Malaysian Institute of Aviation Technology

DO YOU
AGREE ?

HUMAN
FACTORS

Presenter:
MOHD RAZIF AHMAD

Source: Royal Aeronautical Society Human Factors Group

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HUMAN FACTORS IN AVIATION – A brief History

 Flight can be traced back to the classic achievement of Wilbur and
Orvile Wright (Wright brothers), in 1903.

 By the turn of the century, innovations in technologies had led to:

 the era of faster, larger civil transportation
 space flight, and awesome military capabilities.

 Advancements in engineering and technology became useless:

 the more complex machinery/equipment became, the
requirements to operate the system exceeded the human
capability/limitation to operate the system correctly, efficiently,
and most important safely.

 An understanding of the human role in aircraft maintenance is

therefore essential ingredient of the total story.

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HUMAN FACTORS IN AVIATION – A brief History

 Aircraft maintenance personnel involved in the maintenance of aircraft

must be:
 carefully selected and trained
 their equipment needs to match the capabilities and limitations of
human performance
 they must be protected from the hazards of the environment in which
they work.

 Human Factors emerged during WWW II when several pilots lost their
lives not in combat, but as what we hear the term so frequently human
errors.

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Human Factors for Aircraft Maintenance Personnel

 Following the most dramatic accident of Aloha’s Flight 243 on April 28,
1988, the FAA began a series of meeting to begin dealing with the
issue of Human Factors in aircraft maintenance.
 The meeting continues today as the annual international Symposium
on Human Factors in Aviation Maintenance, co-sponsored by FAA, CAA
(UK) and Transport Canada (Canada).
 As far as HF in Maintenance is concerned:
 the FAA has decided to focus on research, publication of
guidance material and the promotion of Human Factors
Programmes without changing the regulatory framework,

 the JAA and Transport Canada decided to enhance their

maintenance regulations by imbedding human factors
concepts in them.

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Human Factors for Aircraft Maintenance Personnel

 In December 1998, JAA set up a Maintenance Human Factors

Working Group with the view of improving the JAR 145
requirements in the light of recent developments in Maintenance
Human Factors research.

 Human Factors training made available to maintenance in the

90’s because maintenance personnel are humans too. As
humans, we make the same unintentional mistakes as pilots.

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Human Factors for Aircraft Maintenance Personnel

 ICAO under its amendment to Annex 6 Chapter 8 now requires
all contracting states to require their approved maintenance
organisations to include " training in knowledge and skill
related to human performance.“

 EASA 66 Module 9 now dictates Human Factors as part of the

basic knowledge requirements for a EASA 66 aircraft
maintenance licence.

 Human Factors training, to help maintenance person

avoid the errors he never intends to make, has finally
arrived.

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The Need To Take Human Factors Into Account

 Why do we need to take human factors into account?
It is because human factors will impinge or influence on everything
maintenance persons do in the course of their job in one way or
another.
 What is “Human Factors”?
Definition:
In the context of aviation maintenance it is referred to as “the study
of human capabilities and limitations in the workplace.”

Aim: To optimise the relationship between maintenance personnel and

systems with a view to improve safety, efficiency and well-
being.

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3.1 Why Human Factors Training is important

• Human Factors training is instrumental in fostering a positive safety culture.
• Human Factors training for the workforce, including for the leadership, is a critical and
cost-effective first step in identifying methods to recognize, understand, and manage
human performance issues.
• Effective Human Factors training not only improves work performance, but also
promotes workforce physical and psychological health.
• Initial and recurrent training on new regulations, procedures, and equipment are
opportunities to reinforce awareness of the Human Factors issues that affect job
performance.
• ICAO and many NAAs mandate or recommend Maintenance Human Factors training,
recognizing its impact on safety and quality.

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TRAITS OF HUMAN FACTORS

 Human Factors include such elements or traits as:

 human physiology (normal functions of humans)

 psychology (incl. perception, cognition, memory, social
interaction, error, etc.)
 work place design
 environmental conditions
 human-machine interface
 anthropometrics (the scientific study of measurements of
the human body)

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Tools, test equipment, aircraft

structure, flight deck designs,
H positioning of controls and
Hardware instruments, etc.
Maintenance Physical
procedures,
maintenance S
L iveware
E
environment (e.g.
conditions in
manuals, checklist Software YOU Environment
hangar, conditions
layout, etc. on the line) and
work environment
Maintenance engineers, L (i.e. work patterns,
supervisors, planners, Liveware management
managers, etc. structures, public
perception of
industry, etc.)
Figure 1 SHEL Model. Source: Edwards, 1972 (as referenced in ICAO Human Factors Digest No.1, Circular 216 (1989))

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MAN, THE “LIVEWARE”

 Modern aircraft embodied latest self-test and diagnostic computer-
powered routines, one aspect of aviation maintenance never changed.
 Do you know which one aspect?

 Maintenance tasks are still done by human beings.

 However, man has limitations. What should be done to assist him?

! All other aspects (SHEL) must be designed or adapted to ASSIST

HIS PERFORMANCE and RESPECT HIS LIMITATIONS.
 What will happen if these two aspects are ignored?
 The human – in this case the maintenance person will not perform
to the best of his abilities, may make errors, and may jeopardise
safety.

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MAN, THE “LIVEWEAR”

 Have to accept the fact that human being is inherently unreliable.
 What shall be done about it?

 Work around that unreliability by providing good training,

procedures, tools, duplicate inspection, etc.

