Dirty Dozen. Human Error In Aircraft Maintenance. Federal Aviation Administration. By: Richard Travis, FAA Safety Team
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1 Dirty Dozen Human Error In Aircraft Maintenance Presented to: National Safety Council By: Richard Travis, FAA Safety Team Date: May 20, 2018
2 The Best People Make the Worst Mistakes 2
3 3
4 Delta Flight 1288 MD-88 4
5 The Dirty Dozen Communication Complacency Lack of Knowledge Distraction Teamwork Fatigue Lack of Resources Pressure Assertiveness Stress Lack of Awareness Norms 5
6 The Dirty Dozen 1. Lack of Communication 2. Complacency 3. Lack of Knowledge 4. Distraction 5. Lack of Teamwork 6. Fatigue 7. Lack of Resources 8. Pressure 9. Lack of Assertiveness 10. Stress 11. Lack of Awareness 12. Norms Safety Nets Use logbooks, worksheets etc. to communicate and remove doubt. Discuss work to be done or what has been completed. Never assume anything. 6
7 Continental Express, 14 Fatalities, Safety Nets Use logbooks, worksheets etc. to communicate and remove doubt. Discuss work to be done or what has been completed. Never assume anything. 7
8 8
9 The Dirty Dozen 1. Lack of Communication 7. Lack of Resources 2. Complacency 8. Pressure 3. Lack of Knowledge 9. Lack of Assertiveness 4. Distraction 10. Stress 5. Lack of Teamwork 11. Lack of Awareness 6. Fatigue 12. Norms Safety Nets Train yourself to expect to find a fault. Never sign for anything you didn t do. 9
10 Therefore the Safety Board concludes that a low expectation of finding a crack in a 219 series fan hub might have caused the inspector to overlook or minimize the significance of an indication. 10
11 Jackscrew 88 11
12 Italian Air Force, Keflavik No lineman present for start-up Crew asked LM to verify battery door closed (near left landing gear) after engines were started LM walked thru prop, killing him instantly First such case in Italian AF in over 50 years 12
13 Loadmaster exits crew door to check battery door. Engines were running Italian Air Force, Keflavik CREW DOOR BATT. DOOR 13
14 Loadmaster killed as he walks into prop. Body and remains scattered over 100 feet. 14
15 Accident cleanup by Fire Department Carelessness and overconfidence are more dangerous than deliberately accepted risk. - Wilbur Wright,
16 Safety Nets 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
17 B Continental Flight 1515 January 16,2006 El Paso International Airport 17
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21 The Dirty Dozen 1. Lack of Communication 2. Complacency 3. Lack of Knowledge 4. Distraction 5. Lack of Teamwork 6. Fatigue 7. Lack of Resources 8. Pressure 9. Lack of Assertiveness 10. Stress 11. Lack of Awareness 12. Norms Safety Nets Get training on type. Use up to date manuals. Ask a Tech. Rep. or someone who knows. 21
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25 Lack Of Knowledge Safety Nets Get training on type. Stay Current -Read, Read, Read Use up to date manuals. Ask a Tech. Rep. -or someone who knows Communicate No Pride! September 2, 1998 Douglas MD-11 in the sea 9KM Off Nova Scotia 25
26 The Dirty Dozen 1. Lack of Communication 2. Complacency 3. Lack of Knowledge 4. Distraction 5. Lack of Teamwork 6. Fatigue 7. Lack of Resources 8. Pressure 9. Lack of Assertiveness 10. Stress 11. Lack of Awareness 12. Norms Safety Nets Always finish the job or unfasten the connection Mark the uncompleted work. Lock wire where possible or use torque seal. Double inspect by another or self. When you return to the job always go back three steps. Use a detailed check sheet. 26
27 Safety Nets Always finish the job or unfasten the connection. Mark the uncompleted work. Lock wire where possible or use torque seal. Double inspect by another or self. When you return to the job always go back three steps. Use a detailed check sheet. 27
28 The Dirty Dozen 1. Lack of Communication 2. Complacency 3. Lack of Knowledge 4. Distraction 5. Lack of Teamwork 6. Fatigue 7. Lack of Resources 8. Pressure 9. Lack of Assertiveness 10. Stress 11. Lack of Awareness 12. Norms Safety Nets Reconfirm duties among team members. Team tasks require a full team. Communicate! FOLLOW THE CORRECT PROCEDURES. 28
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31 Lack of Teamwork Safety Nets Communicate! Team tasks require a full team. Reconfirm duties among team members. FOLLOW THE CORRECT PROCEDURES. 31
32 The Dirty Dozen 1. Lack of Communication 2. Complacency 3. Lack of Knowledge 4. Distraction 5. Lack of Teamwork 6. Fatigue 7. Lack of Resources 8. Pressure 9. Lack of Assertiveness 10. Stress 11. Lack of Awareness 12. Norms Safety Nets Be aware of the symptoms and look for them in yourself and others. Sleep and exercise regularly. Plan to avoid complex tasks at the bottom of your circadian rhythm. Ask others to check your work 32
33 Fatigue ACUTE FATIGUE Produced by physical exertion or sleep loss Alleviated by a single rest period CHRONIC FATIGUE Medical or psychological problem Depression or chronic fatigue syndrome OPERATIONAL FATIGUE Most commonly seen after 3-4 days of heavy tasking Not relieved by a single sleep period 33
