DCAM Human Factor Topic 1

INTRODUCTION TO HUMAN FACTOR Prepared By: Abdul Ghani Abdul Samad

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Human Factors Putting “yoU” In Human Factors !!!

Lessons learned

Prepared By: Abdul Ghani bin Abdul Samad

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Air India A319 Parked on bay28L was push back for departure to Hyderabad. After push back, The technician instructed the helper to remove the tow bar. The helper removed the Tow bar, and in all this time the technician was facing the tow truck with his back towards the engine. In the meanwhile the captain got the taxi clearance from the ATC, inform the co-pilot the a/c is clear. clear. The technician still on headset and with his back facing the engines, Aircraft started to move with both engines on. With no chocks placed the a/c started Moving and sucked the technician still on headset. The helper who was the prime facia To this incident immediately sat down and saved.

Finding During pushback No AME available

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No chock were place after the pushback

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No clearance signal taken taken from ENGG before taxi out

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Lack of proper coordination between P1,P2 and ground

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HF playing important role to have patience, avoid hurrying and to follow SOP

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SO, WHAT WILL LEARN ? ……………… How mistakes are are made and how they can be avoided, we can go a long way to reducing the number of accidents. How the human body works, How the brain processes information received, a little psychology, How we interact interact with others through effective effective communication Learn the types t ypes of human error and ways ways of avoiding these errors.


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Why………………………? To achieve the ultimate goal – safe and efficient flight operations, To minimise accidents and incidents To investigate the causes (including the underlying hidden causes) and put in place Procedures to minimise the risk of the accident or incident happening again.


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Chapter 1 Introduction

• The Need to Take Human Factors Into Account • Incidents Attributable to Human Factors Factors /Human Errors • Murphy’ y’ss Law


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Learning Outcomes Upon completion of this subject, the participants should be able to: Demonstrate the understanding of human performance and Demonstrate limitations in themselves and others.


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The Term 'Human Factor' United States - Human factor, human factors engineering or human engineering

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Europe

- Ergonomics or Cognitive ergonomics

Research

- human performance, technology, technology, design and human/computer human/computer interaction.

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Focuses on how people interact with products, tools, procedures and any processes

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The Term 'Human Factor' Human factors practitioners – Psychologists Psychologists (cognitive, perceptual and experimental) and engineers. Designers (industrial, interaction and graphic), anthropologists, anthropologists, technical communication scholars and computer scientists also contribute.

Ergonomics focus on anthropometrics for optimum human/machine interaction Human factors focused on Cognitive and perceptual factors.

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Prepared By: Abdul Ghani Abdul Samad

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accessibility

safety

workload

fatigue

situational awareness

shiftwork

usability aging individual differences visualisation of data

user interface

Area of Research

learnability

stress control and display design human/computer interaction human reliability 07/02/2017

work in extreme environments including

attention vigilance human performance virtual environments human error decision making.


attention

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1.1 The Need To Take Human Factors Into Account •

Basically definition describes Human Factor as relation between. –

Humans and humans.

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Humans and machines.

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Humans and working processes

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Humans and their environment.

Also describes as: Human capabilities and limitation Interaction Interaction between human entity and the systems Prepared By: Abdul Ghani bin Abdul Samad

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Objectives of this training training


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EASA Part 145 In order to fulfill the organization commitment, it needs to constantly develop the safety awareness and alertness. All employees must permanently question themselves with a view to enhancing safety at all times.

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In terms of safety, safety, all domains domain s are interrelated. Therefore, all employees are expected to look beyond their own field of activity with a challenging spirit in order to anticipate all potential safety consequences of their acts.

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(EASA Part 145.A.3Od) Personnel Personnel Requirements “Human factors continuation training should be of an appropriate duration in each two year period in relation to relevant quality audit findings and other internal/external sources of information available available to the organisation organisation on human errors Prepared By: Abdul Ghani bin Abdul Samad in maintenance.” 17

Para 145.A.30[e] : The organization shall establish and control the competence of personnel involved in any maintenance, management and/or quality audits in accordance with a procedure and to a standard agreed by the competent authority. authority. In addition the necessary expertise related to the job function, competence must include an understanding of the application of human factors and human performance issues appropriate to that person's function in the organization. organization. Human factors' means principles which apply to aeronautical design, certification, training, operations and maintenance and which seek safe interface between the human and other system components by proper consideration of human performance. Human performance means human capabilities and limitations which have an impact on the safety and efficiency of aeronautical operations. 07/02/2017


