Priya Project

A

PROJECT REPORT ON

STUDY AND ANALYSIS ON MANAGEMENT

OF HUMAN ERRORS IN AVIATION

INDUSTRYSUBMITED BY

P.PRIYA DARSHINI

H.T No.10K81E0033

In partial fulfillment of the required for the award of the degree of the

Master of Business Administration

ST.MARTIN’S ENGINEERING COLLEGE

(Affliated to JNT University)

Dulapally, Secunderabad

YEAR 2010-12

DECLARATIONI hereby declare that this project work entitled a study on HUMAN FACTORS

LEADING TO HUMAN ERRORS IN AVIATION INDUSTRY with special

reference to AIR INDIA submitted here is genuine and original work of mine.

This project report is submitted partial fulfillment of the required for the award of

the degree of Master of Business Administration of JAWAHARLAL NEHARU

TECHNOLOGICAL UNIVERSITY, HYDREABAD For the year (2010-2012).

I had done this project work under the supervision of Ms. DIVYA (Asst.

Professor) Department of Management,

St. Martins Engineering College, Dhullapaly.

I also declare that this project is a result of my own efforts and has not been

submitted to any other university for any other degree of diploma.

Date: 26-04-2012

Place: Hyderabad (P.PRIYA DARSHINI)

ACKNOWLEDGEMENT

I am extremely thankful to the management of AIR INDIA for granting

me an opportunity to undertake this project.

A special thanks to Mr. Paul Russel who gave guidance in completing

the project & he exchanged his interesting ideas, thoughts & made this

project successful.

I take this opportunity with thanks and deep sense of gratitude for

constant help and guidance provided by our internal guide Ms.Divya,

Associate Professor , St. Martins Engineering College during project

work who are provided required guidance and constant encouragement

without which I could not have completed the project success

(P.PRIYA DARSHINI)

(10K81E0033

INDEX

SL.NO. CONTENTS PAGE NO

1. CHAPTER-1: INTRODUCTION

2 CHAPTER-2: Theoretical Frame Work

3 CHAPTER-3: COMPANY PROFILE

4 CHAPTER-4: DATA ANALYSIS &

INTERPRETATION

5 CHAPTER-5: FINDINGS

6 CHAPTER-6: SUGGESTIONS

7 CHAPTER-7: ANNEXURES

ABSTRACT

HUMAN FACTOR:

The term “HUMAN FACTORS” is used in many different ways in

the aviation industry. The term is, perhaps best known in the context of aircraft

cockpit design and crew resource management (CRM). These activities constitute

only a small percentage of aviation-related human factors. Broadly speaking it

concerns any consideration of human involvement in aviation.

Some authors refer to the subject as “HUMAN FACTORS” and some as

“ERGONOMICS”. Some see human factors as a scientific discipline and others

regard it as a more general part of the human contribution to system safety.

Although there are simple definitions of human factors exists such as “Fitting the

man to job and the job to the man”, a good definition in the context of aviation

maintenance would be:

“Human Factors is the study of the human as a central part of any system. Human

Factors identifies the capabilities and limitations of humans and then adapts the

human or the system components accordingly”.

The aim of human factors is to optimize the relationship between

maintenance personnel and systems with a view to improving safety, efficiency

and well being.

“Human factors” is a multidiscilipinary subject which includes such attributes as:

Human physiology Psychology Work place design Environmental conditions Human-machine interface

CHAPTER-1

INTRODUCTION OF

THE PROJECT

1.1 Introduction to human factors

As the name implies, the topic, human factors, is about humans and how they interact with their environment and things within that environment. The term “human Factors” is used in many different ways in the aviation industry. The term is, perhaps, best known in the context of aircraft cockpit design and Crew Resource Management (CRM).

There are many definitions available for human factors. Some authors refer to the subject as “human Factors” and some as “Ergonomics”. Although there are simple definitions of human factors exists such as: “Fitting the man to the job and the job to the man”, a good definition in the context of aviation maintenance would be:

“Human Factors is the study of the human as a central part of any system. Human Factors identifies the capabilities and limitations of humans and then adapts the human or the system components accordingly”.

Ergonomics is defined as, “the study of human performance and its application to the design of technological systems”. If ergonomics is properly applied to system design, the overall system reliability can be increased and the human error can be minimized.

As the technical aspects of flight were overcome bit by bit, the role of the people associated with aircraft began to come to the fore. Pilots were supported initially with mechanisms to help them stabilize the aircraft, and later with automated systems to assist the crew with tasks such as navigation and communication. With such interventions, to complement the abilities of pilots, aviation ‘Human Factors’ was born.

Due to modern design and manufacturing, aircraft are becoming more and more reliable. However, it is not possible to re-design the human being: we have to accept the fact that the human being is intrinsically unreliable.

Errors and quality lapses are to be expected: they are a fact of human like breathing and dying. Though they cannot be eliminated, a wide range of measures aimed at the whole team and workplace at large can control errors.

Importance of human factors in aviation industry:

The importance of Human Factors to flight safety was officially recognized by the International Civil Aviation Organization (ICAO) in 1986.Human factors have played a substantial role in aviation. In fact, it is arguably in this domain that human factors have received their greatest acceptance as an essential part of the research, development, test, and evaluation cycle. This acceptance has come from the critical role that humans, notably pilots, play in these human – machine systems, the unique problems and challenges that these systems pose on human perception, physiology and cognition, and the dire consequences of human error in these systems. As a result, there have been numerous opportunities for the development of the science of human factors that have contributed significantly to the safety and growth of aviation.

Human error has been documented as a primary contributor to more than 70 percent of commercial airplane hull-loss accidents. While typically associated with flight operations, human error has also recently become a major concern in maintenance practices and air traffic management. Human factors professionals work with engineers, pilots, and mechanics to apply the latest knowledge about the interface between human performance and commercial airplanes to help operators improve safety and efficiency in their daily operations.

Because improving human performance can help the industry reduce the commercial aviation accident rate, much of the focus is on designing human-airplane interfaces and developing procedures for both flight crews and maintenance technicians.

Problem statement: According to U.S. statistics 80% of aviation accidents are due to human errors and 70% due to maintenance human factor problems. Error investigation tools as a method of risk management is that they are ‘after-the-fact’ – they are reactive. They do not attempt to directly mitigate current errors. If they are not soon combined with some of the more effective HF training programs to increase good communication skills and to begin to develop trust among aircraft mechanics, and between themselves and management – these reactive error reduction programs do not stand much of a chance to succeed “Unless you manage error effectively, error will manage you” – Julian Dinsell, and this is true for organizations in which the activities possess an unusually large number of error- provoking features.

Error poses a serious threat to quality and safety and its control plays a major role in both of these management systems. Indeed, if either of them did not address the control of error, it would be seriously deficient.

Need of the study

The need for studying Human Factors is for consideration of the humanneeds for information, proper controls, and personal safety in the flying of an airplane. Training in human factors is a requirement of the International Civil Aviation Organization(ICAO).

Human error is often treated as a uniform collection of unwanted acts. In reality, errors fall into quite distinct types that require different kinds of remedial measures and occur at different levels of the maintenance organization. Understanding these differences is an essential precondition for effective error management.

The term "human factors" has grown increasingly popular as the commercial aviation industry has realized that human error, rather than mechanical failure, underlies most aviation accidents and incidents.

It is clear from studies made that human factors problems in aircraft maintenance engineering are a significant issue, warranting serious consideration and hence there is a need to study human factors leading to aircraft accidents.

It is a fact that at least 80% of the aircraft accidents and incidents are attributable in some way to human factors problems, especially if neglect of mechanical problems is included. In such situation there should be an increased emphasis on human factors in the training and evaluation of pilots.

Objectives:

1. To understand the application of the principles of human factors.

2. To reduce aircraft accidents.

3. To understand various types of Human Aspects leading to Aircraft accidents.

4. To find out if the HF programs currently implemented have improved HF

errors in the organization.

5. To find out if more needs to be done to manage HF errors in the

organization.

6. To find out the areas needed to be managed better to reduce HF errors.

Limitations:

1. The statistical study covered only 250 respondents of employees working at

the office. Therefore, few opinions may have been left uncovered.

2. The information given by the respondents may not be accurate due to fear of

the management and shyness.

3. Time constraint is also one of the limitations.

CHAPTER-2

THERIOTICAL

FRAME WORK

Human error:

Introduction:

It has long been acknowledged that human performance is at times imperfect. The Roman philosopher Cicero cautioned“It is the nature of man to err”.

In the past, aircraft components and systems were relatively unreliable. Modern aircraft by comparison are designed and manufactured to be highly reliable. As a consequence, it is more common nowadays to hear that an aviation incident or accident has been caused by “human error”.

