U.S. statistics indicate that 80% of aviation accidents are due to human errors with 50% due to maintenance human factor problems. Current human factor management programs have not succeeded to the degree desired. Many industries today use performance excellence frameworks such as the Baldrige National Quality Award framework to improve over-all organizational effectiveness, organizational culture and personal learning and growth. A survey administered to a sample population of senior aviation maintainers in 18 countries revealed a consistent problem with aviation human factors and the need for a more integrated framework to manage human factor problems in aviation maintenance.
Human Factors History
Current Human Factor programs in Aircraft Maintenance
Performance Excellence Framework
Researcher's Work Setting and Role
Statement of the Problem
REVIEW OF RELEVANT LITERATURE AND RESEARCH
Human Factor Errors in Aircraft Maintenance Statistics
Current Human Factor Programs in Aircraft Maintenance 13
Aviation Performance Excellence Framework 12
Statement of Research Question 18
III. RESEARCH METHODOLOGY 19
Research Design 19
Research Model 19
Survey Population 19
Source of Data 20
Pilot Study 20
The Data Gathering Device 21
Distribution Method 22
Instrument Reliability 22
Instrument Validity 22
Treatment of Data and Procedures 23
IV. RESULTS 24
Human Factor Programs and Management 24
Most Common Outcomes of Safety Occurrences 25
Survey Feedback 28
V. DISCUSSION 30
VI CONCLUSION 37
VII RECOMMENDATION 38
Background of the Problem
Imagine you are a member of an aviation organization, such as the military, and you have just been told that you will need to work over the weekend because there has been a fleet grounding issue on your F-16 aircraft. You will need to work to get all the aircraft inspected by Monday morning. You have just put in close to 60 hours of work that week and you are really tired. Your organization has sent you for Human Factors (HF) training and workshops and your management has told you to call for time-out when you feel tired yet they say there is an urgent need to get the aircraft inspected over the weekend.
Although your body tells you that you can no longer take it, your mind tells you that you must keep going and be a team player or else the whole team will fail in this important mission. As you console yourself on your way home, you are reminded of how many times this year you have been doing this and the close encounters you have had with making an error of judgment. You are immediately reminded of that famous lecture you heard during HF training that "the chain is only as strong as its weakest link." The next morning, before you go to work, you hear that one of your friends the night before had hit and damaged the aircraft nose landing gear with a Harlan tractor and now management has called for an urgent safety briefing to remind everyone of the need to be vigilant and aware of such lapses in judgment. You immediately recall how one of your colleagues had been screaming to remove the Harlan tractor or Toyota tractor because they both had exactly the opposite reverse gears, in one you push the lever forward and the other backward. Does this sound far too familiar?
Today, more than ever, the aviation world is faced with the constant challenge of addressing human factors in maintenance. While there have been several advances to the study and implementation of human factors programs, there are still several inconsistencies to the way these programs are implemented and hence the varied results.
Aircraft maintenance work encompasses fast turnaround, high pressure with possibly hundreds of tasks being performed by large numbers of personnel on highly complex and technologically advanced systems in a confined area. It is very easy for information and tasks to fall through the safety net. Events around the world in the late
1970s, 1980s and early 1990s, involving crashes or serious accidents with aircraft, alerted the aviation world to the fact that although the aircraft were becoming much more reliable, the human being in the process had the potential to obliterate any of these technological advances. The role played by human performance can be found below.
In this research project we will analyze the top human factor problems in aviation maintenance and evaluate a holistic solution to addressing these problems through a performance excellence framework. We will start with a brief look at the history of HF
programs and the changes that have taken place over the years. We will also explore the current HF programs adopted by several organizations and try to understand why HF
error occur, and how comprehensive, the solutions currently adopted. Then finally, we will look at the Baldridge national quality program and criteria for performance excellence to see if we can formulate a more comprehensive solution to managing HF in maintenance. In essence, we would be looking at a more systemic solution to HF
management as HF is more than just about people.
Human Factors History
In the late 1970s, Cockpit Resource Management (CRM) featured prominently in pilot training. The term was used to apply to the process of training flight crews to reduce pilot error by making better use of the resources on the flight deck. A change in name was made from Cockpit to Crew Resource Management (CRM) to change the emphasis of training to focus on cockpit group dynamics. Some airline programs dealt with specific topics such as team building, briefing strategies, situational awareness and stress management. (Byrnes and Black, 1993). In the early 1990s, CRM training began to reflect the many factors, such as organizational culture, within the aviation system in which the crew must function which can determine safety.
Similarly, but much later, it was not until in the 90s that Maintenance Resource
Management (MRM) was made available to maintenance personnel. After years of accidents, many caused by HF errors, nothing significant was really done to determine the HF root causes. Unlike CRM, MRM was very new to the aviation maintainers and it was not until June 10, 1990 when a cockpit window blew out at 16,000 feet, and a pilot almost went with it, that an in depth look at the contributing factors to a maintenance error were examined. (System Safety Services, 2000). David King, from the United
Kingdom is one of the first to look at HF in the same light it is looked at today.
Figure 2: Human Factors History. From Xavier.A, 2005.
The need for a change in approach to human errors and their reporting was reinforced during the CAA sponsored 12th Symposium on Human Factors in Aviation
Maintenance that was held in Gatwick Airport, England, on 10-12 March 1998. It was the first of the international symposiums involving the CAA, FAA and Transport Canada.
The foundation of Human Factors training as a modern aviation tool was probably initiated in the United States at a workshop sponsored by the National Aeronautics and Space Administration (NASA) in 1979. This workshop was the development of NASA
research into the causes of air transport accidents. The International Civil Aviation
Organization, (ICAO) now requires organizations to include HFIM training. HF training which helps our fellow maintenance personnel to avoid an error he/she never intends to make had finally arrived (System, n.d).
Current Human Factor Programs in Aircraft Maintenance
MRM which later evolved into Human Factors in Maintenance (HFIM) was developed to provide primarily the training required to understand and prevent HF errors from occurring. The main breakthrough that was achieved in recent years is the emphasis given by senior management in organizations to HF programs. Many consultants and companies have enjoyed this upward focus on HF. Gordon Dupont, formerly of Transport Canada, is one such consultant whose excellent "Dirty Dozen" classification of HF root causes has been widely adopted by several aviation organizations. Other organizations like Boeing have developed their own in-house Maintenance Error and Decision Analysis (MEDA) programs with more in depth analysis including the background of personnel that commit these HF errors to better understand the extent of solutions necessary. Most of these programs are designed to identify the HF errors, educate the personnel on their causal potential, suggest ways to contain and correct the problem and create a HF error-free environment. While many of these programs have truly made the aviation work environment safer, many of them still look at HF from a 'people' perspective rather than "an organization" perspective. There may be a need to develop programs that improve the performance of all areas of an organization as a whole which will provide long-term solutions to HFIM.
Performance Excellence Framework
Performance Excellence Framework (PEF) has been used in several countries and in several sectors such as Education, Healthcare, Tourism and Housing. Most recently, the Defense industry has been using such framework to gauge its quality health. One of the first of such frameworks, established in 1988, is the Malcom Baldridge National Quality
Award (MBNQA) framework which covers all areas of a business such as Process…
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(2) Analyzing all accident data without regard to the type of airframe provides for an easy sampling and less potential bias toward fixed wing vs. rotary wing aircraft.
(3) Not including ground accidents into the research will allow the research to focus only on aviation accidents.
(4) Limiting the research to a four-year period; 2003 to 2006 will provide an adequate sampling of the data and not constrain the research results.