AVIATION SAFETY - HISTORY Pre-World War

1487 - Leonardo da Vinci began research in the area - Prior to World War I, the only test of human to
of ANTHROPOMETRICS. machine compatibility was that of trial and
error. If the human functioned with the
Vitruvian Man machine, he was accepted, if not he
was rejected.
- one of his famous drawings

- one of the earliest sources presenting During World War 1

guidelines for anthropometry
- With the onset of World War I (1914–1918).
- study the Flight of Birds. - more sophisticated equipment was being
developed and the inability of personnel to use
• He grasped that humans are too heavy and such systems led to an increased interest in
not strong enough to fly using wings human capability.
simply attached to the arms
Hawthorne Effect
EARLY 1900’s

- Frank and Lillian Gilbreth - motivational factors could significantly

- Reduce human error in medicine influence human performance.
- The Hawthorne effect refers to a type of
Challenge-Response System reactivity in which individuals modify an aspect
of their behavior in response to their awareness
- concept of using call backs when of being observed.
communicating
- Pilots are required to read back instructions or World War 2
clearances given by air traffic control (ATC) to
ensure that the pilot receives the correct - With the onset of World War II (1939–1945), it
instructions and gives ATC an opportunity to was becoming increasingly harder to match
correct if the information is wrong. individuals to pre-existing jobs.
- take into account human limitations and take
advantage of human capabilities.
Early 1900

- Wright Brothers 1947

- Orville and Wilbur Wright were the first to fly a
powered aircraft and also pioneered - Fitts and Jones on the most effective
many human factors considerations. configuration of control knobs to be used in
aircraft flight decks. Much of this research
Between 1901 and 1903 transitioned into other equipment with the aim
of making the controls and displays easier for
- brothers worked with large gliders at Kill Devil the operators to use.
Hills
- Kitty Hawk, North Carolina Post World War 2
- develop the first practical human interactive
controls for aircraft pitch, roll, and yaw. - Post WWII aircrew studies continued to
focus primarily on flight crews, especially
December 17,1903 pilot selection, simulator training, and
cockpit layout and design.
- they made four controlled powered flights over
the dunes at Kitty Hawk with their Wright Flyer. Vietnam War
- Subsequent studies of the technician focused
United States and Europe during 1908-1909 on his or her individual competency, and
included equipment design (ergonomics)
- developed practical in-flight control of engine “Zero Defects”
power, plus an angle of attack sensor and stick - quality programs in maintenance and
pusher that reduced pilot workload. manufacturing. Generally, this had a positive
- wakened the world to the new age of effect.
controlled flight. - Zero Defects is a management tool aimed at
the reduction of defects through
Orville prevention.

1990
- was the first aviator to use a seat belt and also
- As human factors awareness progressed, a
introduced a rudder boost/ trim control that
“culture change” occurred in U.S. carriers in
gave the pilot greater control authority.
the 1990s.
- new strategy, policy, and values emerged.
Virtually all of these involved communication
and collaboration.
Today Research

