REDA

Investigator Workshop

Maintenance Human Factors

Customers Organization
REDA Presentation Outline
What is REDA
What is an apron system failure
Need for REDA--Safety and monetary costs of
apron system failure
Contributing factors to apron system failures
REDA tool and investigation process
How to implement REDA
Interview techniques
Practice exercises

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What Is REDA?
REDA is a process that is used to investigate the
causes of apron system failures.
Apron system failures are the result of a series of
related contributing factors
Most of the contributing factors are under
management control
Therefore, improvements can be made
Apron operations must be viewed as a system where
the individual worker is one part of the system
Addressing lower level events helps prevent more
serious events
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The Apron System

An apron system is composed of all the

organizations, equipment, facilities,
personnel and information involved in safely
receiving, servicing, maintaining and
dispatching commercial transport aircraft in
the apron environment

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Apron System Failure
An apron system failure results in the inability of the
apron system to meet it’s requirements to safely
receive, service, maintain and dispatch an aircraft in
the required time. An apron system failure may be
the result of:
Human errors
Procedural violations
Other system failures
Organization
Equipment
Facility

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Definitions of Error and
Violation
An error is a human action (behavior) that
unintentionally departs from the expected
action (behavior).

A violation is a human action (behavior)

that intentionally departs from the
expected action (behavior).

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Violations
Violations are often made by well-
intentioned staff trying to finish a job,
not staff who are trying to increase
comfort or reduce their work load.
There are several types of violations
Routine
Situational
Exceptional
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Violation Definitions
Routine—These are “common practice.” Often
occur with such regularity that they are
automatic. Violating this rule has become a
group norm. Often occur when the existing
procedure does not lead to the intended
outcome.

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Violation Definitions (contd.)
Situational—Occur as a result of factors
dictated by the employee’s immediate work
area or environment. Due to such things as…
Time pressure
Lack of supervision
Unavailability of equipment, tools, or parts
Insufficient staff

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Violation Definitions (contd.)
Exceptional—Rare and tend to happen only in
very unusual circumstances, like an
emergency or recovering from equipment
failure. E.g., enter a fuel cell to rescue a
fallen colleague, despite rules that forbid such
a rescue attempt.

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Norms
Definition: Typical behavior in a social group
or organization.
Norms are simply the state of actual conditions
They can be effective or ineffective in the
performance of quality work

Wearing appropriate
Following check lists safety equipment
Tagging connections
and procedures 11
Norms and Job Performance
Effective Norms: Ineffective Norms:
Are a by-product of Develop in part due to
effective communication ineffective communication
within the airline
Reinforce good practices Cause inexperienced
personnel to deviate from
best practices
Increase organizational Reduce organizational
safety and efficiency safety and efficiency

Should become Must be eliminated!

company policy!
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Norms and Violations
It is important to determine if a violation is the
result of normative behavior “every body does
it” because:

Individual behavior – Discipline issue

Normative behavior– Management issue

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Other Types of System Failures
Failures with no associated human error or
procedural violation
Failure to provide required servicing
Failure to service in required time
Failure to perform maintenance task
Failure to perform maintenance tasks in
required time
Failure to receive aircraft at the gate
Failure to push-back
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Results of Apron System Failure
Aircraft damage
Equipment damage
Personal injury
Environmental damage
Schedule interruption

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 Ramp Damage Can Be Expensive for Airlines
Aileron and Tab Assembly $183,545 Outboard Flap
Assembly $255,845

Elevator Assembly
Inboard Flap $264,708
Assembly $224,872
Cargo Door $58,327

Leading Edge Slat

Radome $19,712
Assembly $52,863

Wingtip Assembly
$28,872

Main Entry Door $171,220 Inlet Cowl $329,203

Source: Direct costs provided by Boeing Commercial Airplane Group 16
Damage and Injuries on the Ramp, Study of 182 ASRS Incident Reports
70

13 Other or ambiguous
60
Personnel
50 Other aircraft
8
Ground equipment
40 22
Percentage
of incidents 30

20 22

10 14 16
10
0
Service Jetways Other aircraft Unspecified
vehicles support ground
equipment equipment
Source: Aviation Safety Reporting System
(ASRS), U.S. National Aeronautics and
Space Administration
Percentage of damage
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Personnel Injury: Where To Focus
Efforts Fire
Slide deployed
2
2
No. of fatalities
% of all injuries
Airplane to facility or jetway 2
Person to airplane 2
3
Airplane to vehicle 5
2
Landing gear or pushback 15
1
Jet blast 13
3
Fall 13
Cargo doors 12
2
Elevator: Lower or upper deck 8
Airplane to person 8
Lightning 1
7
Vehicle to airplane 1
7
3
Vehicle to person 7
0 2 4 6 8 10 12 14 16

