Human Factor

Human Factors in Aviation Maintenance
Welcome
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
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
List Human Factors Related to Maintenance

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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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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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
Human Factors in Aviation Maintenance 34
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 What do you see at home with the human factors spectacles? In the mirror?
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A Reminder to Apply Human Factors Principles 24 x 7
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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, 3D, or mental
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The SHELL Model
Originally used for pilots 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 Size
Gender Age Strength The five senses
Psychological
Experience Knowledge Training Attitude Emotional state
Physiological Health
Nutrition Lifestyle Alertness/fatigue
Psychosocial Interpersonal relations

Ability to communicate Empathy Leadership
Chemical dependency
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People Fatigue
Physical Size
Psychological
Nutrition Lifestyle

Lets review one

Alertness/fatigue Chemical dependency
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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 nights 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 nights 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
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

Physical Psychological
Lets review one
Size

Chemical dependency
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Anthropometry
The Study of Body Measurement User populations Why its important Male/female split Individual variation Use of percentiles The myth of the 50th percentile person 5th through 95th percentile
Anthropometry Percentiles
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People Vision and Hearing

Physical Size
Gender Age Strength
Psychological
The Five Senses
The five senses

Chemical dependency
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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 youre having your meal, 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

Sensing and Perception dog house table car tree

Sensing and Perception red blue gray purple green

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 Weather extremes
Location (in/out) Workspace Lighting Sound levels Housekeeping Safety issues
Organizational Personnel
Supervision Labor - management Size of company Profitability Job security 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 everyones 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 Its 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
Its 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 dont work as written Most common violation is failure to follow procedures
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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 Authoritys 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
Boeings 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.

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
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Maintenance Accidents
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Fatal Accidents: Intl 1998 to 2007

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

60 2000 1800 50 1600 1400 1200 30 1000 800 20 600 400 200 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 0
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Fatal Accidents
10
Year
US Accidents World Accidents US Fatalities World Fatalities
Source: US NTSB and Flight International, 8-14 January 2008
Fatalities
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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 maintenancerelated accidents Specific accidents
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Historic Maintenance-Related Accidents
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Recent Maintenance-Related Accidents

Jan 2000 Mar 2001 Apr 2001 Aug 2001 May 2002 Jan 2003 Aug 2003 Jan 2006 Jul 2006 Alaska Airlines Lufthansa Emery Worldwide Air Transat China Airlines Air Midwest Colgan Air Continental Spectrum Aircraft MD-80 A320 DC-8 A330 B747-200 Beech 1900D Beech 1900D B737-500 Spectrum 33 Jackscrew for elevator control Mis-wired side stick Reversed hydraulic check-valve Fuel exhaustion over Atlantic In-flight break-up at 35K feet Trim rigging Trim rigging Engine run-up Mis-rigging
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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
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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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Where to Get Information
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Three Reference Manuals
www.hfskyway.com
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Where to Get Information: Sample Page from Operators Manual for Human Factors in Aviation Maintenance
Training Human Factors Guide for Aviation Maintenance and Inspection Human Factors Operators 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
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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 Operators Manual for Human Factors in Aviation Maintenance, Washington, DC, available at Ops Manual HF in Aviation Maint.pdf FAA (2007), The Operators 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?opendoc ument 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
Summary
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Human Factor

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Human Factor

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Human Factors in Aviation Maintenance

Human Factors in Aviation Maintenance

Human Factors in Aviation Maintenance

Human Factors in Aviation Maintenance

What is Human Factors?

Human Factors in Aviation Maintenance

What is Human Factors?

Human Factors in Aviation Maintenance

List Human Factors Related to Maintenance

Human Factors in Aviation Maintenance

What is Human Factors?

Human Factors in Aviation Maintenance

Human Factors Goal A Summary

Human Factors in Aviation Maintenance

The Elements of Human Factors

Human Factors in Aviation Maintenance

Human Factors in Aviation Maintenance

Human Factors in Aviation Maintenance

Human Factors in Aviation Maintenance

Human Factors in Aviation Maintenance

Human Factors in Aviation Maintenance

Human Factors in Aviation Maintenance

Human Factors in Aviation Maintenance

Principles of learning Ways to help people to remember Design of instruction

Human Factors in Aviation Maintenance

Human Factors in Aviation Maintenance

Human Factors Goal for Review

Human Factors in Aviation Maintenance

History of Human Factors

Human Factors in Aviation Maintenance

The History of Human Factors

Human Factors in Aviation Maintenance

Maintenance Human Factors has Evolved in 20 Years!

Human Factors in Aviation Maintenance

Human Factors Timeline

Human Factors in Aviation Maintenance

Human Factors and Ergonomics Society and International Ergonomics Association

Human Factors Spectacles

Human Factors in Aviation Maintenance

Put on your Human Factors Spectacles

Put on your Human Factors Spectacles

Sensitivity to human factors

Human Factors in Aviation Maintenance

Human Factors in Aviation Maintenance

A Reminder to Apply Human Factors Principles 24 x 7

Human Factors in Aviation Maintenance

The PEAR Model

Human Factors in Aviation Maintenance

Why Use Models?

Human Factors in Aviation Maintenance

The SHELL Model

Human Factors in Aviation Maintenance

The SHELL Model Explained

Human Factors in Aviation Maintenance

The PEAR Model

Human Factors in Aviation Maintenance

Human Factors in Aviation Maintenance

Psychosocial Interpersonal relations

Psychosocial Interpersonal relations

Lets review one

Alertness/fatigue Chemical dependency

What Does This Mean?

Human Factors in Aviation Maintenance