Federal Aviation

Administration
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Maintenance Human
Factors Presentation
System
Prepared by
Aviation Safety Organization
Flight Standards Service
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
Welcome
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
Speak in straightforward terms

Reinforce your current knowledge

Offer new concepts and/or new ways to explain old
concepts

Provide links for more information

Have a few laughs?

Presentation Plans
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
1. What is human factors?
2. History of human factors
3. Human factors spectacles
4. The PEAR model
5. Human error
6. Maintenance accidents
7. Where to get information
8. Summary
Presentation Content
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
1

What is Human Factors?

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Federal Aviation
Administration
Human Factors in Aviation Maintenance
What is Human Factors?
This section shall:

Define human factors as it relates to
maintenance

Show specific examples of maintenance
human factors

Show why the topic is important to you
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
List Human Factors Related to
Maintenance
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
Designing workplaces, tools,
procedures, and policies so people
can use them easily and safely

Primary concern is for people in the
organization

Combines elements from many
disciplines

Critical to the overall flight safety
and personal safety
What is Human Factors?
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Federal Aviation
Administration
Human Factors in Aviation Maintenance

Ensure continuing safety and efficiency by paying
attention to issues that affect human performance.
Human Factors Goal A Summary
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
The Elements of Human Factors
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Federal Aviation
Administration
Human Factors in Aviation Maintenance

Ensure continuing safety and efficiency by paying
attention to issues that affect human performance.
Human Factors Goal for Review
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
2
History of Human Factors
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
Early military work on designing
weapons and uniforms

Time and motion studies (Frank
and Lillian Gilbreth)

World War II aircraft cockpit
controls and displays

Establishment of Human Factors
Society (1957)

Military systems and
consumer products
The History of Human Factors
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
Maintenance Human Factors has
Evolved in 20 Years!
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
Human Factors Timeline
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
Human Factors Spectacles
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
Examples of the human factors
perspective

You can see human performance
issues if you look

The remainder of this presentation
will show you what to look for

Look at others

Look at yourself

Look at the environment that
surrounds you
Put on your Human Factors
Spectacles
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Federal Aviation
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Human Factors in Aviation Maintenance
Sensitivity to human factors

Knowledge of how human factors affect work and
safety

Objectively examine your world

Be willing to make suggestions and comments
Put on your Human Factors
Spectacles
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
What was the premise of the human factors spectacles video?

List 10 things that you see while driving with your human factors
spectacles

List 10 things that you see in this class with your human factors
spectacles

List 10 things that you see at work with your human factors
spectacles

What do you see at home with the human factors spectacles?

In the mirror?
What did you Learn about Human Factors
Spectacles from the Introductory Video?
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
A Reminder to Apply Human Factors
Principles 24 x 7
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
The PEAR Model
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
Models make it easier
to understand complex
things

Easy to remember

Models can be 2-D, 3-
D, or mental

Why Use Models?
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
Originally used for
pilots crew resource
management (CRM)

Has served human
factors training well
worldwide

A bit abstract
The SHELL Model
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
S includes all
documentation

H is physical stuff, like
tools and equipment

E is for the physical
and social environment

L-1 is for individuals

L-2 is for groups
The SHELL Model Explained
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Human Factors in Aviation Maintenance
PEAR is easy to remember

It works for maintenance

It is matched with the SHELL
model
The PEAR Model
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
People who perform the job

Organizational and physical environment

Actions (tasks) performed as part of the job

Tools, procedures, and other resources
PEAR
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
Physical
Size
Gender
Age
Strength
The five senses
Physiological
Health
Nutrition
Lifestyle
Alertness/fatigue
Chemical dependency
Psychological
Experience
Knowledge
Training
Attitude
Emotional state

Psychosocial
Interpersonal relations
Ability to communicate
Empathy
Leadership
People
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Federal Aviation
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Human Factors in Aviation Maintenance
We live in 24x7x365
world

Aviation does not
rest

Humans need rest!
What Does This Mean?
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
Overview of Fatigue
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
Physiological
Health
Nutrition
Lifestyle
Alertness/fatigue
Chemical dependency
Physical
Size
Gender
Age
Strength
The five senses
Psychological
Experience
Knowledge
Training
Attitude
Emotional state

Psychosocial
Interpersonal relations
Ability to communicate
Empathy
Leadership
The Five Senses
People Vision and Hearing
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
When you toast you:

