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Aviation Safety
Intent
This course is designed to study the underlying causes which may result in a well intentioned Aircraft Maintenance Engineer (AME) making a maintenance error. We will also look at what we can do to prevent ourselves from contributing to events which lead to an accident
OBJECTIVES
To create an awareness of the "Human" aspect of aircraft maintenance and develop safeguards to lessen the "Human Cause" factors in maintenance.
To examine the human role of maintenance that can lead to an aviation occurrence and develop ways to prevent or lessen the seriousness of the occurrence.
Failures
The failures caused by those in direct contact with the system, ie, the engineers who are working on the aircraft, are considered to be active failures. These failures are errors or violations that have a direct and immediate effect on the system. Generally, the consequences of these active failures are caught by the engineer himself, or by the defences, barriers and safeguards built into the maintenance system. Thus, the system must rarely deal with the consequences of active failures. However, when an active failure occurs in conjunction with a breach in the defences, a more serious incident occurs.
Latent failures
These are those failures which derive from decisions made by supervisors and managers who are separated in both time and space from the physical system. For example, technical writers may write procedures for a task with which they are not totally familiar. If the procedure has even one mistake in it, the engineer using the procedure will be encouraged to commit an error. The latent failures can often be attributed to the absence or weaknesses of defences, barriers, and safeguards in the system. Often, latent failures may lie dormant in the system for long periods before they become apparent.
In order to simplify the relationship between engineers and the factors which impact upon their every day working lives several models have been produced.
SHELL Model
Here the emphasis is placed upon the interfaces and integration between the engineer and the aspects which affect his/her performance.
PEEP Model
Fateful Combination
For an incident to occur, latent failures must combine with active failures and local triggering events, such as unusual system states, local environmental conditions, or adverse weather. There must be a precise 'alignment' of all of the 'holes' in all of the defensive layers in a system. (See Reason's Swiss Cheese Model). For example, rain may cause a engineers' foot to be wet, allowing his foot to easily slip off the worn brake pedal in a pushback tug when the engineer becomes distracted. The tug may then lunges forward contacting a parked aircraft. The latent failure in the system is that the brake pedal has no anti-slip surface in place, but the problem does not become an issue until the rainy conditions (a local trigger) cause an incident. It can be seen that if any one of the failures had not occurred (engineer did not become distracted, the tarmac was not wet, or the brake pedal was in better condition), the incident would have been avoided.
An incident similar to this at Edinburgh Airport resulted in the loss of life of an engineer during turnaround when, during the removal of a ground power unit following engine start, the engineer maneuvered within the rotating propeller arc.
Types of Error
Basically the types of errors encountered fall into four categories:
Slips Lapses
Mistakes
Violations
Slips can be thought of as actions not carried out as intended or planned, e.g. transposing digits when copying out numbers, or carrying out steps in a procedure in the wrong order. Slips typically appear at the execution stage of a process.
Slips
Lapses Lapses are identified as missed actions or omissions, ie. The occasion when somebody has failed to do something due to a lapse of memory and/or attention or because they have forgotten something, e.g. forgotten to close and secure the oil cap. Lapses typically occur as a result of failures in our capacity to store and retrieve information from our memory bank.
Mistakes are a specific type of error brought about by a faulty plan or intention, i.e. somebody doing something believing it to be correct when it is, in fact, wrong, e.g. an error of judgment such as selecting the wrong bolts when refitting an aircrafts windscreen. Mistakes typically occur during the planning stages of a process.
Mistakes
Violations sometimes appear to be human errors, but they differ from slips, lapses and mistakes because they are deliberate illegal actions, i.e. somebody doing something knowing it is against the rules, e.g. deliberately failing to follow the proper procedures. AMEs may consider a violation is well intentioned, i.e. taking a short cut in order to get the job done on time. Always remember however that procedures must be followed in the interests of not only safety but also of cost.