A working definition of human error that has shown itself to be useful in real-world settings is – “an error is the failure of planned actions to achieve their desired goal, where this occurs without some unforeseeable or chance intervention”.

All errors involve some kind of deviation—the departure of actions from their intended course. There have been several “high profile” incidents and accidents which have involved maintenance human factors problems. Some of the major incidents and accidents are as follows:

Flight Place Date

Accident

Boeing 737, (Aloha flight 243) Hawaii 28 Apr 1988

Accident

BAC One-Eleven, G-BJRT (British Airways flight 5390)

Oxfordshire 10 Jun1990

Incident Airbus A320, G-KMAM (Excalibur Airways)

London Gatwick Airport

26 Aug1993

Incident Boeing 737-400, G-OBMM (British Midland)

Daventry 23 Feb 1995

incident A 320 Lufthansa 20 Marx 2001

In all of these incidents, the engineers involved were considered by their companies to be well qualified, competent and reliable employees. Most of the incidents that occurred due to maintenance errors were found to be characterized by the following:

Staff shortages Time pressure

Shift/task handovers Interruptions occurred Manuals were confusing Inadequate pre-planning and many more

All the above examples above involved a series of human factors problems which formed an error chain. If any one of the links in this “chain” had been broken by building in measures which may have pretended a problem at one or more of these stages, these incidents may have been prevented.

Fig () The error chain

Human Factors Percentage of accidents

Pilot deviated from basic operational procedures

33

Design faults 13

Maintenance and inspection deficiencies

12

Air traffic control failures or errors 9

Insufficient or incorrect weather information

8

Table() Contributing factors for accidents

In 1940, it was calculated that approximately 70% of all aircraft accidents were attributable to man’s performance, that is to say human error. When the International Air Transport Association (IATA) reviewed the situation 35 years later, they found that there had been no reduction in the human error component of accident statistics as shown below:

As can be seen from the list, maintenance and inspection deficiencies are one of the major contributory factors to accidents.

Fig () Human causes versus machine causes for accidents

It is clear from such studies that human factors problems in aircraft maintenance engineering are a significant issue that requires a detailed study of human factors.

From figure (), it is seen that the machine causes for the aviation accident have come down presently due to advanced technology and design in aircraft systems while the human causes for accidents have increased.

History of Human Factors

The use of the term “Human Factors” in the context of aviation maintenance engineering is relatively new. Aircraft accidents such as that to the Aloha aircraft in USA in 1988 and the BAC 1-11 windscreen accident in the UK in June 1990 brought the need to address human factors issues in this environment into sharp focus.

This does not imply that human factors issues were not present before these dates nor that human error did not contribute to other incidents; merely that it took an accident to draw attention to human factors problems and potential solutions.

1. ALOHA FLIGHT 243:ACCIDENT: The accident involving Aloha flight 243 in April 1988

involved 18 feet of the upper cabin structure suddenly being ripped away in flight due to structural failure. The flight had been examined before accident, as required by US regulations, by two of the engineering inspectors having 22 years and 33 years experience respectively. Neither of them found any cracks in their inspection.

PROBABLE CAUSE: Post accident analysis determined there were over 240 cracks in the skin of this aircraft at the time of the inspection. The ensuing investigation identified many human-factors-related problems leading to the failed inspections.

As a result of the Aloha accident, the US instigated a programme of research looking into the problems associated with human factors and aircraft maintenance, with particular emphasis upon inspection.2. British Airways Flight 5390:ACCIDENT: On 10th June 1990 in UK, a BAC 1-11 (British Airways Flight 5390) was climbing through 17,300 feet on departure from Birmingham International Airport when the left windscreen, which had been replaced prior to flight, was blown out. The commander was sucked halfway out of the

windscreen aperture and was restrained by cabin crew whilst the co-pilot flew the aircraft to a safe landing at Southampton Airport.PROBABLE CAUSE: The Shift Maintenance Manager (SMM), short-handed on a night shift, had decided to carry out the windscreen replacement himself. He took the 7D bolt that the windscreen had and purchased few 7D’s bolts, even though the windscreen required 8D bolts.The store man advised him that the job required 8Ds, but due to shortage of 8Ds he purchased 7D bolts. However, he used sight and touch to match the bolts and erroneously, selected 8Cs instead, which were longer but thinner.

There were several human factors issues contributing to this incident, including perceptual errors made by the SMM when identifying the bolts, poor lighting in the store area, failure to wear spectacles, circadian effects, working practices, and possible organizational and design factors.

Accident statistics: Prior to 1960, the annual accident rate for scheduled air carriers was something over 60 per million departures. In the ten years to 1970, this rate improved dramatically to about one or two per million departures. Between 1980 and 1996, there were 621 global fatal accidents to jet and turboprop aero planes weighing more than 5,700 kg, resulting in 16,849 fatalities (source UK CAA CAP681). The fatal accident rate for all North American and European operators during this period was 0.37 and 0.52 per million departures respectively, with JAA full member operators achieving 0.35 per million. U.S. Scheduled and Nonscheduled Service (Airlines) Accidents and Fatalities, 2001 through 2010

* Years in which an illegal act was responsible for an occurrence in this category.

As a result of the increase in world air traffic, the annual number of fatal accidents increased globally by 32% during the period 1980± 1996. If this growth in fatal accidents were to continue, by the year 2010 it was predicted there would be an annual average of 44 fatal accidents (almost one per week), assuming the

same accident rate per million departures. However, over the period 1990±1996 the trend was decreasing.

Human factor aspects-The Dirty Dozen

Julian Dinsell made an adage that “Unless you manage error effectively, error will manage you”, and this is especially true of maintenance organizations in which the activities possess an unusually large number of error-provoking features. The costs of failure are enormous.

Gordon Dupont, formerly of Transport Canada, classified HF root causes into excellent “Dirty Dozen” that has been widely accepted by several aviation organizations.

1. Lack of knowledge:

Lack of knowledge or experience is one of the most obvious local factors leading to maintenance errors. Most maintenance personnel have had the experience of carrying out a new task, while not being entirely sure whether they were doing it correctly. Such trial and error performance is by definition prone to being unreliable. Aviation mechanics spend about 15% of their time on tasks which they have never done before, but senior mechanics spend 20% of their time on such tasks.

ERROR MANAGEMENT: Get training on type aircraft. Use up-to-date manuals. Ask a technical representative or someone who knows.

2. Distraction: All systems with people in them suffer human-related disturbances. These are unwanted deviations from some desired norm that have their roots in various kinds of human behavioral tendencies. Distraction can be physical, emotional or psychological. Physical-it is the physical press of large crowds in a football stadium combined with the risk of violent clashes between supporters, emotional-a divorce from partner creates emotional disturbances and

psychological-on the roads it takes the form of major accident. Maintenance activities are subject to frequent disturbances-someone needs advice, there is a phone call, or an urgent job needs to be finished off elsewhere. The most likely error because of distraction is an omission.

ERROR MANAGEMENT: Always finish the job or unfasten the connection. Mark the uncompleted work. Lock wire where possible. Double inspect by another or self. When you return to the job, always go back three steps. Use a detailed check sheet.

3. Fatigue: Fatigue is a little work covering a wide range of effects including feelings of tiredness, physiological changes and changes in performance relating to length of work and time of day. Statistics from a range of industries reveal that errors are more likely to occur in the early hours of the morning than at any other time. Boring tasks that require a person to detect a rare problem (like some inspection jobs) are most susceptible to fatigue effects. Most important for maintenance is the fact that they have trouble controlling their attention.

ERROR MANAGEMENT: 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.

4. Lack of resources: Among the most influential local conditions influencing work quality are the tools and equipment available to do the job. In an Australian survey, the second most commonly cited contributing factor was equipment deficiency. ERROR MANAGEMENT:

Order and stock anticipated parts before they are required.

5. Stress:

Stress is an inescapable part of life for all of us. Stress is a normal physical response to events that threaten or upset a person’s balance in some way. It is the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker. Stressors may be physical, psychological or reactive.

ERROR MANAGEMENT: Be aware of how stress can affect 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. Ask fellow workers to monitor your work. Exercise your body.

6. Communication:

Some of the most serious maintenance errors have had their origins in poor communication practices. Aircraft maintenance engineers often work as teams. Individuals within teams exchange information and need t receive instructions, guidance, etc. There are two main ways in which communication can cause problems. These are lack of communication and poor communication. The former is characterized by the engineer who forgets to pass on pertinent information to a colleague, or when a written message is mislaid. The latter is typified by the engineer who does not make it clear what he needs to know and consequently receives inappropriate information, or a written report in barely legible handwriting. Spoken messages provide considerable flexibility and informality to express work – related matters when necessary.

