All Aircraft Technical Training Manual Human Factors

ALL AIRCRAFT
TECHNICAL TRAINING MANUAL

HUMAN FACTORS
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ALL AIRCRAFT TECHNICAL TRAINING MANUAL
HUMAN FACTORS
ACRM Welcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ACRM Human Factors and Flight Safety . . . . . . . . . . . . . . . . . . . . . . 6
ACRM Error, Performance and Safety . . . . . . . . . . . . . . . . . . . . . . . . 24
ACRM Factors Affecting Individual Performance . . . . . . . . . . . . . . . 44
ACRM Learning a New Aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
ACRM Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
ACRM Procedures and Practices in Maintenance . . . . . . . . . . . . . . . 92
ACRM Factors Affecting Team Performance . . . . . . . . . . . . . . . . . . 102
ACRM Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
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TABLE OF CONTENTS Feb 27, 2009

HUMAN FACTORS Page 1
ACRM WELCOME
personnel and managers. This is why today we will focus on the human
Welcome dimension of safety, with reference to technical and operational issues.
Tell us what you think about Crew Resource Management?
ACRM stands for Airbus Crew Resource Management.
- Airbus. This training is Airbus oriented. During this workshop we'll try
to learn from some accidents and incidents including Airbus and other
manufacturers. It is integrated in your Airbus transition training - that's
why you heard about CRM during your welcome briefing and during
your VACBI training. You will also practice your CRM skills throughout
MTD and MTS sessions.
- Crew. As already stated, this course is available for three populations:
cockpit, cabin and maintenance crew. This is an implementation of the
most recent JAA and FAA recommendations.
- Resources: people, technology, documentation ...
- Management: coordinated use of all available resources to reach a goal.
Both resources & management will be discussed in detail later in the
course.
All through the day, we need your participation. We want you to discuss
and share your own experiences and opinions with the rest of the trainees.
We want you to stop us whenever you don't understand or disagree.
We will use videos to get the ball rolling and slides to present information
and suggest ideas. But to be successful, this training really requires your
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participation. Please share your ideas and experiences with the rest of
the group.
Before we ask you to introduce yourself, let us give you some information
about today's seminar.
Today's training is probably a bit different from what you are used to.
You are used to being trained about technical matters regarding aircraft
maintenance. For example your present training at the Airbus Training
Centre gives you technical information about the Airbus aircraft family.
But today we would like to do more. Why?
You would agree that safety is one of the most important parts of your
job, wouldn't you? Safety involves more than just the aircraft. It involves
the pilots as well as cabin crew, but also ATC, dispatchers, maintenance
ACRM WELCOME Feb 27, 2009
WELCOME

WELCOME

WELCOME

ACRM HUMAN FACTORS AND FLIGHT SAFETY

A300, 1995, India. The incident occurred during the first flight following
Human Factor and Flight Safety lengthy troubleshooting on the braking systems with opening of the green
and yellow systems / pipes. These systems were not bled as they should
Here is a list of events that had serious safety consequences as they
have been in order to remove air trapped in the systems / pipes.
resulted in injuries and/or fatalities.
Tupolev 134, June 2003, Russia. Poor quality of work from the
B737, 1988, Hawaii. Whilst en route from Hilo to Honolulu and flying
engineering personnel during the replacement and adjustment of hydraulic
at 24 000 ft, a failure of the fuselage caused an explosive decompression
amplifier GU-Y08D. The unsatisfactory flying and technical operation
and loss of the cabin structure. A successful emergency landing on Maui
of the aircraft after the completion of the replacement of the hydraulic
took place. The probable cause of the accident was the failure of the
amplifier, during which the incorrectly installed rudder actuator was not
company maintenance programme to detect significant fatigue cracking,
discovered.
which led to the failure of a fuselage lap joint and the separation of the
A300, 1994, Cairo. During maintenance operations, R/H NLG door was
fuselages' upper lobe. The FAA launches investigation of airline
opened with manual door opening handle. One mechanic worked inside
management after this accident.
the NLG bay. For unknown reasons, hydraulic pressure was applied on
DC10, 1989, Iowa. 1 hour and 7 minutes after take-off from Denver, the
the A/C and R/H NLG door closed. The mechanic was thrown by the
pilot of the DC-10 en route to Chicago reported that the No. 2 engine had
door and seriously injured.
failed. Almost immediately after this, the whole hydraulics failed, leaving
Beech 1900, Aug 2003, USA. The improper replacement of the forward
the A/C with no control. The A/C crashed at Sioux city. The probable
elevator trim cable, and subsequent inadequate functional check of the
cause of the accident was a failure to detect a fatigue crack originating
maintenance performed, which resulted in a reversal of the elevator trim
from a previously undetected metallurgical defect located in the stage 1
system and a loss of control in-flight. Factors were the flight crew's failure
fan disk.
to follow the checklist procedures, and the aircraft manufacturer's
B747, 1992, NL. The A/C was destroyed when it crashed into two 9-storey
erroneous depiction of the elevator trim drum in the maintenance manual.
apartment blocks whilst attempting to return to Schiphol Airport,
2 fat.
Amsterdam for an emergency landing. The 747's N°3 engine separated
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B737, 1988, Hawaii

first, rotated outboard and struck the No. 4 engine which then also broke
DC10, 1989, Iowa
away.
Now let's look at statistics about aviation safety.
N521(Learjet) Arizona. Improper electrical wiring that led to in flight
The chart provides a presentation of hull losses per million departures
fire. The power wires were routed directly to the battery charging bus
(vertical axis) over the last 35 years (horizontal axis) for the first, second
leading to the lack of overload current protections.
and third generation A/C, as well as the global accident rate for the whole
A320, Aug. 1993, London. The A/C had difficulty turning left. Spoilers
commercial jet fleet (curve 'All aircraft').
were left in maintenance position. Airbus has changed component design
The hull loss rate for the first generation A/C is significantly higher than
to prevent reoccurrence.
for the second and third generation A/C. It tends to increase since the
A310, Nov. 1995, Canada. During engine run up check, braking was lost
late 1980s because the B707 & DC8 A/C age, with strong maintenance
from an undue maintenance action, pulling the Ground/Flight C/B.
implications and constraints (A/C mainly used in cargo versions). The
ACRM HUMAN FACTORS AND FLIGHT SAFETY Feb 27, 2009

