04_human factor in maintenance_contoh Dirty dozen (1).pptx

human factors in maintenance

1. Human Error In Aircraft Maintenance Dirty Dozen 1 Capt. Wahyudi

2. Capt. Wahyudi 2 The Best People Can Make the Worst Mistakes

3. 3 Capt. Wahyudi

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6. Communication Complacency Lack of Knowledge Distraction Teamwork Fatigue Lack of Resource Pressure Assertiveness Stress Lack of Awareness Norms Capt. Wahyudi 6 The Dirty Dozen

7. Capt. Wahyudi 7 The Dirty Dozen

8. Capt. Wahyudi Continental Express, 14 Fatalities, 9-11-91 Inspector’s turnover form “helped the mechanic remove the de-ice boots” 8

9. Capt. Wahyudi Continental Express, 14 Fatalities, 9-11-91 Safety Nets Use logbooks, worksheets etc. to communicate and remove doubt Discuss work to be done or what has been completed N ever assume anything. 9

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11. Capt. Wahyudi No lineman present for start-up Crew asked LM to verify battery door closed (near left landing gear) after engines were started LM walked thru prop, killing him instantly First such case in Italian AF in over 50 years 11 Italian Air Force, Keflavik

12. Capt. Wahyudi 12 DOOR Loadmaster exits crew door to check battery door Engines were running CREW DOOR BATT . DOOR

13. Capt. Wahyudi 13 Loadmaster killed as he walks into prop. Body and remains scattered over 100 feet.

14. Capt. Wahyudi C arelessness and over confidence are more dangerous than deliberately accepted risk. -Wilbur Wright, 1901. 14 Accident cleanup by “Fire Department”

15. Capt. Wahyudi Therefore the Safety Board concludes that a low expectation of finding a crackin a –219 series fan hub might have caused the inspector to overlook or minimize the significance of an indication. 15

16. Capt. Wahyudi Face Reality Physical Fitness Create Challenges for yourself Train yourself to expect to find a fault Never sign for anything you didn’t do 16 Safety Nets

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18. Capt. Wahyudi Engineer conduct taxi without training and authorization Only number 2 and 4 engine running Brake system in engine number 1 Steering system in engine number 3 18 Lack of Knowledge

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23. Capt. Wahyudi 23 Lack of Teamwork

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25. Capt. Wahyudi ACUTE FATI Q UE Produced by physical exertion or sleep loss Alleviated by a single rest period CHRONIC FATI Q UE Medical or psychological problem Depression or “chronic fatigue syndrome” OPERATIONAL FATI Q UE Most commonly seen after 3-4 days of heavy tasking Not relieved by a single sleep perio 25 Fati q ue

26. Capt. Wahyudi Attention reduced Memory diminished Mood becomes withdrawn Low situational awareness Long hours of labor (any type) High intensity stress. 26 SYMPTOMS OF FATIQUE

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33. Capt. Wahyudi 33 The youngest pilot flown with her instructor and her father 1996

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47. Capt. Wahyudi FATI Q UE STRESS COMPLACENCY COMMUNICATION AWARENESS DISTRACTION LACK OF KNOWLEDGE TEAMWORK LACK OF RESOURCES PRESSURE LACK OF ASSERTIVENESS NORMS 47 Marvin, Ernest Borgnine, Jim Brown, Charles Bronson, John Cassavetes, TriniLopez, TellySavalas, Donald Sutherland, Clint Walker

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