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Human Error in Maintenance

Presented by:

Alabama & Northwest Florida Flight


Standards District Office

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Section Objectives
After you complete this section you will be
able to:
Define two different types of human error.
Explain why people commit errors.
Explain how human error affects AMT.
Name the types of error prevention.

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Defining Human Error


Example: John drives into standing water and begins
to hydroplane.
1. Slip Having a good plan, but bad execution.

Ex: John knows he should pump his brakes, but


misses the brake and steps on the gas instead

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Defining Human Error


2. Mistake A bad plan is performed, though
not on purpose.
Ex: John thinks that speeding up will give
control over his car. He steps on the gas.

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Defining Human Error


3. Violation The wrong procedure is
performed intentionally.
Ex: John learned in drivers education class
that he should pump his brakes in this
situation. However, John heard from his
older brother that acceleration is best, so
he steps on the gas.
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Error and Aviation Maintenance


This section describes how human error
affects the aviation community, aviation
maintenance and more specifically the
AMT.

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Valuejet flight 597

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Machine/Human Causes for


Accidents.
Airline safety has improved over the past 40
years because of:
better aircraft.
better air traffic control.
better weather prediction.

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Machine/Human Causes for


Accidents.
Human error defined
by red line.
Machine error defined
by yellow line.

120
100
80
60
40
20
0
1850

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1900

1950 2000

2050

Human Error Estimates*.


System

% Due to Human Error

Airlines

70-80%

Air Traffic Control

90%

Ships

80%

Process Control

80%

Nuclear Power

70%

Road Transportation

85%
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Table of Aviation Accident


Causal Factors.
Causal Factors (1982- No. of
Onboard Fatalities
1991)
Accidents
Controlled Flight into
Terrain (CFIT)

36

2169

Maintenance and
Inspection

47

1481

Loss of
Control/Uncontrolled

1387

Air Traffic Control

39

1000

Approach and Landing


(NO CFIT)

133

910

610

In-flight smoke and


fire

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Table of Aviation Accident


Causal Factors.
Ground Deicing/Anti-icing

384

Wind shear

10

381

Un-contained Engine Fire

11

199

Out of Configuration Takeoff

11

188

Airport Ground Ops.


Control

23

138

Rejected Take-off

19

53

TOTAL

394

9639

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Introduction to Human Error


For want of a nail, the shoe was lost,
for want of a shoe, the horse was lost,
for want of a horse, the rider was lost,
for want of a rider, the battle was
lost
--Benjamin Franklin-Downloaded from www.avhf.com

Heinrich Ratio
Heinrich Ratio
Fatal Accident

Non-Fatal Accident

10

Reportable Incident

30

Unsafe Acts

600
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Active and Latent Errors


There are two basic kinds of human errors:
active errors and latent errors.*
Active Error An action that has an
immediate effect.
Latent Error An action that has a delayed
effect
*Reason, J. (1990). Human Error, Cambridge, UK: Cambridge Press.

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Active and Latent Errors


Active errors Actions that have immediate
effect. People are most familiar with active
errors. An example of an active error would
be a pilot believing his aircraft to be much
higher than it really is and failing to adjust
his altitude accordingly. This error leads to
the plane crashing into a mountainside, an
effect that is felt more or less immediately
in the system.
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Active and Latent Errors.


Latent errors Actions that have delayed effect.
Latent errors, on the other hand, are errors whose
effects are delayed in time and space and may not be
felt immediately. An example would be an AMT
neglecting to check a key bolt supporting an engine to
a wing. This bolt happens to be corroded. Over time,
the engine support weakens and fails altogether. Had
the AMT not committed the latent error of neglect,
the corroded bolt would have been replaced and the
support would not have been compromised.

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Active and Latent Errors


Because of the time delay between error and
consequence, latent errors and their causes
are much more difficult to trace than are
active errors.

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Human Error in Maintenance


The average cost of an in-flight engine shutdown is
$500,000.
The average cost of a flight cancellation is $50,000.
The average cost of a return to gate is $15,000.
The Airline Transport Association estimates that ground
damage costs $850 million/year.
The average ground damage incident costs $70,000.
One Airline estimates between $75-$100 million/year is
wasted on error

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A Hangar example

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Example: Resulting Damage

Left-hand horizontal stabilizer.


Rudder.
Rear dock stands.
Hangar wall.

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Example: Cost Factors

Material
Regular and overtime labor.
Repair to dock stands and hangar wall.
Loss of bay during extra repair duration.
Delayed or third party maintenance for other aircraft.
Operational complications due to aircraft availability.
Investigation and remediation.
Estimated total cost = $900,000.

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Example: Cost Implications

Annual airline revenue = $12,000,000,000.


Revenue/day = $33,000,000.
Estimated profit margin = 5%
Profit per day = $1,650,000
Total repair/associated costs = $900,000.
Summary: Error Consumed day of total
profit!
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Top Seven Causes of In-Flight


Shutdowns
1.
2.
3.
4.
5.
6.
7.

Incomplete installation (33%).


Damage on installation (14.5%).
Improper installation (11%).
Equipment not installed or missing (11%).
Foreign object damage (6.5%).
Improper troubleshooting, inspection, test (6%).
Equipment not activated or deactivated (4%).

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Other Maintenance Related


Causes of In-Flight Shutdowns

Missing parts.
Incorrect parts.
Worn parts.
Careless installation of O-ring.
B-nuts not safety wired.
B-nuts wired backwards.
Nuts not torqued
Over torquing.
Not loosening both ends of connections.
Replacing tube assembly without breaking connections.
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Top Seven Common Maintenance


Errors
1. Incorrect installation of components.
2. The fitting of wrong parts.
3. Electrical wiring discrepancies (including crossconnection).
4. Loose objects (tools, etc.) left in aircraft.
5. Inadequate lubrication.
6. Cowlings, access panels and fairings not secured.
7. Landing gear and refuel panels not secured.

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Why Do We Make Errors?

?
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Mental Limits: Disassembly

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Mental Limits: Reassembly

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Definition of Culture
Culture A pattern of beliefs and
expectations shared by an organization and
its members.

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Culture
What would happen if an air carrier made
on-time departure its number one priority?
How would that affect safety?
Do you think management would give you
the time to service an airplane the right
way?
Do you think you would be pressured?
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Culture

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List of Organizational and Local


Factors.
Organizational

Local

Training and selection of Knowledge and skill of


personnel.
personnel.
Quality of resources as
distributed.

Quality of resources on
hangar floor.

Organizational Structure

Hangar environment.

Opportunities for career


development.

Morale & personalities of


employee.

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A Human Factors Accident


Scenario.
Defenses

Good Management
Reliable Maintenance

Teamwork
Operational pressure
High work load.

Missing component
Mis-judgment by senr. Capt.
Young F/O lets it go
Ambiguous instruction
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(goes unchallenged)

Gaps

Error Prevention
Three Basic Strategies

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Types of Prevention Design


1. Exclusion Design The design of a component
makes it impossible to commit an error.
2. Prevention Design The design of a component
makes it difficult, but not impossible for error.
3. Fail-Safe Design The design of a component
reduces the consequences of errors without
necessarily reducing the likelihood of errors.

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Examples of Prevention Design


1. Exclusion design
2. Prevention design
3. Fail-Safe design

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Conclusion
Flying is not inherently dangerous, but
to an even greater extent than the
sea, it is terribly unforgiving of
carelessness, incapacity, or neglect

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