ERROR MANAGEMENT: Use logbooks, worksheets, etc. to communicate and remove doubt. Discuss work to be dine or shat has been completed. Never assume anything.

7. Time pressure:

In a survey of maintenance personnel, time pressure was the most frequently mentioned factor leading to incidents. Management has contractual pressures associated with ensuring an aircraft is released to service within the time frame specified by their customers. Striving for higher aircraft utilization means that more maintenance must be accomplished n fewer hours, with these hours frequently being at night. Failure to do so can impact on flight punctuality and passenger satisfaction. Thus, aircraft maintenance engineers have two driving forces: the deadlines handed down to them and their responsibilities to carry out a safe job. The potential conflict between these two driving pressures can cause problems.

ERROR MANAGEMENT: Be sure the pressure isn’t self-induced. Communicate your concerns. Ask for extra help. Just say ‘No’.

8. Lack of Teamwork:

Most of the aviation accidents involved team errors of one kind or another. A large part of maintenance work is carried out in teams. Working in teams is a two-edged business. The need for several people – both within teams and between teams – to share the same awareness of what is happening or has happened can create increased opportunities for error.

ERROR MANAGEMENT; Discuss what, who and how a job is to be done. Be sure that everyone understands and agrees.

9. Complacency:

This is where we become so self-satisfied that we lose awareness of dangers. It is sometimes called overconfidence and creeps in as we become more proficient at what we do. Awareness of this insidious contributing factor is one of the safety nets that help to reduce it.

ERROR MANAGEMENT:

Train yourself to expect to find a fault. Never sign for anything you didn’t do.

10.Lack of assertiveness:

Lack of assertiveness in failing to speak up when things don’t seem right has resulted in many fatal accidents. However, assertiveness also calls for listening to the views of others before making a decision. Assertiveness isthat middle ground between being passive and aggressive.

ERROR MANAGEMENT: If it’s not critical, record it in the journey log book and only sign for

what is serviceable. Refuse to compromise your standards.

11.Lack of awareness:

Lack of awareness occurs when there is a lack of alertness and vigilance in observing. This usually occurs with very experienced persons who fail to reason out possible consequences to what may normally be a good practice. One of the safety nets for lack of awareness is to ask more “what ifs” if there is conflicting information or things don’t quite seem right.

ERROR MANAGEMENT: 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

Human Factor Programs:

1. BOEING HF Programme:There are many human factor programmes available. One of the common

programmes, formulated by Boeing is Maintenance Error Decision Aid (MEDA), designed for aircraft maintenance organizations.

MEDA conducts an in depth analysis to investigate errors and the employee who made the error and understands the extent of solutions necessary. Most of

these programs educate the personnel about their potentialities (giving training) and create an error free environment.

2. FAA HF Programme:

Steps in developing a human factors programme

This Human Factors Program establishes the approach for applying human factors engineering to the individual systems being acquired through the Integrated Human Factors Plan. The goal is to increase total system performance and reduce developmental and lifecycle costs by optimizing human performance when the system is operated and maintained in the operational environment by members of the target population.

Methodology for error management - Shell model

An approach to explaining human factors is the ‘SHELL Model’ that takes a system approach to human factors. There is an interface between flight crew, machine, systems, equipment and software, which come together in the airspace environment. Edwards (1972), a psychologist, presented this concept which deals with man and machine. Another very popular model is the PEEP Model (P-Paperwork, E-Environment, E-Equipment, P-People), given by British Airways.

These models of human-machine-environment interactions are just simply models. They are the representations of how certain persons conceive reality and are not necessarily flawless or all encompassing.

It is a conceptual model of human factors that clarifies the scope of aviation human factors and assists in understanding the human factor relationships between aviation system resources/environment (the flying subsystem) and the human component in the aviation system (the human subsystem).

The model is named after the initial letters of its components (software, hardware, environment, live ware) and places emphasis on the human being and human interfaces with other components of the aviation system. The components of the shell model are shown in the figure

Figure ()

Shell model interfaces:

Essentially, human factors is the study of the live ware(L) with a focus upon the design and optimization of the interfaces of L with the other components of the model (L-S, L-H, L-E), and L with other humans (L-L).

Liveware-Software (L-S) Interaction between human operator and non-physical supporting systems in

the workplace.

Involves designing software to match the general characteristics of human users and ensuring that the software is capable of being implemented with ease.

Liveware-Hardware (L-H) Interaction between human operator and machine Involves matching the physical features of the aircraft, cockpit or equipment

with the general characteristics of human users while considering the task or job to be performed.

Liveware-Environment (L-E) Interaction between human operator and internal and external environments. Involves adapting the environment to match human requirements. Ex:

o Air conditioning to control aircraft cabin temperature.

o Sound-proofing to reduce noise.

o Using blackout curtains to obtain sleep during daylight house as a

result of transmeridian travel and shift work etc.

Liveware-Liveware (L-L) Interaction between central human operator and any other person in the

aviation system during performance of tasks. Involves interrelationships among individuals within and between groups

including maintenance personnel, engineers, designers, ground crew, ATC’s etc.

Error Models and Theories:

1. Design – versus operator – induced errors.

Errors may have been made before an aircraft ever leaves the ground by aircraft designers. This may mean that, even if an aircraft is maintained and flown as it is designed to be, a flaw in its original design may lead to operational safety being compromised.

1. Variable versus constant errors:

Professor James Reason discusses two types of human error: variable and constant. The variable errors are random in nature and cannot be predicted and are much harder to deal with. The constant errors follow some kind of consistent, systematic erroneous pattern and may be predicted and therefore controlled.

2. Reversible versus irreversible errors:

Another way of categorizing errors is to determine whether they are reversible which can be recovered from or irreversible which cannot be recovered. E.g.: if a pilot miscalculated the fuel he should carry, he may have to divert to a closer airfield, but if he accidentally dumps his fuel, he may not have many options open to him.

3. Slips, lapses and mistakes:

Slips occur as the result of minor errors of execution.Lapses occur when a pilot becomes distracted and doesn’t complete a task or omits a step whilst performing it.Mistakes occur when actions conform to an inadequate plan.

4. Skill- Rule- and Knowledge-Based Behaviors and Associated Errors:

Skill-based behaviors are those that rely on stored routines that have been learned with practice and may be executed without conscious thought. Rule-based behaviors are those for which a routine has been learned. The components of a rule-based behavior may comprise a set of discrete skills.Knowledge-based behaviors are those for which no procedure has been established. These require the aircraft maintenance engineer to evaluate

information, and then use his knowledge and experience to formulate a plan for dealing with the situation.

5. Swiss cheese model:

The "Swiss Cheese Model" illustrates how accidents occur. It postulates that the typical accident occurs because several human errors have occurred at all levels in the organizational hierarchy in a way that made such accident unavoidable. For example, decision makers may have made ill decisions when purchasing aircraft (fallible decisions), line management may have pushed for faster turnarounds (line management deficiencies), pilots may have felt pressurized to cope with a stressful climate, an unsafe culture and little rest (preconditions), the particular pilot who suffered the accident may have gotten distracted with other tasks three seconds prior to the accident (unsafe act), and the aircraft systems fail in providing unmistakable warnings of the danger (inadequate defenses).

The Swiss Cheese Model

CHAPTER-3

COMPANY PROFILE

INDUSTRY PROFILE

HISTORY OF AIR INDIA

Air India traces its history back to October 15, 1932 when its founder, J. R. D. Tata flew a single engined De Havilland Puss Moth registered VT-ADN carrying air mail (postal mail of Imperial Airways) from Karachi's Drigh Road Aerodrome to Bombay’s Juhu Airstrip via Ahmedabad. The aircraft continued to Madras via Bellary piloted by a Royal Air Force pilot Neville Vincent. That same year, the airline was formally established as Tata Airlines, a division of Tata Sons

Ltd. (now Tata Group). Following the end of World War II, regular commercial service was restored in India and Tata Airlines became a public limited company on 29 July 1946 under the name Air India.

After India became Independent, Air India submitted a plan to the Government for the formation of Air India International Limited with Government participation to operate international services. The plan was approved and Air India International launched its first service to London via Cairo and Geneva on 8 th

1948 with Constellation aircraft.

In 1952, the Planning Commission recommended the nationalization of Air Transport Industry, which was effected on August 1, 1953 with creation of two nationalized Corporations. Indian Airlines Corporation and Air-India Limited were merged along with six smaller lines. Air-India International Corporation flew routes overseas. By 1960 the international airline had routes to Singapore, Sydney, Moscow, and New York.

Corporate Vision

To be among top 5 Asian airlines in terms of yield, profitability, productivity, size and quality.

