MTEM Mac 12

8/2/2019 MTEM Mac 12

1/108

Maintenance Threataintenance ThreatAnd Error Managementnd Error Management

8/2/2019 MTEM Mac 12

2/108

Human Factors 2

8/2/2019 MTEM Mac 12

3/108

Primary Causes of Aircraft Accidents *Primary Causes of Aircraft Accidents *

Flight CrewFlight Crew

AirplaneAirplane

MaintenanceMaintenance

WeatherWeather

Airport/ATCAirport/ATC

OtherOther

Percentage of Total Accidents with Known CausesPercentage of Total Accidents with Known Causes

2020 4040 6060Primary FactorPrimary Factor 7070505030301010

Excludes: Sabotage Mil itary Action Turbulence Injury Evacuation Injury Servicing Injury

Pilots are humanilots are humanand humans make errors!nd humans make errors!(Note: this does not mean that errors are OK!)

The Crew usually makes the last mistake!The Crew usually makes the last mistake!The Crew usually makes the last mistake!The Crew usually makes the last mistake!* Copyright 2004 by the Boeing Commercial Airplane Group. Adapted with permission.Human Factors 3

8/2/2019 MTEM Mac 12

4/108

TEM Objectives:TEM Objectives:

The objective :The objective :

understanding how to assess variousunderstanding how to assess variousrisk levels of threatsrisk levels of threats

logical approaches (strategies) tological approaches (strategies) todeal with themdeal with them

reduce human error in dynamic dailyreduce human error in dynamic dailymaintenance operations.maintenance operations.

Human Factors 4

8/2/2019 MTEM Mac 12

5/108

TEM Model

Human Factors 5

8/2/2019 MTEM Mac 12

6/108

Human Factors 6

8/2/2019 MTEM Mac 12

7/108

Some DefinitionsSome Definitions

8/2/2019 MTEM Mac 12

8/108

Human Factors 8

THREATS IN MAINTENANCETHREATS IN MAINTENANCE

ThreatsThreats --events occur outside theinfluence of the maintenance crew,require crew attention andmanagement to maintain safetymargins

Threats increase complexityincrease complexity ofmaintenance operation and weakenbarriers against error

ObservableObservableThreatsThreats

Known e.g.. Poor training , Incomplete

or incorrect documentation

Unexpected e. g, Engine on fire duringground runThreatsThreats == Red Flags!Red Flags!

8/2/2019 MTEM Mac 12

9/108

LATENT THREATSLATENT THREATS

Human Factors 9

Latent ThreatLatent Threat

inherentinherent in system, organization, or individualin system, organization, or individualthatthat increases risksincreases risks..

- not- not directlydirectly observableobservable at the sharp end ofat the sharp end of

operations.operations.

-- usually uncoveredusually uncovered e.g.,e.g.,Equipment design issueEquipment design issue

Optical illusionsOptical illusions

Training philosophy and practicesTraining philosophy and practices

Organizational culture (Positive or Negative)Organizational culture (Positive or Negative)

8/2/2019 MTEM Mac 12

10/108

Typicalypical Latentatent ThreatThreat Poor planning or schedulingPoor planning or scheduling Inadequate design/poor equipmentInadequate design/poor equipment Improper allocation/lack of resourcesImproper allocation/lack of resources Flawed proceduresFlawed procedures

Defective communicationsDefective communications Training deficienciesTraining deficiencies Inadequate selection proceduresInadequate selection procedures Inspection and oversight flawsInspection and oversight flaws

Neglect of known hazardsNeglect of known hazards Lack of motivationLack of motivation

Note that these areote that these are alll l management problems!management problems!Flight Safety Foundation, 2006; Adapted with permission.

Human Factors 10

8/2/2019 MTEM Mac 12

11/108

Human Factors 11

What are the contributingWhat are the contributing

causes? (Threats)causes? (Threats)

FatigueFatigue

Boring repetitive jobsBoring repetitive jobs

Lack of spare parts andLack of spare parts and

toolstools

Personal life problemsPersonal life problems Substance abuseSubstance abuse

Loud noisesLoud noises

Poor communicationPoor communication

Poor languagePoor language

What are the types of things that negatively effect human

performance and may lead to human error?

Your answers:

Our answers how many match?

Poor instructionsPoor instructions

Unrealistic deadlinesUnrealistic deadlines

Smelly fumesSmelly fumes

Poor trainingPoor training

Incomplete or incorrectIncomplete or incorrectdocumentationdocumentation

Poorly designed testingPoorly designed testing

for skill and knowledgefor skill and knowledge

8/2/2019 MTEM Mac 12

12/108

What are the contributing factors?What are the contributing factors?