- Human factors has gone a long way. Airline - optimized by incorporating the many disciplines
operations are now much safer than it was that affect human factors in an effort to
before as airlines and maintenance providers understand how people can work more
focuses on safety. Strict safety guidelines are efficiently and maintain work performance.
now being implemented, safety trainings are
being required and provided to personnel to
ensure proper safety standards are being met.
CLINICAL PSYCHOLOGY
Crackdown Programs
- includes the study and application of
- behavior control is based upon fear and psychology for the purpose of understanding,
punishment, which creates a problem. preventing, and relieving psychologically-
Errors are driven into hiding, and then based distress or dysfunction and to promote
become apparent later, usually at a more subjective well-being and personal
critical time (“Murphy’s Law”). development.
- Clinical psychology in laymans term it is the
study of mental disorders. It is about
Foolproof Equipment’s learning, understanding, diagnosing, treating
or preventing these types of illnesses.
- designs were added to the zero-defect
manufacturing goal and began to
find recognition in the maintenance world as
well. Subsequent efforts focused on effects of EXPERIMENTAL PSYCHOLOGY
positive rather than negative motivators.
- includes the study of a variety of basic
behavioral processes, often in a laboratory
HUMAN FACTOR
environment. These processes may include
learning, sensation, perception, human
- The study of human factors is about performance, motivation, memory, language,
understanding human behavior and thinking, and communication, as well as the
performance. physiological processes underlying behaviors,
such as eating, reading, and problem solving.
- concerned with optimizing performance - with the study of emotional and mental
including reducing errors so that the highest activity
level of safety is achieved and maintained. - concerned with testing theories of human
thoughts, feelings, actions, and beyond –
any aspect of being human that involves the
Importance of Human Factors mind.
-
- The greatest impact in aircraft safety in the
future will not come from improving the ANTHROPOMETRY
technology
- it will be from educating the employee to - is the study of the dimensions and abilities of
recognize and prevent human error. the human body. This is essential to aviation
maintenance due to the environment and
Human Factors spaces that AMTs have to work with.
- imply the systematic measurement of the
physical properties of the human body.
- The term “human factors” has grown - study the interaction of workers with tasks,
increasingly popular as the commercial tools, machines, vehicles, and personal
aviation industry realizes that human error, protective equipment
rather than mechanical failure, underlies most
aviation accidents and incidents. COMPUTER SCIENCE
- Human factors science or technologies are
multidisciplinary fields incorporating - The technical definition for computer science
contributions from psychology, engineering, is the study of the theoretical foundations
industrial design, statistics, operations of information and computation and of
research, and anthropometry. practical techniques for their
implementation and application in
- computer systems.
Elements of Human Factors - Yet how this relates to aviation maintenance is
simpler to explain. As mentioned earlier, AMTs
• The overall goal of aviation maintenance
spend as much time documenting repairs as
human factors research is to identify and
they do performing them.
optimize the factors that affect human
- It is important that they have computer work
performance in maintenance and inspection.
stations that are comfortable and reliable.
MID
- Computer Science is the study of computers
and computational systems.
COGNITIVE SCIENCE INDUSTRIAL ENGINEERING

- it is simply the study of thought, learning, and - deals with the design, improvement, and
mental organization, which draws on aspects of installation of integrated systems
psychology, linguistics, philosophy, and - is the organized approach to the study of work.
computer modeling. It is important for supervisors to set reasonable
work standards that can be met and exceeded.
- is the interdisciplinary scientific study of minds Unrealistic work standards create unnecessary
as information processors. It includes research stressors that cause mistakes. It is also
on how information is processed (in faculties beneficial to have an efficient facility layout so
such as perception, language, reasoning, and that there is room to work. Clean and
emotion), represented, and transformed in a uncluttered environments enhance work
nervous system or machine. performance.
- Another aspect of industrial engineering that
SAFETY ENGINEERING helps in the understanding of human factors is
the statistical analysis of work performance.
- is a field of engineering that deals with accident - Concrete data of work performance, whether
prevention, reducing the risks associated with good or bad, can show the contributing factors
human error, and deriving safety benefits from that may have been present when the work
engineered systems and designs. was done.
- ensures that a life-critical system behaves as
needed even when the component fails.
Ideally, safety engineers take an early design
of a system, analyze it to find what faults can
occur, and then propose safety requirements in
design specifications up front and changes to
existing systems to make the system safer.

MEDICINE SCIENCE

- is the science and art of healing. It

encompasses a variety of health care practices
evolved to maintain and restore health by the
prevention and treatment of illness.

ORGANIZATIONAL PSYCHOLOGY

- Organizational psychologists are concerned

with relations between people and work. Their
interests include organizational structure and
organizational change, workers’ productivity
and job satisfaction, consumer behavior, and
the selection, placement, training, and
development of personnel.

IN AVIATION:

• helps aviation maintenance supervisors learn

about the points listed below that, if exercised,
can enhance the work environment and
productivity.
• Rewards and compensations for workers with
good safety records.
• Motivation for workers to want to do well and
work safely.
• Unifying work teams and groups so they get
along and work together to get the job done
right.
• Treating all workers equally.

