This manual is in response to the industry’s requests for a simple and manageable list of actions to implement a Maintenance Human Factors (MHF) program. A panel of experts selected the following six topics for such a program to be successful:
Event Investigation
Documentation
Human Factors Training
Shift/Task Turnover
Fatigue Management
Sustaining & Justifying an HF Program
For each of the six topics that contribute to the success of any MHF program, this manual offers the following:
Why is the topic important?
How do you implement it?
How do you know it is working?
Key references
Like any good operator’s manual, this document tells you what to do without excessive description of why you should do it. This manual recognizes you already know the importance of Human Factors. For detailed information, see the “Key References” at the end of each topic.
The selected six topics are critical because they are based on operational data and practical experience from the US and other countries. Transport Canada (TC), United Kingdom Civil Aviation Authority (UK CAA), and the European Aviation Safety Agency (EASA) regulations contributed to this manual. The steps are derived from a panel of ten industry and government contributors who have worked in aviation maintenance for an average of twenty-five years and in MHF for fifteen years. The contributors characterized these six topics and related steps as “information they wish they had known 15 years ago.”
These straightforward suggestions provide the key components for implementing a successful MHF program that will benefit your company, business partners, external customers, and the entire industry. Information is presented in summary bullets as follows:
These are six topics, from many, that a MHF program may consider.
Topics are not necessarily in order of importance, except that the data obtained from Event Investigation (Section 1) provide the foundation for many Human Factors activities.
You may implement any or all of the topics, however, they should be coordinated.
Your MHF activity should be based on the identified requirements and resources of your organization.
You are encouraged to supplement this Operator's Manual with additional references.
This document satisfies the industry request for a short and straightforward list of important actions.
Human Factors Training: There's nothing that can't go wrong. This simple insight forms the foundation of human factors training for pilots. In special courses, pilots are prepared for any possible emergency situation and action strategies. Crews learn to analyze and evaluate their own behavior and that of those around them more effectively. Training leads to more efficient work processes, a functioning error management culture, and increased safety. This is a general prsentation and human factors management in aviation training.
In 1994, the University of Texas Human Research Project and Delta Airline developed the Line Operations Safety Audit (LOSA) program. With time, the LOSA program evolved into what is now known as Threat and Error Management (TEM).
The TEM framework is an applied concept which emerged from the observations and surveys of actual flight operations. It considers the various issues that a flight crew may encounter as a result of internal and external factors.
This model explores the contributing factors of the threat to aviation safety and, in turn, allows for the unearthing of ways to mitigate them and maintain proper safety margins. Now recognized and adopted across continents, the TEM framework aims to educate flight personnel on managing threats and errors before they degenerate into serious incidents or accidents. It is important to note that TEM is also applicable to maintenance operations, cabin crew, and air traffic control.
Human Factors Training: There's nothing that can't go wrong. This simple insight forms the foundation of human factors training for pilots. In special courses, pilots are prepared for any possible emergency situation and action strategies. Crews learn to analyze and evaluate their own behavior and that of those around them more effectively. Training leads to more efficient work processes, a functioning error management culture, and increased safety. This is a general prsentation and human factors management in aviation training.
In 1994, the University of Texas Human Research Project and Delta Airline developed the Line Operations Safety Audit (LOSA) program. With time, the LOSA program evolved into what is now known as Threat and Error Management (TEM).
The TEM framework is an applied concept which emerged from the observations and surveys of actual flight operations. It considers the various issues that a flight crew may encounter as a result of internal and external factors.
This model explores the contributing factors of the threat to aviation safety and, in turn, allows for the unearthing of ways to mitigate them and maintain proper safety margins. Now recognized and adopted across continents, the TEM framework aims to educate flight personnel on managing threats and errors before they degenerate into serious incidents or accidents. It is important to note that TEM is also applicable to maintenance operations, cabin crew, and air traffic control.
Human Factors affecting performance in Aviation. Covers the factors which affect human performance, the causes and consequences, and how to combat factors. Also covers how factors propagate into accidents,
Insights from David Alexander ICAO AVSEC Pm and General Manager: AVSEC at Professional Aviation Security on current aviation security challenges including recent airport attacks and providing some possible practical solutions
Welcome to the SMS Fundamentals presentation.
The core processes, elements and components that comprise a functional and robust Safety Management System will be explained.
These lessons will provide you a general understanding of the principles of a Safety Management System (SMS). Also it will provide you an understanding of the components, elements, and core processes that comprise a functional SMS.
Each organization must determine their safety needs and scale their SMS to meet those needs.
I created this presentation to deliver to prospective Afghani Fire Crew leaders as a further stage in advancing their knowledge in health and safety and in dealing with emergencies.
Human factors - Maintenance and inspectionLahiru Dilshan
Maintenance information should be understandable by the technicians and inspectors. Therefore new manuals, job cards and service bulletins should be tested before distribution.
Human Factors in Aviation by Omar KuzbariOmar Kuzbari
Case study on Human Factors in Aviation based on the Air Ontario Flight 1363 Fokker F-28 at Dryden from March 10, 1989 (Ontario) prepared by Omar Kuzbari in 2018.
Introduction to Human Factors Training for Safety Critical Organisations. Human Factors training was originally developed in the aviation industry to enhance safety and reliability in complex environments.
This reviews the strengths and weaknesses of long-established approaches to safety, and proposes new perspectives and concepts underlying a contemporary approach to safety.
This includes the following topics:
a) The concept of safety;
b) The evolution of safety thinking;
c) Accident causation — The Reason model;
d) The organizational accident;
e) People, operational contexts and safety — The SHEL model; and
f) Errors and violations;
Human Factors affecting performance in Aviation. Covers the factors which affect human performance, the causes and consequences, and how to combat factors. Also covers how factors propagate into accidents,
Insights from David Alexander ICAO AVSEC Pm and General Manager: AVSEC at Professional Aviation Security on current aviation security challenges including recent airport attacks and providing some possible practical solutions
Welcome to the SMS Fundamentals presentation.
The core processes, elements and components that comprise a functional and robust Safety Management System will be explained.
These lessons will provide you a general understanding of the principles of a Safety Management System (SMS). Also it will provide you an understanding of the components, elements, and core processes that comprise a functional SMS.
