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Maintenance Human Federal Aviation
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Welcome
Human Factors in Aviation Maintenance Federal Aviation 2

Administration
Presentation Plans
• Speak in straightforward terms
• Reinforce your current knowledge
• Offer new concepts and/or new ways to explain old

concepts
• Provide links for more information
• Have a few laughs?

Administration
Presentation Content
1. What is human factors?
2. History of human factors
3. Human factors spectacles
4. The PEAR model
5. Human error
6. Maintenance accidents
7. Where to get information
8. Summary

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1 What is Human Factors?

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What is Human Factors?
This section shall:
• Define human factors as it relates to

maintenance
• Show specific examples of maintenance

human factors
• Show why the topic is important to you

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List “Human Factors” Related to
Maintenance

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What is Human Factors?
• Designing workplaces, tools,
procedures, and policies so people
can use them easily and safely
• Primary concern is for people in the

organization
• Combines elements from many

disciplines
• Critical to the overall flight safety

and personal safety

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Human Factors Goal — A Summary
Ensure continuing safety and efficiency by paying

attention to issues that affect human performance.

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The Elements of Human Factors

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Clinical Psychology
• Personality types
• Relating to other people
• Dealing with stress
• Coping mechanisms
• Self image
• Accepting criticism

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Anthropometrics
• Study of human body part
sizes
• Can the user reach controls?
• Ability to access aircraft parts

and systems
• Designing for extremes, i.e.,

smallest female and largest
male
• No such thing as the “average”

person

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Experimental Psychology
• Reinforcing desired behavior
• Observations in the workplace
• Statistical analysis
• Effects of stress on behavior
• Controlled studies of the effects

of work policies and procedures

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Computer Science
• Human-computer interaction
• User interface design
• Requirements analysis for

software-based tools and test
equipment
• Accommodation for range of

computer literacy

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Cognitive Science
• The “mental” parts of

perception
• Problem solving ability
• Things that affect

troubleshooting performance
• Effects of stress on mental

processing

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Safety Engineering
• Industrial safety
• Slips, trips, and falls
• Materials handling, e.g., lifting
• Toxic materials storage and

use
• Facility design and safety
• Warnings

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Medical Science
• Skeletal and muscular structure
• Biomechanics
• Physical structure of perceptual

elements, e.g., eyes
• Work physiology, e.g., heat

generation and dissipation
• Fatigue effects

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Organizational Psychology
• Organizational structure
• Rewards and compensation
• Motivation
• Work teams and groups
• Union/management relations
• Equitable treatment

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Educational Psychology
• Principles of learning
• Ways to help people to

remember
• Design of instruction

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Industrial Engineering
• Organized approach to the
study of work
• Setting reasonable work

standards
• Making work tasks efficient
• Statistical analysis of work

performance
• Efficient facility layout

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Human Factors Goal for Review
Ensure continuing safety and efficiency by paying

attention to issues that affect human performance.

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2 History of Human Factors

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The History of Human Factors
• Early military work on designing
weapons and uniforms
• Time and motion studies (Frank

and Lillian Gilbreth)
• World War II aircraft cockpit

controls and displays
• Establishment of Human Factors

Society (1957)
• Military systems and

consumer products

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Maintenance Human Factors has
Evolved in 20 Years!

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Human Factors Timeline

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Human Factors and Ergonomics Society
and International Ergonomics Association
Human Factors and Ergonomics
Society
• Established in 1957
• 5,000 members +/-
• 50/50, psychology/engineering
• In 49 states and 42 countries
International Ergonomics Association

• Established 1959
• 42 federated societies

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3 Human Factors Spectacles

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Put on your “Human Factors
Spectacles”
• Examples of the human factors
perspective
• You can see human performance

issues if you look
• The remainder of this presentation

will show you what to look for
• Look at others
• Look at yourself
• Look at the environment that

surrounds you

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Put on your “Human Factors
Spectacles”
• Sensitivity to human factors
• Knowledge of how human factors affect work and

safety
• Objectively examine your world
• Be willing to make suggestions and comments

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What did you Learn about Human Factors
Spectacles from the Introductory Video?
What was the premise of the human factors spectacles video?
List 10 things that you see while driving with your human factors spectacles
List 10 things that you see in this class with your human factors spectacles
List 10 things that you see at work with your human factors spectacles
List 11 things that you see at home with the human factors spectacles?
List ……. in the mirror?

