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Evolving Human Factors Recurrent Evolving Human Factors Recurrent TrainingTraining for Maintenancefor Maintenance

““Paper Shredder Paper Shredder Guarantees New MaterialGuarantees New Material““

JJ MilanoJJ Milano

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Aren’t Computers Great!

Here, Dr. Bill explains how in the future, technicians will fix aircraft without leaving their office.

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Quick History of Horizon Air

• Northwest Regional Airline• Established 1981• Two leased Fairchild F-27• 36 employees• Seattle – Yakima, WA

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Horizon Air Today

• 4,000+ employees• Serve more than 45 cities• Regional Airline of the

Year 2007

• Today:

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Route Map

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Aircraft In fleet On order Options

Bombardier Q400 37 11 20Bombardier CRJ-700 18 0 0Total 55 11 20

Today’s “Equipment”

Q-400 CRJ-700

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Operations Center Portland, OR

863,000 Square Foot Hanger

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Q400 Tail Dock Portland, OR

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CRJ-700 Nose/Tail Dock Portland, OR

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Human Factors Training & Horizon Air

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Human Factors History

• 400+ Mechanics and Supervisors attended two-day seminar

• Classes later included fleet services• Two-day workshop continues inside a

two week “New Hire” orientation course

• Human Performance In Aviation Maintenance Workshop (HPIAM)• Spring 2001

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• Do we have a “climate” of safety?

• Do we have a “culture” of safety?OR

Climate vs. Culture

* Patankar, M (2005). A Comparative Review of Safety Cultures.

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Culture of Safety

Culture of SafetyMechanics

New Mechanic

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Nothing Lasts Forever

* Patankar, M. & Taylor, J. (2000). Targeted MRM Programs: Setting ROI Goals and Measuring the Results.

• Positive effects of training last no more than a year and likely less (6-9 months)*

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Recurrent Human Factors

• MTX training took 6 months develop• FAA Letters of Investigation (LOI)• ASAP self-disclosure reports• QA audit findings

• Built a one day (eight-hour) course• Launched in January 2006

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Trends Identified4th Qtr QA Audit 2008

3 2

11

27

1 10

5

10

15

20

25

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EQP MAT PRC HF TRG MGT

Root Causes

Occ

uran

ces

Equipment – Materials – Procedures – Human Factors – Training – Management

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Let’s Look at Horizon’s Recurrent HF Course

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• Rooted in HF philosophy• Address current Horizon Air issues• Evolve and change as company changes

What would recurrent training look like?

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1. Quick review of the Dirty Dozen2. “Sell” Horizon’s Safety Culture3. Actual Horizon Air events –

(ASAP Reports, QA Audit Findings & FAA Letters of Investigation)

4. Feedback collection process for next year’s MRM content

Recurrent Human Factors

Four Main Characteristics

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Recurrent Human Factors

Feedback collection process

MRMCourse

StudentFeedback

(Surveys &Critiques)

Error Data/Analysis

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MORNING SESSIONIntroduction & Rules of the Road

Participant IntroductionsStatement of Objectives

The “Dirty Dozen” RevisitedCase Studies: “When Rags become FOD”

Case Studies: “Going Nuts over Nut-plates”FAA Human Factors Manual

Case Studies: “Runaway Run-Taxi”Human Error at Horizon Air

Roundtable Discussion: Are We at Risk?

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Murphy’s LawManagement Greeting

Case Studies: “Pre-Mod/Post-Mod PSU”Norms: The Silent Enemy

Exercise: “Shortcut or Safety Shortfall?”Safety Reporting Systems

ASAP Program Case Studies: “Certs turning into Pumpkins”

Last Year’s Survey ResultsMRM in the Future

Workshop Review & Critique

AFTERNOON SESSION

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1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue7. Lack of Resources8. Pressure9. Lack of Assertiveness10. Stress11. Lack of Awareness12. Norms

“DIRTY DOZEN” REVIEW

Adapted from Gordon DuPont

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Horizon Air Case Study

You will never run out of these!

26When Rags become FOD

MRM Case Study

What’s included in

the case study

package?

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Dash8-Q200 MLGDash8-Q200 MLG

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CASE STUDY: Tear Down Photo

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CASE STUDY: Tear Down Photo

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CASE STUDY: Chronology of Events

• During tear down of #2 MLG a three hour interruption was experienced to locate parts

• Frustration was felt to leave a job in such a state while proper parts were located

• MTX Techs were reassigned to other tasks• No one could remember putting “shop rag”

into strut assembly• Parts were eventually located and the task

was completed• While in service, problems with #2 MLG

caused complete tear down, rag found in strut

• N353PH #2 MLG repack was performed by graveyard tech on 10/24/2006

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• What safety nets would prevent this from happening again?

• Was incident preventable?• What were links in the chain of events?”

ROUND TABLE DISCUSSION: (After each case study.)

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• Landing Gear strut repack / restoration Work Cards (EC) revised for all fleet types

• All fleet types to incorporate QC inspection step for FOD inspection and correct assembly in the build up.

• FAA Liaison office to monitor promised actions• QA to conduct audits of promised actions to

ensure they are effectively implemented

CASE STUDY: ERC ACTION ITEMS

• Event Review Committee recommends (per ASAP report) creation of MTC for Main Landing Gear shock strut repack

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CASE STUDY: ERC ACTION ITEMS

New Task Card with QC Inspection added.

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James Reason’s Swiss Cheese Model

Threat

Adapted from J. Reason

Task Card

Planning

Stress &Distraction

RII / QCCom

pany

C

omm

unic

atio

n

Em

ploy

ee

QX

O

rgan

izat

ion

Insp

ectio

n

Fixing the Task Card, may prevent this type of error.

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• All Participants Sampled• 48 Questions• Course Objectives

• Human Error• QX Resources• MRM Case Studies• Effecting Change• Safety Reporting• MRM Training

Maintenance Resource Management(MRM) Questionnaire

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48 Questions!

Maintenance Resource Management(MRM) Survey

1-5 Likert Scale

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Effecting positive change is both an obligation AND a right of the certificated mechanic.

3.50

3.70

3.90

4.10

4.30

4.50

4.70

4.90

All

PDX

Station

s1-

10 Y

ears

11-20

Yea

rs

21+ Y

ears

Mecha

nicSup

ervis

orsOthe

r MTX

Maintenance Resource Management(MRM) Questionnaire

Like

rt S

cale

1-5

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FAA HF Cookbook

Horizon Air’s secret recipe for a delicious RECURRENT HF TRAINING COURSE?

Get out a sheet of paper and

pencil.

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Horizon Air’s secret recipe for a delicious RECURRENT HF COURSE?

3 fresh ASAP reports4 quarters QA Audit Data1 juicy FAA LOIDash of Missed RII’s

Fold in the Dirty Dozen

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Horizon Air’s secret receipt for a delicious RECURRENT HF COURSE?

Bake at AC120-92 for 4 – 8 hours.

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Horizon Air’s secret receipt for a delicious RECURRENT HF COURSE?

Best served up seminar style

10 – 12 mechanics, supervisors, and inspectors (keep it mixed)

Repeat once a year

42Shredder

Keep your course fresh!

Last Year’s Case Studies

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Keep your course fresh!

Always be thinking about next year.

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Thank You!Thank You!

JJ MilanoJJ Milano

Evolving Human Factors Recurrent Evolving Human Factors Recurrent TrainingTraining for Maintenancefor Maintenance