human factors_Whopping Bird Analysis.ppt

EASA module

1. 1
HUMAN FACTORS
EASA
MODULE 09

2. 2
HUMAN FACTORS
Why Human Factors
Human Performance & Limitations
Factors Affecting Performance
Social Psychology
Communication
The Physical Environment
Tasks
Human Errors
Hazards in the Workplace

3. 3
HUMAN FACTORS
“Principles which apply to aeronautical
design, certification, training and
operations and which seek safe interface
between the human and other system
components by proper consideration to
human performance.”
(CAA) Aircraft Maintenance Standard Department
DEFINITION -HUMAN FACTORS
PRINCIPLES

4. 4
HUMAN FACTORS
WHO MAKES MISTAKES?
Flight Crews
Maintenance Crews
Ground Crews
ATC
Designers
Manufactures
Regulators
EVERYONE

5. 5
HUMAN FACTORS
MURPHY’S LAW
“If anything can be done
incorrectly then someone
will do it incorrectly”

6. 6
HUMAN FACTORS
Human Performance
And Limitations
Physical Conditions
Psychological Condition

7. 7
HUMAN FACTORS
The performance of the human
body’s Senses
The effect of the Environment
of the workplace on the
person

8. 8
HUMAN FACTORS
Vision
How we see
Hearing
How we hear

9. 9
THE BRAIN
INPUTS
Eyes–Vision
Ears–Sound Balance
Nose–Smell
Skin–Touch
Mouth–Taste

10. 10
THE BRAIN
INPUTS
Gases–Oxygen / Carbon Dioxide
Energy–Need for Food
Pressure–Bladder etc

11. 11
THE BRAIN
OUTPUTS
Automatic
Breathing
Heart Rate
Balance
Temperature Control

12. 12
Response
Response Times:
Poor Nutrition
Dehydration
Focusing
Empty Field Myopia
Distraction
Fatigue
Alcohol
Age

13. 13
Increased by:
•Stress Levels
•Task Complexity
•Time Constraints
•Available Skills for the Task
•Mental Attitude
MENTAL WORKLOAD

14. 14
Physical Needs
Breathing
Circulation
Movement
FACTORS AFFECTING PERFORMANCE

15. 15
Social Needs
Interaction
Communication
Sense of Belonging
Being Loved by Others
FACTORS AFFECTING PERFORMANCE

16. 16
Emotional Needs
Life Experiences
Joy
Happiness
Anxiety
Loneliness
FACTORS AFFECTING PERFORMANCE

17. 17
Intellectual Needs
Thoughts & Rationality
Learning
Reasoning
Problem Solving
FACTORS AFFECTING PERFORMANCE

18. 18
Abraham Maslow
Model of Basic Human Needs:
HUMAN FACTORS
Survival
Stimulation
Safety
Love
Esteem
Self Actualisation
Cognitive
Aesthetic

19. 19
Personal Health
Diet
Sleep
Exercise
Personal Hygiene
Personal Habits
Relaxation
PERSONAL HEALTH

20. 20
Sleep and Fatigue
Sleep is essential around 8 hours for the
average person
Recuperates the body from the physical effort
and mental strain of the day
SLEEP & FATIGUE

21. 21
Work Loading
Stress and Strain in engineering terms are
described as:
When a force is applied (Stress) it will
produce a deformation (Strain) in the
material of the structure
STRESS

22. 22
STRESS
FEEDBACK
FEEDBACK
PERCEIVED
DEMAND
PERCEIVED
ABILITY
IMBALANCE
STRESS
STRESS
RESPONSES
PSYCHOLOGICAL
RESPONSE
PSYCHOLOGICAL
RESPONSE

23. 23
Domestic Stress
Work Stress
Organisational Stress
STRESS

24. 24
Alcohol
Simple molecule, when taken orally requires
no digestion
Water speeds up absorption whilst foods
high in protein slow the rate of absorption
Alcohol is a sedative –hypnotic drug, and
can have a damaging effect on the human
body
ALCOHOL

25. 25
Dependant -Alcoholic.
The removal/withdrawal of alcohol from this
individual results in psychomotor agitation.
The earliest and most common signs of
withdrawal are:
Anxiety
Anorexia
Insomnia
Tremor
ALCOHOL

26. 26
If the effects are unknown for any prescribed drug seek
expert medical advice before their use
Sleeping Tablets
Tranquillisers
Antibiotics
Anti-Histamine
Pep Pills
High Blood Pressure (Hypertension)
Anti Malaria Pills
Oral Contraception Pills
Sudafed
Herbal Remedies
DRUGS

27. 27
Licensed aircraft maintenance engineers
personal responsibility when medically
unfit or under the influence of drink and/or
drugs
In the UK the ANO (Air Navigation Order) and AWN
(Air Worthiness Notice) 47 specify your
responsibilities in this area
It is now a legal requirement to monitor your
own fitness for work
FITNESS FOR WORK

28. 28
For Example :
STRESS
EYESIGHT
DRUG or ALCOHOL ABUSE
ANAESTHETICS
FITNESS FOR WORK

29. 29
Social Psychology
“If all members of any social group
acted alike, thought alike and felt
alike, personality would not exist”
SOCIAL PSYCHOLOGY Chap 4

30. 30
Interaction Between
Individuals
When individuals are working towards a
common goal within a team,
personalities and the interaction
between them can have an affect on
the outcome
SOCIAL PSYCHOLOGY

