factores humanos mantenimiento
DESCRIPTION
Factores humanosTRANSCRIPT
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1
Bell Helicopter Textron Inc. is a wholly owned subsidiary of Textron Inc. Bell Helicopter Textron Canada Limited is a wholly owned subsidiary of Textron International Holding S.L, a wholly owned subsidiary of Textron Inc. Each company is a separate legal entity and a member of the Textron family of companies.
© 2014 Bell Helicopter Textron Inc. All registered trademarks are the property of their respective owners.
Human Factors
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2 © Copyright 2014 Bell Helicopter Textron Inc., Fort Worth, Texas 76101 Export Classification C, ECCN No Technical Data
Objectives
• Define human factors • Show specific examples of human factors
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What is Human Factors?
• Designing workplaces, tools, procedures, and policies so people can use them easily and safely
• Primary concern is for people in the organization • Combines elements from many disciplines • Critical to the overall flight safety and personal
safety The purpose of human factors training is to ensure safety and efficiency by drawing attention to issues that affect human performance.
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• About 80 percent of maintenance mistakes involve human factors, according to the Federal Aviation Administration.
• “As aircraft became more reliable and less prone to mechanical failure, the percentage of accidents related to human factors (human causes) increased.”
Human Factors Other Factors
Human Factors
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The Elements of Human Factors
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Clinical psychology: • Relationships with other people • Stress management • Self image
Psychology
Experimental psychology: • Reinforcement of desired
behavior • Effects of stress on behavior • Effects of work policies and
procedures
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Organizational psychology: • Rewards and compensation • Motivation • Work teams and groups • Equitable treatment
Psychology
Educational psychology: • Ways to help people to
remember • Design of instruction
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• Study of human body part sizes
• Can the user reach controls?
• Ability to access aircraft parts and systems
• Designing for extremes, i.e., smallest female and largest male
• No such thing as the “average” person
Anthropometrics
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Computer science: • Human-computer interaction • User interface design • Requirements analysis for software-
based tools and test equipment • Accommodation for range of
computer literacy
Science
Cognitive science: • Problem solving ability • Things that affect troubleshooting
performance • Effects of stress on mental
processing
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Safety engineering: • Slips, trips, and falls • Materials handling, e.g., lifting • Toxic materials storage and use • Facility design and safety
Engineering
Industrial engineering: • Setting reasonable work standards • Making work tasks efficient • Efficient facility layout
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• Skeletal and muscular structure
• Biomechanics • Physical structure of
perceptual elements, e.g., eyes
• Work physiology, e.g., heat generation and dissipation
• Fatigue effects
Medical Science
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Inte
rnal
• Boring repetitive jobs
• Personal life problems
• Substance abuse
• Fatigue • Stress • Poor
communication • Unrealistic
deadlines
Exte
rnal
• Smelly fumes • Loud noises • Snow • Lack of spare
parts • Poor tool
control • Slippery floors • Lack of tools
and equipment • Bad lighting
Trai
ning
• Poorly designed testing for skill and knowledge
• Poor instruction • Incomplete or
incorrect documentation
• Poor training
Human Factors Related to Maintenance
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The Dirty Dozen
• Lack of Communication • Complacency • Lack of Knowledge • Distraction • Lack of Teamwork • Fatigue • Lack of Resources • Pressure • Lack of Assertiveness • Stress • Lack of Awareness • Norm
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• Lack of communication is a major cause of errors
• Verbal and non-verbal • Positive listening • Communication
protocols
Lack of Communication
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Lack of Communication
When changing shifts, maintainers must communicate with one another, explaining what work has and has not been completed. • Affirm reception of
information (read back) • Never assume the information
transmitted is the same information received
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Lack of Communication
Only 30% of verbal communication is received and understood. The safety nets: • Use logbooks, worksheets, etc. to communicate and
remove doubt • Discuss work to be done or what has been
completed • Never assume anything
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Complacency
• Overconfident after becoming proficient in a certain task, which can mask the awareness of dangers.
• Self-satisfaction accompanied by a loss of awareness of the danger – "I've looked back there 1,000 times and never found
anything wrong."
