Part-66 Syllabus Levels - Sub-Module 01 PDF

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FreshestSparrow

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Prince Sultan Aviation Academy

PART-66

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human factors aviation maintenance human error safety

Summary

This document provides an introduction to human factors in aviation maintenance. It covers the need to take human factors into account, incidents attributable to human factors and Murphy's law. It also includes the knowledge required for levels 1 and 2 in relation to understanding the subject and objectives.

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GENERAL PART-66 SYLLABUS LEVELS A B1 B2 CERTIFICATION CATEGORY ¦ Sub-Module 01 GENERAL Knowledge Requirements 9.1 - General The need to take human factors into account; Incidents attributable to human factors/human error; Murphy's Law. Level 1 A familiarization with the principal elements of th...

GENERAL PART-66 SYLLABUS LEVELS A B1 B2 CERTIFICATION CATEGORY ¦ Sub-Module 01 GENERAL Knowledge Requirements 9.1 - General The need to take human factors into account; Incidents attributable to human factors/human error; Murphy's Law. Level 1 A familiarization with the principal elements of the subject. Objectives: (a) The applicant should be familiar with the basic elements of the subject. (b) The applicant should be able to give a simple description of the whole subject, using common words and examples. (c) The applicant should be able to use typical terms. Module 09 - Human Factors 1 2 2 Level 2 A general knowledge of the theoretical and practical aspects of the subject and an ability to apply that knowledge. Objectives: (a) The applicant should be able to understand the theoretical fundamentals of the subject. (b) The applicant should be able to give a general description of the subject using, as appropriate, typical examples. (c) The applicant should be able to use mathematical formula in conjunction with physical laws describing the subject. (d) The applicant should be able to read and understand sketches, drawings and schematics describing the subject. (e) The applicant should be able to apply his knowledge in a practical manner using detailed procedures. 1.1 GENERAL Why are human conditions such as fatigue, complacency, and stress, so important in aviation maintenance? These conditions, along with many others, are called human factors. Human factors directly cause or contribute to many aviation accidents. It is universally agreed that at least 80 percent of maintenance related incidents involve human factors. If they are not prevented, and their causes detected, they can cause injuries, wasted time, and even accidents. (Figure 1.1) THE NEED TO TAKE HUMAN FACTORS INTO ACCOUNT Aviation safety relies heavily on maintenance. When it is not done correctly, it contributes to a significant proportion of accidents and incidents. Some examples of maintenance errors may include; parts installed incorrectly, missing parts, or necessary checks not being performed. In comparison to many other threats to aviation safety, the mistakes of an Aviation Maintenance Technician (AMT) can be more difficult to detect. Often times, these mistakes are present but not visible and have the potential to remain latent, affecting the safe operation of aircraft for long periods of time. AMTs are confronted with a set of human factors unique within aviation. Often times, AMTs are working in Figure 1.1 – The above human factors and how they affect people are very important. Awareness of their influence can help control possible accidents the evening or early morning hours, in confined spaces, on platforms that are up high, or in a variety of adverse temperature/humidity conditions. The work can be physically strenuous, yet also requiring a high degree of attention to detail. (Figure 1.2) Figure 1.2 – Aviation maintenance technicians have many distractions and must focus on detail 1.2 Module 09 - Human Factors GENERAL Figure 1.3 – Factors that affect human performance for AMTs Because of the nature of maintenance tasks, AMTs commonly spend more time preparing for a task than actually carrying it out. Proper documentation of all maintenance work is a key element, and AMTs also typically spend as much time updating maintenance logs as they do performing the work. Human factors and how they affect people are very important to aviation maintenance. Such awareness can lead to improved quality, an environment that ensures continuing worker and aircraft safety, and a more involved and responsible work force. More specifically, the reduction of even minor errors can provide measurable benefits including cost reductions, fewer missed deadlines, reduction in work related injuries, reduction of warranty claims, and reduction in more significant events that can be traced back to maintenance error. Module 09 - Human Factors It is apparent that anticipated or abnormal medical conditions inf luence the AMTs work. Reduction in vision is a signpost of aging that is anticipated in all AMTs over the age of 50 years. It compromises the visual inspection of aircraft. Obesity is an abnormal medical condition that leads to multiple metabolic changes. It produces behaviors described by the Dirty Dozen of human factors. These consequences from normal aging or abnormal medical conditions are classified as Latent Medical or Environmental Conditions (LMEC). Within this book, the many aspects of human factors are discussed in relation to aviation maintenance. (Figure 1.3) The most common of which are introduced along with ways to mitigate the risk to stop them from developing into a problem. 