Maintenance

Human Factors Training

EASA 145 & 66

Maintenance Human Factors

This training is based on EASA 145, which
requires
That maintenance organizations put in place a
maintenance Human Factors program that
addresses ten (10) maintenance Human Factors
issues, and where
One (1) of the issues is the need to train
maintenance staff to be competent in
maintenance Human Factors knowledge and
skills
2

EASA 145 Maintenance Human Factors

Training Requirements
1. General / Introduction to human factors
2. Safety Culture
3. Human Error
4. Human Performance & Limitations
5. Environment
6. Procedures, Information, Tools and Practices
7. Communication
8. Teamwork
9. Professionalism and integrity
10. Organizations HF Program
3

I. General
Introduction to
Human Factors

Definition
Human Factors is a technical discipline aimed at
optimizing human performance within a system by
contributing to the planning, design, and evaluation of
tasks, jobs, products, organizations, environments
and systems in order to make them compatible with
the needs, abilities, and
limitations of
people.

This

Not This

Where Can Human Factors

Be Applied in Maintenance?

Manuals &
Procedures

Training

Operational
Controls & Displays

Human/Computer
Interaction

Design for
Maintainability

Work Group
Procedures
6

SHELL Model

Liveware
Variations in Performance & limitations
Physical size & shape
Physical needs (sustenance, sleep etc)

Input/Output Characteristics
Information processing
Environmental tolerances (temp, pressure,
humidity, enclosed space, stress & boredom)

Liveware Hardware
Ergonomics

Tool design & operation

Instrument interpretation
Work space & access
GSE reliability

Liveware Software
Non-physical aspects of systems such as:
Document design & layout
e.g. maintenance manual
Symbology and computer programmes
Procedures
Training manuals
i.e. content and design
Rules and regulations
i.e. company and authority

10

Liveware Environment
Extremes of temperature affects thought
processes
Excess noise and vibration affects
concentration
Shift work causes fatigue making error prone

11

Liveware Liveware
Leadership, co-operation,
teamwork, personality
interactions
Staff/management relationships,
corporate culture & climate,
company operating pressures
Domestic Pressure
12

Causes of Accidents

Source : FSF , 2000

13

Causes of Accidents
100%

~80% of accidents are now

due to human error

90%
80%
70%
60%
50%
40%
30%
20%

~20% of accidents are now

due to machine causes

10%
0%
1903

TIME

Today
14

Maintenance-Related Accidents

Maintenance system failures, due to errors

and/or violations, can affect safety of flight in two
different ways:
1. Primary Cause of an accident. Accident is due to
the maintenance/inspection failure. Accident is not in
any way due to flight crew action.

2. Contributing Factor to an accident. Accident

chain begins with a maintenance/inspection failure that
is incorrectly handled by the flight crew, ultimately
ending up as an accident (Primary Cause is pilot error).
15

Accident Where Maintenance Is

the Primary Cause
Kahului, Hawaii, U.S.A. 1988

Upper fuselage separation 737-200

16

Kahului 737 Event

Post incident inspection revealed that there were at
least 240 cracks present at the last inspection prior
to incident.
Among the contributing factors to the error of not
seeing the cracks
Lack of resourcesNo proper platform or inspection lights.
FatigueInspection carried out late at night.
Lack of technical knowledgeNot enough inspection
training.
ComplacencyDone other aircraft and had not find any
cracks.
17

Maintenance as a Primary Cause

Data provided in a recent Advance-Notice of
Proposed Amendment No xx/2007 from EASA*.
Primary Cause of HF-Related Accidents
Design
Production
Operations (flight crew related)
Maintenance
ATM
Dispatch
Loading
TOTAL HF-Related Accidents
Non-HF-Related Accidents
TOTAL

# of Accidents
135
101
3038
416
66
18
129
3903
1320
5223

% of Total
3%
2
58
8
1
0
2
75
25
100

*Data obtained from EASA Safety Analysis & Research. It is based on airliner accidents only, covering the period
1990 to January 2006. Only reports where causal factors have been positively identified are included in the analysis.
18

Accident Where Maintenance Is a

Contributing Factor
Lima, Peru 1996

Tape left on static ports 757-200

19

Lima 757 Event

The aircraft's three static ports on the left side were
obstructed by masking tape. The tape had been
applied before washing and polishing of the aircraft
the day before the accident flight.
Work was begun on one shift and handed over to
next mornings shift.
Poor shift handover log was a contributing factor.
Mechanics and pilots both missed tape during walk
around.
20

Safety Costs of
Maintenance Events 2003
The International Air Transport Association (IATA)
Safety Report 2003 found that in 26% of the
accidents a maintenance-caused event started the
accident chain.
IATA Safety Report 200640%
IATA Safety Report 200720%
IATA Safety Report 200815%
Note: IATA did not distinguish between maintenance as
a Primary Cause vs. a Contributing Factor.
21

Monetary Costs of Maintenance Error

Maintenance error caused
20% to 30% of in-flight shutdowns (IFSDs) at a
cost of US $500,000 per IFSD
50% of flight delays due to engine problems at a
cost of US $9,000 per hour.
50% of flight cancellations due to engine problems
at a cost of US $66,000 per cancellation.

22

Murphys Law

23

Summary
About 80% of aircraft accidents today are caused by human
errors.
Maintenance and inspection errors are the primary cause of
8% of the accidents.
Maintenance and inspection errors are a link in the accident
chain in an additional 20% - 30% of the accidents.
Maintenance and inspection errors can also be very costly.
The whole industry (manufacturers, vendors, aviation
authorities, airlines, and maintenance providers) must work
together to reduce the risk from these errors.

24

II. Safety Culture/

Organisational factors

Safety Culture
EASA 145 requires that a maintenance
organization develop a Safety Culture
within the organization.
One way to begin development of a
Safety Culture is to put the elements of
a Safety Management System into
place.
26

Safety Culture
Safety Management System
Definition of culture/safety culture
Importance of a good safety culture
Elements of a good safety culture
Safety Management System (SMS)
International Civil Aviation Organization
(ICAO)
General characteristics and functions of
an SMS
27

Definition of Culture
Culture = Customary beliefs, behavior
patterns, and traits of a racial, religious, or
social group
Any organization has a culture of its own
Management style
Morale
Acceptable behaviors
Norms
28

Definition of Safety Culture

What is a safety culture as it applies to an
aircraft maintenance organization?
A safety culture is a (maintenance
organization) culture in which safety plays a
major role.

29

Importance of a Good Safety Culture

Safety, as it applies to maintenance, has
three components
1. Maintenance actions (e.g., an installation error) can
lead to safety of flight issues
2. Mechanic actions can lead to personal safety issues
(e.g., cuts, puncture wounds, and broken bones)
3. Maintenance actions can lead to environmental
degradation.

A good safety culture will reduce the

instances of all three of these events,
reducing the accident rate and, thus,
saving lives and money.
30

J. ReasonThe Elements
of a Good Safety Culture
Informed CultureA culture in which those who
manage and operate the system have current
knowledge about the human, technical,
organizational and environmental factors that
determine the safety of the system as a whole.
Reporting CultureA culture in which people are
willing to report errors and near misses.
Learning CultureA culture in which people have
the willingness and competence to draw the right
conclusions from its safety information system, and
the will to implement major reforms when the need is
indicated.
31

J. ReasonThe Elements
of a Good Safety Culture
Just CultureA just culture where an
atmosphere of trust is present and people are
encouraged or even rewarded for providing
essential safety-related information, but where
there is also a clear line between acceptable
and unacceptable behavior.
Flexible CultureA culture that has
organizational flexibility typically characterized
as shifting from the conventional hierarchical
structure to a flatter professional structure.
32

Achieving a Safety Culture

A Safety Culture is achieved over time,
requiring:
A commitment to safety from the Senior
Management down through every worker in the
organization.
A process for achieving safety. This process
often is called a Safety Management System.

33

III. Human
Performance
& Limitations

Human Performance &

Limitations
Normal curve
Human strengths and
weaknesses
Vision
Hearing
Information processing
Attention and
perception
Memory
Speed/accuracy tradeoff

Physical work
Fatigue and sleep
Claustrophobia and
physical access
Fitness and health
Alcohol, medication, and
drugs
Repetitive tasks/
complacency

35

Introduction to Human Performance

Human beings have strengths
and weaknesses
Tasks that do not account for
human limitations result in:

Vision

Cognition

Hearing
Strength

Errors
Injuries

If you review a task or work

station, do not ask:
Can it be done?
Ask:
Can it be done safely and
correctly by the people who
do the job?