third generation hull loss rate is significantly less than the rates for the If we don't focus only on maintenance as a primary cause of accident,
two previous generations. There also appears to be a significant "learning recent studies found that maintenance was a contributing factor in about
effect" during the introduction of each new generation A/C. The accident 20% of the accidents (52.6 out of 263).
rate is much higher in the early years than it is after the fleet matures. But, on average, maintenance related accidents tend to be very serious.
Looking at the 'All aircraft' curve, the sharp improvement of safety in As indicated by the statistics (source: Boeing), maintenance (that is to
the late 60's - early 70's can be attributed to progress in reliability due to say your job!) was the second highest cause of fatalities related to air
technical improvements associated with upgrades in the operational accidents, from 1982 to 1991 (1481 fatalities, after CFIT: 2169, and
environment: better safety equipment, more structured procedures and before Loss of control: 1387). 15 % of accident fatalities have been
better technical training for all personnel, including maintenance. attributed to maintenance in the official accident investigation reports.
However, since the mid 70's, there has been a leveling off at the global This value is fluctuating with time.
rate of 2 accidents per million departures, (equivalent to 1 accident per Note: We have no direct statistics about the number of accidents that
million flight hours). The accident rate doesn't decrease significantly have been prevented thanks to maintenance, and this is rather frustrating!
anymore; therefore, even if aviation is now a very safe means of Safety is of course a critical issue, but economics is also a matter of
transportation, something must be done to further improve safety. Why? concern. This slide presents some strong indicators of the role played by
Combined with the current yearly increase in traffic (approx 5.0%), the maintenance on quality and cost-related matters (flight delays, flight
current trend could result by the year 2010 in one or more major jet cancellations, IFTB & Diversions, IFSD).
airliner accidents per week! This will be quite unacceptable for the public - 1 hour delay: 10,000 to 15,000 $
for both human and commercial reasons. As shown on the slide, maintenance contributed to about 15% of flight
The global hull loss accident rate is about 2 accidents per million delays with respect to Airbus aircraft. It also contributed to 50% of delays
departures (2.10-6), but what about the number of fatalities in the same due to engine problems.
time period? Besides the financial impact, delays can also impact safety due to the
Accidents rates stress they generate on the crew. Further, delays attributed to maintenance
What is the direct contribution of maintenance to accidents? may be partially due to constraints imposed by the overall system
This slide presents a statistics about the percentage of total accidents with (technical resources and manpower available, planning and scheduling
known causes (source: Boeing), and demonstrates the role of maintenance of flights, corporate policy...). Delays are also very often the result of
in safety. maintaining safety.
Actually maintenance is not a frequent cause of accidents. As you see on - Flight Cancellation: 50,000 to 90,000 $
the slide, it is ranked number 5 in terms of frequency, just after 'Flight Another A/C is needed for the passengers, that results in more than 1
crew' (62%), 'Airplane' (14%) and 'Weather' (12%). It directly contributed hour delay.
to about 4% of accidents. As shown on the slide, maintenance contributed to 50% of flight
Note. Aircraft accidents involve multiple causes and contributing factors. cancellations due to engine problems.
Because only single cause coding was used, this statistic is a simplification - IFTB (In Flight Turn Back) / Diversion: about 300,000 $
that gives a good idea about the influence of the categories listed. The A/C returns to the main base to be repaired (IFTB). If it is diverted
the cost can be higher if no other A/C is available, because food and
accommodation need to be provided to the passengers.
- IFSD (In Flight Shut Down). Maintenance contributed to 20% of IFSD. Poor use of the documentation: the technician quickly jumps to a
The cost is not estimated because it can have very different consequences: conclusion to give the problem to the electrician!
a short delay if the problem is easily fixed or a flight cancellation if the The electrician is already involved in other work. There is a conflict
problem persists. If the cost of the engine repair or change is included it about work allocation. This conflict is however solved smoothly (no
can easily reach 500,000 $ to a million dollars. crisis).
- Another category is often referred to as well: AOG (Aircraft On Communication is not very good within the team; the atmosphere is
Ground). It is not mentioned here because it results in a flight cancellation. friendly but not very professional.
Two conclusions can be drawn from the previous statistics regarding how No team boss was there to solve the conflict - it's impossible to send a
safety and economics are impacted by maintenance: crew chief to every aircraft!
- maintenance currently does a very good job So what kind of 'resources' are we talking about?
- but current practices can - and have to - be improved. An answer to What does this mean? Any ideas?
these problems is provided by the concept of CRM (Crew Resource Here are some of the things we can call 'resources'.
Management) training. As maintenance staff, you interact with other people. Your colleagues,
What's behind the term 'Crew Resource Management'? as well as engineering, technical, and operations personnel are resources.
JAR-OPS = Joint Aviation Regulations-Operations Cockpit and cabin crewmembers are resources available to you, as you
ICAO = International Civil Aviation Organization are to them.
According to the JAR/OPS, CRM is the effective utilization of all Tools and equipment are needed to perform the job.
available resources to achieve safe and efficient operation. The aircraft systems are a source of information. These are resources
Note: The ICAO Definition of CRM is similar - "CRM is the effective as well.
utilization of all available technical, informational, individual and The company or the manufacturer's documentation is also part of the
collective resources in order to achieve safe and efficient operations". resources you can use, as well as personal reports. Procedures provide
CRM doesn't only refer to cockpit crew, it also includes: you with ready to use responses or actions. They are part of the resources
- Flight attendants available.
- Aircraft dispatchers Time is another resource, even if, when it is lacking, you tend to consider
- Air traffic controllers it as a constraint. Time management is an important component of CRM.

- and Maintenance personnel. Training is certainly another resource.
What is CRM in practice? In order to understand this, we are going to For instance, hangar or weather conditions are other resources we can
watch a video, filmed at Airbus. think of.
The people shown are line maintenance personnel. Now we need to define what 'management' means.
The technician didn't check the logbook, nor was he prompted to do so Resource management can be defined as the coordinated use of all
by the cockpit crew. available resources to reach a given goal.
Even if there was a friendly atmosphere, the communication between When we try to make the best use of a set of resources, we have to (in
cockpit and maintenance (2 way) could be improved. any order):
No use of the Trouble-Shooting Manual (TSM). Set our goal, for example fixing a fault on the A/C engine;
Assess risks: "what if I do this?", "What will occur if I'm late?";
Set priorities, for example prioritizing job quality over time;
Allocate resources: "who will take charge of this task in the team?"
"How much time on this problem?"
Evaluate results to re-direct our choices and priorities when needed.

HUMAN FACTOR AND FLIGHT SAFETY













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ACRM ERROR, PERFORMANCE AND SAFETY

only 'negative errors' are counted as errors. This is where a fundamental
Error, Performance and Safety ambiguity about the concept of error lies.
Psychologists instead usually refer to definition 1 when they speak about
To err is human...
'errors'. When they observe activity, they thus count more 'errors' than
Even very skilled and experienced personnel can make errors.
those referring to definition 2, because they don't focus only on those
To learn from one's errors is wisdom...
errors with technical consequences. (An example in the pilots' world:
We can learn and adapt our performance from the errors we make.
around 5 errors per hour using def. 1 versus less than 1 error per flight
To manage one's errors is professional...
using def. 2). From a psychological point of view indeed, the 'errors' are
We can detect and recover errors before they have serious consequences.
the same with or without consequences. In other words, the consequences
We will address these three issues in this module.
of an error depend on the context and not on the error itself. See the
Definition 1
following slides.
We make errors when our actions deviate from what we intended to do,
Let us now focus on the difference between error and error consequences.
or when our intentions are not appropriate.
As you can see on this picture, the consequences of an error may be very
So an error is never, by nature, intentional. This honorable lady apparently
different. However, it is still the same error. Therefore, we must clearly
made an error: she did not intend to drop the flowers!
differentiate between an error and its consequences.
Errors are often confused with violations. The difference, simply, is that
The tendency is to judge an error by its consequences - the more serious
unlike an error, a violation is an intentional deviation. It is a deviation
the consequences; the more serious the error seems in hindsight. But it
from a rule, a regulation, and a procedure. We will return to violations
is important to remember that it is the same unintentional error, regardless
later in this module. For now, let's concentrate on error and its
of the outcome.
consequences.
The best example of the difference between error and its consequences
Definition 2: another way to define 'error', and a source of ambiguity!
can be found in training.
There is another way to define the term 'error' in the maintenance domain.
Why do we have training devices? So that technicians can get their hands
ICAO for example states in its 1995 Circular that: "Human error in
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on the A/C systems and practice maintenance procedures, of course, but

