Refresher Guide for Aviation Engineers / Personnel

Human Factors
Fuel System Safety
Electrical Wiring Interconnecting Systems

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Human Factors – Review
Human Factors was introduced into aviation (engineering) to try and combat maintenance error
within the working environment.

As human beings, we are not perfect. We often make simple mistakes in normal daily life, such as
forgetting to post a letter, or misjudging the car in front of us resulting in a small accident.

If we accept that we are not perfect in our normal lives, we can assume that we will still be subject
to the same ‘human factors’ that affect us whilst in the workplace.

Human factors in engineering, is aimed at identifying theses common factors and training ourselves
to be aware of the dangers so that we may at times, hopefully be able to recognise when we are
likely to make and error and that we may take a step back and reassess the situation to stop an error
occurring.

Human Factors can be detailed in the following areas

1) Factors which are Internal to us as Human Beings, such as Stress, Worry, Health Issues,
substance abuse etc
2) Factors which are external to us as Human Beings such as the environment, lighting, hot /
cold, windy, etc
3) How we interface with the world around us – ie computers, paperwork, systems, tooling etc
4) How we interact with other Human Beings – ie communication skills, body language, emails,
phone calls, abbreviations in documents etc

From the above areas, industry has produced a outline of what we call the ‘dirty dozen’ or put
simply the 12 most common Human Factors you would most likely encounter in the workplace.

The 12 dirty dozen are known as

1. LACK OF COMMUNICATION
– This is simply the failure to exchange information. The training should focus on not
only how this comes to happen, but also what safety net will prevent it. Very simply,
in good communication, “the mental pictures must match.”

2. COMPLACENCY
– This is where we become so self-satisfied that we lose awareness of dangers. It is
some-times called overconfidence and creeps in as we become more proficient at
what we do. Awareness of this insidious contributing factor is one of the safety nets
that help to reduce it.

3. LACK OF KNOWLEDGE
– With constantly changing technology, this contributor to an error is more common than we think.
Add to that the fact that the average human only retains about 20 percent of what they learn, unless
they use it often. Training is one of the best safety nets we have to help avoid human error.

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4. DISTRACTION
– This is anything that takes your mind off the job at hand even for an instant. Our mind works much
quicker than our hands, and thus we are always thinking ahead. Any distraction can cause us to think
we are further ahead than we actually are. This contributing factor is known to be responsible for at
least 15 percent of all aviation accident

5. LACK OF TEAMWORK
– The larger an organization becomes, the more common this contributing factor is. Because
teamwork is constantly evolving and changing, it must be constantly worked on to prevent accidents
from occurring. It is hard to gain and very easy to lose.

6. FATIGUE
– This is considered the number one contributor to human error. It is insidious, and the
person fails to realize just how much his/her judgment is impaired until it’s too late.
Fatigue seldom works alone but is a contributor to one or more of the other dirty
dozen.

7. LACK OF RESOURCES
– Lack of resources to safely carry a task has caused many fatal accidents. For example, an aircraft is
dispatched without a functioning system that normally would not be a problem suddenly encounters
circumstances where it does become a major problem.

8. PRESSURE
– Pressure to be on time is ever-present in the aviation industry. We are very time-sensitive and
many decisions center on that fact. Over 64 percent of pressure-caused errors are caused by self-
pressure. One has to learn how to recognize and deal with pressure.

9. LACK OF ASSERTIVENESS
– Lack of assertiveness in failing to speak up when things don’t seem right has resulted in many fatal
accidents. However, assertiveness also calls for listening to the views of others before making a
decision. Assertiveness is that middle ground between being passive and aggressive.

10. STRESS
– Stress is the subconscious response to the demands placed upon a person. We all have some stress
in our lives, and it is not all bad until it becomes excessive and we have distress. We must learn how
to manage stress, or it will manage us with a high probability that human error will occur.

