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B1 CATEGORY

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EASA PART-66 COURSEWARE

HUMAN FACTORS

B1 CATEGORY

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TABLE OF CONTENTS

Introduction

Incidents attribuable to human factors/human error

Murphy’s laws.

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ACKNOWLEDGEMENTS:

Many sources of information have been used in the course of producing this PART-66

Chapter 9, including text books on human factors, ergonomics, occupational

psychology and the like accident and investigation data, such as reports produced by

the Air Accidents Investigation Branch (AAIB) or National Transportation Safety Board

(NTSC) and ICAO Human Factors Digests.

This document has also drawn on the FAA Human Factors Guide for Aviation

Maintenance and various other materials from the large body of FAA funded research

into human factors and maintenance engineering.

Acknowledgements are given to all those authors, researchers, editors and

participating organisations who contributed to the sources of information used in the

preparation of this document.

.

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STATISTICS:

Statistics indicate that 80% of aviation accidents are due to human errors with 50%

due to maintenance human factor problems.

The role played by human performance in civil aircraft accidents (IATA sources)

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STATISTICS:

Many industries today use performance excellence frameworks to improve over-

all organizational effectiveness, organizational culture and personal learning and

growth.

Today, more than ever, the aviation world is faced with the constant challenge of

addressing human factors in maintenance.

Over the last 20-30 years, aircraft have become more and more reliable.

Because of these improvements, the locus of aviation accidents has slowly

shifted to improper ground operation and to maintenance; some estimates now

place maintenance errors as the root cause of 20-30% of serious aviation

incidents.

AVIATION MAINTENANCE HAS CHANGED OVER THE YEARS:

o Newer aircraft contain materials, power plants, and electronic subsystems that

did not exist in earlier mod­els, and the number of older aircraft has increased.

o Technicians use more, and more sophisticated, equipment and procedures.

o The nature of aviation maintenance is such that inspectors often work under

conditions that stress their physical, cognitive, and perceptual limits.

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AVIATION MAINTENANCE HAS CHANGED OVER THE YEARS:

What do you think ? Sure, very hot !!!

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INTRODUCTION

EASA REQUIREMENTS:

The European Aviation Safety Agency (EASA) is the centrepiece of the European

Union’s strategy for aviation safety.

EASA mission insures the highest common standards of safety and environmental

protection in civil aviation.

Regulation (EU) No 1362/2014 of 26 November 2014 on the continuing airworthiness

of aircraft and aeronautic products, parts and appliances and on the approval of

organisations and personnel involved in these tasks defines the following:

o Continuing airworthiness: Annex I (PART-M)

o Maintenance organisation approval: Annex II (PART-145)

o Certifying staff: Annex III (PART-66)

o Training organisation approval: Annex IV (PART-147)

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THE AIRCRAFT, A SAFE MEANS OF TRANSPORT, BUT EXPOSED TO

ACCIDENTS:

Today air transport has reached a high level of safety, due to an active policy of

prevention of the risks carried out by the whole personnel in the sector and in which

the technical investigation plays a significant role.

The aircraft remains, indeed, the means of transport the more exposed to the risks of

accidents because of the technological complexity of the aircraft, their speed, as well

as the increase in air traffic.

o In France, over the past 10 years, the number of deaths per year is also

comparable to air and railway transport. It is about a hundred, which is far behind

the 8 000 deads in road accidents.

When the number of deaths throughout the world is compared to the number of

passengers/distance traveled (Km), the results obtained are similar for aircrafts

and trains which are about one death for 500 millions passengers/distance

traveled (Km) throughout the world, i.e. 10 times less than for road accidents.

o Taking into account the performances of the modern aircraft, the least significant

malfunction of an additional component of the aircraft, the least significant human

error can have irreversible consequences.

o The vigilance is even more necessary since the increase in the traffic should

increase the risk of accidents. Forecasts about the growth of the air traffic

established by the International Civil Aviation Organization (ICAO) are

considered to double in 15 to 30 years.

o Consequently, a constant rate of accident can be expected, where the number of

accidents and victims is doubled.

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EXAMPLES OF GROUND HUMAN ERRORS:

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EXAMPLES OF GROUND HUMAN ERRORS:

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EXAMPLES OF GROUND HUMAN ERRORS:

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THE SHEL MODEL:

The “SHEL” model was first advocated by Professor Elwyn Edwards in 1972.

The component blocks of the SHEL model (the name being derived from the initial

letters of its components: Software, Hardware, Environment, Liveware) are depicted

with a pictorial impression of the need for matching the components.

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THE SHEL MODEL:

The concept (the name being derived from the initial letters of its components,

Software, Hardware, Environment, Liveware) was first developed by Edwards in 1972,

with a modified diagram to illustrate the model developed by Hawkins in 1975.

