Human Factors in Aviation Maintenance
Human Factors in Aviation Maintenance
HUMAN FACTORS
AVIATION MAINTENANCE TECHNICAN
BASIC TRAINING
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FORWARD
PART – 66 and the Acceptable Means of Compliance (AMC) and Guidance Material
(GM) of the European Aviation Safety Agency (EASA) Regulation (EC) No. 2042/2003,
Appendix 1 to the Implementing Rules establishes the Basic Knowledge Requirements
for those seeking an aircraft maintenance license. The information in this Module (05) of
the AMT – Cat A Training Manuals compiled by AESC Aviation Training Center meets or
exceeds the breadth and depth of knowledge subject matter referenced in Appendix 1 of
the Implementing Rules. The order of the material presented is at the discretion of the
editor in an effort to convey the required knowledge in the most sequential and
comprehensible manner. Knowledge levels required for Cat A maintenance licenses
remain unchanged from those listed in Appendix 1 Basic Knowledge Requirements.
Tables from Appendix 1 Basic Knowledge Requirements are reproduced at the beginning
of each module in the series and again at the beginning of each Sub-Module.
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Contents
Sub-Module 01 .................................................................................................................. 1
General .............................................................................................................................. 1
INTRODUCTION ............................................................................................................ 2
DISCIPLINES OF HUMAN FACTORS ........................................................................... 3
HISTORICAL REVIEW ................................................................................................... 4
STATISTICS .................................................................................................................. 5
ACCIDENTS .................................................................................................................. 6
INFLUENCE OF MAINTENANCE (3 STUDIES) ............................................................ 7
EXAMPLES OF ACCIDENTS ........................................................................................ 9
SHELL – MODEL ......................................................................................................... 15
MURPHY’S LAW .......................................................................................................... 16
Sub-Module 02 ................................................................................................................ 18
Human Performance And Limitations .............................................................................. 18
INTRODUCTION .......................................................................................................... 19
THE FIVE SENSES...................................................................................................... 19
SIGHT / THE HUMAN EYE .......................................................................................... 20
HEARING / THE HUMAN EAR .................................................................................... 22
INFORMATION PROCESSING ................................................................................... 23
LIMITATIONS OF INFORMATION PROCESSING ...................................................... 27
PHOBIAS ..................................................................................................................... 28
Sub-Module 03 ................................................................................................................ 30
Social Psychology ........................................................................................................... 30
INTRODUCTION .......................................................................................................... 31
MOTIVATION ............................................................................................................... 32
RESPONSIBILITIES .................................................................................................... 35
PEER PRESSURE ....................................................................................................... 37
CULTURE ISSUES ...................................................................................................... 38
TEAMWORK ................................................................................................................ 40
MANAGEMENT, SUPERVISION AND LEADERSHIP ................................................. 43
Sub-Module 04 ................................................................................................................ 45
Factors Affecting Performance ........................................................................................ 45
INTRODUCTION .......................................................................................................... 46
STRESS ....................................................................................................................... 47
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WORKLOAD ................................................................................................................ 50
FATIGUE ...................................................................................................................... 53
ALCOHOL, MEDICATION AND DRUG ABUSE........................................................... 57
Sub-Module 05 ................................................................................................................ 62
Physical Environment ...................................................................................................... 62
INTRODUCTION .......................................................................................................... 63
NOISE .......................................................................................................................... 63
FUMES ......................................................................................................................... 64
ILLUMINATION ............................................................................................................ 65
CLIMATE AND TEMPERATURE ................................................................................. 66
MOTION AND VIBRATION .......................................................................................... 67
DANGEROUS SONIC WAVES .................................................................................... 68
WORKING ENVIRONMENT ........................................................................................ 69
Sub-Module 06 ................................................................................................................ 71
Tasks ............................................................................................................................... 71
INTRODUCTION .......................................................................................................... 72
PHYSICAL WORK ....................................................................................................... 72
REPETITIVE TASKS.................................................................................................... 74
VISUAL INSPECTION.................................................................................................. 75
COMPLEX SYSTEMS.................................................................................................. 78
Sub-Module 07 ................................................................................................................ 81
Communication................................................................................................................ 81
INTRODUCTION .......................................................................................................... 82
DISSEMINATION OF INFORMATION. ........................................................................ 87
Sub-Module 08 ................................................................................................................ 90
Human Error .................................................................................................................... 90
ERROR MODELS AND THEORIES ............................................................................ 91
SWISS CHEES - MODELL .......................................................................................... 92
TYPES OF ERROR..................................................................................................... 92
DIRTY DOZEN ............................................................................................................. 93
LACK OF COMMUNICATION ...................................................................................... 96
LACK OF TEAMWORK ................................................................................................ 96
NORMS ........................................................................................................................ 98
PRESSURE ................................................................................................................. 99
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COMPLACENCY........................................................................................................ 101
LACK OF KNOWLEDGE ............................................................................................ 102
LACK OF AWARENESS ............................................................................................ 103
LACK OF RESOURCES ............................................................................................ 104
DISTRACTION ........................................................................................................... 105
LACK OF ASSERTIVENESS ..................................................................................... 107
FATIGUE ................................................................................................................... 108
STRESS ..................................................................................................................... 109
ERROR MANAGEMENT ............................................................................................ 111
Sub-Module 09 .............................................................................................................. 113
Hazards In The Workplace ............................................................................................ 113
INTRODUCTION ........................................................................................................ 114
DEALING WITH EMERGENCIES .............................................................................. 115
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Sub-Module 01
General
9.1 General
The need to take human factors into account
Incidents attributable to human factors/human error
’Murphy’s’ law
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9.1 GENERAL
The need to take human factors into account;
Incidents attributable to human factors/human error;
’Murphy’s’ law.
INTRODUCTION
Air transport is considered as one of the safest means of travelling in the world today, yet
every now and again an accident occurs which shakes our complacency. All too often, as
we look at the cause of the accident, we will say:
”How could such simple error have combined to cause such a catastrophe?”
An in−depth review of the events after the fact will reveal, time and again, that a series of
human errors (known also as a chain of events) was allowed to from until the accident
occurred. In about one accident out of ten, maintenance errors are part of the chain of
events.
If we brake the chain of events at the maintenance level, the accident will not
happen.
What you will gain from this workshop is very much related to what you are prepared to
invest into it. Be open minded − but if you disagree with anything that is being said, feel
free to speak up.
Take the time to glance through this book from time to time in the future. It may help you
to avoid mistakes and safe you from having to pay the price for them.
What is maintenance Human Factors?
In the most straightforward terms, Human Factors are those conditions that affect a
human in the aviation maintenance work environment.
Often, a Human Factors class begins by asking participants to list human factors that
affect work performance. The following list is only a small sample of the possible topics of
human factors those participants might list:
Fatigue, poor communication, personal life problems, smelly fumes, loud noises, slippery
floors, snow, incomplete or incorrect documentation, poor instructions, substance abuse,
poor training, poorly designed testing for skill and knowledge, bad lighting, unrealistic
deadlines, lack of spare parts and tools, poor tool control, boring repetitive jobs, a rush to
complete jobs.
The list may be endless. Some problems are minor but can become major.
In most cases more than one of these factors contributes to a problem. During this
course we will consider most of these human factors that may contribute to an incident or
accident event.
Costs
Not only does human error in maintenance compromise safety, it also costs money. For
example, the manufacturers estimate that;
The cost of an in−flight engine shutdown is about $500,000.
A flight cancellation costs a minimum of $50,000.
An average ground damage accident is about $100,000 when ramp equipment
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contacts an aircraft.
The airlines lose at least $billion per year from human error. The industry can hardly
afford such losses now, or at any time.
We must do better. Attention to human factors can help us to improve safety
and to return the airline business to profitability.
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Anthropometrics is the study of factors such as size, strength, reach and other
dimensions that can be quantified to match the machine to the human.
Example: An original Coca-Cola bottle, for example, was designed to fit the average
human hand, thus making it easy to hold the bottle and drink a lot of the product.
Computer Science
Computer scientists study the graphical user interface to be sure that humans can easily
operate software. Therefore, Computer Science remains an excel- lent example of
human factors.
Cognitive Science
Cognitive Science studies how humans think, how they solve problems and the ways in
which they process information. This knowledge can be critical to de- sign of equipment,
software, and documentation.
Safety Engineering
Safety Engineering applies to worker safety, with respect to topics like safety equipment,
labeling, rules, and such things.
Medical Science applies to topics such as vision, hearing, balance, and overall health
issues.
Organizational Psychology
Organizational Psychology looks at how people work within various size groups.
Organizational Psychologists have made excellent contributions to the field of Crew
Resource Management, which is mandatory training for flight crews, and important to
maintenance crews.
HISTORICAL REVIEW
It is difficult to identify the exact historical beginnings of the various disciplines of Human
Klinische Psychology
Factors.
Industrial Experimental Psychology
With respect to anthropometrics
Engineering − the size and strength of the human − you can refer to
Leonardo D’Vinci’s (1452 to 1519) Anthropometric man.
Another perspective is the research of Frank (1868 to 1924) and Lillian Gilbreth, (1878 to
1972), Industrial Engineers who studied medical operating procedures in the early
Educational Psychology
1900’s. Anthroprometry
They created the verbal protocol whereby the receiver repeats any command given. The
repetition helps to ensure clear communication.
That protocol continues today in air traffic control communications.
The psychologists
Organisational Sigmund Freud (1856−1939) and Kurt Lewin (1890−1947)
Psychology also
Computer Science
conducted human factors work.
Aviation Human Factors started in the early 1900’s when aircraft designers began to
consider aircraft compatibility with the human.
At the same time, military
Medical researchers
Science were already looking at medical
Cognitive factors concerning
Science
pilots. In World War II, many governments were
Safety Engineering mass−producing military aircraft.
Engineers had to consider such factors as control design and instrument layout for
compatibility with pilots.
Figure 2 Disciplines of Human Factors
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By the 1950’s, the US Air Force was conducting experiments evaluating human
personalities so as to better match people to their military job assignment.