11. LACK OF AWARENESS

– Lack of awareness occurs when there is a lack of alert-ness and vigilance in observing. This usually
occurs with very experienced persons who fail to reason out possible consequences to what may
normally be a good practice. One of the safety nets for lack of awareness is to ask more “what ifs” if
there is conflicting information or things don’t quite seem right.

12. NORMS
– Norms is short for “normal, “or the way things actually are done around an organization. Norms
are unwritten rules followed or tolerated by the majority of a group. Negative norms are those that
detract from an established safety standard. Human factors training can reduce errors, but we must
also provide a work environment that is resistant to human error. This is the role of a safety
management system (SMS), of which human factors training is a part. Human factors training will
help ensure the success of any SMS and are an integral part of any effort seeking to reduce human
error. We can and must do better – our lives depend on it

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To model the above many terms and analogies have been coined to use when discussing Human
Factors

The Error Ice Berg

The error ice berg is an analogy that depicts an ice berg with just the tip showing out of the water

The descriptions is aimed at highlighting that for every ‘fatal accident or incident that occurs in
aviation there have usually been many ‘unseen’ errors occurring before hand – like an ice berg we
often only see the ‘tip’ without seeing the real mass of it lying hidden beneath the water

How many times have you nearly made a mistake but caught it at the last minute ? How often did
you report this error, and if not why not? If you are human and nearly made this mistake, then what
is to stop someone else making the same error again?

The error ice berg is often regarded as a ratio – meaning that if we can reduce the size of the
‘hidden’ errors or unsafe acts then ultimately the amount of accidents will reduce also as it is
regarded as a ration percentage

The Error Chain

The error chain depicts a metal link chain. The idea of the description is that like a metal chain often
accidents are a result of a chain of events.

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A typical error chain description

With the error chain hopefully we in engineering can stop the accident at our stage. Often by the
time the crew discover that something is not right it is often too late.

The Swiss cheese (or sometimes called the James Reason Model)

The Swiss cheese model is used to identify that we protect ourselves from accidents occurring by
setting defensives in place. James Reason was the Human Factors expert who identified this and sed
the Swiss Cheese analogy in his studies.

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For example we have shift handovers in engineering to reduce the amounts of errors produced
when a job changes over a shift. This is a normal defence. Can you imagine how hard it would be if a
job wasn’t handed over properly? Where was the last person up too? Did he tighten all those bolts
correctly?

The Swiss cheese is depicted as an arrow shooting through a Swiss cheese. If all of the holes line up
then the arrow or the event could happen. Our aim in Human Factors is to ensure that all the holes
do not line up by putting adequate defences in place, like a shift handover book, using calibrated
tooling, having adequate rest periods etc.

Looking at the picture you will see the terms ‘Active and Latent’

Active error means when something happens immediately, ie it has an immediate effect. If you
tighten a bolt on a fuel filter housing and it shears off, then normally this is not something that will
effect safety. As hopefully you will correct the damage etc or do what is necessary to fix it there and
then.

Latent error means that the defect or problem can lay dormant for a while before it is found. Taking
the fuel filter example above. If you tightened the bolt and it was just on the edge of failing but
didn’t shear when you tightened it, then the aircraft flies and with the vibration and heat the bolt
shears off and fuel sprays out and catches fire then this would be a ‘latent’ error.

Normally for the reasons above it is Latent errors that are regarded as being the most dangerous

Legislation

As Human Factors developed so did the legislation to reflect this. It is now a requirement for all
personnel working in a Part145 environment to have adequate Human Factors training with a 24
month renewal (EASA Part 145.30 refers)

In conclusion there are many things that effect how we can perform as a human being. The dirty
dozen is a good synopsis of human factors but there are many other areas that we also model things
such as

The limitation of our Eyesight

Sleep (or lack of) and how this can affect our performance

Alcohol, drugs and medications

Time Pressures, lack of tooling and lack of company support when doing a job

Memory – short term and long term.

