Human Factors in

Aviation Maintenance
Dennis A. Vincenzi, Ph.D.
ERAU Worldwide

Overview
Aircraft Accidents and Aviation Maintenance
Brief History of HF in Aviation Maintenance
The PEAR (People, Environment, Actions, and
Resources) Model
HF in Aviation Maintenance according to the
FAA
The Dirty Dozen of Aviation Maintenance
Examples of Maintenance Related Accidents
Wrap up
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Some Quick Questions

Poll #1:
Are you employed in the aviation maintenance
field in some capacity?

Poll #2:
If you are employed in the aviation maintenance
field, what is your job, position, or function?
Poll #3:
If you are employed in the aviation maintenance
field, do you work for an MRO?
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Aircraft Accidents
80% of aircraft accidents are related to
human factors
15% to 18% of aircraft accidents are
associated with some sort of maintenance
related issue
Cost?
Time
Money
Company Reputation
Human Lives
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Human
Factors Defined
The scientific discipline concerned with the
understanding of interactions among
humans and other elements of a system.
The overarching goal of Human Factors is to
optimize human well-being (safety) and
overall system performance (the
relationship between the human and
machine).
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Human Performance
Humans cannot perform well
under adverse conditions
Proper lighting, temperature,
rest to perform well
Proper training to be able to
perform the work
Proper work environment that
promotes safety and
compliance with rules,
regulations, and policies
Proper company culture is
essential
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Brief History of HF
in Aviation Maintenance
HF in Maintenance is relatively new
Began as a formal interest around 1988

Aloha Flight 243 - April 28, 1988 1 fatality; 65 injured

Most agree that this accident was the beginning of HF in Aviation
Maintenance
Fatigue and corrosion cracks visible by passengers boarding the aircraft
All agree that this accident was preventable

Since Aloha Flight

243
HF in aviation maintenance has resulted in a
number of worthy initiatives that act as
guides and aids in identifying and raising
awareness about sources of human error
The People-Environment-Actions-Resources
(PEAR) Model
HF Operations Manual by the FAA
The Dirty Dozen in Aviation Maintenance
And others
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The PEAR Model

PEAR People, Environment, Actions, and
Resources
People the core of any HF assessment
These are the individuals who
Perform the work
Initiate and support regulation
Initiate and support company policy
Initiate and support proper procedures

People are ultimately responsible for all the

above and must be the focus
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The PEAR Model

People
Physical, Physiological, Psychological, and Psychosocial
aspects of people

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The PEAR Model

Environment
Physical and Organizational aspects of the environment

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The PEAR Model

Actions
Task breakdown of what and who is needed to perform a
task or activity
Cognitive breakdown of what knowledge and skills are
needed to perform a task or activity

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The PEAR Model

Resources
Procedures, tech manuals, equipment training, tools
All the things needed to perform the activity and support
the processes, procedures, policies, and regulations
surrounding that activity
Many of the other components of the PEAR model are
dependent upon available resources

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HF in Aviation Maintenance FAA Style

Human Factors deals with anything that has
an effect on humans
FAA Human Factors Operators Manual

* Adapted from The Operators Manual for Human Factors in Maintenance and Ground Operations, 2014

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Hazard Identification
Hazard
A potential source of harm
Personal injury, equipment damage, and environmental
damage
Reduction in ability to perform a prescribed function
Threats and latent conditions

* Adapted from The Operators Manual for Human Factors in Maintenance and Ground Operations, 2014

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Hazard Identification
Why is it important?
To prevent operational problems
Increase operational safety
One more measure to break the chain of potential latent
events

* Adapted from Shuichi Yoshida 2nd International Quality Symposium, 1989

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Procedure Compliance
Procedures

Designed by humans and intended to be followed

Maintenance, inspection, checklists
Designed to enhance safety and reduce human error
Other procedures may be dependent on policies, and policy
violations can affect how other procedures are followed:
For example
Policy violations on rest requirements for pilots can result
in serious errors, fatigue, complacency, decision making,
etc.
Developing a Just Culture for procedure compliance is
essential in any maintenance environment
Dont just deviate from procedure if you see a better way to
do something, go through the process to get the procedure
looked at and officially approved!
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HF Training
HF Training
Crew Coordination Concepts (Continental Airlines, ~1989) >Maintenance Resource Management (MRM)
Patterned after CRM

Why HF Training is important

Promotes a positive safety culture
Helps identify, recognize, understand and manage human
performance issues related to safety
ROI for HF training it improves performance, safety, and
health/well being
Opportunity to cover/develop new regulations, procedures,
and equipment
Can help mitigate performance related safety issues
through voluntary reporting systems through NASA and FAA
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Fatigue and Risk

Management (FRM)
Fatigue is a crippling factor
Fatigue can occur as a result of one long event (awake for 16 or 20
hours) or over a period of weeks or months of sleep deprivation (4
hours per night instead of 8 hours per night)

Results in

Impaired judgement
Impaired communication skills
Decreased attention and information recall
Slower reaction times
Increased risk taking
Poor overall performance!

