maintenance human federal aviation factors: concepts & … · 2013. 9. 6. · dallas, tx...
TRANSCRIPT
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Maintenance Human Factors: Concepts &
Challenges
Dr. William B. Johnson
Chief Scientific & Technical Advisor for Human Factors in A/C Maintenance Systems
TWU/AA System Safety MeetingDallas, November 13 - 14, 2006
Federal AviationAdministration
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1Federal AviationAdministration 1
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Agenda
Considerations & Topics for FAA HF Attention
Future Challenges and Plans
Human Factors Concepts – Key Examples
Selected 2005-2006 Accomplishments
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2Federal AviationAdministration 2
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Human Factors Spectacles
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3Federal AviationAdministration 3
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Agenda
Considerations & Topics for FAA HF Attention
Future Challenges and Plans
Human Factors Concepts – Key Examples
Selected 2005-2006 Accomplishments
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4Federal AviationAdministration 4
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Human Factors Goal – Simply Stated
Ensure continuing safety and efficiency by
paying attention to issues surrounding
human performance.
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5Federal AviationAdministration 5
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Federal AviationAdministration
Maybe we all need some “thought control?”
What is in it for you?Most of our errors are in thinking rather than lack of knowledge.
Think about your actions that may lead to error.
Save time and money?
Apply principles to life.
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6Federal AviationAdministration 6
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Maintenance Errors and the Consequences
Jan 2000 Alaska Airlines Boeing MD-80 Jackscrew for Elevator Control
Mar 2001 Lufthansa Airbus A320 Mis-wired side stick
Apr 2001 Emery Worldwide DC-8 Reversed hyd. check-valve
Aug 2001 Air Transat A310 Fuel exhaustion over Atlantic
May 2002 China Airlines B747-200 In flight break-up at 35K Ft.
Jan 2003 Air Midwest Beech1900D Trim Rigging
Aug 2003 Colgan Air Beech 1900D Trim Rigging
July 2006 Spectrum Aircraft Spectrum 33 Mis-Rigging
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Federal AviationAdministration 7
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Boeing’s top 7 Errors 276 In-flight shutdowns (1994)
• Incomplete installation (33%)
• Damage on installation (14.5%)
• Improper installation (11%)
• Equipment not installed or missing (11%)
• FOD (6.5%)
• Improper troubleshooting, inspection, test (6%)
• Equipment not activated or deactivated (4%)
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8Federal AviationAdministration 8
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
The 12 Common Human Errors
Link
Proprietary graphic used with expressed permission of Lufthansa Technical Training
(www.ltthf.com)
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Federal AviationAdministration 9
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Sensing and Perception
Human SensesHuman Factors
Human Factors
Human Factors
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10Federal AviationAdministration 10
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
How to Remember the 5 Senses
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11Federal AviationAdministration 11
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
What does this mean?
Link
Proprietary graphic used with expressed permission of Lufthansa Technical Training
(www.ltthf.com)
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12Federal AviationAdministration 12
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
“O sleep, O gentle sleep, Nature’s soft nurse”
William Shakespheare
1564-1616
The Fatigue Issue is not New!
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13Federal AviationAdministration 13
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Chronic Fatigue (harder to fix)•Frequent recurrence
•Long duration
•Slow recovery
•Often a physical sickness or mental stress causing chronic fatigue.
Types of Fatigue
Acute FatigueIntense
Short Duration
Cured with a good night’s sleep
Proprietary graphic used with expressed permission of Lufthansa Technical Training
(www.ltthf.com)
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14Federal AviationAdministration 14
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
0
5
10
15
20
25
30
35
Perc
ent o
f AM
Ts
<4 hrs >4<5 hrs >5<6 hrs >6<7 hrs >7<8 hrs >8 hrs
Sleep Duration
Overall
Percent of AMTs from All Shifts by Sleep Duration
Johnson, et al, 2001
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15Federal AviationAdministration 15
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Regarding sleep: Do what your mama told you.
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16Federal AviationAdministration 16
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Agenda
Considerations & Topics for FAA HF Attention
Future Challenges and Plans
Human Factors?