In 1988, the U.S. Government passed a law named the Aviation Safety Act, which
demanded that the FAA conduct research on human factors in aviation, including factors
related to aviation maintenance personnel.
In that year in Hawaii, a B737, experienced an in−flight break−up which, through
investigation, was found to have had many human factors as the root cause of the
incident. This incident generated much public concern about maintenance human factors.
Throughout the 90’s, the FAA conducted extensive research on maintenance human
factors. Much of that research evolved into regulatory guidelines for human factors
training, like the material delivered in this class. Figure 3
STATISTICS
Introduction
Statistics tell a story, often showing the relative safety of a system or airplane. Most
airline safety statistics demonstrate that the system is extremely safe.
It is difficult to improve the worldwide airline safety rate − less than 3 accidents per 1
million departures.
The Boeing Company publishes an annual worldwide safety record, summarized here.
Notice that safety improved radically from 1959 to 1969, but since then has improved
only slightly.
The number of fatalities is quite variable, and almost a matter of chance from one year to
the next.
This chart illustrates at least three facts:
● First, airline travel is very safe.
● Second, the safety rate is not improving much.
● Third, if the safety rate remains the same while the number of departures increases,
there will be an increased number of accidents.
For example, there were about 17 Million Departures worldwide in the year 2000,
equaling 51 accidents. That means somewhere in the world, one airliner accident takes
place each week. That is not acceptable.
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Link: [Link]/commercial/safety
HUMAN AVIATIO
FACTOR N
1900
192 Wright
0 1903
194
0
196 Optimisation
0
198
0 1988: B737
„Cabriolet“
US Congress
200 1988
0 JAA
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Another study, conducted during the eighties to early nineties, showed that maintenance
related accidents were the 2nd leading cause of fatalities.
What causes these accidents?
Experts agree that about 80% of these accidents are a result of human error. Therefore
we must pay attention to human factors if we are going to improve the overall safety of
the world’s airlines.
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100
%
huma
80 n
%
20 technic
% al
191 200
0 0
Figure 6 80 / 20 Rule
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EXAMPLES OF ACCIDENTS
American Airlines DC10 - Chicago O’Hare, 1979
For example, in 1979 in Chicago, an engine separated from a DC10 aircraft shortly after
takeoff. With no altitude for recovery, the aircraft crashed within a kilometer of O’Hare
Field.
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DC 10
1 Kilometer
CHICAGO O’Hare
47 MISSING
SCREW FASTENERS
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Take Off
Miami
ENGINE FAILURE
Nassau
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Oahu
Molokai
BREAK - UP
Honolulu
89 Passengers
Kuhului 6 Crew
Hilo
Maui
Approximately 18 feet of the cabin skin and structure aft of the cabin entrance door and
above the passenger floor line separated from the airplane during flight. There were 89
passengers and 6 crew members on board.
One flight attendant was swept overboard during the decompression.
The flight crew performed an emergency descent and landed at Kahului Airport on the
Island of Maui.
The safety issues discussed in the final NTSB report included:
...the quality of air carrier maintenance programs and the FAA surveillance of those
programs, and the human factors aspects of air carrier maintenance and inspection for
the continuing airworthiness of transport category airplanes...
The ”Human Factors” included repair procedures, training, and certification and
qualification of mechanics and inspectors.
United Airlines DC10, Sioux City, 1989
In 1989 a United Airlines DC10 had a critical engine failure that disabled the aircraft’s
flight controls. The aircraft was en route from Denver to Chicago, but crash landed in
Sioux City Iowa.
The flight crew performed heroically to land the airplane.
The NTSB Accident report indicated ”inadequate consideration given to human factors
limitations in the inspection and quality control procedures used by United Airlines’
engine overhaul facility. This resulted in the failure to detect a fatigue crack
originating from a previously undetected metallurgical defect in the #1 fan disk.
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The separation, fragmentation, and forceful discharge of uncontained stage 1 fan rotor
assembly parts led to the loss of the three hydraulic systems that powered the airplane’s
flight controls.
’This accident led to increased human factors attention to the processes and
procedures associated with inspection of turbine engine rotating components.’
Northwest Airlines B747−200 - Narita, 1994
In 1994, Northwest Airlines experienced a serious “engine drag” upon landing at Narita,
Japan. The aircraft was landing on an intermediate stop from Hong Kong to New York
JFK Airport.
The aircraft stopped on a taxiway at Narita with the front of the No. 1 engine touching the
ground. The lower forward engine nose cowl had been ground away as it dragged along
the runway. Local fire fighters rapidly extinguished a fire near the No. 1 engine.
The reason that the engine fell from the aircraft was that an aft fuse pin was installed,
about 30 days prior, without its proper locking devices.
The event investigation discovered that the locking device was found, in a small cloth
bag, back in the US facility where the heavy maintenance check was performed.
SIOUX CITY
Chicago
New York
NARITA
No. 1 engine touching the ground.
Tokyo
Hong Kong
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− The second L refers to the human in groups, including such factors as teamwork,
communication, group norms and leadership.
In summary, if you can remember the word SHELL, like the oil company, you can
remember key considerations for Human Factors.
MURPHY’S LAW
Most mechanics and engineers know of the fictitious character named ”Murphy.”
The origin of ”Murphy” is unclear, but the name is often used as the example of the
mechanic that makes mistakes.
Interestingly enough, the regulators believe that you should know ”Murphy’s Law” as part
of human factors.
Murphy’s Law is: ”If something can go wrong, it will.”
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Thus, you should always plan for the possible errors that may result from ”Murphy’s
Law.”
MURPHY’s LAW
If something can go
wrong
- it will!
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Sub-Module 02
Human Performance And Limitations
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However, tasting should play NO part in maintenance! At least we are not aware of any
’taste-checks’
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All three activities are physiologically dependent on each other and are con- trolled by six
muscles.
Impairments
The subject ”Limitations to Visual Performance”. At present there are no JAA/ EASA
regulations governing the visual ability of technical personnel.
Airlines and airport authorities often have their own guidelines governing the driving of
vehicles or the taxiing and towing of aircraft on the apron.
Each individual should be made aware of possible impairments to sight and their risks,
including:
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Pressure of sound influences hearing. The auditory threshold is 0 dB(A) (decibels). The
pain threshold is at 140 dB − damage to hearing can be expected above 150 dB (A).
In the middle ear there is a ”natural” protection mechanism, which protects the ear
temporarily from sound levels above 80 dB(A). This reflex can hold back a maximum of
20 dB(A). If noise occurs suddenly (for example in an explosion), the ear is completely
unprotected.
Over a longer period of time a loss of hearing can result. In Germany and other countries,
ear protection, by law, must be worn at sound levels above 90 dB(A).
Not only the sound level but also the period of exposure is decisive. The limit is reduced
to 85 dB(A) if exposure is more than 4 hours.
INFORMATION PROCESSING
Introduction
All impressions of sense are transmitted to the brain via nerves. This simple diagram
shows you how the information is processed.
The model consists of the following modules:
signal input and store,
attention mechanism,
awareness module,
decision generator,
short−term memory,
long−term memory,
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Memory
Memory is imperative for repetitive actions and for learning new things. It serves as a
store, without which we could not deal with the flood of information.
Memory comes in three types:
ultra short−term memory,
short−term memory
and long−term memory.
The ”decision generator” uses the short and long−term memories.
The short−term memory serves as an interim store for information. You could call it the
”RAM“ of the brain. Under normal conditions the ability to store information temporarily is
sufficient. If the load on the decision generator is great, the short−term memory is pushed
to its limits.
In the computer world the ”RAM” is extended if you want to increase its capacity. And
how is it with people?
Training or ”grouping information” can increase efficiency.
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PHOBIAS
A phobia is a compulsive feeling of terror of particular situations or things. Contrary to
fear, a phobia is usually without basis.
There are different types of phobia:
fear of animals such as spiders − arachnophobia,
fear of crowds of people − known as agoraphobia,
fear of enclosed spaces − known as claustrophobia,
and fear of heights − called acrophobia.
In aviation, claustrophobia and acrophobia are the most common.
Claustrophobia
The official definition of claustrophobia is:
− ”abnormal fear of enclosed spaces”.
It occurs in various ways. In enclosed spaces most of us feel uneasy. This is quite normal
and is a natural protective mechanism.
The dangerous thing about claustrophobia is when this uneasiness becomes
panic−stricken fear.
During such an attack the person can no longer calm himself; in other words, self−control
fails entirely.
What can be done about claustrophobia?
The sufferer can free himself from the enclosed space BEFORE an attack. To do
this, the warning signals must be recognized and taken seriously.
Once the panic attack has set in, colleagues must try to get the sufferer out of the
area.
In conclusion, claustrophobia is difficult to foresee.
There must be a collective attitude that it can affect everyone, not only the victim
but also the helper.
Acrophobia
Most people suffer some degree of vertigo. Nobody can fly, which may explain the
normal respect for heights above 1.50 m.
The abnormal, panic reaction to heights is what is really dangerous.
Sudden acrophobia is less common than claustrophobia. A real sufferer could hardly
climb onto a chair without a panic attack.
During maintenance you must often work at great heights.
Safety lines and suitable platforms lessen the risk of a fall and give you a feeling of
security.
Particularly at low heights, people often thoughtlessly do without safety aids. If the phobia
sets in, two protection mechanisms are missing:
The natural protection mechanism is missing - your body tenses up.
Artificial protection mechanisms, for example, are safety lines.
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Team attitude can lessen dangers. So expressions like ”Hey, stop putting it on” should
disappear from your vocabulary.
Claustrophobi Acrophobia
a
Figure 20 Phobias
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Sub-Module 03
Social Psychology
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Influences
Every company has its own culture. This includes:
company philosophy and policy,
procedures,
selection and training criteria,
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MOTIVATION
Maslow’s Hierarchy of Needs
A well-known theory on the subject of motivation stems from MASLOW
− Maslow’s Hierarchy of Needs.