Corporate Mission

Focus on customer satisfaction. Grow with emphasis on sustained profitability

Current Fleet:

Air India fleet as of 1 August 2010:

AircraftIn

service

Orders

Passengers

NotesF J Y

Total

Airbus A310-300 4 — 0 20 181 201 To be phased out

Airbus A330-200 2 — 0 24 255 279 Both dry leased

Boeing 747-400 5 — 12 26 385 423 Includes 3 under sale

Boeing 777-200LR

8 — 8 35 195 238 All owned

Boeing 777-300ER

12 3 4 35 303 342 All owned

Boeing 787-8 — 27 TBA EIS: October 2011[3]

Total 31 30

Air India Cargo:

A member of IATA, Air India carries all types of cargo including dangerous goods (hazardous materials) and live animals, provided such shipments are tendered according to IATA Dangerous Goods Regulations and IATA Live Animals Regulations.

In-Flight Entertainment

Air India's Boeing 777-200LR/-300ER as well as some refurbished Boeing 747-400 aircraft use the Thales Top Series IFE systems for onboard in-flight entertainment.

Air India - Women PilotsThere are 22 women pilots on Air India's rolls. On the occasion of the World

Women's Day, March 3rd 2004, the airline operated an "All women Flight" from Mumbai to Singapore. Capt. Rashmi Miranda, who became Air-India's first woman Commander in November 2003 and Capt. Kshmata Bajpai, piloted the flight, an Airbus A310 aircraft. The flight dispatch activities relating to this flight was also coordinated by a woman Flight Dispatcher, Ms Vasanti Kolnad. The Safety Audit on board was also conducted by another woman, Ms Harpreet D. Singh.

Awards and recognition

Preferred International Airline award for travel and hospitality from Awaz Consumer Awards 2006

Best International West Bound Airline out of India for three successive years by Galileo Express Travel World Award

Best Corporate Social Responsibility Initiative .by Galileo Express Travel World Award

Best Short-Haul International Airline by Galileo Express Travel World Award 2008

Cargo Airline of the Year at the 26th Cargo Airline of the Year Awards. The Montreal Protocol Public Awareness Award was awarded to Air

India by the United Nations for environmental protection, especially in the ozone layer.

INDIAN AIRLINES

Indian Airlines was India’s first state owned domestic airline. Indian Airlines was set up under the aegis of federal Union Ministry of Civil Aviation and based in New Delhi. Its main baseswere the international airports in Chennai, Mumbai, Kolkata and New Delhi.

Indian Airlines came into being with the enactment of the Air Corporations Act, 1953. IndianAirlines started its operations from 1st August, 1953, with a fleet of 99 aircraft and was the outcome of the merger of seven former independent airlines, namely Deccan Airways, Airways-India, Bharat Airways, Himalayan Aviation, Kalinga Air Lines, Indian National Airways and Air Services of India. The year 1964 saw the Indian Airl ines moving into the jet era with theintroduction of Caravelle aircraft into its fleet followed by Boeing 737-200 in the early 1970.

The main base of the Indian airlines are Chatrapati Shivaji International Airport, Mumbai; IndiraGandhi International Airport, Delhi; Netaji Subhash Chandra Bose International Airport,Kolkata; Chennai International Airport, Chennai.

National Aviation Company of India Limited (NACIL)

In 2007, the Government of India announced that Air India would be merged with Indian Airlines. As part of the merger process, a new company called the National Aviation Company of India Limited (NACIL) was established, into which both Air India (along with Air India Express) and Indian Airlines (along with Alliance Air) will be merged. Once the merger is complete, the airline - which will continue to be called Air India - will continue to be headquartered in Mumbai where it now has a fleet of 130+. The new airlines then applied for membership to the Star Alliance. Alliance Air and Air India Express are also to merge as the new airline's low-cost arm.

Air India (the whole merged company along with Indian Airlines) has now been accepted as a part of the Star Alliance. The formal announcement was made at the Star Alliance meeting on the 13th of December 2007.

CHAPTER-4

DATA TABULATION

&

ANALYSIS

RESEARCH METHODOLOGY ADOPTED

4.1 HYPOTHESIS

It is assumed that the extent of training inputs covered, the human error management programs and effectiveness of these programs are interrelated

Training effectiveness is positively related with the methods and techniques of implementing human error management program and the extent the training objectives are met and

It is assumed that the extent of which employees are able to apply the skills, knowledge and aptitudes acquired in the training programs to their job situations and the effectiveness training programs are related.

In general, it is hypothesized that the human factors programs in Air India Limited are effective.

4.1.1 SOURCE OF HYPOTHESIS

General Organizational Culture

The general pattern of the organizational culture is helpful in the formulation of the hypothesis. A culture pattern of the organization has great influence in the thinking process and the attitudes of the employees. The hypothesis is formulated to test one of these ideas.

Analogies

A hypothesis is formulated based on similarities between the phenomenons also. The similar studies undertaken in the past in the Organization is also taken into account for this project work.

Personal Experience

The training programs conducted in Air India Limited at the Central Training Establishment (CTE) at Hyderabad are personally witnessed. The training programs are monitored closely to obtain knowledge on the modes of implementation, outcomes etc. The hypothesis is formed based on this.

RESEARCH DESIGN

The research design used in this study is descriptive in nature. This design is adopted to study various aspects of human factor training programs in AIR INDIA LIMITED. In addition to this the attitudes of the respondents to the questionnaire

regarding the level of effectiveness of human factor training programs with specific hypothesis in mind are analyzed statistically.

AREA OF STUDY

The study, with the prime objective of ascertaining the attitudes of employees toward human factor training programs conducted in AIR INDIA LIMITED are done at all the training schools of AIR INDIA LIMITED at Kolkata, New Delhi, Mumbai and Hyderabad.

The study covers all the cadres of the employees of the organization, viz. pilots, engineers, flight operation officers, managers, executives, technicians and cabin crew etc.

The respondents are from CTE, where major training are imparted and from other places viz., New Delhi, Kolkata, and Mumbai where human factor training programs are conducted.

NATURE OF STUDY

The study is a fact finding study, in which the organization and the human factor training set up is studied thoroughly first. Although, the major objective of thi study is to give emphasis on the evaluation of human factor training program conducted by AIR INDIA LIMITED, more emphasis is given to effectiveness of these training programs.

COVERAGE

The study covers the employees of all the cadres and from all the training schools and disciplines. The employees covered are:

Pilots Engineers Flight engineers

Flight operation officers Cabin crew Aircraft maintenance engineers Technicians Officers of various departments and Executives of various departments

PILOT STUDY

The pilot study is undertaken before the questionnaire is farmed. It is the preliminary study of the universe with the objective of getting an idea about the set up. It is undertaken without formulating any hypothesis.

Firstly, the organization is thoroughly studied with spec Air India Limited emphasis on the various training schools in CTE and other places. In this study, the training policy of the organization, facilities available in all the training schools, training budget, training needs assessment, training mater Air India Limited and evaluation procedures are studied.

4.7METHODOLOGY USED

QUESTIONNAIRE METHOD

The questionnaire method is used for the project. The questionnaire is designed, prepared and pre tested before using it for data collection.

As the main part of the study is to analyze the attitude of the employees towards the training programs, a five-point scale is constructed. The questionnaire is prepared with closed-ended questions with fixes response patterns.

The employees are directly contacted for collecting the responses and studying the various training patters offered in the organization.

INTERVIEW METHOD

To get secondary information about the organization, human factor training set up, training facilities etc and to get the viewpoints of the trainees in various training programs, some of the trainees are interviewed. Due to flexible nature of interviews, they have been extensively used to gather information on many topics including system usability, user perceptions, reactions and attitudes, job analysis, error and many more.

OBSERVATION METHOD

To get a broader and accurate idea about the organization, training schools, and training programs, observation method is also used. Some of the training programs are personally attended to observe the training methods used interaction of participants in the training programs and other aspects of training. Trainees are observed in the classroom training programs and in the practical training programs.

SAMPLING

To study the attitudes of the employees towards training programs, a probability-sampling plan was devised, where all elements have equal and independent chance of getting included and all the units are given equal importance. More specifically, the simple random sampling including the fish bowl method is used.

SIZE OF THE SAMPLE

A random sample of the employees of the Air India Limited is taken. The sample is taken from all the training schools of AIR INDIA LIMITED and it is ensured that the selected sample has the representation of the characteristics of the universe and fulfils the objectives of the study. The total no of samples taken for the studying in this manner is 250.

4.8 DATA PROCESSING AND ANALYSIS

After the completion of the data collection, the data are checked carefully to ensure that they are properly filled. A code book is prepared and all the verbal responses are transformed into the appropriate numerals and entered in the code book.

The answers of the respondents are then transferred into the master chart and entered into the computer for data processing and analysis.