Each organization must determine their safety needs and scale their SMS to meet those needs.
I created this presentation to deliver to prospective Afghani Fire Crew leaders as a further stage in advancing their knowledge in health and safety and in dealing with emergencies.
Human factors - Maintenance and inspectionLahiru Dilshan
Maintenance information should be understandable by the technicians and inspectors. Therefore new manuals, job cards and service bulletins should be tested before distribution.
Human Factors in Aviation by Omar KuzbariOmar Kuzbari
Case study on Human Factors in Aviation based on the Air Ontario Flight 1363 Fokker F-28 at Dryden from March 10, 1989 (Ontario) prepared by Omar Kuzbari in 2018.
Introduction to Human Factors Training for Safety Critical Organisations. Human Factors training was originally developed in the aviation industry to enhance safety and reliability in complex environments.
This reviews the strengths and weaknesses of long-established approaches to safety, and proposes new perspectives and concepts underlying a contemporary approach to safety.
This includes the following topics:
a) The concept of safety;
b) The evolution of safety thinking;
c) Accident causation — The Reason model;
d) The organizational accident;
e) People, operational contexts and safety — The SHEL model; and
f) Errors and violations;
How can we prevent accidents caused by human error? This presentation deals with typical examples of severe accidents related to human errors, and shows methods to prevent them.
Prior to using blockchain technology, data needs to be compiled and entered into the system. How do we achieve human consistency for the traceability mechanism? Who is setting the industry standards? Is it de facto iTunes with its 70-page long style-guide who is acting as the current ‘data police’?
The Human Factor: Debunking The Myth That Technology Drives CollaborationC5 Insight
At the end of the day, people have always been what determines if a business succeeds or fails. They are the ones who work hard and achieve objectives, most often using tools in which their organization has invested. With the proliferation of and advances in technology such as SharePoint, Yammer, Delve, Office Groups, and Office Graph, why are 60-80% of organizations still struggling to achieve collaboration nirvana?
This 60-minute session will answer this question and more, spending time discussing how people, and not technology, lie at the heart of successful collaboration projects. In fact, in its most basic form, collaboration means "To work with another person", and this session will extract and explain the most common human factors that are present in every collaboration initiative, and how slight changes in your approach to people can lead to enhanced user adoption, improved employee engagement, and lasting ROI.
An unclassified bimonthly publication of the Director, Air Warfare Division, Naval Aviation News covers all aspects of naval air operations. Articles review the latest technological advances in aircraft and weapon systems and the influence of U.S. naval air power in global events. Issues include historical profiles of aircraft, aviation ships, important aviators, and organizations that affected the Navy’s control of the air.
The study of interactions between man and machine is key in aviation. Recent years have seen these relationships be transformed, and the emergence of interactions technologies called "natural" or concepts of Augmented Human, or collaborative robotics.
The objective of the studies in Human Factors is always to anticipate tomorrow's world by focusing the development of new operations concepts or new technologies on human, so as to optimize the Human Machine relations and therefore uses.
It is therefore to establish a Human Factors Engineering integrated to the cycle of design and development and operation of complex systems in particular, and to develop the Human Factors disciplines appropriate to the expected changes in the industry, operators and users.
TRAINAIR PLUS Operation Manual TOPM v2 September 2013Amnat Sk
Competent personnel are essential to establish, manage and operate safe
air transportation systems. Training of aviation professionals plays a critical role
in achieving safety objectives and ICAO is committed to supporting Member States
in implementing high quality standards in civil aviation training. As outlined
in the ICAO Civil Aviation Training Policy, the TRAINAIR PLUS Programme is a
key element in ICAO’s strategy to achieve this goal. The TRAINAIR PLUS
Programme provides its Members with support for new and existing aviation
training centres through the provision of technical expertise, and quality oversight.
The result is a cooperative network of ICAO TRAINAIR PLUS Centres that
develop and share high-quality standardized aviation training materials for the
benefit of all Members.
Journal of Aviation Management 2013 by Singapore Aviation AcademyAmnat Sk
Journal of Aviation Management 2013 by Singapore Aviation Academy
With very low accident rates in recent decades, air transportation is widely recognised as the
safest mode of transport. The aviation community, including airlines, aircraft manufacturers,
maintenance organisations, air navigation service providers, airport operators, and the safety
regulators have been working closely to make our skies safer. Amongst all the stakeholders
involved in the aviation industry, there is a particular group of aviation professional who
are seldom mentioned, yet they contribute significantly to improving aviation safety.
They are the air accident investigators – the people whose job is to determine the causes
and circumstances of air accidents and incidents so that similar accidents can be prevented.
One accident is one too many; and whenever it happens, it is bound to hit the news headlines
across the globe almost instantaneously. The idealistic aspiration of zero accident, albeit
statistically unachievable, keeps everyone in the aviation profession focused on building an
increasingly safe aviation system.
In the international civil aviation regime, Article 26 of the Convention on International
Civil Aviation (Ninth Edition 2006) stipulates that it is incumbent upon the State in which
an aircraft accident occurs to institute an inquiry into the circumstances of the accident.
Annex 13 further specifies that the objective of the investigation of an accident or incident
is for the prevention of recurrence and not for the purpose of apportioning blame or liability.
The identification of causal factors to prevent recurrence is best accomplished through
a properly conducted investigation.
To meet all these international obligations and to enable a proper investigation of accidents
or incidents to be conducted, an appropriate establishment needs to be put in place by
the Contracting States. With continuous air traffic growth globally, such an air accident
investigation establishment is essential and instrumental to support the growth and
development of a safe and sustainable air transport system. It should comprise, inter alia, the
following six key elements:
AMT ON CASA_HUMAN_FACTORS_TRAINING_SEPT_13Amnat Sk
Support for Human
Factors Training:
Look Down Under
The Australian Civil Aviation Safety Authority
(CASA) has set a new international standard for high-quality human factors training materials
Lean Six Sigma Course Training Part 16Lean Insight
Here is the Lean Six Sigma Course Training Part 16, presented by Lean-insight.om
Are you looking for six sigma related courses in Bangalore, then consult lean-insight.com
Courses:
Six Sigma Training
Six Sigma Green Belt Training
Six Sigma Black Belt Training
Lean Six Sigma Training
For more details visit: http://lean-insight.com/six-sigma-training-bangalore/
Boost Equipment Performance, Save Money With Proactive MaintenanceJames Fitzgerald
Proactive, timely maintenance of plant equipment is critical to enabling manufacturers to meet a dizzying number of demands, from pressure to achieve target output levels, minimize labor costs, control parts spending and ensure maximum uptime. Manufacturers rely on their maintenance departments to help achieve these goals on a daily basis. However, a great number of manufacturers still use maintenance on a reactive basis rather than viewing it as strategic to operations. Myrtle Consulting helps manufacturers convert maintenance into a proactive, scheduled operation that is used strategically to control costs, maximize uptime, and maintain critical equipment. By following a few fundamental principles, plants can begin to establish a maintenance improvement program that supports operations and improves plant performance.
