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HUMAN ERROR IDENTIFICATION AND MANAGEMENT IN AVIATION

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SCHOOL OF MECHANICAL AND INDUSTRIAL
ENGINEERING
POSTGRADUATE PROGRAM IN INDUSTRIAL ENGINEERING
HUMAN ERROR IDENTIFICATION AND MANAGEMENT IN

AVIATION MAINTENANCE
By: Getnet Bacha
A Thesis Submitted to Addis Ababa University Institute of Technology,

School of Mechanical and Industrial Engineering in Partial Fulfillment
of the Requirement for the Degree of Masters of Science in Industrial
Engineering
Advisor: Professor Daniel Kitaw

Co-Advisor: Kassu Jilcha (PhD Candidate)
March, 2016
ADDIS ABABA INSTITUTE OF TECHNOLOGY (AAiT)
SCHOOL OF MECHANICAL AND INDUSTRIAL ENGINEERING,

INDUSTRIAL ENGINEERING STREAM
“HUMAN ERROR IDENTIFICATION AND MANAGEMENT IN

AVIATION MAINTENANCE”
Submitted by:
Getnet Bacha ____________________ _____________________
Student Name Signature Date
Approved by Board of Examiners:
1. _______________ ____________________ _____________________
Chairman, SMIE Signature Date
2. Professor Daniel Kitaw ____________________ ____________________
Supervisor Signature Date
3. Mr. Kassu Jilcha ____________________ ____________________
Co-Advisor Signature Date
4. Dr. Ir. Eshetie Berhan _____________________ _____________________
Internal Examiner Signature Date
5. Dr. Shewit Woldegebriel ____________________ _____________________
External Examiner Signature Date

DECLARATION
I hereby declare that the work which is being presented in this thesis entitled “HUMAN
ERROR IDENTIFICATION AND MANAGEMENT IN AVIATION MAINTENANCE” is
original work of my own, has not been presented for a degree of any other university and all the
resource of materials used for this thesis have been duly acknowledged.
_____________________________ ________________________
Getnet Bacha Date
This is to certify that the above declaration made by the candidate is correct to the best of my
knowledge.
_____________________________ ________________________
Professor Daniel Kitaw (Advisor) Date
_____________________________ ________________________
Mr. Kassu Jilcha (Co-Advisor) Date
AAiT School of Mechanical and Industrial Engineering Page i

ACKNOWLEDGEMENT
My first heartily acknowledgment goes to my advisors Professor Daniel Kitaw and Mr. Kassu
Jilcha for their valuable assistance, comments, suggestions and constant support throughout the
thesis work, which helped me a lot in completing this paper.
I also want to acknowledge engineers, safety departments and maintenance crew in Ethiopian
Airlines for giving me valuable information’s. Especially my great appreciation and respect goes
to Sagni Amsalu who helped me a lot in doing the software.
In addition I would like to thank my beloved families and friends who are always behind me
with full support in my entire educational carrier.
Lastly my greatest and heartfelt thanks go to the almighty God for his Love and Guidance in all
my ways and giving me another day and another chance to become a better individual.
Getnet Bacha
March 2016
AAiT School of Mechanical and Industrial Engineering Page ii

Human Error Identification and Management in Aviation Maintenance Getnet Bacha, 2016
ABSTRACT
Aviation safety depends on minimizing error in all facets of the system. Aviation maintenance
and inspection tasks are part of a complex organization, where individuals perform varied tasks
in an environment with time pressures, sparse feedback, fatigue, workload and sometimes
difficult ambient conditions. These situational characteristics, in combination with generic
human error tendencies, result in varied forms of error. In worst case it results in accidents and
loss of life.
Maintenance and inspection errors have other important consequences such as air turn-backs,
delays, gate returns, diversions to alternate airports and in worst case accident may occur. This
will decreases productivity and efficiency of the airline operations and inconvenience on
passengers.
In this research top human error causes in aviation maintenance especially the case of Ethiopian
airlines are discussed and evaluate. After those causes are discussed a proposed solution was
raised. The solution is to propose software that has different inputs about the person who
assigned on the aircraft. Before every technician is going to perform a specific task, they have to
login in this software and accept the task given to them.
This software indentifies weather the person assigned on the aircraft is fatigued or not, weather
the task needs more than one person or not, it has also an input from quality assurance
department about the technician and the aircraft on which he/she trained, the other input is
weather the technician takes different short term safety training and also warns the technician if
the safety trainings are going to expire and if they are expired it denies the task. Also the
software opens the maintenance procedure, and it doesn’t let you pass the page in minimum time.
AAiT School of Mechanical and Industrial Engineering Page ii