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A Reminder to Apply Human Factors
Principles 24 x 7

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4 The PEAR Model

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Why Use Models?
• Models make it easier

to understand complex
things
• Easy to remember
• Models can be 2-D, 3-

D, or mental

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The SHELL Model
• Originally used for

pilot’s crew resource
management (CRM)
• Has served human

factors training well –
worldwide
• A bit abstract

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The SHELL Model Explained
• S includes all
documentation
• H is physical stuff, like

tools and equipment
• E is for the physical

and social environment
• L-1 is for individuals
• L-2 is for groups

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The PEAR Model
• PEAR is easy to remember
• It works for maintenance
• It is matched with the SHELL

model

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PEAR
• People who perform the job
• Organizational and physical environment
• Actions (tasks) performed as part of the job
• Tools, procedures, and other resources

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People
Physical Psychological
• Size • Experience
• Gender • Knowledge
• Age • Training
• Strength • Attitude
• The five senses • Emotional state
Physiological Psychosocial
• Health • Interpersonal relations
• Nutrition • Ability to communicate
• Lifestyle • Empathy
• Alertness/fatigue • Leadership
• Chemical dependency

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People — Fatigue
Let’s review one • Alertness/fatigue • Leadership

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What Does This Mean?
• We live in
24x7x365 world
• Aviation does not

rest
• Humans need rest!

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Overview of Fatigue

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Timing is Everything?
Presentation
Time!!
Is best when people

and presenters are
alert!

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Types of Fatigue — Acute Fatigue
Acute Fatigue
Intense
Short duration
Cured with a good night’s
sleep
Chronic Fatigue (harder to fix)

•Frequent recurrence
•Long duration
•Slow recovery
•Often a physical
sickness or mental stress
causing chronic fatigue

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Types of Fatigue — Chronic Fatigue
Acute Fatigue
Intense
Short duration
Cured with a good night’s
sleep
Chronic Fatigue (harder to fix)

•Frequent recurrence
•Long duration
•Slow recovery
•Often a physical
sickness or mental stress
causing chronic fatigue

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Fatigue and Proper Rest
• Get your 8 hours of sleep
• Proper sleep conditions
• Nutrition
• Exercise
• Hydration
• Moderate caffeine

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An Excellent Website About Sleep

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Avoiding Error When Fatigued
• Fatigue is a human condition
• When you are very tired you

will not admit it (like a tired
child)
• Acknowledge fatigue and tell

co-workers
• Try to remain active
• Talk to others
• Use caffeine in moderation

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Promoting Alertness at Work
• Arrive fit for duty (rested)
• Move around, take breaks
• Alert co-workers if fatigued
• Have some caffeine
• Do boring tasks early, if possible

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Charles Lindbergh and Fatigue

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People — Size — Anthropometrics
Let’s review one • Size • Experience

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Anthropometry
The Study of Body Measurement
• User populations
• Why it’s important
• Male/female split
• Individual variation
• Use of “percentiles”
• The myth of the 50th percentile

person
• 5th through 95th percentile

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Anthropometry Percentiles

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People — Vision and Hearing
The Five Senses • The five senses • Emotional state

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People — Vision and Hearing
• European Aviation Safety Agency (EASA) requires an
understanding of the eye, the ear, and the nose
• FAA places more emphasis on protection
• The following slides show EASA-level details

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People — Vision
• This animation reviews the

parts of the eye and how
they function
• Wear your safety glasses
• Have a regular eye exam

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People — Hearing
• This animation reviews the

parts of the ear and how
they function
• Wear hearing protection
• Have an audio check-up

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People — Taste / Touch / Smell
Sensors in the skin

perceive temperature,
pressure, and other tactile
information

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How to Remember the Five Senses
When you toast you:
See
Smell
Taste
Feel
Hear

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Sensing Versus Perception
Human Senses
Human Factors
Human Factors
Human Factors

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A Test / Example of…
Volunteer Needed
As quickly as possible,
say the color of each word on the screen.

