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8/2/2019 TEM Upload
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Human Factors 2
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Primary Causes of Aircraft Accidents *
Flight Crew
Airplane
Maintenance
Weather
Airport/ATC
Other
Percentage of Total Accidents with Known Causes
20 40 60Primary Factor 70503010
Excludes:
Sabotage
Military Action
Turbulence Injury
Evacuation Injury
Servicing Injury
Pilots are human
and humans make errors!(Note: this does not mean that errors are OK!)
The Crew usually makes the last mistake!* Copyright 2004 by the Boeing Commercial Airplane Group. Adapted with permission.Human Factors 3
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TEM Objectives:The objective :
understanding how to assess various risklevels of threats
logical approaches (strategies) to deal withthem
reduce human error in dynamic dailymaintenance operations.
Human Factors 4
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TEM Model
Human Factors 5
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Human Factors 6
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THREATS IN MAINTENANCE
Threats -events occur outside the influence ofthe maintenance crew, require crew attentionand management to maintain safety margins
Threats increase complexityof maintenanceoperation andweaken barriers against error
ObservableThreats
Known e.g. Poor training , Incomplete orincorrect documentation
Unexpected e. g, Engine on fire during ground
run
Threats = Red Flags!
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Latent Threat
inherent in system, organization, or individualthat increases risks.- not directly observable at the sharp end ofoperations.
- usually uncovered e.g.,Equipment design issue
Optical illusions
Training philosophy and practices
Organizational culture (Positive or Negative)
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Typical Latent Threat
Poor planning or scheduling Inadequate design/poor equipment
Improper allocation/lack of resources
Flawed procedures
Defective communications Training deficiencies
Inadequate selection procedures
Inspection and oversight flaws
Neglect of known hazards Lack of motivation
Note that these are all management problems!Flight Safety Foundation, 2006; Adapted with permission.
Human Factors 10
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(Threats)
Fatigue
Boring repetitive jobs
Lack of spare parts andtools
Personal life problems Substance abuse
Loud noises
Poor communication
Poor language
What are the types of things that negatively effect humanperformance and may lead to human error?
Your answers:
Our answers how many match?
Poor instructions
Unrealistic deadlines
Smelly fumes
Poor training
Incomplete or incorrectdocumentation
Poorly designed testingfor skill and knowledge
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What are the contributing factors?
(Threats)
Lets target the 12 most common
Human Factors 12
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Lack of CommunicationComplacency *
Lack of Resources
Distraction *
Lack ofKnowledge *
Fatigue
Lack ofTeamwork
Lack ofAwareness
Stress
Norms *
Lack ofAssertiveness
Pressure
The Dirty Dozen The 12 Most CommonCauses for for Maintenance Errors
Human Factors 13
http://complacency.ppt/http://distraction.ppt/http://lack%20of%20knowledge.ppt/http://norms.ppt/http://norms.ppt/http://lack%20of%20knowledge.ppt/http://distraction.ppt/http://complacency.ppt/8/2/2019 TEM Upload
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Actions or inactions that lead to deviations from intention
Traditional thinking eliminate error i.e., Zero Error!
Contemporary thinking error a part of life, i.e.,humansmake mistakes!
Intentional non-compliance not an error 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 from supervisor
misunderstood)
Human Factors 14
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Maintenance ErrorA performance failure of the maintenance system
where the system did not perform the correct way or asexpected.
Examples:
1. foreign objects or tooling lost in an aircraft duringmaintenance
2. contamination of a fuel system due to poor procedures orpractices
3. failure to correctly install components.
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Common Maintenance Errors?