31. 31
Personality
Character
Temperament
SOCIAL PSYCHOLOGY

32. 32
Character
Behaviour
(Good or Bad Character)
Strength
(Quality –Strong / Weak)
SOCIAL PSYCHOLOGY

33. 33
Personality Assessment
First Impressions
(Build, Appearance)
Association
(Exposure, Talking)
SOCIAL PSYCHOLOGY

34. 34
Visual Characteristics
RACE
SEX
NATIONALITY
BODY APPEARANCE
DRESS
DISABILITY etc
SOCIAL PSYCHOLOGY

35. 35
Communication System
Lines of Management
(Large Elaborate)
COMMUNICATIONS Chap 5 Section 1

36. 36
Processes Difficulties
Feedback
Transmission Understood
COMMUNICATIONS

37. 37
If the message is straight forward
and simple, and the other person
is easily reached, then you may
prefer to do it personally
Written / Verbal ?
COMMUNICATIONS

38. 38
Verbal Reports
Change
(Not Fully Listening / Distracted)
Written
COMMUNICATIONS

39. 39
Written Reports
Clear / Precise
Intended Reader
Purpose Type
COMMUNICATIONS

40. 40
News Summaries
Company Notices
Magazine
Notice Board
Newsletter
COMMUNICATIONS

41. 41
Non-Verbal Communication
Body Language
Expressions
Eye Contact
Touch
Posture
COMMUNICATIONS

42. 42
Non-Verbal Communication
Body Language
Alter Verbal
Pitch / Stress / Pauses
Uncertainty / ‘ums’
Interruption
COMMUNICATIONS

43. 43
COMMUNICATIONS

44. 44
Function of Communications
Manager Must:
Motivate
Instruct
Explain
Advise
Know What is Going on
Listen
COMMUNICATIONS

45. 45
Function of Communications
Manager’s Skills:
Direct Instructions
Public Speech
Lessons
Interviews
Meetings
COMMUNICATIONS

46. 46
Communication Failures
Confused
No Listening
Lack of Definition
Human Behaviour
Insincerity
Speak Before Think
COMMUNICATIONS

47. 47
Communication Failures
Ambiguity
Inattention
Follow Up Actions
Overconfidence
Omission of Information
COMMUNICATIONS

48. 48
Work Logging and Recording
English
(Manuals -Country of Manufacture)
British Register
Log Books
Aircraft Maintenance Records
COMMUNICATIONS

49. 49
Work Logging and Recording
Information
Clear
Concise
Free from ERROR
COMMUNICATIONS

50. 50
Communication
Lines of Communications
COMMUNICATIONS

51. 51
Work Logging and Recording
Don’t do it your way do it the correct way
Do not rely on your memory
Don’t Assume Check
Updating –If the correct information can not be
found then work on the aircraft is to be suspended
COMMUNICATIONS

52. 52
Currency
Keeping Up-To-Date
(Awareness of Change)
QA Department
Personal Updating
COMMUNICATIONS

53. 53
Currency
Developments
Modifications
Techniques
Courses / Seminars
COMMUNICATIONS

54. 54
Updating
Read Instructions
Complacency
Check Amendments
COMMUNICATIONS

55. 55
Dissemination of Information
Confidential Human Factors Incident
Reporting Programme (CHIRP)
The idea of the CHIRPTrust is to publicise
details of the incidents in the hope that, if
people are made aware of the pre-
knowledge might help prevent a further
occurrence
COMMUNICATIONS

56. 56

57. 57
Communication Problems
Exercise
COMMUNICATIONS

58. 58
HUMAN FACTORS
Question Time

59. 59
xx
REVIEW
xx

60. 60
xx
REVIEW
xx

61. 61
Working Conditions
Heat
Light
Ventilation
Noise
Space
Vibration
PHYSICAL ENVIRONMENT Chap 6

62. 62
Facilities
Changing Room
Washing
Resting
Eating
Toilets
PHYSICAL ENVIRONMENT

63. 63
Heating
Indoor work
16C to 21Cfor Non Physical Work
Minimum of 13Cfor Manual Work
PHYSICAL ENVIRONMENT

64. 64
Heating
Warm Climates
Air Conditioning
Relative Humidity
20% to 80%
PHYSICAL ENVIRONMENT

65. 65
Heating / Humidity
PHYSICAL ENVIRONMENT

66. 66
Lighting
Facility Lighting
Task Lighting
PHYSICAL ENVIRONMENT

67. 67
Facility Lighting
Covers Ordinary Hangar and Workshop
Fixed Systems
Evenly distributed without dazzling and
glare
PHYSICAL ENVIRONMENT

68. 68
Task Lighting
Fixed
Adjustable
Portable
PHYSICAL ENVIRONMENT

69. 69
Lighting
Intensity of light is measured in
Candela(SI system) or Lux
Example:
Exit Sign is about 50 lux
Fine Bench Work 5000 lux
PHYSICAL ENVIRONMENT

70. 70
Lighting
Positioned so it does not shine into the
eyes
Greater than 50from the line of sight is
best
Does not produce glare from any
reflective surfaces.
PHYSICAL ENVIRONMENT

71. 71
Lighting
Type
Positioned
Hazards
Obscured
Replaced, Repaired and Cleaned
PHYSICAL ENVIRONMENT

72. 72
Lighting
Colour Rendition
Object Colour
Colour Spectrum
Colour Absorbed
PHYSICAL ENVIRONMENT