The data is systematically tabulated and classified according to the variables and analyzed. A number of statistical tests are also applied for the analysis of the data. The methods like percentage, range, mean, and standard deviation are calculated.

CHAPTER-5

FINDINGS

PROFILE OF THE RESPONDENTS

INTRODUCTION

The personal factors of the employees will also have effect on the attitudes and hence affect the effectiveness of human factors training. Therefore, importance is given to the personal factors too in the projects.

Attitudes are liable to vary according to personal variables such as age, sex, designation, department in which the employee is working, educational qualifications, overall experience, and number of times promoted, etc. Hence, the

above variables are collected and studied carefully. The detailed analysis is given below.

5.1AGE

This personal factor is an important one. Age is perceived as a chronological development order. It not only involves changes related to behavior, but also to changes in developmental tasks. Age has its own status when variables such as responsibilities, feelings, perception, expression, attitudes etc. are concerned. These variables change according to different age groups.

Table 5.1

AGE GROUP (YEARS) FREQUENCY PER CENT

20 to 30 31 to 40 41 to 50 51 to 60

46 108 71 25

18.40 43.20 28.40 10.00

TOTAL 250 100

Form the above table; it is evident that 18.40 per cent of the respondents are in the age group of 20 to 30 years. 43.20 per cent of the respondents are in the age group of 31to 40 years. 28.40 per cent of the respondents are in the age group of 41 to 50 years. In addition, 10 per cent of the respondents are in the age group of 51 to 60 years. Recently, the age for the retirement in the company is raised to 60 years.

THE INFERENCE is that majority of the respondents is in the age group of 31 to 40 years and hence the most of the respondents are young.

5.2SEX

This is also an important factor to be considered under the personal profile. There is a high degree of difference in the perceptions, feelings, opinions etc. between the two sexes.

Table 5.2

SEX FREQUENCY PER CENT

MALE

FEMALE

183

67

73.20

26.80

TOTAL 250 100

From the above table, it is seen that 73.20 per cent of the respondents are males and the remaining 26.80 per cent are females.

INFERENCE is that majority of the respondents are males.

5.3EDUCATIONAL QUALIFICATIONS

This factor is very important as educational qualifications of an individual influence very much with the attitude, perception, and other aspects. Educational qualification gives a vision and helps in forming optimistic and independent rational thoughts. The behavior patterns and the thinking and learning process differ according to his/her level of education. The analysis is made after dividing the aspect of educational qualifications into two type’s viz. Academic and technical.

Table 5.3

Academic Qualifications

EDUCATION FREQUENCY PER CENT

S.S.L.C INTERMEDIATE GRADUATE POST GRADUATE OTHERS

25381215117

10.0015.2048.4020.4006.80

TOTAL 250 100

It is seen from the table that 10 per cent of the respondents are qualified up to S.S.L.C., 15.20 per cent of the respondents are qualified up to intermediate or equivalent, 48.40 per cent of the respondents are graduates, 20.40 per cent of the respondents are post graduates and 6.80 per cent of the respondents have other qualifications.

INFERENCE: Majority of the respondents is graduates.

Table 5.4

Technical Qualifications

EDUCATION FREQUENCY PER CENT

CERTIFICATE DIPLOMA ENGINEERING COMPUTER ENG. OTHERS

38465010313

15.2018.4020.0041.2005.20

As far as the technical qualifications are concerned, 15.20 per cent of the respondents are certificate holders, awarded by Technical Training Institutes, 18.40 per cent of the respondents are diploma holders in various disciplines of engineering, 20 per cent of the respondents are engineering graduates, 41.20 per cent of the respondents are having qualifications in computer engineering and science and 05.20 per cent of the respondents have other qualifications like Aircraft Maintenance Engineers, License etc.

INFERENCE: As far as technical qualification is concerned, most of the respondents are computer engineering holders.

5.5 DESIGNATION

The employees who have responded for the questionnaire are having various designations. The human factor training programs are designed and conducted for the employees of various designations and hence, the designation will play a dominant role in forming attitudes and perceptions.

As the designations of the employees in various departments vary a lot, it is decided to analyze this factor, by classifying the employees as lower grades, middle grades, and upper grades. The grading of employees was in existence in the organization in terms of numbers and it is abolished presently. However, the erstwhile grade system is often used among the employees.

Table 5.5

DESIGNATION FREQUENCY PER CENT

LOWER GRADE MIDDLE GRADE UPPER GRADE

0021238

0084.8015.20

TOTAL 250 100

There is no respondent from the lower grade. For lower grade, training programs are very rarely conducted. The training programs for these grades are conducted in their respective departments itself.

84.80 per cent of the respondents belong to middle grade and 15.20 per cent of the respondents belong to upper grade.

INFERENCE: The majority of the respondents belong to middle grade.

5.6 DEPARTMENT

The experience of the employees helps to perform the job more effectively and helps in forming opinion and perception towards training and other factors

related to the job. The respondents’ experience in an organization gives a picture of his/her exposure to the training program. Experience helps in forming the attitudes. The employees who are having longer work experience may have better formed attitudes than those who have lesser work experience.

Table 5.7

DEPERNMENT FREQUENCY PER CENT

MAIN STREAM SUPPORT DEPT. OTHERS

1755025

702010

TOTAL 250 100

From the above table, it found that, 70 per cent of the respondents are from the organizations’ main stream, 20 per cent of the respondents are from support departments, and 10 per cent of the respondents are from other departments.

INFERENCE: Majority of the respondents is from the main stream departments of the organization.

5.7 LENGTH OF SERVICE

The experience of the employees helps to perform the job more effectively and helps in forming opinion and perception towards training and other factors related to the job. The respondents’ experience in an organization gives a picture of his/her exposure to the training program. Experience helps in forming the attitudes. The employees who are having longer work experience may have better formed attitudes than those who have lesser work experience.

Table 5.7

LENGTH OF SERVICE(YEARS)

FREQUENCY PER CENT

01 to 0506 to 1011 to 1516 to 2021 to 2526 to 30

339675211708

13.2038.4030.0008.4006.8003.20

TOTAL 250 100

From the above table, it is evident that 13.20 per cent of the respondents are having the experience of one year to five years, 38.40 per cent of the respondents are having experience of six years to ten years, 30.00 percent of the respondents are having experience of eleven to fifteen years, 8.40 percent of the respondents are having experience of sixteen years to twenty years, 6.80 per cent of the respondents are having experience of twenty one to twenty five years, and 3.20 per cent of the respondents are having experience of twenty six to thirty years.

INFERENCE: The majority of the respondents are having experience of six to ten years.

5.8 NUMBER OF PROMOTIONS

This is an important factor, as promotions motivate the employees to work hard, improve job knowledge, develop the performance level etc. As training is instrumental for increasing the job performance which will ultimate lead to promotion based on the employee’s work. Thus, the desire to be trained and the attitude towards training are related to the number of times the employee is promoted in the organization.

Table 4.8

No. PROMOTIONS FREQUENCY PER CENT

No PROMOTION1 PROMOTION

2 PROMOTIONS3 PROMOTIONS4 PROMOTIONS5 PROMOTIONS

2575104211708

10.0030.0041.6008.4006.8003.20

TOTAL 250 100

From the above table, it is seen that 10.00 per cent of the respondents did not get any promotions so far. 30.00 per cent of the respondents got promotion for one time, 41.60 per cent of the respondents got promotions for two times, 8.3340 per cent of the respondents get promotions for three times, 6.80 per cent of the respondents got promotions for four times, and 3.20 per cent of the respondents got promotions for five times.

INFERENCE: The majority of the respondents got promotions for two times.

DATA ANALYSIS AND INTERPRETATION

5.1In the aviation maintenance, a failure to carry out a necessary check on progress can be caused by some local distractionDistraction can be physical, emotional or psychological.Maintenance activities are subject to frequent disturbances-someone needs advice, there is a phone call, or an urgent job needs to be finished off elsewhere. The most likely error because of distraction is an omission.

OPINION FREQUENCY PERCENTStrongly AgreeAgreeDisagreeCan’t say

141326836

5.652.827.214.4

TOTAL 250 100

T-Test

HypothesisH0:µ250>60%

H1: µ250<=60

Where µ is the number of opinions given by 250 employees

Test: one – tailed t test

α = 0.05

One – Sample Statistics

One – Sample Test

Test Value = 60

t df Sig.(2 - tailed)

Mean Difference

95% Confidence Interval of the

DifferenceLower Upper

Frequency .078 249 .938 .0040 -.0966 .1046The critical t with 249 degrees of freedom, α = 0.05 and one-tailed is 1.645

Determine if we can reject the null hypothesis or not.

The decision rule I s : if the one-tailed critical t value is less than the observed t and the means are in right order, then we can reject H0.

