cross connections)  Loose objects left in the aircraft  Loose objects left in the aircraft Not enough lubrication  Cowling &/or access panels not secured  Fuel/oil caps &/or refuel panel not secured  Fuel/oil caps &/or refuel panel not secured Landing gear ground lock pins not removed  before departure  before departure

The need to consider the human factor Most important human factor: Most important human factor: Ability to learn from experience & mistakes  committed by others. 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 Design stage – By manufacturer ( e g Cross wires) At user level – By following written procedures.

Manufacturers –
design changes‐make it impossibility to use in  wrong way. e.g. computer connectors.  wrong way e g computer connectors Procedures misunderstood 

Users – i U improve procedures e.g. dual  d d l inspection.

The human brain …
… tricks us...... whenever it can!

The phenomenal power of the human mind

What do you see? 
Research has shown that young children cannot identify the intimate couple because they do not have prior memory associated with such a scenario. Children see nine dolphins. Child i d l hi This is a test to determine if you already have a corrupted mind. If it is hard for you to find the dolphins within six seconds, your mind is indeed corrupted.

What do you see, now!!!

t t th 4 littl d t th stare at the 4 little dots on the  middle of the picture for 30  seconds  then look at a wall near you  a bright spot will appear  twinkle a few times & you‘ll  see a figure 

Who is right? 
Both are right from their  ot a e g t o t e own positions. When you decide  anything or assign any  task to someone, place  k l yourself on his position  & see the things as he  & th thi h perceives.

Ways of Information Transfer Person to Person:
Via verbal communication Via written communication

Display / Product to person:
Job cards Job cards Manuals Displays Indicators

Person to Product: e so to oduct
Key board of computer Controls in aircraft

Information :‐ Hard to See or Hear Noisy environment  Noisy environment
Makes it hard to hear what people say.

Poor lighting 
Can t see cracks, loose tools or parts. Can't see cracks loose tools or parts

Poor communication 
Not speaking clearly  Bad handwriting  g

Information Present but Missed Awareness Problem A P bl
Completely focused on one task & miss  other things around. Distractions: e.g. During walk‐around, a hole  g g , on ground is a distracter. Conversations Interruptions

Attention  & Awareness
Selective Attention: Selective Attention:
Monitoring several sources of information to decide  whether particular event has occurred e.g. deviant  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.  g g y

Divided Attention Sustained Attention Sustained Attention
Security Guards viewing a TV monitor.

Left half of brain thinks  Left half of brain thinks rationally. Used while  dealing with problems. dealing with problems Right half of brain thinks  g emotionally. Related to  y creativity & clever ideas. Which one is correct to  use?
Both should be used.

Information Awareness
Five senses ‐ the sources of information. Smell can warn us of dangers can warn us of dangers. Sense of temperature through touch. p g Taste – very rarely used. The two most used senses: Sight & hearing.

Use of eyes
Inspections: 80% of inspections are visual p p inspection Written documents: Different manuals. manuals Job-cards Writing what you have done. Written Communication: Legible Accurate Complete Order of sentences

Deteriorate with age & also suffers  from non‐reversible permanent  damage when exposed to high level  of noise.  Ear Protections When sound volume > 90 dB Wh d l 90 dB Even at 85 dB if remain exposed  for > 4 hours for > 4 hours Earmuffs / Earplugs. Treatment of ears t k T t t f take years. Use: Ears.  Use: Ears. AF : 20 Hz – 20 kHz


Difference: Hearing & Listening  Hearing
is just the process of taking in sounds. not selective. t l ti Passive. Sound of fan, air‐conditioner etc. Sound of fan air conditioner etc

hearing with selective attention. l i i Involves interpreting the sounds. Active. To each other.

Interest in topic. I t ti t i Distraction tolerance Appropriate time & place. Eye contact What is said & what is not said?  Prejudices : decision already made.
Sometimes more  information in  what is not said. hat is not said

Claustrophobia & Physical Access Claustrophobia:  Claustrophobia:
Definition: An irrational fear of being in a  confined or enclosed space. confined or enclosed space e.g. Maintenance in Fuel Tank.

Space Availability:
More space improves performance. More space improves performance.

Minimum restrictions due to clothes &  Minimum restrictions due to clothes & shoes.

Ways to Learn & Remembered
Hear See See & Hear Say & Repeat S &R Do 25% 30 35% 30‐35% 50% 75% 90%

Team Work
Planning, Co‐ordination & Communication. Pl i C di ti & C i ti Team: a group of inter‐dependent individuals  working together to complete a specific task.  Example: Football Example: Football Team In maintenance, working as a team improves  productivity & reduces injury & equipment  productivity & reduces injury & equipment damage.