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Once we can recognise these human Factors issues in ourselves and others we will hopefully be
better armed to tackle the problems in the work place. I hope the above has given you a refresher of
the main areas of Human Factors in aviation engineering

Further reading on Human Factors can be obtained from the following sites

http://www.caa.co.uk/application.aspx?catid=33&pagetype=65&appid=11&mode=detail&id=275

http://avhf.com/Default.htm

http://www.boeing.com/commercial/aeromagazine/aero_08/human_textonly.html

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Fuel System Safety Training – Review

Fuel system safety training was introduced into aviation after the explosion of TWA Boeing B747 off
the coast of New York (USA) in 1996.

As a direct result of this accident, and many other previous aircraft unknown losses, the American
Federal Aviation Authority (FAA) launched an initiative within aviation to address the possibility of
exploding fuel tanks.

You may have heard of the term ‘SFAR88’ when talking about fuel system safety training

The term SFAR88 was coined from the first FAA document that was issued in respect of the on-going
investigations into the TWA800 flight.

SFAR88 = Special Federal Aviation Regulation – number 88

A SFAR is a document type that the FAA used to publish its data and findings. Number 88 just
happened to be the number of the first SFAR released that discussed the problems of the TWA800
flight. Hence the term SFAR88 is often used when discussing fuel system safety training

Since the TWA Accident – the FAA findings have found themselves being implemented throughout
the world. The aim of this training is to ensure that as maintenance staff we appreciate that the fuel
system and its associated components must be maintained to the highest standard to ensure that
another such accident does not occur again

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The FAA during their investigation found several areas of concern. These were based around

1) Training of industry staff was required

2) The fuel system ‘centre fuel’ tanks when filled with just the right quantity of fuel could
become flammable
3) Ignition sources do exist within the fuel system

To discuss the training – Industry accepted that there needed to be two different levels of training

1 - For the people not directly involved in the system ‘hands on’ maintenance, and

2 - Training for people who have direct contact with the aircraft

They termed these groups Level 1 and Level 2 (although in later years they refer to this as Phase 1
and Phase 2) Hence,

Phase 1 can be described as – Familiarisation Training

Phase 2 can be described as detailed training

Phase 1 training is not subject to a 24 month renewal, as where Phase 2 is.

SFAR88 (or ‘fuel system safety training’ to use its correct term) is aimed at educating aviation staff
that the fuel system has inherent dangers. And that the maintenance of specific items in the fuel
system and on the aircraft is critical to ensure that the integrity of the system remains as it was
designed from the Factory.

The history of the TWA event was briefly that the aircraft exploded due to what investigators believe
was a short circuit in the Fuel Quantity Wiring System (FQIS) somewhere in the aircraft fuselage
section (most likely the forward fright hold roof area)

This resultant short circuit they assume led to the FQIS wiring becoming live with a much higher
voltage in the wiring than would normally be expected.

They suspect that there was a chaffed or exposed piece of wire on a fuel quantity probe within the
tank and that this exposed piece of wiring sparked onto some adjacent aircraft structure

The resultant spark and conditions that were in the tank at the time (the centre fuel tank was near
empty and was full of fuel vapours) was just at the right levels to cause an explosion.

The resultant explosion was of such effect that the forward section of the airframe from the wing
root forward detached from the main fuselage, obviously resulting in the total loss of the aircraft.

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SFAR88 focussed into the areas of the possibilities of a fuel tank explosion. Their findings were
comprehensive in as much as ‘yes’ it was a distinct possibility. They also reviewed several other
famous aircraft losses over recent years and concluded that most if not all were as a direct result of
similar events.

SFAR88 has since paved the way for several aviation initiatives.

The first was the introduction of Airworthiness Limitation Instructions (ALI’s) and Critical Design
Control Configuration limitations (or CDCCL’s) into aviation.