Violations
ErroRs
Errors which can contribute towards mistakes leading to accidents are incalculable. However, some of them will fall into one or more of the following:
Inadequate information
be it visual or verbal can, does and will lead to people making mistakes. If you think the information you have is inadequate or insufficient do something about it.
Lack of understanding
possibly stemming from inadequate information or maybe lack of training can lead to people making presumptions as to how a particular process or procedure is carried out. This can and does lead to accidents. If you're not sure ask.
Poor design
Can result in the best of intentions turning out wrong. Remember Murphy? If there's a wrong way to do it that's the way you'll do it! If you recognize a Murphy do something about it if it's only telling others about it.
Lapses of attention
can and will allow errors to creep in, especially if its a simple straightforward repetitive task. The lesson here is that the more expert you become at a particular task, the more likely you are to make a mistake, because you think you can afford to allocate less attention to it. Beware the expert both in yourself and in others
Mistaken actions
brought about by the classic situation of doing the wrong thing under the impression that it's right. A classic example of this is the 'short cut' wherein the engineer knows what has to be done but chooses his own method of doing it. Don't take short cuts.
Misperceptions
meaning the capacity we have to see what we want to see, hear what we want to hear, feel what we want to feel etc. This factor is particularly relevant to the work of an aircraft engineer in as much as a great many tasks are of a repetitive nature. The lesson here is to be vigilant and on guard against it.
Vision
Vision can be adversely affected by certain medications or drugs, alcohol excess, oxygen shortage (hypoxia), injury, e.g. a blow to the head, etc. It can also be affected either temporarily or permanently by medical conditions e.g. migraine, cataracts, inflammation, corneal problems or refractive surgery or by dirty or dehydrated contact lenses or even very dirty spectacles.
Noise
Can detrimentally affect human performance in terms of damaging hearing, interfering with speech communication, and affecting concentration and performance. It can also be fatiguing. Effects vary between individuals, and noise of a certain type and level may be good for one individual but bad for another. Noise can affect motivation, reduce tolerance of frustration and reduce levels of aspiration. There may be an impact upon the individual's ability to think. It is almost certainly likely to affect inspection or troubleshooting activities where the strategy used is left to the individual, being primarily assessment - rather than activity-based, possibly reducing the likelihood of successfully thinking laterally under such circumstances. How many of us can recall, when concentrating hard on a task, shouting "Stop that noise; I can't think straight!" In order to understand the effect both vision and hearing have in terms of maintenance it is useful to know a little about the anatomy of both the eye and the ear. Likewise, in order to understand the potential each one of us possesses to make mistakes, it will help to know a little about our ability to receive, store and use information.
Noise Makers..
HumanEye
HumanEye
The eye is the organ which receives light information from the external world and passes it to the brain. The visual cortex area of the brain interprets this information, presenting it as a rational, realistic image. The basic structure of the eye is similar to a simple camera, with an aperture, a lens, and a light sensitive screen, the Retina.
The Retina. The retina is a light sensitive screen lying at the back of the eyeball. On this screen are light sensitive cells. The cells are of two types; cones and rods. The cones can only detect colours, the rods can only detect black and white but are much more sensitive at low light levels. This means that in poor light we see only in black or white or varying shades of grey. When light falls on these cells a small electrical charge is generated which is passed onto the brain by the optic nerve. The Optic Nerve. The optic nerve enters the back of the eyeball along with the small blood cells needed to carry oxygen to the cells of the eye.
The Fovea.
The central part of the retina, the Fovea, is composed only of cone cells and only at this part of the retina is vision 20/20 or 6/6. The figures are a means of measuring visual acuity, the ability to discriminate at varying distances. An individual with 20/20 vision should be able to see at 20 feet that which the so-called normal person is capable of seeing at this range. Any resolving power at the fovea drops rapidly as the angular distance from the fovea increases. At as little as 5 from the fovea the acuity drops to 20/40 that is half as good as at the fovea. When the angular displacement increases to 20 the visual acuity will only be one tenth of that at the fovea, that is 20/200. Anything that needs to be examined in detail is automatically brought to focus on the fovea. The rest of the retina fulfils the function of attracting our attention to movement and change,i.e. our peripheral vision, provided by rods.
