HUMAN FACTORS IN

MAINTENANCE

LESSON 1

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GENERAL/INTRODUCTION
Although aviation is the safest means of transportation, the
aerospace industry cannot take aircraft safety for granted.
Within any safety critical industry such as an aerospace,
where human beings play a central role, it is of paramount
importance that the ‘right first time’ approach is applied.
For any technician involved in the manufacture or
maintenance of an aircraft or its components, it is essential
that they have an understanding of how human factors can
impact on their daily routines.
This subject seeks to cover the many performance-
influencing factors that can inhibit a technician, both from an
organisational and personal perspective.

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GENERAL / INTRODUCTION
Many people in the aviation industry wonder why Human Factors
training is seen as being a vital element in their overall training
syllabus. The answer is very simple. We kill people.
Anybody who has any connection with the aviation industry –
whether it be flight crew, engineers, baggage handlers, stores
people, admin staff - all play a vital part in flight safety. We all have
the potential to make mistakes which can ultimately lead to an
aircraft accident.
By understanding how mistakes are made and how they can be
avoided, we can go a long way to reducing the number of accidents.

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GENERAL / INTRODUCTION
To gain this understanding, we must know a little of how the human
body works, how the brain processes information received, a little
psychology, how we interact with others through effective
communication and then learn the types of human error and ways
of avoiding these errors.
All elements within aviation must work together to achieve the
ultimate goal – safe and efficient flight operations, to minimise
accidents and incidents and when these do happen, to investigate
the causes (including the underlying hidden causes) and put in
place procedures to minimise the risk of the accident or incident
happening again.

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 THE NEED TO TAKE HUMAN FACTORS INTO ACCOUNT

• Where human beings are involved in work the possibility of error

is always present. This factor must be recognised and dealt with
in aircraft operation and maintenance by every person who
contributes to airworthiness and safety.
• As aircraft design improved the need to address the human
factor element has become more important.
• Recent statistics show that about 70-80% of aviation accidents
are caused by human error, the pilot error problem having a
higher profile.

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FUTURE PREDICTIONS
The world wide commercial aviation major accident rate has
been nearly constant over the past two decades.
While the rate is low, increasing traffic over the years has
resulted in the absolute number of accidents also to
increase.
It is expected for air travel to increase over the coming
decades, doubling by 2017.
Without improvement in the accident rate such volume in
traffic would lead to 50 or more major accidents a year.

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AIRCRAFT MAINTENANCE

The Human Factor course and notes cover the Module 13 of

BCARs section L and JAR 66 Module 9 requirements to make
Aircraft Maintenance Engineers aware of the possible dangers in
aircraft maintenance due to their own performance and others.
To be aware of conditions that increase the possibility of human
error and identifying ways of reducing errors, develop a positive,
professional approach in the training of ab-initio aircraft
engineers and perhaps develop a new awareness and culture
change in the mature student.
It is a requirement of EASA PART 145:35 that human factors is
part of continuation training whilst working in an approved
maintenance organisation.
In addition to these training notes, reference notes should be
made to the UK CAA Human Factors Handbook, issue dated 8
August 2000, CAP, 715, CAP 716 and CAP 718.

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“Principles which apply to aeronautical design, certification,
DEFINITION-HUMANFACTORSPRINCIPLES

training and operations and which seek safe interface

between the human and other system components by proper
consideration to human performance.”
(CAA) Aircraft Maintenance Standard Department

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INCIDENTS ATTRIBUTABLE TO HUMAN FACTORS /
HUMAN ERROR

Maintenance errors are not some new phenomenon, but with

the advent of more reliable aircraft, and human factor
training for aircrew, the maintenance component as the
cause of an aircraft accident has become more noticeable.

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ACCIDENTS/INCIDENTS
APRIL 28TH 1988 ALOHA AIRLINES B737

The first prominent and major investigation in recent times to

cite engineering maintenance and human factors was the
accident to the Aloha Airlines Boeing 737 in which the top of
the forward cabin came away in flight.
Flight 243 was en route from Hilo to Honolulu at 24,000 ft
with 95 passengers and crew, when an explosive
decompression occurred causing the crown of the forward
fuselage to break away.

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A stewardess was sucked out and never found and there were seven
serious injuries, but because the passengers were belted in, there were
no other fatalities.
The investigation determined that the probable cause was the failure of
the maintenance programme to detect significant disbonding and
fatigue damage of the fuselage lap joints.
Repeated inspections had failed to observe some quite obvious
corrosion around the rivets forming the fuselage lap joints. Eventually
the lap joints failed due to multiple site initiated damage.