Maslow postulated that two different motivation forces drive people:
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Motivation / De-Motivation
How can we recognize highly motivated people?
They perform at a high level and get results.
They are energetic, enthusiastic, and set goals.
They are cooperative problem solvers.
They readily assume responsibility
and are willing to accept change.
De−motivated people have a different set of characteristics:
They may be indifferent,
have little safety awareness,
manage time poorly and are frequently absent,
exaggerate problems and difficulties,
create disputes and grievances,
rarely cooperate to solve problems,
and are opposed to change.
Caution:
Not everything may be labeled de−motivation. Many of these items are serious
signs of stress!
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RESPONSIBILITIES
”An aircraft technician carries a lot of responsibility!”
And what about the other occupations within aviation? What does ”responsible” really
mean?
Somebody must be accountable for the tasks he has been given. He takes this
responsibility individually and within the group setting.
The individual is given tasks − usually from within a group − for which he takes
responsibility. A good example of this is the job card for an inspection.
In accordance with your qualifications, you carry out this job and sign it off. This proven
method guarantees ”traceability”.
Who did what and when?
But what does the responsibility of the individual involve? We must examine whether he
is permitted and able to carry out the task.
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The ”permission” is determined by the task and the qualifications of the individual
to carry out this task.
The ”ability” depends on many factors, such as tools, materials, time and many
other things.
And to complete the list: ”willingness” also plays a role.
Group Responsibility
Group responsibility is often limited to the following formula: ”Group responsibility is the
sum of all individual responsibilities.”
Unfortunately this is the wrong approach. Of course, the inspection is divided among
several job cards, and thus to individuals, but group responsibility refers to the general
goal, for example, to do the inspection within a given time.
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PEER PRESSURE
Do you know the expression ”peer pressure” or group compulsion or pressure from
colleagues? This can exert a massive influence on work.
Think of the statement:
”Everybody must pull his weight − there are NO exceptions”.
But what if they do not pull their weight or have reservations about whether or not ”this is
the right way”? This is exactly where pressure sets in.
On the one hand you want to belong. On the other hand you have reservations. A certain
level of conformity to the group is imperative. But sometimes adaptation goes too far, and
unfortunately the borderline is not always clear. Further, pressure is not always applied
openly. You perceive the pressure or maybe you think you perceive it.
The following factors influence the individual’s susceptibility to pressure from others:
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the cultural environment: In some countries the individual has little value. The
community is everything.
sex: in general, women tend to conform more than men.
knowledge and experience: the newcomer tends to follow the majority, above all if
he feels he has too little knowledge or experience.
self−esteem: people with low self−esteem will give in to pressure more easily.
relationships: Conformity is greater if the members of the group know each other
well.
What if colleagues exert pressure on you to do the job ”properly” or make high demands
regarding safety? Should resist this pressure? Or is it better to con- form?
Usually the individual gives in to pressure if he hears such things as ”Stop making a
fuss.” or ”Forget the manual. This is the way we do it.”
It depends on how you should react. With regard to safety it is clear.
There must be a safety culture within the group and ”everybody must pull his weight −
there are NO exceptions.”
Only in this way can peer pressure be tolerated.
CULTURE ISSUES
General
What springs to mind when you hear the expression ”cultural issues”? Do you think about
”the company?”.
The image shows various ”cultures” of a company:
”safety culture”,
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”technical culture”,
”business culture”,
”cultures within the teams and groups”
and ”location culture”.
How do the circles interact with each other? The head of the organization does not define
every culture - many ”cultures” develop independently.
However, the head of the organization is in the best position to influence all
cultures.
Safety Culture
What does ”safety culture” mean? In the ”ICAO Human Factors Digest No. 10” it says:
”... safety culture is the sum of attitudes, norms, roles and social and technical practices,
which aim to minimize dangerous and risky conditions for employees, managers,
customers and the general public.”
Professor James Reason, one of the leaders in the field of human factors, offers the
following hypothesis on this:
...safety culture is the motor giving the system the goal of ”maximum safety”,
independently of persons and current economic demands...
Some efforts are needed to guarantee a culture of safety:
1. The construction of a safety information system to collect relevant incidents as
well as audit reports, analyze them and distribute the conclusions to everybody.
2. The creation of an atmosphere of trust, within which employees are encouraged to
pass on information relevant to safety. In this respect the distinction between
acceptable and unacceptable behavior must be made clear.
3. Respect for the knowledge, ability and experience of staff and direct superiors.
4. The establishment of a learning culture, in which competence is developed to
draw the right conclusions from events, and in which there is a willing- ness to
carry through important reforms when necessary.
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The culture of an organization can be more accurately measured by deeds rather than
words. What is the use of a highly− praised safety system if it is not implemented on the
working level?
Everybody has to participate. Training and ”tools” such as information systems must be
accepted and used. It is the job of management to make these aids available and to
encourage their usage.
TEAMWORK
General
Within a society there are many groups, for example: men between 18 and 25, women
with a university degree, red−haired children ...
In aircraft maintenance there are also numerous groups:
the group of mechanics,
the group of electricians,
line maintenance personnel, etc.
” Team vs. Group”
Does a ” team of mechanics” exist? What distinguishes the team from the group?
A team consists of persons working together to achieve a common goal.
Alternatively, a team can consist of members working in parallel to achieve the
goal.
A team consists of a recognized ”leader” and at least one ”follower”.
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Communication
is very important, and should not be underestimated as a factor in carrying out safe and
efficient maintenance work. Communication problems are the main cause of
maintenance errors in aviation. For this reason, a separate chapter (M9.7
Communication) will be devoted to communication.
Cooperation
is an important ”adhesive” for the team. Openness, honesty and fairness in- crease
cohesion and mutual respect. Members of the team must treat dis- agreements with
respect, and team leaders should play an active and important role in solving them.
Coordination means:
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1. Delegating: tasks must be clearly and fairly allocated according to the abilities of
the team members.
2. Checking: delegated tasks must be monitored and
3. priorities must be set: Priorities should be subject to change if difficulties or new
circumstances arise.
Mutual support
is the ”heart” of every team. It forms the basis for team identity. Every member introduces
his own strengths and weaknesses into the team. The art is to employ everyone
according to his abilities, and to compensate for his weak points. It is a part of mutual
support to point out somebody’s mistakes realistically and constructively, and to be of
assistance regarding solutions.
Why was ”having parties together” not mentioned as imperative for maintaining a team?
It is the expression for ”social contact”.
It may boost morale, but is not essential for working in a team. It can strengthen ties
within the team but it also holds risks.
For example: what about the colleague who has (had) alcohol problems, and as a
result steers clear of team parties?
Would he otherwise be a better member of the team?
The ”team gearbox” is often oiled only at parties − other lubricants remain un- touched. In
this scenario, you would not have a team, just a ”group of happy workers”.
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Figure 32 Leadership
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Sub-Module 04
Factors Affecting Performance
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Important Note
Even so the regulation JAR 66.50 was not transformed into the new EASA Part 66
regularize (!), the chapter ’health and fitness’ is still subject of EASA Part 66 M.9
Basic Training.
Therefore, we have decided to refer to the regulations (and useful advices) of the
’old’ JAR 66.50 in this book.
Illegal Drugs
Illegal drugs, as well as the ’legal drug’ alcohol, can lead to loss of license according to
EASA Part 66.B.500 (old JAR 66.65).
And, of course, drug use is a criminal offense in many countries.
Most company security checks discover any court records involving illegal drugs.
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STRESS
General
Stress − a word often used in our society. Today, ”stress” has become almost a measure
of performance. The more you are under stress, the more you have managed to do.
What is stress, anyway?
STRESS
=
Stress Performance
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Negative Stress
When we talk about stress, we usually mean adverse or ”negative stress”. What are
some typical stressors? There are two main groups:
1. External factors, such as:
noise, environmental poisons or overstimulation, for example from watching too
much television and
2. Internal factors, such as:
anger, sorrow, performance pressure, physical exertion and sickness.
What are the Effects of Negative Stress?
The physical reaction always begins in the same way:
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Nervous
Unrest
Sleeplessness Irritability
Heart Sleep
Troub Disor
Stomachiques
Diarrhea
Skin Irritation
Allergies
Tensions or Muscle
Cramps
WORKLOAD
Your workload depends on three things:
1. The task itself − the physical and mental demands which are made.
2. The accompanying conditions, such as precision, time frame, outside control,
environmental factors, and
3. Yourself. How good is your ability and knowledge, your experience in the field,
your health and fitness and your emotional state, such as stress level, mood and
degree of stimulation.
Arousal
Stimulation, also known as arousal, influences your performance.
Performance may suffer considerably if you are over− or under−stimulated. Only if
stimulation is in the ’middle ground’ can peak performance be achieved.
But what is the right level of stimulation? That is a very individual thing and also depends
on your daily conditions.
What causes a slump in performance? If we are not stimulated sufficiently, our attention
becomes blunted and we are overcome by indifference or boredom during an activity. If
we are inundated by stimulation, our attention tries to focus itself only on the most
important things at the expense of the total performance of our brains.
In the case of extreme over−stimulation we are no longer aware of new information. This
can also be a stressor!
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Figure 36 Workload
Overload
If you recall the factors of workload − namely the task itself, the accompanying conditions
and yourself − it quickly becomes clear where overload starts.
Imagine an activity which you find easy and enjoyable. Now reduce the time allowed for it
by 50%. What has happened to your load?
Under certain circumstances you are no longer able to complete the task.
What do you do if an electrical system is overloaded? You reduce the load before the
fuse blows. It sounds simple, but that is exactly the solution for human overload. Why is it
so difficult to reduce this load?
Just think which actions are necessary..
It is important to find agreement within your team.
It is better to assess the situation correctly before an overload develops.
Early intervention, for example in time schedules and job planning, helps to
prevent overload.
Good ideas and short−cuts often result from an overload. Such ideas should be
discussed among the team in a low−stress environment.
