Number

Nanjing University of Aeronautics and Astronautics

Graduation Thesis
Managing Human Factors in Maintenance
Student Name ID Number College Major Class Advisor

Aircraft

Muhammad Umer Ajmal 190761209 19 Aeronautical Engineering 1907612 Cao YuYuan June 2011

Nanjing University of Aeronautics and Astronautics Graduation Thesis Letter of Commitment
Private solemn statement: the whole content of this Graduation Thesis (Title:Managing Human Factors in Aircraft Maintenance) is made and the whole results are experimented personally under the guidance of my faculty advisor. Except the deliberately added remarkable contents, this graduation thesis is completed with my own knowledge and doesn‟t involve other thesis written by any other person or group.

Personal‟s signature:

Date: 2011-06

(Student ID Number):190761209

Managing Human Factors in Aircraft Maintenance

Managing Human Factors in Aircraft Maintenance
Abstract
Global statistics indicate that 80% of aviation accidents are due to human errors with 50% due to maintenance human factor problems. Current human factor management programs have not succeeded to the degree desired. Many industries today use performance excellence frameworks such as the Baldridge National Quality Award framework to improve over-all organizational effectiveness, organizational culture and personal learning and growth. A survey administered to a sample population revealed a consistent problem with aviation human factors and the need for a more integrated framework to manage human factor problems in aviation maintenance.

Keywords: Aviation Accidents; industries; Baldridge National Quality Award; Survey

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Managing Human Factors in Aircraft Maintenance 飞机维修管理人为因素 摘要 统计数据表明,全球 80%的航空事故是由于 50%是由于人为因素问题,维修人为错误。 目前的人力因素管理方案没有成功的程度不满意。许多行业都使用性能,如鲍德里奇国家质 量奖卓越架构框架,提高过所有的组织效能,组织文化和个人的学习和成长。人口管理的抽 样调查显示,一个与航空人为因素相一致的问题,必须采取更需要管理的综合框架航空维修 人为因素的问题。 ii .

........ 1 1......................................................................................................................................................................... 8 1....................................................................... 4 1............................................................ 23 2.................................................................................1 Summary of Relevant Data ........................8 Researcher‟s Work Setting and Role ................................................................ 26 2..... 19 2...........4 Current Human Factor Programs in Aircraft Maintenance ...................................................................4 A Model of accident and incident causation by Australian Transport Safety Bureau .................................... 3 1....................3 Human Factors History .... 26 2.......................... 9 1................................ i Chapter 1 INTRODUCTION ........................................................................ 13 2...............................................................1 Background of the Problem ...............1 Some definitions of Human Factors..........................................................................9 Statement of Problem.......2 Current Human Factor Programs in Aircraft Maintenance ............................................................. 17 2....................................................6............................................................................2 SHELL interfaces ...........................2.................. 9 1................................................................................................. 18 2.........11 1.................... 1 1................... 28 Chapter 3 RESEARCH METHODOLOGY ..............................................................................3 Aviation Performance Excellence Framework ..............................................................................11 1............................................................................. 12 Chapter 2 REVIEW OF RELEVANT LITERATURE AND RESEARCH ........7 Performance Excellence Framework ..2...........................................................................6..............................................1 Human Factor Errors in Aircraft Maintenance Statistics ............................................................................. 4 1...........7 Statement of Research Question .................................2 Definition of Human Factors ...... 27 2... 22 2.6 The SHELL Model ...........................11 1......2 ICAO Definitions Relating to Human Factors ...................... 3 1................................................10 Limitations and Assumptions .......2 The Dirty Dozen ............ 29 iii ............1.........................................5 The Cost of Maintenance Error ....................... 13 2........5 The PEAR Model.........................................1 Elements ......Managing Human Factors in Aircraft Maintenance Contents Abstract ................................................................... 13 2.................1..............6 Unique Human Factors issues in Aviation Maintenance ................................................

................................8 Analysis of the Problem .....4.........................................................................................................2 Research Model .............9 Over-Time (OT) Management ..2 Source of Data ..................................................................3 Reasons for Violations ...................................................3 Pilot Study .....................................................................................................4 The Data Gathering Device..............................................1 Most Common Outcomes of Safety Occurrences .4...............2....1 Research Design ............... 41 5................................................................................1...4 Percentages.....Managing Human Factors in Aircraft Maintenance 3...............................5 Types of Violations..............2...............................................................4.... 39 5................................................................4.........4.................................6 Frequency of Violations .....................................................................2.................................................2..................... 29 3................................2.........................................................6 Instrument Reliability .............. 29 3................................................................. 29 3.................. 31 3..................................1 Human Factor Management Program ............................ 42 5.........................................................................................................................................................10 Open Reporting .......... 41 5........................2.. 39 5........................................ 32 Chapter 4 RESULTS ..........................................7 Instrument Validity .........4........1 Safety Culture ......................................................................................... 37 Chapter 5 DISCUSSION ......... 33 4...... 30 3................................................................ 42 5............................................................................................................. 31 3....................... 40 5..................................4.......................................................................................................................3 Top HFIM drivers that need reviewing......................................................................1 Human Factor Programs and Management ...............................................4...1 Survey Population .............................................................. 30 3............................. 30 3............................................2 Most Common Outcomes of Safety Occurrences .......... 41 5.8 Treatment of Data and Procedures ......................4......................2 Safety Quality ......................4.............4 Influence of experience on human factor management ...................... 42 5. 34 4....................................... 40 5....................................... 41 5..........................2...............................7 Calling Time-Out ..........5 Distribution Method .....2..................................... 39 5.. 42 5.......... 32 3.. 33 4......................................................................2 Survey Feedback ......................................................................... 41 5......................................... 43 iv .................

.................................................................................................................................................................................................................................XX v ..................... 44 6....................... XX Appendix ...........................................................................................................................Managing Human Factors in Aircraft Maintenance Chapter 6 CONCLUSION & RECOMMENDATION ........................................................................................... 50 Acknowledgement ...............................1 Recommendation ................................... 45 References .....

such as the military.1 Background of the Problem Imagine you are a member of an aviation organization. You are immediately reminded of that famous lecture you heard during HF training that “the chain is only as strong as its weakest link. you hear that one of your friends the night before had hit and damaged the aircraft nose landing gear with a Harlan tractor and now management has called for an urgent safety briefing to remind everyone of the need to be vigilant and aware of such lapses in judgment. more than ever. and you have just been told that you will need to work over the weekend because there has been a fleet grounding issue on your A320 aircraft. You immediately recall how one of your colleagues had been screaming to remove the Harlan tractor or Toyota tractor because they both had exactly the opposite reverse gears. high pressure with possibly hundreds of tasks being performed by large numbers of personnel on highly complex and technologically advanced systems in a confined area. Although your body tells you that you can no longer take it. in one you push the lever forward and the other backward.” The next morning. You will need to work to get all the aircraft inspected by Monday morning.Managing Human Factors in Aircraft Maintenance Chapter 1 Introduction 1. Your organization has sent you for Human Factors (HF) training and workshops and your management has told you to call for time-out when you feel tired yet they say there is an urgent need to get the aircraft inspected over the weekend. you are reminded of how many times this year you have been doing this and the close encounters you have had with making an error of judgment. before you go to work. While there have been several advances to the study and implementation of human factors programs. your mind tells you that you must keep going and be a team player or else the whole team will fail in this important mission. Aircraft maintenance work encompasses fast turnaround. the aviation world is faced with the constant challenge of addressing human factors in maintenance. Today. You have just put in close to 60 hours of work that week and you are really tired. It is very easy for information and tasks to fall through the -1- . As you console yourself on your way home. there are still several inconsistencies to the way these programs are implemented and hence the varied results.

involving crashes or serious accidents with aircraft. The role played by human performance can be found below.Managing Human Factors in Aircraft Maintenance safety net. we would be looking at a more systemic solution to HF management as HF is more than just about people. we will look at the Baldridge national quality program and criteria for performance excellence to see if we can formulate a more comprehensive solution to managing HF in maintenance. and how comprehensive.1 The role played by human performance in civil aircraft accidents. the human being in the process had the potential to obliterate any of these technological advances. Events around the world in the late 1970s. Then finally. 1975) In this research project we will analyze the top human factor problems in aviation maintenance and evaluate a holistic solution to addressing these problems through a performance excellence framework. We will start with a brief look at the history of HF programs and the changes that have taken place over the years. -2- . We will also explore the current HF programs adopted by several organizations and try to understand why HF error occur. 1980s and early 1990s. (IATA. Figure 1. In essence. the solutions currently adopted. alerted the aviation world to the fact that although the aircraft were becoming much more reliable.