1. Incorrect installation of components
2. The fitting of wrong parts3. Electrical wiring discrepancies (including
cross-connections)
4. Loose objects (tools, etc.....) left in aircraft
5. Inadequate lubrication
6. Cowlings, access panels and fairings notsecured
7. Fuel/oil caps and refuel panels not secured
8. Landing gear ground lock pins not removed
Your answers:
Civil Aviation Authoritys List of Maintenance Errors
Human Factors 16
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Human Factors 17
Incomplete installation (33%)
Damage on installation (14.5%)
Improper installation (11%)
Equipment not installed ormissing (11%)
Foreign object damage (6.5%)
Improper troubleshooting,
inspection, test (6%) Equipment not activated or
deactivated (4%)
What errors cause engine failures?
Your answers:Boeing Study
Data from Boeing study of 276 in-flightengine shutdowns (1994)
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Human Factors 18
Fortunately, not all events become accidents
Serious incident
Routine occurrence
Accident
Statistical event
Significant event
1
10
30
200
600
Flight Safety Foundation, 2006; Adapted with permission.
but events/occurrences can lead to incidents and
accidents
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There are typically far more latent failuresthan active failures in the system
System Failures Contribute toAccidents
(ACTIVE)
(LATENT)
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ExacerbateErrors
Miss ErrorsMitigate
ErrorsTrap Errors
Error Outcomes
Human Factors 20
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Strategies/Countermeasures:
Strategies/Countermeasuresto reduce number of threats and errors
to increase awareness of potential threats anderrors
Errors must be recognized and corrected beforenegative consequences occur!
Focus on managing your future!
Human Factors 21
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Good TEM - plan and use countermeasures to prevent threatsand errors leading to an undesired aircraft/equipment state.
Planning countermeasures
Execution countermeasures
Review countermeasures
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Countermeasures used in TEM include :
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Safeguards:
TEM
SMS FLIGHT SAFETY MRM
MANUALS
SOPs
CHECKLISTSAUTOMATION
TAMM
Human Factors 23
Safeguardsare the hardware & software thatserve as additional barriers to problems *:
* Note: Because these are also developed by humans,the potential still exists for latent defects and errors.
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Desired OUTCOMESorUndesired CONSEQUENCES ?
Successful TEM results in outcomes that are desirable,i.e., safe aircraft
Consequences oferrors not corrected/contained
result in an undesired aircraft /equipment state(US)Anundesiredstate is an aircraft/equipment deviation
or incorrect configuration associated with a clearreduction in safety margins
Human Factors 24
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TEM Principles:TEM is central to all safety processes and
provides defences against hazards inoperational situations; it involves
Identifying hazards to safety, i.e., threats,
errors, or undesired states (deviations) Assessing the risks of these hazards (the
consequence of accepting hazards)
Avoiding or trapping threats and errors Containing the end result (mitigation)
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TEM Concepts: The mission (i.e., safe, effective mission/objective)
may be a pre-flight check, an aircraft repair, a tripplan, or even an ops manual or company procedure
i.e., TEM can be applied to all aviationorganizational entities.
The maintenance crew is only one resource to theoperator or systems manager who must makeaccurate and timely decisions for successful results.
The operator is only as effective as the information heor she receives from all resources (The TEAM).
Human Factors 28
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TEM Concepts Individuals are humans, and humans (all humans!)
make mistakes.
The aviation mission or objective is dynamic.
TEM is not a sequential system! Because all
organizational entities are made up of individuals,threats (hopefully with innovative threat solutions!)and human error (with error resolutions!) areintroduced throughout the timeline of the
particular mission. External threats also continuously occur and must
be dealt with utilizing all appropriate resourcesavailable.
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Accurate Decision-Making
The primary key to a successful mission outcome isaccurate decision-making by the individual orindividuals who are involved in aircraftmaintenance
Accurate Decision-Making = Successful Outcome!
In the maintenance set up, a crew is only as effectiveas the information (not data!) he or she receivesthrough proper teamwork and resourcemanagement.
The crew is the one of the authority regarding thesafety of the aircraft; e.g., a technician can alwayselect to snap a dangerous defect.
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Techniques for Managing Errors: Identify behaviors in the maintenance organization
which are unacceptable, inappropriate, orundesirable. E.g. poor documentation or the perceived
requirement/pressure to work long hours to complete atask.
