Doc 9824an450, human factors guidelines for aircraft maintenance manual. Cap 718 human factors in aircraft maintenance and inspection. The term human factor has grown increasingly popular as the. The human factors approach in maintenance research considers the human as the center of the system. Airlines and suppliers asked for an electronic checklist tool for collecting. However, there is a lack of published information on possible links between specific errors and contributing factors.
Human errors were recognized as a major hazard to safe flight operations at least as early as world war ii. Human factors hf play an important role in the mining and mineral industry. When it is not done correctly, it contributes to a significant proportion of aviation accidents and incidents. Dec 02, 2014 people cannot easily avoid those actions they did not intend to commit. An overview of human factors in aviation maintenance atsb. But the maintenance schedule for a modern aircraft still demands the repeated disassembly, inspection and replacement of millions of removable. The use of the term human factors in the context of aviation. On a routine basis, maintenance workers must contend with. Mishaps in complex activities, ranging from aviation to nuclear power operations, are often the result of interactions between multiple components within an organization. Human factors in aircraft maintenance a preliminary. Kingman road, fort belvoir, va 220606218 1800caldtic 18002253842.
Human reliability and error in transportation systems. The goal of the human factors in aviation maintenance and inspection research. A practical human factors approach to managing error in. Blaming people for their errors is emotionally satisfying but remedially useless. The research presented in this paper is a result of gathering and systematization of errors caused by human factors over the last five years in one organisation for aircraft maintenance certified according to the european standards. As foundation for this discussion, we provide an overview of approaches to investigating human error, and a description of aviation maintenance and inspection tasks and environmental characteristics. Humanmachine interface human factors mental state physical state emotional state aviation safety relies heavily on maintenance. Human factors issues, specifically human errors, contribute to more aircraft incidents and accidents than any other single factor. Fatalities and major accidents are not acceptable to the. The influence of human factor in aircraft maintenance. Students are asked at the end of each segment to answer. During their operation thousands of lives are lost annually due to various types accidents. Towards that end, a questionnaire was developed which was administered to malaysian aviation maintenance professionals.
Not only can human factors research have a significant effect on the design of new systems but it can also mitigate problems. If maintenance errors not detected, they can cause events, worker injuries, wasted time, and even accidents. Pdf human factors in aircraft maintenance researchgate. It is intended to show how human capabilities and limitations can. James reasons 12 principles of error management aerossurance.
Defense technical information center compilation part notice. Human factors human factors is a multidisciplinary effort to generate and compile information about human capabilities and limitations and apply that information to produce safe, comfortable and effective human performance. All four aircraft and a total of 530 occupants were lost ramsden 1992. Human factors directly cause or contribute to many aviation accidents. At present, there are no published studies of the human factor issues relevant to uav maintenance. Atsb transport safety report aviation research and analysis report ar2008055 final an overview of human factors in aviation maintenance alan hobbs ph. A classic example is an aircraft s crew that becomes so fixated on troubleshooting a burned out warning light that they do not notice their fatal descent into the terrain. The naval aviation mishap database contains relevant information, both in quantitative. Human error in aviation maintenance aircraft systems. Chapter 1 human factors federal aviation administration.
The approach is structured around three human factors. Culture, systems and change in aircraft maintenance organisation. While errors resulting in accidents are most salient, maintenance and inspection errors have other important consequences e. Human error the repairreplace task was not successfully completed due to a lack of knowledge or skill on the part of the person performing the repair. A total of 619 safety occurrences involving aircraft maintenance were reported using a selfcompleted questionnaire. Everyone ought to be accountable for his or her errors and acknowledge the errors and strive to be mindful to avoid recurrence. Sa227dc metro 23 aircraft, registered vhtfu, with two pilots and passengers, was being operated by transair on an ifr regular public transport service from bamaga to cairns, with an intermediate stop at lockhart river, queensland. Despite the importance of maintenance quality, there is a lack of empirical research on the nature of maintenance incidents and the human factors which contribute to them. The integrated systems approach to human factors in maintenance systems is designed to provide a maintenance organization with a human factors program structure that will allow the maintenance organization to address a wide range of human factors issues within the maintenance operation. The uk caa produced a list civil aviation authority uk 1992 of the most frequent maintenance incidents in aircraft over 5,700 kg. Objectives this handbook was created to help outline and to provide background information on maintenance resource management. If the accident rate is to be decreased, human factors issues in aviation must. An overview of human factors in aviation maintenance.
Pdf human challenges in the maintenance of unmanned. Civil aviation authority cite numerous aviation accidents and incidents in which maintenance was a contributing factor, including the following. Pdf an overview of human factors in aviation maintenance. Some examples of maintenance errors are parts installed incorrectly, missing. Whatever the reason for this, it is not because maintenance is insignificant. Human factors in aircraft maintenance and inspection. Maintenance errors not only pose a threat to flight safety, but can also impose significant financial costs through delays, cancellations, diversions, and other. Risk compensation is an effect whereby individual people may tend to adjust their behavior in response to perceived changes in risk. This research includes such areas as aircraft design and operation, air traffic control, and, of course, aircraft maintenance. Pdf the influence of human factor in aircraft maintenance. Unique human factors issues in aviation maintenance. The role of cockpit human errors has always been in focus within the aviation industry. This paper is intended to shed light on the fundamental concepts of human factors hf.
