They say it dseon t mttear.. Aoccdrnig to a rscheearch at Cmabrigde Uinervtisy, it deosn t mttaer in what oredr the ltteers in a word are, the olny iprmoetnt tihng is that the frist and lsat ltteer be at the rghit pclae. The rset can be a total mses and you can still raed it wouthit porbelm. This is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but The word as a wlohe Amzanig huh? HUMAN FACTORS CONTINUATION TRAINING Q1 & Q2 2016 Page 1 of 13
CONTENTS: 1 INTRODUCTION 2 The Dirty Dozen revisited 3 Possible Solutions to the Dirty Dozen 4 Shift Handover 5 767-GEN-027 - L/E Slat Defect investigation 6 Inadvertent Escape Slide Deployment Page 2 of 13
1. Introduction The following extract from CAP 716 reminds us why regulations, company procedures, Quality (compliance) Management and Safety Management systems (SMS) are in place, all to assist aviation organisations to manage risk and errors. The fundamental reason for Human Factors Training. The emphasis is upon practical guidance material for real-world situations, acknowledging (but not condoning) the fact that sometimes people fail to comply with procedures, albeit often with the best of intentions. It recognises that organisations operate within a competitive commercial environment, and concentrates upon risk and error management rather than risk and error elimination. An organisation can minimise its vulnerability to human error and reduce its risks by implementing human factors best practice described within the document. This will help enable the Part-145 Accountable Manager to meet his responsibilities as signatory to the Maintenance Organisation Exposition, which includes the company safety and quality policy, and to make sure that the company policies, processes and procedures, and their implementation, are effective in addressing the potentially high risk area of human factors. This training fulfils the company compliance to continuation training for Human Factors, however it should be noted that initial training should have been received in a classroom to meet the PART 145.A.30 syllabus. If this has not been undertaken then this should be highlighted to your supervisor or a course sourced and attended by yourself. Page 3 of 13
2. The Dirty Dozen revisited:- 1 COMPLACENCY 7 STRESS 2 DISTRACTION 8 POOR COMMUNICATION 3 PRESSURE 9 ASSERTIVENESS 4 RESOURCES 10 TEAM WORK 5 KNOWLEDGE 11 DEPENDENCE ON NORMS 6 POOR AWARENESS 12 FATIGUE Page 4 of 13
3. Possible Solutions to the Dirty Dozen 1 COMPLACENCY Train yourself to expect to find a fault. Never sign for anything you didn t see or do. 2 DISTRACTION Always finish the job or unfasten the connection. Mark the uncompleted work. Lockwire where possible or use torqueseal. Double inspect by another or self. When you return to the job, always go back three steps. Use a detailed check sheet. 3 PRESSURE Be sure the pressure isn't self-induced. Communicate your concerns. Ask for extra help. Just say "No." 4 RESOURCES Check suspect areas at the beginning of the inspection and AOG the required parts or equipment. Order and stock anticipated parts and equipment before they are required. Know all available sources and arrange for pooling or loaning of equipment. Maintain a standard and if in doubt, ground the aircraft. 5 KNOWLEDGE Get training on type. Use up-to-date manuals. Ask a technical representative or someone who knows. 6 POOR AWARENESS 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. Page 5 of 13
7 STRESS Be aware of how stress can affect 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. 8 POOR COMMUNICATION Use logbooks, worksheets, etc. to communicate and remove doubt. Discuss work to be done or what has been completed. Never assume anything. CHECK! 9 ASSERTIVENESS If it's not critical, record it in a journey log book and only sign for what is serviceable. Refuse to compromise your standards. 10 TEAM WORK Discuss what, who, and how a job is to be done. Be sure that everyone understands and agrees. 11 DEPENDENCE ON NORMS Always work as per the instructions or have the instructions Changed. Be aware the "norms" don't make it right. 12 FATIGUE 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. Page 6 of 13
4. Shift Handover The following extracts from the MOE and TP9 Shift handovers, have been included below as a refresher to make as detailed reference for handover, whether you are handing over to others or yourself on the next shift. This serves as a reminder for you to pick up from where you were or should you for some reason be unable to attend to the duties as originally planned, allow someone else to continue on the work required. It should be noted that this does not have to be activities on aircraft but can include duties carried out such as tool checks or updating the station library, as this can serve to save duplication and potentially reduce workload and stress, therefore reducing the onset of errors. MOE 2.26SHIFT / TASK HANDOVER PROCEDURES 2.26.1 Aims and Objectives of Shift Handover It is universally recognised that at the point of changing shift, the need for effective communication between the out-going and the in-coming personnel is extremely important. The absence of such effective communication has been evident in many aircraft accident reports. Part 145.A.47 now formalises this requirement with the statement.. relevant information shall be adequately communicated between outgoing and incoming personnel. 