See
Smell
Taste
Feel
Hear
How to Remember the Five Senses
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Administration
Human Factors in Aviation Maintenance
As quickly as possible,
say the color of each word on the screen.
A Test / Example of
Volunteer Needed
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
desk
rock
cat
spoon
book
Sensing and Perception
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
red
blue
gray
purple
green
Sensing and Perception
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Administration
Human Factors in Aviation Maintenance
What is This?
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Federal Aviation
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Human Factors in Aviation Maintenance
Both the letter B and the number 13 are the same figure. However,
the context determines how you perceive it.
(Coren, et al, (1994), Sensation and Perception, Harcourt Brace College Publishers)
What is This Now?
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Federal Aviation
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Human Factors in Aviation Maintenance
Physical
Weather extremes
Location (in/out)
Workspace
Lighting
Sound levels
Housekeeping
Safety issues
Organizational
Personnel
Supervision
Labor - management
Size of company
Profitability
Job security
Morale
Corporate culture
Safety culture
Environment
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
What do you need to know?
What skills are necessary?
Steps to perform a task
Sequence of actions
Communication requirements
Information requirements
Inspection requirements
Certification requirements
Actions
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Federal Aviation
Administration
Human Factors in Aviation Maintenance
How do you communicate error
events?

Are there enough people to do the
job?

Do personnel understand the cost of
aircraft damage?

How can you motivate one another to
care more?

Are you responsible for the things
that others do?
Actions What Can You Do Today?
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Human Factors in Aviation Maintenance
Technical documentation systems
Test equipment
Enough time
Enough people
Lifts, ladders, stands, seats
Materials
Portable lighting, heating, cooling
Training
Resources
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Human Factors in Aviation Maintenance
Are resources ever a problem?

What are the solutions?

Can you give an example?

What advice can you offer?
Resources Please Offer Your
Examples
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Human Factors in Aviation Maintenance
Human Error
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Human Factors in Aviation Maintenance
Definition of human error

Types of errors

The dirty dozen

Examples of errors

Event investigations
Maintenance Error
Decision Aid (MEDA)
Human Error
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Human Factors in Aviation Maintenance
Gravity

Humans
The Greatest Hazard to Aircraft is?
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Human Factors in Aviation Maintenance
80% of Events are Caused by Human
Error
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Administration
Human Factors in Aviation Maintenance
Only one way to
disassemble

40,000+ ways to
incorrectly
reassemble!
The Odds are Against Doing it Right!
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Administration
Human Factors in Aviation Maintenance
A human action with
unintended consequences
Definition of Human Error
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Human Factors in Aviation Maintenance
Types of Human Error
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Human Factors in Aviation Maintenance
Active and Latent Errors
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Human Factors in Aviation Maintenance
Incomplete installation (33%)
Damage on installation (14.5%)
Improper installation (11%)
Equipment not installed or
missing (11%)
Foreign object damage (6.5%)
Improper troubleshooting,
inspection, test (6%)
Equipment not activated or
deactivated (4%)
Data from Boeing study of 276 in-flight
engine shutdowns (1994)
Why Things Go Wrong
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Human Factors in Aviation Maintenance
The Civil Aviation Authoritys List of
Errors
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Human Factors in Aviation Maintenance
Eliminate these causes and
you have conquered most
human errors

Talk about each of these

What are the causes in your
company?

What are the corrective
actions?
The 12 Most Common Causes for
Human Errors
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Iceberg Model
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Federal Aviation
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Human Factors in Aviation Maintenance
Boeings event investigation
system

Used by 500 airlines
worldwide

Finds the contributing factors
Event Investigation MEDA
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Human Factors in Aviation Maintenance
Anything that can increase or decrease the likelihood of human error.
Performance Shaping Factors
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Human Factors in Aviation Maintenance
Maintenance Accidents
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Fatal Accidents: Intl 1998 to 2007
World Accidents World Fatalities
0
10
20
30
40
50
60
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
F
a
t
a
l

A
c
c
i
d
e
n
t
s

0
200
400
600
800
1000
1200
1400
1600
1800
2000
F
a
t
a
l
i
t
i
e
s

Source: US NTSB and Flight International, 8-14 January 2008
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Source: US NTSB and Flight International, 8-14 January 2008
Fatal Accidents: US/Intl 1998 to 2007
US Accidents World Accidents US Fatalities World Fatalities
0
10
20
30
40
50
60
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
F
a
t
a
l