N Mean Std. Deviation

Std. Error Mean

Frequency

250 2.5040 .80783 .05109

Here the critical t is 1.645 (from the table of critical t values) and the observed t is 0.078. Since 1.645 is not less than 0.078 we reject the hypothesis and conclude that less than 60% of employees only accept that a failure to carry out a necessary check on progress can be caused by some local distraction

From the above analysis it is found that:

52.8% of the respondents agree and 27.2% of the respondents disagree that distraction leads to error.

Inference: In the tests above, since the H0 is rejected it can be concluded that less than 60% of respondents agree that human error is the main cause for air accidents and has more significance than technical error.

5.2Despite new technology for detecting faults, most of the aviation maintenance still relay on the human eyeball for most of the fault finding task.

The fault in aircraft systems can be detected by the very sophisticated computers. But the computers can fail at any time or give a wrong report. Now days the reliability of such diagnostic tools are so improved. But most of the aviation jobs depend upon the human eyeball inspection for the crucial jobs. Whatever be the sophistication available in the equipment, it is still required to be inspected by humans.


981311011

39.252.444.4

TOTAL 250 100


39.2% of the respondents strongly agree and 52.4% of the respondents agree that aviation maintenance still relies on human eye ball.

Inference: Majority of the respondents accept that they still rely on human eyeball rather than technology for findings. Hence they should conduct classes on human eyesight limitations to reduce error caused by eyesight.

5.3Maintenance systems normally have built in safeguards such as independent inspection and functional design to capture errors on critical tasks

Most of the systems in aviation have a lot of safeguards built inside that. This can find out error and avoid the manifestation of error well in time. But these systems can also fail anytime. Due to the state of the art technology available, all these things are possible. But still, for critical systems human supervision is necessary.


32204-14

12.881.6-5.6

TOTAL 250 100


12.8% of the respondents strongly agree that there can be failure in technology

81.6% of the respondents agree with the statement 5.6% are unable to answer.

Inference: Majority of employees are aware of the inbuilt technology and its failures. Therefore human supervision is essential.

5.4Although inexperienced persons are the most likely to make knowledge based errors, even experience personnel also makes such errors from time to time.

Knowledge – based errors are particularly likely if the person is performing a task for the first time. Sometimes even the experienced personnel get caught out from time to time. New or unfamiliar tasks, unusual modifications or hard-to-diagnose faults can all breed knowledge-based errors. Nearly 60% of maintenance personnel report that they have continued with an unfamiliar job, even though they were not sure they were doing it correctly.

OPINION FREQUENCY PERCENTStrongly AgreeAgree

75115

3046

DisagreeCan’t say

2832

11.212.8

TOTAL 250 100

5.5Lack of knowledge or inexperience is the most obvious local factor leading to an error

Most maintenance personnel have had the experience of carrying out a new task, while not being entirely sure whether they were doing it correctly. Such trial and error performance is by definition prone to being unreliable. Aviation mechanics spend about 15% of their time on tasks which they have never done before, but senior mechanics spend 20% of their time on such tasks.


5318188

21.272.43.23.2

TOTAL 250 100

Correlation

Statement 1 Statement 2Statement19 Pearson Correlation Sig. (2 – tailed) N

1.

250

0.717**.000250

Statement2 0 Pearson Correlation Sig. (2 – tailed)N

0.717**.000250

1.

250**Correlation is significant at the 0.01 level (2-tailed)

Nonparametric Correlations

Spearman’s Rho Statement 1 Statement 2Statement 19Pearson Correlation Sig. (2 – tailed) N

1.000.

250

.752**0.000

250Statement 20Pearson Correlation Sig. (2 – tailed) N

.752**0.000

250

1.000.

250

**Correlation is significant at the .01 level (2-tailed)

Line of Best fit


30% of the respondents strongly agree and 46% of the respondents agree that even experienced employees make errors.

21.2% of the respondents and 72.4% of the respondents agree that lack of knowledge is also a factor for committing error.

Inference: Majority of the respondents accept that even experienced people sometimes fall in a situation to commit errors and such errors are mostly committed due to lack of knowledge.

5.6Effective error management aims at continuous reform rather than short term local error fixes.

There is always a strong temptation to focus upon the last few incidents and to try to make sure that they, at least, will not happen again. This tendency is further strengthened by the engineer’s natural inclination to solve specific concrete problems. Reform of the system as a whole must be a continuous process whose aim is to reduce and contain whole groups of errors rather than single blunders.

Table 5.23


61174

24.469.6

DisagreeCan’t say

87

3.22.8

TOTAL 250 100


24.4% of the respondents agree that effective error management aims at continuous reform

69.6% of the respondents agree with this statement

Inference: Hence majority of employees accept that effective error management aims at continuous reform i.e., long term error management.

5.7The prerequisite for a resilient organization is a comprehensive safety information system.

A recent development in safety management that has caught attention is “resilience engineering”. It helps people cope with the complexity under pressure to achieve success and one should focus on developing the practice of resilience engg. in socio technical systems.

Table 5.24

OPINION FREQUENCY PERCENTStrongly AgreeAgreeDisagree

4717614

18.870.45.6

Can’t say 13 5.2TOTAL 250 100

Pareto Graph

Inference: The above analysis shows that only 70.4% of respondents agree that a comprehensive safety information system is required for an organization to be resilient. Remaining employees are either confused or do not know the importance of effective information system in aviation industry and they should be given effective training on effective communication and information processing. The Pareto graph shows the 80% of people who should be trained in this field.

5.8Employees are reluctant to report errors because they fear they could be punished

If corrective action is taken rather than punitive action for the errors, then the voluntary error reporting will be popular. This question is to find out that how comfortable the employees feel to report the error voluntarily. Voluntary error reporting is one of the best error detection systems and if the employees have faith in the organization, the method will be very successful. Even the anonymous error reporting system will also be very effective.


4039

1615.6

DisagreeCan’t say

13239

52.815.6

TOTAL 250 100

Lognormal distribution parameters estimated: scale=1.8618772 shape=.34622769

NPar Tests

One-Sample Kolmogorov-Smirnov Test

a. Test distribution is Normalb. Calculated from data

PERCENTN

Normal Parametersa,b

Mean

Std. Deviation

Most Extreme Absolute

Differences Positive

Negative

Kolmogorov-Smirnov Z

Asymp. Sig. (2-tailed)

250

2.680

.9236

.320

.208

-.320

5.052

.000


15.6% of the respondents agree and 52.8% of the respondents disagree that employees are reluctant to report errors because they fear they could be punished

Inference: In the analysis more than half of the respondents feel that reporting errors to the management leads to punishment which is a very bad sign in aviation industry. Even in the n par test it is proved to reject the hypothesis that reporting errors is a good practice. This shows that many of the respondents fear the management and an environment of trust should be built by giving them proper training in human factors.

5.9One of the methods to prevent error is to make sure personnel to follow procedures by ensuing that the procedures are correct and usable.

It helps in knowing how well employees follow the rules and procedures as given to accomplish a particular task. Poorly designed procedures are a common source of maintenance error. Poor procedures not only breed mistakes, they are a major factor leading to violations. Unclear task cards or vague procedures are among the main reasons for deviations from maintenance procedures.

OPINION FREQUENCY PERCENT

Strongly AgreeAgreeDisagreeCan’t say

115416421

4.421.665.68.4

TOTAL 250 100

5.10Poorly designed maintenance / operational procedure are a common source of maintenance error

The time pressure exists in the aviation industry. When people work with time pressure, they tend to miss out many items in the checklist. Many maintenance errors have their origins in inadequate system design. Most maintainers can list examples of components that can be installed upside down or back to front, or systems that are difficult to access, or tasks that have apparently been designed with three-handed maintenance personnel in mind.


11112289

44.448.83.23.6

TOTAL 250 100

Regression

Model Summary ANOVA b

a. Predictors: (Constant), statement 24a. Predictors: (Constant), statement 24b. Dependent variable statement 25

Model R R 2 Adjuste

d R2

Std. Error

of the

Estimate

1 .717a .515 .513 .49672

Model Sum of

squares

df Mean

Square

F Sig.

Regression

Residual

Total

64.910

61.190

126.100

1

248

249

64.910

.247

263.078 .520a

Coefficients a (a.Dependent Variable Statement 25)

Line of best fit

Inference: in the above analysis it can be seen that employees think that procedures are not required to follow while working and at the same time say that poor procedures are main cause for committing errors. Even in the graph it can be seen that the line of best has points loosely scattered which means it has weak correlation. This survey shows that employees are quite confused whether to use procedures or not.Employees should be explained the importance of procedures in aviation industry and effective training should be given regarding this.

5.11Often human performance is affected by social and emotional factors

Model Unstandardized

coefficient

Standardized

coefficient

t Sig.