Selected 2005-2006 Accomplishments
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17Federal AviationAdministration 17
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
• Apply resources to high payoff opportunities
• Ensure that R&D can be applied, but do not ignore good science
• Attack present challenges with an eye to the future
• Communicate in plain language
How to define topics for Mx HF Attention
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18Federal AviationAdministration 18
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
How to Accomplish the Human Factors Goals
Attention to:
• people,
• the environment in which they work,
• the actions they perform,
• and the resources necessary to perform the work.
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19Federal AviationAdministration 19
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
PEAR Details: People
• Physical Factors• Physical size• Sex• Age• Physical characteristics• Strength• Sensory limitations• Physiological Factors• Nutrition• Health• Lifestyle
• Fitness for Duty• Alertness• Chemical Dependence
• Workload• Experience• Knowledge• Training/Certification• Attitude• Mental or emotional state• Interpersonal conflicts• Personal loss
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20Federal AviationAdministration 20
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
PEAR Details: Environment
Physical Environment• Weather• Location inside/outside• Workspace• Shift• Lighting• Noise• Safety
Organizational Environment
• Personnel
• Supervision
• Union management relations
• Pressures
• Crew structure
• Size of company
• Profitability
• Morale
• Culture
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21Federal AviationAdministration 21
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Agenda
Considerations & Topics for FAA HF Attention
Future Challenges and Plans
Human Factors?
Selected 2005-2006 Accomplishments
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22Federal AviationAdministration 22
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
• The Operator’s Manual for Human Factors in Aviation Maintenance (www.hf.faa.gov/opsmanual)
• Plain Language Award• Published in 3 Languages• Widely – adopted by industry• Many website hits with document downloads 3000+
• Support of FAR 145 Rule with Guidance Material
• Study of language-related error in maintenance
Selected 2005 Activity
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23Federal AviationAdministration 23
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
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24Federal AviationAdministration 24
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
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25Federal AviationAdministration 25
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
3 key references plus slides
Key References for Each Chapter
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26Federal AviationAdministration 26
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
www.hf.faa.gov/opsmanual
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27Federal AviationAdministration 27
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
• FAA AC 145-10, Ch. 3, §301(c)
• The FAA concurs with European Authorities in that human factors training related to maintenance practices would provide an additional margin of safety to the repair industry;
• A human factors training program should be related to maintenance practices where possible;
FAA HF Guidance for Part 145
• At this time it is recommended. It is not an FAA regulation.
• EASA Certificate holder’s must follow EASA rules
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28Federal AviationAdministration 28
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Main Findings• Language errors exist but typically found early
• High Accuracy everywhere: Non-native English speakers typically go slower but maintain accuracy
Main Recommendations• Deliver more specialized language training.• Provide and translation (full & partial).
Language Error Study
1000 participants: Asia, Latin America,Europe and US.
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29Federal AviationAdministration 29
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
• International Conference (ATA)
• Unmanned Aerial Systems (NASA)
• International Survey on HF in Maintenance (CAMI)
Selected 2006 Activity
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30Federal AviationAdministration 30
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Survey Goals and Methods
Purpose: Assess status of maintenance HF
Focus: program support and motivation, organizational
policies, fatigue management, error management, and
training.
Distribution: Online survey (80 items) 630 addresses.
Returns: 414 respondents (66%) from 54 countries.
Experience: 65% > 20 yrs. maintenance experience.
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31Federal AviationAdministration 31
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
54 Countries
414 Total Respondents
Respondent Representation
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32Federal AviationAdministration 32
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Where do you work?