2.26.2 Training of Personnel in Shift / Task handover processes All ALT Personnel are subject to procedural examination as part of their approval process. ALT procedures include a full explanation of actions required (Maintenance Procedure No.9) 2.26.3 Recording of shift / task handover processes Details of actions required are identified in Technical Procedure No 9 2.26.4 Description of Shift Handover Process Communication-The handover should ideally be communicated by written communication (handover log), by verbal discussion or by practical demonstration. If only one method is used there is risk of overlooking some relevant information. For this reason, information should be repeated via more than one medium. Page 7 of 13
Responsibility- Engineers must assume personal ownership and responsibility for the tasks they perform and are to fully identify all aspects of any job that has been left incomplete. Outstanding Maintenance-In addition Engineers should ensure that the maintenance documentation relating to outstanding work is totally indicative of the status of the aircraft prior to their departure off shift. This should include maintenance actions taken in accordance with identified maintenance procedures / processes, the staging of such actions, outstanding work and any other important requirements needed prior to the aircraft release. e.g. the removal of rigging pins fitted to an adjacent system to protect maintenance personnel during work compliance. It is not uncommon that a job is left incomplete during a shift, say in the case of someone being called away to attend to a more urgent task on another aircraft. In these cases it is often not known who will eventually pick up the job of completing and certifying the release to service, and as such the above is particularly important prior to the Engineer s relocation onto the other aircraft. Scheduled Maintenance-The paperwork normally associated with scheduled tasks are the Task Cards that are issued at the beginning of the maintenance input. These may have been written by the manufacturer, maintenance organisation or the operator of the aircraft. In all cases the card and the associated task breakdown written on it, assume that the same person will start and finish the job. It is not designed to be used as a handover document. That is not to say that it could not form part of one. Task Cards break down jobs into discrete stages, and ideally jobs should always be stopped at one of these stages so that the last sign off on the card is the exact stage of the job reached. However this may not always be possible and if so, additional information must be provided to clearly identify the point of exit from the task. Deviations or additional work required as a result of findings when undertaking task completion, should as always be identified on a NRC / Worksheet / Supplementary Card as appropriate. Non Scheduled Maintenance These situations by their very nature are unplanned and are normally associated with time pressure and emergency situations. In spite of this, it is essential that time is taken by the person leaving the job to comprehensively record what activities have taken place and to identify what actions are required to complete the job. Complex or lengthy non-scheduled tasks should always be broken down into a number of discrete steps using stage or process sheets and should emphasis any deviations from the normal or expected way of working. Engineers have a responsibility to ensure that they leave sufficient time prior to departure off shift to record their work if they require it to be suspended or transferred to the on coming shift. Page 8 of 13
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The following Safety Notices were issued earlier this year and highlight human factor errors. Tech Note: 767-GEN-027 - L/E Slat Defect investigation Originally issued as Safety Memo SM/02/02/16 This is to provide you with feedback on an MOR report submitted back in April relating to a LE Slat defect on a B767 Aircraft, where No.8 and No.10 slats inboard target sensors were found crossed over with o/board target washers. Following receipt of a SARS report (2015/158) from an AGL Engineer, a request was sent to the Operator to submit to the authorities, investigate and provide feedback to us. The Operator confirmed that the MOR was submitted to the CAA in accordance with the recognised procedure. We subsequently received the following closure from the Operator: Summary: Post 'C' Check aircraft arrived with a LE SLAT defect. Slat moved OK on hydraulics but in alternate slats locked out at selection 1. FSEU BITE carried out with code LE SLAT asymmetry RH code 27-81021. PSEU BITE carried out with codes 302 and 304. Nr 8 and nr 10 slats inspected and inboard slat proximity detectors found missing. On