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Course objectives Satisfy a regulatory requirement (EASA Part Part 145) to; Provide initial Human Factors Factors training

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Improve a return of experience system system (i.e. learning from errors) er rors)

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Provide continuation training on Human Factors Factors

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Improve people and product safety in maintenance m aintenance organisations

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Target audience - EASA AMC 145.A.30 (e) All maintenance, management and quality audit personnel: -holders, managers, supervisors • post -holders,

• certifying staff, support staff and mechanics • technical support such as planners, engineers technician/ record staff

• Quality control/assurance staff • specialised services staff • human factors staff/human factors trainers • store department staff, purchaser department staff • ground equipment operators • contract staff in the above categories Prepared By: Abdul Ghani bin Abdul Samad

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What are human factors? inadequate spares and tools Fatigue

poor lighting

poor communication communication boring, personnel problems

poor tool inspection poor verification of skills and knowledge knowledge

inadequate training

time pressure

Human factors that may influence work performance

poor air quality noise

drug and medication abuse

slippery floor

inadequate instructions

temperature poor documentation documentation

repetitive tasks high pressure to complete a task.


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Human Factors In Aviation During the Second World War many countries launched a mass production of military aircraft. Engineers began to consider factors like the design of control panels that were aligned with the needs and skills of the pilots. During the 1950s the US Air Force initiated experiments to evaluate human personality and to optimize the interaction between man and work flow.


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Human Factors In Aviation In 1988 the US Government passed the “Aviation Safety Act”. demand the FAA to perform human factors research. That same year, a Boeing B737 disintegrated in flight above Hawaii. The causes were mainly found in the human factors sector.


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Human Factors In Aviation This accident did provoke high public concerns in terms of human factors factors related to aircraft maintenance. During the 1990s the FAA invested in extensive research programs related to human factors in maintenance. Many results from these studies were converted into mandatory guidelines for human factors training and therefore became valid also for this course program.


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illustration illustration shows at least three facts: •Flying is very safe •The increase of the safety rate is very small •If safety remains the same while more flights are performed per day, the number of accidents must increase.

Accident statistics statistics – Boeing study Prepared By: Abdul Ghani bin Abdul Samad

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Main Causes For Flying Accidents The data provided by Boeing shows the following main causes for flying accidents: •Cockpit Crew •Aircraft •Weather •Maintenance


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Who causes these mistakes? Approx. 80% of accidents are consequences of human errors. Therefore we have to deal intensively with human factors if we want to improve worldwide airline safety comprehensively.


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Influence of maintenance on incidents and accidents In the early 1990s Boeing did complete a study about the 7 major faults that led to an engine in-flight shutdown. 276 in-flight shutdowns were recorded for this study. The causes were: •Incomplete installation installation

33%

•Component damage (during installation) installation)

14.5%

•Inaccurate installation

11%

•Missing equipment

11% Prepared By: Abdul Ghani bin Abdul Samad

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7 Major Errors


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Pratt & Whitney did examine the reasons for 120 engine in-flight shutdowns on Boeing B747 airplanes.


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The result is almost equal to Boeing and British Civil Aviation Authority (CAA) : Missing components, wrong components, inaccurate installation installation False installation, inadequate components, false connection of electrical wiring and many more.


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Incidents In The Aviation Sector

Aloha flight 243 ( April 1988 )


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1.2.1 American Airlines DC10 – Chicago O’Hare, 1979 In 1979 an engine separated from the wing of a DC10 shortly after take-off. Due to its low altitude the aircraft could not be recovered and crashed into the ground approx. 1 mile from the airport. Investigations found out that unconventional work flows during an engine exchange did contribute to this failure and caused the engine separation. In addition, other DC10 operators were aware of this acutely dangerous situation, but did not provide sufficient with emphasis information to the manufacturer. Today, new industrial reporting and quicker data exchange counteract counteract these human communication problems. Prepared By: Abdul Ghani bin Abdul Samad

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1.2.1 American Airlines DC10 – Chicago O’Hare, 1979


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1.2.2 Continental Express EMB120 The Continental Express accident is a typical human factors example with fatal ending. The aircraft was a Regional Turboprop Embraer 120. The incomplete installation of a deicing system caused the separation of the leading edge from the RH horizontal stabilizer in flight. The crew was helpless and could not regain control over the aircraft. A multiplicity of human factors did play a major role in this accident. The major reasons were poorly written reports and a mainly oral communication during shift change.