If interpreted narrowly, human factors is often considered synonymous with crew resource management crm or maintenance resource management mrm. Human factor plays an inevitable role in maintenance activities and the occurrence of human errors impacts on system reliability and safety, equipment performance and economic results. Maintenance resource management mrm is a general process. Cap 715 an introduction to aircraft maintenance engineering human factors for jar 66 page viii foreword 11. The hra approach is an extension of probabilistic risk assessment pra. Public and regulatory sensitivity to the role of maintenance errors increased dramatically after the aloha airlines b737 accident in 1988. System error the equipment was returned to service after a highrisk maintenance tasks without the repair having been properly inspectedtested. An overview of human factors in aviation maintenance research aviation research and analysis ar2008055 final december 2008. The use of the term human factors in aviation maintenance engineering is new. However, as anyone working in aviation maintenance knows, there have been a number of serious, even fatal, accidents over the years that were caused primarily by maintenance errors. Aircraft accidents such as that of the aloha aircraft in the usa in 1988 1 and the bac 111 windscreen accident in the uk in june 19902 focused attention on human factors. Understanding human error in naval aviation mishaps. Pdf human error is cited as a major causal factor in most aviation mishaps, including the 15% 20% that involve maintenance error.
Maintenance human factors have been a significant contributor to a number of adf accidents and serious incidents ac type problem c main wheel downlock disconnect f18 fuel line connection failure sk50 flight control disconnect nias f111 main wheel departure s70a fire extinguisher discharge p3c control cable chaffingfailure. Maintenance environment poor weather, heat, visibility, high winds, smoke, ash, rain, humidity aircraft servicing limits interoperation with civilian aircraft and agencies deployed maintenance requirements in the field adf aviation maintenance environment navy army air force. This does not mean that human factors issues were not present before these dates or that human. The primary objective of this research is to develop a structural relationship model that incorporates human factors, organizational factors, and their impact on human errors in aviation maintenance. Human error in aviation maintenance federal aviation.
Unintentional human errors in aircraft maintenance occur all the time. However, it is much broader in both its knowledge base and scope. Flight safety foundation flight safety digest october 2002 1 maintenance resource management programs provide tools for reducing human error. We should not, however, confuse blame with accountability. Human factors ntsb case studies technologically advanced aircraft and risk compensation. A may 25, 1979, accident in which an american airlines mcdonnell douglas dc1010 struck terrain. In 2005 the federal aviation administration faa worked with industry representatives to complete the operators manual for human factors in aviation. A mcdonnell douglas dc9 aircraft suffered an inflight. Probabilistic risk assessments identify all risks including human error that a system is exposed to, describe associations among these risks, quantify risk likelihood, and express this information in a fault tree or event tree representation. Sep 24, 20 this human factor case studies course presents six video scenarios based on actual incidents involving lapses in aircraft maintenance.
Human conditions, such as fatigue, complacency, and stress are so important in aviation maintenance. Unlike conventional aircraft maintenance, uav maintenance personnel must ensure the reliability of an entire system that comprises the vehicle, the ground station, and communication equipment. When human errors are factors in an aviation accident, they can usually be broken down into three responsible parties. Each year billions of dollars are being spent to develop, manufacture, and operate transportation systems such as aircraft, ships, trains, and motor vehicles throughout the world. Real people are indispensable when it comes to aviation maintenance. The classic term, pilot error or human error, is attributed to accidents or. An overview of human factors in aviation maintenance skybrary. The investigation report identified a range of contributing and other human factors safety issues relating to the crew of the aircraft, including. These were lauda 767 over thailand, united 737 at colorado springs, nationair canada dc8 in saudi arabia and continental express brasilia in texas. Technicians use more and more sophisticated equipment and procedures.
A brief history and overview is presented followed by a description of the elements that comprise an hf program. Human factors guide for aviation maintenance and inspection. Human errors include errors by the flight crew, maintenance personnel, air traffic controllers, and others who have a direct impact on flight safety. For this reason, after the first flight of the aircraft following this maintenance, when the aircraft put a wheel on the runway, a hard vibration was felt on the right landing keywords.
Dirty dozen in aircraft maintenance human factors youtube. System error the equipment was returned to service after a highrisk. The influence of human factor in aircraft maintenance article pdf available in promet traffic traffico 293. May 21, 2015 human factors in aviation is about optimising the pilot, optimising the direct interaction between the pilot and the other pilot and any other humans, optimising the interaction between the pilot and the aircraft and, finally, optimising the procedures through which the pilot can interact with the other pilot or other humans and the aircraft. In contrast to attention failures slips, memory failures lapses often appear as omitted items in a checklist, place losing, or forgotten intentions. Really the leaders guide pdf document scanned into a powerpoint format. He is a current pilot with commercial, instrument, and mulitengine ratings. Maintenance is one of the largest costs facing airlines.
Human factors in aviation have traditionally concentrated on aircrew and air traffic control errors, but the increasing number of maintenance and inspection errors has seen the rise of human factors research and interventions in this area gramopadhye and drury, 2000. In 1991 worldwide, there were at least four major airline accidents where maintenance was a likely causal factor. Human error is defined as a human action with unintended consequences. A sound aircraft inspection and maintenance system is important in order. Chapter 1 human factors introduction aviation maintenance has changed over the years.898 166 916 1274 334 300 1035 572 1557 1273 12 549 694 420 1140 37 1236 330 1296 96 718 1381 972 506 729 951 1170 499