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Sensing and Perception
desk
rock
cat
spoon
book

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dog
house
table
car
tree
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red
blue
gray
purple
green
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What is This?

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What is This Now?
Both the letter “B” and the number “13” are the same figure. However,
the context determines how you perceive it.
(Coren, et al, (1994), Sensation and Perception, Harcourt Brace College Publishers)

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PEAR — People — Summary: It Takes a
Human to Adapt to this Kind of Work

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Environment
Physical Organizational
• Weather extremes • Personnel
• Location (in/out) • Supervision
• Workspace • Labor - management
• Lighting • Size of company
• Sound levels • Profitability
• Housekeeping • Job security
• Safety issues • Morale
• Corporate culture
• Safety culture

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Noise
• Exposure to noise is cumulative
• People cannot adapt to high
noise levels
• Noise interferes with
communication
• OSHA requires hearing
protection above 85 dbA (TWA)
• Ear protection devices can also
interfere with communication
• Noise increases the rate of errors

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Organizational Factors — Safety
Culture
• Safety is everyone’s responsibility
• Management rewards safe actions
• Everyone is empowered to stop
work for safety concerns
• Employees will enforce safety
practices
• Reporting unsafe acts or conditions
will be rewarded
• Employees work as a team
• Formal safety management systems
are due in 2009 (ICAO)

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Actions
• What do you need to know?

• What skills are necessary?
• Steps to perform a task
• Sequence of actions
• Communication requirements
• Information requirements
• Inspection requirements
• Certification requirements

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Actions — What Can You Do Today?
• How do you communicate error

events?
• Are there enough people to do the

job?
• Do personnel understand the cost of

aircraft damage?
• How can you motivate one another to

care more?
• Are you responsible for the things

that others do?

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Task Analysis — It’s How We Do It
• Identify the steps required to

complete a task
• For each step, identify the

information, tools,
communication links,
procedures, and so forth,
necessary to complete the
step

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Communication
• Lack of communication is a
major cause of errors
• Verbal and non-verbal
• Positive listening
• Communication protocols
• Affirm reception of information
(readback)
• Never assume the information
you transmitted is the same
information received

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Resources
• Technical documentation systems

• Test equipment
• Enough time
• Enough people
• Lifts, ladders, stands, seats
• Materials
• Portable lighting, heating, cooling
• Training

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Resources — Please Offer Your
Examples
• Are resources ever a problem?
• What are the solutions?
• Can you give an example?
• What advice can you offer?

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Test Equipment
• It’s how we get objective

information
• A “must have” for proper
diagnosis
• Can have a good or bad user
interface
• Can be misused
• Might require significant
training to use properly

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Procedures
• Everything in aviation
maintenance is proceduralized
• FAA regulations (part 43)
require aviation maintenance
technicians to follow approved
procedures
• Some procedures don’t work as
written
• Most common violation is

“failure to follow procedures”

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5 Human Error

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Human Error
• Definition of human error
• Types of errors
• The “dirty dozen”
• Examples of errors
• Event investigations –
Maintenance Error
Decision Aid (MEDA)

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The Greatest Hazard to Aircraft is…?
Gravity
Humans

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80% of Events are Caused by Human
Error

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The Odds are Against Doing it Right!
Only one way to

disassemble
40,000+ ways to
incorrectly
reassemble!

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Definition of Human Error
A human action with

unintended consequences

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Types of Human Error

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Active and Latent Errors

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Why Things Go Wrong
• Incomplete installation (33%)
• Damage on installation (14.5%)
• Improper installation (11%)
• Equipment not installed or
missing (11%)
• Foreign object damage (6.5%)
• Improper troubleshooting,
inspection, test (6%)
• Equipment not activated or
deactivated (4%)
Data from Boeing study of 276 in-flight
engine shutdowns (1994)

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The Civil Aviation Authority’s List of
Errors

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The 12 Most Common Causes for
Human Errors
• Eliminate these causes and

you have conquered most
human errors
• Talk about each of these
• What are the causes in your

company?
• What are the corrective

actions?