73. 73
Lighting
Natural Light -best for good colour rendition
Red coloured wire insulation, for example,
will show up red in natural light
Mercury vapour lamp the colour will show up
as orange or even black
More efficient a light source is, the poorer its
colour rendition
PHYSICAL ENVIRONMENT

74. 74
Lighting
Correct Lighting -Rotating Machinery
Fluorescent Tubes Flickering -
Stroboscopic
Multi-tube Fluorescent Fittings
PHYSICAL ENVIRONMENT

75. 75
PHYSICAL ENVIRONMENT
COLOUR RENDITION EFFICIENCY
Incandescent bulb Good Poor
Fluorescent tubes Good Poor
Mercury vapour lamps Poor Good
EXAMPLES

76. 76
Natural Lighting
Maximum Advantage
Clean
Obstructions
PHYSICAL ENVIRONMENT

77. 77
Emergency Lighting
Accident Prevention
Independent Power Source
Automatic
Sufficient Light
PHYSICAL ENVIRONMENT

78. 78
Ventilation
Enclosed Workshops
5 –8 litres per second
Clean Air –Filtered
Serviced & Cleaned
PHYSICAL ENVIRONMENT

79. 79
Ventilation
Natural –Drafts
Screening -Repositioning
PHYSICAL ENVIRONMENT

80. 80
Ventilation Required
Paint Removal –Chemical
Paint Spraying –Fumes are excessive
Grit Blasting
Sweeping Hangar Floors
Removing Cabin Insulation, carpets etc.
Chemical Processes, such as chemical de-
greasing etc.
PHYSICAL ENVIRONMENT

81. 81
PERSONAL BREATHING MASKS or
HOODS SHOULD BE WORN TO
ENSURE A CLEAN AIR SUPPLY
AND PREVENT DAMAGE TO THE
LUNGS
PHYSICAL ENVIRONMENT

82. 82
Ventilation
Internal Combustion Engines
Carbon Monoxide
Colourless
Odourless
Tasteless
PHYSICAL ENVIRONMENT

83. 83
Symptoms of Carbon
Monoxide
NAUSEA
HEADACHES
VOMITTING
LEADING TO UNCONSCIOUSNESS
DEATH
DEPENDING ON THE CONCENTRATION
AND TIME EXPOSED
PHYSICAL ENVIRONMENT

84. 84
Noise
Jet Engine
Propeller
Increase Accident Rate
PHYSICAL ENVIRONMENT

85. 85
Noise
Conversation –2 Metres
Risk Assessment
> 85 dB average 8 Hour
Offered Appropriate Protection
PHYSICAL ENVIRONMENT

86. 86
Noise
> 90 dB average 8 Hour
Ear Protection Zones
Mandatory Protection
Warning Signs
Noise Reduction Arrangements
Maintenance Recorded
PHYSICAL ENVIRONMENT

87. 87
Vibration
Long Periods
Hand Arm Vibration Syndrome
Vibration White Finger
Lower Back Pain
PHYSICAL ENVIRONMENT

88. 88
Reducing Vibration
Problems
Reducing Exposure Operator Time
Equipment Frequencies Outside Critical
Range
Reducing Amplitude of Vibration
Providing Damping Material
PHYSICAL ENVIRONMENT

89. 89
Workspace
Free Space / Free Movement
Maximum Number in Room
Minimum 11 cubic metres per person
PHYSICAL ENVIRONMENT

90. 90
Working Environment
Ergonomics
Fitting Task to Man
Fitting Man to Task
PHYSICAL ENVIRONMENT

91. 91
Working Environment
Designed Work Environment
The skills of an ergonomist include:
Anthropometry –(Body Shape)
Physiology –(Body Functions)
Psychology –(Mental Functions)
Engineering –(Tool/Machine Design)
PHYSICAL ENVIRONMENT

92. 92
Anthropometry
Human Measurements
Wide Range of Sizes
Statistical Analysis
PHYSICAL ENVIRONMENT

93. 93
Physiology
Calorific Requirements
Body Functions
Stimuli
Response
Match Man & Machine
PHYSICAL ENVIRONMENT

94. 94
Psychology
Distractions
Fatigue
Family
Social
PHYSICAL ENVIRONMENT

95. 95
Engineering
Tool / Machine Design
Operator Involvement
Standardisation
PHYSICAL ENVIRONMENT

96. 96
Summary
Physical Effects
Ergonomics
Psychological Effects
Heat, Noise, Ventilation, Vibration
Distraction / Fatigue
PHYSICAL ENVIRONMENT

97. 97
HUMAN FACTORS
Question Time

98. 98
xx
REVIEW
xx

99. 99
xx
REVIEW
xx

100. 100
Physical Work
Inspections
Component Installation
Testing
Body Position
Movement / Brain
TASKS Chap 7

101. 101
Protective Clothing
Overalls
Loose Items
Checks
Climate
Substances
Impact
TASKS

102. 102
Body Posture
Work Height
Vices –Elbow Height / 5cm Lower
Inspection –25cm Higher
Floor Condition
Trip Hazards
TASKS

103. 103
Body Posture
Outside Conditions
Walk Zones
Safety Equipment
Tools
Overstretching
TASKS

104. 104
Body Posture
Sitting
Adjustable
Arm, Shoulders, Neck, Lower Back
Repetitive Motions (RSI)
TASKS

105. 105
Body Posture
Laying Under
Equipment/Aircraft
Crawler Board
Protection
TASKS

