Human Factors Beyond the Dirty Dozen.docx

1、Human Factors Beyond the Dirty DozenHuman Factors: Beyond the Dirty Dozen Saturday, August 1, 2009Human Factors: Beyond the Dirty DozenBy Charlotte AdamsAbout 80 percent of maintenance mistakes involve human factors (HF), according to the Federal Aviation Administration. The maintenance world has un

2、ique HF issues that are more severe and longer lasting than elsewhere in aviation. Operators are looking at various techniques to combat HF challenges.Human factors (HF) are constant watchwords in maintenance operations. Although HF maintenance training is not strictly required in the U.S., many U.S

3、. maintenance organizations have adopted it because they see regulation on the horizon, want to comply with regulations elsewhere or simply accept the business case.Why are human conditions, such as fatigue, complacency and distraction, so important? As one expert put it, if you scratch the surface

4、of a maintenance incident, youre likely to find HF issues. About 80 percent of maintenance mistakes involve human factors, according to Bill Johnson, the FAAs chief scientific and technical advisor for human factors in aircraft maintenance systems. If they are not detected, maintenance errors can ca

5、use accidents. The agencys HF Operators Manual states that maintenance was the primary cause of 8.3 percent of U.S. accidents in the 1990s. It has been a contributing factor in about 18 percent of aircraft accidents, Johnson said. A maintenance event started the accident chain in 26 percent of the w

6、orldwide accidents in 2003 for Western- and Eastern-built jets and turboprops, the manual states.The cost of flight cancellations and delays is also steep. The cancellation of a Boeing 747-400 jumbo jet flight can cost an airline $140,000, according to researcher Alan Hobbs, in an Australian Transpo

7、rt Safety Bureau report. A delay at the gate can shave an average of $17,000 per hour off a companys revenues, the report states. Ramp incidents wreaked $5-billion-worth of damage worldwide in 2004, according to the FAA manual.Another reason to train relentlessly is the constant challenge of the mai

8、ntenance environment. This world has unique HF issues that are more severe and longer lasting than elsewhere in aviation, as Hobbs points out. Mechanics work in a hazardous environment that demands physical strength, coordination and meticulous attention to detail in reading and recording data. They

9、 may work high up on the aircraft structure or deep in some confined inner space in extremes of hot and cold and at night. Communications between team members are crucially important but difficult in high-noise environments. Mechanics may need to diagnose and solve problems in the face of urgent tim

10、e pressures, especially on the flight line. Pilots and air traffic controllers encounter great job stress, as well, but can put it behind them at the end of the day. Like doctors, however, mechanics know that their mistakes may affect the health of their charges months or years down the road.Some ma

11、intenance shops have gone to the length of creating a sterile environment, said Richard Komarniski, president of Grey Owl Aviation Consultants. One civilian helicopter maintenance shop which his company does training for decided to improve focus by controlling phone calls, the presence of sales reps

12、, visitors and other distractions in the work area. It made a difference, he said.HF awareness needs to remain sharp, if for no other reason than to keep complacency at bay. Aviation Maintenance interviewed experts at Lufthansa Technik, Delta TechOps and Aveos to survey the latest HF programs in Eur

13、ope, the U.S. and Canada. AM also talked to the FAA about HF studies and outreach.MRO ProgramsIn their initial HF training, all three maintenance, repair and overhaul (MRO) organizations emphasize the dirty dozen common sources of maintenance errors as well as whats sometimes called the just culture

14、 a work environment that emphasizes objectivity, analysis and a balanced response to maintenance problems. All three offer initial and recurrent HF training, but both Delta and LHT add an upper management focus as well. You have the confluence of all of these different things that can create the rea

15、son why somebody said, Im going to deviate from procedure, says Bob Baron, president of The Aviation Consulting Group, which specializes in human factors training, consulting and research. In many cases it can be because of time stress or pressure thats propagated at some of the highest levels of th

16、e organization. LHT has also crafted an economic metric that includes human factors.Initial HF training is typically an intense, two-day course that encourages participation. Aveos, which started its HF program in 1996, seems to have been doing it the longest of the three. The challenge is to make a