Assessment – SITXOHS004BStudent name ____________________________.docxfredharris32
Assessment – SITXOHS004BStudent name: ____________________________
What you have to do
There are a total of three (3) parts to complete, as follows:
Part A – consists of tasks requiring an extended response answer.
Part B – consists of a task requiring an extended response answer.
Part C – consists of short answers.
Securely attach your answers on separate sheets that clearly identify the question to which you are responding and number the pages in sequence. At the end of each answer, allow adequate space (at least 6-8 lines), for the teacher’s comments and feedback.
You will be assessed on how well you interpret each task request and how you structure each according to layout, sequencing and by providing all relevant and applicable details for each task.
This is an ungraded unit. Your result is based on the evidence you provide to meet the criteria for competence as specified in the unit of competency and grading criteria. You will receive a result of Achieved Competency (AC) or Not yet Competent (NC).
Information on how to submit your assignment is located on the OTEN website under your OLS log-in.
Tasks
Part A: Develop a WHS Program or Procedure
Task
In this Unit of Competency we learnt that it is common practice for organisations to adopt the “Six Step Approach” to develop and implement a Work health and Safety Management System (WHSMS).
As you discovered, an organisation’s WHS Policy forms the “corner stone” of the WHSMS and clearly states the organisation’s commitment to WHS and identifies the initiatives that will be taken to ensure a safe work environment is provided to all persons working in, serviced by, or visiting the workplace.
For part A of this Assessment you are required to write one (1) WHS Program or Procedure that aims to fulfil the goals set by an Organisation’s WHS Policy.
To successfully complete this task you must:
1. Read the following example WHS Policy for “Big Corp Travel”.
2. Select one (1) of the WHS programs or procedures listed in the WHS Policy for this tourism company and prepare (write) a detailed program or procedure that can be included in the Organisation’s WHS Programs manual.
3. Your WHS Program/Procedure must contain and address the following paragraph headings:
· WHS Program/Procedure title (name).
· Purpose and objectives (what does the program/procedure aim to achieve?)
· Scope (who does this program/procedure apply to? Departments and personnel)
· Program/Procedure (outline the steps in the program – what, where, how)
· Implementation Strategies (how will the program be implemented and communicated to staff?)
· Monitoring and Evaluation (how will the program be monitored and evaluated?)
· Review (when will this program be reviewed to ensure that it remains current and relevant and who will conduct this revision?)
Example WHS Policy
Commitment statement
The health and safety of all persons employed within Big Corp Travel, its customers and those visiting the workplace is cons ...
4 Steps – Fix your Preventative Maintenance ProgramEvan McKenzie
By mapping and maintaining critical system information on an interactive, mobile, updateable platform, TPC iSchematic delivers proven results for reduced downtime, enhanced safety, & more efficient facility operations.
BUSINESS PROCESSES MANAGEMENT IMPLEMENTATION IN HEALTH SECTORijmpict
Today the world is in a continuous change, where the organizations have to face the transformation and adapt to the demands. It is said that many companies need to improve and revise their processes to maintain their competitive advantages in an environment of continuous uncertainty. This is an original article where a "BPM" is implemented in the health sector that allows an organization to improve and
review its critical business processes, a project that was carried out in "Rubén Cruz Vélez Hospital" in the city of Tuluá, Colombia, where the implementation of the emergency process was carried out, with the purpose of improving the quality of processes in the health sector, an important indicator that seeks the user to be the protagonist in health security systems, to find the synergy between the Information
technologies in health organizations.
Energy Consulting SDVOSB Organizational Assessmentgasanden
Link’s confidentiality policies for current or recent clients prohibit us from releasing client-specific
information. The following Organizational Assessment case study should thus be considered
representative of services that could be provided to support a spectrum of client circumstances.
The Applications section at the end of this document addresses how Link’s Organizational
Assessment practice can be applied to alternative scenarios.
Energy Consulting SDVOSB Organizational AssessmentLink Resources
Link Resources: providing Energy Consulting, Management, Operations and Maintenance services across Fossil, Nuclear, and Bio Energy power plants globally. No SDVOSB has our energy credentials or competencies!
Energy Consulting SDVOSB Organizational Assessmentnatalyabelmont
Link Resources: providing Energy Consulting, Management, Operations and Maintenance services across Fossil, Nuclear, and Bio Energy power plants globally. No SDVOSB has our energy credentials or competencies!"
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FAA HUMAN FACTOR IN AVIATION MAINTENANCE HF MRO
1. > Introduction
> Event Investigation
> Documentation
> Human Factors Training
> Shift/Task Turnover
> Fatigue Management
> Sustaining & Justifying an HF PrograSustaining & Justifying an HF PrograSustaining & Justif m
> Acknowledgements
Operator’s Manual
Human Factors in
Aviation Maintenance
http://www.hf.faa.gov/opsmanual
Last update: 10.06.2005
2. The Operator’s Manual for Human Factors in Aviation Maintenance 01
This manual is in response to the industry’s requests for a simple and manageable list of
actions to implement a Maintenance Human Factors (MHF) program. A panel of experts
selected the following six topics for such a program to be successful:
1. Event Investigation
2. Documentation
3. Human Factors Training
4. Shift/Task Turnover
5. Fatigue Management
6. Sustaining & Justifying an HF Program
For each of the six topics that contribute to the success of any MHF program, this manual
offers the following:
• Why is the topic important?
