Beruflich Dokumente
Kultur Dokumente
Presented by:
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.
120
100
80
60
40
20
0
1850
1900
1950 2000
2050
Airlines
70-80%
90%
Ships
80%
Process Control
80%
Nuclear Power
70%
Road Transportation
85%
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36
2169
Maintenance and
Inspection
47
1481
Loss of
Control/Uncontrolled
1387
39
1000
133
910
610
384
Wind shear
10
381
11
199
11
188
23
138
Rejected Take-off
19
53
TOTAL
394
9639
Heinrich Ratio
Heinrich Ratio
Fatal Accident
Non-Fatal Accident
10
Reportable Incident
30
Unsafe Acts
600
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A Hangar example
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.
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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?
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Definition of Culture
Culture A pattern of beliefs and
expectations shared by an organization and
its members.
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
Local
Quality of resources on
hangar floor.
Organizational Structure
Hangar environment.
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
Conclusion
Flying is not inherently dangerous, but
to an even greater extent than the
sea, it is terribly unforgiving of
carelessness, incapacity, or neglect