35.0%
8.9%
8.2%
5.6%
27.3%
4.8%
10.1%
Air Maint Repair Stn ManufacturerGA/BIZ Mil/Govt School/TrnOther
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33Federal AviationAdministration 33
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Regulatory Compliance
17.8%Other National Aviation Authority N=72
8.9%Transport Canada N=36
45%Federal Aviation Administration (FAA) N=182
23.5%European Aviation Safety Agency (EASA) N=95
4.7%Civil Aviation Safety Authority (CASA) N=19
Which is the primary regulatory authority your maintenance operations are designed to be in compliance with? N=404
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34Federal AviationAdministration 34
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
FAA has the fewest Human Factors requirements
121.371CAR 571.10145.A.65 (b)3GuidanceError capturing (duplicate inspections)
121.369 (b) 9135.427(b) 9
CAR 573.08145.A.47GuidanceShift and task handover
145.109No145.A.47GuidancePlanning of tasks, equipment, and spares
ASAPCAR 571.05145.A.65 (c) GuidanceProcedural Non-compliance
Continuing Analysis and Surveillance System
CAR 573.30145.A.65Under development Annex 6
Safety Culture/Safety Management System
145.109121.369
CAR 573.08145.A.45GuidanceDocumentation Reporting Requirement
AC120-72, Ops Manual,FAA Website
TP 13459GM145.A.30 (e) &Part 66 Appendix I M9
Doc 9683-AN/950Published HF Guidance Materials
145CAR 106145.A.30NoAccountable Executive
Guidance in Tech Pubs121.377
Proposed, now awaiting consul.
145.A.30(d)incl. AMC
GuidanceFatigue Management System
Rec, 145.211CAR 1145.A.60 GuidanceError Management System
Recommended in ACsCAR 573.06145.A.35 (d)Annex 6Continuation Training for HF
NoCAR 573.06145.A.30(e)incl AMC&GM 145.A.30(i)
Annex 1HF for Initial Certification
FAATCEASAICAOTopic
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35Federal AviationAdministration 35
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Regulatory Support and Close Work
0
2040
6080
100
Support Work Closely
% A
gree
men
t
CASAEASAFAATransport CanadaOther NAA
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36Federal AviationAdministration 36
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Fatigue is “Important” but few programs
Impact of fatigue was recognized by 82.1%.
Fatigue Management SystemOverall, 25% have a fatigue management system.
Training on Fatigue Management35.9% provide training on fatigue management.
0
20
40
60
80
100
System Training%
Yes
CASAEASAFAATransport CanadaOther NAA
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37Federal AviationAdministration 37
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
0
20
40
60
80
100
Existing Course Developing aCourse
SendEmployees
No Course
% R
espo
nden
ts
Overall CASAEASA FAATransport Canada Other NAA
Transport Canada and EASA have HF Training
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38Federal AviationAdministration 38
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Additional Selected 2006 Activity
• Web-Based Surveillance and
Auditing Tool (WebSAT)
• Revised Training Course for FAA Inspectors
2 Days 3 Days
Highly Revised!
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39Federal AviationAdministration 39
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Additional Selected 2006 Activity
• Rewrite of “Human Factors Guide for Maintenance and Inspection.”
• Revive “hfskyway.faa.gov”
• AFS Mx Human Factors Plan
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40Federal AviationAdministration 40
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Agenda
Considerations & Topics for FAA HF Attention
Future Challenges and Plans
Describe an ideal HF Mx & Ramp Safety Conference
Selected 2005-2006 Accomplishments
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41Federal AviationAdministration 41
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Challenges• Maintenance HF Regulations: 25, 65, 121, 135,145, 147.
• Fatigue R&D? Guidance? Regulation?
• Advanced Technologies, VLJs, Rotorcraft, UAVs, Avionics, Commercial Space travel, Aging Aircraft, …..
• Ensuring Quality & Safety in all Maintenance Organizations
• General Aviation Maintenance HF
• SMS in Maintenance
![Page 43: Maintenance Human Federal Aviation Factors: Concepts & … · 2013. 9. 6. · Dallas, TX November 14, 2006 • FAA AC 145-10, Ch. 3, §301(c) • The FAA concurs with European Authorities](https://reader033.vdocument.in/reader033/viewer/2022051916/6007cfebd3ff963eac6c072c/html5/thumbnails/43.jpg)
42Federal AviationAdministration 42
TWU/American Airlines System Safety Meeting
Dallas, TX
November 14, 2006
Agenda
Considerations & Topics for FAA HF Attention
Future Challenges and Plans
Describe an ideal HF Mx & Ramp Safety Conference
Selected 2005-2006 Accomplishments
Q&A (Time permitting)
Thank you