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Ground Safety Costs Vary Among Airlines
Ground Safety Cost per Year
Airline A fleet 500 + $50 million
Airline B fleet 500 + $30 million
Airline C fleet 350 + $11 million
Airline D fleet 250 + $23 million
Airline E fleet 200 + $70 million
Airline F fleet 100 + $60 million
Airline G fleet 50 + $1 million

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 FOD Costs the Airline Industry Huge Amounts of Money
Examples of direct costs of a foreign object damage incident:
$776,000 $1,000,000
Duck and geese strike airplane Wrench left in engine

$610,000 $279,000
Bolts drop off ground Beverage can left
support equipment by servicing truck

$310,000 $574,000
Loose baggage wheel Runway and construction debris
FOD: Foreign object damage 20
REDA Apron System Failure Model
Probability Probability

Contributing Lead
System Leads
to Failure to
Event
Factors
• Aircraft damage
• Equipment damage
• Environmental
impact event
• Personal injury

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Errors and Violations
Errors have been the focus of research, so we
have more theories of why errors occur than
theories of why violations occur.
However, errors and violations often occur
together to produce an unwanted outcome. Data
from the U.S. Navy suggest that
• 60%-80% of unwanted outcomes are caused
by an error and a violation and
• Only 20%-40% are due to “pure” error.

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REDA Error Model
Probability Probability
CF

CF Error Event
CF

Experience has shown that

there is an average of 3 to 4
contributing factors to each error.

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Error and Violation Model 1
Probability Probability Probability

Contributing
Factors Violation Error Event

• Mechanic does not use a torque wrench (violation),

• which contributes to an incorrect installation (error) because
of an under torqued bolt.
• This leads to an in-flight shutdown (event).
• There are reasons why (contributing factors) the violation
occurred (e.g., torque wrench not available in time to do task
or work group norm is not to use a torque wrench).
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 Error and Violation Model 2
Probability Probability

Contributing
Factors Error Event

Contributing
Factors Violation
• The mechanic decides not to carry out the operational check (violation),
which leads to an incomplete installation (error).
• thereby missing the fact that the task was not done correctly.
• The mechanic mistakenly misses a step in the maintenance manual
(contributing factor),
• Because an error was made and this was not caught by the operational
check, an in-flight shutdown (event) occurs.
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 Combined Error and Violation Model
Probability Probability Probability

Contributing
Factors Violation Error Event

Contributing
Factors Violation

• The mechanic does not use a torque wrench (violation)

• which leads to an incomplete installation (error).
• The mechanic decides to skip the operational check (violation),
thereby missing the fact that the task was not done correctly.
• Because an error was made and this was not caught by the
operational
check, an in-flight shutdown (event) occurs 26
 Final Error and Violation Model

Probability CF Probability

CF CF
Probability
CF CF CF

Contributing
Factors
Violation Error Event

CF CF Contributing
Factors Violation

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Contributing Factors to Worker Performance
Anything that affects how a ramp worker does his/her job
can be a contributing factor to system failure.

Immediate Environment Supervision Organization

Facilities Planning Philosophy
Weather Organizing Other Airline
Aircraft design/configuration Prioritizing Organizations
Ramp Worker Equipment/tools/parts Delegating Policies
Knowledge Operators manuals Instructing Procedures
Skills Tasks Feedback Processes
Abilities Time pressure Performance Selection
Other characteristics Teamwork Management Training
On-the-Job training Team Continuous
Communication Building Quality
Improvement

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REDA Results Form
General Information
Events
Failure Type
Contributing Factors
Error Prevention Strategies

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Results Form - General Information

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Results Form - Events

Aircraft damage Personal injury

Equipment damage Environmental
Impact
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Results Form – Apron System
Failures

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Results Form - Contributing Factors
Information Individual Factors
Equipment/Tools Environment/Facilities
Airplane Design/ Organizational Factors
Configuration/Parts
Job/Task Leadership/Supervision
Technical Communication
Knowledge/ Skills

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Information
Defined as written or computerized
source material
For information to be a contributing
factor it could, for example, be . . .
Hard to read or understand
Unavailable
Contain mistakes
Not used
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Equipment / Tools / Safety Equipment
For equipment and tools to be a
contributing factor it could, for example,
be...
Unsafe
Mis-labeled
Unavailable
Not used

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Aircraft Design / Configuration / Parts
For aircraft design, configuration, or parts
to be a contributing factor it could, for
example, be...
Inaccessible--part is difficult to reach
Part is poorly marked
Part is hard to see
Part unavailable

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Job / Task
For the job or task to be a contributing
factor it could, for example, be...
Repetitive / monotonous
Complex / confusing
New task or task changed
Different from other similar tasks