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Underload
Do workers usually complain about underload? Not usually, but it is a potential problem.
Underload is undemanding work.
The risky combination of boredom and no challenge can lower your attention to the
quality of the task. Be careful in such cases. Find additional responsibilities matched to
your knowledge and abilities.
The greatest risk of underload is that attention deteriorates. Along with boring routine
activities this can happen extremely quickly.
Another risk is declining motivation. If you are always given tasks which demand too little
of you − physically as well as mentally − you can easily have the feeling: ”They don’t
think I’m up to it!”.
Real teamwork can help, in the same way as with overload. For example, talk in the
group about:
Training, gaining experience,
Improvements
and sensible short−cuts and Completing unfinished tasks.
In short: Use the time and team resources to get fit for the next ’big load’.
It is sure to come!
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FATIGUE
General
Former US President, William Clinton, once said that every bad decision he ever made
was made when he was tired.
Even the famous playwright William Shakespeare drew attention to the importance of
sleep: ”O sleep, O gentle sleep, nature’s soft nurse.”
This unit is about fatigue, which is often a result of lack of sleep.
But there are many additional factors that affect your levels of ”Alertness”.
The airline industry operates around the globe, where it is always somewhere morning,
afternoon, and nighttime. The industry does not rest! That is a fact!
It is also a fact that humans need sleep. Sleep is like a logistical supply. If you lose it or
disrupt it, you must pay for it.
All humans need rest! This requirement does not vary among cultures of the world. Some
cultures sleep more that others. The US is an example of a culture that does not sleep
enough.
For example, a recent survey by the National Sleep Foundation showed that 2 of 3
Americans from the US do not get 8 hours of sleep. 1 in 4 Americans say that they are
sleepy at work a few days each week.
And, it is estimated that 20% of U.S. auto accidents are related to fatigue. Think about
that the next time you drive home from the night shift!
Effects
We list here some of the effects of fatigue.
First of all, it degrades your work performance.
Fatigue can affect the quality of your judgment.
Fatigue slows your reaction time.
Fatigue affects your ability to solve problems.
Your memory is not as good when you are tired.
Fatigue can affect you mood and your general attitude about the job and you
co−workers.
Fatigue and loss of sleep have much the same effect as alcohol.
In fact, scientists have demonstrated that driving while fatigued can be compared
to driving while drinking.
20 hours of wakefulness has the same effect on driving performance as
drinking 2 beers or 2 wines!
Excessive Fatigue can affect your long−term health.
Fatigue is a serious matter for you and for your safe and efficient work.
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Alertness
”Alertness” is a term that encompasses all aspects of rest and readiness for work.
Alertness may be seen as a range.
On one end you can be well−rested, highly alert and ready for work. Your safety margin
is increased.
At the other end of the range is Fatigue. You may have insufficient sleep.
You may be physically and mentally tired. You are not fully fit for duty. And, you may be
unsafe. ”Fatigue” is a lack of energy, a weariness or tiredness.
Fatigue is a normal and important human response to physical exhaustion, emotional
stress, or to lack of sleep.
It can lead to error and other unsafe conditions.
Circadian Clock
The Circadian Clock is like an automatic clock in the brain. It affects all humans. Some
scientists say that it is in our chromosomes.
The word Circadian comes from two Latin words: ’Circa’, meaning about, and ’Dias’,
meaning a day.
The clock therefore affects our level of alertness over about one day, about 24 hours.
You can see that we are most alert around 9 in the morning and around 7 at night. Our
lowest level of alertness is around 2 in the afternoon and even lower between 1 and 3
am.
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It is probably not a coincidence that many of the worst human error−related disasters of
this century started between 1 and 3 am.
That includes the shipwreck of the Exxon Valdeeze Oil Tanker in Alaska, the nuclear
power plants of Chernobyl, in Ukraine and Three−Mile Island, in the U.S., and the terrible
chemical plant leak in Bhopal, India.
You should consider the implications of the Circadian Clock on your work schedule.
Types of Fatigue
There are two types of fatigue: Acute Fatigue and Chronic Fatigue. Acute Fatigue is
associated with temporary loss of sleep or temporary exhaustion from brief periods of too
much physical or mental work. It is temporary and of short duration. Sometimes acute
fatigue many be associated with too much partying the night be- fore. The party causes
you to stay awake throughout the night and, sometimes, there may be too much alcohol.
The alcohol causes disturbed sleep. Thus, you suffer from a morning or day of acute
fatigue.
The cure for acute fatigue is simple − get some rest and sleep.
On the average you should have 8 hours of sleep each night. Treat sleep like money in
the bank. If you borrow from the bank you must eventually pay it back. If you sleep only 5
hours one night you have to sleep a bit more the subsequent nights.
Chronic fatigue is more serious than Acute fatigue. Chronic Fatigue is long term, and the
recovery is slow. The symptoms are the same as Acute fatigue but they reoccur daily.
You are always fatigued.
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The causes of Chronic Fatigue are not as straightforward as Acute fatigue, often resulting
from physical sickness or some ongoing emotional stress. If you are al- ways tired, you
may have Chronic Fatigue.
When Chronic fatigue is a likely problem one must seek the advice of a
professional in sleep disorders. Many General Practice Doctors do not have the
specialized training to properly diagnose and treat Chronic Fatigue.
Fatigue: ’Routine Maintenance’
Most maintenance personnel underestimate the seriousness of fatigue and its effects on
performance. In turn, they overestimate their ability to overcome fatigue. It is relatively
easy to avoid fatigue. Here is a list of Guidelines.
Strive to obtain 8 hours of sleep per night. Keep a sleep record for 2 weeks and
see how you do.
Set a routine for going to bed and for waking up.
Quality exercise prevents fatigue. It keeps your body in good condition and it helps
you rest.
Sleep experts suggest to avoid caffeine and excessive alcohol before going to
bed.
You should eat a balanced diet throughout the day.
Put the correct ’fuel’ in your tank! (Mineral water, fruit drinks)
Turn off the lights and the television. A dark and quiet room promotes sleep.
Regarding shift work, it is best to sleep before your work shift rather than after the
shift.
Fatigue: „Non-Routine Maintenance“
Although you may take all the appropriate steps to avoid fatigue, there are occasions
when you cannot avoid it.
In those cases you must work smart to avoid fatigue−related errors.
Often you may get so tired that you are too stubborn to admit your fatigue. Face
the fact that fatigue is a normal human response to physical and/or mental
exhaustion.
It is good to remain physically active when you are fatigued. Move around,
exercise and stretch (best in fresh air) when you feel tired.
Conversation and caffeine are both good ways to stay awake.
There are many things that you can do to promote alertness at work. Take ’good
breaks’. A small amount of exercise, like a walk, will help during a break. Working
with a partner helps promote alertness. Eat your balanced meals on a regular
schedule and drink water and fruit drinks.
Caffeine is a legal drug that works to keep you alert, but don’t overstretch it! Drink
caffeine before you are tired.
When it is hard to remain alert, try to schedule the tedious/boring tasks early in the
shift when you are most alert.
Remember that alertness is a ”Fitness for Duty” issue.
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It is a requirement that you come to work fit for duty. When you have alert- ness
challenges, ask your co−workers to assist you. In turn, you should help
co−workers who have an occasional lapse in alertness.
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Here are a few typical medicines along with their effects on our work:
Pain killers, for example aspirin, should be quite safe if taken correctly.
Antibiotics, such as penicillin, are quite safe in themselves, but should only be
taken if you have a serious infection!
Antihistamines, as often found in allergy or cold preparations, often cause
drowsiness. Consult your doctor!
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Over−the−counter cough mixtures are probably quite safe, as long as they do not
contain substances such as antihistamine.
Preparations to reduce swelling of the nasal passages sometimes have
side−effects such as a feeling of apprehension, shivering, racing pulse or
headaches. You may be unfit for a time.
Stimulants are, of course, out! - If you need these to stay awake, you are definitely
unfit.
This list is not comprehensive. Speak to your doctor or pharmacist about the effects of
medicines.
Figure 42 Medication
Cannabis
Cannabis products such as hashish and marihuana are usually smoked in the form of
joints. The ”high” begins within a few minutes, and reaches a maximum after about 15
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minutes. The ”high” lasts for three to four hours, but the medical effect lasts longer −
about nine to ten hours.
The following effects are known:
The brain can no longer distinguish between relevant and irrelevant information,
Movements slow down, lethargy may set in, speech becomes slurred and reaction
time becomes longer and
The thought process and perceptions of space and time are distorted, i.e.
distances and speeds are judged wrongly.
The effects may be particularly severe if even a small amount of alcohol is
consumed at the same time.
Cocaine
Cocaine or ”crack” is usually ”snorted” or smoked. The effect starts almost immediately
and lasts for about four hours. There are three phases:
Euphoria: this lasts about 30 minutes. The user becomes sociable, likely to take
risks and feels ”omnipotent”.
Possible Hallucination: this lasts one to two hours and the user may suffer from
illusions, restricted vision and paranoia.
Possible Depression: fatigue, irritability, sleeplessness, and headaches may
occur.
In all three phases there are strong mental and physical changes, such as
aggressiveness, increased pulse rate and blood pressure with the risk of
blackouts, dilated pupils, with increased sensitivity to dazzling and blurred vision,
and possibly convulsions.
Certainly not ’Fit for duty’!
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They are usually swallowed in the form of a small pill. The effect lasts from about four to
eight hours, depending on the drug. If taken frequently, there is the danger of mental
addiction, resulting in a need to increase the dosage.
Subjectively increased performance leads to a greater willingness to take risks, to
restlessness, irritability, nervousness and loss of inhibitions, possibly to delusions,
optical and acoustic hallucinations, paranoia and panic.
There may also be an increase in pulse rate and blood pressure, with the
possibility of convulsions and a loss of muscular control.
LSD is found in various forms and is usually swallowed or sucked. The effects start within
minutes, and lasts for up to eight hours.
