1. Human Performance In Aviation Maintenance Workshop

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

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

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

5. 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?

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

7. 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.

9. What do you need?
Safety Net

10. A SAFETY NET

11. CHAIN OF EVENTS

12. 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

13. HPIAM History

16. * Run Dryden Video

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

18. The Heinrich Ratio Fatal accident Accidents Reportable incidents1
Accidents 10
Reportable
incidents 30
Incidents
600

19. “[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

20. 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

21. 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

22. 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

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

24. 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

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

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

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

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

29. 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

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

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

33. 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

34. The Dirty Dozen
Introduction

35. 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

36. VIDEO

37. Survival Exercise

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

39. Lost on the Pacific Coast

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

44. TEAMWORK

45. What Makes A Good Team?

46. Name Some Teams Where You Work
Teams within teams

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

48. COMMUNICATION (LACK OF)

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

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

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

52. 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

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

54. AN EXERCISE FOR THE MIND

55. Verbal vs Body Language

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

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

58. Written Communication
“a sharing of thoughts”

59. Shift Change Exercise

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

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

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

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

65. Aggressive Assertive Passive
ASSERTIVENESS
Aggressive
Assertive
Passive

66. 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

67. Assertiveness
Why Does It Matter?

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

69. Survival Exercise Results

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

71. Case Study MacDonald Douglas 369

72. Small details… large results

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

75. Presumed location of container after inspection

76. Engine Inlet

77. 50% air flow restriction

78. Damaged rotor blade and skid gear