Human Factors in

Aviation Maintenance

Dennis A. Vincenzi, Ph.D.

ERAU Worldwide
Overview
• Aircraft Accidents and Aviation Maintenance
• Brief History of HF in Aviation Maintenance
• The PEAR (People, Environment, Actions, and
Resources) Model
• HF in Aviation Maintenance according to the
FAA
• The Dirty Dozen of Aviation Maintenance
• Examples of Maintenance Related Accidents
• Wrap up
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Some Quick Questions…

Poll #1:
Are you employed in the aviation maintenance
field in some capacity?

Poll #2:
If you are employed in the aviation maintenance
field, what is your job, position, or function?

Poll #3:
If you are employed in the aviation maintenance
field, do you work for an MRO?
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Aircraft Accidents
80% of aircraft accidents are related to
human factors
15% to 18% of aircraft accidents are
associated with some sort of maintenance
related issue
Cost?
Time
Money
Company Reputation
Human Lives
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 Human
Factors Defined
• The scientific discipline concerned with the
understanding of interactions among
humans and other elements of a system.
• The overarching goal of Human Factors is to
optimize human well-being (safety) and
overall system performance (the
relationship between the human and
machine).

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Human Performance

• Humans cannot perform well

under adverse conditions
• Proper lighting, temperature,
rest to perform well
• Proper training to be able to
perform the work
• Proper work environment that
promotes safety and
compliance with rules,
regulations, and policies
• Proper company culture is
essential
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Brief History of HF
in Aviation Maintenance
HF in Maintenance is relatively new
Began as a formal interest around 1988
• Aloha Flight 243 - April 28, 1988 – 1 fatality; 65 injured
• Most agree that this accident was the beginning of HF in Aviation
Maintenance
• Fatigue and corrosion cracks visible by passengers boarding the aircraft
• All agree that this accident was preventable

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Since Aloha Flight
243…
HF in aviation maintenance has resulted in a
number of worthy initiatives that act as
guides and aids in identifying and raising
awareness about sources of human error
The People-Environment-Actions-Resources
(PEAR) Model
HF Operations Manual by the FAA
The Dirty Dozen in Aviation Maintenance
And others…

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The PEAR Model
PEAR – People, Environment, Actions, and
Resources
People – the core of any HF assessment
These are the individuals who
Perform the work
Initiate and support regulation
Initiate and support company policy
Initiate and support proper procedures
People are ultimately responsible for all the
above and must be the focus
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The PEAR Model
People
Physical, Physiological, Psychological, and Psychosocial
aspects of people

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The PEAR Model
Environment
Physical and Organizational aspects of the environment

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The PEAR Model
Actions
Task breakdown of what and who is needed to perform a
task or activity
Cognitive breakdown of what knowledge and skills are
needed to perform a task or activity

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The PEAR Model
Resources
Procedures, tech manuals, equipment training, tools
All the things needed to perform the activity and support
the processes, procedures, policies, and regulations
surrounding that activity
Many of the other components of the PEAR model are
dependent upon available resources

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 HF in Aviation Maintenance FAA Style
• Human Factors deals with anything that has
an effect on humans
• FAA Human Factors Operator’s Manual

* Adapted from The Operator’s Manual for Human Factors in Maintenance and Ground Operations, 2014 14
Hazard Identification
• Hazard
– A potential source of harm
– Personal injury, equipment damage, and environmental
damage
– Reduction in ability to perform a prescribed function
– Threats and latent conditions

* Adapted from The Operator’s Manual for Human Factors in Maintenance and Ground Operations, 2014 15
Hazard Identification
• Why is it important?
– To prevent operational problems
– Increase operational safety
– One more measure to break the chain of potential latent
events

* Adapted from Shuichi Yoshida 2nd International Quality Symposium, 1989

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Procedure Compliance
• Procedures
– Designed by humans and intended to be followed
– Maintenance, inspection, checklists
– Designed to enhance safety and reduce human error
– Other “procedures” may be dependent on policies, and policy
violations can affect how other procedures are followed:
– For example…
• Policy violations on rest requirements for pilots can result
in serious errors, fatigue, complacency, decision making,
etc.
– Developing a “Just Culture” for procedure compliance is
essential in any maintenance environment
– Don’t just deviate from procedure – if you see a better way to
do something, go through the process to get the procedure
looked at and officially approved!

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HF Training
• HF Training
– Crew Coordination Concepts (Continental Airlines, ~1989) -
>Maintenance Resource Management (MRM)
– Patterned after CRM
• Why HF Training is important
– Promotes a positive safety culture
– Helps identify, recognize, understand and manage human
performance issues related to safety
– ROI for HF training – it improves performance, safety, and
health/well being
– Opportunity to cover/develop new regulations, procedures,
and equipment
– Can help mitigate performance related safety issues
through voluntary reporting systems through NASA and FAA
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 Fatigue and Risk
Management (FRM)
• Fatigue is a crippling factor
– Fatigue can occur as a result of one long event (awake for 16 or 20
hours) or over a period of weeks or months of sleep deprivation (4
hours per night instead of 8 hours per night)
• Results in
– Impaired judgement
– Impaired communication skills
– Decreased attention and information recall
– Slower reaction times
– Increased risk taking
– Poor overall performance!
• FRM enables maintenance organizations to:
– Detect and identify fatigue symptoms and hazards
– Assess associated safety and health risks
– Implement fatigue countermeasures
– Determine what is effective to mitigate fatigue
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HF Health and Safety
Program
• Concerned with long term health and safety
• LMEC – Latent Medical or Environmental Conditions
– Physiological limitations experienced by the AMT that originates from
abnormal medical conditions, normal aging, and occupational
exposures
• Detrimental effects of operating equipment
• Deleterious effects of aging
• Detrimental effects of occupational exposure to aircraft, equipment, and
environment
• Why HF Health and Safety Programs are Important
– AMTs have a non-fatal occupational injury rate almost double that of
general industry
– Older workers (55 and older) represent a growing percentage of the
workforce
– Aging workforce implies changes to vision, hearing, strength and overall
health
– 27.7% of U.S. workers are considered obese