CONTENTS
ACKNOWLEDGEMENT .......................................................................................................................... ii
ABSTRACT ................................................................................................................................................. ii
CONTENTS ............................................................................................................................................... iii
LIST OF TABLE ....................................................................................................................................... vi
LIST OF FIGURES .................................................................................................................................. vii
LIST OF ACRONYM.............................................................................................................................. viii
1. INTRODUCTION AND BACKGROUND ........................................................................................... 1
1.1. INTRODUTION ....................................................................................................................... 1
1.2. PROBLEM FORMULATION AND IDENTIFICATION ....................................................... 2
1.3. OBJECTIVE ............................................................................................................................. 5
1.4. SCOPE AND LIMITATION OF THE PAPER ........................................................................ 5
1.5. SIGNIFICANCE OF THE RESEARCH PAPER ..................................................................... 6
1.6. ORGANIZATION OF THE PAPER ........................................................................................ 6
2. LITRATURE REVIEW ..................................................................................................................... 7
2.1. INTRODUCTION .................................................................................................................... 7
2.2. DEFINITION OF HUMAN FACTOR ..................................................................................... 8
2.3. ELEMENTS OF HUMAN FACTORS ..................................................................................... 9
2.4. HISTORY OF HUMAN FACTORS ...................................................................................... 13
2.5. THE PEAR MODEL .............................................................................................................. 15
2.6. SHELL MODEL ..................................................................................................................... 20
2.7. ERROR AND ERROR MANAGEMENT.............................................................................. 24
2.8. SUMMARY AND GAPS IDENTIFIED ................................................................................ 26
3. METHODOLOGY ........................................................................................................................... 29
3.1. INTRODUCTION .................................................................................................................. 29
3.2. PRIMARY DATA .................................................................................................................. 29
AAiT School of Mechanical and Industrial Engineering Page iii

3.3. SECONDARY DATA ............................................................................................................ 30
3.4. PROPOSED SOFTWARE ...................................................................................................... 30
3.5. RESEARCH METHODOLOGY FRAME WORK ................................................................ 32
4. DATA ANALYSIS AND FINDING ................................................................................................ 33
4.1. DATA ANALYSIS ................................................................................................................. 33
4.1.1. INTERVIEW ANALYSIS USING MEDA ........................................................................ 33
4.1.2. QUESTIONER ANALYSIS ............................................................................................... 38
4.1.3. SECONDARY DATA ANALYSIS ................................................................................... 41
4.2. FINDINGS AND HUMAN ERROR PRODUCING CONDITIONS .................................... 41
4.2.1. STRESS, WORKLAD AND TIME PRESSURE ............................................................... 41
4.2.2. LACK OF COMMUNICATION ........................................................................................ 43
4.2.3. PROFFESIONALISM (SKILL) AND COMPLACENCY................................................. 44
4.2.4. FATIGUE ........................................................................................................................... 45
4.2.5. POOR LEADERSHIP & DECISION MAKING ............................................................... 47
4.2.6. LACK OF TEAM WORK .................................................................................................. 48
4.3. FISHBONE DIAGRAM ......................................................................................................... 50
4.4. SUMMARY ............................................................................................................................ 51
5. PROPOSED SOFTWARE DEVELOPMENT ............................................................................... 52
5.1. INTRODUCTION .................................................................................................................. 52
5.2. ABOUT THE SOFTWARE.................................................................................................... 52
5.3. ASSUMPTIONS OF SOFTWARE DEVELOPMENT .......................................................... 52
5.4. SOFTWARE INPUTS ............................................................................................................ 53
5.4.1 SHIFT AND CLOCK IN TIME ......................................................................................... 53
5.4.2 SYSTEM COURSE TAKEN.............................................................................................. 53
5.4.3 SHORT TERM TRAININGS ............................................................................................. 54
5.4.4 MAINTENANCE MANUAL ............................................................................................. 55
AAiT School of Mechanical and Industrial Engineering Page iv

5.4.5 MAN POWER .................................................................................................................... 55
5.4.6 COMPLETION TIME ........................................................................................................ 55
6. CONCLUSION AND RECOMMENDATION .............................................................................. 56
6.1. CONCLUSION ....................................................................................................................... 56
6.2. RECOMMENDATION .......................................................................................................... 57
6.3. FUTURE RESEARCH AREA ............................................................................................... 57
REFERENCES .......................................................................................................................................... 58
APPENDEX I ............................................................................................................................................ 60
APPENDIX II ............................................................................................................................................ 65
APPENDIX III .......................................................................................................................................... 68
AAiT School of Mechanical and Industrial Engineering Page v

LIST OF TABLE
Table 2.1: People who do the job ................................................................................................................ 16
Table 2.2: Environment in which they work ............................................................................................... 18
Table 2.3: Actions they perform ................................................................................................................. 19
Table 2.4: Resources necessary to complete the job ................................................................................... 19
Table 4.1: Contributing factors identified from the Interview .................................................................... 35
Table 4.2: Main contributing factors........................................................................................................... 37
Table 4.3: Human Factors Management Survey ......................................................................................... 38
Table 4.4: Most common Outcomes of Safety Occurrences....................................................................... 39
Table 4.5: Most common reasons for the occurrence of the outcomes ....................................................... 39
Table 4.6: Top HFIM drivers that need reviewing ..................................................................................... 40
AAiT School of Mechanical and Industrial Engineering Page vi