Human Factors researchers study system performance. because although it may indicate WHERE in the system a breakdown occurs. environmental conditions.2 Definition of Human Factors Human Factors as a term has to be clearly defined because when these words are used in the vernacular they are often applied to any factor related to humans. adaptable and valuable part of the aviation system. psychology. the equipment -3- . This has commonly been classified as human error. such attributes as human physiology. 1. but are not limited to. Human Factors has been progressively developed.1 Some definitions of Human Factors Human Factors is concerned to optimize the relationship between people and their activities. The term “human error” can be misleading when referring to human factors in accident prevention. some three out of four accidents have resulted from less than optimum human performance. but it is also the most vulnerable to influences which can adversely affect its performance. and is now backed by a vast store of knowledge which can be used by those concerned with enhancing the safety of the complex system which is today‟s civil aviation. contemporary safety thinking argues that human error should be the starting point rather than the stop-rule in accident investigation and prevention. An error attributed to humans in the system may have been design-induced or stimulated by inadequate training. The human element is the most flexible. they study the interaction of humans. by the systematic application of human sciences. Human Factors include.2. work place design. That is. badly designed procedures or the poor concept or layout of manuals. the term “human error” allows concealment of the underlying factors which must be brought to the fore if accidents are to be prevented. Further. human-machine interface.Managing Human Factors in Aircraft Maintenance 1. refined and institutionalized for many decades. it provides no guidance as to WHY it occurs. Throughout the years. An understanding of the predictable human capabilities and limitations and the application of this understanding are the primary concerns of Human Factors. and more. In fact. integrated within the framework of systems engineering [1]. Human Factors refers to the study of human capabilities and limitations in the workplace.

these varied and developing techniques can be applied to problems as diverse as accident investigation and the optimization of pilot training [7]. operations and maintenance and which seek safe interface between the human and other system components by proper consideration to human performance [4]. the written and verbal procedures and rules they follow. sociology and anthropometry [6]. And. Human factors are essentially a multi-disciplinary field. engineering. A change in name was made from Cockpit to Crew Resource Management to change the emphasis of training to focus on cockpit group dynamics.2. there are a growing number of integrated Human Factors techniques or methods.Managing Human Factors in Aircraft Maintenance they use. Cockpit Resource Management (CRM) featured prominently in pilot training. ergonomics has been more widely used outside of the USA. 1.2 ICAO Definitions Relating to Human Factors Human Factors Principles: Principles which apply to aeronautical design. its relationship to the human sciences might well be likened to that of engineering to the physical sciences. Human Factors has been more widely used in the USA.3 Human Factors History In the late 1970s. Aviation Human factors are primarily oriented towards solving practical problems in the real world. certification. -4- . The term was used to apply to the process of training flight crews to reduce pilot error by making better use of the resources on the flight deck. Human Factors and ergonomics and engineering psychology are roughly equivalent terms used for the field of science concerned with the optimization of the relationship between people and the machines they operate through the systematic application of human sciences integrated within the framework of systems engineering. just as technology links the physical sciences to various engineering applications. and the environmental conditions of any system [2]. training. Human performance: Human capabilities and limitations which have an impact on the safety and efficiency of aeronautical operations [5]. As a concept. and engineering psychology has been more widely used in academia [3]. physiology. 1. including but not limited to: psychology.

it was not until in the 90s that Maintenance Resource Management (MRM) was made available to maintenance personnel. within the aviation system in which the crew must function which can determine safety. on 10-12 March 1998. nothing significant was really done to determine the HF root causes. David King. 1990 when a cockpit window blew out at 16.Managing Human Factors in Aircraft Maintenance Some airline programs dealt with specific topics such as team building. from the United Kingdom is one of the first to look at HF in the same light it is looked at today. briefing strategies. Similarly. The need for a change in approach to human errors and their reporting was reinforced during the CAA sponsored 12 Symposium on Human Factors in Aviation Maintenance that was held in Gatwick Airport. and a pilot almost went with it.2 Human Factors History. England. situational awareness and stress management. Figure 1. It was the first of the international symposiums -5- . many caused by HF errors. that an in depth look at the contributing factors to a maintenance error were examined . such as organizational culture. the 12th ICAO Symposium on Human Factors in Aviation Maintenance. but much later. Unlike CRM. MRM was very new to the aviation maintainers and it was not until June 10. After years of accidents.000 feet. In the early 1990s. CRM training began to reflect the many factors.

(ICAO) now requires organizations to include HFIM training.S. The International Civil Aviation Organization. Military aircraft production drove much of the early consideration of human factors. At a minimum.k. knobs) within and between aircraft types. -6- . may be the most common model discussed in aviation human factors circles. HF training which helps our fellow maintenance personnel to avoid an error he/she never intends to make had finally arrived. it can also be reasonably argued that inventors from Leonardo DaVinci to the Wright Brothers considered all items in the PEAR model. the U. The original design. Therefore. it is the field of medicine that may deserve the claim to the first formal study of human factors in aviation. Army was conducting pilot selection and accident investigations based on pilot medical factors. Of course. resulted in the somewhat humorous term “knobology. The attention to knobs and dials. The SHEL model. By 1910.Managing Human Factors in Aircraft Maintenance involving the CAA. FAA and Transport Canada. Icarus. present. the PEAR works. The foundation of Human Factors training as a modern aviation tool was probably initiated in the United States at a workshop sponsored by the National Aeronautics and Space Administration (NASA) in 1979. Investigations during the war lead to the conclusion that cockpit design was a problem. Edwards. The approach to understanding and applying human factors can be simplified using a model. driven by WWII. As we consider the past. the early engineering psychologists had to ensure standardization of displays and controls (a. caused the pilot to commit errors. failed to consider Environment during any human factors analysis he may have conducted. developed in the „60s by E..” which is indeed a small and ongoing subset of human factors. and future direction of human factors. This workshop was the development of NASA research into the causes of air transport accidents. by the way. unfortunately. and between-model modifications to displays and controls. The term “engineering psychology” emerged in the „40s with the focus on designing aircraft with an improved match to the capabilities and limitations of humans. The PEAR model is a means to consider human factors within any organization or context. this author suggests an easier to understand model developed by Dr.a. During the „40s military aircraft were in heavy production throughout the world. However. Michael Maddox for a maintenance human factors course that we offer.

While the PEAR model was not formally used all aspects of PEAR were applicable. such as training. This accident placed focus on the aging aircraft fleet. and use of a manufacturer‟s service bulletins. but just as much attention was focused on maintenance human factors. Research. Even then researchers were lamenting the growing complexity of aircraft and the associated electronics equipment! Human factors research evolved substantially from the „60s through the „80s. many examples of human error taught us that humans sometimes did not fully understand the complex systems that they were “controlling. thus encompassing all physical.000 active members throughout the world. In other industries. the United DC8 fuel exhaustion accident off the Oregon coast (1978). but also by a few famous commercial incidents and accidents. use of procedures. but not limited to. Maintenance human factors began receiving attention in the early „50s at Wright Air Force Base in Ohio. such as nuclear power electric generation. Manned space flight research made significant contributions to formal studies of the human in the system. In 1988 the Aloha Airlines 737 encountered the famous “convertible aircraft” phenomenon.” Critical incidents like the aircraft accidents at Tennerife (1977). communication.) In 1995 the Human Factors Society evolved to the Human Factors & Ergonomics (HF&E) Society. Congress passed the Aviation Safety Research Act (PL 100-592). The design of the complex fighter jets introduced increasingly complex aircraft and weapon systems that could easily overload human processing capability. procedures. The importance of the situation awareness was highlighted. In 1988 the U. not only by the military aircraft. training. The Aloha Accident report identified numerous human factors issues including. S. development. Today the HF & E Society has over 5. Within that -7- .K. and products have evolved as a result of these accidents.) and the Human Factors Society (1957 in the U. and crew resource management. and cognitive aspects of the human in any given system.S. professional societies of human factors engineers and psychologists formed the Ergonomics Research Society (1949 in the U.Managing Human Factors in Aircraft Maintenance In the late „40s and „50s. and the nuclear plant Three Mile Island (1979) focused considerable attention on the study of human factors. situation awareness. Researchers there focused on such aspects as selection and training of maintenance personnel. physiological.