EDUCATIONAL PSYCHOLOGY

- Educational psychologists study how people

learn and design the methods and materials
used to educate people of all ages. Everyone
learns differently and at a different pace.
Supervisors should design blocks of instruction
that relate to a wide variety of learning styles.
- Its goal is to understand how people learn and
retain new information.
DIRTY DOZEN LACK OF KNOWLEDGE

• A lack of knowledge when performing aircraft

• Due to a large number of maintenance-related maintenance can result in a faulty repair that can
aviation accidents and incidents that occurred have catastrophic results.
in the late 1980s and early 1990s, Transport
Canada identified twelve human factors that • Differences in technology from aircraft to aircraft
degrade people’s ability to perform effectively and updates to technology and procedures on a
and safely, which could lead to maintenance single aircraft also make it challenging to obtain
errors. These twelve factors, known as the the knowledge required to perform airworthy
“dirty dozen,” were eventually adopted by the maintenance.
aviation industry as a straightforward means to
discuss human error in maintenance.
TO SOLVE LACK OF KNOWLEDGE

LACK OF COMMUNICATION • Technicians must be sure to use the latest

applicable data and follow each step of the
- between technicians could lead to a procedure as outlined.
maintenance error and result in an aircraft • They must also be aware that differences exist
accident. in the design and maintenance procedures on
- This is especially true during procedures different aircraft.
where more than one technician performs the • It is important for technicians to obtain training
work on the aircraft. on different types of aircraft. When in doubt, a
- It is critical that accurate, complete information technician with experience on the aircraft should
be exchanged to ensure that all work is be consulted.
completed without any step being omitted. • If one is not available, or the consulted
- technician is not familiar with the procedure, a
TO AVOID LACK OF COMMUNICATION manufacturer’s technical representative should
be contacted.
• The approved steps of a maintenance • It is better to delay a maintenance procedure
procedure must be signed off by the technician than to do it incorrectly and cause an accident.
doing the work as it is performed. Continuing a
job that has been started by someone else DISTRACTION
should only occur after a face-to-face meeting
of technicians. • A distraction while performing maintenance on
an aircraft may disrupt the procedure. When
work resumes, it is possible that the technician
COMPLACENCY skips over a detail that needs attention. It is
estimated that 15 percent of maintenance
• is a human factor in aviation maintenance that related errors are caused by distractions.
typically develops over time.
• a sense of self satisfaction and false • Something as simple as a cell phone call or a
confidence may occur. new aircraft being pushed into the hangar can
disrupt the technician’s concentration on a job.
• A repetitive task, especially an inspection item, • Less visible is a difficult family or financial matter
may be overlooked or skipped because the or other personal issues that may occupy the
technician has performed the task a number of technician’s thought process as work is
times without ever finding a fault. performed. This can make performance of the
• When a technician finds him- or herself required maintenance less effective.
performing work without documentation, or
documenting work that was not performed, it is TO AVOID DISTRACTIONS
a sign that complacency may exist
• A good practice is to go back three steps in the
TO AVOID LACK OF COMPLACENCY work procedure from when distraction occurred
and resume the job from that point. Using of a
detailed step-by-step written procedure and
• To combat complacency, a technician must signing off each step only after it is
be trained to expect to find the fault that completed also helps.
created the inspection item in the first
place. He or she must stay mentally engaged • Incomplete work can be marked or tagged,
in the task being performed. especially when the technician is pulled from the
• To combat complacency, a technician must work by a distraction, and it is unknown when
be trained to expect to find the fault that work will be resumed and by whom. Disconnect
created the inspection item in the first any connector and leave it plainly visible if an
place. He or she must stay mentally engaged installation is not complete.
in the task being performed.
LACK OF TEAMWORK LACK OF ASSERTIVENESS

• A lack of teamwork makes all jobs more difficult • Assertiveness is the ability to express your
and, in maintenance, could result in a feelings, opinions, beliefs, and needs in a
miscommunication that affects the positive, productive manner and should not be
airworthiness of the aircraft. confused with being aggressive.
• Sharing of knowledge between technicians,
coordinating maintenance functions, turning • When being assertive with co-workers or
work over from shift to shift, and working with management, the problem. deal with one issue
flight personnel to troubleshoot and test aircraft at a time rather than trying to tackle a number of
are all are executed better in an atmosphere of problems at once.
teamwork. 1. Address managers and supervisors directly by
stating When being assertive with co-workers
HOW TO AVOID LACK OF TEAMWORK or management, the problem.
• They communicate and look out for one another
as they do the job because technician primarily Example: “John, I have a concern with how this
deals with the physical aspect of the aircraft and repair documentation and facts to back up your
its airworthiness. argument, which can is being rushed.”

• Teamwork involves everyone understanding

and agreeing on actions to be taken. 2. Explain what the consequences will be. A lack
of assertiveness in failing to speak up when
FATIGUE things.