Reach

36

Humans Are Better

than Machines in
Detecting small amount of visual and acoustic energy.
Perceiving patterns of light or sound.
Improvising and using flexible procedures.
Reacting to unusual or unexpected events.
Storing very large amounts of information for long periods and recalling
relevant facts at the appropriate time.
Applying originality at solving problems.
Reasoning inductively.
Exercising judgment.
Learning from experience.

Use a human operator when a system component

is needed that can think on its feet, process information
in ways that could not be predicted, and can then act
effectively using the result.
37

Machines Are Better

than Humans in
Responding quickly to control signals.
Applying great force smoothly and precisely.
Performing repetitive, routine tasks.
Storing information briefly and then erasing it
completely.
Reasoning deductively, including computational
ability.
Handling highly complex operationsdoing many
different things at once.
38

Other Major Differences

Machines can be modified, redesigned, and
retrofithumans cannot.
Humans are born with innate, genetically determined
differences that are shaped by the environment.
Innate aptitudes or abilities are developed through
education and training.

Machines can be manufactured to be identical

with (nearly) identical output or performance.
Humans are not identical and vary across all sensory,
cognitive, physical, and performance characteristics.
Specific aspects of human performance can be made
more equal through education and training.
39

Vision Performance Issues

Being able to see clearly is vital
in aircraft maintenance and
inspection.
Vision requirements are task
based.
Illumination requirements are
task based.
Technicians must recognize
their individual visual
limitations and capabilities.
40

The Normal Visual Field

Provide visual access to work
area...
Without excessive bending
For both short and tall people

Visual access is critical to...

Doing the task
Visual validation of the task

Examples of problems due to

poor visual access:
Incorrect attachment
Inspection errors
Increased task time
41

Colorblindness
Complete color blindness is quite
rare.
Most people are actually color
deficient and have problems
seeing red and green.

No Red receptors

About 10%-15% of males and 1%

of females are color deficient.
No Green receptors

Most do not even know.

They learn to compensate with
degrees of brightness and
texture.
If you find you have it, avoid
errors by asking other people
when you are unsure.

No Blue receptors

An estimation of what the spectrum looks

like for different types of colorblindness.
42

A Quick Colorblindness Test

This is a demonstration.
You should see the number 12.

43

What Numbers Do You See?

44

Recommended Illumination Levels*

Illumination Levels in Lux

Tasks

Light
Source

Recommend

Minimum

Perceiving small details with low contrast for

prolonged times, or where speed and accuracy are
essential, such as repairing small components,
inspecting dark materials

1650

1075

General service
plus
supplementary

Perceiving small details with fair contrast where speed

and accuracy are not so essential, such as electronic
assembly

1075

540

General service
and/or
supplementary

Prolonged reading, desk or bench work, general office

and laboratory work, such as assembly work and filing
records

755

540

General service
and/or
supplementary

Occasional reading, recreation, reading signs where

visual tasks are not prolonged, such as reading a
bulletin board

540

325

General service
and/or
supplementary

Perceiving large objects with good contrast, such as

locating objects in a bulk supply warehouse

215

110

General service

Passing through walkways and handling large objects,

such as loading from a platform

215

110

General service

*Illumination requirements for representative tasks (MIL-HDBK-759A)

45

The Human Auditory System

The outer ear collects sound
The middle ear channels sound to the
ear drum
The inner ear converts sound to nerve
impulses
Tiny hair cells (cilia) in the Cochlea
vibrate with different sounds
Excessively loud noise can result in
the hair cells stretching too far and
breaking
Listening to the same frequency or
pitch for a long time can also damage
the hair cells
Listening to loud noise for a long
period can also cause fatigue

Cochlea

Ear Drum

Outer Ear Middle Ear

Inner Ear

46

Protect Your Hearing!!

Types of Hearing Protection
Disposable plugs
Reusable plugs
Custom-fitted plugs
Ear muffs

Wearing Hearing Protection Properly

Follow package directions when putting protection on.
Make sure the selected protection fits properly.
Maintain hearing protective devices in a sanitary condition.
Make sure nothing interferes with the use of hearing
protectors (e.g., eyeglass frames).
47

Sound Intensity Levels

Db Level
Example
Dangerous Time Exposure
0
Lowest sound audible to ear
None
30
Quiet library, soft whisper
None
40
Quiet office, living room
None
50
Light traffic at a distance, refrigerator
None
60
Air conditioner at 6 m., conversation
None
70
Busy traffic, noisy restaurant
Critical level begins
80
Subway, heavy city traffic, alarm clock
More than 8 hours
90
Truck traffic, lawn mower, shop tools
Less than 8 hours
100
Chain saw, boiler shop, pneumatic drill
Less than 2 hours
120
Rock concert in front of speakers,
Immediate danger
sandblasting, thunderclap
140
Gunshot blast, jet plane @ 15 m.
Any exposure is bad
180
Rocket launching pad
Hearing loss inevitable
American Academy of Otolaryngology, Washington, DC
48

Information
Processing/
Attention and
Perception/
Memory

A Model of
Human Information Processing.

Attention (concentration) is a limited

Three types of memory
resource, which must be shared between Sensory memory
Observing the situation
Deciding on a response
Executing the response

Working or short-term memory

Long-term memory

(Adapted from Wickens, C.D. Engineering Psychology and Human Performance. Columbus, Ohio: Charles E. Merrill Publishing Co., 1984.)

50

Attention and Selection

The first process of memory is attention.
There is much more information in your environment
than you can process at any one time.
You must make choices (conscious & unconscious)
regarding the stimuli to which you will attend.
Early theory was that we could only attend to one
thing at a time.
That theory is still believed to be true. However, we
can switch our attention quickly, especially if the
information comes from different channels (e.g.,
hearing and vision).
51

Working (Short-Term) Memory

This is the memory that we use, for example, when
some one gives us a phone number to call or gives
us directions on how to find an office in a building
Working memory lasts only about 20 seconds,
although you can make the memory last longer by
repeating the information to yourself in your head
Working memory can hold about 7 + 2 (5 to 9)
chunks of information. For example, you will
remember the name
Steven as one chunk of information, not as six
separate letters.
52

Moving Information from Short-Term

Memory into Long-Term Memory
All verbal information goes first into the short-term
memory.
When it is rehearsed (recited), part of it goes into
long-term memory.
The rest of it, usually the part we are least
interested in, returns to short-term memory and is
then forgotten.
Whether new information is "stored" or "dumped"
depends, then, on our reciting it out loud and on
our interest in the information.
53

Accessing Long-Term Memory

Two ways to access your memory:
Recallcoming up with the information from memory
Fill-in-the-blank exams
Coming up with a persons name.

Recognitionrecognizing the correct information

Multiple choice tests
True/false tests
Recognizing someone that you know.

Recognition is easier than Recall.

Often need to recall information we learned long
ago. How quickly/reliably we recall it depends on:
Activation: How long since we last used the information.
Strength: How well we have practiced it.
54

Why Do We Forget?

Three possibilities
1. The memory fades away (decays) over time
2. Interference (overlaying new information over the old)
3. Lack of retrieval cues.

Data now suggest that we forget because of 2

and 3 above.
In other words, once we have stored something
in long-term memory, it is always therewe just
have trouble retrieving the information.
55

Negative Transfer of Training

When you learn new material, old material that you
learned before is still in long-term memory.
If the new material is similar to the old material but
with some small differences, you can become
confused.
Example: Mechanic knows how to replace a hydraulic pump on airplane
A. The airline buys a newer model--airplane B.
The pump bolts on airplane A must be torqued to 50 ft lbs
The pump bolts on airplane B must be torqued to 60 ft lbs
Later, the mechanic makes an error by:
Replacing a pump on airplane A and tightening the bolts to 60 ft lbs, or
Replacing a pump on airplane B and tightening the bolts to 50 ft lbs.

MESSAGE: Be sure to check details when things

are almost, but not quite the same.

56

Physical Work

Bio-Mechanics
This image cannot currently be displayed.