B Std. Error Beta

1 Constant

Statement 24

-.506

.779

.137

.048 .717

-3.690

16.22

0

.000

.000

All systems with people in them suffer human – related disturbances, be it social or emotional disturbances. These are unwanted deviations from some desired norm that have their roots in various kinds of human behavioral tendencies. Ex: on the roads, it takes the form of dangerous or reckless driving, in public administrations, it may be corrupt officials, in maintenance organizations, it is human error.


94133815

37.653.23.26

TOTAL 250 100

5.12Sometimes what we perceive is distorted by past experience, or brain can produce results that are ambiguous

There are many examples to prove that brain produces ambiguous results sometimes. Our perception is largely affected by our past experience about the matter. This is very dangerous in the workplace. We all believe that the brain is always consistent on all matters. But the reality is different. This helps us to understand that we have some limitations in our processing ability of brain. This question reveals that whether we are aware of human limitations or not.


901261222

3650.44.88.8

TOTAL 250 100

One Sample t test

Hypothesis:

H0 :µ250>50%

H1 :µ250<=50%

Where µ is the number of opinions given by 250 employees

Test: one – tailed t test

α = 0.05

One – Sample Statistics

One – Sample Test

Test Value = 1.8

t df Sig.(2 - tailed)

Mean Difference

95% Confidence Interval of the

DifferenceLower Upper

Statement 26Statement 27

-.4901.173

249249

.625

.242-.0240.0640

-.0240-.0435

.0725

.1715The critical t with 249 degrees of freedom, α = 0.05 and one-tailed is 1.645

Determine if we can reject the null hypothesis or not.

The decision rule is : if the one-tailed critical t value is less than the observed t and the means are in right order, then we can reject H0.

Here the critical t is 1.645 (from the table of critical t values) and the observed t is 0.078. Since 1.645 is not less than 0.078 we reject the hypothesis and conclude

N Mean Std. Deviation

Std. Error Mean

Statement 26Statement 27

250250

1.77601.8640

.77474

.86283.04900.05457

that less than 50% of employees only accept that our brain distorts at some situations.


37.6% of the respondents strongly agree and 53.2% of the respondents agree that human performance is affected by social and emotional factors.

36% of the respondents strongly agree and 50.4% of the respondents agree that what we perceive is distorted by past experience.

Inference: In the tests above, it is concluded that both statements have to reject the null hypothesis and less than 50% respondents accept the statement. Our brain certainly has certain limitations in work place and error can be committed easily in such situations. Employees have to be trained about the limitations of brain to reduce errors.

5.13Stress can be felt when carryout certain task that are particularly challenging or difficult

Stress results from the in position of any demand or set of demands which require us to react, adapt or behave in a particular manner in order to cope with or satisfy them. Up to a point, such demands are stimulating and useful, but if the demands are beyond our personal capacity to deal with them, the resulting stress is a problem.


1221011314

48.840.45.25.6

TOTAL 250 100


48.8% of the respondents strongly agree to the concept, 40.4% of therespondents agree to the concept.

Inference: Hence three fourth of the respondents strongly agree that stress can be felt while carrying out a challenging task.

5.14Commercial pressures frequently allow the safety culture control to be eroded in an organization.

The main purpose of the organization is to make profit. The optimal utilization of the resources is important for this. If the resources are over utilized for commercial reasons, then there will be a break down at some point. The aviation regulatory authorities normally impose duty time restrictions for operating and maintenance crew. In the same way, the equipment used in aviation also will have limits in the operation. If the commercial pressure is more, then the safety culture will be definitely eroded.

OPINION FREQUENCY PERCENTStrongly Agree 67 26.8

AgreeDisagreeCan’t say

1182243

47.28.817.2

TOTAL 250 100

5.15Excess time pressure exerted reduces the work quality and work in error prone

One of the potential stressors in maintenance is time pressure. Striving for higher aircraft utilization means that more maintenance must be accomplished in fewer hours. Airworthiness issues will always take precedence over commercial and time pressures.

Table 5.30


14685109

58.43443.6

TOTAL 250 100

Correlations

**Correlation is significant at the 0.01 level (2-tailed)

Nonparametric CorrelationsSpearman’s Rho Percent1 Percent2

Percent1 Percent2Statement29 Pearson Correlation Sig. (2-tailed)N

1.

250

.765**0.000

250Statement30 Pearson Correlation Sig. (2-tailed) N

.765**0.000

250

1.

250

Statement29 Correlation CoefficientSig. (2-tailed) N

1.000.

250

0.756*0.000

250Statement30Correlation CoefficientSig. (2-tailed) N

0.756*0.000

250

1.000.

250*Correlation is significant at the .01 level (2-tailed)

Line of best fit

Inference: Majority of the respondents accepts that commercial pressure and excess time pressure reduces the quality of work and work will be error prone.

There is a positive correlation between these two statements from the respondents and the line of best fit drawn has points loosely scattered i.e., there is a weak

correlation as the remaining people do not accept the statement. The remaining people should be given effective training on stress management to reduce human

errors.

FINDINGS AND CONCLUSIONS

(For section IV)

The following are the summary of the detailed analysis made in the project. The conclusions are:

1. The majority of the respondents whose views are taken for the analysis are in the age group of 31 to 40 years. Hence, most of the respondents are of young age.

2. Most of the respondents are males.

3. The majority of the respondents are academically qualified graduates.

4. The majority of the respondents are computer engineering holders.

5. Most of the respondents belong to middle grade in their respective departments in the organization.

6. The majority of the respondents are working in the main stream departments like operations and engineering.

7. The majority of the respondents have the service of 6 to 10 years in the organization.

8. The majority of the respondents got two promotions in their service

(For Section V)

1. Majority of the employees in the organization have a very good idea about ergonomics and the influence of ergonomics on the error reduction.

2. Majority of the employees are willing to be reliable. This helps them to work comfortably according to the change in technology and hence reducing error.

3. More than half of the respondents agree that uncomfortable workplace, inadequate work space, extreme temperature, poor lighting etc. will affect the human performance in the aviation industry. It means that the improper facilities that are available for the employees can be a factor for committing an error.

4. 3/4th of the respondents accept that human beings are intrinsically unreliable. The remaining people do not agree with the statement. This shows that they are not adopting the technology and it is a very critical issue in aviation industry.

5. Majority of people support the statement that highly qualified, skilled and competent employees in aviation industry will not be the cause for any

aviation accidents. But actually even if the human being is having a lot of skill and competency, still certain human factors can affect his performance. Hence employees who are well experienced should also be given training on human factors.

6. Majority of the employees at Air India Ltd., have a sound knowledge about safety culture in the organization which is a contributing factor for Human Error. Hence the management should continuously concentrate on safety culture in the organization to reduce human errors.

7. Majority of the respondents accept that always front end operators are blamed for air accidents and latent failures are not concentrated. Thus maintenance engineers shall be given rigorous MRM training to reduce errors.

8. Majority of respondents agree that human error is the main cause for air accidents and has more significance than technical error.

9. Majority of the respondents agreethat when the intention is not appropriate there can be a violation.

10.Majority of the respondents agree that the design flaw can affect the safety of the aircraft.

11.Majority of the respondents agree that errors are systematic and recurrent pattern of task. It is also seen that few of the respondents are unable to answer which shows that they need training about human aspects that leads to committing errors.

12.Majority of the respondents accept that maintenance error problems can be

solved easily as in the same way that any well defined business risk can do. But maintenance problems cannot be solved easily and the maintenance engineers shall be given training in human factors.

13.Majority of the respondents accept that reassembly of components is more vulnerable to human error than disassembly. Thus, maintenance engineers shall be given effective MRM training to reduce errors.

14.Majority of respondents agree that human error is the main cause for air accidents and has more significance than technical error. This shows that employees are aware that technology is more advanced and can be relied on if there is no human error.

15.Majority of the respondents accept that they still rely on human eyeball rather than technology for findings. Hence they should conduct classes on human eyesight limitations to reduce error caused by eyesight.

16.Majority of employees are aware of the inbuilt technology and its failures. Therefore human supervision is essential before departures of the aircrafts.

17.Majority of the respondents accept that even experienced people sometimes fall in a situation to commit errors and such errors are mostly committed due to lack of knowledge.

18.Majority of employees accept that effective error management aims at continuous reform i.e., long term error management.

19.Only 70.4% of respondents agree that a comprehensive safety information system is required for an organization to be resilient. Remaining employees are either confused or do not know the importance of effective information system in aviation industry and they should be given training on effective communication and information processing.

20.More than half of the respondents feel that reporting errors to the management leads to punishment which is a very bad sign in aviation industry. This shows that many of the respondents fear the management and an environment of trust should be built by giving them proper training in human factors.