1.3 THE PEAR MODEL OF HUMAN FACTORS IN MAINTENANCE Human factors can be divided into four main topic areas using the memory prompt PEAR. Application of the mnemonic ‘PEAR’ makes recognition of Human Factors (HF) even easier. It prompts recall of the four important considerations for HF programs: People who do the job; Environment in which they work; Actions they perform; Resources necessary to complete the job. The lists within each element are not exhaustive, but help to guide people on the human factor influences that should be considered. People PEAR was developed by Dr. Michael Maddox and Dr. Bill Johnson, specifically with maintenance in mind, as an easy way for aviation maintenance personnel to identify human factors and relate to tasks and conditions within the maintenance environment. PEAR has been used for over a decade by some JAR/ EASA 145-approved organisations and is included by the US Federal Aviation Administration (FAA) in their Maintenance Human Factors training package. Environment Actions Resources P stands for People (the humans in the system), with all our capabilities and limitations. It includes senses such as vision and hearing; physical characteristics such as strength and reach; as well as capabilities such as memory, communication styles, decision making, supervision and teamwork skills (leadership/followership etc.). People relates to the suitability (physical, cognitive and social) of the selected personnel for a particular task. Suitability not only covers technical training but also human factors considerations such as fatigue, stress and motivations. It guides the review of the competency, supervision abilities, briefing needs, leadership skills and requirements of individuals against the task demands. People DOING THINKING INTERACTING • Physical capabilities • Knowledge • Team structure • Sensory Capabilities • Experience • Role definition • Health • Attitude • Leadership • Training • Motivation • Followership • Current • Confidence • Supervision skills/needs • Competent • Workload • Interpersonal relationships • Authorized • Fatigue • Communication • Briefed • Stress • Conflicts E stands for the Environment in which the work is done, not just the physical environment, but also the organization itself. The physical environment includes lighting, temperature, noise level and time of day. The organizational environment covers issues such as supervision (quality and ratios), pressures (time, commercial and production etc.), organization and safety culture and existing organizational norms and how these will affect individual and team performance and the potential for error. The organizational environment also covers the leadership shown and the effectiveness of management in supporting positive safety behaviors. 1.4 Module 09 - Human Factors ORGANIZATIONAL • Weather • Management style • Location (inside/outside) • Leadership • Workspace • Staffing levels • Lighting • Size/complexity • Noise • Priorities • Distractions • Pressures • Housekeeping • Morale • Hazards • Norms • Shift (day/night/late) • Culture GENERAL Environment PHYSICAL A represents the Actions people perform. Actions list the requirements of a job to help to identify any specific areas that might increase the risk of error, such as ambiguous information, or complex tasks that need specialist skills and knowledge. Actions • Getting Information • Communication requirements • Preparation • Task management • Briefing/debriefing • Supervision requirements • Steps/sequence of activity • Inspection requirements • Application of Knowledge • Documentation • Application of skill • Certification requirements The list of actions is aligned with a Job Task Analysis (JTA) process which is the standard human factors approach to identifying the knowledge, skills and attitudes necessary to perform each task in a given job. The JTA also helps identify what instructions, preparation and task management are necessary. This may include • Accessing / finding task specific information required • Preparation and briefing requirements • Identifying procedures to be followed • Are those procedures clear and easy to follow? • Task complexity and application of skill and knowledge • • • Communication requirements (headsets required?) The level of supervision and inspection required (is a dual inspection needed?) The certification and documentation, including the complexity or user-friendly nature of the aircraft maintenance documentation. R is for the Resources necessary to perform the work. Resources are the broadest component of PEAR. They can be defined as anything that the maintenance technician needs to get the job done. Resources details both the tangible items required and available, such as personnel, spares, technical manuals, tooling, and personnel protective equipment (PPE), as well as less tangible (but equally important) elements such as time and training availability. Resources Module 09 - Human Factors • Procedures/workcards • Technical manuals • Personnel • Test equipment • Tools • Computers/software • Paperwork/signoffs • Ground handling equipment • Workstands and lifts • Fixtures • Materials • Task lighting • Training • Quality system • Personal Protective Equipment • Interpersonal relationships • Confidence • Supervision skills/needs • Competence • Workload • Interpersonal relationships 1.5 Time and personnel should be the f irst resources considered, as they are critical to the planning process of any job. An important resources element is focusing on identifying the areas where resources are deficient including: • Design (work stands, tools etc.) • Application (e.g. available, accurate procedures) • Where additional resources (time, personnel, training, lighting, PPE and consumables) are required. PEAR APPLIED TO MAINTENANCE People: The human and the interactions between people The part of PEAR dealing with interactions between humans is particularly important in maintenance. Included are normal human capabilities and limitations in this part; the unaided human eye is still the main tool for inspections, yet the limitations of our vision system sometimes lead to defects being missed. We rely on short term memory each time we have to pay attention to a problem for more than a few seconds, yet the limits of our memory help explain why distractions and interruptions can be so dangerous. Good decision making is an important safety net in aviation, yet we are more likely to make poor decisions when under time pressure or stress. A ‘can do’ attitude is normally a positive characteristic, but in maintenance, if we attempt to operate outside our performance limitations it can lead to danger if not tempered by appropriate caution. Environment: Physical and organizational The maintenance environment presents numerous human factors challenges, including the need to work outside, high noise levels, temperature extremes, and at times poor lighting. All these conditions can increase the probability of error. For example, a three engine aircraft lost oil from all engines after maintenance technicians on night shift fitted magnetic chip detectors without the necessary O-rings. The work was performed outside, using the headlights of a tug for illumination. Furthermore, the technicians had no direct view of the task, and fitted each chip detector by feel, reaching inside the oil service door on each engine. In addition to the physical environment, there is the organizational environment surrounding maintenance. Maintenance tasks are often performed under time pressure. Time pressure is a particular threat when technicians are not used to handling it, and allow it 1.6 to have undue inf luence on their decision making. Other aspects of the organizational environment are management style, organizational culture and workplace ‘norms’ – the unwritten, informal work practices that members of the organization follow. Action: Procedures, paperwork and poor design The actions component of PEAR includes all of the hands on requirements needed to complete a task; from gathering information on tasks, identifying approved data and procedures, the physical and mental demands of the tasks, to finalizing and certifying a job complete. The FA A has estimated that airline maintenance personnel spend between 25 and 40 percent of their time dealing with paperwork. In airlines, technicians frequently deal with maintenance documentation that is difficult to interpret, or that describes procedures in ways that appear to be out of touch with current maintenance practices. In General Aviation, the problem may be that approved documentation for older aircraft is simply not available, or is hard to obtain. Many AMTs use “black books”, personal sources of unapproved technical data that may or may not be up to date. A problem faced by AMTs is a conflict between following procedures and the pressure to “get the job done”. An awareness of human factors associated with the actions required to complete a job by people at all levels of the organization can help to identify areas where the formal procedures can be approved. An accurate knowledge of task demands will help to identify informal work practices developed to meet these demands that need to be brought into alignment with formal procedures. Human factors are not just for technicians but also for managers and writers of technical documents. Module 09 - Human Factors disruptions. AMTs have to deal frequently with lack of resources or equipment. Knowing how to deal with the lack of resources requires judgement that takes years to build. THE ORGANIZATIONAL ENVIRONMENT How does your organization stack up? Positive organizational characteristics 1. There are sufficient staff appropriately licensed to cover the workload 2. The organization never encourages shortcuts or procedure violations 3. Management acts quickly to fix unsafe situations 4. Staff are encouraged to report errors and unsafe situations 5. The company has a ‘just culture’ policy. Incidents are investigated to identify why they occurred, not whom to blame 6. Staff receive human factors training Negative organizational characteristics 7. There is an extreme ‘can-do’ culture. Staff do whatever it takes to get a job done on time 8. Tasks are routinely performed according to ‘norms’ (informal work practices), rather than documented procedures. 9. Staff are often required to work excessive hours 10. Work is done differently when there is time pressure 11. Shortages of spares or equipment often lead to workarounds 12. There is rapid staff turnover, or many inexperienced personnel Yes Yes Yes Yes Yes No No No No No Yes No Yes Yes No No Yes Yes Yes Yes No No No No THE DIRTY DOZEN The Dirty Dozen refers to twelve of the most common human error preconditions or conditions that can act as precursors to accidents or incidents. These twelve elements influence people to make mistakes. The following case studies reference some of the Dirty Dozen factors that contributed to accidents: THE LIST 1. 2. 3. 4. 5. 6. Lack of communication Distraction Lack of resources Stress Complacency Lack of teamwork 7. 8. 9. 10. 11. 12. Pressure Lack of awareness Lack of knowledge Fatigue Lack of assertiveness Norms The Dirty Dozen Model will be discussed in depth in Chapter 8. Module 09 - Human Factors 1.7 GENERAL Resources: A lack of, or deficient Many maintenance incidents begin with a lack of necessary resources, such as time, spares, or specialized tools. Shortages will sometimes lead to work arounds or

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