Human Force
Application

Work Posture

Spine Geometry

58

Occupational Risk Factors for

Cumulative Trauma Disorders

Posture
Force

Vibration
Frequency

59

Neutral Position of
Hand and Wrist

60

Work Posture - Hand and Wrist

OK

Avoid
61

Work Posture - Arm and Shoulder

OK
Avoid
62

Work Posture - Arm and Shoulder

OK

Avoid

63

Neck Flexion

Neck flexion greater than 30 degrees

64

Back Flexion

Back flexion greater than 30 degrees

65

Squatting

> 2 Hours per Shift

66

Kneeling

> 2 Hours per Shift

67

Hands Above Head or

Elbows Above Shoulders

> 2 Hours per Shift

68

Repetitively Raise Hands Above

Head or Elbows Above Shoulders

> 4 Times/Minute
69

Highly Repetitive Motion

Neck, Shoulders, Elbows, Hands

> 4 Times/Minute
70

Highly Repetitive Motion and

Forceful Exertions with Hands

30

Greater than 30 degrees

71

Pinch Grip

Objects weighing > 1 kg per hand

or force > 2 kg per hand

72

Pinch Grip Plus Repetitive Motion

> 4 times/minute
73

Pinch Grip Plus Wrist Deviation

30

Greater than 30 degrees

74

Power Grip

Objects weighing > 5 kg per hand

or force > 5 kg per hand

75

Power Grip Plus Repetitive Motion

> 4 times/minute

76

Power Grip Plus Wrist Deviation

Greater than 30 degrees

77

Repeated Impact - Hands

> 10 times/hour
78

Repeated Impact - Knees

> 10 times/hour
79

Intensive Keying and Mousing

> 40 words per minute

80

Lifting

> 11 kg or > 5 kg more than

two times/minute

81

Pushing/Pulling

> 16 kg of initial force

82

Use of Vibratory Tools

83

Workstation Design
Principle

Example

Design work stations for a range of Boeing airplanes are designed for
people, not for the average person people from 157 cm to 193 cm
Permit several different working
positions

A drill which allows the user to

change grip positions

Design should start from the point A component work bench which
holds the component in the center
where the hands spend most of
and the tools around it
their time
Getting a ladder so that you are
Work should be conducted
between shoulder and waist height not working over your head
Raise the work surface for work
that requires precision, so it is
closer to your eyes

Raising a manual to see detail

or a component work bench which
moves up and down.

A component work bench which

Lower the work surface for work
holds a hydraulic pump at about
that requires more force so your
arms are in a more neutral position waist high
84

Fatigue
and
Sleep

Fatigue
EASA-145 requires the organisations
planning procedures to take into
account the limitations of human
performance, focusing on fatigue.

86

Definitions
FatigueA feeling of lack of energy,
weariness or tiredness. Also called
tiredness, weariness, exhaustion, or
lethargy. Fatigue is a normal response to
physical exertion, emotional stress, and
lack of sleep.
AlertnessVigilantly attentive and
watchful; mentally responsive and
perceptive.
87

Effects of Fatigue
More than 100,000 car accidents annually in
the US are fatigue-related
Disasters such as:
Chernobyl (Russian nuclear power plant)
Three Mile Island (US nuclear power plant)
Bhopal (chemical release in India)
Exxon Valdez (oil supertanker accident in
Alaska)

were officially attributed to errors in

judgment induced by fatigue.
88

Effects of Fatigue
Overall performance
gets worse
Loss of motivation
Slowed reactions
Forgetful
Poor cognitive
functioning
Thinking
Reasoning/judgment
Problem solving/
decision making

Loss of creativity
Withdrawal from social
situations
Mood changes
Increase alcohol use
Long term health can
degrade
Quality of life degrades

89

Our Circadian Sleep Wake Clock

Alertness

High

Low
6 am

Noon

3-5 am and pm = sleepy

9-11 am and pm = alert

6 pm

Midnight

6 am

Time of Day
90

Sleep
Sleep is defined as a state of partial or full
unconsciousness during which voluntary
functions are suspended and the body rests
and restores itself.
Lying down
Little movement
Do not respond as readily to disturbances
Reversiblecan wake up

Observed in all mammals, all birds, and many

reptiles, amphibians, and fish.
91

Sleep
Still not totally sure why we need sleep, but there
are two theories
Energy conservationsleep to conserve energy (old theory)
Restoration (new theory)
Neural circuits in the brain are rewired
Memory is consolidated and strengthened
Short-term memory items move into long-term memory
Growth hormone levels are restored
Blood pressure drops
The cells in your organs are strengthened by protein synthesis
Sleep breaks your stress pattern.

Also, we know that bad things happen if we do

not sleep.
92

Effects of Missing Sleep

A person who loses one nights sleep will generally
be irritable and clumsy during the next day and will
either become tired easily or speed up because of
adrenalin.
After missing two nights sleep, a person will have
problems concentrating and will begin to make
mistakes on normal tasks.
Three missed nights and a person will start to
visually hallucinate and lose grasp of reality.
93

How Much Sleep Do You Need?

Depends on
Age
Health
Circadian rhythm
Body metabolism
Physical exercise level
The quality of the sleep
Amount of recent sleep
Body temperature
Personal differences.

Magic number of 8
hours of sleep is an
average.
Short sleepersNeed
around 6 hrs of sleep.
Long sleepersNeed
around 9 hrs of sleep.
1 in 25 people need
more than 10 or less
than 5 hrs of sleep.
94

Avoiding FatigueNo Shift Rotation

Getting a Good Nights Sleep
Get up and go to bed at the same time.
If you are tired, go to bed early.
Use your bed only to sleepno reading, eating, etc.
Keep the bedroom dark, quiet, and cool (58F/15C).
Exercise in the morning or early afternoon, not evening.
Do not eat a heavy meal before bed--a light snack at most.
No alcohol before bedtime, no caffeine after early afternoon,
and avoid nicotine.
Quit worrying about falling asleepit keeps you from falling
asleep!
Stop looking at that clock! Get up if you are not sleeping.
95

Avoiding Errors While Fatigued

Admit you are tired!
Remain physical to remain alert.
Exercise/stretch at frequent intervals.
Talk to people.
Drink plenty of liquids.
Take a nap.
Avoid tedious, boring work.
Work with somebody else so you can catch
each others errors.
Go back over and check your work.
96

Drugs and Diet

Using drugs to get to sleep should be a last resort, because these drugs
decrease REM and deep sleep.
But, remember, there are drugs in food, also (like caffeine in coffee, tea,
soft drinks, and chocolate).
Thus, it makes sense to approach food and drugs together.
Food and drugs release chemical that interact with our basic body rhythms.
This interaction is one cause of the varied effects they produce.
One step in controlling the bad effects of foods and certain drugs is to
control when we consume them.
If you are a morning person, the use of uppers like coffee and sugar-coated
cereal in the morning makes no sense.

Another control strategy is to avoid the combined consumption of food and

drugs that have similar effects.
For example, combining downers, such as alcohol, sleeping pills, and pain
medication can be particularly dangerous.
97

Drugs and Diet

Food in the stomach causes the stomach walls to stretch.
The more the stretch, the stronger the signal to the body to
send blood to the stomach to aid digestion.
Diverting too much blood to the stomach by overeating can
create a shortage of blood elsewhere, like your brain, which
causes you to feel sluggish following a big meal.
Eating frequent, smaller meals is preferable to eating a few
large meals before and during work.

Eating smaller meals in the hours prior to heavy

physical work is a key dietary strategy for shift
workers.
98

Physical Fitness
The Drug and Diet control strategies that we have discussed
are meant to decrease the build up of stress resulting from
shift work.
However, some stress will still occur.
One factor that clearly improves our ability to cope with
stress is physical fitness.
Shift work tends to drain your energy levels; fitness tends to build up
your energy levels.
Physical activity can burn off excess energy and start the cycle
leading to a relaxed state that leads to good deep (non-REM) sleep.
Regular physical activity can help stabilize body rhythms and is
helpful in speeding the resettling of body rhythms in the first few days
of a shift change.
99

Putting It All Together to Get a

Good Sleep after Your Night Shift
Determine how much sleep you need and try to get it every
day. Use naps, as necessary.
Mental relaxation before bed
Physical relaxation before bed
Control your drugs and diet
Get physically fit
Deal with any sleep-related medical problems
Keep the bedroom dark, quiet, and cool (15C)
Use sun-blocking shades
Work with family and neighbors for bedroom quiet

Wear sunglasses on the drive home to fool your brain

Take a nap before the night shift starts in addition to your
after-shift sleep.
100

Repetitive Tasks
Complacency

Complacency
Complacency = Self-satisfaction
accompanied by unawareness of actual dangers
or deficiencies.
Mechanics can become complacent when they
have done a task over and over again without
making an error.
Inspectors can become complacent when they
have done an inspection many times before
without finding a problem.
We must fight complacency!
102

Complacency
One of the Dirty Dozen

103

Environment
Stress and anxiety
Definition
Why worry?
Symptoms
Stressors
Physical
Psychological

Conditions of the
work environment
Cold
Heat
Illumination
Noise level

104

What Are Stress and Anxiety?