 Therefore, our aim here is to help you to recognise human

performance limitations in yourselves and others, and able to
avoid, detect and rectify errors or error prone behaviour and
practices.

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Incidents and Accidents Attributed to Human Factors / Human Error

 In 1940, it was found that approximately 70% of all aircraft accidents were
attributed to man's performance, i.e., human error.

 35 years later, Air Transport Association (ATA) reviewed the situation and
found there had been no reduction in human error component of accident
statistics (Figure 2).
OTHER
CAUSES

30%

HUMAN
FAILURE

70%

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Incidents and Accidents Attributed to Human Factors / Human Errors

 In 1986, Sears of USA, looked at significant accidents causes in

93 aircraft accidents and revealed that maintenance and
inspection deficiencies made up of 12% of accidents in which
this was a factor.

 In 1998, UK CAA looked at causes of 621 global fatal accidents

between 1980 and 1996 again revealed the area “maintenance
or repair oversight / error / inadequate” featured as one of the
top 10 primary causal factors.

 It is clear from such studies that human factors problems in

aircraft maintenance engineering are a significant issue,
warranting serious consideration.

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Examples of ”high Profile” Incidents and Accidents

Case 1
Boeing 737, Aloha flight 243, Maui, Hawaii, April 28 1988
● 18 feet of the upper cabin structure rippled off at 24,000 feet due to
structural failure.
● This 737 had been examined by two of the engineering
inspectors. Neither the inspector who had 22 years experience and
the other, the chief inspector, had 33 years experience found any
cracks in their inspection.
● Post-accident analysis determined there were over 240 cracks in the
skin of this aircraft at the time of the inspection.
● The ensuring investigation identified many human-factors-related
problems leading to the failed inspection.

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FIGURE 1-1. FORWARD FUSELAGE OF B-737 FOLLOWING INFLIGHT STRUCTURAL FAILURE

Source: National Transport Safety Board, U.S.A.

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Case 2
✈ BAC 1–11, (British Airways flight 5390), over Didcot, Oxfordshire on 10
June 1990

● Climbing through 17,300 feet on departure from Birmingham

International Airport, the left windscreen, which had been replaced prior
to flight, was blown out under the effects of cabin pressure.

● It overcame the retention of the securing bolts, 84 of which, out of a

total 90, were smaller than specified diameter.

● The commander was sucked halfway out of the windscreen aperture and
was restrained by cabin crew whilst the co-pilot flew the aircraft to a
safe landing at Southampton Airport.

● Use of wrong size of securing bolts for the replacement of affected

windscreen was the causal factor to this incident. The Shift Maintenance
Manager (SMM) had erroneously selected 8C bolts despite advised by
the storeman the job needed 8Ds. The 8Cs were longer but thinner.

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Case 2

● The SMM completed the job himself and signed off, the procedures
not requiring a pressure check or duplicated check.

● Several human factors issues contributing to this incident,

including perceptual error made by SMM, poor lighting in store
area, circadian effects, working practices, and possible
organisational and design factors.

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Case 3

✈ Airbus A320, G-KMAM at London Gatwick Airport, on 26 August 1993

● Exhibited an undemanded roll to the right after take-off. The aircraft

returned to Gatwick and landed safely.

● Investigation revealed during maintenance, in order to replace the

right outboard flap, the spoilers had been placed in maintenance
mode and moved using an incomplete procedure; especially the
collars and flags were not fitted.

● This misunderstanding was due, in part, to familiarity to the

engineers with other aircraft and contributed to a lack of adequate
briefing on the status of the spoilers during the shift handover.

● The locked spoiler was not detected during standard pilot functional
checks.

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Case 4

✈ Boeing 737, G-OBMM near Daventry, on February 1995

● Loss of oil pressure on both engines. The aircraft diverted and landed
safely at Luton Airport.

● Investigation revealed high pressure rotor drive covers had not been
refitted post borescope inspection on both engines the night before,
resulting in the loss of almost all the oil from both engines during flight.

● The task was supposed to be carried out by the line engineer but was
swapped with the maintenance controller for various reasons. The base
maintenance controller did not have the appropriate paperwork with him
and carried out the task with a fitter despite many interruptions but failed
to refit the rotor driver covers.

● No ground idle engine runs (which would have revealed the oil leak) were
carried out. The job was signed off as complete.

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Characteristics of all the incidents

✈ All of the incidents were characterised by the following:

● There were staff shortages

● Time pressure existed
● All the errors occurred at night
● Shift or task handovers were involved
● They all involved supervisors doing long hands-on tasks
● There was an element of a “can do” attitude
● There was some failure to use approved data or company
procedures
● Manuals were confusing
● There was inadequate pre-planning, equipment or spares

Source: AAIB, 1988

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A Breakdown in Human Factors

✈ Accidents are preventable and could be avoided if any one of a number of
things had been done differently.

✈ Many accidents and incidents involved a series of human factors problems

which formed an error chain. If any one of the links in this “chain” had been
broken by building in measures which may have prevented a window of
opportunity for errors.

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Murphy’s Law

✈ “Murphy’s Law” can be regarded As the notion: “If something can go

wrong, it will”

✈ It is not true that accidents only happen to people who are irresponsible
or ‘sloppy’.

✈ The “high profile” incidents and accidents discussed earlier in this lesson
show that errors can be made by experienced, well-respected individuals
and accidents can occur in organisations previously thought to be “safe”.

✈ We, therefore, must acknowledge Murphy’s Law and overcome the “it will
never happen to me” belief that many of us hold.

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