(Threats)(Threats)

Lets target the 12 most commonLets target the 12 most common

Human Factors 12

8/2/2019 MTEM Mac 12

13/108

Lack of CommunicationLack of CommunicationComplacencyComplacency

Lack of ResourcesLack of Resources

DistractionDistraction

Lack ofLack of

KnowledgeKnowledge

FatigueFatigue

Lack ofLack of

TeamworkTeamwork

Lack ofLack of

AwarenessAwareness

StressStress

NormsNorms

Lack ofLack of

AssertivenessAssertiveness

PressurePressure

The Dirty Dozen The 12 Most CommonThe Dirty Dozen The 12 Most Common

Causes for for Maintenance ErrorsCauses for for Maintenance Errors

Human Factors 13

ERRORSERRORS

8/2/2019 MTEM Mac 12

14/108

ERRORSERRORS

Actions or inactions that lead to deviations from

intention Traditional thinking eliminate error i.e., ZeroZero

Error!Error!

Contemporary thinking error a part of life, i.e.,humans make mistakes!humans make mistakes!

Intentional non-compliance not an error VIOLATION!VIOLATION!

Types of errors: Maintenance errors (e.g., fitment of wrong bolts or

fasteners) Procedural errors (e.g., performing checklist items

from memory)

Communications errors (e.g., instruction fromHuman Factors 14

8/2/2019 MTEM Mac 12

15/108

Maintenance Error

A performance failure of themaintenance system where thesystem did not perform the correct

way or as expected.

Examples:1. foreign objects or tooling lost in an aircraft during

maintenance2. contamination of a fuel system due to poor

procedures or practices

3. failure to correctly install components.Human Factors 15

8/2/2019 MTEM Mac 12

16/108

Common Maintenance Errors?Common Maintenance Errors?

1.1. Incorrect installation of componentsIncorrect installation of components

2.2. The fitting of wrong partsThe fitting of wrong parts

3.3. Electrical wiring discrepancies (including cross-Electrical wiring discrepancies (including cross-

connections)connections)

4.4. Loose objects (tools, etc.....) left in aircraftLoose objects (tools, etc.....) left in aircraft

5.5. Inadequate lubricationInadequate lubrication

6.6. Cowlings, access panels and fairings notCowlings, access panels and fairings not

securedsecured

7.7. Fuel/oil caps and refuel panels not securedFuel/oil caps and refuel panels not secured

Your answers:

Civil Aviation Authoritys List of Maintenance Errors

Human Factors 16

8/2/2019 MTEM Mac 12

17/108

Human Factors 17

Incomplete installationIncomplete installation(33%)(33%)

Damage on installationDamage on installation

(14.5%)(14.5%) Improper installationImproper installation

(11%)(11%)

Equipment not installed orEquipment not installed ormissing (11%)missing (11%)

Foreign object damageForeign object damage(6.5%)(6.5%)

Improper troubleshooting,Improper troubleshooting,inspection, test (6%)inspection, test (6%)

Equipment not activated orEquipment not activated ordeactivated (4%)deactivated (4%)

What errors cause engine failures?What errors cause engine failures?

Your answers:

Boeing StudyBoeing Study

Data from Boeing study of 276 in-flightengine shutdowns (1994)

Data from Boeing study of 276 in-flightengine shutdowns (1994)

8/2/2019 MTEM Mac 12

18/108

Human Factors 18

Fortunately, not all events becomeFortunately, not all events become

accidentsaccidents

Serious incidenterious incidentRoutine occurrenceoutine occurrence

Accidentccident

Statistical eventtatistical event

Significant eventignificant event11

1010

3030

200200

600600

Flight Safety Foundation, 2006; Adapted with permission.

but events/occurrences can lead tobut events/occurrences can lead to

incidents and accidentsincidents and accidents

8/2/2019 MTEM Mac 12

19/108

There are typically far more latenthere are typically far more latentfailures than active failures in the systemailures than active failures in the systemThere are typically far more latenthere are typically far more latentfailures than active failures in the systemailures than active failures in the system

System Failures Contribute toSystem Failures Contribute to

AccidentsAccidents

System Failures Contribute toSystem Failures Contribute to

AccidentsAccidents

Type

sofFailu

re

Type

sofFailu

re

(ACTIVE)ACTIVE)ACTIVE)ACTIVE)

(LATENT)LATENT)LATENT)LATENT)

Human Factors 19

8/2/2019 MTEM Mac 12

20/108

Error OutcomesError Outcomes

Human Factors 20

8/2/2019 MTEM Mac 12

21/108

Strategies/Countermeasures:Strategies/Countermeasures:

Strategies/CountermeasuresStrategies/Countermeasures to reduce number of threats andto reduce number of threats and

errorserrors

to increase awareness of potentialto increase awareness of potentialthreats and errorsthreats and errors

Errors must be recognized andErrors must be recognized andcorrected before negativecorrected before negative

consequences occur!consequences occur!