Stress is a physiological reaction to physical and psychological factors
(stressors) in our environment.
Anxiety (also called angst or worry)
Is a psychological and physiological state characterized by somatic,
emotional, cognitive, and behavioral components.
It is the displeasing feeling of fear and concern in either presence or absence
of psychological stress.
Anxiety can create feelings of fear, worry, uneasiness, and dread.
Anxiety is also considered to be a normal reaction to a stressor.

In other words, stress and anxiety are about the same thing.
Positive

Stressors

Stress/anxiety

Adaptations
Negative
105

Stress/Anxiety and Performance

Time Magazine December 5, 2011

106

Physical & Psychological Stressors

Physical stressors
Illness
Acute
Chronic

Environment
Temperature
Vibration
Noise
Fumes

Fatigue
Shift work
High work load.

Psychological stressors
Unpredictability
Uncertainty
Uncontrollability
Bereavement/tragedy
Daily annoyances
Time pressure
Peer pressure
Management pressure

Chronic stressors
Home environment
Work place pressures.
107

Why Worry About Threat

Stress/Anxiety?
Human Error

Reduced
Productivity

Injury
Illness
108

Conditions of the
Work Environment

Another Effect of Heat and Cold

on Work Performance
Some airlines have noted an increase in
maintenance errors in line maintenance during the
summer. Why?
It is so hot outside or on the aircraft that the mechanic
works quickly so that he can get back to the airconditioned building.
Speed/accuracy trade-off applies, so errors increase.

Similar thing happens during winter

Work quickly to get in out of cold.
Have to wear heavy gloves and clothing, so that it is
harder to do the work. Thus, errors increase.
110

V. Procedures,
Information, Tools, and
Practices

Procedures, Information,
Tools, and Practices
Visual inspection
Task inspections/duplicate inspections
Planning
Work logging and recording
Procedurepractice mismatch
Technical documentationaccess
and quality.
112

Visual Inspection Outline

Definitions
Visual inspectionsearch and decision
Factors affecting visual inspection
Task Factors
Subject Factors
Equipment Factors
Environment Factors
Social Factors

Concept of Damage Tolerance

Systems, Structural, and Zonal Inspections
113

Visual Inspection
Over 80% of inspections on aircraft are visual
inspections.
Visual inspection is often the most economical and
fastest way to find defects on an aircraft.
Airframe manufacturers and airlines depend on
regular visual inspections to ensure the continued
airworthiness of their aircraft.

114

Definition of Visual Inspection

Visual Inspection means inspection using either or
all of human senses such as vision, hearing, touch
and smell.
Visual Inspection typically means inspection using
raw human senses and/or any non-specialized
inspection equipment.

115

Types of Inspection
General visual inspection (GVI)
Detailed inspection (DET)
Special detailed inspection (SDI)

116

Definition of General Visual

Inspection (GVI)
A visual examination of an interior or exterior area,
installation or assembly to detect obvious damage,
failure or irregularity. This level of inspection is
made from within touching distance unless
otherwise specified. A mirror may be necessary to
enhance visual access to all exposed surfaces in
the inspection area. This level of inspection is
made under normally available lighting conditions
such as daylight, hangar lighting, flashlight or
drop-light and may require removal or opening of
access panels or doors. Stands, ladders or
platforms may be required to gain proximity to the
area being checked.
117

Definition of a Detailed Inspection

(DET)
An intensive visual examination of a specific
structural area, system, installation or assembly to
detect damage, failure or irregularity. Available
lighting is normally supplemented with a direct
source of good lighting at an intensity deemed
appropriate by the inspector. Inspection aids, such
as mirrors, magnifying lenses, etc. may be used.
Surface cleaning and elaborate access procedures
may be required.

118

Some of the Operating Rules

Normal cleanup procedures are to be used prior to
conducting general visual or detailed inspections. Specified
cleanup procedures are to be used for special detailed
inspections, if necessary. Sealant and corrosion protection
finishes should only be removed when specified and
restored in accordance with the Corrosion Prevention
Manual after the task is completed.
Excessive dust, debris, or overspray of corrosion inhibiting
compounds found during any inspection are considered to
be an unsatisfactory condition possibly reducing the fire
resistance of the airplane design. Cleanup of these
materials should be a standard part of maintenance activity.
119

Definition of a Special
Detailed Inspection (SDI)
An intensive examination of a specific item(s),
installation or assembly to detect damage, failure or
irregularity. The examination is likely to make
extensive use of specialized inspection techniques
and/or equipment.
Special detailed inspections are to be used when
specified for inspecting hidden details or may be used as
alternatives to detailed inspections.
NDT
Borescope
120

Typical Aircraft Defects Found by

Visual Inspection
Typical airframe defects that can be found by visual
inspection include
Cracks
Corrosion
Disbonding

Other defects that can be found by visual

inspection include
System and component wear
Accidental damage
Environmental damage from long-term storage, sunlight,
etc.
121

Factors Influencing
Visual Inspection

Task Factors
Subject Factors
Equipment Factors
Environment Factors
Social Factors

122

Task Factors
Size/complexity of the object searchedin
general, search time is linearly related to either
search field area or number of inspectable items in
the field.
Number of different types of defectsthe
greater the number of types of defects, the slower
the search performance and/or the lower the hit
rate.
Defect/background contrasthigher
defect/background contrast produces faster and
more accurate searches.
123

Task Factors contd.

Defect sizelarger defects are generally found
more accurately and faster than smaller defects.

Probability that the item contains a defect

the a priori probability that there will be a defect is
positively related to hit rate and false alarm rate.
Timing/pacingin general, a self-paced
inspection task is more effective than an externallypaced task.

124

Task FactorCompany
Inspection Instructions
Before certifying any work, you must be satisfied that all
components, parts and materials utilized have been obtained
from approved sources, are of the correct specification, and are
completely serviceable. You must also ensure that all work are
performed in accordance with current and approved Maintenance
Schedules, Maintenance Manuals, Overhauls Manuals, Repair
Test Schedules/Capabilities List, Drawings or any other relevant
technical publications, and that all applicable Mandatory
Modifications, Inspections or any other special requirements have
been duly carried out. In the case of repairs not covered by the
approved technical publication, all work performed must be in
accordance with the approved instructions of the equipment
owner, e.g., Engineering Notes issued by the Engineering
Department.
125

Subject Factors
Inspector demographicsage, experience, and gender (no
affect)

Trainingnot the same as experience.

Even experienced inspectors

can improve their performance (often dramatically) with a well-designed
training program, which is based on a task analysis and which provides
Knowledge of Results to the trainees.

Visual performancenot related to visual acuity

as measured by a Snellen Chart. The size of the visual
lobe is a predictor of inspector performance.
However, studies done by the US FAA found that 20/20
vision or correctable to 20/20 should be required
for inspectors.

Cognitive performancepeople with the ability to dis-embed

objects from a complex/confusing background make better inspectors.
126

Hidden Figure Example

127

Hidden Figure Example

128

Inattentional Blindness and

Human Errors/Accidents
Someone performing a task simply fails to see what should
have been plainly visible and cannot explain the lapse
afterwards.
Inattentional blindness causes accidents when attention
mistakenly filters away important information, due to a
combination of factors: low conspicuity, divided attention, high
expectation, low arousal.
People are unaware of the blindness. Training mainly affect
conscious, voluntary behavior.