ALI’s and CDCCL’s are implementing efforts within maintenance to reduce the

Possibility of ignition sources

ALI’s are essentially involved with maintenance changes to the MPD and aircraft maintenance
checks. For example we will now re inspect avionic systems and aircraft wiring more frequent and to
a higher level of inspection (now detailed inspections as opposed to general inspections). We will
also perform more frequent inspections for bonding, condition of wiring etc.

CDCCL’s are essentially directly aimed at reducing ‘possible ignition sources’ - as the name suggests,
‘critical design’ is the key point. We as maintenance staff must ensure that these components are
maintained to the exacting standards as were prescribed when the aircraft was new.

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As a result we have seen maintenance data change, and any component that is deemed to be a
CDCCL should now be accompanied with a warning or brief to assist the engineers in highlighting
their importance, an example of a B757 AMM is below with the highlighted warnings we now see in
such manuals to make engineers aware they are dealing with a CDCCL item

The second initiative was the introduction of fuel tank inerting systems.

These systems are designed to inert the fuel tanks to avoid explosions.

For a fire or explosion to occur we need 3 basic things. Oxygen, Fuel and Ignition

Hopefully the Ignition sources will be addressed with the improved ALI and CDCCL initiatives.

The Fuel is something we obviously cant address, they are fuel tanks after all !

With the inerting systems though we can address the final element required, and that is Oxygen

If we can remove the oxygen from the ullage area of the tanks (the air pockets on the tank above the
fuel level) with an inert gas such as Nitrogen, then even if we do get a possible ignition source, we
should hopefully not get an explosion or fire due to their being no Oxygen present.

The solution to this has been that manufactures have now been implementing Fuel tank inerting
systems into all new aircraft to leave the factories.

The inerting systems basically take normal aircraft ‘bleed air’ from the engines and a unit will extract
the Oxygen and Nitrogen elements. The Oxygen is discharged overboard and the Nitrogen is fed into
the tank ullage area.

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This new system even has its own new ATA chapter in the AMM – Chapter 47

An example of a basic nitrogen inerting system is given below

An Example Airbus A320 Installation

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The third and final initiative is the introduction of Electrical Wiring Interconnecting Systems training
(EWIS) for aviation personnel.

As the TWA explosion resulted from a wiring defect, EWIS training as has also now been mandated
as a follow on to the above initiatives, and is discussed in the following sections

Summery

As a result of the TWA accident, fuel tank inerting has been implemented on all new aircraft. The
industry has responded to the increased levels of inspections and maintenance by amending
inspection timings, detail levels and improving maintenance data (ALI’s and CDCCL’s)

EWIS training has now been mandated to raise awareness to Industry personnel of the dangers
associated with poor aircraft wiring standards.

Further reading on Fuel System Safety Training / SFAR88 can be obtained from the following sites

http://www.faa.gov/news/fact_sheets/news_story.cfm?newsId=7318

http://findarticles.com/p/articles/mi_m0UBT/is_39_17/ai_108842701/

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EWIS – Review
Electrical Wiring Interconnecting Systems training (or EWIS for short) can trace its beginnings to the
implementation and findings of SFAR88

TWA flight 800 was the result of an exploding fuel tank. The source of ignition was traced back to
(most likely be) faulty wiring in the forward cargo bay area of the aircraft resulting in low power FQIS
wiring coming into contact with high power aircraft power supply wiring.

Just two years after the TWA flight another aircraft was involved with a wiring problem which
resulted in the total loss of the aircraft

A Swiss Air MD11 (Swiss air flight 111) suffered a large electrical fire in the Flight Deck roof area, a
direct result of incorrect wiring standards for a recent IFE installation. The resultant fire caused a
large fire which resulted in the aircraft being lost with the deaths of all on board.

