Human Performance in Aviation Maintenance (Transport Canada Video)

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it's a passengers worst nightmare one minute this Boeing 737 was cruising at 24,000 feet over Hawaii the next it had lost 1/3 of its room only one person died in this bizarre incident with the remaining passengers must have thought their time had come they owe their lives to luck and a skillful flight crew in the day a passenger boarding the aircraft spotted a small crack next to the door but it was too shy to speak up as the boeing reached his cruising height the skin of the aircraft peeled back like a sardine can the aircraft was nineteen years old and had spent all its life in Hawaii flying short hops between the islands but the airlines maintenance men hadn't noticed the effect that the constant takeoffs and landings were having on the aircraft the metal panels were tugging apart there were fatigue cracks everywhere by the end the 737 was flying on a wing and a prayer on March 10th 1989 on a snowy afternoon air Ontario flight 136 3 took off and crashed moments later into a densely wooded area less than one kilometer west of Dryden's Airport the only surviving crew member was Sonja Hartwig and you can spouse's search and you can smell people starting to burn like the smell of hair burning 24 people lost their lives that day and 45 survived I'm here on behalf of these people I have I think they have the right to know the families of the deceased the survivors my co-workers and the flying public the events of the week that led up to this tragic event on March 10th in hopes to prevent a disaster like this happening in the future this tragedy triggered one of the most exhaustive investigations ever conducted into an aircraft accident the 3-year Dryden Commission headed by the Honorable Virgil Machine ski determined that a buildup of ice on the Fokker f28 swings was only one of the factors that contributed to this disaster other factors were inadequate ground procedures crew stress corporate pressures and poor communications between the cabin crew and the flight deck if someone had spoken up this catastrophe might have been avoided on the previous type of aircraft the convair 580 it was not uncommon for them to fly with considerable amounts of contamination on the wing surfaces captain Morwood had come off that aircraft that chief pilot on the f28 had come off that aircraft it was pretty well known throughout the company that this was sort of an accepted thing within the company as a result going on a new aircraft perhaps the training not enforcing the fact that the critical wing on the f28 was super critical with any kind of contamination the fact that they had probably done it and gotten away with it numerous times on the convair over the previous years that kind of positive reinforcement perhaps led him to believe that he wasn't in as critical a situation as he was fact 80% of all aviation accidents are the result of human error with proper maintenance today's aircraft are built to fly safely for unlimited time they are more dependable than they have a world everything signed up just about today's aircraft are also more automated and more complex however the people who fly them the people he control and the people who maintain and repair these complex aircraft are still the same they're human thanks for staying no problem get some sleep thank maintenance errors are accountable for up to 25 percent of all aviation accidents resulting from human error which way nose up nose up yeah is that is that better that's better checklists checklists June failure disengaged switch press and hold it pitch trim left 8:14 do you have control I have control left 14 circuit breakers in manual elevator trip we got to use that the rest of the way have you got control I have control checklist complete tell the tower we're going back I'll they're declaring an emergency we have bitch control problems need an immediate return Halla hair to a TR you have in return to runway zero six we should be able to make zero six coming here 280 you're clear to left downwind runway zero six the way into zero four zero and 15 advise fuel and souls on board we have 4,000 pounds of fuel in six Souls understanding why an AME made a mistake is difficult that's because a maintenance error most often results from a series of circumstances or a chain of events which interfere with an a Emmys performance at a critical moment there are 12 major causes of performance interference the Dirty Dozen 12 everyday circumstances or events which can cause us to do things we normally would not do some have to do with our physical condition and personal state of mind when we're on the job fatigue doing too much and getting too little sleep stress the emotional and psychological wringer we experience at home and on-the-job complacency I made this inspection a hundred times and there's never been anything wrong communication or lack of it or those maintenance manuals service bulletins and airworthiness directives which sometimes seem confusing or written by designers instead of those who work on aircraft other causes have to do with working conditions in the hangar those pestering distractions throughout the shift the volume of noise