Equipment Factors
Magnificationincreasing magnification may only
change the speed-accuracy trade-off with higher
magnification improving target detection at the
expense of speed.
Field integrationusing a known perfect item
for comparison during the inspection.
Visual enhancementspecific to NDI.

Human/machine function allocationspecific

to NDI. Typically shows that a hybrid of human and
machine functions work better than either alone.
130

Environment Factors
Visual environmentcorrect lighting is important both for
physical inspection and to avoid glare in computer-based
inspection.

Auditory environmentno necessarily clear affects,

although some studies show that noise >90 Db worsened
inspection performance.

Thermal environmentsome data to suggest that really

hot and really cold environments have a negative affect on
inspection.

Workplace comfortno data. However, the myth that

comfortable inspectors lose vigilance has been refuted.
131

Social Factors
Working perioddetection performance decreases rapidly
over the first 20-30 minutes of a vigilance task (e.g., watching
radar), although this phenomenon is hard to replicate in typical
visual inspection tasks.
Job designrest periods have been shown to improve
performance.
Supervision, instruction and other pressuresfrom
signal detection theory, we know that criterion used by an inspector
for reporting defects is influenced by the sum of all biases on the
inspector. These biases are affected by a priori probability of a
defect and also by the perceived costs of misses and false alarms,
which can be affected by supervisory instructions/reprimands.
Information environmentboth feedback of inspection
performance (knowledge of results) and feed forward information
(where to look for a defect) have been shown to improve inspection
performance.
132

Summary
Over 80% of inspections on aircraft are visual
inspections, which are often the most economical
and fastest way to find defects on an aircraft.
Visual Inspection means inspection using either or
all of human senses such as vision, hearing, touch
and smell.
A visual inspection includes a search and a
decision. The decision criteria can be influenced
by outside factors, such as management pressure.
Common aircraft visual inspections include system
inspections, structural inspections, and zonal
inspections.
133

Error Capturing/
Task Inspections
and Duplicate
Inspections

Error Capturing
Error capturing = Adding a task to find a
mistake.
Common error capturing tasks
Operational/functional checks
Mechanic/pilot pre-flight walk around checks
Task inspections/duplicate inspections.

135

Task Inspection
Task (Job) cards typically have two types of signoff:
Worked by (Discussed later under Norms.)
Checked by

What does SIAECs GMM say the checked by

person is supposed to do in order to feel
comfortable in signing off the task or sub-task?
Supposed to watch the whole task, or the critical parts of
the task, being performed?
Must have a high degree of confidence that the work has
been carried out correctly.
136

What Standard Do You Inspect To?

Many are found in the Aircraft Maintenance Manual
(AMM)
Chapter 20 Airframe Standard Practices
Chapter 51 Standard Practices and Structures
Chapter 70 Engine Standard Practices

137

Planning of Tasks,
Equipment, and
Spares

Planning of Tasks,
Equipment, and Spares
Planning of Tasks, Equipment and Spares
EASA 145 does not require a procedure
on the planning of work.
EASA 145 and AMC material clarifies the
objective of good planning and includes
the elements to consider when
establishing the planning procedure.

139

Planning of Tasks, Equipment,

and Spares
Planning is critical to ensure that there are
adequate
Appropriately qualified and alert maintenance staff
Tools
Equipment
Material
Maintenance data
Facilities

for scheduled and un-scheduled maintenance.

Long-term planning.
Short-term planning.
140

Planning of Tasks,
Equipment & Spares
Planning consideration should be given to
Logistics.
Inventory control.
Space availability (hangar and floor space).
Man-hours estimation.
Man-hours availability.
Preparation of work.
Co-ordination with internal and external suppliers.
Scheduling of safety-critical tasks during periods when staff
are likely to be most alert, and avoiding periods when
alertness is likely to very low, such as early morning or
night shift.
141

Work Logging and Recording

Importance of proper work logging/recording
All work on an aircraft should be documented.
Work sign-offs should occur soon after the subtask is completed. Do not wait until the end of
the task to sign off all worked by blocks.
Any work done on the aircraft that is not
covered in the maintenance manual (e.g.,
loosening a clamp on a wire bundle in order to
get access to a part) should be recorded,
typically with a non-routine card.
142

Technical Documentation
EASA 145 addresses technical
documentation (poor maintenance data)
Inaccurate, ambiguous, incomplete
maintenance procedures, practices,
information or maintenance instructions
contained in the maintenance data used by
personnel must be reported to the author of
the data.
143

Technical Documentation
The US Federal Aviation Administration
recently did a study of aircraft maintenance
manuals (AMMs). They found that:
The manuals rarely had technical errors in them,
but
The manuals were not written by mechanics,
meaning that the order of the tasks typically does
not follow the way in which a mechanic would
actually do the task.

144

Documentation and
Maintenance Errors
MEDA investigations have found that
documentation is the most frequent contributing
factor to maintenance error.
Problems include
Not used (50% in MEDA investigations)
Not understandable
Incorrect step
Conflicting information
No illustration.
Poor illustration
145

VI. Teamwork

Team Behavior

Team Behavior - The way people behave

when part of a team.

147

Overview
What Affects
Team Behavior?
Responsibility
Motivation
Norms
Culture

Effective Team
Behaviors
Communication
Assertiveness
Situation
Awareness
Leadership
148

Responsibility
Responsibility is...
Recognizing that you can affect the teams success.
Choosing to act to help that success.

In a team, we tend to feel less

responsible.
Someone else will do it.
The whole team agreed.
Nobody saw me, it could be anyone.
149

Social Influence
How behavior is influenced by the
social environment and the presence of
other people
Obedience to authority
Conformity to group/team.

150

Examples of Taking
Responsibility
Admitting and fixing errors.
Saying something about a situation when
you know there is something wrong.
Addressing non-critical problems

Picking up debris from the ramp

Finding the safety wire you dropped.

Maintaining professional responsibility.

Maintaining technical currency.
151

ProfessionalismSome Examples of
Unprofessional Behaviors in Maintenance
Memorizing tasks instead of using manuals/cards.
Not using torque wrenches or other calibrated tooling.
Troubleshooting through experience, instead of using the
Fault Isolation Manual (FIM).
Deviating from maintenance manual procedures.
Failing to attach Do Not Use tags when pulling
circuit breakers and switches.
Skipping operational or functional tests.
Signing off for tasks neither seen nor checked.
Providing minimum information in task handover log.
Failing to document work not specified in the manual (e.g.,
loosening a clamp on a wire bundle).
152

Why Do We See
Unprofessional Behavior?
Behavior starts to stray from the professional
standard for various reasons (uncomfortable, time
constraints, calibrated equipment unavailable).
Supervisor does not intervene.
Staff believe that supervisor does not care.
Behavior is seen as low risk.
Unprofessional behavior becomes the norm.
Existing workers put peer pressure on new hires to
conform to these behaviors.

153

Why Do We See
Unprofessional Behavior?
Supervisor actually rewards unprofessional
behavior.
Weve got 4 days of work to do in 2 days. I dont care
what you do, just get it done. I am going into my office
and closing the door. [After meeting the 2-day deadline.]
Way to go guys!! Pizza for everybody.

Supervisor threatens punishment for carrying out

professional behavior.
What do you mean you dont feel qualified to do the job?
Youre trained. Youre certified. Go out there and do that
work. You want to keep your job, dont you?
154

Then How Do We Move Back to

Professional Behaviors?
What not to do
Pick out an offender and punish him/her in front
of their work group.
Threaten staff.

155

Then How Do We Move Back to

Professional Behaviors?
What you should do
Management decides what behaviors are desired.
Management and labor meet to agree on the new
behaviors. Address issues brought up by labor, e.g.,
Time it will take
Availability of equipment, calibrated tools, parts, etc.

Supervisors are provided training on new expectations

No threats to staff if they are doing correct behavior.
Reward correct behavior and model correct behavior.