Other organizations like Boeing have developed their own in-house Maintenance Error and Decision Analysis (MEDA) programs with more in depth analysis including the background of personnel that commit these HF errors to better understand the extent of solutions necessary. Gordon Dupont. Yet until recently. Most of these programs are designed to identify the HF errors. Since 1988. educate the personnel on their causal potential. formerly of Transport Canada. many of them still look at HF from a „people‟ perspective rather than “an organization” perspective. There may be a need to develop programs that improve the performance of all areas of an organization as a whole which will provide long term solutions to HFIM. That Act. the FAA Office of Aviation Medicine has invested an average of $1. is one such consultant whose excellent “Dirty Dozen” classification of HF root causes has been widely adopted by several aviation organizations. human factors researchers have studied pilots and the tasks they perform. Many consultants and companies have enjoyed this upward focus on HF. The main breakthrough that was achieved in recent years is the emphasis given by senior management in organizations to HF programs. While many of these programs have truly made the aviation work environment safer. and the associated ongoing funding.4 Current Human Factor Programs in Aircraft Maintenance MRM which later evolved into Human Factors in Maintenance (HFIM) was developed to provide primarily the training required to understand and prevent HF errors from occurring. 1. without doubt.5 The Cost of Maintenance Error Since the end of World War II. The success story of the research program constitutes the next subsection of this paper.Managing Human Factors in Aircraft Maintenance law was the expressed intent to study all aspects of human factors in aviation safety including human factors in maintenance. as well as air traffic control and cabin safety issues. The FAA R&D has been matched by considerable aviation industry services and participation in-kind.25M per year on maintenance human factors research and development. suggest ways to contain and correct the problem and create a HF error-free environment. maintenance -8- . 1. has had the single greatest impact on the current international airline and government attention to human factors in airline maintenance.

Maintenance is one of the largest costs facing airlines.Managing Human Factors in Aircraft Maintenance personnel were overlooked by the human factors profession. requiring a return to gate. in numbing cold or sweltering heat. can involve significant costs. which had previously been the predominant cause of airline accidents. maintenance errors can have grave implications for flight safety. Even a small reduction in the frequency of maintenance-induced schedule disruptions can result in major savings. 12 man-hours of maintenance occur. and other schedule disruptions. The work may be carried out at heights. Maintenance technicians commonly spend more time preparing for a task than actually carrying it out. Accident statistics for the worldwide commercial jet transport industry show maintenance as the „primary cause factor‟ in a relatively low four per cent of hull loss accidents. In 2003. a flight cancellation can cost the airline around USD $140.000. yet it requires clerical skills and attention to detail. According to former NTSB Board member John Goglia. It has been estimated that for every hour of flight. Yet primary cause statistics may tend to understate the significance of maintenance as a contributing factor in accidents. Whatever the reason for this. and maintenance engineers typically -9- .6 Unique Human Factors issues in Aviation Maintenance Maintenance personnel are confronted with a set of human factors unique within aviation. in the case of a large aircraft such as a Boeing 747-400. The work can be physically strenuous. while a delay at the gate can cost an average of USD $17. deficient maintenance has been implicated in 7 of 14 recent airline accidents. diversions. In this context it can be seen that even simple errors such as gear pins left in place. Maintenance technicians work in an environment that is more hazardous than most other jobs in the labor force. it is not because maintenance is insignificant. cancellations. Dealing with documentation is a key activity. 1. in confined spaces. Flight International reported that technical and maintenance failure emerged as the leading cause of airline accidents and fatalities.000 per hour. Maintenance errors not only pose a threat to flight safety. surpassing controlled flight into terrain. Most significantly. For example. but can also impose significant financial costs through delays. compared with flight crew actions that are implicated as a primary cause factor in more than 60 per cent of accidents.

Managing Human Factors in Aircraft Maintenance
spend nearly as much time wielding a pen as they do holding a screwdriver. The work requires good communication and coordination, yet verbal communication can be difficult due to noise levels and the use of hearing protection. The work frequently involves fault diagnosis and problem solving in the presence of time pressures, particularly at the gate. Maintenance personnel also face unique sources of stress. Air traffic controllers and pilots can leave work at the end of the day knowing that the day‟s work is complete. In most cases, any errors they made during their shift will have either had an immediate impact or no impact at all. In contrast, when maintenance personnel leave work at the end of their shift, they know that the work they performed will be relied on by crew and passengers for months or years into the future. The emotional burden on maintenance personnel whose work has been involved in accidents is largely unrecognized outside the maintenance fraternity. On more than one occasion, maintenance personnel have taken their own lives following aircraft accidents caused by maintenance error. From a human factors perspective, maintenance personnel have more in common with doctors than with pilots. We know from medicine that iatrogenic, or doctor caused, injury can be a significant threat to patient health. Medical errors include surgical instruments sewn up inside patients, disorders being misdiagnosed, and very occasionally, surgeons operating on the wrong limb. Most aircraft maintenance personnel will be familiar with these types of errors. Opening up a healthy patient at regular intervals to check that organs are functioning normally would not be an appropriate strategy in health care, yet preventative maintenance in aviation often requires us to disassemble and inspect normally functioning systems, with the attendant risk of error. Just as medicine can be about preventing or responding to a condition, so maintenance can be divided into two categories. These are scheduled and unscheduled maintenance. The distinction between these two categories has significant implications for maintenance human factors. Scheduled maintenance tasks are typically preventative. Many preventative tasks are performed regularly, and so are familiar routines for maintenance personnel. Experienced personnel will be unlikely to make mistakes related to a lack of knowledge or skills on a familiar preventative task. Maintenance discrepancies on familiar tasks are more likely to involve breakdowns in teamwork; everyday „absent minded‟ mistakes such as forgetting to install components, and action slips where a person absent-mindedly performs a routine action that they had not intended to
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Managing Human Factors in Aircraft Maintenance
perform. Unscheduled tasks are usually corrective in nature, and are performed in response to unplanned events such as aircraft damage or component failure. Although some unscheduled tasks are minor, others require extensive system knowledge, problem solving and specialized skills.

1.7 Performance Excellence Framework
Performance Excellence Framework (PEF) has been used in several countries and in several sectors such as Education, Healthcare, Tourism and Housing. Most recently, the Defense industry has been using such framework to gauge its quality health. One of the first of such frameworks, established in 1988, is the Malcom Baldridge National Quality Award (MBNQA) framework which covers all areas of a business such as Process Management, Information Management, Strategic Planning, Human Resource Development and the Use of Results [8]. The key thrust for performance excellence is to establish a culture of continuous improvement and innovation that builds upon a strong foundation of quality, professionalism and team excellence always.

1.8 Researcher’s Work Setting and Role
The researcher is a Bachelors student with the major of Aerospace Engineering (Bach 2007) in Nanjing University of Aeronautics & Astronautics situated in Nanjing, Jiangsu, Peoples Republic of China. This paper is the graduation thesis of the researcher. In order to complete his bachelors the researcher chose this topic for his thesis because it is very interesting and has a very wide role and impact in the field of aviation.

1.9 Statement of Problem
Global statistics indicate that 80% of aviation accidents are due to human errors with 50% due to maintenance human factor problems. Most programs currently implemented are designed to identify the HF errors, educate the personnel on their causal potential, suggest ways to contain and correct the problem and create a HF error-free environment. However, the percentage of HF errors in aviation mishaps is on the rise today. There is a need for a more integrated and holistic approach
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Managing Human Factors in Aircraft Maintenance
to HF management.

1.10 Limitations and Assumptions
Due to the limited time and access to a limited area of the aviation industry, the researcher was limited to survey just the students and professors of the university and only a handful of people who are holding jobs in some aviation industry. Due to lack of time and access the researcher was forced to find details and previously done research on the respected topic and also had to make some assumptions on the way.