• How do you implement it?
• How do you know it is working?
• Key references
Like any good operator’s manual, this document tells you what to do without excessive
description of why you should do it. This manual recognizes you already know the importance
of Human Factors. For detailed information, see the “Key References” at the end of each
topic.
The selected six topics are critical because they are based on operational data and practical
experience from the US and other countries. Transport Canada (TC), United Kingdom Civil
Aviation Authority (UK CAA), and the European Aviation Safety Agency (EASA) regulations
contributed to this manual. The steps are derived from a panel of ten industry and government
contributors who have worked in aviation maintenance for an average of twenty-five years and
in MHF for fifteen years. The contributors characterized these six topics and related steps as
“information they wish they had known 15 years ago.”
These straightforward suggestions provide the key components for implementing a successful
MHF program that will benefit your company, business partners, external customers, and the
entire industry. Information is presented in summary bullets as follows:
• These are six topics, from many, that a MHF program may consider.
• Topics are not necessarily in order of importance, except that the data obtained from
Event Investigation (Section 1) provide the foundation for many Human Factors activities.
• You may implement any or all of the topics, however, they should be coordinated.
• Your MHF activity should be based on the identified requirements and resources of your
organization.
• You are encouraged to supplement this Operator’s Manual with additional references.
• This document satisfies the industry request for a short and straightforward list of
important actions.
INTRODUCTION
3. The Operator’s Manual for Human Factors in Aviation Maintenance 02
Introduction 01
1.0 Event Investigation 03
1.1 Why Event Investigation is important.... 04
1.2 How to implement an Event Investigation
process ...................................................... 04
1.3 How to know it is working .................... 05
1.4 Key References ................................... 05
2.0 Documentation 06
2.1 Why Documentation is important ....... 07
2.2 How to implement a Documentation
program ..................................................... 07
2.3 How to know it is working .................... 08
2.4 Key References ................................... 08
3.0 Human Factors Training 09
3.1 Why Human Factors Training is important
................................................................... 10
3.2 How to implement a Human Factors
Training program ....................................... 10
3.3 How to know it is working .................... 11
3.4 Key References ................................... 11
4.0 Shift / Task Turnover 12
4.1 Why Shift/task Turnover is important .. 13
4.2 How do you implement the Shift/Task
Turnover process? .................................... 13
4.3 How to know it is working .................... 14
4.4 Key References ................................... 14
5.0 Fatigue Management 15
5.1 Why Fatigue/Alertness Management is
important ................................................... 16
5.2 How to implement a Fatigue/Alertness
Management program ............................... 16
5.3 How to know it is working .................... 16
5.4 Key References ................................... 17
6.0 Sustaining & Justifying an HF Program 18
6.1 Why Program Sustainability is important
................................................................... 19
6.2 How to sustain an MHF program ........ 19
6.3 How to know it is working .................... 19
6.4 Why Cost Justification is important ..... 20
6.5 How to implement measures to quantify
Maintenance Human Factors investments for
cost justification ......................................... 20
6.6 Key References ................................... 21
Acknowledgements 22
4. “Jackscrew assembly failure caused by excessive wear
resulting from insufficient lubrication… contributing
factors included extended lubrication and end-play check
intervals, lack of available parts, organizational norms,
regulatory oversight issues, etc.”
NTSB ALASKA 261 FINAL REPORT
The Operator’s Manual for Human Factors in Aviation Maintenance 03
“Jackscrew assembly failure caused by excessive wear
resulting from insufficient lubrication… contributing
factors included extended lubrication and end-play check
intervals, lack of available parts, organizational norms,
regulatory oversight issues, etc.”
NTSB AAR-O2/01 FINAL REPORT
EVENT INVESTIGATION
Chapter 1
5. The Operator’s Manual for Human Factors in Aviation Maintenance 04
The purpose of an event investigation process is to manage the risks from events caused by
human actions that may affect flight safety, personal injury, and equipment damage. An error is
a human action that unintentionally deviates from the required, intended, and expected action.
A violation is a human action that intentionally deviates from company or regulatory policies or
procedures.
Event investigations help organizations identify and understand multiple contributing factors to
errors and violations. Examples include hard-to-understand procedures, time pressure, task
interruption, poor communication, and a variety of additional workplace and life conditions.
The identification of these contributing factors provides an organization with a specific focus to
prevent future events. Often event investigation systems are part of a company’s overall safety
management system.
1.1 Why Event Investigation is important
A. Maintenance was the primary cause of 8.3% of the US accidents in the 1990s for 100+
passenger jets.
B. A maintenance event started the accident chain in 26% of the worldwide accidents in
2003 for Western- and Eastern-built jets and turboprops.
C. Worldwide ramp incidents cost $5 billion in 2004.
D. Event investigation programs help to identify contributing factors to errors and violations
and to create corrective actions to prevent future events.
E. Event investigation is a method for sharing human performance issues within the
organization.
F. Event investigation is a key part of a Safety Management System, required by many
National Aviation Authorities (NAAs).
1.2 How to implement an Event Investigation process
A. Select a manager/department to be responsible for the process.
B. From the very beginning, ensure that the program is a cooperative endeavor of labor,
management and, if appropriate, the regulator.
C. Select an investigation process that systematically determines the contributing factors
of events and on the basis of these findings develop and monitor a comprehensive fix.
D. Write the policies and procedures needed to implement the event investigation process.
E. Consult applicable guidance on voluntary reporting systems, such as FAA’s Aviation
Safety Action Program (ASAP).
F. Develop and implement a reasonable, consistently applied, company disciplinary policy.
G. Identify screening criteria to determine which events will be investigated.
H. Select and train all investigators—company as well as labor—in a consistent manner to
minimize interpretation differences later. Invite/encourage regulatory inspectors to attend
such training sessions.
I. Communicate with management and workforce about the event investigation process
to obtain their input and buy-in.
J. Establish a team to review the investigation findings and to select areas for improvement.
EVENT INVESTIGATION
Chapter 1
6. The Operator’s Manual for Human Factors in Aviation Maintenance 05
K. Follow up to ensure that needed improvements are being made.
L. Inform all personnel on the status of improvements in progress. Use
newsletters, company/labor websites, crew meetings, and posters to demonstrate
and remind everyone that the process is working and somebody is actually
tracking the progress.