LIST OF FIGURES
Figure 1.1: The role played by human performance in civil aircraft accidents. (IATA, 1975) ................... 4
Figure 2.1: Vitruvian Man ......................................................................................................................... 13
Figure 2.2: Leonardo DiVinci’s rendering of a flying device for man. ..................................................... 14
Figure 2.3: The Wright Brothers on December 17, 1903 .......................................................................... 15
Figure 2.4: Liveware ................................................................................................................................. 20
Figure 2.5: Liveware Liveware ................................................................................................................. 21
Figure 2.6: Liveware Software .................................................................................................................. 22
Figure 2.7: Liveware Hardware................................................................................................................. 22
Figure 2.8: Liveware Environment ........................................................................................................... 23
Figure 2.9: Reason model of error............................................................................................................. 24
Figure 2.10: Relationship between PEAR and SHELL models ................................................................ 26
Figure 3.1: The research methodology framework .................................................................................. 32
Figure 4.1: Initial MEDA Error Model ..................................................................................................... 33
Figure 4.2: Final MEDA event model. ...................................................................................................... 34
Figure 4.3: The MEDA Investigation Process .......................................................................................... 34
Figure 4.4: Pareto diagram of contributing factors ................................................................................... 36
Figure 4.5: Final MEDA event model summaries..................................................................................... 37
Figure 4.6: Fishbone diagram of maintenance human error causes. ......................................................... 50
Figure 4.7: PEAR and SHELL model relationship with the Thesis finding. ............................................ 51
AAiT School of Mechanical and Industrial Engineering Page vii

LIST OF ACRONYM
ATC: Air Traffic Control
AMT: Aircraft Maintenance Technician
CAA: Civil Aviation Authority
CF: Contributing Factors
EASA: European Aviation Safety Agency
EWIS: Electrical Wire Installation System
FAA: Federal Aviation Administration
FAR: Federal Aviation Regulation
HF: Human Factor
HFIM: Human Factor in Maintenance
ICAO: International Civil Aviation Organization
IATA: International Air Transport Association
MEL: Minimum Equipment List
MEDA: Maintenance Error Decision Aid
MRO: Maintenance Repair and Overhaul
OSHA: Occupational Safety and Health Administration
PEAR: People, Environment, Action and Resources
SHELL: Software, Hardware, Environment and Live ware
VFSG: Variable Frequency Starter Generator
AAiT School of Mechanical and Industrial Engineering Page viii

CHAPTER ONE
1. INTRODUCTION AND BACKGROUND
1.1. INTRODUTION
Over the last 100 years or so, relatively few accidents result purely from technical failures. In
around 75-80 % of cases, deficiencies in human performance contributed directly to the outcome.
[1] For many years, aviation human factors focused on issues of concern to pilots, including
visual illusion, in-flight decision making, and cockpit communication. Generations of pilots have
studied accidents in which flight crew ran out of fuel, continued in to bad weather, or were
distracted by minor technical faults. In recent years, attention has turned to human factors in
maintenance. Aircraft engineers deal with a unique set of human factors challenges that can lead
to maintenance errors. Studying these human factors issues and understanding their effects will
better prepare you to deal with human factors in your daily work [1].
The impact of human factors can be seen in many parts of a typical aircraft maintenance
operation. Tasks may occur on work stands high above the ground, outside in all weather, in a
noisy environment, or under time pressure. Task procedures might be poorly written or hard to
obtain. Components are often difficult to access, the required tools or spares may be unavailable,
and at times lighting is poor, or the work involves parts not directly visible to the engineer. There
may be multiple interruptions during tasks. Just to make things more interesting, tasks often
require more than one shift to complete, and may need to be handed from one engineer to
another.
When it was said that an accident involved human factors, it rarely mean that there was a
problem with the specific people involved. In most cases of maintenance error, the people
involved had the necessary knowledge and technical skills to perform their job, but were let
down by non-technical factors, typically human factors. In many cases, highly experienced
engineers or senior peoples in their organization made mistakes.
Aircraft maintenance is an essential component of the aviation system which supports the global
aviation industry. As air traffic grows and the stringent requirements of commercial schedules
AAiT School of Mechanical and Industrial Engineering 1

impose increased demands upon aircraft utilization, the pressures on maintenance operations for
on-time performance will also continue to escalate. This will open further windows of
opportunity for human error and subsequent breakdowns in the system's safety. There is no
question that human error in aircraft maintenance has been a causal factor in several air carrier
accidents. It is also beyond question that unless the aviation industry learns from these
occurrences, maintenance-related safety breakdowns will continue to occur [3].
Human factor refers to the wide range of issues that affect how people perform tasks in their
working and non working environments. The study of human factors involves applying scientific
knowledge about the human body and mind, to better understand human capabilities and
limitation so that there is the best possible fit between people and the system in which they
operate. Human factors are the social and personal skills (for example, communication and
decision making) which complement technical skill, and are important for safe and efficient
aviation maintenance [2].
This thesis paper was specifically performed in Ethiopian MRO and has a plan to identify and
manage the causes of human factor issues that observed in aviation maintenance. The human
error in the specified airline has become increasing and this in turn decreases the reliability of
maintenance activity. So, in order to improve the maintenance activity in Ethiopian MRO
controlling software was designed and this software has different input about the technician and
tries to control his/her activity.
1.2. PROBLEM FORMULATION AND IDENTIFICATION
Without the intervention of maintenance personnel, equipment used in complex technological