Focus onFocus on managing your future!managing your future!

Human Factors 21

8/2/2019 MTEM Mac 12

22/108

Good TEM - plan and use countermeasures toGood TEM - plan and use countermeasures to

prevent threats and errors leading to anprevent threats and errors leading to an

undesired aircraft/equipment state.undesired aircraft/equipment state.

Planning countermeasuresPlanning countermeasures

Execution countermeasuresExecution countermeasures

Review countermeasuresReview countermeasures

Human Factors 22

Countermeasures used in TEM include :Countermeasures used in TEM include :

8/2/2019 MTEM Mac 12

23/108

Safeguards:Safeguards:

TEMTEM

SMS FLIGHTSMS FLIGHTSAFETYSAFETY

MRMMRM

MANUALSMANUALS

SOPsSOPs

CHECKLISTSCHECKLISTS AUTOMATIONAUTOMATION

TAMMTAMM

Human Factors 23

SafeguardsSafeguardsare the hardware & software thatare the hardware & software thatserve as additional barriers to problems *:serve as additional barriers to problems *:

* Note: Because these are also developed by humans,* Note: Because these are also developed by humans,

the potential still exists for latent defects and errors.the potential still exists for latent defects and errors.

8/2/2019 MTEM Mac 12

24/108

Desired OUTCOMESDesired OUTCOMES

ororUndesired CONSEQUENCESUndesired CONSEQUENCES ??

Successful TEM results inSuccessful TEM results in outcomesoutcomes that arethat are

desirabledesirable, i.e.,, i.e., safe aircraftsafe aircraft

ConsequencesConsequences ofoferrors noterrors not

corrected/containedcorrected/contained result in anresult in an undesiredundesiredaircraft /equipment stateaircraft /equipment state ((USUS))

AnAn undesiredundesired state is an aircraft/equipmentstate is an aircraft/equipment

deviation or incorrect configurationdeviation or incorrect configuration

associated with a clearassociated with a clear reduction in safetyreduction in safetymarginsmargins

Human Factors 24

8/2/2019 MTEM Mac 12

25/108

TEMTEM

PrinciplesPrinciples

8/2/2019 MTEM Mac 12

26/108

TEM Principles:TEM Principles:

TEMTEM is central to all safety processesis central to all safety processesand provides defences againstand provides defences againsthazards in operational situations; ithazards in operational situations; itinvolvesinvolves

Identifying hazards to safety,Identifying hazards to safety,i.e., threats, errors, or undesiredi.e., threats, errors, or undesiredstates (deviations)states (deviations)

Assessing the risks of theseAssessing the risks of these

hazards (the consequence ofhazards (the consequence ofaccepting hazards)accepting hazards)

Avoiding or trapping threats andAvoiding or trapping threats anderrorserrors

Containin the end resultContaining the end resultHuman Factors 26

8/2/2019 MTEM Mac 12

27/108

Important TEMImportant TEM

ConceptsConcepts

TEMTEM

8/2/2019 MTEM Mac 12

28/108

TEMTEM

Concepts:Concepts: The mission (i.e., safe, effectiveThe mission (i.e., safe, effective

mission/objective) may be a pre-flightmission/objective) may be a pre-flightcheck, an aircraft repair, a trip plan, orcheck, an aircraft repair, a trip plan, or

even an ops manual or companyeven an ops manual or company

procedureprocedure

i.e., TEM can be applied toi.e., TEM can be applied to allall aviationaviationorganizational entities.organizational entities.

The maintenance crew is only one resourceThe maintenance crew is only one resource

to the operator or systems managerto the operator or systems managerwho must make accurate and timelywho must make accurate and timely

decisions for successful results.decisions for successful results.

The operator is only as effective as theThe operator is only as effective as the

information he or she receives from allinformation he or she receives from allHuman Factors 28

TEMTEM

8/2/2019 MTEM Mac 12

29/108

TEMTEMConceptsConcepts

Individuals are humans, and humans (allIndividuals are humans, and humans (all

humans!) make mistakes.humans!) make mistakes.

The aviation mission or objective isThe aviation mission or objective is

dynamic.dynamic.