M. Create a database for documenting investigation information and measures of change.
Events and contributing factors should be classified according to a standardized system
so that data can be analyzed, summarized and trended. Examples of existing classification
tools include Maintenance Error Decision Aid (MEDA) and Human Factors Analysis and
Classification System—Maintenance Extension (HFACS-ME).
N. Use risk assessment techniques to quantify specific event likelihood and severity.
O. Evolve the system to include reporting of potential events that are also called threats.
1.3 How to know is working
A. Events are investigated to understand the contributing factors, and corrective actions
are developed to reduce the likelihood of future occurrences.
B. Deviations from existing procedures are uncovered during the investigations, and
they are corrected.
C. The number of events caused by human performance decreases.
D. The operator saves time and money by decreasing interruptions to revenue flights, rework,
personal injuries, and equipment damage.
E. Throughout the maintenance organization, personnel are discussing events, contributing
factors, and corrective actions.
F. Positive results from an internal audit or adherence to regulatory guidelines.
G. All parties increasingly accept voluntary reporting systems.
1.4 Key References
A. Aviation Safety Action Program AC 120-66B (http://www.faa.gov/safety/programs_initiatives/
aircraft_aviation/asap/policy/).
B. HFACS-ME (www.hf.faa.gov/docs/508/docs/maint_product638b.pdf).
C. Maintenance Error Decision Aid (MEDA) User’s Guide and Results Form and Ramp Error
Decision Aid (REDA) User’s Guide and Results Form (MaintenanceEngineering@boeing.
com and 206-544-7608).
• MEDA User Guide (www.hf.faa.gov/opsmanual/assets/pdfs/MEDA_guide.pdf)
• MEDA form (www.hf.faa.gov/opsmanual/assets/pdfs/MEDA_form.pdf)
• REDA form (www.hf.faa.gov/opsmanual/assets/pdfs/REDA_form.pdf)
EVENT INVESTIGATION
Chapter 1
7. The Operator’s Manual for Human Factors in Aviation Maintenance 06
DOCUMENTATION
Chapter 2
“Mechanics would benefit from using Airliner
Maintenance Manuals with more specific instructions
for critical flight system procedures.”
NTSB/AAR-04/01
8. The Operator’s Manual for Human Factors in Aviation Maintenance 07
Documentation ranges from manufacturers’ technical manuals to an organization’s job
cards to publications from your regulator. Numerous post-event investigations have clearly
demonstrated that failure to use documentation appropriately was a major contributing factor.
Issues associated with maintenance documentation are related to the way the information is
written, to where and how it is accessed in an organization, and to the motivation of aviation
maintenance personnel. There are often numerous and diverse reasons that documentation is
not used properly. A good MHF program must address and correct documentation challenges.
2.1 Why Documentation is important
A. A 2004 UK Flight Safety Committee determined that the top three causes of
maintenance mishaps were:
1. Failure to follow published technical data or local instructions.
2. Using an unauthorized procedure not referenced in the technical data.
3. Supervisory personnel accepting non-use of technical data or failure to
follow maintenance instructions.
B. A 2001 FAA study found that documentation is the leading contributing factor to
maintenance events. In most cases organizational issues resulted in failure to use
documentation that was available.
C. A 2002 study of procedural issues from NASA Aviation Safety Reporting System incident
reports showed that the following factors contributed to documentation-related errors:
procedural design flaws, user errors, currency and accessibility of documents, and
organizational practices.
D. Aviation maintenance personnel spend from 25-40% of their time searching for, using
and completing maintenance documentation.
2.2 How to implement a Documentation program
A. Ensure that your event reporting system is capturing events where documentation is
a contributing factor; code these events so that focused interventions are developed
and tracked.
B. When implementing technology upgrades or changes to the document system,
preserve standardization and best practices; take the opportunity to address
current problems.
C. When addressing standardization issues across mixed fleets, use industry working
group to achieve standardization (e.g., structure, terminology, logic) within and
across manufacturers.
D. For technical documentation that is developed by the maintenance organization,
develop guidelines and standards for the documentation development. The guidelines/
standards should include the following:
1. Use a standard format and page layout.
2. Use one action per statement.
3. Write DANGER, WARNING and CAUTION statements using current international
(American National Standards Institute/International Standards Organization)
standards.
DOCUMENTATION
Chapter 2
9. The Operator’s Manual for Human Factors in Aviation Maintenance 08
4. Avoid using acronyms and abbreviations.
5. Ensure that where an arrow is pointing to a figure or graphic it is immediately obvious.
6. Use A Guide for the Preparation of Aircraft Maintenance Documentation in the
International Aerospace Maintenance Language (Simplified English).
7. Verify the documentation by having a second person check for technical accuracy.
8. Validate the documentation by having a sample of users check for usability.
E. Provide a process for immediate and longer-term improvements to technical documents
based on user feedback.
F. Ensure prompt acknowledgement to submissions for document change.
G. Respond to the document improvement suggestion in a timely manner.
H. Develop measures to track specific documentation problems and corrective actions.
I. Be sure the document delivery system is functional and well maintained.
J. Use advice from documentation research and industry best practices.
2.3 How to know it is working
A. Event investigations and audits indicate a reduction in the number of documentation-
related incidents and findings.
B. There is an increased employee use of documentation, which could require additional
access, room, and equipment.
C. Users report inaccurate, ambiguous, or incomplete documentation.
D. Recommended changes to documentation are being acknowledged and addressed in a
timely manner.
E. Immediate and longer-term change requests may increase following program
modifications and spike under certain conditions (e.g., new fleet), but should
decrease over time.
F. There are decreased documentation complaints from users.
G. Authoring groups adopt a higher standard of quality, including verification and validation.
2.4 Key References
A. SD Simplified Technical English (2005). AeroSpace and Defense Industries Association
of Europe Specification ASD-STE100(tm) (http://www.simplifiedenglish-aecma.org/
Simplified_English.htm#se_guide).
B. Inaba, K., Parsons, S.O., and Smillie, R. Guidelines for Developing Instructions. Boca
Raton, FL; CRC Press (ISBN 0-415-32209) (Amazon.com).