Replace unacceptable behavior with correct behavior.Establish boundaries and framework for maintenance
organizations to operate under. An example would be toestablish rules on work hours and overtime.
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Techniques for Managing Errors cont If something is not correct in the maintenance
organization and system, get it corrected for thefuture..
Maintenance incidents, near misses and accidentsmust be reported to allow the organization to learnfrom error and to put mitigation strategies in place.
An easily accessible, non-punitive, and anonymousreporting system can be very valuable.
Investigating and reporting maintenance errorgenerates understanding as to why an incident
occurred.Expand investigations wider to include latent
errors and defects, not just the active errors and physicalcauses
Human Factors 32
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Human Factors 93
Error ChainAn accident is what?
An unplanned and unfortunate event that resultsin damage, injury, or upset of some kind.
An error chain is what?
Multiple contributing causes that lead to anaccident.
StressNorms
PoorCommunication
Distraction ComplacencyLack of
Awareness
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Human Factors 95
Hardware and software that existbefore the human enters:
Policies andSOPs
MaintenanceManuals
Training
Job Cards
Inspections
Service Bulletins Test Equipment
Regulations
Shift Turnover
Chain Breaking - Resistive
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Human Factors 96
Breaking the Error ChainWhat happens when we use StandardOperating Procedures?
Stress
Norms
PoorCommunication
Distraction Complacency
Lack ofAwareness
UseSOP
Completion of operational goals..
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Proficiency
Vigilance Assertiveness
Procedural Compliance
Effective Communication Teamwork Effective Communication
Decision Making
Experience Leadership
Situational Awareness
Company Safety Culture Workload Management
Chain Breaking - Resolve
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What the human brings to the system - our TEM skills:
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Human Factors 98
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Threat and Error Management
A barrier represents resourcesavailable to the maintenance crewto improve safety by mitigatingthreats and errors.
We use multiple layers of barriersto improve our safety margin.
The holes represent errorsinherent or created in each barrier.
An arrow is a threat to completionof the operational goal.
Human Factors 99
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Regulations
Shift Turnover & Other Resources
Tools & Test Equipment
Job Cards
Policies & SOPs
Barriers - Resistive
Human Factors 100
Inspections
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Teamwork
Situational Awareness
Decision Making
Communication
Vigilance
Barriers - Resolve
Human Factors 101
Workload Management
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TeamworkRegulations
Situational AwarenessTurnover & Resources
Decision Making
Tools & Test Equipment
CommunicationJob Cards
VigilanceInspections
Workload ManagementPolicies & SOPs
Threat and Error Management
Human Factors 102
Resistive and
Resolve Barriers
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TeamworkRegulations
Situational AwarenessTurnover & Resources
Decision MakingTools & Test Equipment
CommunicationJob Cards
VigilanceInspections
Workload Management
Policies & SOPs
Human Factors 103
Threat and Error Management
When the holesline up
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TeamworkRegulations
Situational AwarenessTurnover & Resources
Decision Making
Tools & Test Equipment
CommunicationJob Cards
VigilanceInspections
Workload ManagementPolicies & SOPs
Human Factors 104
Threat and Error Management
When we use our
MRM skills
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TeamworkRegulations
Situational AwarenessTurnover & Resources
Decision Making
Tools & Test Equipment
CommunicationJob Cards
VigilanceInspections
Workload ManagementPolicies & SOPs
Human Factors 105
Management
When we are
vigilant
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YOU are the one of the line of DEFENSE!
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Vigilance
YOUR vigilance will save lives - The buck STOPS here!
Th t E M t
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Threat Error Management
Picture of two maint dudes talking
Human Factors 107
TEM Skill R l
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What the human brings to the system - our MRM skills:
Proficiency
Vigilance Assertiveness Procedural Compliance Effective Communication Teamwork
Decision Making Experience Leadership Situational Awareness Company Safety Culture Workload Management
TEM Skills - Resolve