106. 106
Body Posture
Kneeling
Kneepads
Lower Leg Support
TASKS

107. 107
Body Posture
Lifting / Carrying
Avoid Strain
Assistance
Equipment
TASKS

108. 108
Body Posture -Lifting
Bend Knees
Legs Apart
Back Straight
Assistance
TASKS

109. 109
Body Posture -Lifting
Straightening up
Keep Arms Bent
Item Close to Body
TASKS

110. 110
TASKS –Lifting

111. 111
Body Posture -Carrying
Item Close to Body
Restrict Amount of Time
TASKS

112. 112
Body Posture
Avoid Twisting
Never Pull
Do Not Strain
Overbalance
TASKS

113. 113
Body Posture
Reaching
Max Forearm’s Length Away
Never Over-reach
TASKS

114. 114
Body Posture
Hands
RSI
White Finger
Scratches / Cuts
Correct Hold / Use of Tools
TASKS

115. 115
Working at Height
Ladders
Adjustable Platforms
Docking Systems
Safety Harness
Protective Equipment / Clothing
Identification, Maintenance, Records
TASKS

116. 116
When using height adjustable work platforms, the following precautions
should be observed:
Steady feet in position before raising –if fitted
Never overload the platform. safe working load (SWL) will be indicated on
the side of the platform
Never overbalance the platform –load evenly, distributed on top
Always ensure guardrails are in position
When raising/lowering, ensure personnel and aircraft structures are clear
Protect structure from platform damage using fender cushions (rubber
protective fenders)
Keep gap between structure and platform as narrow as possible
Use safety locks when raised into position
PHYSICAL WORK

117. 117
Guardrails
waist height with a low level screen to
prevent small objects, sockets etc.
from falling off
Acrophobia
Claustrophobia
PHYSICAL WORK

118. 118
HUMAN FACTORS
Question Time

119. 119
xx
REVIEW
xx

120. 120
xx
REVIEW
xx

121. 121
Repetitive Tasks
Short Tasks / High Frequency
Dexterity
PHYSICAL WORK

122. 122
Repetitive Tasks
Boredom
Mistakes
Motor Memory Takes Over
PHYSICAL WORK

123. 123
Repetitive Tasks
Real Thought
Mind Wander / Mistakes
Safety –Job Rotation
PHYSICAL WORK

124. 124
Repetitive Tasks
Regular Breaks
Break Work Pattern
Change Positions
Check Manuals
Team Work
PHYSICAL WORK

125. 125
Inspections
Feel
Smell
Hearing
Vision
Beware ‘Perception Tricks’
Limitations
PHYSICAL WORK

126. 126
Inspections
Physical Environment
Distractions
Physical Health
PHYSICAL WORK

127. 127
Inspections
Instrument Reading Errors
Parallax Error / 90
0
to Scale
Visual Aids
Blind Spots –Eye Movement
PHYSICAL WORK

128. 128
Visual Aids
Magnifying Glass
Mirrors
Boroscopes
Video Cameras
VDUs
PHYSICAL WORK

129. 129
Complex Systems
Extent of Responsibilities
CAP 455
Communication Between Engineers
Signatory CRS
Stage Checks
PHYSICAL WORK

130. 130
Complex Systems
Records
‘Handing Over’
Briefings
PHYSICAL WORK

131. 131
Briefings
Check Card Signatures
Verbal Explanations on Progress
Indication of Problems
Situation Report
Spares Issues
Expected Completion
Future Liaison Contacts
PHYSICAL WORK

132. 132
Completion of Task
Certifying Engineer
Manuals, Card Signatures etc
Duplicate Inspections
Supervision
PHYSICAL WORK

133. 133
HUMAN FACTORS
Question Time

134. 134
xx
REVIEW
xx

135. 135
xx
REVIEW
xx

136. 136
HUMAN ERROR MODELS
AND THEORIES Chap 8
Error Theories and
Models,
. . . staying safe. . .

137. 137
HUMAN FACTORS
Why do we study Human Factors?
“in the last 10 years, the annual average (of
maintenance related incidents) has
increased more than 100% while the
number of flights has increased by less
than 55%”
Being aware of actions/ non actions that can
lead to an accident . . .

138. 138
HUMAN ERROR MODELS AND
THEORIES
There are many models in the aviation
industry that seek to improve the
safety culture
Human Error Models and Theories aid
the understanding of Human Factors
If we can understand the reasons why
accidents happen –surely we can
work towards avoiding them?

139. 139
Never Repeat an Error
Company Culture
Incident Data Bank
Feedback
HF Awareness
HUMAN ERRORS

140. 140
Company Culture
Leaders’ Values & Styles
Interpretation by Management
Interpretation by All Employees
Powerful Motivator
HUMAN ERRORS

141. 141
Company Culture
Influences the ‘Norm’
Positive / Negative
Regulatory Bodies Look Beyond
Active Failure
Latent Conditions
HUMAN ERRORS

142. 142
HUMAN ERROR MODELS AND
THEORIES
James Reason’s Modelof Active
and Latent Errors
Gordon Dupont’s Theoryof the
Dirty Dozen

143. 143
JAMES REASONS MODEL OF ACTIVE AND
LATENT FAILURES (1990)
Latent Failure:
A failure/ accident waiting to happen
A wrong decision by line management
A wrong dimension on a drawing by a designer/
decision maker
Dormant: error occurs at a different time and place
from the accident

144. 144
Latent Errors
Hidden From System
Combine to Become
Active Errors
HUMAN ERRORS