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1.2.2 Continental Express EMB120


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1.2.3 Eastern Eastern Airlines L1011 – Miami 1981 Another example is the accident of former Eastern Eastern Airlines during the early 1980s. A Lockheed L1011, equipped with three engines, left Miami with 175 people on board heading for Nassau on the Bahamas, a quite short charter flight. Approximately 15 minutes into the flight, the pilots noted low oil pressure levels and high oil temperatures on all three engines. Upon failure of two engines, the aircraft returned safely on the remaining engine to Miami. The reason was missing sealing O-rings on the “Primary Chip Detectors” that had been exchanged prior to the flight. The “National Transportation Safety Board” Organization identified that the possible cause was the absence of all O-rings on the “Master Chip Detectors”. This caused an insufficient lubrication and thereafter a damage of all three engines.


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1.2.3 Eastern Eastern Airlines L1011 – Miami 1981 The reasons for this incident were on one hand the failure of a technician to perform the correct and approved procedure for the “Master Chip Detector” installation on the engine oil circuit. On the other hand, quality control failed to instruct the technicians to comply strictly with the stipulated installation installation instructions. Furthermore the Eastern Airlines management misjudged the importance of similar incidents that had appeared recently and failed to initiate respective corrective actions. Prepared By: Abdul Ghani bin Abdul Samad

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1.2.3 Eastern Eastern Airlines L1011 – Miami 1981 An additional, fourth reason for the accident was, that maintenance inspectors from the FAA did misjudge the importance of the incidents related to the Master Chip Detector installation and did also not take any corrective action to prevent a recurrence of the accident. In fact, this event did not cause any fatalities, but a million dollar damage for Eastern Airlines. It simply should not have happened!


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1.2.4 Aloha Airlines B737-200, Hawaii, 1988 In 1988, an Aloha Airlines Boeing B737-200 experienced a rapid decompression and structural failure failure at an altitude of 24.000 ft during a flight from Hilo to Honolulu, Hawaii.


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1.2.4 Aloha Airlines B737-200, Hawaii, 1988 During the flight a structure section including outer skin of 18 ft length aft of the FWD passenger door and above the cabin floor level separated from the aircraft. There were 89 passengers and 6 crew members on board. One cabin crew member was turn from the aircraft by the rapid decompression. The flight crew initiated an emergency descend and landed safely on Kahului airport on Maui island. The safety topics that were mentioned in the last NTSB report included the quality of the maintenance programs and its monitoring by the FAA as well as human factors in aircraft maintenance and the airworthiness inspections of transport aircraft. Thereby human factors include repair procedures, training as well as the certification and qualification of technicians and inspectors. Those are exactly the factors that appear within the “Dirty Dozen”. Prepared By: Abdul Ghani bin Abdul Samad

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1.2.5 United Airlines DC10, Sioux City, City, 1989 In 1998 a critical engine failure caused a complete loss of the aircraft’s control system on a United Airlines DC10. The airplane was enroute from Denver to Chicago and had to perform a crash landing in Sioux City/Iowa. Due to the heroic performance of the flight crew the landing was successful. The NTSB accident report indicated an insufficient consideration of human factors and limitations within the inspections and quality insurance processes of the United Airlines engine overhaul. A fatigue crack in the fan disc No. 1 was not detected that had been caused by a previous unnoticed material m aterial fault. fault.


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1.2.5 United Airlines DC10, Sioux City, City, 1989 The separation and disintegration of fan disc No.1 caused the failure of all three hydraulic systems that supplied the aircraft controls with energy. This accident did generate a much higher awareness for human factors in terms of processes and work flow for the inspection of rotational components components of turbine engines.


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1.2.6 Northwest Airlines Boeing B747-200, Narita/ Japan, 1994 In 1994 Northwest Airlines experienced a heavy engine failure during landing at Narita/Japan. On the flight from Hong Kong to New York/JFK the airplane performed an intermediate landing in Narita. The airplane did stop on the Taxiway in Narita with Engine No. 1 touching the ground. The lower forward engine cowling had been ripped off while it was dragged along the runway. A fire that developed close to the No 1 engine was extinguished by the fire brigade directly on site.


