Human Performance In Aviation Maintenance Workshop

Please state your: INTRODUCTION Name Company Position Number of years in aviation

WORKING AGREEMENT Facilitators agree to: Act as facilitators Provide structure Direct activities Answer questions Confront issues

WORKING AGREEMENT You agree to: Actively participate Share experiences Be open Feel free to disagree Sit back and enjoy yourself

Are you human? Do humans make mistakes? Rate yourself on a scale of 1 to 10 on the following questions (10 is most willing) How willing are you to learn how to reduce the possibility of making a mistake? How willing are you to change?

Workshop Objective To raise awareness of human error and develop ways to prevent or reduce the occurrence and consequences of human error in aviation

What You Will Leave With An awareness of the human aspect of aircraft maintenance. An awareness of how your performance can affect the entire system. Tools to prevent maintenance errors— safety nets.

What do you need? Safety Net

A SAFETY NET

CHAIN OF EVENTS

Aviation Accidents 100 90 80 70 60 % 50 40 30 20 10 1903 Present Day Human Error 70 60 % 50 40 30 20 10 Machine Error 1903 Present Day

HPIAM History

* Run Dryden Video

Industry estimates vary between Maintenance errors contribute to what percentage of aircraft accidents/incidents? Industry estimates vary between 6% and 25%

The Heinrich Ratio Fatal accident Accidents Reportable incidents 1 Accidents 10 Reportable incidents 30 Incidents 600

“[Maintenance] error is not the cause of an accident. The cause is to be found in whatever it was that interfered with the [Aviation Maintenance Specialist’s performance] at a critical moment, the outcome of which was a [maintenance] error.” Jerome Lederer, President Emeritus, Flight Safety Foundation

What are the benefits of Human Performance Training ? At one major airline, after twelve months of training the following was found : Ground damage repair costs decreased 68% Maintenance related ground damage decreased 34% Occupational injury hours decreased 27% Occupational injury medical payout decreased 12% Ref: : Airline Maintenance Resource Management J.C. Taylor & T.D. Christensen

WORKSHOP OUTLINE Day 1 Introduction History Human Error Intro. to the “Dirty Dozen” Survival exercise Teamwork Communication Shift Change Exercise Assertiveness Case study: McDonald Douglas 369

Case study: Human Factors In Aircraft Maintenance WORKSHOP OUTLINE Day 2 Fatigue Stress Distraction Case study: Human Factors In Aircraft Maintenance Lack of Awareness Lack of Knowledge Lack of Resources Case study : Fokker F-28 Pressure Norms Complacency Case study: Boeing 737 Conclusion

RUN THE VIDEO THE HUMAN FACTORS IN AIRCRAFT MAINTENANCE MODULE 1 RUN THE VIDEO THE HUMAN FACTORS IN AIRCRAFT MAINTENANCE

Human Error We all commit errors Any time an action does not produce the desired result Something we do Something we fail to do THINGS THAT INTERFERE WITH OUR PERFORMANCE

Performance Different tasks; different approach Two different types performance: a) Conscious b) Automatic

Automatic Performance Develops only with practice Very fast Can do several things at once Repetitive Little conscious attention Skill-Based

Conscious Performance Two different kinds: a) Rule- Based b) Knowledge-Based

Rule -Based Slower Sequential Can only actually think about one thing at a time Requires effort

Knowledge-Based Not familiar with the situation Not sure how to deal with it Use all the resources available to solve the problem Trial and Error/Success

Types of Errors 1. Execution Errors Forget lockwire Using the wrong procedure 2. Planning Errors Change the wrong component Violation

Error There is often only one way to get it right, but lots of ways to mess up Terrible Odds exercise

Common Errors* Omission—forget a step, a part, etc. 56% Incorrect installation 30% Wrong part 8% Other (ground handling, etc.) 6% * Ref.: ICAO Human Factors Circular 12 - Human Factors in Aircraft Maintenance Digest

The Dirty Dozen Introduction

1. Lack of Communication 2. Complacency 3. Lack of Knowledge 4. Distraction 5. Lack of Teamwork 6. Fatigue 7. Lack of Resources 8. Pressure 9. Lack of Assertiveness 10. Stress 11. Lack of Awareness 12. Norms

VIDEO

Survival Exercise

Beware of any gathering that includes name tags and “Facilitators”

Lost on the Pacific Coast

Fill out questionnaire and submit to facilitators. Survey Fill out questionnaire and submit to facilitators.

TEAMWORK

What Makes A Good Team?

Name Some Teams Where You Work Teams within teams

Five Strategies to Maintain an Effective Team Maintain a clear mission Maintain team expectations Communicate with all team members Maintain trust Pitch in

COMMUNICATION (LACK OF)

and interpret messages. What is Communication ? The dynamic process by which we engage and interpret messages.

Methods Of Communication What you say What experts say ? Verbal 7% Tone of Voice ? 38% ? 55% Body Language 100% 100% Ref.: Albert Mehrabian

The Secret To Good Communication 2 EARS 2 EYES 1 MOUTH Use them in that order and proportion.

COMMUNICATION MODEL 30 A + B + C = What's said Filters Filters A + B + C = What's said A + C = What's said that is subject to interpretation B = What's understood B = About % efficiency 30

Filters or Barriers to Communication Prejudice Noise/lighting Distraction Culture Language Any others?

AN EXERCISE FOR THE MIND

Verbal vs Body Language

To Improve Communication LEARN TO LISTEN Don’t debate Don’t detour Don’t pre-plan Don’t tune out

To Improve Communication Ask questions Paraphrase Make eye contact Use positive body language Watch for filters: theirs and yours

Written Communication “a sharing of thoughts”

Shift Change Exercise

Consider Your Audience ? Knowledge? Values? Experience? Language skills? Expectations? Attitude? Perception? Culture? ?

ASSERTIVENESS Ability to express your feelings, opinions, beliefs and needs Expressing yourself in a positive, productive manner

Assertion basically involves: asking for what you need saying no when necessary

Assertiveness Works Both Ways Assertive behaviour involves being able to receive requests or refusals with respect for others.

Aggressive Assertive Passive ASSERTIVENESS Aggressive Assertive Passive

Assertiveness–How to Know what you want to say Take the time you need to plan what you need to say Stick to the issue at hand Deal with the facts Support what you say with how you say it

Assertiveness Why Does It Matter?

Awareness Knowledge Pressure Fatigue Resources ASSERTIVENESS Norms Teamwork Stress Communication Complacency Distraction

Survival Exercise Results

Personal Safety Nets Lack of Teamwork Lack of Communication Lack of Assertiveness (as per posters)

Case Study MacDonald Douglas 369

Small details… large results

Tennis Ball container supporting by-pass door open AIR BYPASS DOOR AIR BYPASS DOOR Tennis Ball container supporting by-pass door open

Presumed location of container after inspection

Engine Inlet

50% air flow restriction

Damaged rotor blade and skid gear