C. United Kingdom Civil Aviation Publication (CAP) 716: Aviation Maintenance Human
Factors (EASA Part-145), Chapter 6 and Appendices N and O. ( http://www.caa.co.uk/
docs/33/CAP716.PDF).
DOCUMENTATION
Chapter 2
10. The Operator’s Manual for Human Factors in Aviation Maintenance 09
“The Safety issues raised in this report include:…The Human
Factors aspects of air carrier maintenance and inspection
for the continuing airworthiness of transport category
airplanes, to include repair procedures and the training,
certification and qualification of mechanics and inspectors.”
NTSB AAR-89/03 FINAL REPORT
HUMAN FACTORS TRAINING
Chapter 3
11. The Operator’s Manual for Human Factors in Aviation Maintenance 10
Research and experience have shown that Human Factors training can address many of the
issues that contribute to events. Training can reduce costs associated with human performance
issues.
3.1 Why Human Factors Training is important
A. Human Factors training is instrumental in fostering a positive safety culture.
B. Human Factors training for the workforce, including for the leadership, is a critical and
cost-effective first step in identifying methods to recognize, understand, and manage
human performance issues.
C. Effective Human Factors training not only improves work performance, but also promotes
workforce physical and psychological health.
D. Initial and recurrent training on new regulations, procedures, and equipment are
opportunities to reinforce awareness of the Human Factors issues that affect job
performance.
E. ICAO and many NAAs mandate or recommend Maintenance Human Factors training,
recognizing its impact on safety and quality.
3.2 How to implement a Human Factors Training program
A. Maintenance Human Factors experts have identified the following key topics to be
included in a training program:
1. General/introduction to Human Factors.
2. Safety culture/organizational factors.
3. Human error principles, event investigation and case studies.
4. Human performance and limitations.
5. Environment.
6. Procedures, information, tools and task sign-off practices.
7. Planning of tasks, equipment, and spares.
8. Communication.
9. Teamwork.
10. Professionalism and integrity.
11. Shift and task turnover.
12. Undocumented maintenance.
13. Fatigue management/fitness for duty.
B. Determine training requirements and company priorities to map to the key topics listed
above.
C. Work to ensure cooperative development between workforce and management.
D. Integrate training with a system wide Human Factors plan.
HUMAN FACTORS TRAINING
Chapter 3
12. The Operator’s Manual for Human Factors in Aviation Maintenance 11
E. Decide on content and delivery technique matched to audience requirements.
F. Decide on internal/external provider.
G. Deliver initial training and begin planning for recurrent training.
H. Measure the effects of training, provide feedback to the instructors and the management,
improve training, and measure the effects again.
3.3 How to know it is working
A. Regulatory program acceptance/approval.
B. Management/Workforce acceptance/approval.
C. Pre- and post-training evaluations and workplace discussions from trainees
show positive trends.
D. Event investigations indicate a reduction in the number of human-factors-related
contributing factors. Expect increase in reported events at first because of
improved awareness.
E. Work performance is improved in targeted areas.
F. Demonstrated employee behavior change towards safety awareness.
G. Increased requests for more/recurrent training.
3.4 Key References
A. Air Transport Association (2001). ATA Specification 104 Guidelines for Aircraft
Maintenance Training. Washington, DC: Air Transport Association.
(http://66.153.70.186/ATA_eBiz/Default.aspx?tabid=44&action=
ShowProductDetails&args=128).
B. Federal Aviation Administration (2000). Maintenance Resource Management Training
Advisory Circular AC 120-72. Washington, DC: Federal Aviation Administration
(http://www.hf.faa.gov/docs/508/docs/AC120-72.pdf).
C. ICAO (1998). Human Factors Training Manual Doc 9683-AN/950. Montreal, Canada:
International Civil Aviation Organization.
(http://www.icao.int/anb/humanfactors/Documents.html).
HUMAN FACTORS TRAINING
Chapter 3
13. The Operator’s Manual for Human Factors in Aviation Maintenance 12
SHIFT/TASK TURNOVER
Chapter 4
“Departures from approved procedures included failures
to solicit and give proper shift-change turnover reports,
failures to use maintenance work cards as approved, failures
to complete required maintenance/inspection shift turnover
forms, and a breach in the integrity of the quality control.”
NTSB AAR-92/04 FINAL REPORT
14. The Operator’s Manual for Human Factors in Aviation Maintenance 13
Shift and task turnover are critical periods in aircraft maintenance activities because workers
relay crucial information for ending a shift and starting another. This can also apply to an
exchange of task information within a shift. Efficient and effective turnovers require adherence
to policies, procedures, planning guidelines, teamwork, and effective communication practices.
The classic challenges associated with fatigue, distraction, false assumptions, personnel
conflicts, cultural prejudices, and failure to properly document can negatively affect the quality
of shift turnover as well as task turnovers within shifts. Events have shown us that inadequate
information exchange during shift and task turnovers can have serious consequences.
4.1 Why is Shift/Task Turnover Important?
A. Data show that poor shift/task turnover is a common contributing factor to events.
B. Challenges related to shift turnover include:
1. High demand for teamwork and interpersonal communication skills.
2. Need for structured and standardized policies and procedures.
3. Using a location that is conducive for discussion and planning.
4. Ineffective verbal and written communication.
5. Finishing workers are tired and want to depart facility.
6. Lack of adequate shift overlap to provide time to give one-on-one briefings between
the team leaving and the team coming on.
7. Absence of a process to ensure departing personnel have documented all tasks
accomplished or started.
8. Minimal training on procedures for shift/task turnover.
C. High-quality shift/task turnover procedures enable improvement in practice and improve
safety and accountability to all involved in the work.
D. Most NAAs have regulations that require a formal process for shift turnover.
4.2 How do you implement the Shift/Task Turnover process?
A. Create and instill standard policies, procedures, and protocol.
1. Formalize policy and procedures that make the turnover as important as the work.
2. Develop, improve, and implement policies and procedures.
3. Communicate policy and procedures to all personnel.
4. Consider technology enhancements that improve the transfer of visual information
(e.g., photos, graphics, movies).