Labor told of progressive punishment for failure to exhibit

new behaviors
Verbal warning
Letter to file
Time off without pay.
156

Motivation
Motivation = A process within a person that
causes the person to move toward a goal
that is rewarding.
Two types of motivation:
IntrinsicWe move toward a goal because of
rewards that are internal to ourselves (e.g.,
feelings of satisfaction or accomplishment).
ExtrinsicWe move toward a goal because of
rewards that are external to ourselves (e.g.,
praise, a good grade on a test, or money).
157

Motivation Affected by Beliefs

Motivation is determined both by
The intrinsic or extrinsic reward, and
The belief that effort will result in achieving the
reward.
Example: Someone who does not believe they can
win a race will not be motivated to try hard
to prepare for and win the race,
no matter how badly they want
the $100K prize money.
158

Performance = Skill X Motivation

Performance is determined by BOTH:
Skill
&
Motivation
Example: Someone with medium skills
and high motivation can out perform
someone of high skills and no motivation.
159

Implications for Management

Management must not only provide hygiene factors
to avoid employee dissatisfaction, but must provide
motivation factors intrinsic to the work itself in order
for employees to be satisfied with their jobs.
The job should have sufficient challenge to use the full
abilities/skills of the employee.
Employees who demonstrate increasing levels of ability/
skill should be given increasing levels of responsibility.
If a job cannot be designed to use an employees full
abilities/skills, then the organization should consider
replacing the employee with one who has fewer
abilities/skills. If an employees abilities/skills cannot be
fully used, then there will be a motivation problem.
160

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

Tagging connections

Following check lists

and procedures

Wearing appropriate
safety equipment
161

Some Ineffective Norms

We Have Seen at Airlines
Memorizing tasks instead of using manuals/cards
Not using torque wrenches
Troubleshooting through experience, instead of using the Fault
Isolation Manual (FIM)
Deviating from maintenance manual procedures
Failing to attach Do Not Use tags when pulling circuit breakers
and switches
Skipping functional or operational tests
Signing off for tasks not seen nor checked
Providing minimum information in shift handover log
Failing to document work not specified in the manual (e.g.,
loosening a clamp on a wire bundle)
162

Norms
The Asch studies suggest that new staff
will quickly pick up the existing norms in
their work group. If these are norms like
Memorizing tasks instead of using
manuals/cards
Not using torque wrenches,

then new staff will quickly learn these

behaviors.

163

Procedural Non-Compliance
EASA 145 requires that procedural noncompliance be addressed. Very important!
There is an assumption that people will follow the
procedure as written.
When this assumption is broken, the whole basis of the
safety system is put at risk.
Maintenance requirements, therefore safety, are based
almost solely on an assumption that people will follow the
procedures.

Therefore, maintenance organizations should:

Not allow procedural non-compliance to become a
normal behavior (norm), and
Make sure written procedures are easy to follow so that
they will be used.
164

Signing Tasks Not Seen

Nor Checked
EASA 145 requirement to address this
issue.
New Alternate Means of Compliance
material elaborates on the meaning of
sign-off and the need to check or
inspect the task before signing off.

165

Signing Off Tasks

A sign-off is a statement by the competent person
performing or supervising the work that the task or
group of tasks has been correctly performed. This
is a worked by sign-off, not a QC inspection signoff nor a release to service sign-off.
Research has shown that many maintenance
tasks, which are carried out by workers who are not
competent to sign off on their own work (e.g.,
temporary staff or trainees), are signed-off unseen
by the person supervising the work.

166

Signing Off Tasks

Some airlines have one sign-off for each task card.
Other airlines have sign-offs for each sub-task within
a task card.
Signing off small groups of tasks (sub-tasks)
Will help prevent situations where a technician is called
away from a task (to do another task or at shift end), and
the person picking up the previous task has no record of
what has been completed on the task, and
Will encourage a mechanic to continue with the task up to
the next break point before leaving the task (e.g., either to
take a break or end the shift).

Sign-off points would be determined by M&E as

appropriate to the nature of the work.

167

Signing Off Tasks

CAP 716 states
Sign-offs should be considered as a mechanism for
ensuring that all steps in the task have been carried
out correctly
Not a method for knowing whom to blame if the task
is not done correctly.
It is expected that the person signing off anothers
work view or inspect the work before signing off.
However, CAP 716 states, It is understood that, in
some cases, the person signing-off the taskwill be
unable to view or inspect, in detail, the work which
has been carried out, but it is important that that
person has a high degree of confidence that the work
has been carried out correctly.

168

Effective Team Behaviors

Communication
Assertiveness
Situation Awareness
Leadership.

169

Communication

Communication - The ability to clearly and

accurately send and acknowledge information
and to provide useful feedback.
170

Basic Communications Model

Sender

Feedback

Message

Receiver

ENVIRONMENT

171

Communication Model
in the U.S. Nuclear Industry

3. Feedback

Sender

2. Feedback
1. Message

Receiver

ENVIRONMENT

172

Senders Responsibility
Communicating
information clearly.
Covering timely
information accurately.
Requesting verification of
feedback.
Verbalizing plans.
173

Receivers Responsibility
Acknowledge communications.
Repeat information.
Paraphrase information.
Clarify information.
Provide useful feedback.
174

Barriers to Effective
Communication
Passive listening
No feedback
Poor feedback.

Not using the right

words.
Inappropriate method.
Vague or late
information.
175

Active Listening
DO NOT

DO

Argue about things.

Ask good questions.

Bring up things that are not Make eye contact.

important.
Plan out your words while Use positive body
the other person is talking. language.
Think about other things
while the other person is
talking.

Repeat back using your

own words to make sure
you understand.
176

Written Communication
Written communication can be hard.
No visual feedback to tell you if the reader
understands.
The reader cannot ask questions.

Make sure that your writing is:

Correct
Complete
Clear.

Use computer spell checker.

177

Shift and Task Handover

EASA and the FAA require a shift and task
handover procedure acceptable to the
National Aviation Authority.
Incident investigation data shows that task
handovers are one of the major contributing
factors to error-caused events.

178

Shift and Task Handover

The primary objective of handovers is to ensure that all

necessary information is communicated between the outgoing and in-coming personnel.
Effective handovers depend on three basic elements:
1. The outgoing persons ability to understand and
communicate the important elements of the job or task
being passed over to the incoming person.
2. The incoming persons ability to understand this
information.
3. A formalized process for exchanging information
between outgoing and incoming persons and a place
and time for such exchanges to take place.
179

Shift and Task Handover

Organizations should have a recognized
procedure for task and shift handovers which all
staff understand and adhere to. This procedure
should be listed in the GMM.
The procedure should provide for sufficient time
to be made available by way of a shift overlap
20 to 30 minutes is considered good practice.

180

Aids to Effective Communication

at Shift Handover
If only one communication method is used there is a
risk of erroneous transmission. For this reason
information should be repeated using more than
one method.
While all essential information (especially the detailed
status of tasks) should be recorded in written form, it
is also important to pass this information verbally in
order to reinforce it. Then feedback/questioning can
be used to test ones understanding of the handover,
which increases accuracy.
The ability for two-way communication to take place is,
therefore, important at shift handover.
181

Aids to Effective Communication

at Shift Handover
A part of the shift handover process is to help
develop a shared mental picture of the
maintenance system, aircraft configuration, tasks in
work etc. This is particularly true when deviations
from normal working has occurred, such as
Having the aircraft in the flight mode at a point in a
maintenance check when this is not normally done.
When people have returned following a lengthy absence
(the state of things could have changed considerably
during this time) and
When handovers are carried out between experienced
and inexperienced personnel.

In all these cases handovers can be expected to

take longer.

182

Aids to Effective Communication

at Shift Handover
Written communication is helped by the
design of the documents, like the handover
log, which consider the information needs of
those people who are expected to use it.
Involve the people who conduct shift handovers
Ask them what key information should be included and
What format it should be in.