at any given moment ones lack of knowledge about a particular repair and the lack of teamwork to help support an individual's need the lack of resources to do the job properly still other causes are organizational the pressure cooker of flight schedules and deadlines and the norms of the workplace the shortcuts each one of us take to get the job done on time any one of the Dirty Dozen can interfere with an a Emmys performance at a critical moment usually it's several of them linked together into a chain of events which can result in human error and an accident when they let you know yeah well you useless ding-a-ling what you see when you don't have a gun we'll squeeze it in no problem and we'll clear the intermittent generators neg right okay but let's peel back several layers of circumstances in our case study let's try to determine why an AME made a maintenance error let's try to identify how many of the dirty dozen interfered with an a Emmys performance at a critical moment okay still can't make it and this thing's doing fine on schedule 8:00 in the morning think you can pull the double you up to it sure good don't forget it's due for a phase B and there's an intermittent snaggin generator be an all-nighter you know that okay yeah well I don't run the marketing department all right we'll get it out thanks tired come on Jerry cutoff weekend asleep it's one of the reasons I'm separated can you take a look at this not now just follow the wiring diagram and I'll take it later okay Jerry Collins outside line Jerry that's for you take a message yeah you want your dad to take you to hockey tomorrow yeah I'll tell him all right your son wants to know if you're taking in the pocket one can I talk to him already it's only ten-thirty alright alright tell them I'll pick them up at 6:30 can I take him for breakfast after hockey come on Alice we agreed on weekends yeah yeah yeah all right yeah all right look at this more coffee yeah sure that'd be great those are new igniters don't bother pulling those will fire them instead everything signed off just a bit good we'll write it up and file it thanks for staying no problem get some sleep a good a hockey game in about one hour mountebanks our aliens declaring an emergency we have Fitz control problems need an immediate return Calla hair 280 are you able to return to runway zero six we should be able to make zero six Kelly Air 280 you're cleared to left downwind runway zero six the wind zero four zero at fifteen advise fuel and souls on board we have 4000 pounds of fuel and six Souls the TSB initial briefing had it right Jerry Collins had left lock wire pliers in the tail section the hell hole the pliers shook loose from the voltage regulator shelf on takeoff and interfered with the control cables it was a maintenance error a human error Jerry Collins had made a mistake that's a fact the question is why okay well halo yeah yeah you you want the ear drops an hourly okay yeah yeah yeah okay yep yep special charter yeah okay okay yep we can do that then yeah okay okay yeah okay great great okay thanks bye geez turn I forgot we stopped to change that power cable before the plane goes out I'll get Norbert to help me Norbert I need your help what we're here to change a power cable okay as soon as I finish connecting this line no no Barry you don't understand they need the plane now I need your help come on you help me and I'll buy a cup of coffee after yeah okay I could do this later in 1988 a commercial transport aircraft experienced an explosive decompression at 24,000 feet while enroute from Hilo to Honolulu Hawaii 18 feet of the upper skin and structure separated from the fuselage one flight attendant was swept overboard and presumed to have been fatally injured but the flight crew managed an emergency landing on the island of Maui the National Transportation Safety Board in its investigation determined that the probable cause of this accident was the failure of the airlines maintenance program to detect the presence of significant desponding and fatigue damage which ultimately led to failure of the lap joint and the separation of the fuselage upper lobe this incident demonstrates the significance of existing flaws in aircraft structures and of an inspection program that can detect them before they can cause such a catastrophic failure major finding of this program was that the separation of the aircraft's fuselage upper lobe was caused by a failure mechanism involving small flaws emanating from the rivet holes along the lap joint of the fuselage there are other 88 accident shown earlier is a good example of multiple crack growth failure in this incident several small cracks emanated from rivet holes and coalesced with a single large crack to cause the failure of the structure when you come right down to it most a Emmie's encounter at least one of the Dirty Dozen almost every day so how come more mistakes aren't made did you ever ask yourself why you don't make maintenance errors have you just been lucky or did your mistakes get caught in a safety net before they left the hangar most often one of the Dirty Dozen is not enough to interfere with an a Emmys performance at a critical moment linked one with another however and the chance for human error increases