The safety nets are:
• Train yourself to expect to find a fault • NEVER sign for anything you
didn't do
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Lack of Knowledge
• Maintainers must remain up to date on current equipment and how to fix it.
• Aviation organizations have a regulatory responsibility to provide required training to their personnel.
The safety nets offered are:
• Get training on type • Use up-to-date manuals • Ask a Tech. Rep. or someone
who knows
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Distraction
Can cause us to think we are further ahead than we actually are. The safety nets for distractions are: • Always finish the job or unfasten the
connection. • Mark uncompleted work. • When returning to the job, always go
back three steps. • Use a detailed check sheet.
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Lack of Teamwork
• A lack of teamwork can ultimately affect the safety of maintenance work.
• Not working together is tied in with lack of communication.
The safety nets for teamwork are:
• Discuss what, who, and how a job is to be done
• Be sure that everyone understands and agrees
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Fatigue
Many human variables rise and fall daily due to natural circadian rhythm.
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MARUFF, P., FALLETI, M. G., COLLIE, A., DARBY, D. and MCSTEPHEN, M. (2005), Fatigue‐related impairment in the speed, accuracy and variability of psychomotor performance: comparison with blood alcohol levels. Journal of Sleep Research, 14:21–27.
Fatigue can impair speed and accuracy of cognitive performance equal to or greater than blood alcohol concentrations (BAC).
Effects of Fatigue
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Fatigue
Fatigued workers tend to underestimate the problem and overestimate the ability to cope with it.
The fatigue safety nets call for:
• Be aware of symptoms • Avoid complex tasks at the
bottom of circadian rhythm • Sleep and exercise regularly • Ask others to check work
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• Allocate more critical tasks during day shifts when staff are likely to be more alert.
• Carry out appropriate checks after night shift work. • Break up lengthy repetitive tasks into smaller tasks,
with breaks in between.
Mitigate the Effects of Fatigue
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Lack of Resources
• When there is a lack of resources available to properly fix something, cease maintenance until the proper parts are available.
• Lack of supply and support can interfere with one’s ability to complete a task.
The safety nets are:
• Check suspect areas at the beginning of the inspection and AOG the required parts.
• Order and stock anticipated parts before they are required.
• Know all available parts sources and arrange for pooling or loaning.
• Maintain a standard and if in doubt, ground the aircraft.
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Pressure
• Pressure to get things repaired is always present in aviation.
• Do not let the pressures of time constraints get in the way with safely finishing a repair.
• Urgent demands can influence performance.
The safety nets to counteract this are:
• Be sure the pressure is not self-induced • Communicate concerns • Ask for extra help • Just say NO
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Lack of Assertiveness
• Failing to alert others when something does not seem right can result in fatal accidents.
• Assertiveness is the ability to express feelings, opinions, beliefs, and needs in a positive, productive manner.
The counteracting safety nets are:
• If it is not critical, record it in the journey log book and only sign for what is serviceable.
• Refuse to compromise standards.
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• Predictable, universal, human reaction to: – Fatigue – Time pressure – Difficult or unexpected situations – Personal problems
• Component of any human work • Stimulus that results in a change in arousal of the
nervous system and focuses our attention process • Stress hormones released, which changes heart rate • Subconscious response to the demands placed on a
person
Stress
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• Acute Stress – Rapid build up – Shocks the nervous system – Easy to detect – heart rate, pulse, etc. – Can trigger “fight or flight” response – Body chemicals help cope
• Chronic Stress – Gradual build up over a long period of time – Difficult to detect – Does not trigger “fight or flight” response – Can lead to medical problems – ulcers, heart problems,
depression, etc. – Common in boring work, continuous low level of stress, etc.
Types of Stress
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Stress Relievers
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Stress
Stress safety nets call for: • Be aware of how stress can effect work • Stop and look rationally at the problem • Determine a rational course of action and follow it • Take time off or at least have a short break • Discuss it with someone • Ask fellow workers to monitor your work • Exercise your body
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Lack of Awareness
• Failure to recognize all the consequences of an action, or lack of foresight
The safety nets are:
• Think of what may occur in the event of an accident. • Check to see if work will conflict with an existing
modification or repair. • Ask others if they can see any problem with the work
done.