TEM is not a sequential system! BecauseTEM is not a sequential system! Becauseall organizational entities are made up ofall organizational entities are made up of

individuals, threats (hopefully withindividuals, threats (hopefully with

innovative threat solutions!) and humaninnovative threat solutions!) and human

error (with error resolutions!) areerror (with error resolutions!) areintroducedintroduced throughoutthroughout the timeline of thethe timeline of the

particular mission.particular mission.

External threats also continuously occurExternal threats also continuously occur

and must be dealt with utilizingand must be dealt with utilizing allallHuman Factors 29

8/2/2019 MTEM Mac 12

30/108

Accurate Decision-Accurate Decision-

MakingMaking The primary key to a successful missionThe primary key to a successful mission

outcome is accurate decision-making byoutcome is accurate decision-making bythe individual or individuals who arethe individual or individuals who areinvolved in aircraft maintenanceinvolved in aircraft maintenance

Accurate Decision-Making = SuccessfulAccurate Decision-Making = SuccessfulOutcome!Outcome!

In the maintenance set up, a crew is onlyIn the maintenance set up, a crew is onlyas effective as theas effective as the informationinformation (not data!)(not data!)

he or she receives through properhe or she receives through properteamwork and resource management.teamwork and resource management.

The crew is the one of the authorityThe crew is the one of the authorityregarding the safety of the aircraft; e.g., aregarding the safety of the aircraft; e.g., a

technician can always elect to snap atechnician can always elect to snap aHuman Factors 30

8/2/2019 MTEM Mac 12

31/108

Techniques for Managing

Errors: Identify behaviors in the maintenance

organization which are unacceptable,inappropriate, or undesirable. E.g. poordocumentation or the perceived

requirement/pressure to work long hours tocomplete a task.

Replace unacceptable behavior with correctbehavior. Establish boundaries and framework for

maintenance organizations to operate under. Anexample would be to establish rules on work hoursand overtime.

Human Factors 31

8/2/2019 MTEM Mac 12

32/108

Techniques for Managing Errorscont

If something is not correct in the

maintenance organization and system, get itcorrected for the future..

Maintenance incidents, near misses andaccidents must be reported to allow the

organization to learn from error and to putmitigation strategies in place. An easilyaccessible, non-punitive, and anonymous reportingsystem can be very valuable.

Investigating and reporting maintenanceerror generates understanding as to why anincident occurred. Expand investigations widerto include latent errors and defects, not just theactive errors and physical causes

Human Factors 32

8/2/2019 MTEM Mac 12

33/108

Human Factors 33

8/2/2019 MTEM Mac 12

34/108

The Dirty Dozen

Stress Fatigue

Complacency

Distractions Lack of

Awareness

Lack ofCommunication

Lack ofAssertiveness

Lack of

KnowledgeNormsPressureLack ofTeamwork

Lack ofResources

8/2/2019 MTEM Mac 12

35/108

8/2/2019 MTEM Mac 12

36/108

Stress Effects

Anxiety Difficulty concentrating on task

Feeling overwhelmed

Fatigue

Health problems

Memory problems Poor judgment

8/2/2019 MTEM Mac 12

37/108

Stress Example An experience SNCO who normally

performed well.

Makes several errors where he forgot todo a task at the correct time.

Part of his action plan was to work withme on improving his work planning andways to use reminders.

He told me(hadnt told others) that: He was having financial problems, and

His wife and children had left him, and

He was not sleeping much.

8/2/2019 MTEM Mac 12

38/108

Low Medium High

STRESS

PERFORMANC

E

High

BasicLivingStressors

BasicJobStressors

Capacity

to Cope

Caution

Danger

Distress

Yerkes-Dodson Curve (1908)

Adapted by G. Dupont

Danger

Go Go Stress So So Stress

No No Stress

Stress Curve Model

8/2/2019 MTEM Mac 12

39/108

Stress Safety Valves

Be aware of the effects of stress on yourwork.

Most businesses provide educationalmaterials.

Discuss what is happening with someone.

Ask a co-worker to check your work.

Take time off; take breaks regularly.

Turn off your devices. Eat properly, rest adequately, exercise.

Plan an appropriate course of action.

8/2/2019 MTEM Mac 12

40/108

8/2/2019 MTEM Mac 12

41/108

Make more mistakes. Delayed reactions.

Difficult to maintain attention and awareness.

Not able to handle much information. Every task becomes more difficult to perform.

Doesnt want to talk or interact with people

Irritable or bad mood. Involuntary lapses into sleep may occur.

Fatigue Effects

8/2/2019 MTEM Mac 12

42/108

Fatigue Example

During a shutdown, a crew worked34 hours installing a new pipingsystem.