systems such as aviation, rail and marine transport, and medicine would drift towards a level of
unreliability that would rapidly threaten efficiency and safety.
Despite the essential contribution of maintenance to system reliability, maintenance is also a

major cause of system failure. The rate of power station outages increases shortly after
maintenance, maintenance quality is a major concern in the chemical industry, and in aviation
there is evidence that maintenance is contributing to an increasing proportion of accidents. As
automated systems become increasingly common, humans are performing less direct manual

control of equipment and systems. As a result, maintenance is becoming a major remaining point
of direct interaction between people and technology, where human capabilities and limitations
can have a significant impact on system safety and reliability. Understanding the human factors
in maintenance is more necessary than ever if we are to improve safety and reliability in aviation
maintenance [8].
Modern technological systems in industries such as manufacturing, transport and healthcare

comprise equipment, procedures, and of course people. In most cases, we have a fairly good
understanding of the performance characteristics of the engineered equipment that form parts of
these systems. Aircraft come with manuals that specify their performance envelopes and
capabilities. Procedures too, have been created by people and can be documented and
understood. But when it comes to people, we are faced with a system element that comes with no
operating manual and no performance specifications, and that occasionally performs in ways not
anticipated by the system designers. Some of these failures can be easily explained, an arithmetic
error for example, while others are harder to predict. Although individuals differ, researchers
have discovered general principles of human performance that can help us to create safer and
more efficient systems. The focus of this paper is on the functioning of people as elements of
maintenance systems in aviation [8].
U.S. statistics indicate that 80% of aviation accidents are due to human errors with 50% due to
maintenance human factor problems (Source FAA). Today, more than ever, the aviation world is
faced with the constant challenge of addressing human factors in maintenance [1].
Aircraft maintenance work encompasses fast turnaround, high pressure with possibly hundreds
of tasks being performed by large numbers of personnel on highly complex and technologically
advanced systems in a confined area. It is very easy for information and tasks to fall through the
safety program. Events around the world in the late 1970s, 1980s and early 1990s, involving
crashes or serious accidents with aircraft, alerted the aviation world to the fact that: the aircraft
were becoming much more reliable, but the human factor error become more increasing [1].
As per the annual report from Ethiopian airlines there are a lot of human factor related errors that
causes accidents, incidents and loss of life. This in turn decreases maintenance efficiency,
decreases the profitability and incurs extra charge on insurances.

The role played by human performance can be found below.
120
Human
100 Cause
80
60
40
20
Machine
Cause
0
1903 TODAY
Figure 1.1: The role played by human performance in civil aircraft accidents. (IATA, 1975)
Therefore from both the international and local airline experiences it has been concluded that the
aircrafts were becoming more and more reliable, but human error become increasing. From
general observation and the annual company report it was mentioned that the reliability of the
maintenance activity is decreasing, human error issues are increasing.
The following Research Questions are answered.
 What is the current maintenance practice in Ethiopian MRO?

 What are the main causes of maintenance Human errors?
 How to decrease maintenance Human errors?
 How to control and direct the industry and regulatory body to improve maintenance
activities?
 How to develop a controlling mechanism that controls maintenance personnel from doing
errors that causes maintenance accidents and incidents?

1.3. OBJECTIVE
The general objective of the paper is to reduce aircraft maintenance and ground operation
accidents, incidents, and related errors and makes the aviation maintenance activity reliable and
dependable for the customers.
The specific objectives are:
 To assess the aviation human errors at Ethiopian MRO.
 To identify the main causes of maintenance human errors.
 To direct and coordinate industry and regulatory efforts nationally to improve the
maintenance activity.
 To develop improvement approaches on maintenance activity to decrease Human error in
aviation maintenance and increase aviation safety
 To develop a software program that controls maintenance activities and crew.
1.4. SCOPE AND LIMITATION OF THE PAPER

1.4.1. SCOPE OF THE PAPER
The research focuses on the human error producing conditions in Ethiopian MRO aviation
maintenance activity. In this research the main human error producing conditions are assessed
and for each causes one accident/incident that is practically happened in the airline are discussed.
After the causes are identified software was designed. The software has different inputs about the
person who is practically assigned on the aircraft and it controls the maintenance activity. The
software designed was not fully operational and there are items that are missing, and it was the
future task and plan of this thesis.
1.4.2. LIMITATION OF THE PAPER
The most challenging problems in conducting this research were being busy on the aviation
maintenance jobs, time limitation to conduct research at a bench, and having the deficiency of
not getting a proper data due to the culture of the company. The other challenging thing was
developing the software. However, the limitations do not affect the quality of the research
addressed within its scope, because the data is comprehensive, the researcher used different tools
and mechanisms to complete the task on time, and developed the software by consulting the
experts.
1.5. SIGNIFICANCE OF THE RESEARCH PAPER
As stated in the problem identification the human error was increasing and this will in turn
decreases the reliability of the maintenance activity. If not managed properly it will have a very
bad effect on the airline brand and will result in customer dissatisfaction. In the extreme case will
result in losing customer and will even has bad effect on national economy. Since the causes of
human error producing conditions are discussed properly in this research, it will give a
comprehensive starting point for more studies in human error in aviation maintenance. In
addition, if the software designed at the end of this paper were practically applied it will help the
industry to control their human error conditions. And this will result in smooth maintenance
activity and increases on time performance. And it will practically increase customer satisfaction
and also will increase national economy.
1.6. ORGANIZATION OF THE PAPER
The study first defines and explains the concept of Human factor in detail, and its consequences.
Then the second chapter explains the literature review about human factor in detail, its history
and impact of human errors on aircraft maintenance. The third chapter is about the methodology.
The fourth chapter discusses the current human factor related problems, the culture of the
maintenance activity in this airline, the accidents and incidents encountered and their main
causes in detail. The fifth chapter proposes a software that decreases human factor related
accidents and incidents. And then finally conclusion and recommendation were designed.