deeper inspection (Ref IPC 27-81-02) found inboard proximity detector target fitted to outboard slat proximity detector and outer fitted in inboard position. Targets swapped into correct positions for slats 8 and 10 (Ref IPC 27-81-02) and functions c/o AMM 27-81-00 all now satisfactory. Action: Engineering investigation determined that the inboard and outboard slat position sensor targets on the #8 and the #10 leading edge slats were transposed. The targets were removed and refitted in their correct locations. These slats were among those which had been removed from the aircraft during the 'C' Check at BHX and from here the aircraft was positioning at the time the incident occurred. Following rectification the aircraft underwent a check flight involving two take-offs and landings with no further reports and was returned to service. Subsequent investigation by the C check agency found that the sensor targets were transposed through human error. The team involved was not aware of B767-300F Technical Note 767-Gen-027, which drew attention to Vulnerable Maintenance Tasks and cited this specific issue although the Technical Note was available to them. The MRO agency has taken appropriate remedial action. Company (Operator) Closure Recommendation: This report is recommended for closure by Engineering Management in view of the above action. The Reporter has received this feedback and it was suggested that it would be useful to circulate a notice to all engineers in order to highlight this potential hazard. Please see attached a copy of Technical Note 767-GEN-027, for your information. Page 11 of 13
Inadvertent Escape Slide Deployment Originally issued as Safety Memo SM/03/02/16 This Safety Memo is issued to highlight a recent MEDA investigation into an inadvertent escape slide deployment. All Engineers are reminded that when entering/exiting an Aircraft, the AMM for that particular type must be adhered to with regard to arming/disarming the door. Prior to opening a door from the inside, ensure that the correct procedure for disarming has been carried out in accordance with the applicable AMM. On aircraft that have arrived, the doors must not be opened externally; you must wait until the crew opens the door before proceeding up the steps. For information, please see below a copy of the DHL Global Aviation Procedures & Standards Manual PART C, Aircraft Ground Handling Chapter: 1 Issue Nr: 01-17 Issued January 2016 (GAPS procedure) for the opening of cabin doors: GAPS C105.5.1 Opening Of Cabin Doors 1. Opening aircraft doors Cabin Doors Aircraft doors must only be operated by the flight crew or by appropriately trained and qualified staff. When the flight crew are on-board i.e. on arrival, the cabin doors shall only be opened from the inside and after the appropriate signal has been given by the ground crew. The standard signal to be used is: Knocking on the door As soon as the signal has been given by the ground crew, the ground crew must immediately retreat to a safe distance on the stairs platform to avoid being struck by either the door or the escape slide in case of inadvertent activation (if applicable). Ground crew must remain well clear of the door until it has been fully opened. If a flight crew member is visible at the time of knocking, a thumbs up signal may be given. If the flight crew are unavailable at the time of knocking, the ground crew must immediately retreat after knocking and shall not approach the door again unless contact has been made with the crew to clarify the situation. For aircraft which do not have a window in the passenger door, the thumbs up signal may be given by a member of the loading team positioned at the head of the stand in full view of the flight crew. Once the door is fully open, the handrails of the stairs must be extended. Page 12 of 13
In situations where a flight crew member is not on-board the aircraft, cabin access doors shall only be opened by authorised personnel and shall only be opened in accordance with the approved procedures. Under no circumstances shall the cabin door be opened if the stairs have not been positioned and the standard signal given by the ground crew. Similarly, the stairs must never be taken away from the aircraft until the crew have been notified and the door has been fully closed. If the cabin door is to be re-opened after it has been fully closed, approval must first be sought from the commander via headset or approved hand signals, then the door shall be re-opened using the approved process. Note: Positioning of the stairs must be fully in accordance with procedures outlined in GAPS C105.4.3 (Point 6) Positioning of Mobile or Towable Aircraft Steps. Main-deck cargo doors Main deck cargo doors must only be operated by the crew or ground staff that have been specifically trained and authorised for the function. Training must be specific to the type of aircraft and door being operated. Main-deck Cargo Door Safety Barrier Nets Safety Barrier Nets must always be installed whenever the cargo-door is open and no High- Loader is positioned at any Main-deck Cargo Door. - END - Page 13 of 13