At hour 28, a laborer was trying toget two flanges aligned.

He stuck his hand in the wrongplace.

Two fingers were cut and smashed.

8/2/2019 MTEM Mac 12

43/108

Fatigue Example

Aircraft technicians a few SORreports

Either the supervisors do not reactquickly to abnormal operatingconditions, OR

They do not react correctly. People who work rotating shifts have

the effects of fatigue.

Many examples from all over the world.

8/2/2019 MTEM Mac 12

44/108

Fatigue Safety Valves

Get adequate amounts of sleep. 8 hours each day/night for most people.

Educate self on causes and cures of

fatigue. Many resources on fatigue management.

Get a physical check-up annually. Address any sleep disorders.

Eat properly and drink plenty offluids. Use caffeine strategically.

8/2/2019 MTEM Mac 12

45/108

8/2/2019 MTEM Mac 12

46/108

Complacency Effects

Letting your mind wander.Taking shortcuts and omitting steps.Fooling around or showing off.Thinking that everything will work

perfectly.

Working too long without a break.Taking the attitude that safety is

someone elses job.Performing a task without using the

procedures or recommended personalprotective equipment.

C l Pi li

8/2/2019 MTEM Mac 12

47/108

Complacency PipelineExample

Corrective Maintenance Performed OnWrong System Familiarity and complacencywith the

work environment allowed workers to

troubleshoot an electrical system that wasnot isolated.

Opened wrong valve Person reported that he had performed

task hundreds of times. Didnt think abouttask.

Did not refer to procedure, andperformed task incorrectly.

C l S f t

8/2/2019 MTEM Mac 12

48/108

Complacency SafetyValves

Understand the human factorsinvolved: We have a mental bias that allows our past

experiences to guide present expectations.

We dont use our brains fully in the situationsince our present circumstances normallymatch our past circumstances

We devote our brains to more interesting partsof a task, or to a more interesting task.

Recognize that It cant happen tome is a wrong belief.

Expect success, but be prepared for

failure.

C l S f t

8/2/2019 MTEM Mac 12

49/108


Always practice risk assessment.

Use the 5 Questions

Use STAR with every task.

Practice independent verification.

Follow all policies and procedures.

Train continually and review often. Create mental challenges for

yourself.

Sustain a questioning attitude.

Complacency Safety

8/2/2019 MTEM Mac 12

50/108


Five Questions Simple RiskAssessment

1. Why am I doing this task at all?

2. What could go wrong?3. How likely is it to happen?

4. What effect could it have on me orothers?

5. What can I do about it?

STARREVIEWSTOP THINK ACT

8/2/2019 MTEM Mac 12

51/108

8/2/2019 MTEM Mac 12

52/108

Distractions

Interruptions How can interruptions cause an error?

Multitasking is counterproductive.(CNN.com)

Multitasking makes us stupid. (WSJarticle)

There is a time-cost to switching tasks.

There is a switching-cost.

One must change goals.

What do I want to do now?

One must change rules.

8/2/2019 MTEM Mac 12

53/108

Distractions Examples

Driving and Doing Other Things Vehicle accidents Near misses

People talking on phones, surfing

Internet, etc. and failing to noticethat it is time to perform a task ORignoring an alarm or other signal.

Technician was interrupted during atask and did not return pressureswitch to service. Caused damageto equipment, and an abnormaloperation.

8/2/2019 MTEM Mac 12

54/108

Distractions Safety Valves

Minimize or eliminate distractions. Ask people to be quiet and leave

your area.

Finish the task if possible.

Complete tasks step by step.

Flag or tag all uncompleted work.

Use STAR.

Use memory aids.

Focus by practicing mindful

8/2/2019 MTEM Mac 12

55/108

8/2/2019 MTEM Mac 12

56/108

Lack of Awareness

1. Perceive(see, hear, notice) thecritical elements around you.

2. Understand what those criticalelements mean, particularly asthey relate to the current task.

3. Forecast what is going tohappen in the near future.

8/2/2019 MTEM Mac 12

57/108

Lack of Awareness -

Example Engine accidently top up withhydraulic fluidDidnt know a hydraulic fluid can

was similar to engine oil can.

Thought the hydraulic fluid canwas a engine oil.

Didnt think I would damage the

engine by filling it with hydraulicfluid.

L k f A

8/2/2019 MTEM Mac 12

58/108

Lack of Awareness -Example

Controller has no change in display,but field equipment has changed.

Received brief explanation of change.

Is aware he cannot rely on display asaccurate.

Relying on Controller to maintain

awareness of change and make switchcorrectly.

Controller did not make switch correctly.

