1. 1 SWISS Safety, 30 March 2006 SVFB Welcome! Operational Safety – Technical Safety

2. 2 SWISS Safety, 30 March 2006 SVFB Operational Safety – Technical Safety

3. 3 SWISS Safety, 30 March 2006 SVFB Operational Safety – Technical Safety

4. 4 SWISS Safety, 30 March 2006 SVFB Operational Safety – Technical Safety

5. 5 SWISS Safety, 30 March 2006 SVFB Operational Safety – Technical Safety

6. 6 SWISS Safety, 30 March 2006 SVFB Human Factor –Intentional non - compliance –Proficiency –Operational Decision –Communication –Procedural –Incapacitation Operational Safety – Technical Safety

7. LOSA results: Errors committed and consequences (per 100 flights) 0102030405060 Violation (intentional) Procedural (un-intentional ) Communication Proficiency / Skill Operational Decision-making number of errors which became consequential number of flights with errors Source: UT; Dr. R. Helmreich Note: Crews which committed violations where twice as likely to encounter an additional error!

8. 8 SWISS Safety, 30 March 2006 SVFB Operational Safety – Technical Safety Without the whole hearted commitment of management, any safety program will be ineffective Safety is good for business Question: Who is producing Safety? Safety Culture Senior Management Commitment

9. 9 SWISS Safety, 30 March 2006 SVFB Reactive Focus Normal Operations Exceedences Proactive Focus Incidents Accidents Accident Precursors Incident Precursors Operational Safety – Technical Safety

10. 10 SWISS Safety, 30 March 2006 SVFB Operational Safety – Technical Safety Data provided by Quick Access Recorder B - 747-500 Parameters MD - 11-1500 Parameters A320-2500 Parameters A330-4000 Parameters out of 10000

11. 11 SWISS Safety, 30 March 2006 SVFB Operational Safety – Technical Safety Stop shaking, man! Just tell me what happened?

12. 12 Flight Data Monitoring 12 SWISS Safety, 19 May 2005 WANO Operational Safety – Technical Safety

13. 13 SWISS Safety, 30 March 2006 SVFB Operational Safety – Technical Safety Contributing factors to maintenance errors

14. 14 SWISS Safety, 30 March 2006 SVFB We must not aim to eliminate human error Error is a useful mechanism to allow humans to learn However, we must manage error where it can have a significant impact on: –Aircraft Safety –Health and Safety –Economics Operational Safety – Technical Safety Managing maintenance errors

15. 15 SWISS Safety, 30 March 2006 SVFB In Europe, EASA have identified maintenance human factor issues Currently have plans to develop regulations governing all areas of the industry between 2005 and 2007: –Design organisations, (Part21-P-NPA) –Airframe manufacturers, (Part25- P- NPA 25-310) –Powerplant manufacturers (Part E- NPA-E-38) –Maintenance organisations: (Part 145 Amendment 5) Operational Safety – Technical Safety Regulators approach

16. 16 SWISS Safety, 30 March 2006 SVFB –Error reporting system –Efficient shift and task handover procedures –Organisation of shifts –Effective planning of maintenance tasks –HF training –etc EASA PART Part 145 Amendtment 5 requires Operational Safety – Technical Safety Regulators approach

17. 17 SWISS Safety, 30 March 2006 SVFB Maintenance organizations are faced with the practical questions of Human Factors, including: –Minimizing the number of errors and their consequences Error detection (e.g. reporting) Event analysis and improvement actions Training –Dealing with violations Understanding violations and removing the need to violate Violation management Operational Safety – Technical Safety Managing maintenance errors

18. 18 SWISS Safety, 30 March 2006 SVFB The Challenge –The conflict of maintenance professionalism –Maintenance personnel in some organisations are unable to openly report for fear of disciplinary action The Solution –These issues cannot be solved by one measure alone, but in the development of a Just and Learning Safety Culture Blame Just and Learning No Blame Styles of Safety Culture Operational Safety – Technical Safety Managing maintenance errors

19. 19 SWISS Safety, 30 March 2006 SVFB Operational Safety – Technical Safety Airbus maintenance error study

20. 20 SWISS Safety, 30 March 2006 SVFB Operational Safety – Technical Safety Top Six Error Types: –13%Installation incomplete, component installed but not secured –10%Installation incorrect, incorrect torque applied –9%Installation incomplete, component/ fluid/ material missing –8%Installation incomplete, access panel not closed/ secured –6%Installation incorrect, system/ equipment incorrectly set or reset –5%Installation incorrect, incorrect component/ part/ fluid/ gas/ material installed Airbus maintenance error study

21. 21 SWISS Safety, 30 March 2006 SVFB Goal FHABCDEG Removal: 1 way C F B E D G H A Installation: 40,000 combinations - not including omissions [Adapted from Hall, Human Factors Training Module 1

22. 22 SWISS Safety, 30 March 2006 SVFB Reducing Errors to Make Flights Safer The Wall Street Journal Europe Operational Safety – Technical Safety Conclusion Reducing seemingly minor errors is only going to become more critical As skies and airport get more crowded, mistakes can have more serious consequences What is safe today is not going to be safe enough tomorrow

23. 23 SWISS Safety, 30 March 2006 SVFB Operational Safety – Technical Safety Thank you! Questions? and Answers!