maintenance usually manifests itself as an unintended aircraft discrepancy
also so that they can learn from their errors without suffering the
(physical degradation or failure) attributable to the actions or non-actions
consequences of these errors as they would on the job. Consider indeed
of the aircraft maintenance technician." (p. 10).
the difference between an error made in the training devices and the exact
Notice that these 'actions' or 'non-actions' can be either 'errors' or
same error made in a real aircraft: the consequences would (very often)
'violations', referring to definition 1.
be drastically different!
Safety analysts referring to definition 2 (pragmatic definition of error)
The HF training could use the James Reason's systemic approach to make
thus only consider those rare errors whose consequences overshoot the
people aware of their personal role in safety/efficiency employee's role
safety limits in the system or put the system in an inappropriate state (e.g.
in safety
CB pulled instead of pushed) They thus usually do not take into account
- Errors can be made at all these different levels.
the majority of errors that the operators detect and correct in the course
of action before technical consequences can develop. In other words,
ACRM ERROR, PERFORMANCE AND SAFETY Feb 27, 2009
- But each level also constitutes a protection or line of defense against - First it means that even the most experienced maintenance personnel
the errors made (the plates). can make mistakes. Is there anybody in this room who could honestly
- Those protections are however not perfect: holes appear here and there say: 'I have never made and never will make an error'? (Remember, an
in the plates, defenses are flawed or weakened, letting the errors pass error is unintentional, e.g., nobody starts the day saying 'today I intend
undetected. to forget my keys')
- Most of the time however, errors finish by being detected and corrected, - 'To err is human' also implies that human beings can learn from making
as the holes in the plates are usually not aligned. errors. The natural outcome of error is adaptation of behavior.
Note: the multi-layer defenses include strategies as varied as technical So we have an interesting contradiction in that we need errors to remain
redundancy, procedures, checklists, safety equipment, safety notices and safe!
tags, etc. It is often the way we calibrate our performance - an error tells us to pay
At each level more attention, rethink things, to get back on track, etc.
- What is their personal role in the safety / efficiency? Let's see how errors can interact with performance.
- What kind of decision they can take The rule of the exercise is very simple. All you have to do is call the
- What kind of impact they may have on other level: same, upper, lower colors in which these words are written. Call the colors, do not read the
level words.
- What kind of tools do they have to maintain safety / efficiency? And you have to do this as fast as possible. You are under time pressure.
- What kind of support, resources Is the rule clear? Ok, you can start now.
- What are the topics/subjects on which they have an impact? So, what happened?
- What the new situation with a new a/c will change? The first line was a quick one, as the colors and the words matched. But
But when the failures or weaknesses in each line of defense are aligned, after that quick start, you encountered your first error or risk of error, and
the error(s) continue their own way up to producing and incident or worst, then you started slowing down, to reduce the number of errors being
an accident. committed. If you had continued at the same speed as the first line, you
Such 'windows of opportunity' are of course pretty rare! would have made much more mistakes than you actually did. Slowing
This model allows us to understand why most errors don't lead to an down after the first error you made or anticipated is how you improved
accident: this because most of them are 'blocked', i.e. detected, corrected (calibrated) your performance.
or recovered by the different personnel at the different activity levels, Nice-to-know
before safety-threatening consequences can develop. The difficulty of this task comes from a conflict between color perception
One of the major points of this module is to emphasize this fact: "To err and reading. It's called the 'Stroop effect', from the name of the
is human". psychologist who first discussed it.
In an ideal (or very unrealistic) world, we would simply say 'humans in This is the main characteristic of maintenance errors: their lack of
aviation should not make errors; therefore they are not allowed to make visibility. Maintenance errors can remain silent for a very long time in
errors.' the system before producing visible effects. That's the reason why they
BUT, we are living in the real world, and in the real world, humans make are called 'latent errors' (see the note below).
errors. Example
There are two meanings we can take from the saying.
In the case of the 1989 Iowa DC10 engine disk failure, the suspected 63% installation, 12% servicing, 7% improper fault isolation
inspection failure occurred 17 months before the accident! And where is the knowledge found? The answer is:
Nice-to-know - 'Memory', that is to say 'Knowledge in the head', which mainly comes
Human factors specialists discuss 'active errors' or 'active failures' when from training and previous experience.
the effects of failures are immediately visible, and 'latent failures' when - The object itself, which provides 'Knowledge in the object'. As we have
effects remain dormant in the system for a long time, until revealed by seen, in the case of re-assembling such information is rather poor.
some triggering conditions or as time passes by. - And/or documentation, including procedures, which is knowledge in
Using this terminology, maintenance errors often generate latent failures. written or schematic form, either in paper or micro-film or electronic
Here is a list of the main maintenance problems or, more accurately, the format.
main maintenance errors in the sense of definition 2. As you see in this slide, knowledge in the head, knowledge in the world
Airbus ISAIM (In-Service Aircraft Information Management) database and knowledge in documentation form a kind of triangle.
Maintenance Error Study emphasize the incorrect installation of In maintenance, as in other professions, knowledge in the world (object)
components - is the largest percentage of errors by far (72%). is not sufficient (especially in the case of re-assembling) and memory
Mention Servicing and Task Support as making up top 3 error types. can be misleading.
Point out small percentage of Removal compared to Installation. Therefore, as argued all through this module, the only way to interact
Airbus studies the maintenance activity in detail to understand what aspect safely with today's aircraft technology is to refer to standard procedures,
of installation is proving problematic and the results show Top Six Error that is to say knowledge from the documents (either in paper or electronic
Types. format). They are the reference!
This level of detail provides with the information to understand and tackle Let us discuss violations now, as separate from error.
specific issues in maintenance. Violations are done intentionally - at least in early occurrences - but can
It is very difficult to decide what course of action at an "installation" then become routine. You no longer realize it is a violation, you don't
level. feel concerned at all, you feel you are doing the right thing - as you usually
The more important for us is to know why. (This will be discussed in the do - but you are not!
next slide) From an individual point of view, a systematic underestimation of risk,
Airbus has initiatives to ensure that maintenance human factors are an absence of negative feedback and the development of overconfidence
considered in design. favor violations.
We have other aviation maintenance researches (Boeing or UK databases), Furthermore, from an initial departure, which is often limited, practice
which provide us with similar percentages: often progressively drifts away from what is stated! The risk is when you
- Boeing Significant Incident Reporting System (SIRS) database (>3000 are not aware of this drifting process.
incidents): Violations can also be favored by operational constraints (lack of time,
75% installation, servicing 9% lack of equipment, etc.) and by team and organizational factors (e.g. "The
- Monarch Maintenance Error Database: way we did it before", "The way we do it here", etc.)- See the Team
51% installation, 11% improper fault isolation/ inspection/ testing, 8% Performance module.
servicing Speeding is an obvious example: the short-term benefit is getting there
- UK OTG: faster, spending less time in the car. But what of the risk of a speeding
ticket (a regulatory infraction) or worse still, an accident? It is the nature - Briefings. They allow the team members to share common objectives
of humans to choose the certainty of a small short-term benefit over the and situation understanding and to build up common action plans.
low probability of a long-term disaster. - Procedures. By using documented procedures, you increase the chances
These short terms 'efficiency and benefits' involve some form of risk and of preventing, detecting, and recovering from errors.
are gained at the expense of safety. In a system as complex as aviation, - Checklists. Checklists contribute to error prevention and help to detect
most violations are a threat to safety! and correct errors that would otherwise be hard to detect.
We need to know this trap and protect ourselves against it: - Checks, double-check and crosschecks are standard safety practices,
Manage your time: many violations result from saving time under time which support individual and team error monitoring.
pressure. Violations are also often made to recover from errors, or to hide - Using warning notices (installed in the cockpit during maintenance)
errors, or not to lose face in front of colleagues. and similar safety devices also contribute to error prevention and
Group pressure and group conformity also play an important role. This detection.
is particularly true for apprentices. Have you ever heard: - Design protections contribute in a physical way to error prevention.
"Forget what you have learned at school, here, it is real life..." (!) They protect against adverse effects of errors (physical protections such
Recommendations: as switch covers).
- For those more experienced: do not allow your young colleagues to The following good practices will also help preventing or managing
deviate! Stick to procedures; errors:
- For the less experienced: protect yourself against non-standard practices. - First, remain in your domain of competence.
The lesson here is not: 'It is ok to make an error'. That is not what we are - Second: we make more errors when in a hurry, or when overloaded.
saying! Many serious incidents occur during 'hurry up' phases. About 50% of
The philosophy of error management is quite different from that, but still accidents have been found to occur during delayed flights (NTSB report,
simple: 1994). Set your priorities; manage your time and your workload.
1. We must accept that we do make errors. - Work as a team: communicate, share intentions, share tasks.
Humans have physical and mental limitations - limits on how long we Refer to the Team Performance module.
can go without sleep, how much we can remember at any one time, how - Use the reference procedures and documentation.
much information we can process at any one time. As a result of these - Then recognize your errors and accept to learn from them: keep to the
limitations, and as part of how we learn to adapt to our environment, we facts; don't listen to your ego telling you that you are too good to make
make errors. errors!
2. At the same time that error is inevitable, we also need to prevent errors
from threatening safety.
The lesson is: Stop errors ASAP before they have a chance to develop
consequences or multiply! Don't leave your errors unchecked and free
to grow.
Use appropriate defenses.
But some maintenance errors can be difficult to detect...
Several standard tools or practices are useful for error management.
ERROR, PERFORMANCE AND SAFETY
