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Towing events . the main types. however. Table 2.1 Human Factor Errors in Aircraft Maintenance Statistics In the United Kingdom (UK) between 1982 and 1991. 1992). there were 230 MORs and in 1995 to 1996 there were 534. Of these.1 Boeing field test with MEDA In 1998.1991 revealed that 56% of human factors errors resulted in omissions with a further 30% resulting in incorrect installations. Systems operated unsafely during maintenance 2. In a field test by Boeing in 1994 to 1995 with nine maintenance organizations. the Australian Transport Safety Bureau (Hobbs & Williamson. only 230 resulted in an unexpected or undesirable occurrence that interrupts normal operating procedures that may cause an accident or incident.1. The CAA concluded that there was no significant risk to the public.1. there were 1.270 Mandatory Occurrence Reports (MOR) which involved maintenance errors submitted to the CAA Safety Data Department (CAA. 1998) surveyed close to 1400 Licensed Aircraft Maintenance Engineers (LAMEs).13 - . Similarly a study by Boeing in 1993 of 122 occurrences between 1989. causes and results of errors are summarized below in table 2. The number of reported errors was occurring at a greater frequency. The most common outcomes for airline related maintenance occurrences were: 1. In the period 1992-1994.Managing Human Factors in Aircraft Maintenance CHAPTER 2 Review of Relevant Literature and Research 2.1 Summary of Relevant Data 2.

the top three violations were: 1. Servicing without a checklist 2.2 1997 Survey by Australian Transportation Safety Bureau A ground crew attitude survey in the military in Asia (classified source.Managing Human Factors in Aircraft Maintenance 3.d) revealed similar findings to that of the Australian Transport and Safety Board. Omitting job steps Approximately 20% of those surveyed disclosed that they would violate rules daily or once a week. The top three reasons for these violations were: 1. Table 2. Incomplete installation The most common outcomes of non-airline occurrences were: 1. Incorrect assembly or orientation 2. Speeding 3. Incomplete installation 3. In the survey conducted in 1999.2.14 - . Persons contacting hazards The most common causes to these unsafe acts are summarized below in table 2. too little time . n. Too much work. The surveys were conducted bi-annually from 1999 to 2003 on approximately 2500 aviation technicians.

The survey results comparison between 1999 and 2003 revealed the following significant improvements which is show below in table 2. several key initiatives had been implemented to address HFIM such as: 1. has emerged as Reasons for Violations the 5th reason.30%) and personnel (94. Embracing a local version of the Malcom Baldridge Performance Excellence Framework for the military over six years from 1998. Training 100% of the licensed aircraft engineers in Human Factors Management. when the survey was conducted again.15 - . 3. Chief Executive Officer (CEO).3. Embracing additional performance excellence measurement tools such as the Balanced Score Card and Enhanced Value Organization principles. Implementing a Human Factor training program initiated by Mr. which registered an increase of 11% (13% to 24%). registered a significant increase of 14% (7% to 21%). Top 4 reasons remain unchanged. Implementing a MEDA type Human Error Analysis Tool (HEAT). Table 2. 4. supervisors (97. Gordon Dupont. "Lack of proper tools".38%) showed strong emphasis and take safety / quality seriously. Insufficient manpower 3.Managing Human Factors in Aircraft Maintenance 2. Personnel also Safety Culture (new) agreed that management (96. Types of Violations Overall reduction of 4% (14% to 10%) was . Time pressure to complete duties In 2003. the 6th reason.3 Asian Study survey comparison between 1999 and 2003 Survey Coverage Results 99% agreed that the organization placed strong emphasis on safety and quality. “Easy way out (Taking short cuts)”.43%). 5. and System Safety Services in 1999. 2.

Improvement of 16% (66% to 82%) that open Open Reporting Culture reporting is being practiced widely in the organization. Safety / Quality Management are also conducting briefings and Information disseminating safety/quality information more Dissemination frequently. Reduction by 16% (49% to 33%) in frequency Overtime Management (weekly) of overtime. 98% (an improvement of 8%) agreed that Safety/Quality information is readily available. Improvements of 22% (21% to 43%) that Frequency of Violations violations observed were “very infrequent.4. using a common MEDA taxonomy.Managing Human Factors in Aircraft Maintenance noted for the 6 common types of violations observed everyday and once a week.16 - . a selection of which is listed below in table 2. .” Reduction by 11% (50% to 39%) in holding Calling Timeout back to call timeout. The initial results were presented at a MEMS-MEDA seminar in the UK in May 2003. matching closely to that desired in the previous survey. Several UK maintenance organizations have pooled their Maintenance Error Management System (MEMS) data.

Managing Human Factors in Aircraft Maintenance Table 2. A typical HFIM course such as the one developed to comply with JAR145-12 includes: 1. In recent years. FAA as well as JAR compliant courses to ensure consistency and conformance to minimum standards set out by the governing bodies.4 Several UK Maintenance Error Management System (MEMS) data. limitations and Human Error models .17 - .2 Current Human Factor Programs in Aircraft Maintenance Several HFIM courses have evolved since ICAO required HFIM training which include those by the UK CAA.1. The maintenance error trends in US. There is still an uptrend of these maintenance errors and violations in the aviation maintenance field. 2. Time pressure seems to be the main factor due to lack of manpower and excess workload. HF training has focused on these lapses in rules and the detrimental consequences of such actions. Australia. A General introduction to Human Factors 2. A closer look at the statistics indicates that these trends are due mainly to lapses in the organizational operational culture and business processes. Asia and United Kingdom from 1982 to 2003 are alarmingly similar and they continue to plague the aviation industry and in some areas of aviation such as in the military. Safety Culture/Organizational factors overview 3. The trends in maintenance human factor errors have continued to increase. Human Performance.

Complacency 2. Tools and Practices 6. Professionalism.Managing Human Factors in Aircraft Maintenance 4. now CEO of System Safety Services. Fatigue 4. Some dirty dozen posters are shown in figure 2. Communication and Teamwork 7. Figure 2. Names of the “dirty dozen” 12 points: 1.2 The Dirty Dozen Gordon Dupont. is a renowned human factors proponent and conducts several of his HPIM courses all around the world in the aviation sectors.1 “The dirty dozen” posters from Gordon Dupont. Norms . formerly from Transport Canada.18 - . Organization HF program including the management of HF errors 2. System Safety Services. Integrity. Information.1 below. Environmental issues impacting Human Performance 5. Procedures. He is best known for his “Dirty Dozen” [9] posters which depict the most common 12 human factor errors in maintenance. Distraction 3.

Lack of Resources 12. organizational culture and risk management and ways to manage them. Lack of Teamwork Gordon conducts three workshops.Managing Human Factors in Aircraft Maintenance 5. one of the first lapses in defenses in his model starts at organizational influences as can be seen from the model below. 2. Gordon Dupont. Pressure 6. Professor James Reason and his “Swiss Cheese” model propounds that there are several latent conditions prior to an active failure or unsafe act. HPIM Part One to Part Three.19 - . and covers areas such as the background to HFIM behaviors and errors through case studies. This in essence is the main coverage for most HFIM courses and programs adopted by commercial airline and other aviation industries. Lack of Awareness 9. Equip personnel with the tools necessary to contain.3 Aviation Performance Excellence Framework More than 66 business excellence awards in 43 countries have been established adopting . Interestingly. System Safety Services modified James Reason‟s “Swiss Cheese model” incorporating his famous “Dirty Dozen” human error factors as the preconditions to unsafe acts which could eventually cause an accident/incident. correct and prevent HF errors and Evaluate the management of HFIM programs. current HFIM courses generally adopt the three E‟s or Educate personnel. As can be seen from the typical course structures above. Lack of Knowledge 11. Lack of Assertiveness 8. Gordon attributes 70% of accident causation to fallible decisions by management. CEO. Stress 7. deficiencies in line management and the preconditions which are the “Dirty Dozen” human error factors. These failed or absent defenses line up to cause a mishap or injury waiting to happen. Lack of Communication 10.

3 explains these criteria systematically. Process Management 6. Business Results Figure 2.Managing Human Factors in Aircraft Maintenance similar frameworks to the MBNQA framework. systems and methods of achieving excellence. Strategic Planning 3. Most of these performance excellence frameworks have seven main criteria areas namely: 1.20 - . Analysis and Knowledge Management 4. Human Resource Focus 5. Customer and Market Focus 7. Measurement.3 MBNQA Criteria for Performance Excellence Framework one One of the main objectives of the framework criteria is to motivate an organization into creating strategies. Figure 2. stimulating innovation and . Leadership 2. One of the many objectives of this framework is to create the values desired by businesses and customers and build a system which can sustain a competitive edge for an extended period of time.