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 The Dirty Dozen for
Aviation Maintenance?
• Human Factors deals with anything that affects
humans
• The key to effectively dealing with aviation
maintenance issues are:
– Be aware of the areas of concern
– Minimize human error
1.Lack of Communication
2.Complacency
3.Lack of Knowledge
4.Distraction
5.Lack of Teamwork
6.Fatigue
7.Lack of Resources
8.Pressure
9.Lack of Assertiveness
10.Stress
11.Lack of Awareness
12.Norms 21
 The Dirty Dozen for
Aviation Maintenance
• Examples
– Lack of Communication
• Shift work, handoffs, brief/debrief of work in progress
– “I guess the day shift can finish this job”
– Complacency
• Expect to find problems, never sign for anything you didn’t
personally do or inspect
– “I’ve looked back there 1000 times and never found anything wrong!”
– “That’s the way we’ve always done it!”
– Distraction
• Always finish a job whenever possible; mark and document
uncompleted work
• Have someone else double inspect and recheck yourself, use
a detailed check sheet
– “Hey! Your water heater broke and it’s going to cost $1200 to fix. Your
wife wants you to call the plumber now!”

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Examples of Maintenance Related Accidents?

• Just a few examples

– American Airlines Flight 191 – May 25, 1979
– Aloha Flight 243 – April 23, 1988
– United Airlines Flight 232 – July 19, 1989
– British Airways Flight 5390 – June 10, 1990

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American Airlines
Flight 191
• American airlines flight 191 – May 25, 1979
• MD DC – 10
• Fatalities: 258 passengers; 13 crew members; 2
people on the ground
• Engine separated from the aircraft and severed
hydraulic lines due to flange and pylon damage
during maintenance.
• Damage caused partially by a faulty maintenance
procedure which was ultimately banned

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American Airlines
Flight 191
• Aircraft was serviced just 8 weeks prior
• Custom procedure for removing engine using
forklift was used instead of following procedure
outlined in manuals – saved over 200 man hours!
• Shift change occurred during procedure causing
engine to remain on forklift for hours
• Flange bolted to pylon was damaged and not
noticed.
• Resulted in engine separation 8 weeks later.

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Aloha Flight 243
• Aloha Flight 243 – April 28, 1988
• 1 fatality; 65 injured
• Aircraft certified for 70,000 compression/decompression cycles
but had already far exceeded that number (~89,000 to date)
• Metal fatigue with heavy corrosion
• Debonding due to salt and humid operating environment

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Aloha Flight 243
• Other causes?
• Poor company policy on aircraft maintenance?
• Maintainer/inspector fatigue?
• Poor maintenance records?
• Inspections done at random intervals in poor working conditions (low
light, artificial lighting)?
• Result were poor inspections and errors detecting noticeable
debonding and fatigue cracks in numerous areas.
• Alternative theory – Fluid Hammer Theory
• Plane was designed to break up in 10 inch sections creating safety
valve for controlled pressure release at high altitudes
• Flight attendant who was sucked out of plane blocked that 10 inch
section causing a “Fluid Hammer” which caused enough pressure to
blow the top of the aircraft off ( which was weak from fatigue cracks
and debonding)
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United Airlines
Flight 232
• United Airlines Flight 232 – July 19, 1989
• Another DC – 10
• 111 fatalities; 185 survivors
• This accident cause was greatly overshadowed by the
exemplary CRM exhibited by the crew in controlling
this aircraft with only engine thrust
• Maintenance aspect of this accident is rarely discussed
when talking about this accident in HF circles

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United Airlines
Flight 232
• Probable cause: inadequate consideration given to human factors
limitations in the inspection and quality control procedures
• Failure to detect a fatigue crack originating from a previously undetected
metallurgical defect located in a critical area of the stage 1 fan disk
• It is believe that the “crack” was originally due to a manufacturing defect
and was extremely small and not detectable to the human eye
• Over time, the crack grew
• Prior to this accident, the size of the crack was roughly 13mm in length
• Very detectable to the human eye but was missed due to human error
• Maintenance personnel complied with procedures but simply did not
detect the crack
• Inspection procedures were updated in accordance with stricter HF
principles (more regular inspections, better lighting, etc.)

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 British Airways
Flight 5390
• British Airways Flight 5390 – June 10,
1990
• No fatalities; pilot suffers frostbite and
broken bones; flight attendant suffers
frostbite
• Cockpit window blows out during
flight/pilot almost ejected out of the
cockpit
• Cause: Improperly installed windscreen
using incorrect bolts
• Windscreen has since been redesigned
so it cannot blow out.
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British Airways
Flight 5390
• Maintenance issues include:
– Cold hanger/environment
– Insufficient lighting in working environment
– Aircraft window was in a difficult to reach location
– Failure to check maintenance documentation when
selecting replacement bolts
– Complacency - “We’ve always done it this way!”
AMT thought it was proper to use visual inspection
only when selecting replacement bolts.
– Design flaw in aircraft where window was secured
from the outside as opposed to being secured from
the inside.
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Questions?

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