Lack of Awareness Safety

8/2/2019 MTEM Mac 12

59/108

Lack of Awareness SafetyValves

Learn the principles and practices ofsituation awareness.

Pay attention to your surroundings.

Create a safety zone. Recognize that jobs and the

requirements are complex.

Understand that vigilance candeteriorate while performing a task.

Learn and use human performanceprinciples.

8/2/2019 MTEM Mac 12

60/108

8/2/2019 MTEM Mac 12

61/108

Lack of Assertiveness

In group settings, some people arehesitant to express their opinions.

Affects work planning, hazard analysis,

safety concerns. New employees may not ask

relevant questions, even when

uncertain. Can cause accidents, rework, qualityissues.

Some employees will not contradict

Lack of Assertiveness

8/2/2019 MTEM Mac 12

62/108

Lack of AssertivenessExample

Younger employee knew moreexperienced employee was notfollowing company requirements,BUT did not question AND nothinghappened for months, until a tankoverflow.

Supervisordid not questiontemporary operating directions,which led to an abnormal operatingcondition.

Lack of Assertiveness Safety

8/2/2019 MTEM Mac 12

63/108

Lack of Assertiveness SafetyValves

Practice your values and beliefs. Practice the companys values and

beliefs.

Refuse to compromise company andpersonal standards.

Ask for what you need.

Dont be afraid to express youropinion and ideas.

Recognize your contributions matter.

Learn how to be assertive on the job.

8/2/2019 MTEM Mac 12

64/108

8/2/2019 MTEM Mac 12

65/108

Lack of Communication

Lack of communication affectsperformance:

Misunderstandings occur betweenworkers.

Hurt feelings lead to petty disagreements.

Job doesnt get done or is delayed.

Anger may affect individuals or groups.

Loss of trust and respect

Near misses or incidents may result.

Lack of Communication

8/2/2019 MTEM Mac 12

66/108

Lack of CommunicationExample

Field technician did not informsupervisor of a communication

device failure, and the controller wasnot receiving accurate information.Abnormal event!

Many, many, many other examples.

Lack of Communication Safety

8/2/2019 MTEM Mac 12

67/108

Lack of Communication SafetyValves

Practice 3-way communication. Write down important information.

Always conduct briefings before, during, and afterjobs.

Use the Management of Change process. Provide the right information to the right people at

the right time.

Assume nothing.

Dont tell someone something when they are inthe middle of doing something else.

Give people your full attention when listening.

Expect peoples full attention when talking.

8/2/2019 MTEM Mac 12

68/108

8/2/2019 MTEM Mac 12

69/108

Lack of Knowledge Factors contributing to lack of knowledge:

Inadequate training

New equipment

Procedures and regulations

New technology. Provide adequate training and reference

materials.

Use resources like the expertise of other people

on shift, other people, and the manufacturersmanual.

Teamwork and communication help to reduce thepotential error due to the lack of knowledge.

Address all changes, including temporary ones.

8/2/2019 MTEM Mac 12

70/108

Lack of Knowledge Example

Technician did not know theprocedure for maintenance onelectrical equipment, BUT did the

task AND was injured. Operator did not know how to locatethe pipeline and marked its locationincorrectly, ANDline got

damaged. Supervisordid not receive training,

after a change in operating

procedures, AND product was

8/2/2019 MTEM Mac 12

71/108

Lack of Knowledge Safety Valves

Get the necessary training.

Use procedures and manuals.

Dont do a task if you do not knowhow to do it safely and correctly.

Ask someone who knows.

Dont let pride get in the way. Be a lifelong learner.

8/2/2019 MTEM Mac 12

72/108

8/2/2019 MTEM Mac 12

73/108

Norms Norms can be positive or negative.

Use procedures or not.

Completing checklists or pencil whipping.

Naps encouraged or punished.

Norms exist for a reason Restaurants have signs requiring

employees to wash their hands. Why?

Sign in Nashville restaurant says wash

hands twice. Why? Norms are set by the employees

Pipeline example

8/2/2019 MTEM Mac 12

74/108

Norms Example

Do not shut the pipeline down forany reason.

Every employee has the authorityto shut the pipeline down if he or shesuspects a problem.

Which one of those is closer to the normfor your company?

8/2/2019 MTEM Mac 12

75/108

Norms Safety Valves

Recognize norms where we work andlive.

Work on removing bad habits andbehaviors.

Accentuate the positive, eliminate thenegative.

Dont use shortcuts.

Abide by standards and requirements.

Be a good example for others.

Follow policies and procedures.

8/2/2019 MTEM Mac 12

76/108

8/2/2019 MTEM Mac 12

77/108

Pressure Demands are sometimes made for

workers to: Meet unrealistic deadlines.