21 - . It also helps monitor performance and provides a clear basis for improving results. Achieving the highest levels of business performance requires a well-executed approach to organizational and personal learning. Human Resource Focus 4. Today. Several defense related organizations have adopted this framework and tailored it to their needs. and to human factor management. . adaptive. Leadership and Organizational Culture 2. Innovation means making meaningful change to improve an organization‟s products. education and most recently in the defense industry in Asia over the last 10 years. Some of the key realigned objectives from the framework can be found below. The framework provides excellent criteria for organizations to follow to permeate a culture of excellence. services and processes and to create a new value for the organization. Most relevant for the defense industry. Measurement. Organizations should be led and managed so that innovation becomes part and parcel of the learning culture and is integrated into daily work. Process Management The key objectives for the Malcom Baldridge National Quality Award framework for performance excellence can be translated to key objectives for a successful Human Factor program. innovative and efficient thus giving an organization marketplace sustainability and performance advantages while it gives employees the satisfaction and motivation to excel [10]. Analysis and Knowledge Management 3. the main focus in many businesses is the relentless pursuit for innovation. The use of a balanced composite of leading and lagging performance indicators measures the effective means to communicate short and long term priorities. The MBNQA framework has been adopted by many sectors in the industry namely health.Managing Human Factors in Aircraft Maintenance building knowledge and capabilities. are the four main areas of the framework namely: 1. This will result in not only better products but also move toward being more responsive. The adoption of this framework constitutes a systemic approach to managing an organization and is proposed in this paper as a necessary means for reducing significantly aviation‟s “Dirty Dozen” maintenance human factor issues.

These are features such as procedures. such as pilots or maintenance engineers. workplace conditions. and equipment.Managing Human Factors in Aircraft Maintenance 2. The Figure below shows the main causal elements involved in accidents and incidents. local conditions and individual actions can. According to this model. resource allocation. Risk controls. in turn. It is an adaptation of the „Swiss Cheese‟ model originally developed by James Reason. but to understand how and why maintenance errors occur. we need to understand the organizational context in which they occur.4 A Model of accident and incident causation by Australian Transport Safety Bureau The errors of maintenance personnel can be the most visible aspects of maintenance human factors. and management decisions.4. Figure 2. In order to understand and ultimately prevent accidents. such as communication.4 A model of accident and incident causation . be influenced by organizational factors such as company policies.22 - . This is often referred to as root cause analysis. it is necessary to trace the chain of causes back through all the elements of the system including organizational influences. checks or precautions designed to manage hazards that threaten safety. However. these actions occur in the context of local conditions. The model is shown in figure 2. The task environment also includes risk controls. accidents or incidents are usually triggered by the actions of operational personnel.

2. Although they are unwanted events. errors are valuable opportunities to identify improvements.16 So it should not be surprising to learn that human error is a significant threat in airline maintenance. There are plenty of excellent resources to help you tailor a program for your organization. the Federal Aviation Administration (FAA) has provided extensive information on human factors. the Environment in which they work.23 - . and at least 58 per cent of medical misadventures. A human factors program will help minimize errors and complement the design of a safety management system (SMS).15 According to some authorities. to characterize human factors in aviation maintenance. A recent Google search of the term “maintenance human factors” delivered 11. For nearly 20 years.000 people in the US die each year because of avoidable medical errors. The Aircraft Electronics Association (AEA) acknowledges that PEAR is an excellent way to remember key considerations for a human factors program.Managing Human Factors in Aircraft Maintenance Individual Actions Human error is a threat to virtually all advanced technological systems. PEAR prompts recall of the four important considerations for human factors programs: People who do the job. maintenance errors are symptoms of underlying problems within the organization. It has been estimated that human error is involved in 70 per cent of aircraft accidents.300 hits. A maintenance human factors program does not have to be complex. the European Aviation Safety Authority (EASA) and Transport Canada have also published human factors information. The use of the term „human error‟ should not imply that we have a problem with people. around 80. In many cases. as well as 80 per cent of shipping accidents. the term “PEAR” has been used as memory jogger. There are two main approaches to describing errors: physical descriptions and psychological descriptions. expensive. More recently.5 The PEAR Model For over a decade. the Actions they perform. and the Resources necessary to complete the job. or a burden to the organization. The real challenge is convert the vast .

and the factors that affect them. psychological. and address physical. Resources necessary to complete a job This article will consider these four topics and their relevance to human factors and safety management systems. and conditions that may affect their interaction with others.24 - . cognitive capacity. It must focus on It should also consider their mental state. Actions they perform 4. People who do the job 2. It stands for: 1. physiological.Managing Human Factors in Aircraft Maintenance amount of information into understandable and practical solutions for your organization. and psychosocial factors. People Aviation maintenance human factors programs focus on the people who perform the work. Environment in which they work 3. their physical capabilities. . individuals. The memory jogger PEAR makes the recognition and mitigation of human factors even easier.

An excellent organizational environment is promoted with leadership. Adherence to the JTA helps ensure that each worker is properly trained and that each workplace has the necessary equipment and other resources to perform the job. Job task analysis (JTA) is the standard human factors approach to identify the knowledge. and the culture of the company. cleanliness. . tools. The physical environment is obvious. Companies must acknowledge these conditions and cooperate with the workforce to either accommodate or change the physical environment. A human factors program must pay attention to both environments. Actions Successful human factors programs carefully analyze all the actions people must perform to complete a job efficiently and safely. There is also the organizational environment that exists within the company. and other key factors. The important factors in an organizational environment are typically related to cooperation. The JTA helps identify what instructions. The second. skills. lighting. mutual respect. communication. in the hangar.25 - . less tangible. and workplace design. and attitudes that are necessary to perform each task in a given job. and shared goals associated with safety. It includes ranges of temperature. There is the physical workplace on the ramp. shared values. Many regulatory authorities require that the JTA serve as the basis for the company‟s general maintenance manual and training plan. environment is the organizational one. and other resources are necessary.Managing Human Factors in Aircraft Maintenance Environment – Physical and Organizational There are at least two environments in aviation maintenance. or in the shop. humidity. profitability. communication. It takes a corporate commitment to address the physical environment. noise control.

26 - . Hawkins developed the concept into the „SHELL Model‟ with an introduction of another Liveware into the original concept. tools. technical manuals. Many resources are tangible. Examples are the number and qualifications of staff to complete a job. Again. Other resources are less tangible. „SHEL Model‟. In general.1 Elements The main elements in the model can be listed as follows: Hardware Various equipments. test equipment.6 The SHELL Model The SHELL Model is defined as “the relationship of human factors and the aviation environment. and others. Environment. supervisors. vendors. which are for organically operation. Environment. such as lifts. 2. Software The Software comprehends all non-physical resources. . the amount of time allocated. In 1975. This concept has originated from the „SHEL Model‟ by Edwards in 1972. Hardware. and Actions dictate the Resources. computers. workspace. the characteristics of the People. and so forth. buildings and other physical resources without human elements in aviation constitute the Hardware. and Liveware). which the name was derived from the initials of its components (Software. aircraft. it is sometimes difficult to separate Resources from the other elements of PEAR. 2. tools. and the level of communication among the crew.Managing Human Factors in Aircraft Maintenance Resources The final PEAR letter is “R” for Resources.6.

6.2 SHELL interfaces L-H System Firstly. in the SHELL Model. crew cooperation and personality interaction and human factors experts have ascertained that. As the Software indicates intangible objects than those of the Hardware. goggles against the effects of altitude. leadership and norms. procedures. for the passenger‟s comfortable flight. Environment The Environment includes not only the factors which influence where people are working such as climate. which is in the centre of the SHELL Model. such as errors within team-work. L-L System Finally. . but also socio-political and economic factors. attitudes. This Liveware is regarded as the core of the SHELL Model and other components match with the Liveware as the central figure. which help overcome obstacles of flight. which is the interaction between the Liveware and Liveware. there is the last interface in the SHELL Model. communication. L-E System The efforts toward the error of this L-E interaction is well shown from flight instruments. like helmet against the noise. cultures and stress.Managing Human Factors in Aircraft Maintenance like organizational policies/rules. is represented as the interaction between the Liveware and Software. This system can be easily explained by an example which aircrafts should provide a great value of services as much as they can. flying suit against the cold. temperature. Liveware The Liveware includes factors like teamwork. 2. This L-L interface is also related to leadership. manuals and placards. vibration and noise. can be defined as human elements such as knowledge.27 - . the interaction between the Liveware and the Hardware (L-H system) is usually named man-machine system. the problems of L-L interaction. it is clear that the error of L-S interaction is more difficult to solve than the error of L-H interaction. L-S System The second interface. had caused a great deal of accidents. Central Liveware The Liveware. such as fitting seat in aircraft.

