Module eee ew Le tel ao HUMAN FACTORS Aviation Maintenance Technician Certification Series eee Human Performance and Limitation, SL a od Seas Tasks aoe cd See RdMODULE 09 FOR LEVEL B1 AND B2 CERTIFICATION HUMAN FACTORS Aviation Maintenance Technician Certification Series 72819 US. Hwy 40 “Tabernash, CO 80478-0270 USA wonwactechbooks.com 1970 726-51 $1970 726-5185 raxTre AVIATION MAINTENANCE TECHNICIAN CERTIFICATION SERIES ee eee Contr Jere W Alan MF, MPH = Werking Hey = Amys \ayouDesgn Shot Hat ‘Ausaan Goverment - CM Aton Safty Auroty «Safty Sehawors - ran Factors Peecurce Gude fr Engeors ‘CecupatorlSfety ana Heals Acrineraten (O54) Mta/woaha ‘hrp-memsco-Uk-Lauming rom Esperance 2 Cop © 201 — Areraf Tecra! Book Company. Al Fights Rese, oper ft pbtcaton maybe rerodced tre ina reba estar, waned ay form ory an means, dectone, mechenes, ptotoesnyng. ecorng cr eerie, wut Pe ot ten pein of he pba. Torr books ofr Customer Sence, pease ca +1 970728. Wl.FORWARD PART. 66 andthe Accepable Means of Compliance (AMC) and Guidance Material (GM) ofthe European Aviation Safety Agen (EASA) Regulation (EC) No. 1521/2014, Appeodix 1 tothe Implementing Rules establishes the Basie Koowledge Requirements fr thor seeking an arcraft maintenance license, The information inthis Module ofthe Aviation Maintenance Technical Certction Series published by the Alrcraft Tenia! Book Company ‘meets orexcende the breadth and depth of knowledge subject mar referenced in Appendix! ofthe Implementing [Rulex Hower, he order ofthe material presented is atthe discretion of the editor in an effort to convey the required know in the enst sequential and comprehensible manne. Knowledge levels reuied for Category A, ‘BI B2, B3,andCsircraftmintenance licenses eran unchanged fom thot listed in Appenlix1 Basic Knowledge Requisements, Tables fiom Appendis 1 Basie Knowledge Requirements ae seproduced athe begining ofeach ‘module in the series and again a the beginning ofeach Sab-Module onus re written in this book “This book uses the International Ci Aviation Organization (ICAO) standard of writing mumbers. Tis methods splays large numbers byadnga space between each group ofS digs. This is opposed tothe American method ‘which wes commas and the Buropean method which uses periods For example, the umber ne milion is expressed ICAO Standird 1000000, European Sundard 1.000.000, ‘Amerisn Sedard 1,000,000 Unite: “The Imenatonal Sytem of Units (SD developed and maintained by the General Conftence of Weights and ‘Measures (CGPM) shall be wed athe standaed system of units of measurement forall aspecs of international vl tiation sr and ground operations Preis “The prefnes and symbol listed inthe table below shal be used wo form names and symbols ofthe decimal maliples nd ubmliples of International Sytem of Uais SI) unis Vomomemece ci! eT Tomemens <0 ge Yomoeco sit mM ee 0 110" he 0210 den orootootbotsomect “30 ee tn tm tb PatWELCOME ‘The publishes of this Aviation Maintenance Technician Certication Series welcome you t the work of vation maimenance. Asyou move towaads EASA certification, you are required to gain utable knowledge and ‘xperence in your chosen ares. Qualifation on base subject foreach aircraft mainencnce license category or subetegryisaccomplished in accoalance with the flowing mati, Where applicable, sibjectsae indicted by an "X" inthe column below the liens heading. For other edveational tools rented o prepare candidate fr license, const Aicaft Technical Book Company. ‘We wish you good hck and success in your studies and in your aviation cae! EASA LICENSE CATEGORY CHART a 4 eee a TA Mantes Pte 8 ie eo on | a Fosse 50 son on [ “uns enon Asaerance Scie a ns Renae so2yames Suse Sme pa hoya Stes nd SensPREFACE “This module ncdes an examination ofthe dsipline known as Human Factors, In many senses a¢ human ere is ced a the primary case of alos al aviation incidents and acidnt, this subject may be eonsieved the most important of oar entre dy Interpersonal communications, a shared sense of «company culture, anda good tndertanding of personal and workplace sess ae absoltely crit to aviation safety fr you, your eames, ‘and the tens of thousands of people who will y inthe sree you maintain. The other asec of human factors it your own personal safety. Your eduction, experience, and profesional goals will mean lite if struck down by an Injury oc other waplae haatd, While this module covers each of these arpets and mort most empotant to ‘understand that human fctors not jst