The following interpretations are suggested:

o Software (procedures, symbology, etc.),

o Hardware (machine),

o Environment (the conditions in which the L-H-S system must function),

o Liveware (human),

Liveware characteristics applied to aviation:

o Software - the rules, procedures, written documents etc., which are part of the

standard operating procedures.

o Hardware - the Air Traffic Control suites, their configuration, controls and

surfaces, displays and functional systems.

o Environment - the situation in which the L-H-S system must function, the social

and economic climate as well as the natural environment.

o Liveware - the human beings - the controller with other controllers, flight crews,

engineers and maintenance personnel, management and administration people -

within in the system.

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THE REASON MODEL:

Professor Reason views the aviation industry as a complex productive system.

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THE REASON MODEL:

o One of the basic elements of the system is the decision-makers (high-level

management, the company's corporate or the regulatory body) who are

responsible for setting goals and for managing available resources to achieve

and balance two distinct goals.

The goal of safety and the goal of on-time and cost-effective transportation of

passengers and cargo.

o A second key element is line management, those who implement the decisions

made by upper management.

For upper management decisions and line management actions to result in

effective and productive activities by the workforce involved, certain

preconditions have to exist.

For example, equipment must be available and reliable, the workforce has to be

skilled, knowledgeable and motivated, and environmental conditions have to be

safe.

o The final element, defences or safeguards, is usually in place to prevent

foreseeable injury, damage or costly interruptions of service.

The Reason model shows how humans contribute to the breakdown of complex,

interactive and well-guarded systems - such as commercial aviation - to produce an

accident.

In the aviation context, “well-guarded” refers to the strict rules, high standards,

inspection procedures and sophisticated monitoring equipment in place.

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THE REASON MODEL:

Because of technological progress and excellent defences, accidents seldom

originate exclusively from the errors of operational personnel (front-line operators) or

as a result of major equipment failures.

Failures can be of two types, depending on the immediacy of their consequences:

o An active failure is an error or a violation which has an immediate adverse effect.

These errors are usually made by the front-line operator. A pilot raising the

landing gear lever instead of the flap lever exemplifies this failure type.

o A latent failure is a result of an action or decision made well before an accident,

the consequences of which may remain dormant for a long time. Such failures

usually originate at the decision-maker, regulator or line management levels; that

are, with people far removed in time and space from the event.

Latent failures, which originate from questionable decisions or incorrect actions,

although not harmful if they occur individually, can interact to create “a window of

opportunity” for a pilot, air traffic controller or mechanic to commit an active

failure which breaches all the defences of the system and results in an accident.

In a well-guarded system, latent and active failures will interact, but they will not often

breach the defences.

When the defences work, the result is an incident; when they do not, it is an accident.

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ACCIDENTS ATTRIBUTABLES TO AN

HUMAN ERROR

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TENERIFE (CANARY ISLANDS - MARCH 27, 1977: 583 DEAD):

Two Boeing 747s collide on a fog-shrouded runway at Tenerife in the Canary Islands,

killing 583 people in the worst accident in aviation history.

Sixty-one people survive.

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TENERIFE (CANARY ISLANDS - MARCH 27, 1977: 583 DEAD):

The planes, Pan Am flight 1736 originating in Los Angeles and KLM Royal Dutch

Airlines flight 4805, a charter from Amsterdam crashed into each other on Los Rodeos

Airport's single runway.

The latter continued its taxi forgetting to use the taxiway.

That day, there was a thick fog on the runway.

The 747 from KLM airlines started to accelerate without permission, while the Pan Am

was still on the runway.

The aircraft from KLM hit the 747 from Pan Am at the take-off point.

The two aircrafts caught fire. It is the most fatal accident in air travel history. 583

people died. 71 people survive.

Visibility on the ground was poor, limited to 1,000 feet or so, but many other factors

led to the disaster.

Muddled instructions, malfunctioning runway lights and an overcrowded airport played

roles, too, but perhaps the major factor was pilot error, specifically the bad judgment

exercised by the Dutch captain.

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TENERIFE (CANARY ISLANDS - MARCH 27, 1977: 583 DEAD):

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MAUÏ (HAWAII - ALOHA FLIGHT 243, April 28 1988 – 1 DEAD, 65 INJURED):

The accident involving Aloha flight 243 in April 1988 involved 18 feet of the upper

cabin structure suddenly being ripped away in flight due to structural failure.

The Boeing 737 involved in this accident had been examined, as required by US

regulations, by two of the engineering inspectors.

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MAUÏ (HAWAII - ALOHA FLIGHT 243, April 28 1988 – 1 DEAD, 65 INJURED):

As a result of the Aloha accident, the US instigated a programme of research looking

into the problems associated with human factors and aircraft maintenance, with

particular emphasis upon inspection.