ACRM FACTORS AFFECTING INDIVIDUAL PERFORMANCE

in the work organization. Night shift is more demanding regarding sleep
Factors Affecting Individual Performance management (see slide 8).
- Multi-qualifications. In many airlines, maintenance staff is qualified on
The physical maintenance-working environment will certainly affect
several aircraft types from several manufacturers. Large differences may
one's performance;
be found even among aircraft of the same type due to numerous
- At a personal level, and possibly as a consequence of the working
modifications within the same generation. The main risk of multiple
conditions, many maintenance personnel are likely to be affected by:
qualifications is confusion, use of non-applicable procedures, and
* Fatigue,
difficulty in developing and maintaining skills. The current tendency
* Sleep disturbances (sleep deprivation or poor sleep quality),
among airlines is therefore to limit the number of qualifications.
* Stress ...
Economical factors:
- At a collective level, conflicts (at the levels of the group or of the
- Production and time pressure. Parts availability. These factors induce
organization) can also deteriorate substantially the performance of a team.
a lot of errors and violations. Violations are particularly likely to occur
Let's discuss all these issues in more detail.
under strong time pressure or other operational constraints (e.g.,
Maintenance working conditions are external factors that contribute to
organization and recruitment problems, bad equipment availability, intra
the generation of errors and violations committed by the front-line
and inter-professional conflicts, hub structure, etc.).
technicians. Three families of factors are considered here:
- Lack of training. The need for training has been reinforced since the
Environmental factors:
introduction of new technology in the aircraft. In many airlines around
- Light: Bad lighting weakens visual performance and generates visual
the world, maintenance staff training could be improved, both regarding
fatigue, with repercussions on production (more errors, lower quality,
course content and methodology (Computer Based Training, On the Job
and increased risks). Noise can convey useful information or warn of a
Training, Classroom Training...).
danger, but can also have negative effects depending on its intensity and
The physical maintenance-working environment will certainly affect
on the duration of the exposure (between 55 & 85 dB: concentration
one's performance;
problems, hearing & mental fatigue, nervous disorders; over 85 dB: risk
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- At a personal level, and possibly as a consequence of the working

of deafness).
conditions, many maintenance personnel are likely to be affected by:
- Temperature and weather conditions. Mental (reasoning) and physical
* Fatigue,
(gesture precision) performances are affected under cold or warm thermal
* Sleep disturbances (sleep deprivation or poor sleep quality),
conditions. Humidity and atmospheric pollution can also generate
* Stress ...
irritation, discomfort, intoxication that badly affects the activity.
- At a collective level, conflicts (at the levels of the group or of the
Organizational factors:
organization) can also deteriorate substantially the performance of a team.
- Shift work is a special work regime: people often work together for a
Let's discuss all these issues in more detail.
very long time, which creates a special way of communicating, and a
What is fatigue?
strong team spirit (often called a 'clanic' structure). Shift hand-over is
We experience 'fatigue' after intense physical or mental effort.
crucial for safety and work quality but time for it is not always planned
Fatigue comes from consuming our physical or mental resources.
ACRM FACTORS AFFECTING INDIVIDUAL PERFORMANCE Feb 27, 2009

Our resources, mental and physical, are like fuel in a car. During a normal attention and fast reaction are particularly affected. The ability to detect
day, we consume our fuel at a fairly constant level (like being in 'cruise rare or low-level signals decreases.
mode' on the highway). But if we have to go faster or if we have to work - Difficulties in creative and rational thinking: It will affect
harder, then just like a car, we will consume our fuel more quickly. The problem-solving abilities (for instance a trouble-shooting diagnosis)
result is obvious: No fuel, no go! We will talk about how to 'refuel' because it impairs the ability to make innovative associations as well as
shortly. reasoning, critical analysis and advocacy.
What are the physiological and psychological effects of fatigue? - Change in mood and attitudes: depressive state, irritability, loss of
You all have first hand experience of this. interest in people and events, more aggressiveness and less motivation.
Fatigue downgrades several abilities: This of course affects teamwork.
- Muscular force and coordination: this has negative effects on physical Let's now go through a few practical recommendations about sleep and
effort (static and dynamic), especially for work requiring precision or fatigue management at the individual level.
balance; - Respect your sleep needs.
- Vision, especially in low illumination conditions, and more generally, Sleeping is a necessity and it is the only cure for sleep deprivation.
perception (when your eyes start to play tricks on you - illusions); Try to sleep during the day if you are scheduled for a night shift. As you
- Memory, error monitoring, decision-making and other cognitive abilities; must have experienced before, the first night shift is rather hard to perform
- Motivation, willingness to maintain high performance; but the second and third ones are even harder! Sleeping during the day
- Communication: when you are tired, you tend to withdraw from the is not natural because the brain is built in such a way that sleep normally
team; takes place in a regular rhythm at night. After some days however, your
- Cooperation: lacking energy and motivation, it's harder to work as a day sleep will stabilize and you will adapt to a new rhythm.
team. - Take naps
The circadian rhythm NASA (the US National Space Agency) studies show that short naps of
Let's now look at some of the effects of sleep deprivation on performance. 20 minutes increase vigilance for about 1.5 - 2 hours.
Lack of sleep makes our whole being suffer. Sleep loss leads to fatigue - Regular physical activity of moderate intensity increases your resistance
in addition to the normal fatigue that results from the consumption of our to both fatigue and stress. But too much physical activity (including a
physical and mental resources. second job) before your shift, will tire you and favor hypo vigilance (low
Sleep deprivation can be quantitative (not sleeping long enough: 2 hours alertness).
less than usual sleep needs are enough to experience sleep loss) and/or - Eat balanced meals and adopt a healthy lifestyle. Minimize high sugar
qualitative (not getting good quality sleep, mainly through a lack of or fat meals.
paradoxical sleep). - Drink water! Water is useful for eliminating toxins. Water absorption
Sleep deprivation has several negative effects on an individual's also stimulates the body. Tea and coffee stimulate the cardiac and nervous
performance: systems, but they are also diuretics, that are they dehydrate the body,
- Physical fatigue and a sense of heaviness which increases fatigue.
- Difficulties in focusing attention: you might look at a part or a system - Avoid doing a second job: this point needs to be emphasized. It is
without really noticing what is written on it. Tasks requiring sustained fundamental to rest during the day before or after a night shift, and not
to invest in another activity as much as in the main one.
- Do not self-medicate or, at least, be careful with self-medication. Beware Such a situation can be either unexpected (an emergency) or anticipated
of the secondary effects of some medicine. Refer to a medical doctor. (ex. when you know in advance that you will work under time pressure,
Fatigue and sleep deprivation can also be managed at the team level... of when you know you will be overloaded - a lot of work to do).
- Keeping the team alive! - Stress is a vital adaptation mechanism, as it mobilizes resources against
External stimulation helps to combat fatigue and this stimulation can be any kind of aggression agent also called a 'stressor'.
provided by other team members. So, keep communicating, exchanging Stress is not only a physical reaction but also an emotional one.
ideas, jobs, ask for support whenever possible... Note:
- Crosschecking of actions and of results is another powerful standard How do we react to a stressful situation?
protection against the effects of fatigue and sleep deprivation. There are three extreme adaptation reactions (sometimes referred to as
Crosschecking requires at least two persons, which is not always possible. the 3F), which are inherited from a very long life evolution process:
Solving such a difficulty is a matter of organization. - 'Freezing', i.e. being unable to react in any active way (ex: the deer you
- At shift hand over: if you haven't solved a problem (for instance, during surprise in your car headlights reacts by not moving)
Trouble-Shooting), especially when you feel very tired, try to properly - 'Fleeing', i.e. escaping or trying to escape from the stressful situation
brief the next team (report carefully about what has been done and remains - 'Fighting', i.e. facing the problem.
to be done) in order to ensure work continuity. How does stress affect performance?
Note: shift hand over is particularly important for safety! This is often Stress can either be good or bad, it is a matter of intensity: it is good when
where problems originate or are passed on. Shift hand-over is therefore moderate, enabling us to adapt to the situation, but bad when in excess,
also where major progress can be made! We will talk about this again in resulting in drastic performance impairment.
module 7, on team performance. Moderate stress improves performance, up to a maximum.
The physical maintenance-working environment will certainly affect High stress seriously impairs:
one's performance; - Mental abilities: perception, understanding, decision-making and error
- At a personal level, and possibly as a consequence of the working monitoring.
conditions, many maintenance personnel are likely to be affected by: Mental activities are disorganized because mental control is impaired.
* Fatigue, * Under acute stress, maintenance staff won't be able to use the knowledge
* Sleep disturbances (sleep deprivation or poor sleep quality), they have acquired recently, or in the way they normally do.
* Stress ... * Under high stress, they can also abandon their standard professional
- At a collective level, conflicts (at the levels of the group or of the phraseology, revert to mother tongue and even forget what actions were
organization) can also deteriorate substantially the performance of a team. performed or have to be performed.
Let's discuss all these issues in more detail. * Mental incapacitation: many more actions will be taken but they will
Let's now address the issue of stress, how it arises, and how it affects be poorly organized! In a stressful situation, there is often a need to do
performance. something immediately.
The first question that comes to mind is 'What is stress?' You can hardly refrain from reacting under strong pressure!
- Stress is an automatic response to a disturbing situation. - Behaviors and attitudes, with two opposite reactions: aggressiveness
and withdrawal.
- Teamwork:
At the individual level, the ability to communicate and to co-operate is Let's now talk about conflicts, which are particular stressful situations.
impaired. Maintenance staff may have conflicts with...
At the team level, awareness of what the others are doing decreases. - Other maintenance crew
Overall team performance is downgraded. - Cockpit crew
When the limits are reached, it is breakdown. Performance drastically - Cabin crew
drops. ...?
The person under stress is exhausted, 'washed up', 'burned out'. Any kind of conflict, interpersonal, with the boss, the pilots, the cabin
Here are a few recommendations about how to cope with stress, at the crew, between technicians of different expertise domains, during shift
individual and at the team level. turnover, strikes ... can have a negative impact on safety if it is badly
- Accept the situation first, especially if it is being difficult to handle managed.
- Go back to the basics! Trust and use your basic skills and knowledge. We will now review a few tips for conflict management.
Don't try to invent something great. Just make it simple. Here are a few rules for conflict management:
- Stick to the documented procedures, when you don't know. - Listen carefully and try to understand the others' constraints.
Documentation usually provides proven and experimented solutions to Ask yourself what are the reasons behind their attitude. What would you
all sorts of problems. do in their shoes?
- Try to share the problem with others, and, more generally, try to use all - Show respect; be polite.
available resources (people, equipment, information...). - Adhere to the facts; focus on what is right instead of who is right.
- Plan ahead, 'buy time': give yourself the time needed to perform your - Don't take it personally, control emotions and keep a professional
job, with some reasonable margins. attitude. Depersonalize the conflict. Try to see the situation globally.
- Stress can also be managed at the team level: don't forget you are - Refer to documented procedures or to any other standard document:
member of a team! they might provide a valuable consensus.
Good teamwork is an effective antidote against stress. - Propose a solution: it's wiser to spend energy identifying one (or several)
The better the team works together the weaker the effects of stress. No solution(s) than discussing who is right.
one should hesitate to call for assistance. We are all human. On the other Handle the conflict in an assertive way if safety is threatened, save time,
hand, you should be ready to provide technical as well as moral support think safety!
to team members, particularly when the group is under stress. If colleagues - Refer to the team. Negotiate and search for a compromise. Use a
need extra help because of the workload or because they lack confidence, moderator or ask the supervisor to make a decision.
it should be given.
Breaks should be proposed when necessary, especially in situations of
high stress.
Note: 2 other antidotes against stress:
- Always express your doubt. Do not fear to lose face. 'Loss of face' and
safety do not match together.
- Finally, humor can ease the pressure, and give the team extra resources
to tackle the problem.
FACTORS AFFECTING INDIVIDUAL PERFORMANCE

