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Dirty Dozen — Lack of Communication

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Dirty Dozen — Lack of Teamwork

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Dirty Dozen — Norms

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Dirty Dozen — Pressure

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Dirty Dozen — Complacency

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Dirty Dozen — Lack of Knowledge

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Dirty Dozen — Lack of Awareness

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Dirty Dozen — Lack of Resources

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Dirty Dozen — Distraction

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Dirty Dozen — Lack of Assertiveness

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Dirty Dozen — Fatigue

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Dirty Dozen — Stress

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Iceberg Model

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Event Investigation — MEDA
• Boeing’s event investigation

system
• Used by 500 airlines

worldwide
• Finds the contributing factors

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Performance Shaping Factors
Anything that can increase or decrease the likelihood of human error.

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MEDA Process

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MEDA Corrective Actions

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Noise
• Exposure to noise is cumulative
• People cannot adapt to high
noise levels
• Noise interferes with
communication
• OSHA requires hearing
protection above 85 dbA
• Ear protection devices can also
interfere with communication
• Noise increases the rate of
errors

Administration
6 Maintenance Accidents

Administration
Fatal Accidents: Intl – 1998 to 2007
60 2000
1800
50
1600
1400
40
Fatal Accidents
1200
Fatalities
30 1000
800
20
600
400
10
200
0 0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
World Accidents World Fatalities
Source: US NTSB and Flight International, 8-14 January 2008

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Fatal Accidents: US/Intl – 1998 to 2007
60 2000
1800
50
1600
1400
40
Fatal Accidents
1200
Fatalities
30 1000
800
20
600
400
10
200
0 0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
US Accidents World Accidents US Fatalities World Fatalities
Source: US NTSB and Flight International, 8-14 January 2008

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Intl Accident Cause Factors 2007
Other
27%
Human Factors
45%
Controlled Flight Into
Terrain
1%
Technical/
Maintenance
27%
Source: Flight International, 8-14 January 2008

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Causes of Helicopter Accidents
(1985 - 2006)
Published March 2006
21 Human factors
10 Engine failure
1 Mechanical failure
9 Probable cause unknown
or undetermined (NTSB
investigation not
completed)
7 Weather
3 Structural failure

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Implications of the Safety Statistics
for Maintenance Human Factors
• There are “opportunities for improvement”
• Maintenance and technical issues are areas of concern
• Technical documentation systems!!
• Human factors challenges are ever present

– Alertness/fatigue
– Communication (flight crew to maintenance)
– Inadequate use of lessons learned (event reporting)
• Challenges are similar for all aviation segments!

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Maintenance Accidents
• Maintenance errors cause
accidents
• Accident statistics
• Common maintenance
errors
• Examples of maintenance-
related accidents
• Specific accidents

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Historic Maintenance-Related
Accidents

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Recent Maintenance-Related
Accidents
Jan 2000 Alaska Airlines MD-80 Jackscrew for elevator control
Mar 2001 Lufthansa A320 Mis-wired side stick

Apr 2001 Emery Worldwide DC-8 Reversed hydraulic check-valve
Aug 2001 Air Transat A330 Fuel exhaustion over Atlantic
May 2002 China Airlines B747-200 In-flight break-up at 35K feet

Jan 2003 Air Midwest Beech 1900D Trim rigging
Aug 2003 Colgan Air Beech 1900D Trim rigging
Jan 2006 Continental B737-500 Engine run-up

Jul 2006 Spectrum Aircraft Spectrum 33 Mis-rigging

Administration
Colgan Air Elevator Trim Mis-rigging
• Beech 1900D
• Forward elevator trim control

cable replacement
• Reversed elevator trim
• Diagram in maintenance manual

depicts reversed trim cable drum
• Failure to perform functional test
• Flight symptoms mimic runaway

trim

Administration
Your Accident or Near-Miss Stories
Time for your “war stories”…
The rules:
No company names
No last names for the people
involved

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7 Where to Get Information

Administration
Three Reference Manuals
www.hfskyway.com

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Where to Get Information: Sample Page from
Operator’s Manual for Human Factors in
Aviation Maintenance
• Training
• Human Factors Guide for

Aviation Maintenance and
Inspection
• Human Factors Operator’s

Manuals (one for aviation
maintenance and one for
airport operations)
• www.hfskyway.com
• FAA human factors resources