• Fatigue is a major human factor that has

contributed to many maintenance errors Example: “If we continue, the result will be that the
resulting in accidents. do not seem right has resulted in many fatal
accidents. This part will break sooner rather than
• Fatigue can be mental or physical in nature. later.”
Emotional fatigue also exists and affects mental
and physical performance.
STRESS
• A person is said to be fatigued when a reduction
or impairment in any of the following occurs: • Aviation maintenance is a stressful task due to
cognitive ability, decision-making, reaction time, many factors
coordination, speed, strength, or balance.
• Everyone handles stress differently and
particular situations can bring about different
LACK OF RESOURCES degrees of difficulty for different.

• A lack of resources can interfere with a person’s For example, working under a strict timeline can be a
ability to complete a task because of a lack of stressor for one person and normal for another of stress
supplies and support. are referred to as “stressors” and are categorized as
physical, psychological, or physiological.
• Any lack of resources to safely carry out a
maintenance task can cause both non-fatal and
fatal accidents. • Following is a list of each and how they may
• Parts are not the only resources needed to do a affect maintenance.
job properly, but all too frequently parts become
a critical issue. AMTs can try to be proactive by
checking suspected areas or tasks that may PHYSICAL STRESSORS - add to a person’s workload
require parts at the beginning of the inspection and make his or her work environment uncomfortable.

PRESSURE • NOISE
• TEMPERATURE
• Aviation maintenance tasks require individuals
• LIGHTING
to perform in an environment with constant
pressure to do things better and faster without • CONFINED SPACES
making mistakes and letting things fall through
the cracks. Unfortunately, these types of job
pressures can affect the capabilities of
maintenance workers to get the job done right.
• Airlines have strict financial guidelines, as well
as tight flight schedules, that pressure
mechanics to identify and repair mechanical
problems quickly so that the airline industry can
keep moving.
• Sacrificing quality and safety for the sake of time
should not be tolerated or accepted. Likewise,
AMTs need to recognize on their own when time
pressures are clouding their judgments and
causing them to make unnecessary mistakes.
PSYCHOLOGICAL STRESSORS - relate to emotional HUMAN ERROR
factors, such Work-related stressors as a death or
illness in the family; business worries; poor
interpersonal relationships with family, co-workers, or HUMAN ERROR is the unintentional act of performing
supervisors; and financial worries. a task incorrectly that can potentially degrade the
system. There are three types of human error:
- Psychological stressors are events that cause
experiences of psychological stress. 1. Omission: not performing an act or task.
2. Commission: accomplishing a task incorrectly.
• Work-related stressors
3. Extraneous: performing a task not authorized.
• Financial problems
• Marital problems here are also four consequences of human error:
• Interpersonal problems
1. Little or no effect.
2. Damage to equipment/hardware.
PHYSIOLOGICAL STRESSORS - include fatigue,
poor physical condition, hunger, and diseases. 3. Personal injury.
4. Catastrophic.
- is a particular form of stress which refers to the
consequences of the failure of a human or
animal body to respond appropriately to the Why are human conditions, such as fatigue,
load of a physical reaction.. complacency, and stress, so important in aviation
maintenance?
• Poor physical condition
• Proper meals • These conditions, along with many others, are
• Lack of sleep called human factors.
• Human factors directly cause or contribute to
• Conflicting shift schedules many aviation accidents. It is universally
agreed that 80 percent of maintenance errors
involve human factors.
LACK OF AWARENESS
• If they are not detected, they can cause events,
worker injuries, wasted time, and even
- is defined as a failure to recognize all the of accidents.
time. consequences of an action or lack of
foresight. HUMAN ERROR

- Human error is defined as a human action

• In aviation maintenance, it is not unusual to
with unintended consequences.
perform the same maintenance tasks
- Training, risk assessments, safety inspections,
repeatedly. After completing the same task
etc., should not be restricted to an attempt to
multiple times, it is easy for technicians to
avoid errors but rather to make them visible
become less vigilant and develop a lack of
and identify them before they produce
awareness of what they are doing and what is
damaging and regrettable consequences.
around them. Each time a task is completed it
Simply put, human error is not avoidable but it
must be treated as if it were the first time.
is manageable.
•
• Unintentional
NORMS
- An unintentional error is an accidental
wandering or deviation from accuracy. This can
• Norms is short for “normal,” or the way things are include an error in your action (a slip), opinion,
normally done. or judgment caused by poor reasoning
• They are unwritten rules that are followed or • Intentional
tolerated by most organizations
- In aviation maintenance, an intentional error
• can detract from the established safety standard should really be considered a violation. If
and cause an accident to occur. someone knowingly or intentionally chooses to
do something wrong, it is a violation, which
• Newcomers to the situation are then accepted means that one has purposely deviated from
into the group based on adherence to norms. safe practices, procedures, standards, or
regulations.