CHAPTER TWO
2. LITRATURE REVIEW
2.1. INTRODUCTION
Why are human conditions, such as fatigue, complacency, and stress, are so important in aviation
maintenance? These conditions, along with many others, are called human factors. Human
factors directly cause or contribute to many aviation accidents. It is universally agreed that 80
percent of maintenance errors involve human factors [1]. If they are not detected, they can cause
events, worker injuries, wasted time, and even accidents.
Aviation safety relies heavily on maintenance. When it is not done correctly, it contributes to a
significant proportion of aviation accidents and incidents. Some examples of maintenance errors
are parts installed incorrectly, missing parts, and necessary checks not being performed. In
comparison to many other threats to aviation safety, the mistakes of an aviation maintenance
technician (AMT) can be more difficult to detect [8]. Often times, these mistakes are present but
not visible and have the potential to remain latent, affecting the safe operation of aircraft for
longer periods of time. AMTs are confronted with a set of human factors unique within aviation.
Often times, they are working in the evening or early morning hours, in confined spaces, on
platforms that are up high, and in a variety of adverse temperature/humidity conditions. [1] The
work can be physically strenuous, yet it also requires attention to detail [8].
Because of the nature of the maintenance tasks, AMTs commonly spend more time preparing for
a task than actually carrying it out. Proper documentation of all maintenance work is a key
element, and AMTs typically spend as much time updating maintenance logs as they do
performing the work [14].
Maintenance personnel are confronted with a set of human factors unique within aviation.
Maintenance technicians work in an environment that is more hazardous than most other jobs in
the labor force. The work may be carried out at heights, in confined spaces, in numbing cold or
sweltering heat. The work can be physically strenuous, yet it requires clerical skills and attention
to detail. Maintenance technicians commonly spend more time preparing for a task than actually

carrying it out. Dealing with documentation is a key activity, and maintenance engineers
typically spend nearly as much time wielding a pen as they do holding a screwdriver. The work
requires good communication and coordination, yet verbal communication can be difficult due to
noise levels and the use of hearing protection. The work frequently involves fault diagnosis and
problem solving in the presence of time pressures, particularly at the gate [8].
Maintenance personnel also face unique sources of stress. Air traffic controllers and pilots can
leave work at the end of the day knowing that the day’s work is complete. In most cases, any
errors they made during their shift will have either had an immediate impact or no impact at all.
In contrast, when maintenance personnel leave work at the end of their shift, they know that the
work they performed will be relied on by crew and passengers for months or years into the future.
The emotional burden on maintenance personnel whose work has been involved in accidents is
largely unrecognized outside the maintenance fraternity. On more than one occasion,
maintenance personnel have taken their own lives following aircraft accidents caused by
maintenance error [8].
Human factors awareness can lead to improved quality, an environment that ensures continuing
worker and aircraft safety, and a more involved and responsible work force. More specifically,
the reduction of even minor errors can provide measurable benefits including cost reductions,
fewer missed deadlines, reduction in work related injuries, reduction of warranty claims, and
reduction in more significant events that can be traced back to maintenance error [4].
2.2. DEFINITION OF HUMAN FACTOR
The term human factors have grown increasingly popular as the commercial aviation industries
realize that human error, rather than mechanical failure, underlies most aviation accidents and
incidents. Human factors science or technologies are multidisciplinary fields incorporating
contributions from psychology, engineering, industrial design, statistics, operations research, and
anthropometry. It is a term that covers the science of understanding the properties of human
capability, the application of this understanding to the design, development, and deployment of
systems and services, and the art of ensuring successful application of human factor principles
into the maintenance working environment [1].

The list of human factors that can affect aviation maintenance and work performance is broad.
They encompass a wide range of challenges that influence people very differently as humans do
not all have the same capabilities, strengths, weaknesses, or limitations [6]. Unfortunately,
aviation maintenance tasks that do not account for the vast amount of human limitations can
result in technical error and injuries. Some are more serious than others but, in most cases, when
you combine three or four of the factors, they create a problem that contributes to an accident or
incident [2].
Human factors, which affect aircraft maintenance technicians, are:

 Poor instruction, Skill
 Boring and repetitive work
 Poor tool control
 Poor training, Incorrect documentation
 Fatigue, loud noise
 Poor communication
 Incorrect documentation
 Personal life problem
 Lack of tools and equipment
 Unrealistic deadlines
2.3. ELEMENTS OF HUMAN FACTORS
Human factors are comprised of many disciplines. This section discusses ten of those disciplines:
Clinical Psychology, Experimental Psychology, Anthropometrics, Computer Science, Cognitive
Science, Safety Engineering, Medical Science, Organizational Psychology, Educational
Psychology, and Industrial Engineering. The study and application of human factors is complex
because there is not just one simple answer to fix or change how people are affected by certain
conditions or situations. Aviation maintenance human factors research has the overall goal to
identify and optimize the factors that affect human performance in maintenance and inspection.
The focus initiates on the technician but extends to the entire engineering and technical
organization. Research is optimized by incorporating the many disciplines that affect human

factors and help to understand how people can work more efficiently and maintain work
performance [2].
By understanding each of the disciplines and applying them to different situations or human
behaviors, we can correctly recognize potential human factors and address them before they
develop into a problem or create a chain of problems that result in an accident or incident.
2.1.1. Clinical Psychology
Clinical psychology includes the study and application of psychology for the purpose of
understanding, preventing, and relieving psychologically-based distress or dysfunction and to
promote subjective well-being and personal development. It focuses on the mental well-being of
the individual. Clinical psychology can help individuals deal with stress, coping mechanisms for
adverse situations, poor self image, and accepting criticism from coworkers.
2.1.2. Experimental Psychology
Experimental psychology includes the study of a variety of basic behavioral processes, often in a
laboratory environment. These processes may include learning, sensation, perception, human
performance, motivation, memory, language, thinking, and communication, as well as the
physiological processes underlying behaviors, such as eating, reading, and problem solving. In
an effort to test the efficiency of work policies and procedures, experimental studies help
measure performance, productivity, and deficiencies [2].
2.1.3. Anthropometrics
Anthropometry is the study of the dimensions and abilities of the human body. This is essential
to aviation maintenance due to the environment and spaces that AMTs have to work with.
For example, a man who is 6 feet 3 inches and weighs 230 pounds may be required to fit into a
small crawl space of an aircraft to conduct a repair. Another example is the size and weight of
equipment and tools. Men and women are generally on two different spectrums of height and
weight. Although both are equally capable of completing the same task with a high level of
proficiency, someone who is smaller may be able to perform more efficiently with tools and
equipment that is tailored to their size. In other words, one size does not fit all and the term
“average person” does not apply when employing such a diverse group of people [2].

2.1.4. Computer Science
The technical definition for computer science is the study of the theoretical foundations of
information and computation and of practical techniques for their implementation and
application in computer systems. How this relates to aviation maintenance is a lot simpler. As
mentioned earlier, AMTs spend as much time documenting repairs as they do performing them.
It is important that they have computer work stations that are comfortable and reliable. Software
programs and computer-based test equipment should be easy to learn and use, and not intended
only for those with a vast level of computer literacy [2].
2.1.5. Cognitive Science
Cognitive science is the interdisciplinary scientific study of minds as information processors. It

includes research on how information is processed (in faculties such as perception, language,
reasoning, and emotion), represented, and transformed in a nervous system or machine (e.g.,
computer). It spans many levels of analysis from low-level learning and decision mechanisms to
high-level logic and planning. AMTs must possess a great ability to problem solve quickly and
efficiently. They constantly have to troubleshoot a situation and quickly react to it. This can be a
viscous cycle creating an enormous amount of stress. The discipline of cognitive science helps us
understand how to better assist AMTs during situations that create high levels of stress so that
their mental process does not get interrupted and effect their ability to work [2].
2.1.6. Safety Engineering
Safety engineering assures that a life-critical system behaves as needed even when the
component fails. Ideally, safety engineers take an early design of a system, analyze it to find
what faults can occur, and then propose safety requirements in design specifications up front and
changes to existing systems to make the system safer. Safety cannot be stressed enough when it
comes to aviation maintenance, and everyone deserves to work in a safe environment. Safety
engineering plays a big role in the design of aviation maintenance facilities, storage containers
for toxic materials, equipment used for heavy lifting, and floor designs to ensure no one slips,
trips, or falls. In industrial work environments, the guidelines of the Occupational Safety and
Health Administration (OSHA) are important [2].

2.1.7. Medical Science
Medicine is the science and art of healing. It encompasses a variety of health care practices
evolved to maintain and restore health by the prevention and treatment of illness. Disposition and
physical well-being are very important and directly correlated to human factors. Just like people
come in many shapes and sizes, they also have very different reactions to situations due to body
physiology, physical structures, and biomechanics [2].
2.1.8. Organizational Psychology
Organizational psychologists are concerned with relations between people and work. Their
interests include organizational structure and organizational change, workers’ productivity and
job satisfaction, consumer behavior, and the selection, placement, training, and development of
personnel. Understanding organizational psychology helps aviation maintenance supervisors
learn about the points listed below that, if exercised, can enhance the work environment and
productivity [2].
• Rewards and compensations for workers with good safety records.