Be multi-skilled.

Do many tasks in a workday, whilemultitasking.

Be as good or better than coworkers.

Perform all tasks safely and withouterror.

Over time or anytime, thesepressures can cause performance

problems.

l

8/2/2019 MTEM Mac 12

78/108

Pressure Example

For instance, during the 36-month periodfrom January 1, 2001 through December31, 2003, 18 workers were injured andapproximately 86 others were involved innear miss events.

Oftenpressure to get the job done results inactions that can permit disastrousconsequences (i.e., personal injury and/orproperty damage).

This is from a DOE report.

Technicians were pressured by managersto work excessive hours to repair a pump.

The repair took longer because thetechnicians, being fatigued, made somemistakes that caused rework.

i C l

8/2/2019 MTEM Mac 12

79/108

Pressure in Control Rooms

Perform tasks when a protective device isnot working properly or a safety device isinhibited.

Take a shortcut in a procedure. Do things that may compromise safety or

quality, for the sake of profitability. Work an extra shift or extra hours, when

fatigued. Do too many tasks at once, or in a short

time period. Stay at the console, when you need a

break. Work in a stressful environment, even

when improvements can easily be made.

P S f V l

8/2/2019 MTEM Mac 12

80/108

Pressure Safety Valves

Dont overwhelm yourself or others. Dont be afraid to ask for help.

Communicate your concern to your

manager and coworkers. Dont create a false sense of

urgency.

Dont take shortcuts; do the jobright.

Say no to pressure.

Develop good planning and coping

8/2/2019 MTEM Mac 12

81/108

L k f T k

8/2/2019 MTEM Mac 12

82/108

Lack of Teamwork Roles and responsibilities, if not clear,

cause confusion and frustration.

Teamwork problems lead to performanceissues.

Decisions are made by one or two peoplein the group, without the teamsknowledge.

Problems and underlying issues may not

be addressed. Trust and respect are compromised.

Cynicism and sarcasm are present.

L k f T k E l

8/2/2019 MTEM Mac 12

83/108

Lack of Teamwork Example

Tank Volume Record Keeping Employee purposely recorded wrongvolume to cover up his mistake. He

got fired for lying.

G d T k E l

8/2/2019 MTEM Mac 12

84/108

Good Teamwork Example

Tank Fire When lightning caused atank fire, the regular drills withemployees and local fire

departments proved that teamworkand preparation was worthwhile.

8/2/2019 MTEM Mac 12

85/108

Lack of Teamwork

8/2/2019 MTEM Mac 12

86/108

Lack of Teamwork Safety Valves

Clarify the team goals. Have an effective team plan. Clearly define the roles. Clear communication. Reward good team behavior. Punish poor team behavior. Use well-defined decision procedures.

Balanced participation. Establish ground rules. Be aware of the group process.

8/2/2019 MTEM Mac 12

87/108

L k f R

8/2/2019 MTEM Mac 12

88/108

Lack of Resources

When supplies are not available,employees spend time trying to findsubstitutes.

When parts are not available, delaysare necessary while a part isordered, made, or retrofitted.

Employees are tempted to omitsteps that require a missingresource.

Employees may guess at a

L k f R E l

8/2/2019 MTEM Mac 12

89/108

Lack of Resources Example Most pipeline companies I consult with are

operating with fewer employees than theyhad a few years ago.The result is that employees are doing more

tasks, driving more miles, working more

overtime. Causes stress, pressure, fatigue.

This can lead to errors, accidents, injuries.

Most pipeline companies I consult with are

reducing expense budgets. Fewer spare parts are available.

Fewer supplies are available.

Fewer dollars are available for training.

Lack of Reso rces

8/2/2019 MTEM Mac 12

90/108

Lack of Resources Have the correct complement for

the schedules required to operatethe pipeline.

Assess needs for new parts beforebeginning a job.

Purchase and maintain criticalparts inventory.

Dont compromise standards if the

correct resources are lacking. Dont use work arounds if youdont have the proper parts orsupplies.

The Dirty Dozen

8/2/2019 MTEM Mac 12

91/108

The Dirty Dozen

Stress Fatigue

Complacency

Distractions Lack of

Awareness

Lack ofCommunication

Lack ofAssertiveness

Lack ofKnowledge

NormsPressureLack ofTeamwork

Lack ofResources

E Ch iError Chain

8/2/2019 MTEM Mac 12

92/108

Error ChainError Chain

Human Factors 92

8/2/2019 MTEM Mac 12

93/108

Human Factors 93

Error Chainrror ChainAn accident is what?