something to lear and tet fr during couple of wks in class. eis a way fie afesing everything you do snd every day you do it. Learing to incorporate these concpsin your day-to-day ‘wrk will ensues long, ewding and ccs profesional career. Mada 09 Sylabus a tine in PART: 65, Append CERTIFICATION CATEGORY ~+ Sub-Module 0 - General “The ned to uke human fictors int account, Tncdensserbtabl o human fctor/tumas exo, Murp/s Law Sub-Modile 02 - Human Performance and Limitations Visions Hesrings Information proceasig: Amtnton and pscepcion; Memory, Clauropobi Physica acces. ‘Sub-Madile 03 ~ Social Peychology t Responsibility, Indie ad group, 9) oO; “Motivation ad demsivaton; Peer Pressure; Clare sme, “Team working: “Management ropervsion and leadenhip Sub-Modile 04 - Factors Affecting Performance Fines and helt; 2) Sees: domestic aa weak related; ‘Time pestureand deadlines, ‘Workload: weoad and underoad, Seep and fatigue, shifework, Alcohol, meicton, drag abeLEVELS CERTIFICATION CATEGORY A B1 B2 Sub-Modul 05 - Physi Environment Nove sd fumes, ‘Wumination; 7 1 u Climate nd Teper Min sad Viates Wosg Boonen Sub-Module 06~ Tasks Physical work, Repetitive Tasks 1) et Visual inepection; CCompler systems, Sub-Module 07 - Comma ‘Within and between teams, Work logging snd cording, 2782 2 Keeping up dae; Currency, Dissemination of information. ‘Sub-Module 08 - Human Error Error modes and theories, “yps of evorin unten tasks, 1a 2 Impliations of ers (ie accident); Avoiding and managing ere. Sub- Module 09 - Hazards in the Workplace Recogoizing and avoiding bara, Dealing with Emergencies, JR 2REVISION LOG aon 201601 ACKNOWLEDGMENTS 1 James W. All, ME, MPH —Woeking Healthy ~ Alaye 2 “Assan Goverment ii Aviation Saery “Authority ~ Safty Behaviors ~ Human Faetrs- Resource Gale fr Engines 2 Federal Avan Admiaiston~Dt Wiis B. Johan (FAA) + Ocepatinal Say snd Heath Adminiain (OSHA) kerpetirwosba gor Seb-Modale01~ General Laan Medel and Eevionmentl Conditions (LMEC) 2 797-300 accident > PEAR ‘Seb Mdule 2 ~ Human Performance and Limitations 1 ging Eye Symptoms 2 Hearing Protection Hearing Low Sais 2 afoation Procing 2 Memory (Case Study Taking It Foe Grated ~ 2 Teanwork 2 What Lenderap I Not 2 Leadeip Under Sires 2 Conse he Following Scnaio 2 Se: Dometic od Work Related 2) Worked ~ Ove’ and Under oad Madile Craton and Rel 2 Sep and Fatigue 2 Alcohol, Medication, Dag Abst Sub-Modale05~ Physi Environment 1 Famer, Chemical Tae Mead Solvents 2 Climate od Tempertre Sub-Madul 06~Tasks TLackof Resourses. Nota rol ~CASA Sub-Module07~ Communication 2” Commanicaion Chane 2 Wilkin and erwsen Teme 2 An Acsden Reed wo Shift Handover = CASA 2 Four Ways to Improve Shift Handover CASA 2 fei and Inet Hendoes CASA. Seb-ModaleO-Haman Eror ¥ ateduton 2 MheDiry Doon 2 Ayeig ond Managing Ere 3 PEAR 2 Typetof Boom +” Recogriaing and Avoiding HazadsHUMAN FACTORS. Wet. Forward —— Revision Log. Ackaoledgens| a Cae een a ‘SUB-MODULE 01 GENERAL Kosledge Regret neem a Genel ua “henwed wo tke Homan Fooorrnt aceunt 12 ‘ThePEAR motel ofan cto in maintenance 14 People The hare ad the inert Beet Pep 18 Environment Physic and opiiatinal 2.6 Action: Procedures, paperoiand POO nnn Routes A lack of or delet w “Te orginal environment oar ‘Te Diny Dosen moar hein elite Human Facto. ue (Case uly Aloha Anes Fight 25. rr “nverigetion cas Safty Recommendation 1 Some of "The Dirty Doze" Haman Factors pci thie up (Case Sy Bash Ainge BACT Winaeen Blow. ae 10 ioe ee = 140 Sify Resoimendatons nn ua Some of "The Dirty Done Hlman acer pci thi accent ut (Case Sy Nowe Wheel Janae on DASHES. Trveiation - Sone of The Dey Does Hlarn Pacts specie iaecdene a 12 ‘Case Sta Fate Presi After Ovtlow Ve Latin Open Posie ewes 143 Tovergaion “an Snfy Recommendations as Some of The Diy Does? Haman Facts apse thi ade 1M ose Sad Main Wheel acon Ftol on 138 Neg nnn =a CONTENTS Say Resend ennnnenenen 14S Some of The Dity Doses? Hyman Pcs specie tthe acident 15 (Case Say Tach et in ose wie etn en £08 nr com MS Tverignionand Recomininons ve 16 Some The Dity Dozen? Human Factors peer thitacident 216 Marple Law. uw Qyetoat 19 nome ness a ‘SUB-MODULE 02 HUMAN PERFORMANCE AND LIMITATIONS Koowlelge Reguirements ey Inet aa a = 22 “The Base Faction fhe Eye 22 Components ofthe Eyer ns 22 “The Caen mn 22 ‘Deldsand Pag Tees 2 23 Te Retin 23 Fics Acting Cty of Sight 23 ‘Blind Spor 23 RefactveEirrt nnmrnns 24 ter ial problems inde maa Fg Sabet nn 25 nvionmenal Fete O35 ‘he Narre of the Ober Beng Viewed soneos 28 Colo Visa 25 Nigh Visa and Calor Lowe 26 Vision and he Aging Byer = 26 What ane ne? 27 Hearing. oe een ay “The Base Putin ofthe Es : 28 et BaF on 28 Mile Ear on 28 Toner Bar . 