34 SYMPTOMS OF FATIGUE Attention reduced Memory diminished Mood becomes withdrawn Low situational awareness Long hours of labor (any type). High intensity stress. 34
35 CIRCADIAN RHYTHMS 35
36 Fatigue Safety Nets 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. 36
37 The Dirty Dozen 1. Lack of Communication 2. Complacency 3. Lack of Knowledge 4. Distraction 5. Lack of Teamwork 6. Fatigue 7. Lack of Resources 8. Pressure 9. Lack of Assertiveness 10. Stress 11. Lack of Awareness 12. Norms Safety Nets Check suspect areas at the beginning of the inspection and AOG the required parts. Order and stock anticipated parts before they are required. Know all available parts sources and arrange for pooling or loaning. Maintain a standard and if in doubt ground the aircraft. 37
38 Lack of Resources Safety Nets Check suspect areas at the beginning of the inspection and AOG the required parts. Order and stock anticipated parts before they are required. Know all available parts sources and arrange for pooling or loaning. Maintain a standard and if in doubt ground the aircraft. 38
39 The Dirty Dozen 1. Lack of Communication 2. Complacency 3. Lack of Knowledge 4. Distraction 5. Lack of Teamwork 6. Fatigue 7. Lack of Resources 8. Pressure 9. Lack of Assertiveness 10. Stress 11. Lack of Awareness 12. Norms Safety Nets Be sure the pressure is not self- induced. Communicate your concerns. Ask for extra help. Just say NO. 39
40 Jessica Dubroff
41 Chiang Kai-Shek Airport Taiwan June 6,
42 Pressure Safety Nets Be sure the pressure is not self- induced. Communicate your concerns. Ask for extra help. Just say NO. 42
43 The Dirty Dozen 1. Lack of Communication 7. Lack of Resources 2. Complacency 8. Pressure 3. Lack of Knowledge 9. Lack of Assertiveness 4. Distraction 10. Stress 5. Lack of Teamwork 11. Lack of Awareness 6. Fatigue 12. Norms Safety Nets If it s not critical, record it in the journey log book & only sign for what is serviceable. Refuse to compromise your standards. 43
44 Assertiveness High Performance Others Rights Assertive Both Party s Rights Team Work Synergy Your Rights Low Passive Acquiesce Compromise Aggressive Anger Offense 44
45 45
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47 Lack of Assertiveness Safety Nets If it s not critical, record it in the journey log book & only sign for what is serviceable. Refuse to compromise your standards. 47
48 The Dirty Dozen 1. Lack of Communication 2. Complacency 3. Lack of Knowledge 4. Distraction 5. Lack of Teamwork 6. Fatigue 7. Lack of Resources 8. Pressure 9. Lack of Assertiveness 10. Stress 11. Lack of Awareness 12. Norms Safety Nets Be aware of how stress can effect your work. Stop and look rationally at the problem. Determine a rational course of action and follow it. Take time off or at least have a short break. Discuss it with someone. Ask fellow workers to monitor your work. Exercise your body. 48
49 STRESS 49
50 Stress Safety Nets Be aware of how stress can effect your work. Stop and look rationally at the problem. Determine a rational course of action and follow it. Take time off or at least have a short break. Discuss it with someone. Ask fellow workers to monitor your work. Exercise your body. 50
51 The Dirty Dozen 1. Lack of Communication 2. Complacency 3. Lack of Knowledge 4. Distraction 5. Lack of Teamwork 6. Fatigue 7. Lack of Resources 8. Pressure 9. Lack of Assertiveness 10. Stress 11. Lack of Awareness 12. Norms Safety Nets 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. 51
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55 Lack of Awareness Safety Nets 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. 55
56 The Dirty Dozen 1. Lack of Communication 2. Complacency 3. Lack of Knowledge 4. Distraction 5. Lack of Teamwork 6. Fatigue 7. Lack of Resources 8. Pressure 9. Lack of Assertiveness 10. Stress 11. Lack of Awareness 12. Norms Safety Nets Always work as per the instructions or have the instructions changed. Be aware that norms don t make it right. 56
57 This picture was taken by an amateur photographer seconds before an American Airlines DC-10 crashed at Chicago O'Hare Airport, after losing an engine during takeoff. Below is the resulting explosion. Improper maintenance procedures was to blame. Two-hundredseventy-one people aboard were killed as well as 2 on the ground. (May 25, 1979) 57
58 Norms Safety Nets Always work as per the instructions or have the instructions changed. Be aware that norms don t make it right. 58
59 FATIGUE STRESS COMPLACENCY COMMUNICATION AWARENESS DISTRACTION LACK OF KNOWLEDGE TEAMWORK LACK OF RESOURCES PRESSURE LACK OF ASSERTIVENESS NORMS Lee Marvin, Ernest Borgnine, Jim Brown, Charles Bronson, John Cassavetes, Trini Lopez, Telly Savalas, Donald Sutherland, Clint Walker 59
60 Face Reality 60
61 Air France Concorde Flight July 25, passengers, 9 crew, and 4 people on the ground were killed when the aircraft hit hotel. 61
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