Download - Consequences of Errors in Aviation
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
CONSEQUENCES OF CONSEQUENCES OF ERRORS ERRORS
IN IN AVIATION MAINTENANCEAVIATION MAINTENANCE
PREPARED BY:PREPARED BY:
SQN LDR SQN LDR
OMAR HAYAT KHAN OMAR HAYAT KHAN
PAF BASE PAF BASE MIANWALIMIANWALI
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
WHAT ARE ERRORS?WHAT ARE ERRORS?
• A failure arising from – an action that was not completed as intended
– a plan for action that was inadequate to begin with
• Slips & Lapses (skill-based)Slips & Lapses (skill-based)– occur at execution stage (memory and attention errors)
• Mistakes (rule- and knowledge-based)Mistakes (rule- and knowledge-based)– occur at judging or inference stage (planning errors)
(Reason, 1990)
Ultimate outcome (detected or undetected, mitigated or leading to further errors, catastrophic or inconsequential) is not part of
the definition
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
MAINTENANCE ERRORMAINTENANCE ERROR
“A maintenance error is considered to have occurred when the maintenance system, which includes the human element, fails to perform in the manner expected in order to achieve its safety objectives.”
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
TO ERR IS HUMAN!TO ERR IS HUMAN!
• Aviation (U.S. air carriers)Aviation (U.S. air carriers)– 2 errors per flight (LOSA data, 2001)
– <0.3 fatal accidents/ 100,000 flight hours annually– 60-80% of accidents involve human error (Foushee 1984)
• Hospital admissionsHospital admissions– 1,000,000 people injured/yr by errors in treatment at hospitals
in US (Marx,2001) – 44,000-98,000 errors are fatal (= 1 jumbo jet crash per day) (IOM
report 1999, Leape, 1999)
– UK: 40,000 errors are fatal (QuIC report, 2000)
• Drug administration Drug administration – 1 in 5 injuries or deaths annually in hospitals (AHRQ 1991)
– 7,000 deaths annually (QuIC report, 2000)
AND THE LIST GOES ON……….
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
ACCIDENTS
INCIDENTS
ERRORS (UNREPORTEDOCCURRENCES)
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
Old View New View Revised
• Human error is the cause of accidents
• Human is the most unreliable component
• Improve safety by restricting human action
• Human error is the effect of deeper issues
• Human is necessary to create safety
• Get away from blame and ask “why”?
• Improve safety by understanding (and leveraging) human and organizational performance
Human Error & Aviation SafetyHuman Error & Aviation Safety
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
• Human Factors Directorate established in 2002
• Stage I - Initially focused to address HF issues amongst aircrew by launching a CRM (Crew Resource Management) Course later made mandatory for all aircrew.
• Stage II - To address HF issues amongst Ground Crew, an MRM (Maintenance Resource Management) program is under development.
Human Factors & PAFHuman Factors & PAF
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
Maintenance Resource Maintenance Resource ManagementManagement
The The
dirty
dirty
dozendozen
Complacency
Distraction
Fatigue
Norms
Pressure
Stress
Lack of Assertiveness
Lack of Awareness
Lack of Communication
Lack of Knowledge
Lack of Resources
Lack of Teamwork
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
A technician over torqued the outlet union nut damaging internal threads of the hydraulic filter cover and de-shaping the sealing ring of the assembly (F-7P)
Error – 1Error – 1
UNION AND SEAL OF THE HYDRAULIC FILTER COVER ASSEMBLY
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
After 10 minutes of Flight (F-7P), once gears were lowered for a touch and go landing, main hydraulic warning light came steady on with pressure dropping to below normal limit due to hydraulic leak!
Error – 1 (Consequence)Error – 1 (Consequence)
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
A technician adopted incorrect posture for locking fasteners of the electronic nose compartment (F-7P) using a T-handle.
Error – 2Error – 2
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
While applying force upon the T-handle to tighten the fasteners, the tool slipped and impacted the front wind shield of the aircraft inducing a crack!
Error – 2 (Consequence)Error – 2 (Consequence)
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
Maintenance team worked inside the gas path to rectify an engine anomaly (F-7P). A tool was left behind which went undetected through all supervisory checks and the aircraft was given a full power ground run!
Error – 3Error – 3
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
The undetected tool inside the gas path was ingested during Funco run and induced damage to compressor blades (all six stages)!
Error – 3 (Consequence)Error – 3 (Consequence)
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
BA maintenance technician on night shift installed the incorrect bolts during windscreen replacement and did not consult the applicable IPB/Tech Manual.
Error – 4Error – 4
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
The incorrect bolts could not hold the left windscreen in flight due to cabin pressure resulting in the wind screen blowing off in air. The pilot was jerked out of his seat by the rushing air and was forced out of the cockpit with his knees snagging onto the flight controls!
Error – 4 (Consequence)Error – 4 (Consequence)
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
To save on engine change time, AA maintenance bypassed TO procedure (DC-10 Aircraft) of step-wise removal of engine + pylon and started removing them as a set for the plea of saving 200 man-hours and reducing the number of disconnects (i.e., hydraulic and fuel lines, electrical cables, and wiring) from 72 to 27.
Error – 5Error – 5
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
The self evolved maintenance procedure for engine change resulted in damage to the left wing engine pylon during engine change on aircraft DC-10 (Tail No. N110AA) at AA aircraft maintenance facility on March 29, 1979. Eight Weeks later, the aircraft when scheduled as Flight 191, crashed just after take-off due to No.1 engine/pylon separation from the left wing.
Error – 5Error – 5
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
HUMAN FACTORS HUMAN FACTORS ACCIDENT SCENARIOACCIDENT SCENARIO
Defenses
Gaps
Teamwork
Reliable Maintenance
Good Management
Ambiguous instruction(goes unchallenged)
Pilot lets it go / fails to check
Mis-judgment by Supervisor
Error by Worker
Operational pressureHigh work load.
Reason’s Swiss Cheese ModelReason’s Swiss Cheese Model
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
TOP SIX TOP SIX MAINTENANCE ERRORSMAINTENANCE ERRORS
1. Incorrect installation of components.2. The fitting of wrong parts.3. Electrical wiring discrepancies
(including cross-connection).4. Loose objects (tools, etc.) left in
aircraft.5. Inadequate lubrication.6. Cowlings, access panels and fairings
not secured.
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
ORGANIZATIONAL & LOCAL ORGANIZATIONAL & LOCAL FACTORS CRITICAL TO DEVELOPING FACTORS CRITICAL TO DEVELOPING
A SAFETY CULTUREA SAFETY CULTURE
Organizational Local
Training and selection of personnel.
Knowledge and skill of personnel.
Quality of resources as distributed.
Quality of resources at Flight Lines / Shops / COE.
Organizational Structure Hangar environment.
Opportunities for career development.
Morale & personalities of Aircraft Technicians.
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS
CONCLUSIONCONCLUSION
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS QUESTIONSQUESTIONS??
CONSEQUENCES OF ERRORS IN CONSEQUENCES OF ERRORS IN AVIATION MAINTENANCEAVIATION MAINTENANCE
WHAT ARE ERRORS?
TO ERR IS HUMAN!
ERRORS & SAFETY
HUMAN FACTORS & PAF
EXAMPLES - PAF
EXAMPLES - GLOBAL
HF ACCIDENT SCENARIO
ORG & LOCAL FACTORS
CONCLUSION
Q & A
TOP SIX MAINT. ERRORS THANK THANK YOUYOU!