5. Consider best practices documents for shift/task turnover.
SHIFT/TASK TURNOVER
Chapter 4
15. The Operator’s Manual for Human Factors in Aviation Maintenance 14
B. Provide a time and place for formal shift/task turnover.
1. Dedicate a location for shift turnover meetings that is clean, comfortable, and relatively
free of distractions. Access to computers and data sources should be provided, if
appropriate.
2. Include a dedicated time for a proper shift turnover within the regular work hours.
3. Carry out the task turnover at the aircraft where the task is being accomplished.
C. Ensure the quality of shift/task turnover Information.
1. Standardize written communications.
2. Ensure consistent level of detail in turnover documentation.
D. Deliver initial and recurrent training on how to conduct a good shift/task turnover.
1. Emphasize the criticality of shift/task turnover and impact on continuing safety.
2. Emphasize use of checklists, shift status reports, and applicable shift/task turnover
documents.
3. Define acceptable communication practices.
4. Describe how to conduct and participate in turnover meetings.
4.3 How to know it is working
A. Decrease in regulatory findings/concerns related to shift/task turnover.
B. Audit findings show reduced errors.
C. Less task rework.
D. Improved quality of the documentation for describing both the shift and task turnover
processes.
E. Noticeable improvement in communication and cooperation between/among shifts. Less
“blaming the other shift.”
4.4 Key References
A. Maddox, M. (1998) Shift work and Scheduling in Maddox (Ed, 1998) The Human Factors
Guide for Aviation maintenance and Inspection, Washington, DC. Federal Aviation
Administration (http://www.hf.faa.gov/docs/508/docs/shiftwork.pdf).
B. Jiang, X., Master, R., Kelkar, K. and Gramopadhye, A. K. (2002). Task Analysis of Shift
Change Activity in Aviation Maintenance Environment: Methods and Findings, Human
Factors and Aerospace Safety, 2(1), 45-69. (http://www.hf.faa.gov/opsmanual/assets/
pdfs/Analysis_of_Shift_Change.pdf)
C. Offshore Technology Report - OTO 96 003. Effective Shift Handover - A Literature
Review. Health and Safety Executive. Author - Ronny Lardner. (http://www.hf.faa.gov/
opsmanual/assets/pdfs/CAP716.pdf)
SHIFT/TASK TURNOVER
Chapter 4
16. The Operator’s Manual for Human Factors in Aviation Maintenance 15
“A combination of 16 hours of straight work compounded
by influenza contributed to fatigue and falling asleep
at the wheel…”
AIRPORT INTERNAL REPORT
FATIGUE MANAGEMENT
Chapter 5
17. The Operator’s Manual for Human Factors in Aviation Maintenance 16
Fatigue can be caused by many factors, including physical and mental exertion and lack of
proper sleep. Fatigue issues can also be called “Alertness” issues because alertness includes
a broader range of factors associated with human fitness for duty.
Most aviation maintenance personnel, who have worked extended hours to repair an aircraft
away from base, remember that they were fatigued more than they remember the complexity
of the technical repair. The entire workforce is susceptible to errors induced by fatigue. FAA
research found that the maintenance workforce does not achieve proper sleep. Further, the
workforce does not recognize their fatigue and compensate accordingly.
Fatigue/Alertness Management programs are generally voluntary. Nevertheless, Fatigue/
Alertness Management is an important component of a Human Factors program.
5.1 Why Fatigue/Alertness Management is important
A. Longer commutes and extended shifts, double and triple shifts, shift swapping, and extra
jobs impose greater demands on the workforce and reduce the time to sleep.
B. Reduced numbers of maintenance personnel result in increased workload on remaining
workers.
C. Fatigue affects emotional, physical, and mental capabilities.
D. Fatigue causes performance decrements similar to those caused by alcohol.
E. Few regulations adequately address the issue of alertness.
5.2 How to implement a Fatigue/Alertness Management program
A. Seek expertise to develop, implement, and measure the effectiveness of the program.
B. Fatigue/Alertness Management programs must adjust to shift rotation patterns, worker
schedules, and local circumstances.
C. Encourage workforce participation and input.
D. Ensure that fatigue issues are considered during event investigations.
E. Implement Fatigue/Alertness Management awareness training.
F. Ensure compliance with applicable regulations from your National Aviation Authority.
5.3 How to know it is working
A. Less absenteeism/sickness/injuries.
B. Less rework.
C. Increased self-awareness of fatigue.
D. Reduced events related to fatigue/alertness.
FATIGUE MANAGEMENT
Chapter 5
18. The Operator’s Manual for Human Factors in Aviation Maintenance 17
5.4 Key References
A. ICAO (2003) Human Factors Guidelines for Aircraft Maintenance. Doc. 9824 Appendix H, of
Chapter 3, ‘Possible fatigue management interventions’ (http://www.hf.faa.gov/opsmanual/assets/
pdfs/ICAOHF.pdf).
B. Johnson, W.B., Mason, F., Hall, S., and Watson, J (2001). Evaluation of Aviation Maintenance
Working Environments, Fatigue, and Human Performance. Washington, DC: Federal
Aviation Administration Office of Aviation Medicine. (http://www.hf.faa.gov/docs/508/docs/
WorkingEnvironments.pdf).
C. Dawson, D., Fletcher,A., and Hussey, F. (2001). Beyond the midnight oil. Proceedings of the 15 th
Annual FAA Symposium on Human Factors in Aviation Maintenance and Inspection. (http://www.
hf.faa.gov/docs/508/docs/MidnightOil.pdf).
FATIGUE MANAGEMENT
Chapter 5
19. The Operator’s Manual for Human Factors in Aviation Maintenance 18
SUSTAINING & JUSTIFYING AN HF PROGRAM
Chapter 6
“…various initiatives come and go sometimes based on
corporate whims… a sustainable maintenance human factors
program must have shared support from senior management
and all levels of company personnel… the program must
show value in continuing safety, worker job satisfaction,
and cost control…”
W.B. JOHNSON, FAA
20. The Operator’s Manual for Human Factors in Aviation Maintenance 19
SUSTAINING & JUSTIFYING AN HF PROGRAM
Chapter 6
The first five topic areas of this document recommend specific actions. The topics of Program
Sustainability and Cost Justification are general and apply to all aspects of a MHF program.