• Active and Latent

- An active error is the specific individual activity

that is an obvious event. A latent error is the
company issues that lead up to the event. For
example, an AMT climbs up a ladder to do a
repair knowing that the ladder is broken. In this
example, the active error was falling from the
ladder. The latent error was the broken ladder
that someone should have replaced.
 • The company must match the physical
HUMAN FACTORS characteristics of each person to the tasks each
performs.

- In comparison to many other threats to aviation

safety, the mistakes of an aviation - Physical
maintenance technician (AMT) can be more - Physiological
difficult to detect.
- Often times, these mistakes are present but not - Psychological
visible and have the potential to remain latent, - psychosocial factors.
affecting the safe operation of aircraft for longer
periods of time.
PHYSICAL
AVIATION SAFETY MANAGEMENT SYSTEM
• Strength
• Physical size
• A safety management system in
aviation commonly refers to a set of processes • Sensory limitations
and tools to formally manage a structured safety • Age
program.
• Most aviation service providers have processes
in place to mitigate risk to an acceptable level. In
fact, every operator has a "safety management
system" in place; however, when we refer to an
aviation safety management system, commonly
called SMS, we refer to the formal processes
and methodologies to manage safety.

Aviation SMS programs today are based on ICAO

standards or recommendations

- Guidelines for managing safety programs at a PHYSIOLOGICAL

state level and the individual operator level are
found in the "SMS Bible," ICAO Document
9859. • Learn how to be flexible to different kinds of
psychological stressor and learn how to control
your thoughts and emotions.

ENVIRONMENT
THE PEAR MODEL
• There are at least two environments in aviation
maintenance. There is the physical workplace on
• here are many concepts related to the science the ramp, in the hangar, or in the shop. In
and practice of human factors. However, from a addition, there is the organizational environment
practical standpoint, it is most helpful to have a that exists within the company. A human factors
unified view, or a model of the things we should program must pay attention to both
be concerned about when considering aviation environments.
maintenance human factors.
• For more than a decade, the term “PEAR” has
been used as a memory jogger, or mnemonic, to PHYSICAL
characterize human factors in aviation
• The physical environment is obvious. It includes
maintenance. The PEAR mode prompts recall of
ranges of temperature, humidity, lighting, noise
the four important considerations for human
control, cleanliness, and workplace design.
factors programs, which are listed below.

• People who do the job. ORGANIZATIONAL

• Environment in which they work. • The second, less tangible, environment is the
organizational one. The important factors in an
• Actions they perform. organizational environment are typically related
to cooperation, communication, shared values,
• Resources necessary to complete the job. mutual respect, and the culture of the company.

PEOPLE

• People Aviation maintenance human factors

programs focus on the people who perform the
work and address.
• The programs must focus on individuals, their
physical capabilities, and the factors that affect
them.
ACTIONS

• Successful human factors programs carefully

analyze all the actions people must perform to
complete a job efficiently and safely. Job task
analysis (JTA) is the standard human factors
approach to identify the knowledge, skills, and
attitudes necessary to perform each task in a
given job.
• JTA helps ensure each worker is properly
trained and each workplace has the necessary
equipment and other resources to perform the
job.

RESOURCES

• In general, the characteristics of the people,

environment, and actions dictate the resources.
Many resources are tangible, such as lifts, tools,
test equipment, computers, technical manuals,
and so forth. Other resources are less tangible.

• Examples include the number and qualifications

of staff to complete a job, the amount of time
allocated, and the level of communication
among the crew, supervisors, vendors, and
others.

• A resource is anything a technician (or anyone

else) needs to get the job done. For example,
protective clothing is a resource. A mobile
phone can be a resource. Rivets can be
resources. What is important to the “Resource”
element in PEAR is focusing on identifying the
need for additional resources.