Airworthiness: Maintenance Error Dirty Dozen

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Airworthiness: Maintenance Error Dirty Dozen

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Airworthiness: Maintenance Error Dirty Dozen

  1. 1. Presented to:By:Date:Federal AviationAdministrationAirworthinessHuman FactorsR1Maintenance Error- Dirty Dozen
  2. 2. 2Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceObjectives• Illustrate that human error inmaintenance causes death anddestruction• Identify 12 causes ofmaintenance error, “The DirtyDozen”• Suggest how to reducemaintenance error
  3. 3. 3Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceThe Best People Makethe Worst Mistakes
  4. 4. 4Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance
  5. 5. 5Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceDelta Flight 1288 MD-88
  6. 6. 6Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceThe Dirty Dozen• Communication• Complacency• Lack of Knowledge• Distraction• Teamwork• Fatigue• Lack of Resources• Pressure• Assertiveness• Stress• Lack of Awareness• Norms
  7. 7. 7Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue7. Lack of Resources8. Pressure9. Lack of Assertiveness10. Stress11. Lack of Awareness12. NormsSafety NetsUse logbooks, worksheets etc. tocommunicate and remove doubt.Discuss work to be done or what has been completed.Never assume anything.
  8. 8. 8Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance
  9. 9. 9Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceSafety NetsUse logbooks, worksheets etc. to communicate and remove doubt.Discuss work to be done or what has been completed.Never assume anything.Continental Express, 14 Fatalities, 9-11-91
  10. 10. 10Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue7. Lack of Resources8. Pressure9. Lack of Assertiveness10. Stress11. Lack of Awareness12. NormsSafety NetsTrain yourself to expect to find a fault.Never sign for anything you didn‟t do.
  11. 11. 11Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceItalian Air Force, Keflavik• No lineman present for start-up• Crew asked LM to verify battery doorclosed (near left landing gear) afterengines were started• LM walked thru prop, killing him instantly• First such case in Italian AF in over 50years
  12. 12. 12Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceItalian Air Force, KeflavikCREW DOORBATT. DOORLoadmaster exits crew door to check battery door.Engines were running
  13. 13. 13Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceLoadmaster killed as he walks into prop.Body and remains scattered over 100 feet.
  14. 14. 14Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceAccident cleanup by “Fire Department”Carelessness and overconfidence are more dangerous thandeliberately accepted risk.- Wilbur Wright, 1901.
  15. 15. 15Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceTherefore the Safety Board concludesthat a low expectation of finding acrack in a –219 series fan hub mighthave caused the inspector to overlookor minimize the significance of anindication.
  16. 16. 16Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceFace RealityPhysical FitnessCreate Challenges for yourselfTrain yourself to expect to find a fault.Never sign for anything you didn‟t doSafety Nets
  17. 17. 17Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue7. Lack of Resources8. Pressure9. Lack of Assertiveness10. Stress11. Lack of Awareness12. NormsSafety NetsGet training on type.Use up to date manuals.Ask a Tech. Rep. or someone who knows.
  18. 18. 18Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance
  19. 19. 19Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance
  20. 20. 20Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance
  21. 21. 21Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceLack Of KnowledgeGet training on type.Stay Current-Read, Read, ReadUse up to date manuals.Ask a Tech. Rep.-or someone who knowsCommunicateNo Pride!Safety NetsSeptember 2, 1998Douglas MD-11 in the sea9KM Off Nova Scotia
  22. 22. 22Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue7. Lack of Resources8. Pressure9. Lack of Assertiveness10. Stress11. Lack of Awareness12. NormsSafety NetsAlways finish the job or unfasten the connectionMark the uncompleted work.Lock wire where possible or use torque seal.Double inspect by another or self.When you return to the job always go back three steps.Use a detailed check sheet.
  23. 23. 23Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceAlways finish the job or unfasten the connection.Mark the uncompleted work.Lock wire where possible or use torque seal.Double inspect by another or self.When you return to the job always go back three steps.Use a detailed check sheet.Safety Nets
  24. 24. 24Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue7. Lack of Resources8. Pressure9. Lack of Assertiveness10. Stress11. Lack of Awareness12. NormsSafety Nets“Reconfirm duties among team members.”“Team tasks require a full team.”“Communicate!”“FOLLOW THE CORRECT PROCEDURES.”
  25. 25. 25Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance
  26. 26. 26Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance
  27. 27. 27Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance“Communicate!”“Team tasks requirea full team.”“Reconfirm dutiesamong team members.”“FOLLOW THE CORRECT PROCEDURES.”Safety NetsLack of Teamwork
  28. 28. 28Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue7. Lack of Resources8. Pressure9. Lack of Assertiveness10. Stress11. Lack of Awareness12. NormsSafety NetsBe aware of the symptoms andlook for them in yourself andothers.Plan to avoid complex tasks atthe bottom of your circadianrhythm.Sleep and exerciseregularly.Ask others tocheck your work
  29. 29. 29Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceACUTE FATIGUEProduced by physical exertion or sleep lossAlleviated by a single rest periodCHRONIC FATIGUEMedical or psychological problemDepression or “chronic fatigue syndrome”OPERATIONAL FATIGUEMost commonly seen after 3-4 days of heavy taskingNot relieved by a single sleep periodFatigue