ACRM LEARNING A NEW AIRCRAFT

- Stress. It is always more stressful to work on something new than on
Learning a New Aircraft something you know already because risks are less understood and less
well mastered (uncertainty is stressful). The positive aspect of stress is
Learning a new aircraft type affects performance.
that it will mobilize resources and induce extra caution.
What are the main difficulties?
Here is a simplified representation of the learning process.
. Lack of familiarity with the Airbus philosophy, in other words the
Time flows from the left to the right.
manufacturer's global approach to maintenance tasks.
1. The left side of the slide (in blue) is the starting point. Suppose for
. Lack of familiarity with A/C systems, procedures and documentation.
example that you are used to work on a B767.
. Poor knowledge of specific A/C hazards (electricity, hydraulics, moving
2. Then you go to the Airbus Training Center for an A340 type rating.
surfaces, power plant; risks involved from working with the MCDU,
There you will learn that certain things remain the same (in particular
etc.).
the basic maintenance rules of thumb) while others are different.
. Tendency to work like on the previous aircraft type: because you are
We recognize this is a hard time because you have to learn a lot in a
accustomed to working in a certain way and because problems can look
limited period of time. Note that the Airbus instructors are there to help!
similar, you may be tempted to work from habits, the way you are used
Everyone at Airbus training will do his best to make this learning process
to work on your previous aircraft type.
a successful one, and the least painful possible.
As we have just said, learning a new aircraft type affects performance.
Acquiring knew knowledge and developing skills is demanding: it is a
What are the main consequences?
little like building physical muscle. With repetition, just as with a physical
- Increased attention and workload, as skills have not yet developed.
work-out, we repeat some actions and ideas until they become automatic.
- Lack of overview, as the knowledge and understanding of the overall
We develop automatic routines, we develop skills based on certain rules
systems are under development.
we have learned, and we build our knowledge of the world. In this way,
- Lack or excess of confidence because what you think you know about
we become experts, able to use our mental resources in an extremely
the aircraft is under- or over- estimated. Extreme lack of confidence or
efficient and effective manner.
fear to make an error can even sometimes lead beginners to abandon a
X9K09091 - X0529T0 - XM00BELEARNIN01
3. When you return to your airline, you will practice what you have
task in the middle of a problem ... (instead of calling for assistance!)
learned
- Errors and surprises, coming from a lack of familiarity with the A/C
(On the Job Training). The learning process thus continues well beyond
systems, Airbus philosophy and procedures, from a lack of skills, from
your formal training at Airbus. To have a rough idea, we consider that
risky attitudes related to a lack or an excess of confidence, from increased
at least 1 year is needed to become 'experienced' on a new A/C type.
workload, etc.
An extra difficulty can come from working on several aircraft types
- Risk of breakdown in team co-ordination, because the role played by
during this skill acquisition and consolidation phase. Consider for example
each actor is not well mastered. Team members experience difficulties
that while starting to work on the A340, you resume working on the
to synchronize their tasks, to know or to guess what the others are doing
B767.
in real time, etc. Problems with troubleshooting can also affect teamwork
To avoid the risk of confusion, adhering to procedures is the only safe
because the aircraft remains grounded which modifies work scheduling.
way!
ACRM LEARNING A NEW AIRCRAFT Feb 27, 2009

There are several challenges involved in transition training. 2. On the right: With time and experience, behaviors become skills,
- New skills and automatic routines are not yet available. requiring far less mental resources to execute them. Doing the same task
- At the same time, there may be interference from former inappropriate on this skill-based mode is also less demanding in terms of workload.
routines on the previous aircraft. ("Old habits die hard"). But beware; the price to pay for skill-based behavior is routine error
As a result extra mental resources are needed to build new routines, while (when we don't pay enough attention on what we are doing).
at the same time checking that you are on 'the right plane'... observing Note: the 90/10 split is the most extreme example, e.g. moving from the
and checking yourself, a sort of higher-order self-supervision. Tupolev to the A330. If transitioning within the Airbus family, the
This is especially important under pressure, when the tendency to revert distribution will be less extreme, e.g., 70/30 or even 60/40 as many skills
to old/automatic behavior will be strongest. Interestingly, it is just as will transfer to the new aircraft.
important when there is no pressure... when the mind is not fully engaged, Environment changes.
not paying attention, the old routines will surely surface. Be "positive minded!"
In both cases, procedures are here to protect against the risk of error! Those recommendations are always valid. But they have a special
Example: driving on the other side of the road when in a different country. importance in the context of transitioning to a new aircraft.
Usually ok until a complex intersection... have to monitor that you make - Co-ordinate work at the team level, communicate on who is doing what
the turn on the correct side. how and when. See the Communication module.
Memory, prior experience, learning, expectations, and expertise allow - Think global. Consider troubleshooting, for example. Knowing what
us to perform well in our professional (as well as private) environment system is faulty, ask yourself what are the systems it is connected to,
- we would be lost without them. when did the fault occur and in what (flight) context.
But for a successful transition to a new aircraft, you will need to adapt. Example: Rejected take off. The maintenance performs the CSM/G test
These graphs show the benefit of experience in terms of resources needed without complying with the testing procedure. During the next take off,
to perform the job. the cockpit crew gets a "BLEED" warning at the ECAM, as the aircraft
1. On the left: In your transition course, learning a new aircraft, you will 'considers' there is not enough power to take off. This is not the real cause.
spend up to about 90% of your time doing non-routine, that is, The problem actually comes from the 'Flight Warning Computer' because
non-automated, behaviors. You have to concentrate because things or of a maintenance-related bug (power shutdown during the test).
tasks are unfamiliar. Working this way is very demanding in terms of - Select and use the relevant procedures and use the safety devices.
mental resources and induces workload. Note: Remember that your instructors are here to help during your stay
For example, when you get out of training sessions, you probably feel at the Airbus Training center, and after when you are back in your airline.
exhausted. - In the framework of the procedures, think before acting: there are actions
This is normal, for three reasons: that you can't unduce. Always think about the energy involved!
- First, you are developing new knowledge and skills. Mistakenly performing a command, for example from the MCDU, can
- Second, you are monitoring your old habits, making sure they are indeed have dramatic consequences. See the Procedure module. Also
appropriate in the new context or resisting them. refer to the ATA MTD briefings.
- Third, you have the stress associated with performing in front of others. - Keep in mind the system philosophy: every action calls for a specific
All of this increases your workload, and you become mentally fatigued A/C reaction! Thus monitor the result of each action.
much faster... remember your mental resources are limited.
LEARNING A NEW AIRCRAFT