28 Pfomanee snd Limitation oe Eat 28 Inpsctof Noe 09 Perms: ns 29 High and Low Tone Dest 29 Heng Ptetioa nn aay) Hing Loe Sides mn 20 Infurmtin Posing an Tafertion Processing Model nnn 2CONTENTS Stge 1: Gathering infrmation ewes 211 Athted and undertoad gpa manne 30 Suge 2 Perception crasesment.-n 2.12 fletiveledeeip nd fone. aan Suge: Erato od decion making.---- 212 —_Ashured memal node ~ sat Saget Atowespone vewinnnueenne 232 Pree Clear and BsctveCommunicaon =. 311 Suge 5: Feedback COL 217 Clear deption& Rae defatio, saa Astetion xo Pescpion OT 213 Charopeting proces. coo 2 ‘AEA nn 233 Appropiaealloson of werd a2 a 2b Appropine ater geadenn a ‘Examples ofthe prepa process = 2.4 Coie elton cee as — 216 Keyes a3 oo 237 Mangement, Soperion and Leneip = 3.4 a 238 The Managenene Role = si The Supervoory Roe eee ical emer: ndlg au Avett oon 220 Chanter ofa Good Lei su What ise ethip nnn SS ‘SUB-MODULE 03 i sas ‘SOCIAL PSYCHOLOGY Reinforcing God Ards and Behavior 315 Keowldge Requirements 3 Demonstrating hy Example ans 315 Intron enn 32 ‘Mainsning the Grp. ~ 3s Respontiliy oer) Fling Management Ble nm 325 Tilda! Response 32 What debi nnn bas Cae Sead Taking Fo Grane. 33 Lendercipunderres, 36 Key Lemons ms 33 Cone the following ena. 38 Key Poi IEEE 33 Coehon ae 316 Grp oe Teas Rerponaiy SO 3A Quenione = 7) Tntergraup Coalce OT 34 Anos = a8 Grp Polson Groupie a4 Socal Loong. 34 SUB-MODULE 04 Mosiation and Demottion 35. FACTORS AFFECTING PERFORMANCE Moevation 35° Koowldge Reguements 4a Reva and Pusher: Esc on Bcavor 38. Inueduetoa a 42 Mass Heaths of Neti wenn 36 Fheseand Heath a Dentin 36 Preempleyment Physical a Pee Prot ~ 7 Day Dayne and Hench 42 Experinent lust coor Postve Meteo a (Arh 951) 58 Stes: Domestic nd Work Reb 43 Cur od Safety Care eee 43 How does the opainsona cure Chance of Se 43 aft the monk ol 9 AMT? nnn 39 Stress Cumulative — 43 “Theinfuence of opinions cukureon afey— 39 Cases ofS enn 43 Rolin developing thecal of fy S10 Steen a How do you rsogize anonganization Syec fBate nnnne nee with 0d sy Fn Contoaenes foe ANT ' “a Tea ne Dometic Sees nnn Chance of ea = ‘Work Reed Stee aa Canons eect exe Managing Stes nn 45CONTENTS Sees Coping Steg 45 Conroe. nnn 421 “Achieving eration ee AS Cala 42 How stewed ae yo? 46 Brea 42 ‘Tine Pree and Dealings ons Prev retitog nnn ABR ‘Time protean slfimposed presen AT Key Pea TT an How can nape acta or selfimpoedprestore Shift Wodk 225 bemanaged mene AT Adrntges and Disuranages of Sit Week» 423, Sues and time posure in shiftand taskhandovers 48 Raling Sift Patera encnnnscwrnnns 423 ‘Managing Shit andes nnwnenere 48 Sep aig, Shift Work a he Key Pt a cece Workoeé—Ovekad sd Une 49° Akio, Mediation, Dag Abuse 424 Factors emising wots AB Alber 44 Work oveoad What loa no 424 Cases fhigh workod Aleool ad Safe aa rey (Cae Sly Share Handed vn ‘Alene an Sep mon 425 Work Undid Disurance of prada REM) Step and Fatigoe — . eee eo ‘What gu e Daytime rperesions of anls “The eerie ects on sleep, “Tink stou i ‘Alabl na Areation = Cone thee wo iagnay eerie ccs 413 What would 00d necro SEE Lerner 19 Drv Co Seete nnn 4n | Whnuadup. 47 Memory Sires, coms 418 Howare dag sie? nnn a7 ikmomariinepdie 4 | Lapin, ae) se Stal 410 Tegal dns z an ‘Aree the bet ages of ur Ceca ner 86 ar dere of ig "Hw do drags aft papel 48 “he Input of fague inthe workplace. 4M Some ito comidr ines nn nes 428 “Dae Cases Of Paigue eennennnnenns 45 Lega Drg~ Preston a Slap Debtenncnnnnnnnnnnnns 415 Overthe Counter. pence 429 Sep Apnea. inne $6 Key Poe a ae ‘Wher sees dt nnn 406 Concasn oS a0 Crcadan Ries. oe AMP Qpetons cnn = ai Do shift worker ada operon Aniwes : E a ight thit snc ABT Beate the WOCL! rons 4a7 SUB-MODULE 05 ‘Fico ht nce tempat of igue.--- 418 PHYSICAL ENVIRONMENT Case Stay enn AB Kaede Reames en ve SA ‘Manag the is of aie in Tawodvetion 52 ition mains — 419 Noise and Pomer a Sep incr (AKA rp drennee”) = 49 Nae ome ea Responsibilities of the employees 420 Preeti Your Hearing nnn ome ea) Responbii ofthe emgage 420 ——“Krowyourwrk envionment = Sate te death gue acne 420 Select Appoprie Hearing Paton Devices 5.2 ‘Germore se! cv 420 Fumes, Chanel Tare Meals 1nd Sent anae 53 ‘Typelorbenerdecp ns AZ Gane Engine Esha (Caren Monoxide). 53CONTENTS: Kerosene Based Fl a Kerotee ted inc tnd ied i von 53 Toxic Meats. I sa ‘Cadi cosa Beryl sa Preventive scton fr torie mer expome. 