There are four phases:
Coming up. This takes about 45 minutes, with effects that may include dizziness,
anxiety, and increased pulse rate.
The high. This lasts for about eight hours, with possible hallucinations and
reduced muscular control.
Coming down. Depression, exhaustion and anxiety may result
Flashback. This can last for days!
The effects could be: hallucinations, distorted perception, and illusions, with
paranoia and a tendency to violent acts, extremely dilated pupils with extreme
sensitivity to light, increased pulse rate and may be convulsions, confusion and
disorientation.
Opiates
Opiates include opium, morphine and heroin. Opium is usually smoked, morphine and
heroin usually injected. When injected, the effect is immediate. The effect lasts for a
maximum of five to six hours, but in the case of heroin addiction this becomes shorter
and shorter.
There are three phases:
The flash or rush. There is a strong feeling of happiness, euphoria and
subjectively increased performance.
Stoned. Apathy, indifference and blankness of expression, even virtual
unconsciousness are the symptoms and
Coming down. The fear of coming down itself sets in, and the mind concentrates
on finding more dope.
Opiates are extremely addictive, with a high degree of tolerance leading to an increase in
dosage. The risk of an overdose is great.
Physical effects are:
Pin−point pupils with no reaction to light and complete night blindness, drowsiness, slow
physical movements, including stumbling, slurred speech and loss of muscular control.
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Sub-Module 05
Physical Environment
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NOISE
Noise at the workplace can distract, disturb communication (if not make it to- tally
impossible), and camouflage warning sounds. Noise can cause stress, with all its
negative effects on the human being.
Noise can be thought of as any unwanted sound, and may be annoying and
unpleasant, especially if it is loud.
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Figure 44 Noise
FUMES
In the maintenance environment there are many materials such as grease, oil, paint and
solvent − that vaporize.
The resulting fumes can be categorized as unpleasant and hazardous to health. In the
case of health hazards, warning notices and safety regulations must be obeyed. Serious
damage to health can otherwise result.
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FUMES
Safety
Regulations
Figure 45 Fumes
You are only ”aware” of unpleasant fumes. They often smell nasty, and may irritate the
eyes .
Working under those conditions, the ’motivation’ is often lowered and you want to get the
job done as soon as possible.
Besides the health aspects, fumes lead to performance limitations.
ILLUMINATION
In order to carry out maintenance you need proper illumination. But what is proper
illumination?
Whether natural or artificial, light sources have very different light properties.
This is clearly illustrated by our perception of color under different light sources.
Natural light is best for recognizing colors.
The ratings for artificial light are:
− good for candescent light,
− average for florescent tubes
− and poor for mercury vapor lamps.
In this case, a red cable appears as anything from orange to black.
Clearly, correct color recognition depends on proper illumination!
When the focus is on light efficiency, the rating changes completely. The mercury vapor
lamps do best.
Note:
Mercury vapor lamps are often found as Hangar and Apron illumination, because of its
efficiency.
Caution:
Rotating parts quickly appear to be stationary when illuminated by florescent tubes. This
is also called the stroboscope effect.
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Optimum Sunlight
Strong Winds
Precipitation
18 - 25 Celsius
25 - 85 %
relative
Figure 46 Illumination66
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Extract from
EASA Part 145.A.25 Facility requirements
5. ....
[Link] working environment for line maintenance is such that the particular maintenance
or inspection task can be carried out without undue distraction. Therefore where the
working environment deteriorates to an unacceptable level in respect of temperature,
moisture, hail, ice, snow, wind, light, dust/other airborne contamination, the particular
maintenance or inspection tasks must be suspended until satisfactory conditions are
re−established.
7. ....
MOTION AND VIBRATION
Vibrations
Of course, such scenes are rarely seen in aviation.
Vibrations and motions reduce performance and lead to fatigue and distraction.
Vibrations in maintenance stem mainly from the use of tools, such as rivet guns or
grinding and polishing machines.
Vibration can be a safety challenge. Fingers and hands can become numb as a result of
using machines that vibrate strongly. It can take a long time for feeling to return to the
hands. In the meantime, precise work, such as making fine ad- hutments, is virtually
impossible.
Platforms
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What comes to mind when you look at this picture? Physical activities which are not
carried out on firm ground, can lead to sudden movement.
Height affects the reaction of a person more strongly than when on solid ground. At first
he focuses on his safety, and as a result is distracted.
In some circumstances a task cannot be completed safely.
Vibrations
Movements
Fatigue
Distraction
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ULTRA−SONIC WAVES are above our hearing range (>20.000Hz). These sonic waves
can damage nerve canals.
WORKING ENVIRONMENT
Confined Spaces
You do not have to suffer from claustrophobia to get an uneasy feeling at the thought of
climbing into a fuel tank.
Of course, apart from the ’classical example’ of the fuel tank, other areas, depending on
the type of aircraft, can also lead to uneasy feelings and claustrophobia.
When working in confined spaces, especially if entry and exit is limited, good planning is
recommended. Here are some tips:
Follow all safety regulations,
Let a colleague assist you,
Make sure that ventilation and lighting are good,
and make your job as comfortable as possible for yourself.
Stay in contact with your colleagues. Should you still feel uneasy, it is nothing to be
ashamed of. Speak openly about it and take a break.
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The time between feeling uneasy and having a panic attack can be very short, and is
usually not under your control.
There have been cases of working in tanks where people have had to be rescued by the
emergency services.
The build of the worker should be considered. It should not be necessary to send a
six−foot−six mechanic into the smallest of tanks.
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Sub-Module 06
Tasks
9.6 Tasks
Physical work
Repetitive tasks
Visual inspection
Complex systems
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9.6 TASKS
Physical work
Repetitive tasks
Visual inspection
Complex systems
INTRODUCTION
Chapter M9.6 Tasks combines many topics of ”Human Factors” that have already been
discussed previously.
The ”SHELL” model of chapter M9.1 shows how these individual topics are interlocked.
PHYSICAL WORK
Planning
Thorough planning must precede all work procedures. The individual mechanic, a group
of mechanics or process engineering − they all have to do their preparatory planning
before starting with the actual job.
This planning includes:
exact analysis of the work to be performed
considerations concerning the required means and tools − are these available in
the necessary numbers and in due time; which spare parts will be needed; what
about the documentations, availability of hangars etc.
planning of personnel with respect to number of persons, required qualifications
and skills
specific tasks must be detailed on ”Task Sheets”.
The individual tasks have to be clearly specified as check, inspection, repair,
replacement, or overhaul. Furthermore additional information like AMM references
or part numbers must not be missing
In cases of doubt concerning the work to be performed, the mechanic has to refer to
written documentations.
To just ask a colleague for clarification is by no means sufficient, as wrong or improper
information could be passed on. − On the other hand such a conversation is advisable
should the documents provide no specific details or only imprecise information.
Communication between colleagues can often help to eliminate ambiguities.
In general the shift supervisor is responsible for the provision of the means and tools
necessary to perform the work. The supervisor usually delegates individual jobs to the
members of his team.
As an alternative the supervisor of course can delegate a complete work procedure to a
team. In this case the individual members of the team will perform those jobs which
correspond to his/her qualifications (CAT A, B1/B2 etc.) and experiences that have been
acquired in a specific field of work.
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Figure 51 Task-Planning
Physical work
Maintenance work is a rather energetic activity and it requires a relatively high amount of
physical energy from the employees.
This applies for both, precision work with a high demand on fine motor skills and work
which requires physical strength and thus a high demand on gross motor skills.
The physical properties of people are different of course.
The attempt to lift an extremely heavy object is usually beyond our physical properties
and might even lead to injuries. Many tasks are only possible with the help of suitable
tools and devices (e.g. lifting heavy structural components) or they are facilitated in this
way.
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The older a person gets, the stiffer the body and the weaker the muscles be- come. This
increases the risk of injury and prolongs the healing time. Exercise can minimize this
process, but the effects of aging cannot be eliminated all together.
In the long run intensive physical work will lead to exhaustion.
If the body is granted sufficient time for relaxation and recovery, this will not create
problems. But when break−times are ignored in order to finish a particular job within a
certain time, the result may well be injury instead of productive- ness, because
exhausting our motor skills to the limit will decrease our faculty of perception, our
awareness and our work standards.
The amount of aircraft maintenance work has to be physically manageable for the staff.
The Boeing company uses a computer program that is based on human performance
data (average body size, strength etc.) and on the force that is necessary to create for
example a certain leverage.
The aim of the Boeing Company is to facilitate maintenance of modern aircraft by
incorporating data on the physical abilities and capabilities of its staff.
REPETITIVE TASKS
Monotonous activities may have a tiring effect and can decrease stimulation (see chapter
M9.4).
Most scientific research on that topic has been done in the field of manufacture
(assembly line) and thus is not easily transferable to aircraft maintenance.
In maintenance the monotony is usually created by repetitive activities that have to be
performed when doing a certain check, during shift−work, or during
any other short period of time.
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A sensible change between physical and mental work can improve matters (ø see task
planning).
A further aspect of visual inspections is assessment. Training, experience and common
sense are important here.
Those topics are also called ”situation awareness”.
Situation Awareness
Situation awareness is an important topic in ”Human Factors” and is a complicated
process that takes place in the attention, awareness and decision reaching areas in our
brain.
In the past the term for situation awareness was used only for cockpit personnel. Today it
is also recognized in aircraft maintenance.
Situation awareness can be divided into three stages:
The first stage is Perception − for example loose bolts and missing parts. This
stage may involve listening attentively.
The 2nd stage of Situation Awareness is understanding: Why is it so? Is it the way
it should be?
The third stage is Prediction: How will it develop? What effects can it have?
’Prediction’ can also look back and ask − What was the reason?
Situation awareness in the technical field means: − recognizing the state of the system, −
forming a relationship between defect and modification and − predicting the possible
effect on other systems.
Example
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The following example should help clarify the three stages of situation aware- ness.
Look carefully at the picture and go consciously through the three stages.