MHF programs often get off to a good start but then struggle over time. Challenges to program
sustainability include changes in policies and projects when management changes, a lack
of cost justification, and limited program integration. The ideas presented here help sustain
multiple MHF initiatives and provide a straightforward consideration of cost justification.
6.1 Why Program Sustainability is important
A. Benefits of a MHF program are seldom immediate. A long-term commitment to the
program is needed.
B. A long-term sustained program is necessary to create and maintain culture change.
C. Motivation and enthusiasm for programs will subside if programs are constantly changing
like a “flavor of the month.”
D. Programs must be sustained long enough to collect measurement data and demonstrate
a Return on Investment (ROI).
6.2 How to sustain a MHF program
A. Establish a Steering Committee to develop and monitor planning and implementation of
MHF programs.
B. Start with a program plan with sufficient detail to secure a policy-level commitment from
leadership with workforce buy in.
C. Ensure that each MHF-related initiative can stand-alone without depending on other MHF
initiatives.
D. Ensure that the program plan is consistent with corporate policies and procedures and
that it is designed to achieve specific goals that are consistent with the corporate mission
and values.
E. Ensure that all parties within the company can share the success of various components
of the program. Communicate these successes.
F. Build an individual-level and team-level recognition system that acknowledges everyone’s
efforts to improve the system and celebrates successes.
G. Prepare for occasional setbacks. Examine each setback seriously and develop timely
recovery strategies so that it does not jeopardize the entire program.
H. Conduct regular meetings (not one-way briefings) with leadership and workforce to share
goals, successes, and lessons learned.
6.3 How to know it is working
A. Heightened employee attitude towards safety, months after initial training.
B. Consistent follow-up by leadership to support system-wide improvements.
C. Employees are not disciplined for reporting their errors.
D. Increased trust between workforce and leadership.
21. The Operator’s Manual for Human Factors in Aviation Maintenance 20
E. Increased involvement of the workforce sharing their ideas for improvement.
F. Increased voluntary workforce error disclosure (NOTE: Increased reporting may appear
to be increased “errors.” Be sure these two are not equated).
G. Decreased repetitive errors/rework.
H. High interest in event investigation results and MHF initiatives.
I. Increased positive feedback on the MHF initiatives from all levels of the organization.
J. Increased positive responses on annual employee surveys.
6.4 Why Cost Justification is Important
A. Maintenance Human Factors interventions compete for resources. Senior managers ask
for measures to show how Human Factors interventions can affect the “bottom line.” They
want to know the return on investment for Maintenance Human Factors.
B. When Maintenance Human Factors programs are voluntary, not regulatory, they are likely
justified either on the grounds of safety or cost.
6.5 How to implement measures to quantify Maintenance Human Factors
investments for cost justification
A. Useful cost justifications must be straightforward and easy to understand. They need not
be computed by economists.
B. The imprecise measurement of Human Factors interventions may complicate cost
justification calculations.
C. Try to use existing maintenance event examples for cost justifications. Use data from the
event investigation system described in Section 1.
D. How to calculate a Return on Investment (ROI) of a specific maintenance-related event.
1. The basic equation for ROI is simple: merely divide benefit by cost.
2. Estimate the annual cost of a particular type of maintenance error. Call this “Cost.”
3. Determine the contributing factors to the event, and estimate the cost to mitigate these
factors. Keep it simple and call this “Cost to Fix.”
4. Estimate a reasonable “Probability of Success” that the interventions will be
successful. Say, for example, that you estimate an 80% success rate.
5. Multiply “Cost” by “Probability of Success.” Call this “Return.”
6. Divide (“Return” – “Cost to Fix”) by “Cost to Fix.” Call this “Return on Investment”
(ROI).
7. A positive ROI (> 1.0) may not be achieved in one year.
SUSTAINING & JUSTIFYING AN HF PROGRAM
Chapter 6
22. The Operator’s Manual for Human Factors in Aviation Maintenance 21
6.6 Key References
A. Stelly, J. and Poehlman, K. 2000. Investing in Human Factors Training: Assessing the
Bottom Line. Presented at the 14 th Annual Human Factors in Aviation Symposium.
Vancouver, Canada. (http://www.hf.faa.gov/508/docs/508/JSTELLY.PDF).
B. Patankar, M.S., and Taylor, J.C. (2004). Risk management and error reduction in aviation
maintenance. Aldershot , U.K.: Ashgate Publishing. (Amazon.com)
C. Johnson W.B., Sian, I.B., and Watson, J. (2000). Measuring the impact of human factors
interventions. SAE Meeting on Advances in Aviation Safety. Daytona Beach, Florida, April
11-13, 2000. SAE paper. (http://www.hf.faa.gov/docs/508/docs/Johnson_ROI.pdf)
SUSTAINING & JUSTIFYING AN HF PROGRAM
Chapter 6
23. The Operator’s Manual for Human Factors in Aviation Maintenance 22
The Federal Aviation Administration gratefully acknowledges the following working group
members and their organizations that willing gave of their knowledge, time, and expenses:
John J. Hiles
FAA Flight Standard Service - Aircraft Maintenance Division
Roger Hughes
jetBlue Airways
William B. Johnson
FAA Office of Aviation Safety
Ernie Kiss
Aircraft Mechanics Fraternal Association, Northwest Airlines
Barbara Kanki
NASA - Ames Research Center
Terry Kleiser
FedEx Express
Manoj Patankar
Saint Louis University
William Rankin
The Boeing Company
Dave Supplee
International Association of Machinists and Aerospace Workers, US Airways
Dennis Watson
Transport Workers Union, American Airlines
The authors thank photographic contributions from:
FedEx Express
jetBlue Airways
Lufthansa Technical Training
The authors thank Dr. William K. Krebs, FAA ATO-P R&D, for editorial comment and overall
assistance with quality assurance.
Photographic contributions and web-based development provided by FedEx Express,
jetBlue Airways, Lufthansa Technical Training, and HumanCentric Technologies.
This document and website was guided by the FAA Office of Aviation Safety
and the Flight Standards Service. The project was funded through ATO-P R&D
Human Factors Research and Engineering Division.
http://www.hf.faa.gov/opsmanual
ACKNOWLEDGEMENTS