• Motivated workers that want to do well and work safely.
 Unified work teams and groups that get along and work together to get the job done right.
• Treat all workers equally.
2.1.9. Educational Psychology
Educational psychologists study how people learn and design the methods and materials used to
educate people of all ages. Everyone learns differently and at a different pace. Supervisors
should design blocks of instruction that relate to a wide variety of learning styles.
2.1.10. Industrial Engineering
Industrial engineering is the organized approach to the study of work. It is important for
supervisors to set reasonable work standards that can be met and exceeded. Unrealistic work
standards create unnecessary stressors that cause mistakes. It is also beneficial to have an
efficient facility layout so that there is room to work. Clean and uncluttered environments

enhance work performance. Another aspect of industrial engineering that helps in the
understanding of human factors is the statistical analysis of work performance. Concrete data of
work performance, whether good or bad, can show the contributing factors that may have been
present when the work was done [2].
2.4. HISTORY OF HUMAN FACTORS
Around 1487, Leonardo DiVinci began research in the area of anthropometrics. The Vitruvian
Man, one of his most famous drawings, can be described as one of the earliest sources presenting
guidelines for anthropometry [2].
Figure 2.1: Vitruvian Man
Around the same time, he also began to study the flight of birds. He grasped that humans are too
heavy and not strong enough to fly using wings simply attached to the arms. Therefore, he

sketched a device in which the aviator lies down on a plank and works two large, membranous
wings using hand levers, foot pedals, and a system of pulleys. [Figure 2.2]
Figure 2.2: Leonardo DiVinci’s rendering of a flying device for man.
Today, anthropometry plays a considerable role in the fields of computer design, design for
access and maintainability, simplicity of instructions, and ergonomics issues. In the early 1900s,
industrial engineers Frank and Lillian Gilbreth were trying to reduce human error in medicine.
They developed the concept of using call backs when communicating in the operating room. For
example, the doctor says “scalpel” and the nurse repeats “scalpel” and then hands it to the doctor.
That is called the challenge-response system. Speaking out loud reinforces what tool is needed
and provides the doctor with an opportunity to correct himself/herself if that is not the necessary
tool. This same verbal protocol is used in aviation today. Pilots are required to read back
instructions or clearances given by air traffic control (ATC) to ensure that the pilot receives the
correct instructions and gives ATC an opportunity to correct if the information is wrong. Frank
and Lillian Gilbreth also are known for their research on fatigue [2].
Also in the early 1900s, Orville and Wilbur Wright were the first to fly a powered aircraft and
also pioneered many human factors considerations. While others were trying to develop aircraft
with a high degree of aerodynamic stability, the Wrights intentionally designed unstable aircraft
with centralized control modeled after the flight of birds. Between 1901 and 1903, the brothers
worked with large gliders at Kill Devil Hills, near Kitty Hawk, North Carolina, to develop the

first practical human interactive controls for aircraft pitch, roll, and yaw. On December 17, 1903,
they made four controlled powered flights over the dunes at Kitty Hawk with their Wright Flyer.
Figure 2.3: The Wright Brothers on December 17, 1903
They later developed practical in-flight control of engine power, plus an angle of attack sensor
and stick pusher that reduced pilot workload. The brothers’ flight demonstrations in the United
States and Europe during 1908-1909, awakened the world to the new age of controlled flight.
Orville was the first aviator to use a seat belt and also introduced a rudder boost/trim control that
gave the pilot greater control authority. The Wrights’ flight training school in Dayton, Ohio
included a flight simulator of their own design. The Wrights patented their practical airplane and
flight control concepts, many of which are still in use today. Prior to World War I, the only test
of human to machine compatibility was that of trial and error. If the human functioned with the
machine, he was accepted, if not he was rejected. There was a significant change in the concern
for humans during the American Civil War. The U.S. Patent Office was concerned about
whether the mass produced uniforms and new weapons could effectively be used by the infantry
men [2].
2.5. THE PEAR MODEL
There are many concepts related to the science and practice of human factors. However, from a
practical standpoint, it is most helpful to have a unified view of the things we should be
concerned about when considering aviation maintenance human factors. A good way to gain this
understanding is by using a model. For more than a decade, the term “PEAR” has been used as a

memory jogger, or mnemonic, to characterize human factors in aviation maintenance. PEAR

prompts recall of the four important considerations for human factors programs, which are listed
below [1].
• People who do the job.

• Environment in which they work.
• Actions they perform.
• Resources necessary to complete the job.
2.5.1 People
Aviation maintenance human factors programs focus on the people who perform the work and
address physical, physiological, psychological, and psychosocial factors.
Table 2.1: People who do the job
People
Physical Psychological Physiological Psychosocial
 Physical  Nutritional  Workload  Interpersonal
size  Health  Experience conflicts
 Sex  Lifestyle  Knowledge
 Age  Fatigue  Training
 Strength  Attitude
 Mental state
It must focus on individuals, their physical capabilities, and the factors that affect them. It also
should consider their mental state, cognitive capacity, and conditions that may affect their
interaction with others. In most cases, human factors programs are designed around the people in
the company’s existing workforce. You cannot apply identical strength, size, endurance,
experience, motivation, and certification standards equally to all employees. The company must
match the physical characteristics of each person to the tasks each performs. The company must
consider factors like each person’s size, strength, age, eyesight, and more to ensure each person
is physically capable of performing all the tasks making up the job. A good human factors
program considers the limitations of humans and designs the job accordingly. An important
element when incorporating human factors into job design is planned rest breaks. People can
suffer physical and mental fatigue under many work conditions. Adequate breaks and rest