145. 145
JAMES REASONS MODEL OF ACTIVE AND
LATENT FAILURES (1990)
Active failure:
Errors at the sharp end
Immediate adverse effect
Front Line Operators: Pilots/ Engineers
Breaches all the defences and results in
an accident

146. 146
Incident Investigation
Certification, Documentation
& Recording
History / Monitoring / Trending
Likely Causes
HUMAN ERRORS

147. 147
Heinrich’s Ratio
HUMAN ERRORS

148. 148
Investigation Team
Root Causes
Trust
Action on Recommendations
Part of the Solution
HUMAN ERRORS

149. 149
Discipline
Laws & Regulations
Punishment –Deterrent
CAA Investigation
Falsification / Forged
HUMAN ERRORS

150. 150
Discipline
Confessing
Sharing Experiences
Free Reporting of Incidents
Discipline –Correct & Fair
HUMAN ERRORS

151. 151
Is Discipline Required?
Was it Deliberate
Accept Responsibility for
Actions
Likely to Repeat
HUMAN ERRORS

152. 152
Lose / Lose
Win / Win
HUMAN ERRORS

153. 153
Incident Data Analysis
Information is Power
Accurate Data
Informed Analysis
Rigorous Recording
Training
HUMAN ERRORS
Gut
Feeling
Safety
Nets
HF Awareness

154. 154
HF –SAFEYTY NETS

155. 155
Feedback
Positive or Negative
Avoid Repeating Same Errors
Don’t Afraid to Share
Experiences / Data
HUMAN ERRORS
Air Dirty Laundry

156. 156
JAMES REASON’S MODEL
“Swiss Cheese Effect”
Each of the five layers
has the potential of
causing or preventing
an accident
If the error goes
unchecked at each
level, an accident will
occur

157. 157
JAMES REASON’S MODEL
Decisions by
management/
manufacturer
Line Management
deficiencies/ planning/
communication
Psychological
reasons/ unsafe
behaviour/ fatigue

158. 158
JAMES REASON’S MODEL
Productive Activities/ doing
the job/ shortcuts
Inadequate defences;
nothing to prevent the
accident from happening
ACCIDENT!!!
Limited windows of
opportunity
What Do Need ?

159. 159
JAMES REASON’S MODELSAFETY NET

160. 160
JAMES REASONS MODEL
5 Basic Elements
Decision Makers
Line Management
(Psychological) Preconditions
Productive Activities
Defences

161. 161
GORDON DUPONT’S DIRTY DOZEN
Builds on all areas of Human Factors.
Is the core of the Psychological
Preconditions in James Reason’s Model.
Concentrates on 12 main factors of the
human condition that could cause an
accident . . .

162. 162
Expect Errors
Recognise Errors
Reduce Frequency
Safeguards
Safety Nets
GORDON DUPONT’S DIRTY DOZEN

163. 163
1.Lack of Communication
2.Complacency
3.Lack of Knowledge
4.Distraction
5.Lack of Teamwork
6.Fatigue
GORDON DUPONT’S DIRTY DOZEN

164. 164
7.Lack of Resources
8.Pressure
9.Lack of Assertiveness
10.Stress
11.Lack of Awareness
12.Norms
GORDON DUPONT’S DIRTY DOZEN

165. 165
GORDON DUPONT’S DIRTY DOZEN
Lack of
Communication

166. 166
GORDON DUPONT’S DIRTY DOZEN
Complacency

167. 167
GORDON DUPONT’S DIRTY DOZEN
Lack of
Knowledge

168. 168
GORDON DUPONT’S DIRTY DOZEN
Distraction

169. 169
GORDON DUPONT’S DIRTY DOZEN
Lack of
Teamwork

170. 170
GORDON DUPONT’S DIRTY DOZEN
Fatigue

171. 171
GORDON DUPONT’S DIRTY DOZEN
Lack of
Resources

172. 172
GORDON DUPONT’S DIRTY DOZEN
Pressure

173. 173
GORDON DUPONT’S DIRTY DOZEN
Lack of
Assertiveness

174. 174
GORDON DUPONT’S DIRTY DOZEN
Stress
-Psychological Health
-Physical Health
-The Environment
-The Job in Hand
-The Organisation/Management

175. 175
GORDON DUPONT’S DIRTY DOZEN
Lack of
Awareness

176. 176
GORDON DUPONT’S DIRTY DOZEN
Norms

177. 177
HAZARDS IN THE WORKPLACE
Recognising and Avoiding Hazards
Basic Safety Points
-learn the Safeway
-if you don’t know . . . Ask
-CHECK THE MANUAL!!
-watch outfor actions of others, as well as
your own

178. 178
GORDON DUPONT’S DIRTY DOZEN
Lack of
Communication
ComplacencyLack of
Knowledge
Distractions
Lack of
Teamwork
Fatigue Lack of
Resources
Pressure
Lack of
Assertiveness
Stress Norm Lack of
Awareness

179. 179
Prevention
Reduce
Remove
SAFETY NETS

180. 180
Lack of Communication
Log Books / Worksheets
Record Stages
Each Stage / Task Signed
Shift Change Briefing / Lists
SAFETY NETS

181. 181
Complacency
Expect a Fault
Check if Repetitive
Signing for Not Doing Task
SAFETY NETS

182. 182
Lack of Knowledge
Training
Keep Up-To-Date
Ask
Strive to Improve
SAFETY NETS