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NEW DELHI (INDIA - NOVEMBER 12, 1996: 357 DEAD):

A Boeing 747 from Saudi Arabian Airways just took off from New Delhi airport to flight

level 140 when the II-76 of Kazakhstan Airlines, which was in the landing phase. 320

people were killed on board the 747, 37 on board the Ilyushin Il-76 which went below

its allotted altitude.

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NEW DELHI (INDIA - NOVEMBER 12, 1996: 357 DEAD):

The commission determined that the accident had been the fault of the Kazakh Il-76

commander, who (according to FDR evidence) had descended from the assigned

altitude of 15,000 feet (4,600 m) to 14,500 feet (4,400 m) and subsequently

14,000 feet (4,300 m) and even below that.

The report ascribed the cause of this serious breach in operating procedure to the lack

of English language skills on the part of the Kazakh aircraft pilots; they were relying

entirely on their radio operator for communications with the ATC Kazakh officials

stated that the aircraft had descended while their pilots were fighting turbulence inside

a bank of cumulus clouds.

Also, a few seconds from impact, the Kazakh plane climbed slightly and the two

planes collided. If they had not climbed slightly, it is likely that they would have passed

under the Saudi plane.

This was due to the fact that only then did the radio operator of Kazhak 1907

remembered that he had not conveyed to the pilots that they had to fly at 15000 ft.

He asked the pilot to do so and the captain gave orders for full throttle and the plane

climbed, only to hit the oncoming Saudi plane.

The recorder of the Saudi plane revealed the pilots reciting the prayer that they had to,

according to Islam Law, when they face death.

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CHICAGO (USA - MAY 25, 1979 - 273 DEAD):

A little while after takeoff, a DC-10 of American Airlines from Chicago airport had its

left engine and its engine mount separated from the aircraft damaging the wing and

the hydraulic system and causing its crash.

Bad maintenance procedures were used by American Airlines during the

disassembling of the engines for inspection, subjecting the engine mount to a lot of

stress.

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GONESSE (CDG-FRANCE - JULY 25 2000 - 109 DEAD):

The Concorde aircraft of Air France fought to gain altitude right after its takeoff from

the Roissy/Charles de Gaulle airport.

The pilot noted engine failure #2 and tried to reach the aerodrome of Le Bourget

because smoke and fire were coming out from the left wing of the aircraft.

The aircraft was unable to rise, lost speed and crashed on a hotel.

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FLIGHT AF 447 (RIO TO PARIS - JUNE 01, 2009: 228 DEAD):

The accident took place at high-altitude cruise flight (about 10 700 m), at the crossing

of the Intertropical Front. A violent storm, icing of the Pitot probes will cause a

momentary loss of the speed indications.

Inappropriate reactions of pilot led to the stalling of the aircraft, stall maintained until

impact, pour unexplained reasons.

The BEA Survey Report (Bureau Enquête Accidents) underlines the problem of

competence of the crew and gaps in training.

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FLIGHT MH370 (KUALA LUMPUR TO BEIJING - MARCH 08, 2014: 239 DEAD):

Since the crash, the Boeing 777 of Malaysia Airlines company, which was flying

between Kuala Lumpur and Beijing, was not found, despite the colossal means

deployed for weeks.

The search area was tightened and moved, having extended from Central Asia, via

the eastern regions of China, south of the Indian Ocean.

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FLIGHT MH370 (KUALA LUMPUR TO BEIJING - MARCH 08, 2014: 239 DEAD):

Floating debris likely to come from the unit were spotted, a little less than two weeks

after his disappearance, west of Perth, Australia.

The plane, carrying 239 people on board (227 passengers and 12 crew members)

have deviated from its original flight plan, without any explanation from the crew and

without the control of the Malaysian air traffic nor the airline, noticing.

Questions:

o Why has the MH370 flight deviated from its course and disappeared and why its

various automatic monitoring systems have they sent any message?

o Were they voluntarily disconnected?

o What about the people on board?

The Malaysian government has asked all nations that have identified the plane

nationals to carry out checks, without any "significant information" emerges again.

Various assumptions have emerged:

o The aircraft could he be a victim of software piracy?

o Or a loss of cabin pressure, causing a loss of consciousness of passengers and

crew members, has it occurred, the aircraft while pursuing his own road before

crashing?

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FLIGHT 4U9525 (SPAIN TO DÜSSELDORF - MARCH 24, 2014: 150 DEAD):

The crash of the Airbus A320 Germanwings, which crashed in the French Alps, near

Barcelonnette, has delivered much of its secrets.