personal stress fatigue and on-the-job pressures are three of the Dirty Dozen which most often aggravate the negative influence of any one of the others a tired brain and the emotional wringer from personal and on-the-job stress can complicate even the simplest of situations and cause you to do what you would normally not do we squeezed in an inspection to please the marketing department didn't we yeah that's a problem we all have to correct him and we have to correct this too I'm doing it that way for years not anymore our checklist doesn't tell you to take your tools over time yeah but if you use it right you can catch a lot of other mistakes government safety regulations industry procedures and checklists our safety nets which can catch our mistakes before they leave the hangar what about personal safety nets we all get tired we all get stressed we all feel the pressure of flight schedules we all make mistakes in addition to the safety nets the government and the industry have set in place what personal safety nets protect you from human error generally what I do and with my co-workers as well as we we try to set our toolboxes up so there isn't a blank spot and the in the toolbox it's an old military the thing that we've picked up on and it works very well every very tools got its spot and when you're completed the inspection you go back through your toolbox and you check all your spots if there's something missing then you've got to account for it it doesn't embarrass me whatsoever to go up to someone and say I don't understand this system or I don't understand what's going on we all work together as a team you know it's a team effort even though we have different trades and different responsibilities our goal is to make the aircraft mechanically safe for flight and we all work together to achieve that goal generally if I'm if I have to leave a job for whatever reason I usually try to finish it to a point where I know when I come back that particular part of the task is done and I make sure I finish a stage of the job where if I come back I can continue on without the risk of having any errors developed well once you've completed and inspect you generally would want to go back and just double-check the work that you've done in particular if you're working alone and in a lot of cases depending on the company size let's say the AME will be working by himself I'll go through and a lot of times that I'll do is even though I've done the inspection a hundred times complacency will set in after a time but I try to think of today when I open that panel and look at there there's actually going to be something wrong I'm gonna find something today today's today that this inspection is going to find something and if I do that every time then I find I put more effort into doing the inspection properly I think it comes along a lot with the training that we get you know right from when we go into school it's a matter of it's almost like a game of you want you're looking for stuff and you always you know try and sort of make a game of of trying to find things that are wrong follow the man let's give yourself enough time make sure that you stand up and say no when Noah's required if the airplanes are not air worthy that's not ready to go well sometimes it's up to the enemy to make that decision we're there to fix the aircraft and that's what we'll do we'll fix the aircraft and when it's fixed correctly then you can carry on and have it for your flights good I mean there's stressful times and it's it's just a matter of dealing with it the best way you can and trying to organize yourself so that you minimize the stress fatigue is a is a factor of the type of work we do we're providing human factors training for all our people and this you know gives them an understanding and an appreciation of what fatigue is and to recognize when they become fatigued it also gives the supervisors an opportunity to know when their workers are becoming fatigued I think if a regulation was put in place that would probably go a long ways to help the Aimi's have something on their side and reduce the fatigue factor so after your 12 hours or 14 hours then you go home and you have eight hours of uninterrupted rest I think that would be a big benefit there's only one way to do the work that we do and that's to do it correctly to do the work correctly is to be constantly and consistently aware of the Dirty Dozen by appreciating how each can interfere with good performance is probably your first and perhaps your best safety net awareness means keeping alert when you do the job and check your work it means continually reminding yourself throughout your shift to work with your rational mind awareness means recognizing the fact that like all the rest of us you are human like the rest of us when you are not thinking your best when one of the Dirty Dozen interferes with your performance that's when you make errors human errors understanding why we make human errors is the first step to building safety nets to catch mistakes before they leave the hangar for help in building those safety nets and for information on human factors training contact your regional aviation safety officer

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