Professional Documents
Culture Documents
Introduction
With the traffic growth and increased demands upon aircraft utilization, the pressure of maintenance operations on-time performance tends to increase. Consequently, there is at present a growing need for an enhanced awareness of the importance of human factors issues in aircraft maintenance. The safety and effectiveness of airline operations are also becoming more directly related to the performance of the people who maintain, inspect and service the aircraft fleets. The diverse nature of operations within today's complex aerospace industry gives rise to dramatically different maintenance structures. With the dynamics of aviation maintenance operations and the associated technician human factors there is a need to understand the varying effects imposed by the unique maintenance environment. The objectives of this Maintenance Briefing Note are: To provide the reader with an enhanced human factors awareness on aircraft maintenance; To show how human capabilities and limitations can influence task performance and safety within the maintenance environment; and, To guide the reader towards the related prevention strategies.
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II
Case Studies
To enhance awareness of maintenance operations this Maintenance Briefing Note includes educational background coming with statistical data and case studies on reported maintenance events, highlighting what happened, why it happened and what can be done to avoid recurrence.
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III
Statistical Data
Human failures are often recognized as being a contributor to incidents and accidents. Technical and maintenance faults took over from CFIT as the biggest cause of fatal airliner accidents. Some authorities consider that improper maintenance is now contributing to a greater proportion of accidents than it did in the past. This is because we did a lot to reduce CFIT. Graphic 1 summarizes all the above.
Number Of Accidents
11 (31%)
4 (12%) 5 (15%)
7 (21%)
Weather/icing Unknown Technical/Maintenance Human Factors
7 (21%)
Controlled Flight Into Terrain
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IV
The Job is well designed to match known strengths and limitations of the person or team doing it. This includes: work areas, the environment, tools, materials, machinery, control and display devices, management and communications systems and all technical documentation for guidance and job control.
Management within the Organization takes responsibility for all aspects of work and work design and encourages a good safety culture by showing commitment and consulting the workforce when making decisions. A learning organization will take into account the latest thinking on best practice in safety and will learn from accidents and near misses.
The company will also select Individuals matched to the needs of the job. (Fitting the human to the job). They will have: the most suitable physique (size, build and strength), personality and intelligence fitted to the job. They will be fully competent by having the right skills, understanding, experience and training.
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The Individual: Physical fatigue, synchronization (time zone, date/night shifts), medical conditions, hearing, sight; Insufficiency of technical knowledge; and, Communication skills, moral, attitude towards work and colleagues.
The Organization: Procedures can be missing or are out of date; Unclear designed checklists; Not enough tools, inappropriate equipment; Aircraft design is not always good for maintainability; and, Lack of spare parts and relevant material.
Errors are possible in all maintenance tasks some are more error-prone than others. Human errors are major cause of accidents and can occur in all jobs including operations, maintenance, modification and management. Does this mean that people have become more careless, forgetful, inattentive and reckless over this period? Probably not, but it does reflect two important and widespread trends: Aircraft components, along with most other items of equipment, have become both more sophisticated and more reliable over the past three decades; and There is a growing appreciation that designers, manufacturers, corporate decision makers, and maintenance managers can make mistakes which, in turn, create the conditions promoting errors on the hangar floor.
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Error is a normal component of human behavior. The trouble with an error in aviation lies with the negative consequences it may generate in operational context. However, we can trap the negative consequences before they produce damage. Organizations can manage human errors by implementing re-active and pro-active measures, and strategies.
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Familiarity/Routine job with: The task; Safety procedures; Ground Support Equipment (GSE) and tools (availability, quality, location, delivery and/or collection, identification, handling heavy or awkward items, etc.); and, Paperwork (unavailability of relevant manuals or procedures, failures to complete paperwork correctly, etc.).
Morale: Personality conflicts; Being unhappy with the work situation; and, Inadequate incentives/motivations .
Support: Difficulties with support from other areas; and, People unavailable in other areas, insufficiency of manpower.
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Fatigue: Problems with tiredness, unusually slow working; Disturbed sleep patterns, particularly at the beginning of a shift; and, The balance between work and rest.
Pressure / Time constraints: High workload; The workforce being spread too thinly over the jobs; Many interruptions; Too little time to perform the job; and, Pressure of flight schedule.
Shifts working: Difficulties with shift patterns, time of day or night; and, Communication at shift handover.
Environment: Weather inconveniences; High noise levels; Inadequate lighting; and, Insufficient environmental protection, etc.
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VI
Maintenancerelated event
Defenses Inadequate Productive Activities Unsafe Acts Preconditions Line Management Deficiencies Decision Makers Fallible decisions
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In aircraft maintenance engineering, the entire team needs to have situational awareness, not just of what they are individually doing, but of their colleagues activities as well.
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Base your maintenance program on major accident risk assessment; Communicate well during shifts and between shifts; Take special care of temporary or inexperienced maintenance technicians and contractors; Do walk around inspections of maintenance tasks in progress; Look for early signs of problems (e.g. a large backlog of jobs; excessive repair times; adverse feedback from staff); and, Investigate near misses and accidents while learning from failure.
VII
Case study
VII.2 Findings
When the arming lever is placed in the ARMED position the activation lever moves under the release lever of the percussion mechanism on the actuator. If the door is then opened in ARMED mode the door lifts and the activation lever operates the release lever which in turn punctures the diaphragm in the reservoir to operate the actuator. Refer to Figure 2, on Page 12.
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Door 1L Emergency Actuator Percussion Mechanism Release Lever Position Release lever was not placed in the correct fully extended position. A gap can be seen under the knurled screw.
Door 4L Emergency Actuator Percussion Mechanism Release Lever Position Release lever was not placed in the correct fully extended position. A gap can be seen under the knurled screw.
VII.3 Recommendations
In order to reactivate the percussion mechanism, the following steps have to be accomplished:
- Push release lever to the fully extended position against the spring and hold it; - Tighten the knurled screw, fully engaged in the bore of the release lever; and, - Safety the knurled screw by wire locking to the lug provided on the release lever.
Release lever placed in the correct fully extended position with the knurled screw engaged and tightened
In order to avoid similar issues in the future, a caution has been included in the relevant AMM tasks to highlight that if the release lever is not placed in the correct position then the emergency actuator will not operate correctly when the door is operated in emergency mode.
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It is very important to read Warnings and Cautions. WARNING: calls to use of materials, processes, methods, procedures, or limits which must be followed precisely to avoid injury to persons. CAUTION: calls attention to methods and procedures which must be followed to avoid damage to equipment.
VIII
This Maintenance Briefing Note (MBN) is part of a set of Briefing Notes that provide an overview of the applicable standards, techniques, best practices, human factors, suggested company prevention strategies and personal lines-of-defense related to major threats and hazards that may affect maintenance. This MBN is intended to enhance the reader's safety awareness but it shall not supersede the applicable regulations and the Airbus or airline's maintenance documentation; should any deviation appear between this MBN and the Airbus or airlines maintenance documentation, the latter shall prevail at all times. In the interest of aviation safety, this MBN may be reproduced in whole or in part - in all media - or translated; any use of this MBN shall not modify its contents or alter an excerpt from its original context. Any commercial use is strictly excluded. All uses shall credit Airbus. Airbus shall have no liability or responsibility for the use of this MBN, the correctness of the duplication, adaptation or translation and for the updating and revision of any duplicated version. Airbus Customer Services Maintenance Engineering Services 1 Rond Point Maurice Bellonte - 31707 BLAGNAC CEDEX FRANCE MBN Reference : MAINT HUM_PER SEQ 01 REV 01 NOV. 2006
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