This helps accurate communication and gets their

buy-in, which contributes to its use and
acceptance of the process.
183

Handing Over a Task Directly to

Another Person
When the task is being directly handed over to
someone who is present, the task handover should
be done face to face using verbal and written
communication.
In these cases the written element is normally the
task card or non-routine process sheets. These
should be accurately completed and clearly identify
where in the task the work ended.
Any deviations from normal working practices or
procedures must be clearly highlighted with the
non-routine sheets.
184

Handing Over a Task for Somebody to

Complete Later
It is common that a job is left incomplete during a shift.
In these cases it is often not known who will eventually pick
up the job of completing and certifying the release to
service.
These situations present a far greater risk and challenge to
effectively communicate the stage of task accomplishment
and what is required to complete the job.
Face to face communication is not possible. Therefore, total
reliance has to be placed on written communication. This
provides no redundancy or an opportunity to question and
test a true understanding by the person expected to finish
the job.
185

Handing Over Non-Scheduled Tasks

Complex or lengthy non-scheduled tasks should always be
broken down into a number of discrete steps using stage sheets
or process sheets.
Many incidents have occurred when people have started a nonscheduled task, but had to leave before it was finished without
anybody to handover to.
These situations are normally associated with time pressure or
emergency situations.
It is vital that time is taken by the person leaving the job to record
in detail what activities have taken place and what is required
to complete the job. Record this on stage sheets and
emphasize any deviations from the maintenance manual.
Management and supervisors have a responsibility to ensure that
adequate time is given to maintenance staff to record their work,
if the task is not completed for any reason.
186

Cultural Differences in Communication

Culture = Customary beliefs, behavior
patterns, and material traits of a group
(organization).
Some of these beliefs deal with
communication issues.
Do not admit to mistakes.
Indirect (not straightforward) communications.
Pilots will not talk to maintenance staff, etc.

Discuss how the participants national/

organizational cultures affect communication.
187

Assertiveness

Assertiveness - The willingness to actively

participate, and the ability to state and maintain
individual position.

188

What Is Assertiveness?
Providing relevant information without being asked.
Making suggestions.
Asking questions as necessary.
Confronting ambiguities.
Willingness to make decisions.
Maintaining position when challenged until convinced
by the facts.
Clearly stating positions on decisions and procedures.
Refusing an unreasonable request.

If a disagreement exists, take the most conservative

action until more information is available.
189

Situation Awareness

Situation Awareness - The ability to maintain

awareness of what is happening on the ramp or the
hangar, as well as what is happening on the task. 190

Situation Awareness
Is the Ability to...
See elements (e.g., people and equipment) in
the work environment.
Where they are now.
Whether they are moving or stationary.

Understand the importance of what you see,

especially with regard to hazards/problems.
Project the status of the elements for the near
future (i.e., determine future implications) in
order to detect situations requiring action.
191

Barriers to Situation Awareness

Insufficient communication
Fatigue/stress
Task overload/underload
Groupthink mindset
Press-on mentality
Degraded operating conditions.

192

Overcoming Barriers
to Situation Awareness
Actively question/evaluate.
Use assertive behavior when necessary.
Analyze/monitor situation continuously.

193

Leadership

Leadership - The use of influence to direct and

coordinate the activities of the members of a group
toward the accomplishment of group objectives.194

Types of Leadership
Designated - Leadership by authority,
position, rank, or title.
Formal/permanent.

Functional - Leadership by knowledge

or experience.
Informal/temporary.

195

Designated Leadership Behaviors

Company Level
Inspire a shared vision, develop a mission, and establish
standards that help the organization achieve its next stage
of development.
Foster teamwork, collaboration, and ownership and motive
team members by recognizing/rewarding individual and
team contributions.
Plan and manage change efficiently and nurture the
strengths of followers to facilitate goal directive activities.
Serve as a symbol of the group and influence others beyond
the group to achieve mutually workable arrangements.
Establish an environment that is conducive to learning.
196

Functional Leadership Behaviors

Crew Level

Direct and coordinate crew activities.

Delegate tasks to crew members.
Ensure crew understands expectations.
Focus attention on critical aspects of situations.
Keep crew informed of task/shift information.
Ask crew members for relevant task/shift
information.
Provide feedback to crew on their performance.
Create and maintain a professional atmosphere.
197

Effective Functional Leadership

Make suggestions; do not dictate.
Encourage crew to participate.
Lead by inspiration.
Provide feedback to the crew.

198

Barriers To Effective
Leadership
Micro-management - failure to delegate
Poor interpersonal skills
Easily frustrated
Pressures crew members to perform
Unable to adapt to new situations
Rigidity.
199

Summary
Effective team
Factors that affect the
way that people behave behaviors include
Good communication,
when part of a team
including active listening
include
Obedience to authority
Conformance to team
Amount of responsibility
Motivation to do a good
job
Work group norms
Work group and national
culture.

Assertiveness
Situation awareness
Leadership.

200

VII. Human Error/

Incident
Investigation

Human Error/Incident
Investigation
Errors and violations
Types of errors
Error models and theories
Reasons Swiss Cheese model
Boeing Maintenance Error Decision
Aid (MEDA) contributing factors model

Incident Investigation
Practice
202

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).

203

Violations
Violations are often made by wellintentioned 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
204

Violation Definitions
RoutineThese 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. Condoned by management.

205

Violation Definitions (contd.)

SituationalOccur as a result of factors
dictated by the employees immediate work
area or environment. Due to such things
as
Time pressure
Unavailability of equipment, tools, or parts
Insufficient staff
Lack of supervisor/degreed engineer to ask
questions to.
206

Violation Definitions (contd.)

ExceptionalMechanic/inspector willfully
breaks standing rules while disregarding the
consequences.
These are very rare in our business!

207

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
~20% of the events are caused by a violation only
~20% of the events are caused by an error and a
violation, and
~60% of the events are caused by an error only.
208

Types of Maintenance Error

Maintenance Error = Error by a
mechanic/engineer/inspector that leads to
problems on the aircraft.
Installation errors
Servicing errors
Repair errors
Fault isolation/inspection/testing errors
Errors causing foreign object damage (FOD)
Errors causing equipment damage
Errors causing personal injury.
209

Human Error in Aircraft

Maintenance: UK CAA 1992
1. Incorrect installation of components.
2. Fitting of wrong parts.
3. Electrical wiring discrepancies.
4. Loose objects left in aircraft.
5. Inadequate lubrication.
6. Access panels/fairings/cowlings not
secured.
7. Fuel/oil caps and fuel panels not secured.
8. Gear pins not removed before departure.
210

UK Flight Safety Committee 2004

Top 10 Causes of Maintenance Mishaps
1. Failure to follow published technical data or local instructions.
2. Using an unauthorized procedure not referenced in the
technical data.
3. Supervisors accepting non-use of technical data or failure to
follow maintenance instructions.
4. Failure to document maintenance properly in maintenance
records, work package.
5. Inattention to detail/complacency.
6. Incorrectly installed hardware on an aircraft/engine.
7. Performing an unauthorized modification to the aircraft.
8. Failure to conduct a tool inventory after task completion.
9. Personnel not trained or certified to perform the task.
10. Ground support equipment improperly positioned for the task.
211

Why Are Technicians Such a Valuable

Asset in Reducing Mx Errors/Violations?

212

Error Models and

Theories

Error Theories
Now we will focus on the theories
of error.
Reasons Swiss Cheese model
MEDA contributing factors model.

214

Reasons Swiss
Cheese Model

Reasons Model of Accident

Causation
Defenses
Functional Tests
Checklists

A maintenance organization has

Productive Activities
many barriers to error.
Repairs, Servicing
Fault Isolation

Errors can happen

at any level.

Pre-Conditions
Off work activities
Physical size
Facilities
Schedule

Line Management
Delegation
Prioritization
Planning

Active And
Latent Failures
Active Failures

Decision Makers
Policies, procedures,
corporate culture

Latent Failures
Latent Failures
Latent Failures

Latent Failures

216

Reasons Model of Accident

Causation
Defenses
Functional Tests
Checklists

In most cases, errors are

Productive Activities
caught before an
Repairs, Servicing
Fault Isolation
accident occurs.
Pre-Conditions
Off work activities
Physical size
Facilities
Schedule
Line Management
Delegation
Prioritization
Planning

Active And
Latent Failures

Decision Makers
Policies, procedures,
corporate culture

Active Failures
Latent Failures
Latent Failures

Latent Failures

Latent Failures

217

Reasons Model of Accident

Causation
Defenses
Functional Tests
Checklists

An accident only occurs

Productive Activities
when a failure occurs Repairs, Servicing
Fault Isolation
in all of the
Pre-Conditions
Off work activities
barriers.
Physical size

Accident

Facilities
Schedule
Line Management
Delegation
Prioritization
Planning

Active And
Latent Failures

Decision Makers
Policies, procedures,
corporate culture

Active Failures
Latent Failures
Latent Failures

Latent Failures

Latent Failures

218

Three Types of Error

SLIP: An error in EXECUTING the steps of a task
Example: The mechanic knows how to install a pump, but
turns the wrench too hard and breaks a fitting.
Also called an error of commission
LAPSE: An error in RETRIEVING information about a task
Example: A mechanic is called to help on a different task
after torquing 3 of 5 bolts. When he comes back to his
original job he forgets that he had two bolts left to torque
and moves on to the next task.
Also called an error of omission
MISTAKE: An error in PLANNING a task
Example: I do not need to do the fault isolation, because I
have seen this problem before! I will replace this box.
Based on Reason, James; Human Error, New Your: Cambridge University Press, 1997

219

HF Programs in AMO
Occurrence Reporting and Recording Process:
Incidents, occurrences, errors and potential safety hazards may
be identified as a result of an event (an incident, air turnback,
rework, etc) or by a report submitted by a staff member (e.g.
reporting an error made by themselves or a colleague which was
detected and did not result in an event).

