follow procedures! johnsonfollow procedures ! dr. bill johnson chief scientific and technical...
TRANSCRIPT
Follow Procedures! – Johnson
Follow Procedures !
Dr. Bill Johnson Chief Scientific and Technical Advisor
Human Factors in Maintenance [email protected]
Federal Aviation Administration
28 August 2018
3 of 29
Federal Aviation Administration
Presentation Plan: Follow Procedures
The FFP Challenge
Follow Procedures Project
Misc FAA Initiatives
28 August 2018
4 of 29
Federal Aviation Administration
Follow Procedures?
4
5 of 29
Federal Aviation Administration
Not Always Failure to Follow Procedures?
6 of 29
Federal Aviation Administration
Presentation Plan: It Takes a Village
To Follow Procedures
The FFP Challenge
Follow Procedures Project
Misc FAA Initiatives
28 August 2018
7 of 29
Federal Aviation Administration
7
2016-17 Study Methodology
Phase 2: (2017)
Field Interviews
“Describe a personal FFP event” Matched story to the 92 CFs
Rated effectiveness value of mitigations
Phase 1: (2016) Reviewed ASRS and NTSB reports
92 Contributing Factors 15 Mitigations
8 of 29
Federal Aviation Administration
Who was Interviewed?
• 156 Participants including:
– AMTs
– Inspectors
– Managers
– Engineers & Procedure writers
– Supervisors
• 7 Companies including:
– Airliner manufacturers
– Repair stations for 91, 135,121,
9 of 29
Federal Aviation Administration
9
49
49
51
57
60
60
62
65
67
0 10 20 30 40 50 60 70 80
Top Contributing Factors
10 of 29
Federal Aviation Administration
10
Lowest Contributing Factors
28 August 2018
11 of 29
Federal Aviation Administration
11
Findings – Summary
Multiple CFs contribute to FFP
A multi-level challenge
Documentation not the top CF
Social/cultural issues are the major CF
Safety Culture!
13 of 29
Federal Aviation Administration
Resources
Environment
Managers AMTs
Supervisors Inspectors
Authors
Enforce Policy Peer Pressure
Culture
Peer Pressure Commitment
Reinforcement Follow Prs.
Design Templates
RII Technology
Training
Good Access & Lighting
People Actions
15 of 29
Federal Aviation Administration
15
16 of 29
Federal Aviation Administration
16
17 of 29
Federal Aviation Administration
17
18 of 29
Federal Aviation Administration
18
19 of 29
Federal Aviation Administration
19
20 of 29
Federal Aviation Administration
20
21 of 29
Federal Aviation Administration
21
www.followprocedures.com
Launching date: September 30. 2018
22 of 29
Federal Aviation Administration
Presentation Plan: Follow Procedures
The FFP Challenge
Follow Procedures Project
Misc FAA Initiatives
28 August 2018
23 of 29
Federal Aviation Administration
www.humanfactorsinfo.com
24 of 29
Federal Aviation Administration
Fatigue Support
25 of 29
Federal Aviation Administration
AC 120-115 for Fatigue Risk Mgmt.
25
26 of 29
Federal Aviation Administration
BTW: AC120-72A for HF Training
27 of 29
Federal Aviation Administration
27 of 45
Go to: Humanfactorsinfo.com
28 of 29
Federal Aviation Administration
Presentation Summary: Follow Procedures
The FFP Challenge
Follow Procedures Project
Misc FAA Initiatives
28 August 2018
29 of 29
Federal Aviation Administration
Thank you,
Bill Johnson