A
c
c
i
d
e
n
t
s

0
200
400
600
800
1000
1200
1400
1600
1800
2000
F
a
t
a
l
i
t
i
e
s

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Other
27%
Controlled Flight Into
Terrain
1%
Human Factors
45%
Technical/
Maintenance
27%
Intl Accident Cause Factors 2007
Source: Flight International, 8-14 January 2008
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21 Human factors
10 Engine failure
1 Mechanical failure
9 Probable cause unknown or
undetermined (NTSB
investigation not completed)
7 Weather
3 Structural failure

Published March 2006
Causes of Helicopter Accidents
(1985 - 2006)
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There are opportunities for improvement

Maintenance and technical issues are areas of concern

Technical documentation systems!!

Human factors challenges are ever present
Alertness/fatigue
Communication (flight crew to maintenance)
Inadequate use of lessons learned (event reporting)

Challenges are similar for all aviation segments!
Implications of the Safety Statistics
for Maintenance Human Factors
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Maintenance errors cause
accidents

Accident statistics

Common maintenance
errors

Examples of maintenance-
related accidents

Specific accidents
Maintenance Accidents
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Historic Maintenance-Related
Accidents
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Human Factors in Aviation Maintenance
Jan 2000 Alaska Airlines MD-80 Jackscrew for elevator control
Mar 2001 Lufthansa A320 Mis-wired side stick
Apr 2001 Emery Worldwide DC-8 Reversed hydraulic check-valve
Aug 2001 Air Transat A330 Fuel exhaustion over Atlantic
May 2002 China Airlines B747-200 In-flight break-up at 35K feet
Jan 2003 Air Midwest Beech 1900D Trim rigging
Aug 2003 Colgan Air Beech 1900D Trim rigging
Jan 2006 Continental B737-500 Engine run-up
Jul 2006 Spectrum Aircraft Spectrum 33 Mis-rigging
Recent Maintenance-Related
Accidents
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Where to Get Information
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Human Factors in Aviation Maintenance
www.hfskyway.com

Three Reference Manuals
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Human Factors in Aviation Maintenance
Training

Human Factors Guide for
Aviation Maintenance and
Inspection

Human Factors Operators
Manuals (one for aviation
maintenance and one for
airport operations)

www.hfskyway.com

FAA human factors resources
Where to Get Information: Sample Page from
Operators Manual for Human Factors in
Aviation Maintenance
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Human Factors in Aviation Maintenance
www.hfskyway.com
For More Information Publications
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Human Factors in Aviation Maintenance
For More Information
www.hf.faa.gov
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Human Factors in Aviation Maintenance
FAA Human Factors Resources:
www.hfskyway.com
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References
FAA (2005), Human Factors Policy, FAA Order 9550.8A, available at
http://www.hf.faa.gov/docs/508/docs/HForder.pdf#search=%22faa%20order%209550.8%22

FAA (2005), The Operators Manual for Human Factors in Aviation Maintenance, Washington, DC,
available at http://www.hf.faa.gov/opsmanual

FAA (2007), The Operators Manual for Human Factors in Airport Operations, Washington, DC,
available at http://hfskyway.faa.gov/2007/OpsMan_Ramp_Final.pdf

FAA (1996), Human Factors Guide for Aviation Maintenance and Inspection, available at
http://hfskyway.faa.gov

FAA (2007), Maintenance Human Factors Training Program, Evaluate and Accept, FAA Order 8900.1,
available at:
http://fsims.faa.gov/wdocs/8900.1/V03%20Tech%20Admin/Chapter%2024/03_024_002.htm?opendoc
ument

Hackworth, H., Holcomb, K., Dennis, M., Goldman, S., Bates, C., Schroeder, D., Johnson, W. (2007).
An International Survey of Maintenance Human Factors Programs (Report No. 07/25). Oklahoma City,
OK: FAA Civil Aerospace Medical Institute.

Hall, S., Johnson, W.B. and Watson, J. (2001). Evaluation of Aviation Maintenance Working
Environments, Fatigue, and Human Performance: Phase III. Washington, DC: Federal Aviation
Administration Office of Aviation Medicine. http://hfskyway.faa.gov
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Summary
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