Human Factors Beyond the Dirty Dozen.docx

Human Factors Beyond the Dirty Dozen.docx

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HumanFactorsBeyondtheDirtyDozen

HumanFactors:

Beyondthe"DirtyDozen"

Saturday,August1,2009

HumanFactors:

Beyondthe"DirtyDozen"

ByCharlotteAdams

About80percentofmaintenancemistakesinvolvehumanfactors（HF）,accordingtotheFederalAviationAdministration.ThemaintenanceworldhasuniqueHFissuesthataremoresevereandlongerlastingthanelsewhereinaviation.OperatorsarelookingatvarioustechniquestocombatHFchallenges.

Humanfactors（HF）areconstantwatchwordsinmaintenanceoperations.AlthoughHFmaintenancetrainingisnotstrictlyrequiredintheU.S.,manyU.S.maintenanceorganizationshaveadopteditbecausetheyseeregulationonthehorizon,wanttocomplywithregulationselsewhereorsimplyacceptthebusinesscase.

Whyarehumanconditions,suchasfatigue,complacencyanddistraction,soimportant?

Asoneexpertputit,ifyouscratchthesurfaceofamaintenanceincident,you’relikelytofindHFissues.About80percentofmaintenancemistakesinvolvehumanfactors,accordingtoBillJohnson,theFAA’schiefscientificandtechnicaladvisorforhumanfactorsinaircraftmaintenancesystems.Iftheyarenotdetected,maintenanceerrorscancauseaccidents.Theagency’sHF"Operator’sManual"statesthatmaintenancewastheprimarycauseof8.3percentofU.S.accidentsinthe1990s.Ithasbeenacontributingfactorinabout18percentofaircraftaccidents,Johnsonsaid.A"maintenanceevent"startedtheaccidentchainin26percentoftheworldwideaccidentsin2003forWestern-andEastern-builtjetsandturboprops,themanualstates.

Thecostofflightcancellationsanddelaysisalsosteep.ThecancellationofaBoeing747-400jumbojetflightcancostanairline$140,000,accordingtoresearcherAlanHobbs,inanAustralianTransportSafetyBureaureport.Adelayatthegatecanshaveanaverageof$17,000perhouroffacompany’srevenues,thereportstates.Rampincidentswreaked$5-billion-worthofdamageworldwidein2004,accordingtotheFAAmanual.

Anotherreasontotrainrelentlesslyistheconstantchallengeofthemaintenanceenvironment.ThisworldhasuniqueHFissuesthataremoresevereandlongerlastingthanelsewhereinaviation,asHobbspointsout.Mechanicsworkinahazardousenvironmentthatdemandsphysicalstrength,coordinationandmeticulousattentiontodetailinreadingandrecordingdata.Theymayworkhighupontheaircraftstructureordeepinsomeconfinedinnerspaceinextremesofhotandcoldandatnight.Communicationsbetweenteammembersarecruciallyimportantbutdifficultinhigh-noiseenvironments.Mechanicsmayneedtodiagnoseandsolveproblemsinthefaceofurgenttimepressures,especiallyontheflightline.Pilotsandairtrafficcontrollersencountergreatjobstress,aswell,butcanputitbehindthemattheendoftheday.Likedoctors,however,mechanicsknowthattheirmistakesmayaffectthehealthoftheirchargesmonthsoryearsdowntheroad.

Somemaintenanceshopshavegonetothelengthofcreatinga"sterileenvironment,"saidRichardKomarniski,presidentofGreyOwlAviationConsultants.Onecivilianhelicoptermaintenanceshopwhichhiscompanydoestrainingfordecidedtoimprovefocusbycontrollingphonecalls,thepresenceofsalesreps,visitorsandotherdistractionsintheworkarea.Itmadeadifference,hesaid.

HFawarenessneedstoremainsharp,iffornootherreasonthantokeepcomplacencyatbay.AviationMaintenanceinterviewedexpertsatLufthansaTechnik,DeltaTechOpsandAveostosurveythelatestHFprogramsinEurope,theU.S.andCanada.AMalsotalkedtotheFAAaboutHFstudiesandoutreach.

MROPrograms

IntheirinitialHFtraining,allthreemaintenance,repairandoverhaul（MRO）organizationsemphasizethe"dirtydozen"—commonsourcesofmaintenanceerrors—aswellaswhat’ssometimescalledthe"justculture"—aworkenvironmentthatemphasizesobjectivity,analysisandabalancedresponsetomaintenanceproblems.AllthreeofferinitialandrecurrentHFtraining,butbothDeltaandLHTaddanuppermanagementfocusaswell."Youhavetheconfluenceofallofthesedifferentthingsthatcancreatethereasonwhysomebodysaid,‘I’mgoingtodeviatefromprocedure,’"saysBobBaron,presidentofTheAviationConsultingGroup,whichspecializesinhumanfactorstraining,consultingandresearch."Inmanycasesitcanbebecauseoftimestressorpressurethat’spropagatedatsomeofthehighestlevelsoftheorganization."LHThasalsocraftedaneconomicmetricthatincludeshumanfactors.

InitialHFtrainingistypicallyanintense,two-daycoursethatencouragesparticipation.Aveos,whichstarteditsHFprogramin1996,seemstohavebeendoingitthelongestofthethree.Thechallengeisto"makeaconnectionatthepersonallevel,"sothatthestudentsarelikelytoapplytheconceptsintheirlives,saidJimCairns,theCanadianMRO’sgeneralmanageroftechnicaltraining.