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10TH JUNE 1990 BRITISH AIRWAYS FLIGHT
5390
During the climb to cruising altitude and while passing through
17,300 feet, there was an explosive decompression caused by
the release of the left hand windscreen.
The Commander, who had released his shoulder harness and
loosened his lap strap, was partially sucked out of the
windscreen aperture and the flight deck door was blown on to
the flight deck where it lay across the centre console. A steward
had managed to grasp the Commander by his waist to prevent
him being completely pulled out of the aircraft, and was assisted
by another steward to hold the Captain throughout the remaining
flight.
The co-pilot regained control of the aircraft and initiated a rapid
descent. In spite of difficulty with radio communications due to
wind noise, he managed to obtain vectors to Southampton and
made a visual approach to runway 02 and a successful landing.
The Captain was pulled back into the aircraft and taken to
hospital where he was found to have suffered a broken right arm
and frostbite.

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The windscreen of the aircraft was found near Cholsey, Oxfordshire. Of
the 90 bolts retaining it, one had remained in the airframe and 29 were
found in the windscreen or nearby. The windscreen had been replaced on
the previous night shift. The report made the following findings, amongst
others:
‘The left windscreen had been replaced and the task certificated by the
Shift Maintenance Manager with the appropriate company authorisation 27
hours before the accident flight and the aircraft had not flown since its
replacement.’
‘The replacement windscreen had been installed with 84 bolts (A211-8C)
whose diameter were approximately 0.026 of an inch below the diameters
of the specified bolts (A211-8D) and 6 bolts (A211-7D) which were of the
correct diameter, but 0.1 of an inch too short.’
The cockpit window blow out in the opinion of Gordon Dupont (System
Safety Services, Canada) was the very first human factors investigation
which looked beyond the man to find ‘why’ he had committed the error.
The report found the contributing factors that lead to the person making
the error and an effort was made to determine how a simple error could be
made by a very experienced person.

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26TH AUGUST 1993 AIRBUS A320
An Airbus A320 registration KMAM commenced its takeoff roll from
London’s Gatwick Airport, with 185 passengers and 7 crew on
board, with the co-pilot handling.
The aircraft was configured for a FLAP 1+F (Slats 18, flaps 10)
takeoff and was at a weight of 66,803kg. MTOW is approximately
75,500kg. Immediately after rotation the handling pilot noticed a
marked roll to the right despite the application of almost full left
sidestick. Suspecting a sidestick failure the handling pilot handed
over control of the aircraft to the Captain, who confirmed the roll
problem.
The takeoff was continued but the aircraft was unable to turn left,
and unable to comply with its ATC departure clearance. ATC were
advised of the problem and the aircraft was vectored to return to
Gatwick. During the approach, as FLAP 2 (22 slat, 15 flap) was
selected the Captain was unable to maintain the runway heading and
initiated a go-around. ATC then vectored the aircraft for a second
approach making right turns, and the Captain flew this approach
using FLAP 1 (18 slat, 0 flap) configuration.

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This approach was successful and the aircraft landed safely at 16:07 hours.
As the aircraft taxied in several spoilers on the right wing were noted to be
partly extended. The aircraft was examined by two engineers who found
four of the five right hand spoilers to be selected to Maintenance Mode,
leaving them free to move under aerodynamic loads and isolated from the
hydraulic systems. The spoilers were set to Operation Mode and function
checked satisfactorily. The aircraft then departed without further incident.
When the AAIB became aware of the incident it became apparent that this
was the first flight following an overnight change of the right hand outboard
flap section, which required the isolation of the four spoilers found in
Maintenance Mode. It also became clear that, had the aircraft taken off in
FLAP 3 takeoff, the remaining roll authority would not have been sufficient
to overcome the adverse roll moment from the free-floating spoilers.

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MURPHY’S LAW
If anything can be done incorrectly then someone will do it
incorrectly. If there is task that can be performed incorrectly
then someone will do it that way. Even the best motivated
enthusiastic engineer may fall foul of Murphy’s Law. We must
always be on guard against it to minimise these possible
errors, then accidents can be reduced.
It is wrong to think that accidents can be eliminated altogether.
It would be a nice idea to think that this is possible, but life is
not like that. With the safest of procedures carried out in the
strictest way there is always the possibility of an accident.
However the right person, correctly trained, with the right
attitude, correct equipment and working within a framework
dedicated to safe practices accidents can be reduced
dramatically.

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Consider a bolt with seven nuts and washers labelled and assembled as in the
figure above.
How many times can it be assembled incorrectly?
How many times can it be assembled correctly as shown?
The bolt, nuts and washers can only be assembled correctly one way.
However, they can be assembled incorrectly many different ways, which shows
how much more likely it is for components to be incorrectly assembled than
correctly.
This exercise illustrates Murphy’s Law. One of the major causes of human
error in maintenance is the incorrect installation or omission of aircraft parts
and components.
Accidents can occur because of one error or may be the result of several quite

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unrelated errors.
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