1. By: FAA Safety Team Date: Federal Aviation Administration Airworthiness Human Factors R1 Human Error = System Failure

2. Federal Aviation Administration 2 Objectives 1.Reveal that existing aircraft accident & incident data shows human error contributes to many LG failures. 2.Discuss how human error may have resulted in several LG failures on a specific aircraft. 3.Emphasize how you can reduce or mitigate human error when performing inspection or maintenance

3. Federal Aviation Administration 3 September 21, 2005

4. Federal Aviation Administration 4

5. Federal Aviation Administration 5 Question Is “Improper Maintenance” failure to follow procedures? –Yes Is “Inadequate Maintenance” failure to follow procedures? –Yes What are these numbers telling us? –Virtually ALL maintenance failures can be associated with “Failure to Follow Procedures”!!!

6. Federal Aviation Administration 6 Improper Maintenance Where do you find the definition for improper maintenance? Answer – There is no definition found in any FAR, FAA Guidance, Order, or in Title 49. So how do we understand or apply the term Improper Maintenance? Answer – Maintenance Error

7. Federal Aviation Administration 7 Improper Inspection Where would you find the definition of inspection? Answer – Part 43 Where do find the definition of improper inspection? Answer – Again, this is not defined by FAR, FAA Guidance/Order or in Title 49. Lets think in terms of Inspection Error

8. Federal Aviation Administration 8 Improper Installation Where do you find the instructions to install components? Manufacture Maintenance Manuals and/or other Methods and Techniques Acceptable to the Administrator. There is no definition for Improper Installation so lets think in terms of Installation Error

9. Federal Aviation Administration 9 Human Error = System Failure The very sharpest technician on the crew can make a mistake if he/she sleeps poorly or becomes distracted by a cell phone call. Dirty Dozen ?

10. Federal Aviation Administration 10 The Dirty Dozen Communication Complacency Lack of Knowledge Distraction Teamwork Fatigue Lack of Resources Pressure Assertiveness Stress Lack of Awareness Norms

11. Federal Aviation Administration 11 SAFETYTOOL

12. Federal Aviation Administration 12 SAFETY TOOL

13. Federal Aviation Administration 13 April 08, 2008 – Nose Gear Failure

14. Federal Aviation Administration 14 Human Error = System Failure

15. Federal Aviation Administration 15 Human Factors Teamwork – Resources - Communication

16. Federal Aviation Administration 16 Maintenance Personal Minimums Checklist

17. Federal Aviation Administration 17 Situational Awareness 2

18. Federal Aviation Administration 18 Lack of Awareness & Distraction

19. Federal Aviation Administration 19

20. Federal Aviation Administration 20 Situational Awareness Nose Gear Down Lock Link Assembly 1 3 2

21. Federal Aviation Administration 21 AD 2005-13-16 & Piper Service Bulletin No 1123A

22. Federal Aviation Administration 22 AD 2005-13-16

23. Federal Aviation Administration 23 AD 2005-13-16

24. Federal Aviation Administration 24 Failure to Follow Procedures What are the procedures we are referring to? –Procedures contained in data approved/accepted by the FAA. What is “Failure to Follow Procedures”? –Deviations from data approved/accepted by the FAA. What do we need to learn from this? Where do we need to go from here?

25. Federal Aviation Administration 25 Mental Limits: Disassembly There is only one way to disassemble the nuts, but over 40,000 wrong ways to reassemble. Your task here is to remove these nuts from the bolt. Now reassemble them back into alphabetical order.

26. Federal Aviation Administration 26 Human Factors and Failure to Follow Procedures Learning from all the mistakes we have made or can make is not practical. We must learn to associate the mistakes we make with the human factor and environmental circumstance that spawned that mistake. This challenge of association is vital to learning!!!

27. Federal Aviation Administration 27 Situation Awareness Knowing what is going on around you –The perception of important elements Seeing: loose bolts, missing parts Hearing: verbal communications –The comprehension of their meaning How this affects your job Compliance with procedures –The projection of their status in the future Future effects on safety, schedule, air worthiness

28. Federal Aviation Administration 28 Why is Situational Awareness Important? SITUATION AWARENESS DECISION MAKING PERFORMANCE Situation Awareness Drives Performance

29. Federal Aviation Administration 29 Poor Situational Awareness Poor Situational Awareness People doing the right thing for the situation that they believed they were in but their action was incorrect due to misunderstanding not comprehending the actual situation.

30. Federal Aviation Administration 30 Summary 1.FFP happens when we deviate from FAA approved/acceptable data. 2.Virtually all maintenance errors can be attributed to FFP. 3.Human Factors are at the root cause of FFP mistakes. 4.Human Factors contribute to virtually all maintenance failures.

31. Federal Aviation Administration 31 Summary 5.Situational awareness. 6.We must learn to associate the mistakes we make with the human factor and environmental circumstance that spawned that mistake. 7.This challenge of association is vital to learning!!! 8.Learning paves the road to understanding!

32. Federal Aviation Administration 32 Conclusion FAA Safety Team website: FAASafety.gov AMT Award program GA Award Program WINGS FEEDBACK Wanted at this web site: http://www.faa.gov/about/office_org/headquarte rs_offices/avs/stakeholder_feedback/afs/field/sf _faasteam/