7 Statement of Research Question Since the dawn of aviation. suggest ways to contain and correct the problem and create a HF error-free environment.Managing Human Factors in Aircraft Maintenance 2. the aviation maintenance community has been constantly motivated to reduce human factor errors and its operational/organizational impact. educate the personnel on their causal potential. Most programs currently implemented are designed to identify the HF errors. While many of these programs have truly made the aviation work environment safer. There is a need for a more integrated and holistic approach to human factor management. .28 - . human factor errors still continue to persist today.

3.1 .1 Survey Population The survey population for this study is 25 People.29 - . Out of the 25 people surveyed 15 were students of aerospace engineering. Survey results were the sole source of data collection for this study.Managing Human Factors in Aircraft Maintenance Chapter 3 Research Methodology 3. Australia and the United States to understand the current state of HFIM and the initiatives currently implemented. The survey was done in complete confidentiality and with the consent of the personnel involved in the survey. The researcher used a survey that will be e-mailed to 25 OO-ALC/YPX Senior National Representatives (SNR) representing close to 18 countries with military ranks ranging from Major to Brigadier General at Hill AFB. The survey was administered to ascertain the effectiveness of human factor management through various programs and initiatives adopted.2 Research Model The researcher has collected a wealth of HFIM data and results from organizations in Asia. The survey demographics are listed in table 3.1 Research Design The research design used for this study was the self-report descriptive research method. A quantitative descriptive approach will be used to collect and assess the data.2. 5 were senior professors and 5 were employees of some aviation organization which they wish to be remained undisclosed. 3.

of Professors No. of Aviation Industry Employees 25 25 100 % 15 5 5 3.2 Source of Data The sources of data was a combination of completed research from organizations such as NTSB. The survey sample for this study was 15 personnel with varied background majors such as maintenance. The survey included questions to determine the engineering field.4 The Data Gathering Device The data gathering device used in this study was a researcher designed survey. FAA.2. administration and contracts. Invaluable feedback was given by the classmates on the researcher‟s use of terms. The researcher consulted the opinion of several renowned HFIM activists and organizations on the details of questions in the survey.30 - .2. Boeing and civil aviation organizations that is available on the internet as well as a data collection device in the form of a survey.3 Pilot Study A pilot survey was presented to the researcher‟s Nanjing University of Aeronautics & Astronautics Bach 2007 classmates. .1 Survey Demography Overall Participation of Personnel Total (R) Total Participants (TP) Participation Rate (%) No. flow of questions in the questionnaire as well as the clarity of certain feedback surveyed. 3. of Students No.2. HFIM awareness and nine questions designed to determine the implementation and effectiveness of HFIM programs. job description (If Any).Managing Human Factors in Aircraft Maintenance Table 3. 3. total length of job experience (If Any).

2.31 - .2 Survey coverage and objectives 3.6 Instrument Reliability This researcher‟s Nanjing University of Aeronautics & Astronautics Bach 2007 classmates conducted a peer review of the HFIM management Survey which gave the researcher good feedback on the reliability of the survey. the . The people surveyed were given one week to review the questions. 3. The researcher also took the opportunity to gather personal feedback from senior officers in some airlines on their experiences with human factor issues.5 Distribution Method The HF survey was written as a word document and e-mailed to the personnel who agreed to be a part of this research. Upon completion of the survey on these personnel. The researcher met with the personnel involved personally prior to sending out the survey so as to notify them of such an effort.Managing Human Factors in Aircraft Maintenance Table 3. The researcher also met with them to go through the survey and clarify each question as required. All responses were collected back by the researcher at a stipulated time.2.

32 - . the researcher consulted several experts in the field of Human Factor management such as those from the University‟s aircraft maintenance department and human resources office. on the survey structure and contents. The researcher then made conclusions and recommendations based on the provided data. 3. The data gathered from the HFIM management surveys were analyzed to determine the effectiveness of HFIM programs. Each question was reviewed to evaluate the relevancy to the purpose.Managing Human Factors in Aircraft Maintenance researcher conducted a stability or test-retest reliability analysis. namely those with only the knowledge of extensive maintenance and no experience in the relevant field and those with only a few years of experience. the researcher was forced to omit some points raised by some classmates using statistical analysis.7 Instrument Validity This researcher‟s Nanjing University of Aeronautics & Astronautics Bach 2007 classmates conducted a peer review of the HFIM management Survey. As the survey population was too small. he reviewed the results of the survey by experience level. . Additionally.8 Treatment of Data and Procedures Because the researcher surveyed two groups of people. and the researcher was able to validate the accuracy of the measurement instrument. 3.2.2. The results of the survey were collected.

Managing Human Factors in Aircraft Maintenance Chapter 4 Results The results of the Human Factor Management Survey carried out from March 2011 to May 2011 can be found below. The responses on the effectiveness of tools and training to manage human factor errors in maintenance were mixed in that 54% thought they were adequate while 45% thought otherwise. Of these countries that have a structured program. . 96% was sampled. Most countries agree that the programs in their organizations have improved human factor error management. The results are broken down to the four parts of the survey questionnaire. or 95. Of the survey population. The survey can be found in Appendix. a good majority.1 Human Factor Programs and Management Of the countries surveyed.6% have a structured Human Factors Maintenance Program. 4.33 - .8% of those surveyed clearly felt that “More needs to be done to manage HFIM Errors”. However. 66. 80% have had it for more than five years.

More than 50% of those surveyed thought that these were the Top two outcomes of safety occurrences in their organization.6 25.1 Most Common Outcomes of Safety Occurrences The most common outcome of HFIM safety occurrences were “System operated unsafely during maintenance”.1 Human Factors Management Survey 4.0 33.0 26. This was followed closely by “Incorrect assembly or orientation of part”.Managing Human Factors in Aircraft Maintenance Table 4.34 - . Table 4.2 Most common Outcomes of Safety Occurrences POS 1 2 3 4 5 6 Outcomes System Operated Unsafely during maintenance Incorrect assembly or orientation of part Part/aircraft damaged during repair Tool lost on aircraft/in maintenance facility Material left of aircraft Injury to personnel % 62.0 .3 29.1.5 50.

Managing Human Factors in Aircraft Maintenance “Pressure” was the top most likely reason for the occurrence of safety violations. Table 4. “Training Effectiveness” and “Organizational Culture” as the top factors that need to be reviewed to better manage human factor errors in maintenance.5 In the opinion of those surveyed.3 54. more than 50% listed the “Attitudes of Personnel”.35 - .0 33.5 50. “Pressure” and “Lack of Training” were the two top reasons for safety violations.3 33.8 41. Table 4.4 Top HFIM drivers that need reviewing POS 1 2 3 4 5 6 Outcomes Attitudes of Personnel Training Effectiveness Organizational Culture Processes Leadership Management of Information % 58.1 50.5 12.0 45.3 25 .6 12.3 Most common reasons for the occurrence of the outcomes POS 1 2 3 4 5 6 Outcomes Pressure Lack of Training Fatigue Supervision Lack of Equipment Environment % 62.

Xavier.Managing Human Factors in Aircraft Maintenance Figure 4.36 - . 17% “strongly agreed” that they had a structured HF program and that the . Figure 4.1 Influence of experience on human factor management survey from A.2 Breakdown of results of those who “strongly agree” that they have a structured HFIM program. 2005 Comparison of the survey answers by experience level revealed very little differences in the answers and agreement levels between the three bands of experience levels surveyed. Of those surveyed.