54 ae sa Hydric Fie So oeemeees se =a as ‘What asec? oss Skin Conse 56 Eyer and Respiratory yen O56 Preventative ston fr oe metal exponare—- 5.8 Preventive seo frsohent expan 56 eae eee Bee | (Cates Tengen 58 “The Boys Reson Heat 59 Heat Sem and Mac Dace so Wiking inthe Cl) ene S10 Kow Your Tempest, sa Preventing Cald Reid Disorder su Moding an Viton eee ais Wering Enver 513 ‘Whats Sty Cale? nnn 58 Bailing a fey case 53 Sonar 2 su pesos —— 53s ae 516 ‘SUB-MODULE 06 TASKS Keoldge Roque en nennnn a Inrodton — 62 Planing nn ma Planing of ik equpmenand peer = 62 Lac ofeouree nt pole, 62 ‘What would yo de? as 5 Isthisyor peered dation? nnn 63 Key Pointe 63 Physi Woe. mae Repetive Tiss 6s Visa Iepeston 65 Complex Systems 6 yertone 6 eae = ‘SUB-MODULE 07 COMMUNICATION Keowledge Reuienents snnees TE Ineoducton —— 72 ‘What is Common oa 72 Communication chanaele a= a a = a Document . moa [Nonverbal comminicdon. nnn 73 Pry eat 73 ‘Within and Between Team a) Sh Hinder 7 a 75 ‘Aids o Efe Comins Shi Hane nen 75 are To Effective Communion a Shift Handover nen 8 Shift Handover Meetings 76 Wallahouphe aS ania enna "7 Handing vernal © another pion, oy Handing overs fo srbody cml at later age 7 ‘An ache eied shift nde 18 rors prone hit hander 79 ctv and inetve bande 79 Fourtypesof hit andowe 3 Work Logging and Resting 710 ‘Sched Tsk Cais ao [Nonachedle Tsk =n ma Keeping Upt-Date, Caney. mm Distntinatin of nfeemation ma “Tp fingering conmication tnd otlingerore a CConcon = What yu eed ow ne 72 pete ee 713 Aneto a) ‘SUB-MODULE 08 HUMAN ERROR Kaowldge Requirements a Inndoction = : 82 ror Model nd Theres, = a) “The PEAR Mode ~ mas “he Diny Daten nn 8 Pacha Steere anee Additional Mote/Teoris no SHEL Mod ansvsnsonvnnnnnns “Types of Eos in Maines Tasks i eae Slips apie Itenfed Enos ‘Mises RuleBared Minako Koowedge Based Miah nnn Wt en a Excepoml Viton. Inpatient) nn Avoiding and Marging Ears. noe Managenes Sytem (EMS) [sinenanes Evtor Deron Aid (MEDA) “The MEDA Philbeophy nena The MEDA Paces nn Deion Iesignion a Preention Seti conn Fae on ‘Management Rees Implementing MEDA “The benef o€ MEDA (Ce eee Qyestioa nn : Anime wn a ‘SUB-MODULE 09 HAZARDS IN THE WORKPLACE Knowledge Requrenents 7 Tauedtion oon a Wentiying workgace bard Dean with Emergent nnn ‘What isan emexeney? Prpaing foe Baege0 on es Acsiade of Sify The Righe Supls Energency Contacts and Coramanicatoay Responding tax Emagen none ans 816 ais 816 16 7 a7 a7 a7 a 87 aie 20 sai e21 en a2 a2 82s 22 a2 en sas 424 en CONTENTS Posie work rete acide or emergence. Breathing Emergence Rear Breathing and CPR on Cheri Bia nennnronons Head Injury . Hypothermia Spal Lary ‘Stang, Spina Broken Bones Spite ‘Conchson (Other oun ovvnnrcnnn Fist Aid wn Developing ob Hazard Anais fee Risky Take (Ochre Ses. a Alans nnn Acronym Index. Index . 99 39 99 99 930 a0 oa on ona oad on on on 9 aa iSeb-Modste 01 GENERAL Koowldge Reems 24~ General The need ake hana tr int coun Incidents tbl man foam er, ‘Murs Lae (Oh pplicanscldfailarwth nbs element SUB-MODULE 01 HUMAN FACTORS PART-66 SYLLABUS LEVELS comnemonomecon A BI B2 one atta neGENERAL ‘Why are human conditions suchas fst, somplacency, snd tesco important in aviation maitenance? These ‘ondiion, along with many others, are called human factors, Human factors directly cause or contibute to ‘many rition accidents, Is univecaly agreed that at least 80 percent of maintenance related incidents nvohe human factors. If they are aot prevented, and thele ‘causes detected, they can ease injures, wasted ime, and even aides (Figure £1) THE NEED TO TAKE HUMAN FACTORS INTO ACCOUNT Aviation safety relies heavily on maintenance. When itis noe done correctly, i contributes toa significant proportion of acidens snd incidents, Some examples of toaintenance erors may include; parte installed incortetiy missing pars, or necestary check nt being performed. In comparison to many other threats 10 vation safety the mistakes ofan Aviation Maintenance Technician (AMT) can be more difficul to detect. (Often times, these estas are present but not vse snd have the potential to remain latent, afeting the ‘fe operation ofsireraft for lng pecods aftime. AMTs tte confioated witha st of human factors unique within aviation. Often timer, AMT are working in Environmental ‘Conditions Faye 11 Testo Pumas anon ey set eg ery erin zs at Inanecanbeb ora pte cans the evening or early morning hots, in confined spaces, on platforms tha are up high rina variety of adverse temperatre/humidity