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Airworthiness: Maintenance Error Dirty Dozen
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Presented to:
By:
Date:
Federal AviationAdministration
AirworthinessHuman Factors
R1
Maintenance Error- Dirty Dozen
2Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
Objectives• Illustrate that human error in
maintenance causes death and destruction
• Identify 12 causes of maintenance error, “The Dirty Dozen”
• Suggest how to reduce maintenance error
3Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
The Best People Make the Worst Mistakes
4Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
5Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
Delta Flight 1288 MD-88
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Dirty Dozen- Human Error in Aircraft Maintenance
The Dirty Dozen
• Communication
• Complacency
• Lack of Knowledge
• Distraction
• Teamwork
• Fatigue
• Lack of Resources
• Pressure
• Assertiveness
• Stress
• Lack of Awareness
• Norms
7Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue
7. Lack of Resources 8. Pressure 9. Lack of Assertiveness10. Stress11. Lack of Awareness12. Norms
Safety NetsUse logbooks, worksheets etc. to
communicate and remove doubt.
Discuss work to be done or what has been completed.
Never assume anything.
8Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
9Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
Safety NetsUse logbooks, worksheets etc. to communicate and remove doubt.
Discuss work to be done or what has been completed.
Never assume anything.
Continental Express, 14 Fatalities, 9-11-91
10Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue
7. Lack of Resources8. Pressure9. Lack of Assertiveness
10. Stress11. Lack of Awareness12. Norms
Safety Nets
Train yourself to expect to find a fault.
Never sign for anything you didn’t do.
11Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
Italian Air Force, Keflavik
• No lineman present for start-up• Crew asked LM to verify battery door
closed (near left landing gear) after engines were started
• LM walked thru prop, killing him instantly• First such case in Italian AF in over 50
years
12Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
Italian Air Force, KeflavikCREW DOOR
BATT. DOOR
Loadmaster exits crew door to check battery door.
Engines were running
13Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
Loadmaster killed as he walks into prop. Body and remains scattered over 100 feet.
14Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
Accident cleanup by “Fire Department”
Carelessness and overconfidence are more dangerous than deliberately accepted risk.
- Wilbur Wright, 1901.
15Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
Therefore the Safety Board concludes that a low expectation of finding a crack in a –219 series fan hub might have caused the inspector to overlook or minimize the significance of an indication.
16Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
Face Reality
Physical Fitness
Create Challenges for yourself
Train yourself to expect to find a fault.
Never sign for anything you didn’t do
Safety Nets
17Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue
7. Lack of Resources8. Pressure9. Lack of Assertiveness
10. Stress11. Lack of Awareness12. Norms
Safety Nets
Get training on type.
Use up to date manuals.
Ask a Tech. Rep. or someone who knows.
18Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
19Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
20Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
21Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
Lack Of Knowledge
Get training on type.
Stay Current -Read, Read, Read
Use up to date manuals.
Ask a Tech. Rep.
-or someone who knows
Communicate No Pride!
Safety Nets
September 2, 1998Douglas MD-11 in the sea
9KM Off Nova Scotia
22Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue
7. Lack of Resources8. Pressure9. Lack of Assertiveness
10. Stress11. Lack of Awareness12. Norms
Safety NetsAlways finish the job or unfasten the connection
Mark the uncompleted work.
Lock wire where possible or use torque seal.
Double inspect by another or self.
When you return to the job always go back three steps.
Use a detailed check sheet.
23Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
Always finish the job or unfasten the connection.
Mark the uncompleted work.
Lock wire where possible or use torque seal.
Double inspect by another or self.
When you return to the job always go back three steps.
Use a detailed check sheet.
Safety Nets
24Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue
7. Lack of Resources8. Pressure9. Lack of Assertiveness
10. Stress11. Lack of Awareness12. Norms
Safety Nets“Reconfirm duties among team members.”
“Team tasks require a full team.”
“Communicate!”
“FOLLOW THE CORRECT PROCEDURES.”
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Dirty Dozen- Human Error in Aircraft Maintenance
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Dirty Dozen- Human Error in Aircraft Maintenance
27Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
“Communicate!”
“Team tasks require a full team.”
“Reconfirm duties among team members.”
“FOLLOW THE CORRECT PROCEDURES.”
Safety Nets
Lack of Teamwork
28Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue
7. Lack of Resources 8. Pressure 9. Lack of Assertiveness10. Stress11. Lack of Awareness12. Norms
Safety NetsBe aware of the symptoms andlook for them in yourself andothers.
Plan to avoid complex tasks atthe bottom of your circadian rhythm.
Sleep and exerciseregularly.
Ask others tocheck your work
29Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
ACUTE FATIGUEProduced by physical exertion or sleep lossAlleviated by a single rest period
CHRONIC FATIGUEMedical or psychological problemDepression or “chronic fatigue syndrome”
OPERATIONAL FATIGUEMost commonly seen after 3-4 days of heavy taskingNot relieved by a single sleep period
Fatigue
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Dirty Dozen- Human Error in Aircraft Maintenance
Attention reduced
Memory diminished
Mood becomes withdrawn
Low situational awareness
Long hours of labor (any type).
