Human Error In Aircraft Maintenance

Dirty Dozen

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The Best People Can Make the Worst Mistakes

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The Dirty Dozen
 Communication  Lack of Resource
 Complacency  Pressure
 Lack of Knowledge  Assertiveness
 Distraction  Stress
 Teamwork  Lack of Awareness
 Fatigue  Norms

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The Dirty Dozen

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 Continental Express, 14 Fatalities, 9-11-91

Inspector’s turnover form

“helped the mechanic remove the de-ice boots”

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 Continental Express, 14 Fatalities, 9-11-91

Safety Nets
Use logbooks, worksheets etc. to communicate and remove doubt

Discuss work to be done or what has been completed

Never assume anything.

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Italian Air Force, Keflavik
 No lineman present for start-up
 Crew asked LM to verify battery door closed

(near left landing gear) after engines were

started
 LM walked thru prop, killing him instantly
 First such case in Italian AF in over 50 years

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DOOR Loadmaster exits crew door to check battery door
Engines were running

CREW DOOR

BATT. DOOR

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Loadmaster killed as he walks into prop.
Body and remains scattered over 100 feet.

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Accident cleanup by “Fire Department”

Carelessness and over confidence are more

dangerous than deliberately accepted risk.
-Wilbur Wright, 1901.
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 Therefore the Safety Board concludes
that a low expectation of finding a
crackin a –219 series fan hub might
have caused the inspector to overlook
or minimize the significance of an
indication.

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Safety Nets

Face Reality

Physical Fitness

Create Challenges for yourself

Train yourself to expect to find a fault

Never sign for anything you didn’t do

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Lack of Knowledge

 Engineer conduct taxi without training and

authorization
 Only number 2 and 4 engine running
 Brake system in engine number 1
 Steering system in engine number 3
sokhib al rokhman 18
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Lack of Teamwork

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Fatigue
 ACUTE FATIGUE
◦ Produced by physical exertion or sleep loss
◦ Alleviated by a single rest period

 CHRONIC FATIGUE
◦ Medical or psychological problem
◦ Depression or “chronic fatigue syndrome”

 OPERATIONAL FATIGUE
◦ Most commonly seen after 3-4 days of heavy tasking
◦ Not relieved by a single sleep perio d.

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SYMPTOMS OF FATIGUE

 Attention reduced
 Memory diminished
 Mood becomes withdrawn
 Low situational awareness
 Long hours of labor (any type)
 High intensity stress.

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The youngest pilot flown with her
instructor and her father

1996
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  FATIGUE
 STRESS
 COMPLACENCY
 COMMUNICATION
 AWARENESS
 DISTRACTION
 LACK OF KNOWLEDGE
 TEAMWORK
 LACK OF RESOURCES
 PRESSURE
 LACK OF ASSERTIVENESS
 NORMS

Marvin, Ernest Borgnine, Jim Brown, Charles Bronson, John Cassavetes, TriniLopez,
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TellySavalas, Donald Sutherland, Clint Walker sokhib al rokhman
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