  30. 30. 30Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceAttention reducedMemory diminishedMood becomes withdrawnLow situational awarenessLong hours of labor (any type).High intensity stress.SYMPTOMS OF FATIGUE
  31. 31. 31Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceCIRCADIAN RHYTHMS
  32. 32. 32Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceBe aware of the symptoms and look forthem in yourself and others.Plan to avoid complex tasks at the bottomof your circadian rhythm.Sleep and exercise regularly.Ask others to check your work.Safety NetsFatigue
  33. 33. 33Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue7. Lack of Resources8. Pressure9. Lack of Assertiveness10. Stress11. Lack of Awareness12. NormsSafety NetsCheck suspect areas at the beginning of the inspectionand AOG the required parts.Order and stock anticipated parts before they arerequired.Know all available parts sources and arrange forpooling or loaning.Maintain a standard and if in doubt ground the aircraft.
  34. 34. 34Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceJackscrew88
  35. 35. 35Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceCheck suspect areas at the beginning of theinspection and AOG the required parts.Order and stock anticipated parts before they arerequired.Know all available parts sources and arrange forpooling or loaning.Maintain a standard and if in doubt ground theaircraft.Safety NetsLack of Resources
  36. 36. 36Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue7. Lack of Resources8. Pressure9. Lack of Assertiveness10. Stress11. Lack of Awareness12. NormsSafety NetsBe sure the pressure is not self- induced.Communicate your concerns.Ask for extra help.Just say NO.
  37. 37. 37Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceJessica Dubroff 1988- 1996
  38. 38. 38Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceChiang Kai-Shek Airport TaiwanJune 6, 2005
  39. 39. 39Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceBe sure the pressure is not self- induced.Communicate your concerns.Ask for extra help.Just say NO.Safety NetsPressure
  40. 40. 40Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue7. Lack of Resources8. Pressure9. Lack of Assertiveness10. Stress11. Lack of Awareness12. NormsSafety NetsIf it‟s not critical, record it in the journey log book &only sign for what is serviceable.Refuse to compromise your standards.
  41. 41. 41Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceAggressivePassiveAssertivePerformanceAssertivenessAngerOffenseAcquiesceCompromiseOthersRightsYourRightsBoth Party‟s RightsTeam WorkSynergyHighLow
  42. 42. 42Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance
  43. 43. 43Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance
  44. 44. 44Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceIf it‟s not critical, record it in the journey log book& only sign for what is serviceable.Refuse to compromise your standards.Safety NetsLack of Assertiveness
  45. 45. 45Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue7. Lack of Resources8. Pressure9. Lack of Assertiveness10. Stress11. Lack of Awareness12. NormsSafety NetsBe aware of how stresscan effect your work.Stop and look rationallyat the problem.Determine a rationalcourse of action andfollow it.Take time off or at leasthave a short break.Discuss it withsomeone.Ask fellow workers tomonitor your work.Exercise your body.
  46. 46. 46Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceSTRESS
  47. 47. 47Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceBe aware of how stress can effect your work.Stop and look rationally at the problem.Determine a rational course of action andfollow it.Take time off or at least have a short break.Discuss it with someone.Ask fellow workers to monitor your work.Exercise your body.Safety NetsStress
  48. 48. 48Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue7. Lack of Resources8. Pressure9. Lack of Assertiveness10. Stress11. Lack of Awareness12. NormsSafety NetsThink of what may occur in the event ofan accident.Check to see if your work will conflictwith an existing modificationor repair.Ask others if they can see anyproblem with the work done.
  49. 49. 49Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance
  50. 50. 50Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance
  51. 51. 51Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance
  52. 52. 52Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceThink of what may occur in the event of anaccident.Check to see if your work will conflict with anexisting modification or repair.Ask others if they can see any problem with thework done.Safety NetsLack of Awareness
  53. 53. 53Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue7. Lack of Resources8. Pressure9. Lack of Assertiveness10. Stress11. Lack of Awareness12. NormsSafety NetsAlways work as per the instructions orhave the instructions changed.Be aware that „norms don‟t make it right.
  54. 54. 54Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceThis picture was taken by an amateur photographerseconds before an American Airlines DC-10 crashed atChicago OHare Airport, after losing an engine duringtakeoff. Below is the resulting explosion. Impropermaintenance procedures was to blame. Two-hundred-seventy-one people aboard were killed as well as 2 on theground. (May 25, 1979)
  55. 55. 55Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceAlways work as per the instructions orhave the instructions changed.Be aware that „norms don‟t make it right.Safety NetsNorms
  56. 56. 56Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceFATIGUESTRESSCOMPLACENCYCOMMUNICATIONAWARENESSDISTRACTIONLACK OF KNOWLEDGETEAMWORKLACK OF RESOURCESPRESSURELACK OF ASSERTIVENESSNORMSLee Marvin, Ernest Borgnine, Jim Brown, Charles Bronson, John Cassavetes, Trini Lopez, Telly Savalas, Donald Sutherland, Clint Walker
  57. 57. 57Federal AviationAdministrationDirty Dozen- Human Error in Aircraft MaintenanceFace Reality
  58. 58. 58Federal AviationAdministrationDirty Dozen- Human Error in Aircraft Maintenance• Information for You• A Request from Us• Any Questions???Before We End

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