# Presentation: 261089

## Human Factors In Maintenance

**Human Factors In Maintenance**

## Human Factors In Maintenance

**“****Why?”  (**_**Systems**_** Approach)**
-     - Recommended new checklist sign-off method to
-        prevent possible future errors.
_**Shift Supervisor**_
- “**Who?”  (**_**Blame**_** Approach)**
-     - Lack of Assertiveness with Marketing led to poor
-       scheduling decisions.

**Human Factors In Maintenance**

**Notes:**
Note the different philosophies of the Maintenance Manager and the Supervisor:

The Maintenance Manager wants to find out WHY the accident happened to prevent similar accidents.  She also acknowledges that people don’t just mess up, instead, the organization somehow failed as a whole.   She later demanded a checklist change to help prevent future accidents caused by poor tool control procedures (a system intervention vice individual punishment).

The Supervisor was only interested in WHO to blame.   His prevention strategy consisted of  eliminating  personnel who “failed” , vice discovering WHY the “best person” made a mistake within this overall organizational failure.   He didn’t even  acknowledge  his own scheduling failure that initiated this chain of events.

## “The Dirty Dozen”

_**Stress**_**        **_**Fatigue**_**       **_**Pressure**_

_**Lack of**_**:**
**Communication**
**Resources**
**Assertiveness**
**Awareness**
**Teamwork**
**Knowledge**

_**Abundance of**_**:**
**Pressure**
**Stress**
**Norms**
**Fatigue**
**Distraction**
**Complacency**

**“****The Dirty Dozen”**

**Human Factors In Maintenance**

**Notes:**
The Dirty Dozen (shown on slide) provides the factors that may lead to maintainer errors.  The film notes that combinations of the Dirty Dozen, vice just one factor, usually lead to accidents.  The three most often cited are Stress, Fatigue, and Pressure.

## Human Factors In Maintenance

- Fatigue (all nighter)
- Stress (separated/0630 pick up)
- Distraction (phone call/son)
- Lack of Resources (additional trained personnel)
- Pressure (plane needed in morning)
- Lack of Awareness (missed tool)
- Norms (paperwork sign-off: “ruler method”)
_**Assistant Mechanic**_
- Helpful, but Lack of Knowledge increased Lead’s burden

**Human Factors In Maintenance**

**Notes:**
For example, the film mentions the Dirty Dozen factors that most influenced the Lead Mechanic (Jerry Collins) and his assistant.

## Human Factors In Maintenance

**Organizational:**
**Checklists **
**Procedures  **
**Regulations**
** **
**Personal:**
**Tool accountability****	**** ****	****Task prioritization/organization**
**Identifying stop points ****	****Finding/expecting problems**
**Health/Rest****	****	****	****Situational awareness**** **** **

**Human Factors In Maintenance**

**Notes:**
The Dirty Dozen philosophy does not only list the factors that affect maintainers, it also highlights the need to implement “safety nets” to prevent their occurrence.  
Safety nets can be implemented at the overall organizational level or at the individual/personal level (see slide for examples).

## Human Factors In Maintenance

**Tool control/Scheduling/QA****	****	****Inadequate Processes **
**Checklists ****	****	****	****	****Inadequate Documentation**
**Insufficient Maintenance Personnel ****	****Inadequate Resources**
**No QA inspector****	****/Supervisor went home****	****Inadequate Supervision **
**Excessive work hours****	****	****	****Inappropriate Operations**
**Stress/Family/“Can do attitude”****	****	****Mental State**
**Fatigue ****	****	****	****	****	****Physical State**
**Task acceptance****	****	****	****	****Assertiveness**
**Excessive hours/Shortcuts****	****   ****	****Adaptability/Flexibility**
**Tool partially hidden by equipment****	****Obstructed**
**Failed to notice or remember tool****	****	****Attention/Memory**
**Checklist sign off/Tool inventory****	****	****Judgment/Decision Making**
**Checklists/Shortcuts****	****	****	****Routine Violation (not the 1st time)**

**Human Factors In Maintenance**

**Notes:**
The Dirty Dozen tends to focus more on the Maintainer and what he or she should do individually to prevent errors.  HFACS-ME provides a broader view to classify all organizational conditions and errors.  By investigating, classifying, and reporting all of these factors using HFACS-ME as a guide, an organization is better prepared to understand and prevent future incidents and accidents.  Here is an example of how HFACS-ME could be used to classify this same accident:

Accident Factors			HFACS-ME Categories
Tool control/Scheduling/QA			Inadequate Processes 
Checklists 				Inadequate Documentation
Insufficient Maintenance Personnel 		Inadequate Resources
No QA inspector/Supervisor went home		Inadequate Supervision 
Excessive work hours for unnecessary task		Inappropriate Operations
Stress/Family/“Can do attitude”			Mental State
Fatigue 				Physical State
Task acceptance				Assertiveness
Excessive hours/Shortcuts taken	   		Adaptability/Flexibility
Tool partially hidden by equipment			Obstructed
Failed to notice or remember tool			Attention/Memory
Checklist sign off/Tool inventory			Judgment/Decision Making
Checklists/Shortcuts			Routine Violation (not the 1st time)

Note: Why not aircraft design and confining work areas?  The problem was the misplaced tool, not that the mechanic couldn’t accomplish the task of maintenance within that space. 

As you can see, HFACS-ME classification allows more specific intervention strategies to be implemented at the organizational, local supervisory, and shop floor levels.

## Break!

**Notes:**
Break!