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1.2.6 Northwest Airlines Boeing B747-200, Narita/ Japan, 1994 The reason why the engine fell off from the airplane was found in the installation of the aft safety bolt that had been performed 30 days ago, however however without the appropriate securing elements. The investigation of the incident did show that these elements were found in their package at the facilities in the US where the maintenance maintenance had been performed.


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1.2.7 ValueJet DC-9, Florida, 1995 During this accident the cargo of the aircraft, a DC-9 enroute from Miami to Atlanta, caught fire. The fuels for the fire were old aircraft tires and passenger oxygen generators.


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1.2.7 ValueJet DC-9, Florida, 1995


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Human factors, that contribute to the accident include, the following following aspects: •Insufficient training of the cargo dispatcher’s technicians •violation of the stipulated stipulated procedures •failure to secure and mark the dangerous goods correctly •insufficient monitoring by the controlling bodies.

In this example many errors were on behalf of the workers, the company and the controlling bodies.


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1.2.8 ValueJet DC-9, Atlanta Atlanta 1995: During the take-off run, a catastrophic engine failure occurred on a ValueJet DC-9. When the aircraft accelerated, the occupants and the tower controllers heard a “loud bang”. The engine fire warning came on and the crew of the following aircraft informed the ValueJet pilots that their RH engine was on fire. The take-off take-off was aborted. Small debris of the RH engine penetrated the aircraft fuselage and the main fuel supply line of the RH engine, which caused a cabin fire. The airplane did stop on the runway and all occupants were evacuated. Nevertheless the aircraft fuselage was completed destroyed.


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1.2.8 ValueJet DC-9, Atlanta What was the cause? Again, human factors! factors! The previous aircraft operator did not perform a detailed inspection of the high pressure compressor’s stage No. 7. In addition, the maintenance personnel did not have a detailed monitoring system available to allow a step by step documentation of any inspection procedure. These factors are also part of the “Dirty Dozen”.


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Accident or incident incident could have have been avoided. avoided. An individuals individuals failed to 1. Reco Recogn gniz ize e po pote tent ntia iall haza hazard rds, s, 2. Did Did not not reac reactt as as exp expec ecte ted d 3. Diversion Incidents and accidents which involved human factors problems could formed an error chain.


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Cost Human errors in aircraft maintenance maintenance do not only endanger safety, safety, they also cost a lot of money m oney.. 1. In-flight failure - USD 500.000 2. Flight cancellation - USD 50.000 3. Incident on ground - USD 100.000

Airlines losing at least $ 1.000.000 per year.


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Fender Benders

Fender Bender incidents are not really noticed by public. Theses incidents happen quite often on the runway, taxi way, apron or in the hangar, hangar, documented only by the airlines themselves and causing costs in the order of millions of US dollars. do llars. 07/02/2017


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1.6 MURPHY’S MURPHY ’S LAW Murphy's law is a popular adage in Western culture that most likely originated at Edwards Air Force Base in 1948. The law broadly states that things will go wrong in any given situation, if you give them a chance. 'If there is more than one way to do a job, and one o ne of those ways will result in disaster, then somebody will do it that way.' •

Tendency of human being towards complacency.

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Can be regarded regarded as notation “if “if something can go wrong it will”.

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It is not true incidents or accidents ONLY ONLY happen to people peo ple who are irresponsible or sloppy. Prepared By: Abdul Ghani bin Abdul Samad

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1.6 MURPHY’S LA LAW W

Simply means when an a/c parts can possibly be installed installed incorrectly, someone will do it.

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Many times these maintenance error are not discovered until the a/c is in flight •

Read as ‘if there are two or more ways to do something, and one of those ways can result in a catastrophe, then some one will do it ’ •


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1.6 MURPHY’S LA LAW W “If something can go wrong, it will go wrong”

Some remarks to think about: •Nothing is as simple as it may appear

Everything takes longer than you assume •Everything •If there is the possibility that things may go wrong, they will go wrong and cause the most severe damage. •Things you leave on their own will go from bad to worse.


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1.6 MURPHY’S LA LAW W •You are always intervened, if you seriously want to spend time with something. •Every Every solution generates two new problems. •It is impossible to design anything absolutely safe. Fools are very inventive. •Nature always takes sides for the hidden error.


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END OF PRESENTATION

07/02/2017

DCAM Human Factor Topic 1

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