183. 183
Distraction
Finish Task First
Mark Starting/Interruption Points
Fit Locking Devices
Double Check
Use Detailed Worksheet
Go Back Three Steps on Return
SAFETY NETS

184. 184
Lack of Teamwork
Discus / Briefing / Task
Allocation
Understanding
Flexibility
Team Bonding
SAFETY NETS

185. 185
Fatigue
Awareness of Symptoms
Plan to Avoid
Sleep & Exercise
SAFETY NETS

186. 186
Lack of Resources
Forward Planning
Maintain Adequate Stock
Pool Resources
Do Not Compromise Standards
SAFETY NETS

187. 187
Pressure
Avoid Self-Induced
Communicate
Ask for Help
Say No
SAFETY NETS

188. 188
Lack of Assertiveness
Be Strong
Do Not Compromise
Do Not Give Way to Pressure
SAFETY NETS

189. 189
Stress
Awareness of Symptoms
Find Cause
Perception
Relax
Don’t Bottle Up
Problem Shared
SAFETY NETS

190. 190
Lack of Awareness
Think Through any Scenario
Check for Conflicts
Check for Problems
SAFETY NETS

191. 191
Norms
Always Read the Manual
Suggest Amendments
Avoid ‘Duff Gen Books’
Only One Right Way
SAFETY NETS

192. 192
Active Failure
Hidden
Mistakes
Safety Nets
Mandatory Occurrence Reports
SAFETY NETS

193. 193
Mandatory Occurrence
Reports
(MOR)
CAA Reports
Analysis
FAILURES

194. 194
OCCURRENCE REPORTS
INCORRECT INSTALLATION 49%
INADEQUATE SERVICING 31%
DAMAGE DURING MAINTENANCE 4.5%
COMPONENT OVERHAUL ERROR 6.3%
CONSEQUENCE OF RECORDING ERROR 1.8%
NON-COMPLIANCE WITH
REQUIREMENTS
7.3%

195. 195
Inadequate Safety Nets
Protection From Human Errors
Built-in Redundancy
Special Checks
Functional Checks
SAFETY NETS

196. 196
Failsafe
Duplication / Triplicating
Critical Components
Safe Life
Set by Manufacturer
Damage Tolerance
TOLERANCE / REDUNDANCY

197. 197
Failsafe
Tolerant of Error
Vital Systems
Little Tolerance –Special Checks
TOLERANCE / REDUNDANCY

198. 198
Special Checks
Independent Checking /
Inspector
Complex Tasks
Stage Inspections
Two Signatures
DUPLICATE INSPECTIONS

199. 199
Special Checks
Depth of Check / Supervision
Vital Points
Checks Installation
Checks Movement & Accuracy
SAFETY NETS

200. 200
Functional Checks
Maintenance Manuals
Built-in Testing
Function Not Quality
SAFETY NETS

201. 201
HUMAN FACTORS
Question Time

202. 202
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203. 203
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REVIEW
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204. 204
EXERCISE
HUMAN FACTORS

205. 205
GORDON DUPONT’S DIRTY DOZEN
ACTIVITY!
-Split into groups, each group to take
Threeof the Dirty Dozenand think of
a workplace scenario that may involve
all three
-Swap Group Lists
-What ‘Safety Nets’could be put in
place to prevent each of the Dirty
Dozen that you have?

206. 206
GORDON DUPONT’S DIRTY DOZEN
Group One
----------------Lack of Communication, Complacency and Lack of Knowledge
Group Two
---------------–Distractions, Lack of Teamwork and Fatigue
Group Three
-----------------Lack of Resources, Pressure and Lack of Assertiveness
Group Four
---------------–Stress, Norms, and Lack of Awareness

207. 207
TYPES of ERRORS
TYPES OF ERROR IN MAINTENANCE TASKS
1.Crew & Human Factors
2.Design Related
3.Regulatory Oversight
4.Company Management
5.Failure to Maintain Safe Separation
6.Freight, Ferry & Positioning Flights
7.Occupant Survivability
8.Incorrect/Inadequate Procedures
9.Non JAA/FAA Operator Safety
10.Failure to Adopt/Fit Best Available Technology

208. 208
Crew & Human Factors
Maintenance Human Factors
Omission of Action/Inappropriate Action
Flight Handling
Poor Professional Judgement/Airmanship
Failure in Crew Resource Management
Lack of Positional Awareness
SAFETY NETS

209. 209
Maintenance
Incorrect installation of components
Fitting of wrong parts
Electrical wiring discrepancies
Loose objects left in aircraft
Inadequate lubrication
Access panels/fairings, cowlings not secured
Fuel/oil caps and fuel panels not secured
Gear pins not removed before departure
SAFETY NETS

210. 210
Example
Lack of Resource Planning
Job Distraction
Lack of Communication
Inadequate Shift Handover
Lack of Assertiveness
Aircraft design
Perceived Pressure
Inadequate Maintenance Aids
Christmas
SAFETY NETS

211. 211
Implications of Errors
Heinrich’s Ratio 600 : 1
Fatal Accidents
Cause / Cost
Recoverable
Compensation
SAFETY NETS

212. 212
HUMAN FACTORS
IMPLICATIONS OF ERRORS
Insurance Deductibles
Insurance Premiums
Loss of useof the aircraft and equipment
The Costof the accident investigation
Disruptionto the Schedules
Disruptionto Servicing and Maintenance
The hire and Trainingof new personnel