1. Perception recognizes a blue−green smear along the side of the fuselage,
beginning at the service panel and ending in the middle of the wing.
2. Our knowledge tells us that the service panel belongs to the forward toilet
facilities. The aircraft is obviously losing a considerable amount of liquid. The pipe
seal or the ”donut” is defective or completely missing.
3. The prediction is that the liquid could freeze and then blocks of ice could hit the
engine or other components.
Often it was only the ”donut” that was replaced. The nicks remained in the fan
blades!
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COMPLEX SYSTEMS
All modern aircraft can be seen as ”complex systems”. Within this system there are many
individual systems and components which are complex themselves. This complexity will
increase even more in the future, as the trend goes from mechanical operation towards
advanced electronic systems.
The future will be dominated by integrated mechatronics, which will be even more
complex, although trouble shooting will be far easier.
Operation of the elevator is used here to clarify this trend.
Basic System
Purpose, configuration and function of a basic system are usually easy to comprehend
for an aircraft technician.
Routine work, trouble shooting and diagnosis should be relatively simple − but the
respective manuals must be consulted nevertheless.
Complex Systems
When dealing with complex systems the aircraft technician must be familiar with the
purpose of the system at least.
Configuration and function are usually quite difficult to understand completely. In order to
maintain such systems, you need a specific training.
Here it is important to observe a balance of detailed technical knowledge and analytic
proceeding during trouble shooting.
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Manuals and released procedures are of an even greater importance than in the case of
comparable basic systems. Today the documentation of the manufacturers is put
together according to the most advanced standards.
They enable the technician to perform his work or to facilitate it.
Due to the linkage of individual systems one cannot be sure to understand everything in
detail anymore. Thus we have to follow manufacturers’ instructions, but not without a
critical attitude.
Another aspect of this complexity is the necessary specialization of the technicians. In
our example ”elevator operation” knowledge in the areas airframe/engine (EASA CAT
B1) and avionics (EASA CAT B2) is required. Teamwork is absolutely necessary and its
importance will be increased even more in the future.
A single modern aircraft is usually complex enough − nevertheless the aircraft
technicians are normally qualified for more than one aircraft type.
It will not be practicable to achieve the same level of familiarity with all these aircraft
types − one more reason to adhere to the manufacturers’ instructions.
Different ”philosophies” of the manufacturers have quite a share in the hazard potential
as well.
Here an example:
In order to be able to lift a spoiler for maintenance purposes, a maintenance unlocking
device (hex drive) is turned.
This is almost identical on Airbus and Boeing airplanes.
B757/767:
The cylinder is internally unlocked and hydraulically isolated and bypassed
The spoiler can then be lifted manually
Resetting of the cylinder is effected automatically when the spoiler is retracted
again.
A320:
The cylinder is hydraulically isolated and bypassed permanently.
The spoiler can be lifted manually
Resetting the cylinder has to be effected via the maintenance unlocking device
(hex drive).
Several incidents on A320 airplanes have been reported worldwide where the spoiler(s)
where suction during approach (airspeed/ landing flap position) has caused the spoilers
to lift.
Sudden changes in the lateral attitude of the aircraft in proximity to the ground were the
result (!)
In almost all cases the technicians had achieved ”several years of experience with
Boeing aircraft and had only recently finished an A320 training”
(quote from the incident report).
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Sub-Module 07
Communication
9.7 Communition
Within and between teams
Work logging and recording
Keeping up to date, currency
Dissemination of information
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9.7 COMMUNICATION
Within and between teams;
Work logging and recording;
Keeping up to date, currency;
Dissemination of information.
INTRODUCTION
General
Communication is a critical component of safe and efficient maintenance work.
Communication issues are the number one type of cause of events in aviation
maintenance. Therefore, this unit is very important. In it, we will discuss communication
by offering a small amount of theoretical explanation and a number of practical ways to
minimize communication−related issues.
The list of results of poor communication is endless. A few examples are: Lower quality
and performance, loss of time and money, unnecessary revisions, maintenance error,
frustration, delays, personnel conflicts, and many more.
Why is communication difficult? How do communication errors lead to so many errors in
maintenance?
What does Communication mean?
Communication is the exchange of information between two or more persons. Among the
many ways that humans communicate:
Writing and Reading;
Speaking and Listening;
Facial Expressions;
Leg, Arm, Eye, and Head movements; and Body posture.
Which of these methods is most important in aviation maintenance? Check the correct
box.
All of these methods are critical for effective communication.
In each conversation we use wording, tone of voice and body language as so called ’non-
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verbal elements’.
Assume a ’normal’ conversation. How much is transported by words and how much by
non−verbal signals
Communication model
As a rule, communication is performed from
a sender (speaker, author, artist)
to a receiver (listener, reader, spectator).
In order to make communication possible the sender has to translate his
thoughts, messages or his knowledge into recognizable signals.
He has to encode them.
The receiver has to understand the meaning.
He has to decode.
The receiver is left to his own devices when doing so. The meaning he gives to what he
hears depends on his former experience, his expectations and apprehensions.
This way, some messages may be misunderstood. Some may not be understood at all.
This makes it very important for the sender to make sure his messages are correctly
understood.
In every day life we can usually tell from the receiver’s reactions whether or not he or she
has understood correctly what we tried to get across.
But if we are dealing with information whose correct comprehension is vital.
We have to give or demand feedback.
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Oral Communication
Each verbal Communication process has three areas where you can actively make
improvements:
1. Speaking (transmitting)
2. Listening (receiving)
3. Feedback (give and receive)
Proper communication is important to each of us. Thus, as we are responsible for our
communication, we need to make every effort to optimize it.
There is a good rule for optimal communication. It is the rule of the ’Three C’s’. The
’Three C’s’ represent the three main principles of every communication: Clear − Correct
and Complete.
An example:
Mike: ”Hey, you over there, did you see the cut in the propeller?”
Was that clear? No! At least 3 kinds of information are missing:
Which aircraft?
Which propeller?
Which blade?
Clear communication is concrete and easily understandable. Was this correct? No! At
least 2 questions remain:
Who is ”Hey, you over there?“ and,
at which part of the propeller is the cut? At the leading edge? At the trailing edge
or at the blade tip?
Correct communication is precise, and provides exact information without mistakes.
Was this complete? No! Complete communication is thorough and explicit. So, when you
meet Mike the next time, tell him to say:
”John, on the aircraft ABC, did you see the cut in the Number 2 propeller, blade
Number 3 at the blade tip?”
Whenever you communicate: keep it clear, correct and complete.
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Don’t interrupt. Don’t wait for the ”catchword” you always use to make your
point.
Listen actively. Ask questions.
Rules for feedback
Feedback can be given and received. It is important that nobody tries to use the
feedback procedure to get the better of others. If you do this, the person you are talking
to will probably refuse to communicate with you any further.
Be conscious of place and time. It’s no use to show your feelings about something
four weeks after the incident happened. People will not even remember the
incident, leave alone understand your hurt feelings.
In addition to that you might have worked yourself in a rage over four weeks. This
can make a matter of fact conversation difficult for you. You would have made the
previous four weeks easier for you if you had reacted immediately.
When you are giving feedback you should be together with only those you are
offering the feedback to and you should have enough time at your disposal. Don’t
choose the breakfast break in the canteen when you are surrounded by the other
colleagues.
Feedback is a personal process.
FEEDBACK
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Receiving feedback
Clarify the facts. Ask, if anything remains unclear.
Listen to the end before you answer. Don’t start preparing your answer before the
other person has finished speaking.
Check if there is anything in the answers you can learn from.
Thank the person who gives you feedback It shows that you are important enough
to him or her to care about you and your problems.
FEEDBACK
(IDEAL)
Message
Figure 58 Feedback
Giving feedback
Be precise. If you are vague you might not be understood.
Use the first person singular. You can only give your impressions, not those of
others.
Speak for yourself only, do not generalize. It is unfair and will cause your partner
to take up a defense position anyway.
Criticize behavior, not persons.
Be constructive. Try to make suggestions.
Show respect. Check on your motivation. Do you intend to help or to hurt?
DISSEMINATION OF INFORMATION.
Written communication - General
In your work area the written word is as important as the spoken word. Job−cards, work
plans, instructions for work procedures and log book entries are some examples for a
communication that’s based on writing and reading.
When writing a message you should observe the following:
The text has to...
be readable
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This document is the ”Medical History” of the aircraft. The captain will rely on it to assess
the condition of the airplane. Maintenance uses the documentation to determine whether
the airplane can be released to service again.
It must be clear, correct and complete.
Do your very best to follow the company procedure on log book completion.
Take your time, and complete the logbook with attention to detail. Most of the
errors are caused by carelessness.
The common mistakes are: illegible handwriting, imprecise or incomplete descriptions or
citation of incorrect ATA chapter. Safety is dependent on all of your work tasks including
the ”Paperwork”.
Treat written communication as a critical safety item.
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Sub-Module 08
Human Error
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TYPES OF ERROR
How is ERROR defined?
There are many definitions of error, only a few of which are offered here.
Generally an error is ”an unsafe act unintentionally committed”. In other words, we don’t
err on purpose! An error can be a slip or a mistake. Think about it.
A slip (and lapse) is merely a good plan poorly executed.
For example, you read a torque value from the job card and you transposed 26 to
62.
A mistake is a ”bad plan”.
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For example, you select the wrong work card to conduct a specific job. Much of
the information on the card may not apply to the work task.
A violation is a very serious mistake. Contrary to mistake or slip, a violation is
always conducted willingly (on purpose or intentionally)
NOTE: ’good intentions’ - may have the same result as ’bad intentions’!
A violation occurs when you deviate from;
− safe practices,
− procedures,
− standards,
− or regulations.
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Lack of communication
Lack of teamwork
Norms
Pressure
Complacency
Lack of knowledge
Lack of awareness
Lack of resources
Distraction
Assertiveness
Fatigue
Stress
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LACK OF COMMUNICATION
YES!
BILL!