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For More Information — Publications
www.hfskyway.com

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For More Information —
www.hf.faa.gov

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FAA Human Factors Resources:
www.hfskyway.com

Administration
References
FAA (2005), Human Factors Policy, FAA Order 9550.8A, available at
http://www.hf.faa.gov/docs/508/docs/HForder.pdf#search=%22faa%20order%209550.8%22
FAA (2005), The Operator’s Manual for Human Factors in Aviation Maintenance, Washington, DC,
available at http://www.hf.faa.gov/opsmanual
FAA (2007), The Operator’s Manual for Human Factors in Airport Operations, Washington, DC,
available at http://hfskyway.faa.gov/2007/OpsMan_Ramp_Final.pdf
FAA (1996), Human Factors Guide for Aviation Maintenance and Inspection, available at
http://hfskyway.faa.gov
FAA (2007), Maintenance Human Factors Training Program, Evaluate and Accept, FAA Order
8900.1, available at: http://fsims.faa.gov/wdocs/8900.1/V03%20Tech%20Admin/Chapter
%2024/03_024_002.htm?opendocument
Hackworth, H., Holcomb, K., Dennis, M., Goldman, S., Bates, C., Schroeder, D., Johnson, W. (2007).
An International Survey of Maintenance Human Factors Programs (Report No. 07/25). Oklahoma
City, OK: FAA Civil Aerospace Medical Institute.
Hall, S., Johnson, W.B. and Watson, J. (2001). Evaluation of Aviation Maintenance Working
Environments, Fatigue, and Human Performance: Phase III. Washington, DC: Federal Aviation
Administration Office of Aviation Medicine. http://hfskyway.faa.gov

Administration
8 Summary

Administration
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Administration

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Maintenance Human Federal Aviation

Video Instructions for

Human Factors in Aviation Maintenance Federal Aviation 2

• Reinforce your current knowledge

• Offer new concepts and/or new ways to explain old

• Provide links for more information

• Have a few laughs?

Human Factors in Aviation Maintenance Federal Aviation 3

1. What is human factors?

2. History of human factors

3. Human factors spectacles

4. The PEAR model

7. Where to get information

Human Factors in Aviation Maintenance Federal Aviation 4

Human Factors in Aviation Maintenance Federal Aviation 5

This section shall:

• Define human factors as it relates to

• Show specific examples of maintenance

• Show why the topic is important to you

Human Factors in Aviation Maintenance Federal Aviation 6

Human Factors in Aviation Maintenance Federal Aviation 7

• Primary concern is for people in the

• Combines elements from many

• Critical to the overall flight safety

Human Factors in Aviation Maintenance Federal Aviation 9

Ensure continuing safety and efficiency by paying

Human Factors in Aviation Maintenance Federal Aviation 10

Human Factors in Aviation Maintenance Federal Aviation 11

• Relating to other people

• Dealing with stress

Human Factors in Aviation Maintenance Federal Aviation 13

• Can the user reach controls?

• Ability to access aircraft parts

• Designing for extremes, i.e.,

• No such thing as the “average”

Human Factors in Aviation Maintenance Federal Aviation 14

• Reinforcing desired behavior

• Observations in the workplace

• Effects of stress on behavior

• Controlled studies of the effects

Human Factors in Aviation Maintenance Federal Aviation 15

• User interface design

• Requirements analysis for

• Accommodation for range of

Human Factors in Aviation Maintenance Federal Aviation 16

• The “mental” parts of

• Problem solving ability

• Things that affect

• Effects of stress on mental

Human Factors in Aviation Maintenance Federal Aviation 17

• Slips, trips, and falls

• Materials handling, e.g., lifting

• Toxic materials storage and

• Facility design and safety

Human Factors in Aviation Maintenance Federal Aviation 18

• Skeletal and muscular structure

• Physical structure of perceptual

• Work physiology, e.g., heat

Human Factors in Aviation Maintenance Federal Aviation 19

• Rewards and compensation

• Work teams and groups

Human Factors in Aviation Maintenance Federal Aviation 20

• Ways to help people to

Human Factors in Aviation Maintenance Federal Aviation 21