Aircraft Maintenance Technology

MAR 2018

The aircraft maintenance professional's source for technological advancements, maintenance alerts, news, articles, events, and careers

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FROM THE FAA HOW TO TELL THE HUMAN FACTORS STORY USING ACCIDENTS AND EVENTS By Dr. Bill Johnson TRAINERS ARE ALWAYS LOOKING FOR EXAMPLES OF HUMAN or organizational performance that contributed to an incident/event. Johnson characterizes and shows example events that provide the best opportunity to learn. BACKGROUND I started teaching human factors contribution to accidents around 1980. With a fresh Ph.D. diploma, I was teaching an accident investigation course at the University of Illinois. I could not have imagined that I would be so fortunate as to still be "telling accident stories" nearly 40 years later. Of course, the example cases have changed as aviation safety has evolved. The hardware failures have diminished the increasing attention to human error as a contributing factor. Pre-1980 accidents, like the Hindenburg may have historical value and even human factors examples. However, the old accidents lack necessary modern relevancy. Dual engine failure on a 777, fuel exhaustion and dead stick landing on an A330, flight controls on a Beech 1900 commuter, or AS 350 helicopter, strike closer to home with today's learners. What kind of events are best for maintenance human factors learning environment? CHARACTERISTICS OF A SUITABLE LEARNING EXAMPLE First and foremost, we know that many events resulted in loss of lives. Always acknowledge that fact at the outset of post-event analysis. Second, company names are associated with events. A negative event must be fact-based and is not usually directly associated with the overall continuing quality and safety of parties involved. Mention that at the outset of a discussion. Third, assume that parties to the event may be in your audience. From experience, I have learned to ask that question before getting into the details of an accident. I have had audience members who serviced and or flew the event aircraft, knew the crew members, were at the accident scene, and may have lost family members or colleagues. For these reasons it is ideal to find accident examples where there were no injuries or fatalities. Further, surviving crew and aircraft can detail the circumstances surrounding the accident leading to the best understanding of contributing factors. In a perfect world use an event directly matched to your audience. General aviation mechanics want to hear about GA accidents; airline mechanics want airliners, pilots want flightcrew-related contributing factors; and managers/executives need to hear about organizational factors. Because of the accident chain, one accident often addresses many audiences. Human error and organizational factors are generic. Safety culture is generic. Issues like failure to follow procedures, fitness for duty, and crew communication cross all industry segments. Look for events where there are supporting pictures, graphics, or videos. In today's YouTube world a trainer must be judicially selective about appropriate and legally available content. Published accident report data is usually the best source and publicly available. If it is in a government report it has cleared the hurdles of fact-checking, language appropriateness, and public-use suitability. EXAMPLE LEARNING EVENTS THAT WORK FOR MAINTENANCE The accident reports described below are easy to find via a quick Google search. Example 1: Airbus A319, London Heathrow, May 24, 2013 The flight took off with unlatched cowlings on both engines. At take-off speed the cowlings detached damaging the fuel line on the right engine. The cowling damage leaking fuel was visually FIGURE 1. Unlatched cowling and evacuation.

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