I checked the oil
Are the screws
tightened
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LACK OF COMMUNICATION
Communication errors are the most common type of error. There are many opportunities
to fail in communication.
You must be continuously aware of the communication challenge, therefore a whole
chapter (M9.7 Communication) deals with this factor exclusively.
Tips
What are some of the corrective actions that can be taken?
First of all: Be aware of the challenges.
Remember that complete communication requires a transmitter, a receiver and
feedback. All three are important!
When you communicate, remember the 3 C’s: Correct − Clear − Complete.
Assumptions are dangerous. Try to avoid assuming that your message was
understood. Be sure by looking for the feedback.
LACK OF TEAMWORK
Maintenance requires teamwork. ”Lack of Teamwork” is another of the Dirty Dozen. Lack
of teamwork is the failure of a group to work together to achieve a common goal.
Tips
What are the Corrective Actions for Lack of Teamwork?
Communicate the group goal.
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NORMS
Norms are the commonly accepted work practices within an organization. Norms are not
usually written down − they are simply the methods by which the organization works.
Often „norms“ are bad practices, bypassing „inconvenient procedures“ but there are
examples of „good norms“ as well.
Here is an example of a good norm for shift turnover.
(Klaus): ”Hi Stefan, let me tell you what we did today and what are the next tasks.
We also wrote this information on the job cards”
(Stefan): ”Thanks Klaus, I want to be sure I understand this so I can explain it to
the team. By the way, are the lock pins and power−on warnings installed as
usual?”
(Klaus): Also Stefan, remind everyone that the lock pins for the thrust reverser are
hard to see, and must be removed before the aircraft is ready for service. I also
wrote that down.”
(Stefan):”OK Klaus, have a good evening and I will see you the same time
tomorrow.”
Tips
Now let’s look at some of the corrective actions for bad norms. Remember that a
violation was defined as a disregard of regulations and operating procedures.
Often the difference between a norm and a violation is based on whether or not
there is an incident.
If you do something merely ”because everyone does it that way” you may be
subject to legal action.
Therefore, a corrective action may be finding proper documentation for the norm.
It is OK to ask why a procedure is not documented. There should be a reasonable
answer or you should not follow the action.
Pressure from your co−workers can force you to follow undocumented
procedures.
Assume leadership. Be assertive and push for converting the good norms to good
written procedures. Finally, adopt the ”Good Norms”.
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Figure 66 Norms
PRESSURE
There is often pressure in maintenance, which can come from many sources. Often, you
put the greatest pressure on yourself. You press yourself for high quality performance in
minimal time.
Your managers may apply pressure. Pressures to meet a deadline are the most
common. And, your co−workers may also apply pressure. They can
create a sense of urgency that forces you to work at a pace faster than you are
comfortable with. Conditions cause pressure. The closer it gets to departure the more
pressure builds up to get the task completed quickly. So, pressure is one of the dirty
dozen. It is a possible contributing factor to an event.
Tips
We have established that negative pressure can have negative consequences on your
maintenance work. It can lead to error, but you can control it.
What are the Corrective Actions for Pressure?
First, when pressured, stop and assess the situation. Be rationale. Cool down -
”Chill”.
Remind yourself of the consequences of error.
As the saying goes, ”If you do not have time to perform the job correctly the first
time, how will you have time to redo the task?” Haste makes waste.
Don’t let pressure become the norm. If there is always undue pressure, it becomes
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Figure 67 Pressure
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COMPLACENCY
Complacency can contribute to a maintenance event when the mechanic is overconfident
about a task. This is usually a result of performing the tasks repeatedly. Psychology
experts say that many tasks become ”Automatic”.
Like driving to work, you sometimes can forget the trip. That is because you
were on ”Automatic.” You may have been inattentive. You have been ”unsafe.”
Most likely you were Complacent!
Tips
COMPLACENCY
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Figure 68 Complacency
LACK OF KNOWLEDGE
Lack of knowledge is one of the 12 common mistakes that contribute to events, but is
rather rare.
However, the Lack of Knowledge factor is usually compounded by a worker’s failure to
consult the manual, or failure to work as a team, or failure to communicate the lack of
knowledge.
Fatigue may also contribute to a Lack of Knowledge error type.
Tips
Lack of knowledge should not be an error in today’s aviation maintenance. There are
many ways to avoid such error. What are the Corrective Actions for Lack of Knowledge?
First of all, strive to recognize what you do not know.
When something is unfamiliar, acknowledge that you need assistance.
Often your co−workers are the best source of new knowledge. They can offer
explanations and can show you how to do a task.
Use the manual. If you have the appropriate type training you can read the manual
to learn how to do a job.
If you have many situations where you lack appropriate knowledge, you may
request additional training.
Don’t let lack of knowledge become a company norm. If many people lack
knowledge, then additional training is necessary.
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LACK OF AWARENESS
Lack of Awareness is an error that is often combined with other errors in the dirty dozen.
Quite simply it can be called ”Failure to Pay Attention.”
All too often, an event investigation will result in quotes like the following: ”I was not
paying attention,” ”I did not see the obstacle,” ”I did not notice the wing tip was so close
to the hangar door.”
Whatever the confounding excuse, usually the person acknowledges that there was a
lack of awareness.
LACK OF AWARENESS
Tips
Lack of Awareness is a challenge that can be overcome. What are the Corrective
Actions?
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First of all, and most simply, remain alert to workplace conditions. Maintain
situation awareness by observing conditions, knowing what they mean, and
project to the impact of the conditions.
For example, if you recognize a close clearance between equipment, buildings,
and aircraft then you should project the potential danger and remain aware of it.
Cooperate with colleagues to maintain awareness. Help one another.
Lack of awareness does not have to be a common error. However, you must work hard
to maintain constant awareness of the maintenance work environment.
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DISTRACTION
DISTRACTION
Jobs and life are full of distractions! That is why ”Distraction” is another of the Dirty
Dozen. Distraction can come in the form of thoughts, noise, bright lights, people, radio
messages or telephone calls.
Since you cannot easily eliminate distractions, you must accept them and find
ways to cope with them.
Tips
”Keep your mind on the job.” ”Concentrate to avoid distractions”.
That is easier said than done. What can be done to overcome Distractions?
Beware of other dirty dozen errors. If you are pressured, fatigued, or lack
assertiveness, then you are more likely to be bothered by distractions.
LACK OF RESOURCES
TIME
TOOLS
COMPUTERS
PEOPLE
MANUALS MONEY
Figure 72 Distraction
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LACK OF ASSERTIVENESS
Assertiveness is a good thing! It means that you speak up when you believe it is
necessary. When an assertive worker sees an opportunity, they bring it to the attention of
their co−workers or the management.
There are times when assertiveness is an absolutely necessary part of aviation
safety.
LACK OF ASSERTIVENESS
Tips
What are the corrective actions needed for assertiveness?
Usually you must speak up to assert your opinion. Do it politely and at the right
time.
− If you speak too soon you may be embarrassed.
− However, if you wait too long you may not be able to properly influence the
situation.
When you do speak up, follow the ’3 Cs’: Clear, Correct, and Complete.
Sometimes your actions show your assertiveness. That is demonstrated when you
insist on doing a job properly, or by refusing to do a job in a manner that is
unacceptable to your standards.
Sometimes you must document situations to show assertiveness.
For example, you write in the logbook only the items that you believe to be air
worthy.
Assertiveness is a good thing. It is not to be confused with stubbornness,
aggressiveness, bossiness or other negative characteristics.
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FATIGUE
’Fatigue’ is one of the dirty dozen errors that we make in maintenance.
It is a potential problem for many. Fatigue can be a serious on−going ’chronic’ problem or
it may be ’acute’ − just caused by a few nights of missed sleep.
Usually you make errors because you are fatigued.
For example, you may forget to complete a task, you may be unclear in your
communication, or you may be temporarily too lazy to do the job correctly. But fatigue is
the real problem. When you are fatigued, your physical strength and mental ability are
impaired. Fatigue can be managed, but first you must be aware of the risks.
FATIGUE
Tips
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Figure 74 Fatigue
STRESS
Stress is a psychological and sometimes physical condition caused by some kind of
”stressor.” The stressor can be a once−only situation or it can be an ongoing one. For
example, a short−term stressor may be a very difficult repair that must be done quickly.
Once the repair is completed the stress goes away.
An example of long−term stress could be a divorce situation or other personal problems.
Like fatigue, there is short−term stress, called acute stress, and
long−term stress, called chronic stress. Whether acute or chronic, stress can affect your
life and your work performance. You must deal with it.
What are the symptoms of stress? Different individuals may have different symptoms;
however, many behaviors are reliable indications of stress. Usually you know when you
are stressed.
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Stress may make you irritable. It may affect your memory, your ability to pay attention, or
your ability to make rational decisions. Stress affects health.
It may cause loss of appetite, headaches, stomach problems, and inability to sleep.
Stress causes one to be nervous or restless. Stress can lead to alcohol or drug abuse.
Obviously, all of these conditions may put at risk the quality of your work.
STRESS
Stress is often a part of daily life and therefore a part of work. While stress is not an error,
it can lead to error. What can you do about it?
First of all, always be aware that stress can impact the quality of your work.
When stressed, you should slow down, or stop, and regain your composure. You
should try to think rationally, not emotionally, about the situation. Sometimes you
may want a ”TIME OUT” − a short break to think over the stressful situation. It is
often helpful to discuss the conditions that are causing the stress.
You should ask your colleagues to monitor your work if you are stressed out.
Engage in physical activity − exercise relieves stress. Do not let a stress
compound itself by performing poorly in your maintenance responsibilities.
Figure 75 Stress
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ERROR MANAGEMENT
General
Airlines are the safest mode of transportation. That is a FACT!
However, incidents, accidents and events happen, albeit to a minute percent- age of
flights. The ”Event Investigation” describes a process that was
Introduced by the Boeing Company in the early nineties.
The process is called Maintenance Error Decision Aid or MEDA for short. The prime
philosophy is that we can learn a lot from our errors. MEDA helps us to document,
classify, understand, and minimize our errors.