ACRM COMMUNICATION
In which way can technical terminology and/or abbreviations impair
Communication communication?
The fact is that documents like the FCOM, the AMM and the TSM do
It is a unique feature of the Maintenance environment that personnel
not always use the same terminology. There might be several ways of
often receive conflicting requests, often under serious time pressure.
designating the same component, between manufacturers, or inside the
Corporate policy will often dictate priorities.
Airbus Company.
Operational requirements must always take precedence.
This example:
So, we can all agree that effective communication will facilitate safe
- 'Pylon valve' (Boeing culture),
practices. So why is communication sometimes so difficult?
- 'Bleed valve' or
Now let's look at other factors that impair communication.
- 'PRV valve' (Airbus culture): all three designate the same valve.
- Differences in language can impair communication. The main problem
Multi-qualifications can therefore increase the risk of confusion.
is the poor understanding of English by some maintenance personnel.
Abbreviations and acronyms can also be confusing when the same
The term language is used here in a broader sense than 'native language'
acronym refers to different systems (the context is then needed to
or 'mother tongue'. It includes technical phraseology, and more generally
understand what we are talking about):
the way things are expressed (non verbal communication, that will be
Examples:
developed later in this module).
- PCU = Power Control Unit or Passenger Control Unit
- High stress impairs communication as well as team and individual
- FCU = Flush Control Unit, Flight Control Unit or Fuel Control Unit
performance (as we saw in module 3).
- AP = Auto Pilot, PA = Public Address.
- Time pressure downgrades communication because people get
There are many Airbus abbreviations and they have been grouped and
overloaded but communication is absolutely necessary to organize the
listed in documents.
activity and keep the team alive.
The most used document in practice is the 'Airbus Industrie Abbreviation
- Conflicts upset communication but communication is needed to avoid
Summary' (AP2080).
and to solve conflicts (i.e. to restore team work).
X9K09091 - X0529T0 - XM00BFCOMMUNI01
But from the A320 to the A330, some abbreviations have changed.
- Pre-conceived ideas operate as a kind of filter that sets our expectations
To prevent maintenance staff from getting confused we recommend:
regarding people with whom we communicate.
- Solve possible ambiguities: express any doubt; clarify what you are
- Authority and hierarchy are often a barrier to communication.
talking about! Use feedback and crosscheck to check that you understand
- Personality and attitudes: it's hard to communicate with
and that you are understood!
un-communicative people...
- Use the FIN (Functional Item Number) to refer to an A/C component:
- Adverse physical (noise, lighting, weather...) or social environments
it is the only unambiguous (unique) terminology and the only
(problems of salary, social tensions, strikes, merging of airlines,
cross-reference in the documentation (AMM, TSM, etc.).
subcontracting...) impair communication.
Let's now look in detail at another major factor that impairs daily
- Technical terminology and abbreviations.
communication: Interruptions. In order to deepen this, let's watch another
- Interruptions.
video.
ACRM COMMUNICATION Feb 27, 2009

Because human communication is complex, demanding and fragile, it 2. The receiver repeats what he/she has heard or understood with his own
deserves specific protections. So, what are these protections? words: this is called "read-back". In case of doubt, he/she asks the sender
You are the sender: to repeat his/her message.
Do not disturb the receiver(s): protect their task performance (check 3. The sender compares the repeated message with the original message
his/her activity before), wait if needed, ask yourself: "May I interrupt?" he/she has delivered:
You are the receiver: - "Yes, this is it, we agree" or "Fine!"
- 'Protect' your task, - or "No, this isn't what I said, I'm repeating again: ..."
- Delay the communication if needed; make a sign or say, "stand by!" This is what we call "hear-back". Hear-back is used systematically in the
When you end the communication: communications between the Air Traffic Controllers and the pilots. It is
Help the other person (receiver) to resume his/her task: "Before I not infallible but filters about 95% of the errors committed.
interrupted you, this is what you were doing". BEWARE
We've gone through several factors that impair communication. Now 1. Do not say "OK" if you haven't heard, listened or memorized the
let's think about how we can make communication more reliable. message that was communicated to you or if you are unsure!!!
The first point is: clarifying the context. 2. We should also protect ourselves as senders against a natural tendency
The following exercise will demonstrate very clearly why this is that pushes us to hear-back what we want to hear back, that is what we
fundamental. have said and not what the receiver has repeated at stage 2!
The second point is: listening. The sixth point is: using written communication.
Communication is a two-way transfer. It is speaking and also listening: Written communication is also very much used in maintenance operations,
as states, "We have been given two ears and but one mouth in order that e.g.: cockpit, cabin and maintenance logbooks, job cards, aircraft technical
we may hear more and talk less!" file, shift hand-over notebook, etc.
Listening is an extremely important 'skill'. In all these cases, the communication is asynchronous (the reception of
Active listening demands that attention be directed towards the speaker the message is delayed regarding its emission).Written communication
and his/her message. If you listen to the other person, you will catch more is a much disciplined exercise. Because we rarely see the person who has
information. There is also more chance that he/she also listens to what written or who will read our written document, specific protections need
you are saying. to be used.
The fourth point is: using feedback. Here are some specific traps to avoid:
We insist here on the importance of feedback to make communication - Writing too little: Communication is about providing the right
more reliable. information. As has been emphasized before about implicit
A very practical and efficient version of closed-loop communication communication, if the other person doesn't understand on the basis of
using 3 steps is presented as follows: what we have written, he or she may compensate by making suppositions
Let's take the following example: You're on the phone and you have to that may be incorrect.
give your phone number to the person you are talking to. What can be Example: "APU inop." instead of "failure of the APU fire detection loop
done to avoid errors? 1".
1. The sender transmits his/her message In case of doubt, he or she will have to call us, which makes everyone
waste time.
- Writing too much: too much is as bad as too little: the receiver is lost flying with two crew members / glass cockpit aircraft. Ex: A320) have
among all the information provided. had several consequences on communication:
- Writing in a complicated, clumsy way. The message becomes Increased human-machine communication, especially with on board
ambiguous. systems:
- Using the wrong verbal form. The meaning may be different. OMS = On board Maintenance System
Example: "tightened" for "tighten": is it done or does it need to be done? ACARS = Aircraft Communication Addressing and Reporting System
Here are some good practices: AIDS = Aircraft Integrated Data System (A320 family)
- Write things in the right order, i.e. in the order in which they actually ACMS = Aircraft Condition Monitoring System (A330 / 340)
happened or in which they must be done. In other words, respect the There is a possible reduction in communication between humans:
chronology of the events. - On-board Maintenance Systems are recorders. They provide maintenance
Note the time at which things happen. This will facilitate the shift with a lot of information (ex: CFDS/CMS and PFR provide data from
hand-over. the last 64 flights). Consequently, some of the reports previously made
- Be clear and unambiguous, same as for oral communication. by the crew (especially the Flight Engineer) are performed by on-board
- Ask for feedback whenever possible. As said before, this makes systems.
communication more reliable. - Single technicians can now perform some operations. Flight crew may
The seventh and last point to make communication more reliable is: think that information provided by On board Maintenance Systems are
wondering what the other will understand. self-explanatory, and therefore deserves no briefing, which is of course
What is important is not so much the message sent but what is understood misleading.
by the receiver. Therefore, keep on communicating with your colleagues and with the
Therefore it is fundamental to always wonder what the receiver will flight crew!
understand with the information we have provided him/her. Nice-to-know
The true question is not: "Have I said or written what I wanted to?" - New technology is more complex, more opaque. Interfaces provide
but: "What should I write or what should I say to be understood?" much more information than before, and information is much more
or: "With what I've said or written, what will the other understand, integrated, centralized.
knowing his own context, habits, constraints, professional qualification, - Human-machine communication is less flexible than communication
expectations, etc.?". between humans: it has its own logic and requires respecting rules. This
For written communication, it is also worth wondering what the receiver means in particular that you cannot have the same expectations towards
may understand in case of an emergency or in case of problem (e.g. machines as towards humans.
temporal pressure, poor lightening conditions, missing equipment, etc.). - It is important to keep control of what you are doing, to monitor the
Initial understanding is very important because it may be hard and costly effects of your actions, to use feedback and to crosscheck. You and your
to change it afterwards (contact the person back, explain him what needs colleagues are your own safety net!
to be changed, looking for an agreement, etc.). The electronic documentation is not just associated to the library. Aircraft
The introduction of new generation aircraft (Aircraft equipped with a data, aircraft anomaly reports, record documents are also heavily linked
sophisticated auto-pilot and a number of automated systems supporting to the electronic media.