An unplanned and unfortunateevent that results in damage,injury, or upset of some kind.

An error chain is what?Multiple contributing causes that

lead to an accident.

StressNorms

Poor

CommunicationDistraction Complacency

Lack of

Awareness

Accid

ent

8/2/2019 MTEM Mac 12

94/108

Error Chain How do we breakrror Chain How do we breakit?t?

Human Factors 94

Ch i B ki R i tiCh i B ki R i ti

8/2/2019 MTEM Mac 12

95/108

Human Factors 95

Hardware and software thatexist before the human enters:

Policies andSOPs

Maintenance

Manuals

Training Job Cards Inspections

Service Bulletins Test Equipment Regulations Shift Turnover

Chain Breaking - ResistiveChain Breaking - Resistive

Breaking the Errorreaking the Error

8/2/2019 MTEM Mac 12

96/108

Human Factors 96

ChainhainWhat happens when we use

Standard Operating Procedures?

Stress

Norms

PoorCommunication

Distraction Complacency

Lack of

Awareness

Accide

nt

Use

SOP

Completion of operational goals..

Chain Breaking - ResolveChain Breaking - Resolve

8/2/2019 MTEM Mac 12

97/108

Proficiency Vigilance Assertiveness Procedural Compliance

Effective Communication Teamwork Effective Communication

Decision Making Experience Leadership Situational Awareness

Company Safety Culture Workload Management

Chain Breaking Resolveg

Human Factors 97

What the human brings to the system - our TEM skills:

8/2/2019 MTEM Mac 12

98/108

Human Factors 98

Threat and Error ManagementThreat and Error Management

8/2/2019 MTEM Mac 12

99/108

Threat and Error ManagementThreat and Error Management

A barrier represents resources

available to the maintenance crew

to improve safety by mitigating

threats and errors.

We use multiple layers of barriersto improve our safety margin.

The holes represent errors inherent

or created in each barrier.

An arrow is a threat to completionof the operational goal.

Human Factors 99 Barriers -arriers -

8/2/2019 MTEM Mac 12

100/108

RegulationsRegulations

Shift Turnover & Other ResourcesShift Turnover & Other Resources

Tools & Test EquipmentTools & Test Equipment

Job CardsJob Cards

Policies & SOPsPolicies & SOPs

Resistiveesistive

Human Factors 100

InspectionsInspections

Barriers -arriers -

8/2/2019 MTEM Mac 12

101/108

Teamwork

Situational Awareness

Decision Making

Communication

Vigilance

Resolveesolve

Human Factors 101

Workload Management

Threat and Errorhreat and Error

8/2/2019 MTEM Mac 12

102/108

Teamwork

Regulations


Turnover & Resources

Decision Making

Tools & Test EquipmentCommunication

Job Cards

Vigilance

Inspections

Workload Management

Policies & SOPs

Managementanagement

Human Factors 102

Resistive and

Resolve Barriers


8/2/2019 MTEM Mac 12

103/108

Teamwork

Regulations



Decision Making

Tools & Test Equipment

Communication

Job Cards

Vigilance

Inspections

Workload Management

Policies & SOPs

Human Factors 103

Managementanagement

When the holes

line up


8/2/2019 MTEM Mac 12

104/108

Teamwork

Regulations



Decision Making


Communication

Job Cards

Vigilance

Inspections

Workload Management

Policies & SOPs

Human Factors 104

Managementanagement

When we use our

MRM skills

Threat and ErrorThreat and ErrorM tM t

8/2/2019 MTEM Mac 12

105/108

Teamwork

Regulations



Decision Making


Communication

Job Cards

Vigilance

Inspections

Workload Management

Policies & SOPs

Human Factors 105

ManagementManagement

When we are

vigilant

8/2/2019 MTEM Mac 12

106/108

YOU are the one of the line ofOU are the one of the line ofDEFENSE!EFENSE!

Human Factors 106

Vigilance

YOUR vigilance will save lives - The buck STOPS here!

Threat Error ManagementThreat Error Management

8/2/2019 MTEM Mac 12

107/108

Threat Error ManagementThreat Error Management

Picture of two maint dudes talking

Human Factors 107

TEM Skills - ResolveTEM Skills - Resolve

8/2/2019 MTEM Mac 12

108/108

What the human brings to the system - ourMRM skills:

Proficiency Vigilance

Assertiveness Procedural Compliance Effective Communication Teamwork

Decision Making Experience

Leadership Situational Awareness Company Safety Culture Workload Management

TEM Skills - ResolveTEM Skills - Resolve

Documents

MTEM Mac 12