There are other investigation programs available, which have a structured design to
evaluate incidents. Which of the many programs is used within a maintenance
organization is rather secondary. MEDA is widely spread throughout the MRO
community, therefor we will give a brief overview of its operation.
We use the word ”Event” to include accidents and incidents where maintenance is a
contributing factor.
Iceberg Model
The ”Iceberg Model” provides a rationale for recording and understanding human error
using processes like MEDA. On a large iceberg, the tip of the iceberg is above the water
level.
The tip of the iceberg represents the one human error that causes a serious airliner
event. At the large base of the iceberg are the multitudes of minor human errors that are
committed daily within an airline maintenance organization.
Most of these errors do not compromise safety but can cause large expenses of wasted
time and resources. However, some are ”operationally significant” causing delays,
cancellations or in−flight shutdowns.
We must reduce the number of errors below the water level to reduce the serious events
above the water level.
By understanding our current errors we can prevent future errors.
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MEDA Proses
”Maintenance Error Decision Aid” or MEDA is a process used to investigate human error.
Many airlines and MRO customers support the development of the MEDA system with
Boeing.
The process is quite simple.
It starts with an identified error.
Then the ”Contributing Factors” will be identified. Usually there is more than one
contributing factor.
In the last step you have to determine corrective actions.
Thus, the combination of contributing factors and corrective actions are the basis for
understanding and minimizing human error.
After the error is identified, you must identify the factors that contributed to causing it.
Boeing offers 10 categories on the MEDA form.
While the MEDA form is an excellent way to identify Contributing Factors, you may also
choose to list any of the Dirty Dozen as contributing factors.
An incident is usually a chain of events, and there is seldom one contributing factor.
Therefore, you are likely to choose many factors.
Consult the MEDA form to see all the contributing factors. Once you become familiar with
these contributing factors you will be more aware of them when they appear in your work
environment.
Each contributing factor has a reasonable set of corrective actions. Many of the
corrective actions were described in the Dirty Dozen.
Corrective actions are often specific to the individual workplace and are best determined
once the contributing factors are identified.
Your event investigation practice during the classroom training will help you practice
ways to identify corrective actions.
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Sub-Module 09
Hazards In The Workplace
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The Employer...
The employer must recognize potential hazards. If possible, he must remove them
or limit them. In addition, he must inform the employees about them though
suitable instructions or notices, and provide the necessary aid and protection.
The employee...
The employee must report hazards when he sees them, take note of safety
information and make use of the safety measures provided.
This is controlled by national regulations and standardized in accordance with European
harmonization.
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At most airlines, the people responsible for keeping the rules are: the safety engineer, the
safety representatives, the works council, and the technical supervisory committee of the
occupational insurers.
Good question: Who is the safety representative in your field?
DEALING WITH EMERGENCIES
Dealing with Emergencies
How would you behave in an emergency? Probably − run away. But where?
It would be a good idea to memories the alarm plan for your area. It shows the escape
routes and the assembly points. It also includes a checklist for rules of behavior.
The most important points for general emergencies are:
1. Try to stay calm and think: What has happened? What are the dangers for others
and myself?
2. Report the emergency.
3. Make things safe: that means, among other things, the hazard, e.g. switch off the
power source, rescue the person in danger, and think about yourself at the same
time. Don’t try to be a hero.
4. Take care of the victim and
5. Make yourself available, and help in any way you can.
Caution: Die recommendations here reflect on the Maintenance environment.
Probably you may (or will) recall other priorities from general First Aid Training!
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117
Underload, much like overload, can negatively impact work performance and employee well-being. When employees are underloaded, or experience insufficient work, they may face decreased motivation and demotivation due to lack of engagement or purpose in their work tasks . This can lead to stress and dissatisfaction, reducing overall productivity and contributing to mental health issues such as anxiety and depression . On the other hand, overload can cause physical and mental exhaustion, impacting decision-making and increasing the likelihood of errors . Both scenarios can be addressed by promoting a balanced workload through effective planning and management. Task planning should consider both physical and mental demands to avoid exhaustion and stress . Ensuring that tasks match the skill and capacity of workers and providing adequate rest and breaks are essential for maintaining productivity and safety in the workplace . Regular feedback and adjustments to work plans can help maintain an optimal workload balance, contributing to a healthier work environment ."}
Assertiveness and effective communication are crucial for aviation safety as they minimize misunderstandings and promote clear instructions. Communication encompasses various methods, including verbal and non-verbal signals like tone and body language, which are essential for conveying accurate information in aviation maintenance . Poor communication can lead to maintenance errors, delays, and increased operational costs . Assertive communication involves clear, correct, and complete messages, enhancing comprehension and reducing errors, such as maintenance mistakes that jeopardize safety . Crew Resource Management (CRM), which is mandatory in aviation, emphasizes these principles to ensure cohesive team operations and to avoid incidents caused by miscommunication . Organizational psychology contributes by fostering a culture where communication and assertiveness are integral to handling team dynamics and improving safety outcomes .
Fatigue significantly impacts aviation safety by degrading work performance, judgment, and problem-solving abilities while slowing reaction times to levels comparable to alcohol impairment . Fatigue also contributes to reduced communication clarity, increased forgetfulness, and impaired physical strength and mental capabilities, which can lead to mistakes and accidents . Preventative measures include ensuring 7-8 hours of sleep nightly, maintaining regular sleep schedules, engaging in regular exercise, and consuming a balanced diet . Additionally, staying physically active during work, taking breaks, avoiding tedious tasks when tired, and ensuring good lighting and noise reduction can help manage fatigue . Implementing a robust safety culture that emphasizes these measures is crucial for minimizing risks associated with fatigue in aviation .
With the advent of modern aviation, the focus in human factors development shifted significantly towards addressing the compatibility between humans and increasingly complex aircraft systems. Initially, human factors concentrated on issues such as anthropometry and medical factors for pilots. By World War II, attention was given to control design and instrument layout to ensure compatibility with pilots . The 1950s saw the US Air Force evaluating human personalities to align individuals better with their military roles, and by 1988, incidents like the B737 in-flight breakup due to human factors led to heightened public concern and regulatory action, including the Aviation Safety Act which mandated FAA research into human factors . The focus expanded to include maintenance human factors, driven by incidents where maintenance errors were part of the causal chain, leading to extensive research and the implementation of guidelines . The increasing complexity of aviation systems required integrating various human factors disciplines such as cognitive science, organizational psychology, and error management theories like the "Swiss Cheese" model to enhance safety and efficiency in airline operations ."}
The improvement in industry reporting and data sharing has significantly enhanced safety communication in aviation by ensuring critical information is shared more rapidly and effectively across the industry. After the 1979 American Airlines DC10 accident, where unconventional communication led to a structural failure, the industry recognized the necessity for better communication structures to prevent similar issues . The development of safety information systems and a culture of trust where employees are encouraged to report safety-relevant information have become crucial components in fostering a robust 'safety culture' . Additionally, the emphasis on clear, correct, and complete communication as captured by communication rules has been integrated into aviation maintenance and operational practices . These changes have reduced the impact of human factors on accidents and incidents, with enhanced procedural adherence and better feedback mechanisms to detect and address potential hazards more efficiently .
Organizational psychology has significantly contributed to Crew Resource Management (CRM) by enhancing how individuals work in group settings, which is crucial for flight and maintenance crews in aviation. The discipline focuses on improving communication and teamwork, both vital components of CRM. Effective CRM relies on clear communication protocols, such as repetition of commands to ensure understanding, a concept partially rooted in early studies of human factors in psychology . Furthermore, organizational psychology helps in understanding team dynamics and leadership roles, essential for managing the 'Life ware' aspects of the SHELL model used in CRM to address team communication and group norms . These contributions help reduce human errors and improve safety in aviation by fostering a structured and cooperative environment ."}
Essential elements for maintaining a team in a large organization include communication, cooperation, coordination, and mutual support. Effective communication is vital for safe and efficient maintenance work as it reduces the likelihood of maintenance errors, which are often caused by communication problems . Cooperation involves openness, honesty, and fairness, increasing team cohesion and respect . Coordination requires clear task delegation, monitoring delegated tasks, and setting flexible priorities . Mutual support is fundamental for team identity as it encourages utilizing team members' strengths and addressing weaknesses constructively . Teamwork enhances safety by fostering a safety culture where norms and values that promote safety are institutionalized. This includes acknowledging each person's contribution to the team goal and ensuring everyone's understanding of the group goals . Management plays a crucial role by mediating between team feedback and company directives, contributing to both safety culture and maintaining a stable work environment .
The 1988 Aloha Airlines incident had several human factors identified as root causes. These included deficiencies in repair procedures, as well as inadequate training and lack of certification and qualification of mechanics and inspectors . Additionally, the incident highlighted issues with the quality of air carrier maintenance programs and the effectiveness of FAA surveillance of these programs . Human error was a significant contributor, aligning with broader findings that human factors such as incomplete or incorrect documentation, poor instructions, and inadequate communication can lead to accidents .
Significant human factors errors identified in the Continental Express accident with the EMB120 turboprop included poor written and verbal communication during shift turnover, leading to an incomplete installation of a de-icing system. This resulted in the leading edge of the right horizontal stabilizer separating in flight, causing the crew to lose control of the aircraft . Additionally, the incident highlights the importance of proper communication and procedures in preventing accidents .
The 1989 United Airlines DC10 accident significantly impacted inspection processes for turbine engine components by highlighting the need to address human factors in maintenance procedures. The National Transportation Safety Board (NTSB) report indicated that inadequate consideration of human limitations in inspection and quality control at United Airlines' engine overhaul facility was a factor. This oversight led to a failure to detect a fatigue crack from a metallurgical defect in the #1 fan disk . Consequently, this accident underscored the importance of improving human factors attention in the inspection of turbine engine rotating components, promoting better training and awareness among inspectors and mechanics to prevent similar failures .