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Lack of Awareness
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Norms
• The way things are normally done. • Unwritten rules followed or tolerated
by most of the organization. • Negative norms can detract from
established safety standard and cause an accident to occur.
The safety nets offered are:
• Always work as per the instructions or have the instructions changed
• Be aware that "norms" don't make it right
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Issue Helicopter meets hangar Technician meets
rotating shaft
Reason Pilot lacks awareness of
surroundings Technician lacks
awareness of surroundings
Field Issues
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Tell Tales Aircraft destroyed Hairy shaft
Cause
Lack of awareness Complacency Fatigue
Field Issues
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206B Case Study
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206B Case Study
Sequence of events: Owner contracted for maintenance work.
Owner hired commercial pilot to oversee the work.
25 April – Work began as per contract and to correct
discrepancies.
Apprentice mechanic removed, stripped, and primed droop restrainers and mast nut.
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206B Case Study
• 26 April – Mechanic A directed parts to be stripped again and he would prime them the evening of 27 April.
Parts remained on work bench.
• 27April – No work scheduled on helicopter.
Apprentice mechanic working on adjacent aircraft. Mechanic B doing paperwork.
Pilot arrived at 0930 and requested Mechanic B to work on the helicopter.
Mechanic B agreed to devote the remainder of day to servicing helicopter.
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206B Case Study
Pilot assisted Mechanic B with roof water leak – moved helicopter out/in hangar.
Pushed helicopter out onto ramp at 1500.
Pilot with Mechanic B aboard started engine, brought helicopter to a hover, and then landed to talk to Mechanic A.
Pilot and Mechanic B took off to perform flight checks.
When returning to field, helicopter crashed.
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206B Case Study
Safety Board Investigation determined:
• Flap restraint and mast nut
not installed
• At 500 ft above ground level, the entire main rotor separated
• Extensive discussion concerning:
– Lack of logbook entries
– Absence of an adequate
Preflight Check
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206B Case Study
Human Factors involved:
• Complacency with logs/record keeping
• Failure in communications
• Assumptions:
– Apprentice assumed mast nut reinstalled
– Pilot assumed aircraft OK
Expectations:
• Pilot expected aircraft OK if Mechanic aboard
• Mechanic expected Pilot to ensure aircraft OK
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Human Error
Count the number of “f”s in the following sentence.
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Human Error
Finished files are the result of years
of scientific study combined with the
experience of years.
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Human Error
Did you count 3? Did you count 4?
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Human Error
The answer “6” Finished files are the result of years
of scientific study combined with the
experience of years.
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The Odds are Against Doing it Right!
Human Error
• Only one way to disassemble
• 40,000+ ways to incorrectly reassemble!
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Cost:
• Loss of money • Personal injuries • Loss of life
Consequences vary:
• Major errors do not always lead to major accidents • Minor errors can lead to major accidents
Costs and Consequences
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Traditional ways of addressing human error:
• Selection of personnel • Procedures/standardization • Technology/automation • Redundancy • Training • Motivation
Addressing Human Error
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Conduct maintenance in a way that enables the aircraft to be released to service in a safe condition.
Approach to Human Factors & Safety
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Question
A. True B. False
TrueFa
lse
0%0%
Do you have a Safety Management System at your workplace?
10
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A. 1 – 3 years B. 4 – 6 years C. 7 or more years D. Never trained at Bell
Training Academy
1 – 3 years
4 – 6 years
7 or more ye
ars
Never t
rained at Bell T
r...
0% 0%0%0%
Question
How long has it been since you last trained at the Bell Training Academy?
10
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A. Pilot Initial B. Pilot Refresher C. Field Maintenance D. Electrical/Avionics E. Other F. Never trained at Bell
Training Academy
Pilot In
itial
Pilot R
efresh
er
Field M
aintenance
Electrica
l/Avio
nicsOther
Never t
rained at Bell T
r...
0% 0% 0%0%0%0%
Question
What type of course did you take at the Bell Training Academy?
10
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