2201 - accident

Information

Information

refers to the written or computerized source data that a maintenance technician needs to carry out a task or job.

Equipment tools and parts

necessary for performance of a maintenance task. Equipment and tools refer to things such as non-destructive test equipment, work stands, calibrated torque wrenches, screwdrivers, test boxes, and special tools called out in maintenance procedures.

designed and configured

An airplane should be _________ so that parts and systems are accessible for maintenance. The maintenance technician should be able to reach a part, should be able to remove it from a reach and strength stand point, and should be able to easily replace the part in the correct orientation.

maintenance investigation

reviews the maintenance history of the airplane, the actions of the maintenance organization and its staff and the program under which it was maintained to determine:

maintenance technician’s work

A ______ can logically be separated into a series of tasks. Under certain circumstances, when the tasks are poorly planned and/or combined, the work can become quickly become unmanageable.

Technical skills and Technical knowledge

Maintenance technician/engineer technical knowledge/skills

Technical skills

(sometimes also referred to as abilities) refer to tasks or subtasks that maintenance technicians are expected to perform without having to refer to other information.

Technical knowledge

refers to the understanding of a body of information that is applied directly to performing a task.

Airline Process knowledge, airplane systems knowledge, and maintenance task knowledge

Three broad categories of knowledge are required of a technician:

Airline process

knowledge refers to knowledge of the processes and practices of the airline or repair station in which the maintenance technician works.

Aircraft system knowledge

refers to knowledge of the physical aircraft systems and equipment.

Maintenance task knowledge

refers to the specific knowledge required to perform a unique task.

Factors affecting individual performance

vary from person to person and include factors brought to the job by individuals (e.g., body size/strength, health, and personal events) and those caused by outside factors (e.g., peer pressure, time constraints, and fatigue caused by the job itself).

Physical health

includes the acuity of human senses as well as physical conditions and physical illnesses.

Physical conditions

such as headaches and chronic pain, also have been shown to relate to errors.

Fatigue

has been defined by the U.S. Federal Aviation Administration (FAA) as a depletion of body energy reserves, leading to below-par performance.

Time constraints or time “pressure”

are common to the maintenance technician. The need to finish a maintenance task so an airplane can be released from the gate or to finish a heavy maintenance task so an airplane can be put back into service often causes technicians to feel pressure to get their tasks done.

Peer pressure

can also influence a maintenance technician’s performance.

Body size and strength

are two obvious factors that affect a maintenance technician’s ability to perform a task. If someone is too small to reach a plug or if someone is unable to let down an LRU from an upper rack, this can contribute to error.

working environment and facilities

The ______ can contribute to error. For example, temperature extremes (either too hot or too cold), high noise levels, inadequate lighting (reflection/glare, etc.), unusual vibrations, and dirty work surfaces could all potentially lead to maintenance errors.

organizational culture

The ____ can have a great impact on maintenance error. Factors such as internal communication with support organizations, trust level between management and maintenance technicians, management goals and technician awareness and support of those goals, union activities and attitudes, morale, etc., all affect productivity and quality of work.

supervisors

Even though _____ normally do not perform the tasks, they still contribute to maintenance error by poor planning, prioritizing, and organizing of job tasks

leadership

Also, supervisors and higher-level management must also provide _____. That is, they should have a vision of where the maintenance function should be headed and how it will get there. In addition, leadership is exhibited by management “walking the talk,” that is, showing the same type of behavior expected of others.

Edwards (1972) and Hawkins (1987),

The SHEL model, originally developed by ____ and modified by -----, facilitates a systematic approach to data collection. Each component of the SHEL model (software, hardware, environment, and liveware) represents one of the building blocks of human factors studies.

Liveware-Hardware (Human-Machine)

This interaction includes any physical or mental interactions between the human and the machine, design limitations and peculiarities in work-station configuration.

Liveware-Software (Human-System)

This interaction concerns the nature of the information transfer between the human and supporting systems such as checklists, manuals, training, procedures, and regulations.

Liveware-Environment (Human-Environment)

This interaction subdivides into two areas:

• Internal: Personal comfort and physical working conditions.

• External: Weather, aerodrome surroundings and infrastructure

Liveware-Liveware (Between People)

This interaction explores the nature of human interactions and communication breakdowns between individuals.

Reason’s Model of Accident Causation

A framework proposed by James Reason (1990) explains how humans contribute to the breakdown of complex, interactive, and well-guarded systems such as the aviation industry. In such a system, accidents rarely originate from active failures or unsafe acts of front-line operators alone.

James Reason (1990)

the framework Reason’s Model of Accident Causation was proposed by ____ explains how humans contribute to the breakdown of complex, interactive, and well-guarded systems such as the aviation industry. In such a system, accidents rarely originate from active failures or unsafe acts of front-line operators alone.

Latent Unsafe Conditions (LUC) Framework

The _____ is an extension of the Reason model, with an emphasis on a systematic means for examining personal and organizational factors. This framework comprises the elements of the SHEL model within the Reason concept of latency.

Latent unsafe conditions

include all those latent factors in the transportation system which can adversely affect safe operations or maintenance. They include latent factors at both the personal and the organizational level and may be referred to as LUC factors.

reason

According to _____, accidents result from the interaction of a series of flaws, or latent failures, already present in the system.

Personal LUC Factors

Latent unsafe conditions at the personal level are known as _____. These factors may limit or degrade an individual’s expected performance, resulting in an error of some type.

Organizational LUC Factors

Latent unsafe conditions at the organizational and management level are known as ______.

Behavior and Error Framework

has been adapted primarily from Rasmussen (1987) taxonomy of behaviors and Reason’s (1990) generic error-modeling system (GEMS) framework which facilitates the linkage of an error to an individual’s level  of performance (i.e., behavior) at the time the failure occurred.

Skill-based performance

describes behavior for a person engaged in a well-learned activity.

Rule-based performance

is less automatic. Decisions are based on learned procedures; these procedures are stored in long-term memory and require the involvement of the central decision maker and working memory because rule-based behaviors are actioned at the conscious level

Knowledge-based performance

is behavior that arises when an operator is faced with novel situations for which there are few pre-established rules, but which require that appropriate action be taken.

Human Errors of Behavior

There are two distinct categories of error, those actions that deviate from intention or are unintended (i.e., actions that do not proceed as planned) and those that are intended (i.e., actions that proceed as planned, but they fail to achieve the desired consequences).

Unintended Actions

“Was the action that was carried out, the action that was planned”?

Intended Actions

Was the action that was carried out, the action that was planned”? If the answer to that question is yes, then it is an

Skill-based slips and lapses

If the error involves skill-based performance, then a slip or a lapse would have occurred due to either inattention or over attention