21.Majority of the employees think that procedures are not required to follow while working and at the same time say that poor procedures are main cause for committing errors. It shows that employees are quite confused whether to use procedures or not. Employees should be explained the importance of procedures in aviation industry and effective training should be given regarding this.

22.Majority of the respondents accept that brain can produce ambiguous results most of the time and performance is affected by social and emotional factors. Our brain certainly has certain limitations in work place and error can be committed easily in such situations. Employees have to be trained about the limitations of brain to reduce errors.

23.Threefourth of the respondents strongly agree that stress can be felt while carrying out a challenging task. Hence employees shall be given training on stress management to reduce errors.

24.Majority of the respondents accepts that commercial pressure and excess time pressure reduces the quality of work and work will be error prone. Hence the employees shall be given training on optimum utilization of resources and time management to reduce errors.

Through this study and analysis, it is concluded that the human factors training programs conducted in Air India Limited are showing good results.

However good a training program may be, there is always scope for improvement. Hence, all the shortcomings, loopholes and drawbacks of the training programs may be still identified and rectified in all the future training programs. This will help to improve the work efficiency of the employees and help to reduce errors for a safe air journey.

CHAPTER-6

SUGGETIONS

SUGGESTION AND RECOMMENDATIONS

As human factors leading to human error are an important aspect of any industry, a thorough analysis is required with more respondents.

1. Specific human factors training objectives should be outlined based upon the type of performance required to reduce the human error. An audit personal needs and operational requirements are to be done and compared to determine the specific training needs of individual employees. Training should be specific to the job handled by the employees rather than comprehensive.

2. Whenever an employee is sponsored or nominated for training, he/she should be told the reasons for sponsoring or nominating him/her. In addition, the expectations of the organization from him/her after the training program is over are also to be explained to the trainee.

3. The training program should be planned so that it is related to the trainees’ previous experience and background. This background can be used as a foundation for development of new skills or behavior.

4. Attempt should be made to determine whether the trainee has the basic knowledge about human factorsto successfully complete the training programs. If any deficiencies are noted, the training may be postponed or cancelled, until improvements are visible.

5. It is advisable to go for employees’ participation in determining and selecting any of the human factor training programs they need to attend.

6. Any distractions on the way of training should be removed, as distractions will spoil the process of learning.

7. Organization may give some sort of incentives or rewards after successfully attending the training programs. This will motivate the employees for learning more.

8. The people performing important roles in the organization should be encouraged to go for training programs periodically, as errors may be committed by them also.

9. The trainees should be provided with regular and constructive feedback concerning his/her progress in training programs.

CHAPTER-7

BIBLIOGRAPHY

Bibliography

1. Risk Management and Error Reduction in Aviation Maintenance —Manoj S.

Patankar, James C. Taylor, Ashgate Publishing Limited (2006).

2. Managing Maintenance Error, A Practical Guide —James Reason, Alan Hobbs,

Ashgate Publishing Limited (2002).

3. Human Factors in the Training of Pilots —Jefferson M. Koonce, Taylor and

Francis e-library(2003).

4. Human Performance and Limitations in Aviation —R.D.Campbell &

M.Bagshaw, Blackwell Science Ltd.(2002)

5. Safety Management Systems in Aviation —Alan J. Stolzer, Carl D. Halford and

John J. Goglia, Ashgate e-book(2008)

6. Why Airplanes Crash, Aviation Safety in a Changing World —Clinton V.

Oster, John S. Strong and C. Kurt Zorn, Oxford University Press, Inc.

7. The Limits of Expertise, Rethinking Pilot Error and the Causes of Airline

Accidents—R. Key Dismukes, Benjamin A.Berman and Loukia D.

Loukopoulos, Ashgate Publishing Limited

8. Aviation Human Factors – John A.Wise, V.David Hopkin, Daniel J.Garland –

Second Edition.

9. Ask the Pilot – Patrick Smith, The Berkley Publishing Group.

10.The Multitasking Myth - Loukia D. Loukopoulos, R. Key Dismukes,

Immanuel Barshi, Ashgate Publishing Ltd.

11.www.aviation knowledge.wikidot.com

12.http://www.boeing.com

13.www.ntsb.gov

14.www.ihst.org – the dirty dozen by Gordon Doupont.

15.http://www.crewresourcemanagement.net

http://www.crewresourcemanagement.net/

http://www.ihst.org/

http://www.ntsb.gov/

http://www.boeing.com/

http://www.aviationknowledge.wikidot.com/

Index of keywords used in the report

OPINION: This is what one feels, thinks or perceives on any subject

matter connected with the training programs.

ATTITUDE: It is defined as a mental state of readiness organized

through experience, exerting a dynamic influence upon the individual’s

response to all situations and objects with which it is related.

EFFECTIVENESS: it means, to bring out on accomplished,

impressionable fruitful result. It depends upon the level of attainment of

training objectives. If a training program is to be effective, it has to be

need based, well planned and properly monitored.

TRAINING: This is a systematic program, which aims to increase the

knowledge, skill, abilities, and aptitudes of workers to perform specific

jobs. By training programs, the employees will acquire new skills,

technical knowledge, problem solving abilities etc

TRAINING PROGRAMS: The term “program” means, a plan of

intended proceedings, designed to achieve the pre determined objectives,

goals, and demands of the organization. Training programs are selected

based on needs, job requirements, and specific problems faced by the

employees in the performance of the job. The training programs should

develop the capabilities of the employees and impart necessary

knowledge about the problem solving techniques etc.

MORALE: It is generally referred to attitudes and willingness to work.

It is a state of mental condition, which is closely associated with egoism,

enthusiasm etc. the main motives of morale are psychological needs.

OBSOLESCENCE: It is the stage of stagnation in learning which may

be due to age, temperature, lack of motivation or the inability of the

person to adopt himself to technology changes.

FATIGUE: It is a stage when an employee exhausts his/her power to

work and feels dissatisfied with the continuance of the work. It affects

the efficiency of the worker and affects the quality of work.

COMPLACENCY: A feeling of contentment or self – satisfaction

especially when coupled with an unawareness of danger, trouble or

controversy,

LIVEWARE : A term used to denote people working in an environment,

and is based on the need for a human, or liveware, to operate the system

using hardware and software.

DISTRACTION : These are unwanted deviations from some desired

norm that have their roots in various kinds of human behavioral

tendencies.

ACCIDENT : An occurrence associated with the operation of an aircraft

that takes place between the time any person boards the aircraft with the

intention of flight and all such persons have disembarked, and in which

any person suffers a fatal or serious injury or the aircraft receives

substantial damage.

FATAL INJURY : Any injury that results in death within 30 days of the

accident.

http://www.webopedia.com/TERM/S/software.html

http://www.webopedia.com/TERM/H/hardware.html

ANNEXURES

QUESTIONNAIRE

SECTION I

PERSONAL PROFILE

1. NAME :

2. AGE (In years) : 20 – 30

31 – 40

41 – 50

51 – 60

3. SEX : MALE

FEMALE

4. EDUCATION : ACADEMIC

S.S.C

INTERMEDIATE

GRADUATE

POST GRADUATE

TECHNICAL

CERTIFICATE

DIPLOMA

ENGINEERING

COMPUTER ENGG.

5. DESIGNATION :

6. DEPARTMENT/ SECTION:

7. LENGTH OF SERVICE IN AI:

8. No. TIMES PROMOTED :

SECTION II

(Please indicate the extent to which each of the following items is true in your organization using the following four point scale)

1. In a maintenance work, reassembly of components is more vulnerable to human error than disassembly

a) Strongly agree b) Agree c) Disagree d ) Can’t say

2. In the aviation maintenance, a failure to carry out a necessary check on progress can be caused by some local distraction


3. Despite new technology for detecting faults, most of the aviation maintenance still relay on the human eyeball for most of the fault finding task.


4. Although inexperienced persons are the most likely to make knowledge based errors, even experience personnel also makes such errors from time to time.


5. Maintenance systems normally have built in safeguards such as independent inspection and functional design to capture errors on critical tasks


6. Lack of knowledge or inexperience are the most obvious local factors leading to an error


7. Poorly designed maintenance / operational procedure are a common source of maintenance error


8. Effective error management aims at continuous reform rather than short term local error fixes.


9. The prerequisite for a resilient organization is a comprehensive safety information system.


10. Employees are reluctant to report errors because they fear they could be punished.


11. One of the methods to prevent error is to make sure personnel to follow procedures by ensuing that the procedures are correct and usable.


12. Often human performance is affected by social and emotional factors


13. Sometimes what we perceive is distorted by past experience, or brain can produce results that are ambiguous


14. Stress can be felt when carryout certain task that are particularly challenging or difficult


15. Excess time pressure exerted reduces the work quality and work in error prone


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