Investigation of Occurrences.
Data Analysis and Review.
Managing Identified Hazards.
Feedbacks.
HF training: initial & Recurrent.

220

The Maintenance
Error Decision Aid
(MEDA)
Contributing
Factors Model

What Is MEDA?
MEDA is a process that is used to investigate events
caused by mechanic/inspector performance.
A maintenance-related event can be caused by an error, by
not following company policies, processes, and procedures
(violation), or by an error/violation combination.
Maintenance errors are not made on purpose.
Errors result from a series of contributing factors in the
workplace.
Violations, while intentional, are also caused by contributing
factors.
Most of the contributing factors to errors and/or violations are
under management control.
Therefore, improvements can be made so that these
contributing factors do not contribute to future events.
222

MEDA Contributing Factors

Things that affect human performance
are called contributing factors
Best understood using a maintenance
system model

Mechanic

Immediate Work
Environment

Overall
Supervision Maintenance &
Engineering
Organization

223

Contributing Factors to
Maintenance Error

Mechanic
Knowledge
Skills
Abilities
Other characteristics

Immediate Environment
Facilities
Weather
Aircraft design/configuration
Component design
Equipment/tools/parts
Maintenance manuals
Tasks
Time pressure
Teamwork
On-the-Job training
Communication

Supervision
Planning
Organizing
Prioritizing
Delegating
Instructing
Feedback
Performance
Management
Team
Building

Organization
Philosophy
Other M & E
Organizations
Policies
Procedures
Processes
Selection
Training
Continuous
Quality
Improvement

224

Levels of Causation
Two 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.
The most common level of causation in
error investigation is probabilistic

225

MEDA Error Model

Probability

Contributing
Factors

Lead
to

Poor lighting
Missing step
Poor hand over report
Lack of skill
Hard to reach
Miscalibrated tool
Wrong part from Spares
Understaffed
Poor supervision

Probability

Error

Leads
to

Incomplete installation
Wrong part installed
Incorrectly serviced
Not repaired correctly
Incorrect troubleshooting
Missed during inspection

Event
Flight cancellation
Gate return
In-flight shut down
Diversion
Equipment damage
Personal injury

226

MEDA 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.
227

MEDA Error Model

Probability
Probability

CF

CF

CF

CF

CF

CF

CF

Probability

Probability

Error

Event

Also, there are contributing factors

to the contributing factors.

228

Errors and Violations

We now know that errors and violations often
occur together to produce an event. Data
from the U.S. Navy suggest that:
~20% of the events are caused only by a
violation
~20% of the events are caused by both an
error and a violation, and
~60% of the events are caused only by an
error.

Let us look at the ways that violations can

contribute to errors and events.
229

Error and Violation Model 1

Probability

Contributing
Factors

Probability

Violation

System
Failure

Probability

Event

Mechanic does not use a torque wrench (violation),

which contributes to an incorrect installation (system failure)
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).

230

Error and Violation Model 2

Probability

Probability

Contributing
Factors

System
Failure

Contributing
Factors

Violation

Event

The mechanic mistakenly misses a step in the maintenance manual

(contributing factor),
which leads to an incomplete installation (system failure).
The mechanic decides not to carry out 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.
231

Incident
Investigation/
MEDA Results Form

Incident Investigation
The EASA 145 organizations are now required to
investigate, evaluate, collect reports, analyse,
identify trends and apply corrective actions.
Those that were, or could have been, a serious
hazard to the aircraft are submitted to the NAA.
Those of a lesser threat to safety are still required
to be investigated, evaluated, and analysed.
Corrective actions to make the system resistant to
similar maintenance errors.
233

MEDA Results Form

I. General Information
II. Events
III. Maintenance System Failure
IV. Contributing Factors
V. Error Prevention Strategies
234

Results Form - General

Information

Boeing provides Results Form on a diskette for

airline to modify
235

Results Form
Event

Process loss
Aircraft damage

Personal injury
Rework
Airworthiness control

236

The Event Iceberg

Serious
Events

Present level of
investigation

Costly Events
In-flight shutdowns, turn backs,
delays/cancellations, equipment
damage, and personal injuries

Other Events

Where MEDA
should start
Where MEDA
should go

Rework--Maintenance tasks done incorrectly

but caught by inspection or functional test

All events are due to similar contributing factors. Therefore,

responding to lower level events will prevent higher level events.

237

Results Form
Maintenance System Failure

238

Results Form - Contributing Factors

Information

Individual Factors

Equipment/Tools/Safety
Equipment

Environment/Facilities

Aircraft Design/
Configuration/Parts
Job/Task

Organizational Factors
Leadership/Supervision
Communication

Knowledge/Skills

239

Information
Information is a contributing factor when it is...
Hard to read or understand
Incorrect
Not used because it is
Unavailable
Inaccessible
Simply not used

Out of date
Not modified to meet the
current configuration
240

Equipment /Tools/Safety Equipment

Equipment or tools may be a contributing factor
when they are. . .
Unsafe
Hard to use
Not used
Unavailable
Mis-calibrated
Inappropriate for the task
Cannot be used in intended environment
No Instructions
241

Aircraft Design/Configuration/Parts
Aircraft design is a contributing factor when. . .
Design contributes to
access problems
A part is difficult to
reach and remove
Aircraft configuration
varies
A part is easy to
replace incorrectly
A part is unavailable
A part is incorrectly labeled
242

Job/Task
The job or task is a contributing factor
when it is. . .
Repetitive / monotonous
Complex / confusing
Different from other,
similar tasks
New task or task changed.
243

Knowledge/Skills
Knowledge or skills may be a contributing factor
when . . .
Technical skills are inadequate
Mechanics task planning is inadequate
Technical knowledge is lacking in...
Maintenance organization process
Aircraft system
Job / task

Other skills may be lacking

English language proficiency
Teamwork skills
Computing skills.
244

Individual Factors
Examples of individual contributing factors include:
Physical health
Senses (eyesight, hearing, etc.)
Physical conditions / illnesses

Fatigue
Time pressure
Peer pressure
Body size and strength
Task distraction/interruption
Memory lapse (forgot)
Stress.
245

Environment / Facilities
This image cannot currently be displayed.

Examples of the environment or facilities being

contributing factors include:
Environment
Noise
Temperature
Weather

Facilities
Hazards
Air quality
Lighting
Markings
Labels/placards/signage.

246

Organizational Factors
Examples of organizational contributing factors:
Quality of support from technical departments
Lack of parts
Uncalibrated tools

Company policies
Shift work and overtime
Staffing levels

Company work processes

Not a good processerror inducing
Good process, but not followed
No documented process
Company norm not to follow process.
247

Leadership/Supervision
Leadership or supervision
may be a contributing factor
when. . .
There is poor planning or
organizing of work.
Work is assigned to mechanics
who are poorly suited for the job.
Supervision has an inaccurate
belief about how long it takes to
do a task.
There is inadequate supervision.
248

Communication
Poor written and verbal communication
between . . .
Mechanics
Mechanics / lead
Lead / management
Flight crew / maintenance
Across shifts
Departments.
249

Results Form
Contributing Factors

Must describe how factor contributes to the system

failure
N/A = Not applicable
250

The Dirty Dozen

251

Summary
We have provided information about the key
maintenance Human Factors requirements from
EASA 145.
These requirements were put into place in order
to increase safety, quality, and efficiency in
aircraft maintenance operations by reducing human
error and its impact on maintenance activities.
We hope that you are able to use the information
that we have provided in order to enjoy these
benefits at your airline.
252

Questions?

253