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Technical Knowledge / Skills
For technical knowledge or skills to be a
contributing factor it could, for example, be...
Lack of skill
Lack of technical knowledge
– Ramp organization process
– Aircraft configuration
– Job / task
Task planning on the part of the worker

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Individual Factors
For individual factors to contribute it could, for
example, be…
Physical health issues
– Senses (eyesight, hearing, etc.)
– Physical conditions/illnesses
Fatigue
Time constraints
Peer pressure
Body size and strength
Personal events
Workplace distractions
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Environment / Facilities
For environment to contribute it could, for
example, be...
Noise
Temperature
Weather
For facilities to contribute it could, for
example, be...
Lighting
Hazards
Air quality
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Organizational Factors
For organizational factors to contribute it could,
for example, be...
Quality of support from other departments
Company work processes
• Does not achieve the desired result
• Not followed
• Not documented
• Normal practice (norm) not to follow
process/procedure

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Leadership / Supervision
For leadership or supervision to contribute it
could, for example, be...
Inadequate planning/organizing work
Inadequate prioritization of work
Poor delegation of work
Unrealistic belief about how long it takes to
do a task
Too little supervision

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Communication
Communication is defined as written or verbal
communication
For communication to contribute it could be
inadequate communication between . . .
Departments
Workers
Shifts
Workers / lead
Lead / management
Flight crew / ramp personnel

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Results Form - Contributing Factors

Must describe how factor contributes to error

N/A = Not applicable

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Keep Digging for Details
If relevant to the investigation, find out what
contributed to a contributing factor
Example—Person says that he did not use wing
walkers while guiding aircraft during arrival at
jetway. Find out why…
• Not available (find out why)
– The shift was short handed because of multiple illnesses
– Aircraft arrived early and personnel were at another gate at
the time
• Decided not to use (find out why)
– Had done the task a lot, so did not think he needed them

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Causation
When filling out the REDA Results Form,
the investigator must indicate how the
factor contributed to the Failure.
To do this, we need to discuss some
issues (rules) about causation.

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Bias in Making Causal Judgments
Attribution Theory from Social Psychology
When I make an error, I attribute my making
the error to (external) contributing factors
When you make an error, I attribute your
making the error to factors internal to the
person (e.g., lazy, complacent, or careless)
As an event investigator, you must
overcome this attribution bias.
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Other Biases
Experience/knowledge Representative causes
Severity effects Hedonistic relevance
Locus of control Counterfactual variation
Temporal contiguity Covariation
Spatial contiguity Discounting/augmenting
Perceptually salient Historical attribution
stimuli

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Levels of Causation
Cause-in-Fact: If “A” exists (occurred),
then “B” will occur.
Probabilistic: If “A” exists (occurred),
then the likelihood of “B” increases.

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Rule of Causation 1
Each human error much have a preceding
cause/contributing factor.
Rule Not Applied—”Aircraft was damaged as a
result of being struck by baggage cart
Rule Applied—” Aircraft was damaged as a
result of being struck by baggage cart.
Worker received no training on driving a tug ,
increasing the probability of error. Worker
was fatigued after 12 hours of work,
increasing the probability of error.”
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Rule of Causation 2
Causal statements must clearly show the
“cause and effect” relationship.
Rule Not Applied—”Because it was very hot out,
the worker made an error.”
Rule Applied—”Because it was very hot out, the
worker wanted to get back into the air
conditioned facility as soon as possible.
Therefore, he worked more quickly than usual,
which increased the probability of an error.”
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Rule of Causation 3
Negative descriptors (such as “poorly” or
“inadequate” may not be used in causal
statements.
Rule Not Applied—”Worker exercised poor
judgment in proceeding without supplemental
lighting.”
Rule Applied—”Technician did not use the
supplemental lighting that was available,
which increased the probability of hitting the
aircraft with the baggage cart.”
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Rule of Causation 4
Each procedural deviation must have a
preceding cause.
Rule Not Applied—”Worker did not use wing
walkers during pushback as required by the
ramp procedures manual.”
Rule Applied—”Worker believed that if he
kept the nose wheel on the yellow line there
was no risk of collision.”

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Rule of Causation 5
Failure to act is only causal when there is a
pre-existing duty to act.
Rule Not Applied—”If the worker had been
more careful where he parked the truck the
aircraft would not have hit it.”
Rule Applied—”The worker did not park the
truck in the marked off safe parking area and
the aircraft hit it while taxing into the jetway.”