conditions. The work ean be Physeally strenuous, yee als equting a high degree of statin det Figure 2.2) ro 1.2 At moans he mary tone nd mat ss onBecause ofthe natuce of maintenance tasks, AMTs commonly spend moce time preparing fora task chan scualy carrying it ot. Proper documentation of all ‘maintenance work i a key element, and AMT also ‘ppl spend as much die updating maintenance logs asthe do performing the week, Human factors and how they affect people are very Smportan t aviation maintenance, Such awareness ca lead to improved quality, an environment that nnures continuing worker snd aircraft safety, and amore involved and responsible work force. More specifically, the seduction of even minor error ean provide measurable bene including cost eductons fewer misted deadlines, reduction in work related injuries, eduction of warranty elas, and redaction in more significant events chat canbe teaced back 10 Fae 13 Fasten parton ar Ts Ie is apparent that anticipated or abnormal medical conditions influence the AMTs work. Reduction in vision is signpost of aging tiie anticipated in all AMTs oes the age 50 yeas, Itsompeomisesthe vel Inspection ofrreraft. Obesity ian sbnoemal medical condition that lead to mukiple metabolic changes. I produces behaviocs described bythe Disty Dozen of Fhuman factors. These consequences from normal aging or abaormal medical conditions ae cased ae Latent Medical or Environmental Condtions (LMEC). ‘Within this book the many apects of human fctore sre dicassed in relation to wiation maintenance. (igure 1.5) Tae most common o which are introduced long with ways to mia the dk to sop ther Soca Aevlopng nto a problem,‘THE PEAR MODEL OF HUMAN FACTORS IN MAINTENANCE ‘Human factors can be divided ino four ain topic areas sing the memory rompe PEAR. Applicaton ofthe mnemonic PEAR’ makes tecgaition fof Human Factors (HF) even ease I prompts recall of the four important considerations for HF programs: People who do the job; Environment in which they work; Actions they perfor; Resources neceeary€ Complete the job, The ists within each element aze not txhrusve, but help oguide people oa the human ctor PEAR was developed by Dr Michael Maddox nd Dr Bill Johnson, speifialy with maintenance in mind, san easy wy fr aviation maintenance personnel to identity human fctrs and slate tasks and conditions ‘within the mintnance environment. PEAR hasbeen sed for over a decade by some JAR/ EASA 145-approved organisations and is incladed by the US Federal Aviation Adminbtaion (FAA) in het ‘Maintenance lunan Pastors rsning package Jnfluences that should be considered. ® Poople @ 2 P stands for People (the humans in the system), with all our capabilities and limitation. Ie includes senses such as vision and hearing; phyial characteris such ax strength and reach; ar well scapes such as memory, Communication tls, dession making siperviion and teamwork sil Veadershiplloweshp ec). Environment Poop relitesto the suitability (physical, cognitive and soci ofthe selected personnel fora particulartask Sutaiity rot only coves tech training bt also human factor consberatlons such as fatigue, sts and motivations. It [uldes the review ofthe competeney, supervision silts, briefing needs, lesderhip skis and requirements of individuals agin the eck demands. ‘ane "aan ‘area + seal ees + eons «= asttze + Sry as + eeatece + Peete ett ate + atesie rooie ae + a0 + tp + out come + apn ites + camp = We + hens + nots rte + mnt i ee + ts, stands forthe Environment in which the work s done, nts the pica envionment bx lo the ongaizaton {sel The physical environment includes lighting temperature, abe level and time of di. The oxganiztionl cmvronment covers sues uch at supervision (quality and rato), pressares (Sime, commercial and production et), ‘ngtnization and safety culture and exiting organiztional noes and how these wil affect invidual and team pevormance and che potential for er. The organizational eovzonment also covers the lelership shown andthe ‘flctivnes of management i supporting postive safety behaviors.vaca ama ater + Morante + ate pei + xin + Woe + Soles vimamint + Lig + sax + Dats + rss + Yspe9 + ste + Sint oe represents the Actions people perform. Actions li the requirements of job to help to dently any speci arse ‘tha might inreae the risk of err, such as ambiguous information, oe complex task that need specialist lle and koowedge 7 engi 7 amma and + eptan kangen + trtrgtng + Stason eters + Sigstoners tary + inci narenes eine + Aeeson eos + esa + else sit + oataen pent “The lis ofsesons i ligne with Job Task Analysis (JTA) process which ithe standard human factor approach to identifying th koowledge, sil and atéader necessary t perform each ask na gienjob. The JTA ale help ‘identify what insroctions, preparation and tsk management are necessary. “This may include + Communication requiremens (headsets roquiea?) 