17、 connection at the personal level, so that the students are likely to apply the concepts in their lives, said Jim Cairns, the Canadian MROs general manager of technical training.Line and base mechanics at Aveos, as well as executives with technical responsibilities, take the course, although employe

18、es working in sales and finance generally do not. Recurrent training occurs on a 36-month cycle. The Canadian MRO recently revised its program from a rehash of the initial course to focus on case studies and root cause analysis in the context of four homogeneous modules: 1) complacency, fatigue and

19、lack of awareness; 2) communications, assertiveness and teamwork; 3) lack of resources, knowledge and norms; and 4) stress, pressure and distraction.Another interesting aspect of HF training in Canadian maintenance facilities is that many of the mechanics coming through Aveos initial course already

20、have been exposed to the concepts. Aircraft maintenance engineers receive their academic training at community colleges in Canada, and programs that are approved by Transport Canada include a human factors element.Besides their initial and recurrent training, Delta and LHT also have developed variou

21、s specialized modules. Delta is adding lessons learned from its initial HF course to its Technical Operations Policies and Procedures manual. The manual also includes the methodology used in Deltas new administrative action decision tool class aimed at managers, general managers and directors.The ne

22、w class sets forth guidelines about how to handle errors, incidents and accidents, explained Christian Vehrs, an instructor and developer in Deltas human factors program. It uses a methodology derived from FAAs Enforcement Decision Tool (see FAA Order 2150.3), a document that provides a way to categ

23、orize behavior by intention. Participants learn to look at the mesh of human factors involved in a case, such as the availability of proper documentation, fatigue, pressures and work place norms. The aim is to guide management into making more consistent decisions.Whereas in the past, there had been

24、 a wide range of outcomes in management decisions, the new training has helped to instill more consistency. The first, one-hour segment of the class emphasizes the need for more consistent outcomes for similar incidents and how variables affect administrative actions. The second reviews the new poli

25、cy. Then an instructor shows how to apply the tool via a Delta Air Lines case study.In the remaining two hours the students break into small groups and learn to apply the tool for themselves. So far, 261 managers, general managers and directors have taken the course, and the consistency of the outco

26、mes for these incidents has been remarkable, the MRO said. The primary incident used during the instructor-led module has generated the recommended outcome 100 percent of the time.LHT also provides specialized training. Senior managers, for example, receive a one-day initial HF training course that

27、focuses on problem-solving, communications and their responsibilities within the organization. Supporting and certifying staff members who sign off on overhauls also receive an additional two days of recurrent training related to their technical responsibilities, including one day of HF training, sa

28、id Stephan Liebenow, team leader for qualification and training, with LHTs commercial overhaul and VIP completions organizations.In addition, the German MRO is also developing HF training for incident investigators to show them how to conduct interviews in a non-punitive atmosphere, Liebenow said. D

29、eveloped initially for line maintenance investigators, the techniques are being adapted to base maintenance.LHT also stresses its positive work culture. Im interested in the facts what happened, why and how to improve things, Liebenow said. Its a different approach, and people realize that and come

30、to us.Error Reporting SystemsWhether voluntary or required, error reporting systems are crucial and therefore commonplace in the industry. Participants are providing information, as well as listening to the instructor, Liebenow pointed out. LHT prides itself in being a learning organization, and und

31、erstands that input from these interactions and the reporting system is good information that you wouldnt get from traditional audits. An understanding of human factors helps to identify the root causes behind problems and to come up with corrective actions.LHTs reporting system also helped to adjus

32、t German legal requirements. Some inputs concerned a requirement that anyone taking part in aircraft radio communications should have a full radio license, Liebenow said. LHT did not think that it is cost-effective to require a mechanic running a functional test of a radio to have a radio license, as long as the technician knows what hes doing. After two years of hard work, we managed to change the law, so that there is an exception for maintenance mechanics, Liebenow said.Unlike some other maintenance organizations, however, LHT also focuses on the economic side of human fa