uk TRAINING MANUAL

HUMAN FACTORS INTRODUCTION

engineering MODULE 9

INTRODUCTION

Nobody comes into work to do a 'bad job', indeed we strive to do our very best. Despite our
best endeavours however, mistakes happen and accidents occur as a result of those
mistakes. It was Cicero, a renowned Roman politician who first coined the phrase 'to err is
human', and I believe we can all agree that this is so. What we must also believe in
however is that we can learn from mistakes, both the ones we ourselves make and also
from the mistakes made by others. If we can grasp this basic concept, of learning from our
own and others mistakes then we will reduce the possibility of accidents occurring.

This course is designed to study the underlying causes which may result in a well
intentioned AME making a maintenance error. We will also look at what we can do to
prevent ourselves from contributing to events which lead to an accident.

You will get out of this course only what you are prepared to put into it. Be open-minded, but
if you disagree with anything that is being said, then feel free to speak up. Because we are
dealing with the human in the equation, you will find that there are often no "right" or "wrong"
answers but "what works for you" and it could work for someone else if you share it.

We will start with a look at some of the factors which can influence how we see and interpret
our (working) environment. We will then progress to the means whereby we can by
understanding their impact utilise our knowledge in order to reduce the possibility of
maintenance error occurrences. First though some facts:

JAR-M.80 Maintenance Human Factors States:

i. No person may be required to complete a maintenance work task within an unrealistic

timeframe. This includes any personnel engaged in management, supervision,
planning, maintenance, inspection, maintenance release, record keeping and quality
audit.
ii. No person may be required to perform planning, maintenance, inspection,
maintenance release or record keeping without the appropriate tooling, equipment
and working instructions.
iii. No person may be required to perform planning, maintenance, inspection,
maintenance release or record keeping unless their competence in the task has
been proven.
iv. No person should be pressurised to release an aircraft or aircraft component when that
person has reason to question the safety standard.
v. Any person who is unable to perform the maintenance task correctly for whatever
reason must report such fact to the supervisor.
vi. No person may be required to release or authorise the release of an aircraft unless that
person is able to inspect the aircraft.

1st DRAFT 2 September 1996

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 uk TRAINING MANUAL
HUMAN FACTORS INTRODUCTION
engineering MODULE 9

Aviation Accidents

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 uk TRAINING MANUAL
HUMAN FACTORS INTRODUCTION
engineering MODULE 9

CAUSES AND COSTS OF AIR ACCIDENTS

(1982-91) Causal Factors No. Accidents O/B fatalities

Controlled flight into terrain (CFTT) 36 2169

Maintenance and inspection 47 1481
Loss of control/uncontrollable 9 1387
ATC and communication 39 1000
Approach & landing without CFIT 133 910
Postcrash smoke & fire 41 729
Inflight smoke & fire 6 610
Ground de-icing/anti-icing 9 384
Windshear 10 381
Uncontained engine failure 11 199
Out-of-configuration takeoff 11 188
Airport ground operations control 23 138
Rejected takeoff 19 53

FROM: J REASON, Omissions and their Management.

Colloquium held at the University of Amsterdam.
March 4, 1996.

MAINTENANCE ERRORS (122 occurrences 1989-91)

Major category Per cent of total

Omissions 56%
Incorrect installations 30%
Wrong parts 8%
Other 6%

FROM: J REASON, Omissions and their Management.

Colloquium held at the University of Amsterdam.
March 4, 1996.

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 uk TRAINING MANUAL
HUMAN FACTORS INTRODUCTION
engineering MODULE 9

Airbus A320 incident at Gatwick, 26/08/93

During the first flight following a trailing edge flap change the aircraft developed a persistent
roll to the right after take-off with loss of spoiler control. Spoilers 2 to 5 on the right wing
were found to be in maintenance mode on subsequent inspection. A number of human
errors were identified during both the initial flap change maintenance and during potential
recovery operations.

Example errors and their classification as identified from Accident Report

Error identified Error Cause Error Classification

Collars and flags were not
fitted to spoilers by the
nightshift engineer after
placing in maintenance
mode for flap replacement.
Incomplete printing from film
reader and subsequent
execution of sub-tasks
associated with spoiler
maintenance.
Contributing event - Execution of procedure -
unavailability of spoiler step omitted.
locking collar. Choice of hypothesis -
(inappropriate
Inherent human limitation - generalisation).
lack of adequate training and
experience.
Inherent system limitation - Execution of procedure -
Inadequate usability of (step incorrectly performed).
maintenance manual.
Inherent human limitation -
lack of adequate training.

BAC One-Eleven Incident over Didcot, 10/06/90.

During the first flight following windscreen replacement the new windscreen was blown out
under cabin pressure causing explosive decompression and the commander to be half
sucked out of the windscreen aperture. Investigation found that the bolts used to secure the
windscreen were of an inadequate size (approximately 0.026 inches smaller in diameter
than required) and were not, therefore, capable of withstanding the normal operating cabin
pressure loads.

Example errors and their classification as identified from Accident Report

Error identified Error Cause Error Classification

Illustrated Parts Catalogue
(IPC) was not used by the
Shift Maintenance Manager
to identify part number of
required bolt.
Feel of undersize bolt
threads slipping was
mistakenly assumed to be
the torque screwdriver
'breaking' at its pre-set
torque.
Inherent human limitation - Execution of procedure -
complacency/mind set. (inadequate step
substitution).
Inherent system limitation Observation of system state
- poor bit retainment on - incorrect.
torque limiting
screwdriver.
- inadequate access to
centre of windscreen using
safety raiser.

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