1 Accssing/fnding tsk specific information eqused + “The level of supervision and inspection eequted (is + Preparation and ifing rue oa inspection needed?) + Identifying procedures tobe flowed +The eertfcaion and docuentation, inchadig the 1+ Are those procedures learn ey flo? complesty or userfrendly natore ofthe aicrae + Taskoompletyandapplicasonofukllandlnowledge maintenance documentation, Ais forthe Resources necesry o perform the wok. Resources ave she broadest component of PEAR, They can be defined as anything thatthe maintenance technician needs to get the job done. Resources details both the tangible tems required and avalable, sucha personal, spe, echnical mansal ooling, sd personnel protective equipment (PPE) aswel ar les tangible (ba equally importa) lente sac as tine and raining availability, ~ Prcnercne ia ane Pee + Tete se + coma + soot + Grunt hangeupmert + Woks ins ace + tet pan ae nen ity ss + Prato Ean + poworteetosige + cngace + Sten siterods + teens Ment + spa sionsTime and personnel should be the frst resources considered as they ae cial othe planning proces any job, Animportant resources elemenieficusing on identilying the ares where resources ae deen inching ‘Design ork taney, ole te + Applian eg aval, ascerte procedures) ‘Where adiional resoures ne, sonnel tuning, lighting, PPE snd easumable) are equi PEAR APPLIED TO MAINTENANCE People: The buman and tbe interactions between people “The part of PEAR dealing with interactions between humans is pariculryiemportane in matenance Included are normal human cxpailies and Limitations in this part the unaided human ee i ei the main tool for inspections, yt the imitations of ou vision tystem sometimes lead to defects being missed. We felyon short teen memory each time we hive © pay tntnton to problem for more than afew seconds, yet the limits of oar memory help explain why dstetons tnd interruption can be #9 dangerous. God decision ‘haking ian important safey net in aviation, yet we tre more likely to make poor decisions when under time pressure or ste, A ‘an do atitade normaly 2 poe characters, butin maintenance ifwe atempt fo operate outside our performance limitations i ean lead to danger foe tempered by appropiate caution. Environment: Physical and organizational ‘The maintenance environment preseats aumerous human fector challenges, including the ned to work ‘outside, high nose level emperture extremes, snd at times poor lighting. All these conditions can incense the probability of eros, For example, a three engine ‘rcaft lst ol fom sll engines after maintenance technicians on night shift ted magnetic chip deectors ‘without dhe necessary O-rings. The work was performed. ‘outside, using the headlights oF tg for umination Furthermore, the technicians had go direct view of the task, and ted each chip detector by fe, reaching Inside the el evise door on each engine. In addition tothe physial environment, there the ‘tgenestonal environment surrounding nalntenance, ‘Maintenance tasks are often performed onder dime pressure. Time pressor i particular threat when technicians are not wed to handling i, and allow i to have undue influence on their decision making. (Other aspects ofthe orgenitatinal enviroment are management eye organizational eueure and workplace ‘norm = the unwetten, informal work practices that smeners of the organization fll. Action: Prcdres, paperwork and poor design ‘The actions component of PEAR includes all ofthe hands on requirerents needed ro complet task; fom ‘gathering information on tasks, identifying approved data and procedures, he physi and mental demands ofthe tas, to flzing and cerdfying job complete. ‘The FAA has estimated tha airline maintenance personnel spend between 25 and 40 percent of thele time dealing with paperwork Ie aines, technicians Frequently deal with maintenance documentation thats ial ointerpet,o that describes procedresin ways that appear tobe ou of touch win cureat maintenance ‘rates. Geral Aviation, the problem maybe chat {pproved documentation fr ole ieraf i simply noe irailble, o is hard to obtain, Many AMT we “lack ‘ole’, personal sources of unapproved tecalcal data ‘that may or may not be upto date A problem fic by AMT isa confit beeen allowing procedures and the presnze oye the jb done’ ‘An awareness of human fector: associated with the factions required to complete ajob by people a all Ievel of the ongsnication can belp to identify areas where the formal procedures can be approved. An accurate knowledge of task demande will help t0 ‘Mentify informal work practices developed o meet these demands that need to be bought into alignment vith formal procedures. Hamas factors are not jst for technician but also for managers and waiters of technical documentsResources lack or dfcient isuptons, AMT have to del frequently with lick of Many maintenance incidents begin with a lack of resources orequipment. Knowing how to deal withthe necessary sesoures, such a8 ie, spares, or pecalized lack of revourees require judgement that taker yeare tools. Shoreages wll sometimes lad to work aounds or 0 bald ‘THE ORGANIZATIONAL ENVIRONMENT rm tion tack up? Pasiiveorganizallonal characteristics Tere te sn staf eppropriaay hens o cove the workoad “The organization never encores shortcuts o procedure vations, ‘Sa ar encouraged wo repo eros and unsee sats 2 ‘3 Wanagement acts quit fc unset stustons 4 5 he company has st cute poy. nes are ivestiated to Gey why ay oon, ot wham alae ale Sa ecsve human fos waning | Negative organizational characterises 7._ Ther san exter ‘car-do’ clue. Saf do whaive takes gla ob done an tine ‘8 Tasks ae reutnly permed acuring toners’ tora work practoes) aha than ocumeie process. ala 3. Stare often roqured to wrk excessive ours 1D Werks done cteenty when thr is tine pressure 11. Shortages of spares or equpment often ead to workarounds 2. Thare rap sa turove, o many nexpereneR personne elle ie) sel |e alee Bese ‘THE DIRTY DOZEN “The Disty Dozen er o tle ofthe most common human enor presonditions of conditions that can act a precursors to accident or incldens. These twelve elements influence peopl to make mistkes, The following cise ies reference ome ofthe Dirty Dozen facas tht consbuted accidents THE UST 1. Lackof communication 1 Presure 2. Disaetion B Lackofawarenese 3. Lackof resources 9. Lackof knowledge 4. Stee 10 Fatigue 5. Complacency 11, Lack of astertiveness 6 Lackof teamwork 12, Norms ‘De Dirty Dazen Model wil be dscsed indepth in Chapter 8. Nal 02-hanan Feces =e ooINCIDENTS RELATED TO HUMAN FACTORS: "Te flowing re major incidents that have been dirty attributed to buman actors (CASE STUDY: ALOHA AIRLINES FLIGHT 243 Complaceneysidentied as one ofthe“Dirty Dozen of slteraft maintenance himan Fctors. (Discussed in fll in sch module 93, along with other err model). The Disty Doaen ate 12 detifed human factor that ea 0 maintenance ers. Complcency eat the tp ofthishist, Ana isthe desliea f the 12. Tie ie demonstrated by the tragic Aloha Flight 243, which tok pace on April 28,1988. Complacency with the state of aging alrcaft ‘was expe a the cause of the aciden and this event became the watershed acidet that would being much needed change ‘Aloha Aisines Flight 243 (AQ.243, AH 243) was a scheduled Aloha Asdnes light between Hilo and Honolua in Hawaii. On April 28, 1988, a Bocing 731.297 serving the Hight suffered extensive damage after an explosive decompression in ight, bu was able to land sly at Kahl Aisport on Mau. There wat ‘ne fatality a nee ofthe ight crew who wae swept ‘oveboard fom the sirplane. Another 5 pagers and row wee jel “Te safe landing of the aircraft despite the substantial Adumage inflicted by the decompression established ‘Ao Alnes Flight 243 asa significant event inthe istry of aviton, with reaching ees on aviation safety polices and procedures Figure 14) “The ight departed Hilo at 1325 HIST on 28 Apel 1988 ‘wih sc crew members and 89 pasenger, bound for FHonolus, No unas] occurence were noticed during the pe departure inepection ofthe aca. The arate tna previously completed thee round tip Might from “Honolulu vo Hilo, Mau, and Kava that dy all which wer uneventful, Meeorlgial ondiions were checked btn aioe fr weather phensenen accused along the al route, per Alsman’s meteonlogcl information ot significant metercogica information. The epain Was tn experienced pilot with #500 Might hour; 6 700 of ‘hose were in Boing 737. The fr ofcerhad significant experience fying 77s, aving logge 3 500 of hee weal 18000 ight hour ia them, No unurual occurrences were reported during the takeoff and ascent, Around 18:8, ar