Aeronautics Study - Safety Threats Term Paper

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Percentage (a)

System operated unsafely during maintenance 80 13

Incomplete installation 48 8

Maintenance worker contacted hazard 45 7

Incorrect assembly or location 44 7

Towing event 44 7

Vehicle or equipment contacted aircraft 31 5

Material left in aircraft 27 4

Wrong equipment or part installed 23 4

Part not installed 22 4

Part damaged during repair 21 3

Panel or system not closed 21 3

Required service not performed 20 3

Failure of component or tool 15 2

Fault not found 15 2

Falls and trips 14 2

System not made safe before maintenance 12 2

System not reactivated 10 2

Pin or tie left in place 9 1

Documentation error 9 1

Note. For an additional 14 occurrences, the outcome could not be determined.

A a) Figures are rounded to nearest percentage.

Errors

Perceptual error

Example: After being on duty for 18 hr on a long overtime shift, the worker was carrying out a general inspection on an engine at around 22:00. He missed obvious damage to the internals of the cold stream duct area. The damage was found later, when another defect was being investigated.

Memory lapse

Example: Just prior to the departure of the aircraft, I remembered I had left a blanking plug within the engine inlet area. I advised the pilot that I needed to check that area again and retrieved the blank.

Slip

Example: Without thinking, I moved to wipe oil with a rag. The rag was ingested in the engine intake causing FOD [Foreign Object Damage].

Rule-based error

Example: A mechanic did not check the position of the flap lever before he pushed in a cockpit circuit breaker that provided electrical power to a hydraulic pump. When the pump started, the flaps began to retract automatically. This could have caused damage to the aircraft or injured other workers.

Violation

Example: At the end of a shift we realized that an engine hadn't been run to check for oil leaks when the aircraft was to be placed online. Under pressure to avoid a delay due to this oversight, the run was carried out too quickly and the engine was not un-cowled properly to check for oil leaks and consequently after departure that particular engine ran out of oil as the result of a damaged seal.

Knowledge-based error

Example: I wanted to turn the radio master on but could not find it, as the switches were poorly marked or unreadable. I was unfamiliar with the aircraft, so I asked an airframe tradesman who was working on the aircraft and he pointed to a red rocker switch. I queried him and he said that must be it. I pushed the switch and the right engine turned over, with the propeller narrowly missing a tradesman who was inspecting the engine. There is no radio master in this aircraft. I immediately marked the "start" and some other switches and learned a valuable lesson.

Mischance

Example: A service procedure was carried out in accordance with the aircraft maintenance manual. The manual however, contained an error, which resulted in an aircraft system failing to operate correctly during a functional test at the end of the maintenance procedure.

Factor n or Fatigue 1-0.2

Pressure 8-1.9

Coordination 6-1.4

Training 1-0.2

Supervision 5-1.9

Procedure 16 9.0 **

Equipment 1-0.3 deviation 4-4.3 *

Environment 1-0.8 chi square](9, N = 805) 46.68

Wald test significant at p<.05, ** Wald test significant at p <

Memory lapse

Violation

Unclassifiable behavior

Knowledge-based error

Slip

Rule-based error

Hardware event

Perceptual error

Mischance

Environment event

Figure 4. Factors contributing to maintenance occurrences.

Percentage of occurrences involving event

Pressure

Equipment

Training

Coordination

Fatigue

Procedure

Supervision

Environment

Previous deviation

REF

Runway Safety

The Human Element

Runway safety is one of the FAA's highest priorities - specifically the problem of runway incursions. A runway incursion is defined as: Any occurrence at an airport involving an aircraft, vehicle, or person on the ground that creates a collision hazard or results in a loss of separation with an aircraft taking off, intending to take off, landing, or intending to land.

Though relatively few in number when compared to the massive amount of traffic that moves safely through our nation's airports every day, runway incursions present a special problem. Not only do they have the potential to put more lives at risk due to the number and proximity of aircraft operating on the airport surface, they also take place in a complex and dynamic environment where root causes are difficult to isolate.