213. 213
IMPLICATIONS OF ERRORS
Reputation
Branded Image
Morale
Blame Culture
SAFETY NETS

214. 214
HUMAN FACTORS
AVOIDING AND MANAGING ERRORS
Safer Aircraft Designs
System and Structural Redundancy
Improved Working Practices
Introducing Quality Assurance
Better Training of the Staff
Improved Support Systems for the Aircrew
and Engineers
Improved National and International
Regulations

215. 215
Safety Management System
Responsibility
Motivation
Teamwork
Trust
Leadership
Justice
Respect
Commitment
SAFETY NETS

216. 216
Structure in Place?
The industry is already heavily
regulated
We have systems and procedures in
place
All work is done in accordance with
procedures laid down
We already think of Flight Safety and
work safely
Most of the problems lie in human error
and NOT in our systems
SAFETY NETS

217. 217
Regulations?
Minimum Requirements
Safe Operations
Human Performance 100%
Above Minimum
SAFETY NETS

218. 218
Procedures?
Used Systematically
Errors
Reviewed
SMART
Added Safety
SAFETY NETS

219. 219
Systems?
Investigations
Record & Monitor
Trends
Knowledge
SAFETY NETS

220. 220
Human Error?
Main Factor
Not Intentional
Cognitive Shortfall
Perceived Pressure
Management Attitudes
SAFETY NETS

221. 221
Liability?
Corporate Liability
Top Level
Safety Management System
Reduce as Low as Reasonably
Practicable
SAFETY NETS

222. 222
Liability?
Accountability
Risk Awareness
Identified Hazards
Risk Management
SAFETY NETS

223. 223
Liability?
The Safety Case
Safety Critical Activities
Feedback
New Technology / Regulations
SAFETY NETS

224. 224
Hazard Model
Reactive
Checklists
Controls
Barriers
Underpinning
SAFETY NETS

225. 225
Hazard Model
Training
Assurance
Awareness
Accountabilities
Bow-Tie Analysis Tool
SAFETY NETS

226. 226
SAFETY NETS

227. 227
Proactive Measures
Reactive Measures
SAFETY NETS

228. 228
Proactive Measures
Identify Hazard
Identify Threats
Identification Threat Controls
Identification Escalation Factors
Assessment Escalation Controls
Identification Hazardous Event
SAFETY NETS

229. 229
Reactive Measures
Assess Recovery Measures
Identification Escalation Factors
Identification Escalation Controls
Assess Consequences
Damage Limitation
SAFETY NETS

230. 230
Bow –Tie Tool

231. 231
Risk Assessment Matrix
How Bad?
How Often?
(What is the worst outcome?)
SAFETY NETS

232. 232
Un-airworthy Aircraft
Hazard
Threat
Control
Escalation
Control
EXAMPLE
People / Assets
Errors, Mistakes, Violations
Competence, Procedures,
Systems
Non-Compliant Practice
Monitor / Feedback

233. 233
Un-airworthy Aircraft
Recovery
Escalation
Control
Consequence
Mitigation
EXAMPLE
Recall Aircraft
Already Airborne
Crew Competence and
Awareness
Aircraft Crash
Effective Emergency
Response

234. 234
Engineers
Trained
Experienced
Knowledgeable
MADE ERRORS
CONCLUSION

235. 235
Critical Tasks
Protected
Single Path to Failure
CONCLUSION

236. 236
Philosophies
Self-Certification
Company Approvals
Assumption
WILL NOT MAKE ANY SIGNIFICANT
ERRORS
CONCLUSION

237. 237
Quality Systems
Scope of Inspection / Monitor
Timing of QA
CONCLUSION

238. 238
Advancing Technology
Complexity
Culture Change
BY THE NUMBERS
CONCLUSION

239. 239
Attitudes
Total Compliance
Consequences of Deviation
Re-Evaluation of Certification
Processes / Procedures
PROGNOSIS

240. 240
Safety Awareness -Basic Points
Learn –Safe Way
Ask
Use –Safe Methods
Awareness
Practices –Housekeeping
Co-operation –Emergencies
Reporting
Draw Attention
HAZARDS IN THE
WORKPLACE Chap 9

241. 241
HAZARDS IN THE WORKPLACE
Basic Safety Points:
-Practice good house keeping
-Emergency: Know your exits!
-Know who the first-aider is
-Log all accidents
-Potential hazards –make safe
and inform

242. 242
HAZARDS IN THE WORKPLACE
Think
Sharp edges cut: sheet metal/ locking wire
Hot things burn: soldering irons/ heat guns
Acids and solvents: are harmful
Powered Equipment: trap fingers/ clothing
Electricity: shock
Heavy equipment: dropped/ fall/ posture

243. 243
HAZARDS IN THE WORKPLACE
Whether in the
hangar or factory at
a work-station or
working on the
ramp; the aviation
industry is a
dangerous place
BE AWARE OF YOUR
ENVIRONMENT!

244. 244

245. 245
Emergency
Emergency Drills
Location FAFA
Prevent Loss of Life
Prevent Further Injury
Prevent Escalation
HAZARDS IN THE WORKPLACE

246. 246
HAZARDS IN THE WORKPLACE
THE SAFETY TRAINING CENTRE
Safety is based largely on the rule
‘A place for everything and everything in its
place’.
This is not just a demanding request, but
GOOD COMMON SENSE!