150 people were killed in a terrible crash.The co-pilot of the Airbus A320

Germanwings, Andreas XXXXXX, depressed, voluntarily rushed the plane, against a

mountain in the French Alps.

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OTHER CRASHES:

o In 1974, a B-707 crashed during approach at Pago-Pago in American Samoa,

with a loss of 96 lives. A visual illusion related to the black-hole phenomenon was

a cause factor (NTSB/AAR 74-15).

o In 1974, a DC-10 crashed after take-off because a cargo door failed (it opened

and blew out). The force applied by a cargo handler to close the cargo door, the

door design and an incomplete application of a service bulletin were cited as

factors (ICAO Circular 132-AN/93).

o In 1974, a B-727 approaching Dulles Airport in Washington crashed into Mount

Weather, with a loss of 92 lives. The absence of timely action of the regulatory

body to resolve a known problem in air traffic terminology was also listed as a

factor (NTSB/AAR 75-16).

o In 1984, a DC-10 overran the runway at John F. Kennedy Airport in New York.

Excessive reliance on automation was noted in the accident report (NTSB/AAR

84- 15).

o In 1987 an MD-80 crashed on take-off in Detroit.

The pilots had not set the flaps, thus violating standard operating procedures.

Also, the take-off configuration warning did not sound, for undetermined reasons

(NTSB/AAR 88-05).

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OTHER CRASHES:

o In 1977, a DC-8 crashed after take-off in Alaska. The influence of alcohol on pilot

performance was cited as a factor (NTSB/AAR 78-07).

o In 1979, a DC-10 crashed into Mount Erebus in Antarctica. Information transfer

and data entry errors played a role in the accident (Accident Report No. 79/139,

New Zealand).

o In 1982, a B-737 crashed after take-off in icing conditions in Washington.

Erroneous engine thrust readings (higher than actual), and the co-pilot’s lack of

assertiveness in communicating his concern and comments about aircraft

performance during the take-off run were among the factors cited (NTSB/AAR

82- 08).

o In 1983, t he report of A300 accident at Kuala Lumpur suggests that variations in

panel layout amongst the aircraft in the fleet had adversely affected crew

performance. (The aircraft was on a dry lease.) (Accident Report No. 2/83,

Malaysia).

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NTSB STATISTICS:

Approximately 80 percent of all air crashes fall into this category (NTSB - National

Transportation Safety Board) .

While the previous definition called it "pilot error," the term has been changed to

"human error" to more realistically reflect that anybody who acts in a support capacity

of a flight may contribute to the error chain. Not just the pilot.

Human errors are analysed into the following categories:

PILOT ERROR

AVERAGE STATISTICS

PERCENT

UNPROFESSIONAL ATTITUDES 47%

VISUAL PERCEPTION MISJUDGMENT 19%

PILOT TECHNIQUE 19%

IMPROPER OPERATION OF

EQUIPAGE 11%

UNKNOWN CAUSES 4%

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MURPHY’S LAWS

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MURPHY’S LAWS

VARIANT OF RULES:

Murphy's Law ("If anything can go wrong, it will") was born at Edwards Air Force Base

in 1949 at North Base.

It was named after Capt. Edward A. Murphy, an engineer working on Air Force Project

MX981, designed to see how much sudden deceleration a person can stand in a

crash.

“Murphy’s Law” can be regarded as the notion: “If something can go wrong, it will.”

A number of variants on the rule have been formulated, as have several corollaries.

o Murphy's Original Law:

If there are two or more ways to do something, and one of those ways can result

in a catastrophe, then someone will do it.

o Murphy's Law:

If anything can go wrong -- it will.

o Murphy's First Corollary:

Left to themselves, things tend to go from bad to worse.

o Murphy's Second Corollary:

It is impossible to make anything foolproof because fools are so ingenious.

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OTHER EXAMPLES:

Ten others Murphy’s laws:

o The risk that a bread slice falls on the side spread with butter is directly

proportional to the cost of the carpet.

o Usually the user’s manual, which is essential for the good running of an

equipment, is thrown away when the equipment is bought.

o Whatever the time and the care you put in to buy an object, once it has been

bought it would be sold at a cheaper price somewhere else.

o Any device taken randomly in a group of 99% of reliability belongs to the group of

the 1%.

o The damaged matter will be directly proportional to its value.

o Each solution generates new problems.

o Everything takes more time than you think.

o Things become worse under pressure.

o The light at the end of the tunnel is the headlight of an approaching train.

o Beauty is a superficial characteristic, ugliness forms part of the body.

Murphy was an optimist.

Having read this chapter you can readily see that Murphy was an optimist. If the truth

of all these laws makes you depressed, just remember that Murphy's Law even

applies to itself. At times, it too goes wrong, allowing you to accomplish something.

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MURPHY WAS AN OPTIMIST :

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