Airworthiness: Maintenance Error Dirty Dozen

Presented to:

Federal AviationAdministration

AirworthinessHuman Factors

Maintenance Error- Dirty Dozen

2Federal AviationAdministration

Dirty Dozen- Human Error in Aircraft Maintenance

Objectives• Illustrate that human error in

maintenance causes death and destruction

• Identify 12 causes of maintenance error, “The Dirty Dozen”

• Suggest how to reduce maintenance error

The Best People Make the Worst Mistakes

Delta Flight 1288 MD-88

The Dirty Dozen

• Communication

• Complacency

• Lack of Knowledge

• Distraction

• Teamwork

• Fatigue

• Lack of Resources

• Pressure

• Assertiveness

• Stress

• Lack of Awareness

• Norms

“The Dirty Dozen”1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue

7. Lack of Resources 8. Pressure 9. Lack of Assertiveness10. Stress11. Lack of Awareness12. Norms

Safety NetsUse logbooks, worksheets etc. to

communicate and remove doubt.

Discuss work to be done or what has been completed.

Never assume anything.

Safety 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

7. Lack of Resources8. Pressure9. Lack of Assertiveness

10. Stress11. Lack of Awareness12. Norms

Safety Nets

Train yourself to expect to find a fault.

Never sign for anything you didn’t do.

Italian Air Force, Keflavik

• No lineman present for start-up• Crew asked LM to verify battery door

closed (near left landing gear) after engines were started

• LM walked thru prop, killing him instantly• First such case in Italian AF in over 50

Italian Air Force, KeflavikCREW DOOR

BATT. DOOR

Loadmaster exits crew door to check battery door.

Engines were running

Loadmaster killed as he walks into prop. Body and remains scattered over 100 feet.

Accident cleanup by “Fire Department”

Carelessness and overconfidence are more dangerous than deliberately accepted risk.

- Wilbur Wright, 1901.

Therefore the Safety Board concludes that a low expectation of finding a crack in a –219 series fan hub might have caused the inspector to overlook or minimize the significance of an indication.

Face Reality

Physical Fitness

Create Challenges for yourself

Train yourself to expect to find a fault.

Never sign for anything you didn’t do

Safety Nets

Get training on type.

Use up to date manuals.

Ask a Tech. Rep. or someone who knows.

Lack Of Knowledge

Get training on type.

Stay Current -Read, Read, Read

Use up to date manuals.

Ask a Tech. Rep.

-or someone who knows

Communicate No Pride!

Safety Nets

September 2, 1998Douglas MD-11 in the sea

9KM Off Nova Scotia

Safety NetsAlways 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.

Always 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

Safety Nets“Reconfirm duties among team members.”

“Team tasks require a full team.”

“Communicate!”

“FOLLOW THE CORRECT PROCEDURES.”

“Communicate!”

“Team tasks require a full team.”

“Reconfirm duties among team members.”

“FOLLOW THE CORRECT PROCEDURES.”

Safety Nets

Lack of Teamwork

Safety NetsBe aware of the symptoms andlook for them in yourself andothers.

Plan to avoid complex tasks atthe bottom of your circadian rhythm.

Sleep and exerciseregularly.

Ask others tocheck your work

ACUTE FATIGUEProduced by physical exertion or sleep lossAlleviated by a single rest period

CHRONIC FATIGUEMedical or psychological problemDepression or “chronic fatigue syndrome”

OPERATIONAL FATIGUEMost commonly seen after 3-4 days of heavy taskingNot relieved by a single sleep period

Fatigue

Attention reduced

Memory diminished

Mood becomes withdrawn

Low situational awareness

Long hours of labor (any type).

High intensity stress.

SYMPTOMS OF FATIGUE

CIRCADIAN RHYTHMSCIRCADIAN RHYTHMS

Be aware of the symptoms and look for them in yourself and others.

Plan to avoid complex tasks at the bottom of your circadian rhythm. Sleep and exercise regularly.

Ask others to check your work.

Safety Nets

Fatigue

Safety NetsCheck suspect areas at the beginning of the inspection and AOG the required parts.

Order and stock anticipated parts before they are required.

Know all available parts sources and arrange for pooling or loaning.

Maintain a standard and if in doubt ground the aircraft.

Jackscrew

Check suspect areas at the beginning of the inspection and AOG the required parts.

Order and stock anticipated parts before they are required.

Know all available parts sources and arrange for pooling or loaning.

Maintain a standard and if in doubt ground the aircraft.

Safety Nets

Lack of Resources

Safety Nets

Be sure the pressure is not self- induced.

Communicate your concerns.

Ask for extra help.

Just say NO.

Jessica Dubroff1988- 1996

Chiang Kai-Shek Airport Taiwan June 6, 2005

Be sure the pressure is not self- induced.

Communicate your concerns.

Ask for extra help.

Just say NO.

Safety Nets

Pressure

Safety NetsIf it’s not critical, record it in the journey log book & only sign for what is serviceable.

Refuse to compromise your standards.

AggressivePassive

Assertive

Assertiveness

AngerOffense

AcquiesceCompromise

OthersRights

YourRights

Both Party’s RightsTeam WorkSynergy

If it’s not critical, record it in the journey log book & only sign for what is serviceable.

Refuse to compromise your standards.

Safety Nets

Lack of Assertiveness

Safety NetsBe aware of how stress can effect your work.

Stop and look rationally at the problem.

Determine a rationalcourse 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.

STRESS

Be aware of how stress can effect your work.

Stop and look rationally at the problem.

Determine a rational course of action and follow 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 Nets

Stress

Safety NetsThink of what may occur in the event of an accident.

Check to see if your work will conflict with an existing modificationor repair.

Ask others if they can see any problem with the work done.

Think of what may occur in the event of an accident.

Check to see if your work will conflict with an existing modification or repair.

Ask others if they can see any problem with the work done.

Safety Nets

Lack of Awareness

Safety NetsAlways work as per the instructions or have the instructions changed.

Be aware that ‘norms don’t make it right.

This picture was taken by an amateur photographer seconds before an American Airlines DC-10 crashed at Chicago O'Hare Airport, after losing an engine during takeoff. Below is the resulting explosion. Improper maintenance procedures was to blame. Two-hundred-seventy-one people aboard were killed as well as 2 on the ground. (May 25, 1979)

Always work as per the instructions or have the instructions changed.

Be aware that ‘norms don’t make it right.

Safety Nets

FATIGUE STRESS COMPLACENCY COMMUNICATION AWARENESS DISTRACTION LACK OF KNOWLEDGE TEAMWORK LACK OF RESOURCES PRESSURE LACK OF

ASSERTIVENESS NORMSLee Marvin, Ernest Borgnine, Jim Brown, Charles Bronson, John Cassavetes, Trini Lopez, Telly Savalas, Donald Sutherland, Clint Walker

Face Reality

• Information for You

• A Request from Us

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Before We End

Airworthiness: Maintenance Error Dirty Dozen

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