the airerafe reached ite normal fight atte of 24000 fee (7300, 1m) about 23 nautical miles (45 kn) south southeast of Kabul, Maui, «small section on the left side of the roof ruptured with 3 “whooshing” sound. The capain {El the aieaf ol left and igh nd the controls went Faw 4 ies lg 23 Awsres maeniin tne Rrra ou eesa hage ‘atonnahinnen Kacey nee age act wa he ma cosy kro ce.Joos. The fit ofces noticed pisses of grey insulation ‘eating over the cabin. The dart the cockpit was gone so the captun could lok behind him and se blue sy. “The renting explosive decompression toe off large section of the roof, consisting ofthe entire top half of the aircraft skin extending from jst behind the cockpit tothe frewing aren. “The first ofcer was Ang the plane the time ofthe Incident. After discovering the damage, the captain took over and sered the plane tothe closest aepor, fon Maui Island. Thirteen minutes later, the erew performed an emergency landing on Kaus Airports Runway 2. Upon landing, the crew deployed the sireraf's emergency evacuation slides and evacuated passengers fom the aircraft quickly. In ll, 65 people ‘were reported inured, eight eis INVESTIGATION The main factor was the failuse ofthe Aloha Aistines maintenance program to detect the presence of Signieantdabonding and fatigue damage Contributing causes were the failure of Aloha Aisines ‘management to supervte properly its maintenance {orc the illu ofthe Peder Aviation Admiietetion (FAA) to evaluate properly the Aloha Airlines maintenance program and to assess the siline’s Inspection and quality conto! deficiencies the failure ofthe FAA to require Airvorthines Directive 87.21- (08 inspection of al the lap joint proposed by Boeing ‘Alert Service Bulletin SB 757,S3A103%; andthe lace ‘ft complete terminating action (nether generated by Boring nor required bythe FAA) ater the discovery of rly production dficlies in che B-737 cold bond lap eit wich read in low bond ducal, coresion, tnd a prmatore fatigue cracking [SAFETY RECOMMENDATIONS Investigators made 18 Safety Recommendations that wee enacted aa + Provide specific guidance and proper engineering supporto principal maiotenanceingpetors to erat ‘motifctions of sirline maintenance programs and pertions specifications, which popote segmenting ‘aor msntenanceinepecsons. Revit the regulation governing the certifeation of vation maintenance techneal schools and sensing fain and power plant mechanics to sequie that ‘curicalum and testing requirements inckule modern aston indaty technology. Require formal certification and rcurtet taining of aviation maintenance inspectors performing ondestructiveingpetion factions, Foal taining should include apprenticeship and periode skill, ernonstation. Develop a continuing inspection program for those 'B-737sigplanes that have incorporsted lp joint termination action (potrucing head old fasteners Installed in the upper roo al ap splice) wo detect any fatigue cracking that my develop inthe mide ‘or lower rows of fuselage lp joint fasteners hoes (for both the inner and oster skin panels) or the sujacent tear steap fastener oles. Additionally, t0 define the types of inspections, inspection intervals, and corrective actions needed for continuing slrweethines Develop a model program fora comprehensive orosion contol program tobe included in exch ‘opera approved nntenance progam, sue an airworthiness directive for B737 aeplanes ‘equipped with carbon steel control cables to inspect the cables for evidence of corrosion and if chet le evince, to acomplih the ation set forth in Boeing Service ter 737L-762-A. Enhance stature and peefoimance of the principal tnspectors throughs (femal management ening and guidance, (2) Greaterencoragemeat and bucking ‘by headquarters of efforts by principal inspectors to secure che implementation by carriers of levels of safer above the regulatory minimums, (3) Impeove accountability for quality of che surveillance; () ‘Additional hetdquarters atstance in standardizing suvilinee stv, Discontinue classification of Fuselage skin ax “malfunction evident” of "damage obvious" on ‘supplemental stracturallyegnifican items inthe damage obvious eegory fo ome inclsin in the ‘oppemenary inspection progam Ive ansirearier operation allen or allsicaeir Aight teaining departinents to review the seeident scenaio and reiterate the reed to assess srplane aleworthiness as stated in the operators manual before taking action that ny ene farther damage ot Treakap ofa damaged sine