Characteristics of an Effective Team
A clear purpose:  accepted by all members.  Relaxed:  no  tensions among the members.  R l d t i th b Participation:  in decisions making &/or activities.  Participation: in decisions making &/or activities g Listening:  listens to the others.  Disagreement: agree to  disagree with each other. 

Characteristics of an Effective Team  …….contd.
Openness: full & open communication. Clear expectations: about the roles each member & assignments fairly distributed Shared l d Sh d leadership: D l hi Delegation of P ti f Power. Relations with others: With other teams teams. Team maintenance: focus on their primary goal but l b t also spend ti d time recognising & maintaining th i i i t i i the functions of the team.

The ability to direct & co‐ordinate the activities  of group members & stimulate / inspire them to  work together to complete a specific task, lead 

by example.

Responsibilities of Leaders
Direct & co ordinate team activity  Direct & co‐ordinate team activity Delegate tasks to appropriate team members  Make sure team members know what is expected of them  M k t b k h ti t d f th Focus attention on important aspects of the situation  Adapt to internal & 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 & maintain a professional atmosphere Create & maintain a professional atmosphere

Effective Leader
Make suggestions  M k ti Encourage the team to perform  Lead by inspiration  Provide feedback 

How well you lead, depends on  how well you communicate!! how well you communicate!!

Types of Leaders
Authoritative L d A th it ti Leader Runs the show alone. Sole decision maker. Controls all the resources resources. Dictates actions with little input from team members. Participatory Leader Encourages participation. Distributes resources & delegate power. Get maximum input f from members b Group decisions.

Authoritative & Participatory?
Done quickly. Task t t d Cl T k structured. Clear Answers. Conflicts Accepts decision taken by single person.

Time available. Task T k unstructured. Inputs t t d I t required. Work well together together. Do not accepts decision taken by single person.

Which type of leadership is better?

Balance b B l between the two types h

Factors Affecting Performance ‐ Stress
Definition: Physical or psychological tension caused by  Definition: Physical or psychological tension caused by
dealing with difficult situations.

Stressors St
Personal problems. Work related problem. W k l t d bl Social problems.

Cost of Stress
Poor work quality – Public safety jeopardised. q y yj p Heart diseases – Sleeping problem

Components of Situation Awareness Be aware of your surroundings.  B f di Use all the senses.

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

General Model of Human Error

The Transactional Analysis Model (Contd.)
Parent: Orders  Claims to know  Claims to know everything  Caring, encouraging,  g, g g, supportive &  protective. Sentences: S Let me help you. Leave it to me, I will  L it t I ill do this.

The Transactional Analysis Model (Contd.) Child: Adult: Emotional Asks for reasons. Free & natural. Free & natural Talk on equal level. Talk on equal level Obey, retreat, be polite. Sentences: Not sure of itself. Not sure of itself What is your  Wh t i opinion? Sentences: I do not agree. I do not agree I do not like you. Id t lik I do not know, I want  leave. leave

Results of poor communication
Errors  Inefficiencies  Duplication of effort. Conflict  Conflict Reduced quality Cost increases 

Results of good communication
Reach an understanding with one another.  Co‐ordinate their efforts. Agree who does what.  Decide on actions & make decisions effectively.  Take correct action to reach their goals. 

Forms of communication
Verbal communication the spoken word. face‐to‐face or through an electronic medium  f f h h l d such as a telephone, radio, loud speaker etc.  Non‐verbal communication  Non verbal communication as body language.   Wave, smile or frown.  Wave smile or frown Written communication Manuals, Job cards,  letters, magazines, books,  Manuals, Job‐cards, letters, magazines, books, forms, e‐mail etc. 

Communication Model
Communication in its simplest form involves two  l f l people:  The Sender th Th S d : the speaker or writer who is  k it h i transmitting a message.  The Receiver : the person who sees, hears or reads  The Receiver : the person who sees hears or reads the message.  Feedback Messages filtered through feelings, opinions &  intentions. The message includes body language. intentions The message includes body language

Three Cs of Communication Be  B correct
Standard part names. Standard part names

Be  Be complete.
Enough information.

Be clear
Say what you mean to say.

The impact of information technology
e‐mail, voice mail, fax machines, mobile phones & pagers.  e‐mail voice mail fax machines mobile phones & pagers Information technology (IT) improves communication in  organisations in the following ways:  organisations in the following ways: It cuts across time boundaries.  It cuts across geographical boundaries. It t geographical bo ndaries It allows multiple, simultaneous reception. Bottlenecks can be avoided as electronic information channels are  typically direct between sender & receiver.  It helps reduce paperwork.

Shift Work

Conclusions Errors affect both lives & 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. 

It is difficult  to fix  a faulty person than  to fix a faulty component.

Do you  Do you agree?