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Results Form – Failed Barriers
A.What current existing procedures, processes, and/or policies in your organization are intended to prevent the
incident but didn’t?
Apron Operation Policies or Processes (specify) _________________________________________________
Maintenance Policies or Procedures (specify) ___________________________________________________
Inspection, Functional Check or Safety Check (specify)___________________________________________
Required Maintenance documentation _________________________________________________________
( ) Maintenance Manuals (specify) ____________________________________________________________
( ) Logbooks (specify)______________________________________________________________________
( ) Work cards (specify) ____________________________________________________________________
( ) Engineering documents (specify) __________________________________________________________
( ) Other (specify) _________________________________________________________________________
Required Apron Operation Documentation ______________________________________________________
Supporting Documentation ___________________________________________________________________
( ) Training materials (specify) _______________________________________________________________
( ) All operator letters (specify) _______________________________________________________________
( ) Inter-company bulletins (specify) ___________________________________________________________
( ) Other (specify) _________________________________________________________________________

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Results Form - Improvement Strategies

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Examples of Error Management Ideas
Error reduction / elimination:
Make it easier for the mechanic to do the task
correctly
• Simplified English procedures
• Replace worn non-slip pads

Error capturing:
Tasks added to find a mistake
• Inspection or functional check

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Examples of Error Management Ideas
Error tolerance:
Doing maintenance tasks so that the aircraft
is functional after a maintenance error
• Not doing the same maintenance tasks on both
engines on an aircraft

Error audit:
Quality surveys and special audit programs

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Current Error Investigation Process

Event
Event Caused by Find Who Punish
Occurs Ramp Made Error Worker
Error

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REDA Process
Event Investigation Finds Find Who
Occurs Event Caused by Was involved
Apron System Failure

Interview Apron Staff Follow-up to

• Find Contributing Factors Obtain Additional Add to
• Get Ideas for Process Contributing Factors Apron Event
and Information Data Base
Improvement

Make Process Improvements Provide Information

• Based on This Event to All Employees Affected
• Based on Analysis of Data By Process Improvements
for Multiple Events

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Things that Affect REDA Use
Organizational culture
Management fails to put REDA process in
place
History of punishment for errors
National culture
Country Aviation Authority
Investigation process already in place

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Steps to Implement REDA
1. Pick a manager to be responsible for
REDA
2. Assign a department to establish and
coordinate REDA
3. If needed, develop & use a new
discipline policy
4. Pick the events that will be investigated

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Steps to Implement REDA
5. Pick people to be on the investigation
team
6. Inform staff about the REDA process
7. Set up a management team to review
ideas for improvement

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Steps to Implement REDA
8. Begin REDA investigations
9. Follow investigations and make sure ideas
for improvement are put in place
10. Tell Boeing when its aircraft design or
support products contribute to apron
system failures
11. Tell staff about investigation results and
improvements

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REDA Overview Summary
Apron system failures affect safety and
are costly
REDA philosophy is . . .
System failures are due to contributing
factors
Future failure can be reduced by making
improvements to the apron operations
REDA is a process that can be used to
investigate apron system failures

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Interview Techniques
REDA Interview
1. Get as much information as possible
about the error and the event before the
interview.
2. Interview people separately if more than
one person is involved.
Important to keep people from influencing
each other’s memories
If there are significant differences of
opinion, follow-up interviews may be needed
67
REDA Interview (continued)
3. Interview in an appropriate place
Pick a neutral location like a private room
or a quiet corner
Try not to interview in a supervisor’s
office sitting behind the desk

68
REDA Interview (continued)
4. Put the person at ease
Put yourself in their place
Act relaxed
Use a neutral tone of voice
Have eyes at the same level
Use neutral body language
Make eye contact
Respond in a positive manner

69
REDA Interview (continued)
5. Determine their knowledge of the REDA
process
If they know about REDA, quickly summarize the
main points of the REDA process
If they do not know about REDA, take some time
to explain what REDA is about
If they ask about discipline, tell them that you
are not involved in discipline decisions. Your job
is to understand why the error occurred.

70
REDA Interview (continued)
6. Get the person’s view of what happened
Start the interview with, “Would you please tell me
about what was happening before and during the
time leading to the error.”
Do not interrupt unless the person gets off of the
subject
Make notes (do not use tape recorders) on the
REDA Results Form about contributing factors
Then ask for more detailed information about the
contributing factors that they mentioned
Review the contributing factors that were not
mentioned
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REDA Interview (continued)
6. Get the person’s view of what
happened (continued)
Avoid asking questions…
• That lead the person
• That put the person on the defensive
• That can be answered with a simple “yes” or
“no”—use open-ended questions
Do not make statements of judgment—
stick to the facts.

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REDA Interview (continued)
7. Give the person some feedback on
what they said
Paraphrase—Put key points in your own
words and repeat them. Say, “I think I
heard you say that…”
• Assures that you understood what was said
• Gives the person a chance to correct a detail
• Shows active listening.

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REDA Interview (continued)
8. End on a positive note
Ask the person for ideas on how to
improve the contributing factors that led
to the error
Thank them for their time
Commit to give them feedback

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Practice Exercises