Visual Defects.
Most visual defects are caused by distortion of the natural shape of the eyeball. Hypermetropia. Is long sightedness, (Hypermetropia). A shorter than normal eyeball along the visual axis results in the image being formed behind the retina and unless the combined refractive index of the cornea and the lens can combine to focus the image in the correct plane a blurring of the vision will result when looking at close objects. A convex lens will overcome this refractive error. Myopia. Is short-sightedness, (Myopia). The problem is that the eyeball is longer than normal and the image forms in front of the retina. If accommodation cannot overcome this then distant objects are out of focus whilst close up vision may be satisfactory. A concave lens will correct the situation. Astigmatism. This condition is usually caused by a misshapen cornea. Objects will appear irregularly shaped. Modern surgical techniques can reshape the cornea with a scalpel or more easily with laser beams.
Human Ear
The Ear
The ear performs two quite separate functions: Firstly it is used to receive vibrations in the air (sounds), Secondly it acts as a balance organ and acceleration detector.
Inner Ear which is filled with liquid. The last of the bones connects to another membrane in the inner ear.
Hearing
The Inner Ear. The vibrating membrane causes the fluid in the Cochlea to vibrate. Inside the cochlea there is a fine membrane covered with tiny hair like cells. The movement of these small cells will be dependent on the volume and pitch of the original sound. The amount and frequency of displacement is detected by the auditory nerve which leads directly to the brain where the tiny electrical currents are decoded into sound patterns.
Hearing Impairments
. Hearing difficulties are broadly classified into three categories:
Conductive deafness Noise Induced Hearing Loss (NIHL). Presbycusis. (Loss through ageing).
Conductive deafness.
Any damage to the conducting system, the Ossicles or the ear drum, will result in a degradation of hearing. It is possible that perforations of the ear drum will result in scarring of the tissue thus reducing its ability to vibrate freely. A blow to the ear may cause damage to the small bones in the middle ear again limiting the transfer of vibrations. Modern surgery may help in some circumstances.
Airport Pekak
The noise level on and around a busy airport can be very high and it is essential that ear defenders are worn by all personnel working in the area of high noise levels. Put on ear muffs
Notes:
For the younger element the noise level in discos can be excessive and personal stereos can reach above the safety level. Noise Induced Hearing Loss (NIHL) is not treatable at the moment. Recent experiments hold out some hope of a cure as researchers have been able to regrow the fine hair like cells in the cochlea of young rats. The treament involves the use of retinoic acid, made from vitamin A. The treatment in humans is still however a long way off and the only sure way to avoid NIHL is to protect the ears from loud noises.
Presbycusis.
(Loss through ageing). Hearing deteriorates with advancing age. Young children can hear high pitched noises outside the range of adults. The loss of some hearing is natural as one grows older but if combined with some NIHL there may be a chance of increased impairment.
Within the inner ear are three Semi-circular canals, tubes filled with liquid and arranged in three planes at 90 degrees to each other. Within these tubes are fine hairs which are bent as the liquid in the tubes moves in relation to the walls of the tubes. The movements of these hairs generates a small electric current which is passed to the brain to be detected as a movement of the head.
Alcohol in the fleshy stalk of the Otolith may persist for days after all traces of alcohol have vanished from the blood. It is not unusual for even small movement of the head to cause disorientation or motion sickness up to three days after alcohol was last consumed.
Information Processing
Information processing can be represented as a model. This captures the main elements of the process, from receipt of information via the senses, to outputs such as decision making and actions. One such model is shown. Information processing is the process of receiving information through the senses, analysing it and making it meaningful.
Information Processing
Attention
This can be thought of as the concentration of mental effort on sensory or mental events. Although attention can move very quickly from one item to another, it can only deal with one item at a time. Attention can take the form of: Selective attention, Divided attention, Focused attention Sustained attention.