The resulting investigations of SFAR88, and Swiss Air 111, led the industry to rethink the way aircraft
wiring was viewed. The new thought process is to regard the wiring as ‘another system’

EWIS = Electrical Wiring Interconnecting Systems

EWIS has resulted in various other industry changes also

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Changes to the Basic EASA licence structure have now seen improved levels of electrical basic
knowledge being taught for Basic EASA Part66 modules to ensure new engineers into industry have
a greater appreciation of aircraft wiring and systems

We have also seen changes to EASA Part147 approved, aircraft type training courses so that more
detail is emphasised on electrical systems for Both B1 and B2 trades.

EWIS is now a mandated form of training and is subject to 24 monthly refresher training similar to
HF and SFAR88

The authorities have accepted however than not all personnel will require the same level of training,
and as such they have split the personnel into 8 target groups as listed bellow

The purpose of EWIS training for all staff within EASA Part145 organisations is to bring to highlight
various areas of attention

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EWIS training consists of

1. Basic electrical principles – ie static sensitive systems / components and the

precautions when handling these items
2. Basic electrical precautions - when dealing with live aircraft – safety of circuits,
electrical shocks
3. Wiring contamination sources - Swarf, Fluid contaminations,
4. Wiring general standards - Chaffing wiring, Poor wiring standards and non-approved
repairs
5. Inspection Techniques – Correct lighting, typical damage found
6. Standard practices – Correct use of the AWM and chapter 20 within the AMM

In addition to the above theoretical training, for target group 1, an element of hand skills should also
be undertaken to ensure that the students can demonstrate adequate skills when dealing with
typically

 Circular Connectors
 Rectangular Connectors
 Terminal Blocks (Modular)
 Terminal Blocks (Non Modular)
 Grounding Modules
 Pressure Seals

The hand skills would normally be conducted over a 1 day period and involve physical interaction
with the above so the students should undertake various tasks to achieve a level of competency
when dealing with these components in the field on live aircraft

When detailing the training for each target group, the level of depth of the above subjects will vary
depending on which group is being taught. For example you would not teach standard practices and
chapter 20 to flight crew and cabin crew, as they would have no need for this information, but you
would teach typical damage to aircraft wiring for example and what to be aware of etc

In addition to training the Air Transport Association (ATA) released a new specification called
ATA117 which was titled Wiring Maintenance Practices/Guidelines.

ATA117 was designed to help organisations and manufacturers bring together a common
understanding of the problems inherent to aircraft wiring, and the production of standard terms,
standard abbreviations, and standard methodology when dealing with EWIS related subjects.

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Further reading on EWIS can be obtained from the following sites

http://uk.search.yahoo.com/r/_ylt=A7x9QfhwQ_dPIVUAK81LBQx.;_ylu=X3oDMTE1MjJ2bGc1BHNlY
wNzcgRwb3MDNgRjb2xvA2lyZAR2dGlkA0FDQllVSzNfODE-
/SIG=143h2bg50/EXP=1341633520/**http%3a//www.faa.gov/training_testing/training/air_training
_program/job_aids/media/EWIS_job-aid_2.0_Printable.pdf

http://en.wikipedia.org/wiki/Electrical_wire_interconnection_system

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REVISION

What are the Human Factor Dirty Dozen ?

What is the ‘Error Chain’ ?

How long does your Human Factor training remain valid ?

What was ‘SFAR 88’ ?

What caused the loss of TWA Flight 800 ?

What is a CDCCL ?

What gas is used to inert the fuel tanks ?

What does EWIS stand for ?

How many target groups are there ?

What is ATA 117 ?

What happened to Swiss air Flight 111 ?

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This document is designed to be a guide only. Some of the information has been diluted
considerably in order that it may achieve its objective in a compacted format.

It is by no means complete, and as such is only to be used as a guide only and should not be utilised
quoted or referenced

This document is for TRAINING PURPOSES ONLY and will not be subject to review

We hope this document will empower you with a quick review of the subject areas discussed

Kind Regards

David Owen

CATTS Ltd

CATTS Ltd

UK.147.0077

www.catts.org.uk

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