LineandbasemechanicsatAveos,aswellasexecutiveswithtechnicalresponsibilities,takethecourse,althoughemployeesworkinginsalesandfinancegenerallydonot.Recurrenttrainingoccursona36-monthcycle.TheCanadianMROrecentlyreviseditsprogramfromarehashoftheinitialcoursetofocusoncasestudiesandrootcauseanalysisinthecontextoffourhomogeneousmodules:

1）complacency,fatigueandlackofawareness;2）communications,assertivenessandteamwork;3）lackofresources,knowledgeandnorms;and4）stress,pressureanddistraction.

AnotherinterestingaspectofHFtraininginCanadianmaintenancefacilitiesisthatmanyofthemechanicscomingthroughAveos’initialcoursealreadyhavebeenexposedtotheconcepts.AircraftmaintenanceengineersreceivetheiracademictrainingatcommunitycollegesinCanada,andprogramsthatareapprovedbyTransportCanadaincludeahumanfactorselement.

Besidestheirinitialandrecurrenttraining,DeltaandLHTalsohavedevelopedvariousspecializedmodules.DeltaisaddinglessonslearnedfromitsinitialHFcoursetoitsTechnicalOperationsPoliciesandProceduresmanual.ThemanualalsoincludesthemethodologyusedinDelta’snew"administrativeactiondecisiontoolclass"aimedatmanagers,generalmanagersanddirectors.

Thenewclasssetsforthguidelinesabouthowtohandleerrors,incidentsandaccidents,explainedChristianVehrs,aninstructoranddeveloperinDelta’shumanfactorsprogram.ItusesamethodologyderivedfromFAA’sEnforcementDecisionTool（seeFAAOrder2150.3）,adocumentthatprovidesawaytocategorizebehaviorbyintention.Participantslearntolookatthemeshofhumanfactorsinvolvedinacase,suchastheavailabilityofproperdocumentation,fatigue,pressuresandworkplacenorms.Theaimistoguidemanagementintomakingmoreconsistentdecisions.

Whereasinthepast,therehadbeena"widerangeofoutcomes"inmanagementdecisions,thenewtraininghashelpedtoinstillmoreconsistency.Thefirst,one-hoursegmentoftheclassemphasizestheneedformoreconsistentoutcomesforsimilarincidentsandhowvariablesaffectadministrativeactions.Thesecondreviewsthenewpolicy.ThenaninstructorshowshowtoapplythetoolviaaDeltaAirLinescasestudy.

Intheremainingtwohoursthestudentsbreakintosmallgroupsandlearntoapplythetoolforthemselves.Sofar,261managers,generalmanagersanddirectorshavetakenthecourse,andtheconsistencyoftheoutcomesfortheseincidentshasbeenremarkable,theMROsaid.Theprimaryincidentusedduringtheinstructor-ledmodulehasgeneratedtherecommendedoutcome100percentofthetime.

LHTalsoprovidesspecializedtraining.Seniormanagers,forexample,receiveaone-dayinitialHFtrainingcoursethatfocusesonproblem-solving,communicationsandtheirresponsibilitieswithintheorganization.Supportingandcertifyingstaffmemberswhosignoffonoverhaulsalsoreceiveanadditionaltwodaysofrecurrenttrainingrelatedtotheirtechnicalresponsibilities,includingonedayofHFtraining,saidStephanLiebenow,teamleaderforqualificationandtraining,withLHT’scommercialoverhaulandVIPcompletionsorganizations.

Inaddition,theGermanMROisalsodevelopingHFtrainingforincidentinvestigatorstoshowthemhowtoconductinterviewsinanon-punitiveatmosphere,Liebenowsaid.Developedinitiallyforlinemaintenanceinvestigators,thetechniquesarebeingadaptedtobasemaintenance.

LHTalsostressesitspositiveworkculture."I’minterestedinthefacts—whathappened,whyandhowtoimprovethings,"Liebenowsaid."It’sadifferentapproach,andpeoplerealizethatandcometous."

ErrorReportingSystems

Whethervoluntaryorrequired,errorreportingsystemsarecrucialandthereforecommonplaceintheindustry.Participants"areprovidinginformation,aswellaslisteningtotheinstructor,"Liebenowpointedout.LHTpridesitselfinbeing"alearningorganization,"andunderstandsthatinputfromtheseinteractionsandthereportingsystemis"goodinformationthatyouwouldn’tgetfromtraditionalaudits."Anunderstandingofhumanfactorshelpstoidentifytherootcausesbehindproblemsandtocomeupwithcorrectiveactions.

LHT’sreportingsystemalsohelpedtoadjustGermanlegalrequirements.Someinputsconcernedarequirementthatanyonetakingpartinaircraftradiocommunicationsshouldhaveafullradiolicense,Liebenowsaid.LHTdidnotthinkthatitiscost-effectivetorequireamechanicrunningafunctionaltestofaradiotohavearadiolicense,aslongasthetechnicianknowswhathe’sdoing."Aftertwoyearsofhardwork,wemanagedtochangethelaw,sothatthereisanexceptionformaintenancemechanics,"Liebenowsaid.

Unlikesomeothermaintenanceorganizations,however,LHTalsofocusesontheeconomicsideofhumanfa