FRM enables maintenance organizations to:

Detect and identify fatigue symptoms and hazards

Assess associated safety and health risks
Implement fatigue countermeasures
Determine what is effective to mitigate fatigue
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HF Health and Safety

Program
Concerned with long term health and safety
LMEC Latent Medical or Environmental Conditions
Physiological limitations experienced by the AMT that originates from
abnormal medical conditions, normal aging, and occupational
exposures
Detrimental effects of operating equipment
Deleterious effects of aging
Detrimental effects of occupational exposure to aircraft, equipment, and
environment

Why HF Health and Safety Programs are Important

AMTs have a non-fatal occupational injury rate almost double that of
general industry
Older workers (55 and older) represent a growing percentage of the
workforce
Aging workforce implies changes to vision, hearing, strength and overall
health
27.7% of U.S. workers are considered obese
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The Dirty Dozen for

Aviation Maintenance?
Human Factors deals with anything that affects
humans
The key to effectively dealing with aviation
maintenance issues are:
Be aware of the areas of concern
Minimize human error
1.Lack of Communication
2.Complacency
3.Lack of Knowledge
4.Distraction
5.Lack of Teamwork
6.Fatigue
7.Lack of Resources
8.Pressure
9.Lack of Assertiveness
10.Stress
11.Lack of Awareness
12.Norms

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The Dirty Dozen for

Aviation Maintenance
Examples
Lack of Communication
Shift work, handoffs, brief/debrief of work in progress
I guess the day shift can finish this job

Complacency
Expect to find problems, never sign for anything you didnt
personally do or inspect
Ive looked back there 1000 times and never found anything wrong!
Thats the way weve always done it!

Distraction
Always finish a job whenever possible; mark and document
uncompleted work
Have someone else double inspect and recheck yourself, use
a detailed check sheet
Hey! Your water heater broke and its going to cost $1200 to fix. Your
wife wants you to call the plumber now!
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Examples of Maintenance Related Accidents?

Just a few examples
American Airlines Flight 191 May 25, 1979
Aloha Flight 243 April 23, 1988
United Airlines Flight 232 July 19, 1989
British Airways Flight 5390 June 10, 1990

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American Airlines
Flight 191
American airlines flight 191 May 25, 1979
MD DC 10
Fatalities: 258 passengers; 13 crew members; 2
people on the ground
Engine separated from the aircraft and severed
hydraulic lines due to flange and pylon damage
during maintenance.
Damage caused partially by a faulty maintenance
procedure which was ultimately banned
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American Airlines
Flight 191
Aircraft was serviced just 8 weeks prior
Custom procedure for removing engine using
forklift was used instead of following procedure
outlined in manuals saved over 200 man hours!
Shift change occurred during procedure causing
engine to remain on forklift for hours
Flange bolted to pylon was damaged and not
noticed.
Resulted in engine separation 8 weeks later.
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Aloha Flight 243

Aloha Flight 243 April 28, 1988
1 fatality; 65 injured
Aircraft certified for 70,000 compression/decompression cycles
but had already far exceeded that number (~89,000 to date)
Metal fatigue with heavy corrosion
Debonding due to salt and humid operating environment

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Aloha Flight 243

Other causes?

Poor company policy on aircraft maintenance?

Maintainer/inspector fatigue?
Poor maintenance records?
Inspections done at random intervals in poor working conditions (low
light, artificial lighting)?
Result were poor inspections and errors detecting noticeable
debonding and fatigue cracks in numerous areas.

Alternative theory Fluid Hammer Theory

Plane was designed to break up in 10 inch sections creating safety

valve for controlled pressure release at high altitudes
Flight attendant who was sucked out of plane blocked that 10 inch
section causing a Fluid Hammer which caused enough pressure to
blow the top of the aircraft off ( which was weak from fatigue cracks
and debonding)
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United Airlines
Flight 232

United Airlines Flight 232 July 19, 1989

Another DC 10
111 fatalities; 185 survivors
This accident cause was greatly overshadowed by the
exemplary CRM exhibited by the crew in controlling
this aircraft with only engine thrust
Maintenance aspect of this accident is rarely discussed
when talking about this accident in HF circles

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United Airlines
Flight 232

Probable cause: inadequate consideration given to human factors

limitations in the inspection and quality control procedures
Failure to detect a fatigue crack originating from a previously undetected
metallurgical defect located in a critical area of the stage 1 fan disk
It is believe that the crack was originally due to a manufacturing defect
and was extremely small and not detectable to the human eye
Over time, the crack grew
Prior to this accident, the size of the crack was roughly 13mm in length
Very detectable to the human eye but was missed due to human error
Maintenance personnel complied with procedures but simply did not
detect the crack
Inspection procedures were updated in accordance with stricter HF
principles (more regular inspections, better lighting, etc.)

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British Airways
Flight 5390
British Airways Flight 5390 June 10,
1990
No fatalities; pilot suffers frostbite and
broken bones; flight attendant suffers
frostbite
Cockpit window blows out during
flight/pilot almost ejected out of the
cockpit
Cause: Improperly installed windscreen
using incorrect bolts
Windscreen has since been redesigned
so it cannot blow out.
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British Airways
Flight 5390
Maintenance issues include:

Cold hanger/environment
Insufficient lighting in working environment
Aircraft window was in a difficult to reach location
Failure to check maintenance documentation when
selecting replacement bolts
Complacency - Weve always done it this way!
AMT thought it was proper to use visual inspection
only when selecting replacement bolts.
Design flaw in aircraft where window was secured
from the outside as opposed to being secured from
the inside.
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Questions?

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