Today, a pilot as well as a mechanic can raise a technical complaint - Write beside any logbook entry (Maintenance action) the FIN of the
through a laptop, provided he has the right to access to the document. removed or replaced component,
But also, the pilot can use the electronic medium as the access to important - Use the electronic documentation dictionary (I.e. scroll down menu for
flight operational documentation (MEL, ATIS, FCOM, company information request, dictionary associated to the document like MENU
reporting, Airline operation documents...) HELP)...
Similarly, the maintenance staff will access to trouble-shooting
documentation, but also operational manuals, technical notes...
The issue is: Where to find the correct information and how to use it?
This is a training issue and it has to be correctly addressed.
The training on such tool will be done in accordance to the population
(line maintenance, base maintenance or engineering), since their need
differs.
The Base maintenance staff might use AIRN@V but also in-house
electronic documents.
The Engineering staff will have access to all available documentation
(100 manuals approx) in electronic format.
The new technology offers advantages. There is a necessity to know the
electronic tools before being at ease.
When not knowledgeable on the tool, the staff will face:
- Time consuming for access,
- Frustrations linked to search of the right key for access,
- Corruptions of the INTRANET network, and then possibly stop the
work ...
When not at ease with the AIRBUS acronyms and standardized wording,
the staff will face:
- Time consuming thus risks delaying aircraft dispatch,
- Wrong result due to incorrect fault or snag insertion,
- Misinterpretation of the result,
- On the aircraft MCDU, a faulty acronym might lead to wrong result
(e.g.; during Aircraft Condition Monitoring System analysis of a specific
parameter)...
The rules:
- Stick to AIRBUS REFERENCE LANGUAGE AP2080,
- One computer/item/ Line Replaceable unit (LRU) is associated to one
Functional Item Number (FIN),
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ACRM PROCEDURES AND PRACTICES IN MAINTENANCE

Therefore, the only way to interact safely with today's aircraft technology
Procedures and Practices in Maintenance is to refer to standard procedures, that is to say knowledge from the
documents.
The calculator exercise (scientific model and non scientific model).
Thus we cannot safely and efficiently deal with automation using only a
We expected the 2 calculator models to work in the same way. But they
naive, naturalistic approach, just acting the way we feel, hoping it will
didn't.
work.
Most of us got different results and were not very confident about them
This was clear with the calculator exercise. Let's take another example:
(or perhaps too confident!).
It is like when you are installing a new TV or video equipment at home.
The procedure was frustrating for some -not precise enough (even if it
You can try to do it with no guidance at all, relying only on your previous
was totally feasible from a mathematical viewpoint): can we use
expertise: "I plug in the equipment, play with the controls looking for
parentheses?
the installation menu, and try to get what I want. Eventually, if I get stuck,
Did we really know the logic of the technology?
I open the operating manual and look for a documented procedure". Of
We could have been trapped by typing or finger errors.
course, I can still manage in Basic Mode - I can turn it on and watch TV.
Conclusion: it can be risky to use modern technology:
But if I want to use any of the special features, I first have to know they
- Without a clear comprehension of the design principles and philosophy:
exist, and then know how to use them. In a sense, I can manage, but it is
What the designers wanted the calculators to do and why,
my loss not to take advantage of at least some of the features.
- Without proper training (we were not told what to do),
Do you think this is the best strategy? Do you think you can work this
- And without proper documentation (the calculator manuals).
way in an aircraft? Why can't you?
In this exercise, the calculator manuals were not provided. This greatly
So what do we need to take full benefit of automation?
explains the difficulty of the exercise (although it looked very simple at
1. Proper knowledge and training ('knowledge in the head')
first glance), the variety of results and the low confidence level among
2. Appropriate design ('knowledge in the objects or systems')
the trainees.
3. A set of operation guidelines ('knowledge in the documentation') = the
Reminder from Module 2 Error, Performance and Safety:
X9K09091 - X0529T0 - XM00BGPROCEDU01
REFERENCE.
The knowledge required using an object; system or piece of technology
Additionally, you will benefit from:
can come from 3 different sources:
1. A good understanding of the Airbus philosophy (which is part of the
- Memory, that is to say 'Knowledge in the head', which mainly comes
required knowledge in the head)
from training and previous experience.
2. And from a good motivation to learn a new way to perform tasks.
- The object or technical system itself (here the calculators), which
Consider this other example. It illustrates a more subtle difference between
provides 'Knowledge in the world'.
procedure and practice.
- And documentation, including procedures, which is knowledge in written
Consider the questions you can ask yourself while reading the instruction
or schematic, forms (another source of 'Knowledge in the world').
presented on the left:
In maintenance, as in other professions, knowledge in the world is not
- Running or motoring for how long?
sufficient, and human memory is subject to error.
- With what tool or equipment?
ACRM PROCEDURES AND PRACTICES IN MAINTENANCE Feb 27, 2009

- Under which conditions? - The role of shift turnover in safety has to be emphasized: many problems
- How is a leak defined? originate or are transmitted along the production line during this process.
A procedure is therefore like a music score; it is 'interpreted' during the - Using non-applicable procedures. There are so many aircraft types that
course of action and transformed into practice. maintenance staffs often have difficulties to select the proper procedures.
In other words, instructions cannot tell you everything. You need to be Consequently, we recommend:
knowledgeable and properly trained to follow instructions the way they - At the level of the maintenance staff: to always carefully check that you
were intended to be followed. are using the relevant procedures;
By the way, most of the answers to those questions can be found in the - At the level of the airline: to carefully manage technical documentation.
AMM! But the language itself can already be a problem...
Procedures do not replace basic knowledge and skills: maintenance staff Maintenance personnel are sometimes tempted to modify the procedure
needs to be properly trained in order to execute procedures correctly. during execution, using personal short cuts or expert tricks.
Safe procedure application requires that maintenance staff understand: Such a practice is absolutely unsafe: never modify a procedure while on
- The main reasons behind the procedures the job!
Note: modern technology is too complex to be fully understood. That is However, it is important to provide feedback on procedure quality and
the reason why procedures were designed and must be used. In this sense, on possible unforeseen side effects.
the main reason behind procedures is to cope with complexity. Learning from experience is essential for safety: warning notices can be
- The consequences of their actions released, procedure modifications can be proposed and individual and
Example 1 (A320 family) team activity can be adapted.
What will occur when you activate the any HYDRAULIC SYTEM for It is thus very important to report any possible failure or surprise
example during an AFS/LAND TEST? Surfaces will move. So you need encountered during procedure implementation, as well as any proposal
to know if any person or any materials stand in the vicinity before for modification to your airline Management and/or to the Engineering
executing this instruction. or Technical Departments.
Example 2 (A320 family)
When you pull the EIU CB = Engine Interface Unit C B, window heating
and pitot heating are automatically activated. The ice protection system
turns to fail safe position. There have been several incidents and job
injuries due to burns and the pitot protection devices melting.
Some specific remarks are proposed below:
- Poor training or knowledge can produce errors in procedure execution
because following a procedure requires basic professional knowledge
and skills.
- Changing habits or environment increases the risk of routine errors.
Due to habit indeed, there is a strong tendency to perform actions in the
habitual way, without taking into account the changes in the situation.