Also. I think that the lack of pressure and fatigue are special human error producer. Most mistakes are made when technicians get interrupted during their tasks to do other jobs and feel pressure to always get done quickly. 2. Managers and Supervisors need to be more patient when shops get a lot of work. 56% “strongly agreed” that more was needed to be done to improve the HFIM program. 5. Most common outcome is repeat or recurring of present malfunction due to lack of efficient maintenance procedures related to HFIM. 4. Not paying attention to the little details. it‟s the amount and variety of different tasks that causes problems. the air forces have to consider a rest time for technicians just like the rest time valid for crew members. Involvement of leaders and supervisors with the subordinates 4.2 Survey Feedback Several senior professors that were surveyed. The first thing that maintenance leaders/managers and maintainers must believe is in the necessity and help of the HFIM concept.37 - . b. I think generally. To improve or reduce HFIM management/errors you need: b. Personnel should be trained and watched by supervisors to make sure they are gaining an understanding of correct processes and staying to the procedures. had very good comments and feedback during the survey.Managing Human Factors in Aircraft Maintenance program was showing improvements to HF management. Timely sharing of information (incidents/accidents) d. It is hard to do tasks that may be quite complicated when you are always in a rush. in favor of closely following pre-established procedures. The main issue in my opinion is “complacency”. 3. . Personal opinions as to how a job should be done should be eliminated. A lot is due to repeated jobs over and over. The Technicians are usually very good. Some of these comments were: 1. most of whom had been teaching maintenance in the university. 6. Motivation at all levels e. Effective implementation of supervisory training c.

attitudes and motivation) then next comes human sensory factors and physiological factors. The most important is psychological factors (i. As a 16 years aircraft maintenance officer to me the most problematic area for HFIM management in aircraft maintenance are: i. wants .Managing Human Factors in Aircraft Maintenance c.38 - . Norms of the maintenance people ii.e. d. Night shifts (you‟d better check the effectiveness of shifts and their change over consequences in A/C maintenance) .expectations.

ASTB. This is a testament to the focus and attention given by all major aviation agencies such as the FAA. The management survey conducted revealed very consistent findings thus far on the management of HF errors in maintenance. equipment or just the attitude of the personnel or organizational culture.1 Human Factor Management Program It was very comforting to note that many (80%) of the organizations surveyed had implemented a structured human factor program for at least five years now with a good proportion (70. Although aviation operations are high. CAA.0%). the „pressure‟ factor has consistently been the main influencing factor for human factor errors for the last 20 years.Managing Human Factors in Aircraft Maintenance Chapter 5 Discussion While many research studies in the past have been done mainly on airline organizations.8%) of them seeing improvements from these programs. Many people have different eustress levels which are the stress level that allows them to perform optimally.39 - . operational tempo environments. NTSB. and JAA on the need for educating and evaluating aviation maintainers on the nature and detriment of human factors.5%) and “incorrect assembly or orientation of parts” (50. Some of the reasons for “pressure” could be due to lack of training. this research study has also shown consistent results with those studies in the last 20 years. 5. The discussion here is a combination of the study done by the researcher and the comprehensive studies already done by many organizations.0%) and “fatigue” (45. tools. “lack of training” (50. As such. 5.8%) seem to be the clear catalysts for the most common outcomes which are “system operated unsafely during maintenance”(62.5%) .2 Most Common Outcomes of Safety Occurrences The top three common reasons for the occurrence of safety outcomes which are “pressure” (62. . job matching and training needs analysis are vital to ensuring organizations have the right people at the right place at the right job.

These six factors are so varied that one can only conclude that it is clearly the view of those surveyed that there is a need for an extensive review of an organization to eradicate human factor errors.3%).40 - .8%) that they had a structured HF program. as well as personally to me during our discussions that the three main areas they see as contributory to errors occurring in the workplace were: 1. even those with a few years of experience had similar responses to the effectiveness of human factor management and the types of errors it produced. „processes‟. Even those surveyed who “strongly agreed”(20. reaped several significant results such as a 50% reduction in human factor errors and in many others such as these: . leadership and „management of information‟.4 Influence of experience on human factor management The results of the survey shows that the experience level had little or no effect on the views of current human factor management programs.1%) and “organizational culture”(50. the remaining three factors were just as contributory namely.6%). 5. Not following proper procedures These contributory human factors support the results of the most common safety outcomes derived from the survey. after implementing several new initiatives and a performance excellence framework similar to the MBNQA framework.Managing Human Factors in Aircraft Maintenance 5. Distraction 3. These factors are similar to what the “Dirty Dozen” factors by Mr. The Asian study from 1999 to 2003. It was evident in the comments and feedback given by the professors and employees of the aviation organization being surveyed at the end of the survey.0%). that is. and that the program was improving the management of human factor errors. Gordon Dupont warn us to take note of daily in aviation maintenance. “training effectiveness” (54. Complacency 2. felt that “more was needed to be done to manage human actor errors” (56.3 Top HFIM drivers that need reviewing While the top three drivers for human factor errors were “attitudes of personnel”(58.

Analysis was also done by examining whether there were any adverse trends by specific units or by specific group of personnel (years of service).02% = Strongly Agree.01% (51.4.e.4. personnel also agreed that management (96. The top four reasons remained unchanged.2 Safety Quality A good safety and quality culture is due to the many years of strong and continual safety and quality emphasis at the various staff and command levels.4.99% = Agree) of personnel agreed that the organization placed strong emphasis on safety and quality. Similarly.Managing Human Factors in Aircraft Maintenance 5.” “Too much work. “Too much work. The results showed that there was no specific trend.5 Types of Violations The results showed an overall improvement of 4% for the six common types of violations observed everyday and once a week. especially after the 911 accident.4 Percentages The increase in percentages for the top three reasons for violations correlated with the increase in airline schedules.3 Reasons for Violations. whereas “Time pressure to complete task.” “Insufficient manpower” and “Unrealistic requirements from management. coupled with the comprehensive safety and quality programs and initiatives implemented at the various levels as part of the performance excellence framework reviews. 47. 5. “Time pressure to complete task”. from the organization level down to individuals. e. 5. 5. i.4.41 - .38%) also showed strong emphasis and take safety and quality seriously. “Unrealistic requirements from management” registered a 9% drop (35% to 26%).1 Safety Culture This was a new segment of questions that surveyed on the safety and quality culture at the various levels.” Among the top four reasons. 5. too little time” “Insufficient manpower” increased by 10%.6 Frequency of Violations . 5.30%) and personnel (94.4. supervisors (97.43%).g. Results showed that 99. 11% and 5% respectively.4. where more standby requirements were put in place. too little time.

Though it shows that they are committed. e." "Fear of being labeled as lazy” and "Manpower shortage.7 Calling Time-Out The results showed an overall drop of 11% (50% to 39%) in holding back to call time-out.8 Analysis of the Problem Analysis revealed that the length of service played a part in the willingness of personnel to call time-out.Managing Human Factors in Aircraft Maintenance There was an across-the-board reduction in the frequency of violations being observed. 5. These results showed that calling time-out is slowly gaining acceptance." Other reasons include "Pressure from colleagues. particularly. Better (3% improvement) time management of personnel.4. c. A 6% reduction of “Unrealistic requirements from management b." This is not surprising because they are the group who holds the responsibilities to ensure that the work is completed on time.42 - . "Fear of being labeled as lazy" registered a significant drop of 23%. it must not be overdone. Better (3% improvement) co-ordination among multi-trade rectification.4.4. with an across-the-board drop in all the concerns. This effect was indeed reflected by the junior as one of their concerns was "Fear that supervisors are not supporting for calling time-out.9 Over-Time (OT) Management The results showed a 16% reduction in the frequency of OT done weekly. This is most likely contributed by the following: a. Slight improvements were also noted for "Everyday" (5% to 4%) and "Once a week" (9% to 6%).4. 5. 5. or else it would create unnecessary pressure on the junior to hold back on calling time-out when the real need arises." 5." from 21% to 43%. The more senior personnel concerns were "Do not wish to 'let down' supervisors or management" and "Worry for not meeting operations requirements. Lesser (8% lesser) secondary duties. a significant reduction of 100% was noted for "Very Infrequent. A balance must be struck. Lesser (45% improvement) waiting time (<2 hours) between jobs d. f. 11% increase in “Easy way out (taking short cuts)”.10 Open Reporting .

Forty percent of personnel held back from open reporting due to “Uncertainty of what the consequences would be” if they open report. over the years.43 - .Managing Human Factors in Aircraft Maintenance Open reporting is a concept of reporting those minor/major incidents that did not result in damage or anything clearly visible to management or your peers but yet can contribute significantly when shared amongst peers so as to create a culture of sharing and learning. The open reporting concept has. the willingness to open report has improved. Chapter 6 Conclusion and Recommendation . Although there was a 6% drop on “Open reporting is well accepted in the organization” to 84%. encouraged people from reporting mistakes/incidents without the fear of being punished.

the researcher‟s hypothesis for an urgent need for a more holistic and integrated approach to managing human factor errors in maintenance is supported by this study. Figure 6. Without a doubt. that there has to be a transformation. and the downward trends from the Asian study between 1999 and 2003 . they will not succeed in eliminating the “Dirty Dozen” from their organizations.Managing Human Factors in Aircraft Maintenance In summary. be adopted to review the organizations people. in terms of organizational reviews and human factor training. processes and results. The researcher recommends a performance excellence framework. The results from the Asian study from 1999 to 2003 reported in this study.1 Recommendation Based on the results of the survey. like the MBNQA framework.44 - .1 Human Performance X’cellence Model 6. processes and antiquated operational strategies. unless aviation maintenance organizations transform their people. The solutions adopted today. it is recommended that aviation maintenance organizations adopt a human . Many experts believe and this study supports the argument. supports the researcher‟s hypothesis and proposed solution to the problem. have been done in isolation and not as an integrated review of the entire organization.