247. 247
HAZARDS IN THE WORKPLACE
HAND TOOLS
HORSEPLAY
ELECTRICITY

248. 248
HAZARDS IN THE WORKPLACE
HAND TOOLS
HORSEPLAY
ELECTRICITY

249. 249
HAZARDS IN THE WORKPLACE
HAND TOOLS
HORSEPLAY
ELECTRICITY

250. 250
HAZARDS IN THE WORKPLACE

251. 251
HAZARDS IN THE WORKPLACE

252. 252
HAZARDS IN THE WORKPLACE

253. 253

254. 254
GENERAL WORKSHOP SAFETY PRECAUTIONS
Overalls
Loose Clothing
Rings etc.
Hair
Boots
Barrier Cream
Do NOT run
Do NOT shout
Keep workshop tidy
Return tools
Mop up any spilt water, oil, etc.
Keep all gangways clear.
Do NOT skylark or play around in the workshop
REMEMBER!!
ACCIDENTS DO NOT
HAPPEN,
THEY ARE CAUSED

255. 255
Electrical Safety
Defective Equipment
Wet Hands
Damage Reported
Authorised
Earthed
Insulated
Correct Voltage
HAZARDS IN THE WORKPLACE

256. 256

257. 257
Compressed Air
Direct to Person
Tight Connections
PPE
Damage
HAZARDS IN THE WORKPLACE

258. 258

259. 259
Acids, Chemicals &
Solvents
Ventilation
Breathing Apparatus
PPE
HAZARDS IN THE WORKPLACE

260. 260

261. 261
Sheet Matal
Sharp Edges
PPE
Machines
HAZARDS IN THE WORKPLACE

262. 262
Machinery Safety
Clothing
Hair
PPE
Guards
Adjustment
HAZARDS IN THE WORKPLACE

263. 263
Do
Clean / Good Condition
Know How to Operate
Emergency
Fluid Levels
Check Set-up
MACHINE SAFETY

264. 264
Do
Correct Cutters / Drills
Replace Damaged Tools
Report Faults
Guards / Work Area
Check Set-up
MACHINE SAFETY

265. 265
Do Not
Operate Unless Trained
Tamper
Override Settings
Correct Operation
Change When in Operation
MACHINE SAFETY

266. 266
Do Not
Walk Away
Fool Around
Leave Suspended
Interrupt Anyone
MACHINE SAFETY

267. 267
OVERALLS These will give you protection from normal dirt, dust and
oil.
APRONS These are made of RUBBER for protection from acids and
or LEATHER for protection from heat.
SAFETY FOOTWEAR Boots or shoes with steel toe-caps will protect the toes
from falling objects.
GAUNTLETS
These are worn to protect your hands.
(i) Rubber gauntlets must be worn when handling
acids.
(ii) Leather gauntlets must be worn when handling
hot or very cold objects.
GOGGLES AND FACE
SHIELDS
Used to protect the eyes from such dangers as
metal particles, molten metal, acids and glare.
When welding it is important to use goggles or face
shield with the correct filter.
HARD HATS Must be worn when there is a danger that when
overhead working is taking place, tools and
equipment can be dropped.

268. 268
Security
Cowlings, Panels & Doors
Loose Article Checks
Correct Storage / Identification
Report Faults
Care Taken
AIRCRAFT SAFETY

269. 269
Do Not
Lean
Force
Hammer
Throw
Storage Surface Condition
No Step
Keep Clean
AIRCRAFT SAFETY

270. 270
Danger Notices
Testing -Pressures
Testing Radio / Radar
NDT
Engine Running
Noise etc
AIRCRAFT SAFETY

271. 271
Operating Notices
Normal
Emergency
Break-In
Working On Aircraft
AIRCRAFT SAFETY

272. 272
Danger Zones
Keep Clear
Correct Access Route
PPE
AIRCRAFT SAFETY

273. 273

274. 274
Loose Articles
Tools
Consumables
Cleaning Items
Personal Items
Retrieve / Find All Missing Items
Report All Loose Articles
AIRCRAFT SAFETY

275. 275
Loose Articles
Sound Servicing Sense
Don’t Leave to Chance
Report Everything
FOD
COSTS MONEY & LIVES
AIRCRAFT SAFETY

276. 276
Fire
Efficient Servicing Methods
Fire Regulations
Training
Effective FAFA Use
FIRE SAFETY

277. 277
Prevention is Better Than Cure
Husbandry
Power Ground Equipment
Fuel / POL
Smoking
Electrical Equipment
FIRE SAFETY

278. 278
Manual Lifting
Correct Lifting Technique
Training
LIFTING SAFETY

279. 279

280. 280
Question Time
HUMAN FACTORS

281. 281
SAFETY
MANAGEMENT
AWARDS
2006

282. 282
10
th
Place –The Porter

283. 283
9
th
Place –The Baggage Handler

284. 284
8
th
Place –Air Conditioning

285. 285
7
th
Place –The Mechanic

286. 286
6
th
Place –The Fork Lift

287. 287
5
th
Place –Cable Fixing

288. 288
4
th
Place –Basement Painting

289. 289
3
th
Place –Aircraft Engineer

290. 290Notice the bare feet for better continuity
2
th
Place –The Electrician

291. 291
And the
First Prize
…

292. 292
1
st
Place –Street Lamp Fixing

293. 293
And this one won an
extra prize
MilitaryService in North Korea
SPECIAL PRIZE

294. 294

295. 295
HUMAN FACTORS

296. 296

297. 297

298. 298

299. 299

300. 300

301. 301

302. 302

303. 303

304. 304
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305. 305
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