PROCEDURES AND PRACTICES IN MAINTENANCE









ACRM FACTORS AFFECTING TEAM PERFORMANCE

- Moods are usually good and members show solidarity. For instance,
Factors Affecting Team Performance members who exhibit poor performance or who experience temporary
difficulties (e.g., alcoholism, divorce, health problems, fatigue, and exam
See the video
preparation) are 'protected' (they will not be assigned too demanding
So what makes a good team?
tasks, but only up to a certain limit). A truly alcoholic person will end
- When you listen to a jazz orchestra, you wonder how the musicians
up by being rejected because he puts team performance at risk.
succeed in playing solos back and forth, without missing the beat and
Long lasting teams however, also presents drawbacks for safety:
playing without a music score. Great!
- Group pressure, conformism and designation of scapegoats.
-When you watch a soccer game, you sometimes wonder at the teamwork
- Reinforced stereotypes (e.g. "We are the best team!", "Problems can
- how the players seem to intuitively know.... A player sends the ball to
happen to the others but not to us").
one of his teammates coming at his left side between two adverse players.
- A lot of implicit communications favoring co-ordination and routine
The teammate sharply receives the ball, controls it, dribbles some
errors based on suppositions favoring co-ordination and routine (see the
opponents, and kicks the ball and scores a goal. Great!
Communication module).
But if the same soccer player kicks the ball to nobody, or if the saxophone
- Routine violations (e.g. "We don't need the procedures, that's way we
player finishes his solo and then nobody picks up the beat, then you have
do it here...").
a real embarrassment.
- Closure towards the outside and implicit, covert 'laws of silence',
Team performance requires more than individual performance!
reticence against incident reporting systems (e.g. "We don't wash our
Team performance obviously depends on individual performance - good
dirty linen in public!").
teamwork can never be a substitute for technical proficiency. And
A shift hand-over aim at ensuring work continuity, and is especially
conversely, having technical proficiency is not enough to guarantee
important for those tasks that cannot be finished within one shift.
effective team performance.
It is a complicate exercise, which also consists in transmitting verbally
Expected answers to the questions asked on the previous slide are thus:
and in a written way a reliable representation of the systems state, of the
Yes, you will never have a good orchestra with bad musicians: individual
X9K09091 - X0529T0 - XM00BHTEAMPER01
operations performed and of the ones remaining to be done.

performance does influence team performance.
It also consists in transferring responsibilities from persons to other
No, because individual performance is not everything! The best orchestra
persons (signatures).
does not necessarily include the best performers.
Constraints:
A great team performance implies something more...
- Available time is short.
So, what makes a good team performance better than the sum of its
- Once hand-over is completed, there is no easy way to complement
members' individual contributions?
missing information.
What are the advantages and the drawbacks of long lasting teams
Two recommendations:
regarding safety?
- When you start a shift: adopt a questioning attitude (the 'fresh eye
Long lasting teams present important advantages for safety:
advantage'). Doing so, you can help solving problems encountered during
- People know each other quite well, trust each other, easily co-operate
the previous shift, and detect possible errors.
and work in an efficient manner.
ACRM FACTORS AFFECTING TEAM PERFORMANCE Feb 27, 2009
- Perform briefings between shifts, if possible. - Procedures, which define the content of the tasks to be performed, both
Note: sometimes there is no shift overlap allowing direct exchanges at the individual and at the team level;
between technicians during shift hand-over, so briefings are actually - Regulations, which establish an overall framework.
impossible. This is a management issue that can't be developed in this Note: the top figure (appearing in blue on the screen) represents the leader.
course. Notice that we have included him (her) in the team.
Briefings contribute to building and updating a common team Leadership first comes from a recognized social position providing
understanding and to support anticipation. They define who is doing authority. For example, the status of Team Supervisor / Chief technician
what, when and how, which reduces uncertainty and prepares action. A / Technician is always attributed by the airline. (The terms used can of
task is much more reliable when performed after everyone has been course vary with the airline).
prepared to do so and has clear, explicit expectations about their own But leadership also stems from proficiency and other technical, personal,
role and the role others will be playing. social and cultural characteristics such as personality, attitudes, age, look
De-briefings allow reporting about the tasks done and remaining to be and origin. In some cultures, age is an important factor; people with 'white
done. Particular problems like difficult trouble shooting can also be hair' are very much respected. We recognize there are other sources of
discussed. leadership: the list is not exhaustive.
Use briefings in particular during shift hand-over (if possible, refer to A good leader doesn't need to resort to authority to lead the others.
previous slide) and before a task that is seldom performed. He (or she) 'naturally' gets from the team members what he wants because
Here is a simple metaphor for smooth and effective teamwork: he is proficient and is considered as a reference, trusted and respected
- A shared objective (goal) for his technical and human qualities.
- A proper task allocation, The leader is normally the team supervisor: leadership and authority
- A leader, normally correspond. But sometimes, the leadership may be taken by
- And willingness to work together, a good fit between the people. someone who is not officially in command, for example because of some
Remember also that communication is the social lubricant that allows specific skill or knowledge that fits the situation well ('situational
the machine to operate smoothly. leadership').
Safety and efficiency for a shared goal. And now, what are the main leader's roles?
Other objectives are: The leader's roles are multiple.
- Safety on the job (occupational safety), In particular the leader has to:
- Aircraft availability, respect of schedules, - Make decisions,
- Job and team satisfaction, - Allocate tasks,
- Personal and team achievement, - Manage workload,
- Recognition, - Manage time,
- Fun, - ...
- Etc. He also has to:
Proper task allocation is mainly defined by: - Monitor results;
- Team organization, which defines task and role allocation (who does - And praise team members for success and achievement.
what) and specifies team hierarchy (who is the boss);
Praise reinforces good practice, improves team spirit and increases
motivation.
- ...
Team spirit stems from different aspects:
- Common goal and common reference
The feeling of belonging to the same team and of pursuing the same goal
provides a common reference.
-Team atmosphere
The atmosphere in the team must be professional (team discipline) and
based on good relationship (a sort of solidarity or friendship).
- Motivation
Motivation to work together can lead team members to outstanding
performance.
Nice-to-know: motivation is affected - and can be improved - by several
external and internal factors.
- 'Followership'
All team members must express their willingness to follow the leader,
but not 'blindly'. So in case of doubt or if you have any question related
to the job or to safety, you should express your concern ('assertiveness'
and 'advocacy'), adopting the most suitable way according to your airline
culture and policy.

FACTORS AFFECTING TEAM PERFORMANCE











ACRM CONCLUSION
Conclusion
Human performance in aircraft maintenance
This course has focused on Crew Resource Management and its
relationship to safety. As we said at the start, these skills can never be a
substitute for technical proficiency...
However, technical proficiency alone cannot guarantee safety: the HF
dimension needs to be taken into account too.
Main expected benefits of this ACRM are:
- Improved flight safety
- Less personnel injuries (improved occupational safety)
- Better aircraft availability and economics benefits
- Higher motivation and job satisfaction
This course is not the end...For A320:
ATA 104 program: Safety and Human Factors will be addressed, in an
integrated manner, in the course of your technical training, in:
- The ATA chapters' briefings and debriefings
- And the MTD / MTS briefings and de-briefings
X9K09091 - X0529T0 - XM00BICONCLUS01
ACRM CONCLUSION Feb 27, 2009

CONCLUSION

CONCLUSION

CONCLUSION

CONCLUSION

CONCLUSION

AIRBUS S.A.S.
31707 BLAGNAC cedex, FRANCE
STM
REFERENCE X9K09091
FEBRUARY 2009
PRINTED IN FRANCE
AIRBUS S.A.S. 2009
ALL RIGHTS RESERVED
AN EADS COMPANY

All Aircraft Technical Training Manual Human Factors

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ALL AIRCRAFT

TECHNICAL TRAINING MANUAL

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AIRBUS Environmental Recommendation

TABLE OF CONTENTS Feb 27, 2009

ACRM WELCOME Feb 27, 2009

ACRM WELCOME Feb 27, 2009

ACRM WELCOME Feb 27, 2009

ACRM HUMAN FACTORS AND FLIGHT SAFETY

B737, 1988, Hawaii

ACRM HUMAN FACTORS AND FLIGHT SAFETY Feb 27, 2009

- Air traffic controllers it as a constraint. Time management is an important component of CRM.

ACRM HUMAN FACTORS AND FLIGHT SAFETY Feb 27, 2009

HUMAN FACTOR AND FLIGHT SAFETY

ACRM HUMAN FACTORS AND FLIGHT SAFETY Feb 27, 2009

HUMAN FACTOR AND FLIGHT SAFETY

ACRM HUMAN FACTORS AND FLIGHT SAFETY Feb 27, 2009

HUMAN FACTOR AND FLIGHT SAFETY

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HUMAN FACTOR AND FLIGHT SAFETY

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HUMAN FACTOR AND FLIGHT SAFETY

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HUMAN FACTOR AND FLIGHT SAFETY

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HUMAN FACTOR AND FLIGHT SAFETY

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ACRM ERROR, PERFORMANCE AND SAFETY

on the A/C systems and practice maintenance procedures, of course, but

ERROR, PERFORMANCE AND SAFETY

ACRM ERROR, PERFORMANCE AND SAFETY Feb 27, 2009

ERROR, PERFORMANCE AND SAFETY

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ERROR, PERFORMANCE AND SAFETY

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ERROR, PERFORMANCE AND SAFETY