At the simplest level, incursions occur because people make mistakes. Humans are superbly skilled at making decisions under a wide range of circumstances but, for a variety of reasons, they are also fallible. Consider this human vulnerability within the context of the numerous variables that may contribute to human error and you can appreciate the problem. Its not just a pilot, controller, or vehicle operator problem, it a problem that all of us in the aviation community share.

July 11, 2007 http://www.faa.gov/runwaysafety/data/ri_tot.cfm?fy1=2007&fy2=2006

Runway Safety Data and Statistics

Runway Incursion Totals by quarter FY2007 vs. FY2006

1 st-Qtr 2007

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Probe Questions

Safety incidents happen in all professions, including aircraft maintenance. Such incidents can help us to identify areas where improvements can be made. We are interested in your experience of safety incidents. Please tell us about a maintenance incident which involved you or someone else. A maintenance incident can be anything which could have prevented an aircraft from operating normally or could have put the safety of a worker at risk. (if you cannot recall any incidents, go on to [next section of the survey].)

Reporters were required to indicate that they had either witnessed or participated in the events they described. Background information associated with each occurrence -- such as the time of day, the type of aircraft involved, and whether an official report had been filed -- was collected with the aid of multiple-choice or restricted-response questions and is not reported here.]

What happened?

Most incidents involve a chain of events. Start with the first thing that happened and then describe each of the things that happened next. Try to give as much detail as you can. If people played a part in the incident, tell us whether they were a LAME [Licensed Aircraft Maintenance Engineer], AME [unlicensed Aircraft Maintenance Engineer] or an apprentice, but please do not identify anyone.

2. " Why do you think the incident happened?

3. " Was there anything about the way things are done at your company which contributed to the incident (for example, something about the equipment, documentation, procedures etc.)?

4. Did the incident occur because of something you or another person did, or didn't do?

Yes [right arrow] -- Another person -- Myself

No (go on to [remaining restricted response questions])

Please describe the most important thing that you or they did wrong (or didn't do). (Hobbs and Williamson, 2003)

References

Bruggink, Gerard M. (2000, August). "Remembering Tenerife." Retrieved November 23, 2007, at http://cf.alpa.org/internet/alp/2000/aug00p18.htm

Dismukes, Key, Berman, Benjamin a. And Loukopoulos, Loukia D. (2007). The Limits of Expertise: Rethinking Pilot Error and the Causes of Airline.... Ashgate Publishing, Ltd. Retrieved November 23, 2007, at http://books.google.com/books?id=mMxaYxhu0l0C&dq=runway+excrusions+causes

Fadden, S., Ververs, P.M., & Wickens, C.D. (2001). Pathway HUDs: Are They Viable?. Human Factors, 43(2), 173. Retrieved November 19, 2007, from Questia database: http://www.questia.com/PM.qst?a=o&d=5001043570

Hobbs, a., & Williamson, a. (2003). Associations between Errors and Contributing Factors in Aircraft Maintenance. Human Factors, 45(2), 186+. Retrieved November 23, 2007, from: Questia database: http://www.questia.com/PM.qst?a=o&d=5002089765

Jentsch, F., Barnett, J., Bowers, C.A., & Salas, E. (1999). Who Is Flying This Plane Anyway? What Mishaps Tell Us about Crew Member Role Assignment and Air Crew Situation Awareness. Human Factors, 41(1), 1. Retrieved November 20, 2007, from Questia database: http://www.questia.com/PM.qst?a=o&d=5001307301

Johnson, Chris W. And Palanque, Philippe. (2004). Human Error, Safety and Systems Development. Springer. Retrieved November 23, 2007, at http://books.google.com/books?id=wjo5s3zCxiEC&dq=runway+incursion

Kirwan, Barry, Rodgers, Mark and Sch fer, Dirk. (2005). Human Factors Impacts in Air Traffic Management. Retrieved…[continue]

Some Sources Used in Document:

"Remembering-Tenerife" 

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