High intensity stress.
SYMPTOMS OF FATIGUE
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Dirty Dozen- Human Error in Aircraft Maintenance
CIRCADIAN RHYTHMSCIRCADIAN RHYTHMS
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Dirty Dozen- Human Error in Aircraft Maintenance
Be aware of the symptoms and look for them in yourself and others.
Plan to avoid complex tasks at the bottom of your circadian rhythm. Sleep and exercise regularly.
Ask others to check your work.
Safety Nets
Fatigue
33Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue
7. Lack of Resources8. Pressure9. Lack of Assertiveness
10. Stress11. Lack of Awareness12. Norms
Safety NetsCheck suspect areas at the beginning of the inspection and AOG the required parts.
Order and stock anticipated parts before they are required.
Know all available parts sources and arrange for pooling or loaning.
Maintain a standard and if in doubt ground the aircraft.
34Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
Jackscrew
88
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Dirty Dozen- Human Error in Aircraft Maintenance
Check suspect areas at the beginning of the inspection and AOG the required parts.
Order and stock anticipated parts before they are required.
Know all available parts sources and arrange for pooling or loaning.
Maintain a standard and if in doubt ground the aircraft.
Safety Nets
Lack of Resources
36Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue
7. Lack of Resources 8. Pressure 9. Lack of Assertiveness10. Stress11. Lack of Awareness12. Norms
Safety Nets
Be sure the pressure is not self- induced.
Communicate your concerns.
Ask for extra help.
Just say NO.
37Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
Jessica Dubroff1988- 1996
38Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
Chiang Kai-Shek Airport Taiwan June 6, 2005
39Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
Be sure the pressure is not self- induced.
Communicate your concerns.
Ask for extra help.
Just say NO.
Safety Nets
Pressure
40Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue
7. Lack of Resources8. Pressure9. Lack of Assertiveness
10. Stress11. Lack of Awareness12. Norms
Safety NetsIf it’s not critical, record it in the journey log book & only sign for what is serviceable.
Refuse to compromise your standards.
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Dirty Dozen- Human Error in Aircraft Maintenance
AggressivePassive
Assertive
Perfo
rman
ce
Assertiveness
AngerOffense
AcquiesceCompromise
OthersRights
YourRights
Both Party’s RightsTeam WorkSynergy
High
Low
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Dirty Dozen- Human Error in Aircraft Maintenance
43Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
44Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
If it’s not critical, record it in the journey log book & only sign for what is serviceable.
Refuse to compromise your standards.
Safety Nets
Lack of Assertiveness
45Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue
7. Lack of Resources8. Pressure9. Lack of Assertiveness
10. Stress11. Lack of Awareness12. Norms
Safety NetsBe aware of how stress can effect your work.
Stop and look rationally at the problem.
Determine a rationalcourse of action andfollow it.
Take time off or at least have a short break.
Discuss it with someone.
Ask fellow workers to monitor your work.
Exercise your body.
46Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
STRESS
47Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
Be aware of how stress can effect your work.
Stop and look rationally at the problem.
Determine a rational course of action and follow it.
Take time off or at least have a short break.
Discuss it with someone.
Ask fellow workers to monitor your work.
Exercise your body.
Safety Nets
Stress
48Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue
7. Lack of Resources8. Pressure9. Lack of Assertiveness
10. Stress11. Lack of Awareness12. Norms
Safety NetsThink of what may occur in the event of an accident.
Check to see if your work will conflict with an existing modificationor repair.
Ask others if they can see any problem with the work done.
49Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
50Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
51Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
52Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
Think of what may occur in the event of an accident.
Check to see if your work will conflict with an existing modification or repair.
Ask others if they can see any problem with the work done.
Safety Nets
Lack of Awareness
53Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue
7. Lack of Resources8. Pressure9. Lack of Assertiveness
10. Stress11. Lack of Awareness12. Norms
Safety NetsAlways work as per the instructions or have the instructions changed.
Be aware that ‘norms don’t make it right.
54Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
This picture was taken by an amateur photographer seconds before an American Airlines DC-10 crashed at Chicago O'Hare Airport, after losing an engine during takeoff. Below is the resulting explosion. Improper maintenance procedures was to blame. Two-hundred-seventy-one people aboard were killed as well as 2 on the ground. (May 25, 1979)
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Dirty Dozen- Human Error in Aircraft Maintenance
Always work as per the instructions or have the instructions changed.
Be aware that ‘norms don’t make it right.
Safety Nets
Norms
56Federal AviationAdministration
Dirty Dozen- Human Error in Aircraft Maintenance
FATIGUE STRESS COMPLACENCY COMMUNICATION AWARENESS DISTRACTION LACK OF KNOWLEDGE TEAMWORK LACK OF RESOURCES PRESSURE LACK OF
ASSERTIVENESS NORMSLee Marvin, Ernest Borgnine, Jim Brown, Charles Bronson, John Cassavetes, Trini Lopez, Telly Savalas, Donald Sutherland, Clint Walker
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Dirty Dozen- Human Error in Aircraft Maintenance
Face Reality
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Dirty Dozen- Human Error in Aircraft Maintenance
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