Organizations that adopt a performance excellence framework should tailor the framework to their needs rather than implement the details of the framework lock-stock and barrel. Figure 6. Measurement. Analysis and Knowledge Management 4. if not eradicate. There are many areas that an organization can focus on but results of surveys in the last 20-30 years suggest that the key areas requiring improvement are: 1. Process Management A major change that is required in these organizations is the reduction in time pressure imposed on their staff to complete maintenance jobs and tasks. Instead.45 - . The key thrust for performance excellence is to establish a culture of continuous improvement and innovation that builds upon a strong foundation of quality. Leadership and Organizational Culture 2.1 Human Performance Excellence Model In order to establish a culture of excellence. the uptrend and spate of avoidable human factor errors in their organizations. always. organizations should fit their systems and processes into the framework and make changes where necessary. organizational reviews cannot be restricted to .Managing Human Factors in Aircraft Maintenance performance excellence model like the MBNQA framework to reduce. Learning and Growth 3. professionalism and team excellence.

How the organization overcomes any difference between the current culture and the desired culture How information needed to drive day to day management and improvements to Measurement. organizations performance is selected and Analysis and managed. + Key performance indicators for Safety must be selected crisis teams to review organization. HFIM relation + Human Factor goals. Table 6. How the organization permeates a culture consistent with its values. + Open reporting. practices and behavior. Leadership And Organizational Culture How the organization translates these values into policies. + Training. targets.46 - . A framework such as the one proposed in the tables that follow. provide the over-arching framework for an organization to review its current health and the issues that require attention to prevent an incident or accident from occurring. Reviews done in isolation underestimate the interdependency of several areas in a complex organization such as the aviation industry. process reviews. Knowledge + Create a database of cases management List key types of information and describe how they are related to organizations performance and incident/accidents and measure its effect such as cost and managed.1 Performance Excellence Framework in relation to HFIM Criteria Objectives How senior executives develop. . rewards. + Surveys. feedback. tools for data collection.Managing Human Factors in Aircraft Maintenance certain areas of the aviation business such as safety and training. + Management view on errors. communicate and demonstrate the purpose. vision and goals for the organization that focus on Safety/Quality.

How the organization evaluates and improves its management of information How comparative and benchmarking information is selected to improve the organizations performance. innovation and the achievement of the organizations goals and objectives. + Accessibility of database and sharing of lessons learnt to prevent a re/occurrence through meetings/forums etc. accessible and disseminated quickly to employees and external parties. Describe the organizations human resource requirements and plans. based on the organizations strategic objectives and plans. staff performance management and recognition.47 - . training and development needs to support its goals and objectives. How the organization ensures information is reliable. rewards. recognition system and constant review based on complexities of tasks. training. innovations efforts to improve + Deployment of personnel based on needs. + Implementation of safety information system. + Benchmark accident statistics and do comparative studies with leading companies. . +Manpower levels with relation to task levels. How the organization implements and reviews its human resource plans. of a HF error etc.Managing Human Factors in Aircraft Maintenance objectives & goals. How the organizations employee performance + Implementation of cross functional/project mgt teams. How the organization identifies and reviews it‟s education. Learning & Growth Mechanism available to encourage employee involvement and commitment to teamwork.

acquire. feedback channel. The organization has a systematic process to +Safety improvements. +Audits/inspections and There are various methods to access the quality and performance of the organization‟s key business processes. Interviews with staff on their needs. management system. processes? The organization has a system to analyze root +Safety Management system Process Management causes. +Committee/program/track follow-up actions. evaluate and implement creative ideas.Managing Human Factors in Aircraft Maintenance and recognition systems support its objectives and goals. task saturation. +Morale of employees.48 - . +Training needs analysis. . to meet specified standards or targets. promotion and rewards. work environment. The organization‟s key processes have clear +Is safety one of the key objectives and targets. take prompt corrective action and that tracks and follow-ups on prevent future occurrence when a process fails safety findings. process changes. and review based on HFIM trends/cases.

. Gordon Dupont. Annex 6. Massachusetts. Part 2. Part 2. United States: FAA. [5]Guidance Material on the UK CAA Interpretation of Part-145 Human factors and error Management Requirements[S]. [8] Human Resource Development and the Use of Results[C]. [9] The dirty dozen[N]. part 1. Nagel Human Factors in Aviation [M].4. Hertz. Canada 1997. Academic Press.Managing Human Factors in Aircraft Maintenance References [1] David C. Waltham. Hertz. part 1. [3] Jensen R.6.49 - . Annex 6. 2004. [2] FAA Human Factors Guide for Aviation Maintenance[S]. 2002. Toronto. [10] Human Resource Development and the Use of Results[C]. Definitions. [7] ICAO HF Training Manual[S]. 1989. 2004. Opening address for the 9th International Symposium on Aviation Psychology[A].3.4. System Safety Services. [6] ICAO HF Training Manual[S]. [4]Guidance Material on the UK CAA Interpretation of Part-145 Human factors and error Management Requirements[S]. Para 1. Para 1.

and most importantly. I could not have imagined having a better advisor and mentor for my Graduation Thesis. My sincere thanks also goes to my fellow classmate and friend Dennis Ochengo for his valuable advice and priceless time on every turn during my research. I wish to thank my parents. To them I dedicate this thesis.50 - . . They bore me.Managing Human Factors in Aircraft Maintenance Acknowledgements First and Foremost. for his patience. taught me. I would like to express my sincere gratitude to my advisor Prof. enthusiasm. and immense knowledge. Lastly. I would like to thank all my fellow Bach mates who gave invaluable information without which this thesis would not have been possible. raised me. motivation. supported me. His guidance helped me in all the time of research and writing of this thesis. and loved me. Cao YuYuan for the continuous support of my Graduation Thesis.

suggest ways to contain and correct the problem.Managing Human Factors in Aircraft Maintenance Appendix HUMAN FACTORS MANAGEMENT SURVEY Name: (Optional) Rank (if any): Years in > 20 years organization : < 10 years None Job Description (if any): Excellent Involved in Maintenance? □ □ Good □ HFIM Awareness Poor □ □ □ Y/N Human Factors (HF) Fact: Global statistics indicate that 80% of aviation accidents are due to human errors with 50% due to maintenance human factor problems. However.51 - . HFIM errors are still on the rise today.2 The training and tools currently available in the aviation organizations are sufficient to manage HFIM? 2. Please mark your response in boxes Strongly agree Strongly disagree 6 5 4 3 2 1 1.2 If yes. Most programs currently implemented are designed to identify the HF errors.1 The HFIM programs currently implemented have improved the management of human factor errors? 2. educate the personnel on their causal potential.3 Is it important to have one? 2. how many years has it been in existence? 1.1 There is a structured Human Factors Program in your Maintenance organization? 1.3 More needs to be done to manage HFIM errors in maintenance? > 10 years years 5-10 years <5 . and create a HF error-free environment. Human Factors Management 2. Human Factors Programs 1.

which of these are the most common outcomes of HFIM safety occurrences? □Incorrect assembly or orientation of part □Injury to personnel □Tool lost on aircraft / in maintenance facility □Part/aircraft damaged during repair □Material left on aircraft □System operated unsafely during maintenance 3.52 - .Managing Human Factors in Aircraft Maintenance 3. Most Common Outcome of Safety Occurrences (check all that apply) 3.3 In your opinion.2 The most likely reason for the occurrence of these outcomes □Pressure □Fatigue □Lack of training □Supervision □Lack of equipment □Environment 3. HFIM errors can be managed better by reviewing it‟s □Leadership □Processes □Management of information □Organizational culture (not just safety) □Attitudes of personnel □Training effectiveness .1 In your opinion.

Managing Human Factors in Aircraft Maintenance 4. Do you have any additional comments or suggestions to improve or reduce HFIM management/errors? Thank You for your valuable input.53 - . .

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