periods ensure the strain of the task does not overload their capabilities. Another “People”
consideration, which also is related to “E” for “Environment,” is ensuring there is proper lighting
for the task, especially for older workers. Annual vision testing and hearing exams are excellent
proactive interventions to ensure optimal human physical performance [1].
Attention to the individual does not stop at physical abilities. A good human factors program
must address physiological and psychological factors that affect performance. Companies should
do their best to foster good physical and mental health. Offering educational programs on health
and fitness is one way to encourage good health. Many companies have reduced sick leave and
increased productivity by making healthy meals, snacks, and drinks available to their employees.
Companies also should have programs to address issues associated with chemical dependence,
including tobacco and alcohol. Another “People” issue involves teamwork and communication.
Safe and efficient companies find ways to foster communication and cooperation among workers,
managers, and owners. For example, workers should be rewarded for finding ways to improve
the system, eliminate waste, and help ensure continuing safety [1].
2.5.2 Environment
There are at least two environments in aviation maintenance. There is the physical workplace on
the ramp, in the hangar, or in the shop. In addition, there is the organizational environment that
exists within the company. A human factors program must pay attention to both environments.
Physical
The physical environment is obvious. It includes ranges of temperature, humidity, lighting, noise
control, cleanliness, and workplace design. Companies must acknowledge these conditions and
cooperate with the workforce to either accommodate or change the physical environment. It
takes a corporate commitment to address the physical environment. This topic overlaps with the
“Resources” component of PEAR when it comes to providing portable heaters, coolers, lighting,
clothing, and workplace and task design [1].

Organizational
The second, less tangible, environment is the organizational one. The important factors in an
organizational environment are typically related to cooperation, communication, shared values,
mutual respect, and the culture of the company. An excellent organizational environment is
promoted with leadership, communication, and shared goals associated with safety, profitability,
and other key factors. The best companies guide and support their people and foster a culture of
safety. A safe culture is one where there is a shared value and attitude toward safety. In a safe
culture, each person understands their individual role is contributing to overall mission safety.
Table 2.2: Environment in which they work
Environment
Physical Organizational
 Weather  Personal
 Location in/out  Supervision
 Workspace  Pressure
 Shift  Crew structure
 Lighting  Size of company
 Sound level  Profitability
 Safety  Moral
 Corporate culture
2.5.3 Actions
Successful human factors programs carefully analyze all the actions people must perform to
complete a job efficiently and safely. Job task analysis (JTA) is the standard human factors
approach to identify the knowledge, skills, and attitudes necessary to perform each task in a
given job. The JTA helps identify what instructions, tools, and other resources are necessary.
Adherence to the JTA helps ensure each worker is properly trained and each workplace has the
necessary equipment and other resources to perform the job. Many regulatory authorities require
the JTA serve as the basis for the company’s general maintenance manual and training plan.
Many human factors challenges associated with use of job cards and technical documentation
fall under “Actions.” A crystal clear understanding and documentation of actions ensures
instructions and checklists are correct and useable [1].

Table 2.3: Actions they perform
Action
 Steps to perform a task  Knowledge requirements
 Sequence of activity  Skill requirements
 Number of people involved  Altitude requirements
 Information control requirement  Certification requirement
2.5.4 Resources
The final PEAR letter is “R” for “Resources.” [Table 2.4]. Again, it is sometimes difficult to
separate resources from the other elements of PEAR. In general, the characteristics of the people,
environment, and actions dictate the resources. Many resources are tangible, such as lifts, tools,
test equipment, computers, technical manuals, and so forth. Other resources are less tangible.
Examples include the number and qualifications of staff to complete a job, the amount of time
allocated, and the level of communication among the crew, supervisors, vendors, and others.
Resources should be viewed (and defined) from a broad perspective. A resource is anything a
technician (or anyone else) needs to get the job done. For example, protective clothing is a
resource. A mobile phone can be a resource. Rivets can be resources. What is important to the
“Resource” element in PEAR is focusing on identifying the need for additional resources [1].
Table 2.4: Resources necessary to complete the job
Resource
 Procedures/ Work cards
 Technical manuals
 Other peoples
 Computer/Signoffs
 Ground handling equipment
 Work stands and lifts
 Fixtures
 Materials
 Task lighting
 Training

2.6. SHELL MODEL
ICAO SHELL Model is a conceptual framework proposed in ICAO Circular 216-AN31. The
concept (the name being derived from the initial letters of its components, Software, Hardware,
Environment, Live ware) was first developed by Edwards in 1972, with a modified diagram to
illustrate the model developed by Hawkins in 1975 [9].
One practical diagram to illustrate this conceptual model uses blocks to represent the different
components of Human Factors. This building block diagram does not cover the interfaces which
are outside Human Factors (hardware-hardware; hardware-environment; software-hardware) and
is only intended as a basic aid to understanding Human Factors:
 Software - the rules, procedures, written documents etc., which are part of the standard
operating procedures.
 Hardware - the Air Traffic Control suites, their configuration, controls and surfaces,
displays and functional systems.
 Environment - the situation in which the L-H-S system must function, the social and
economic climate as well as the natural environment.
 Liveware - the human beings - the controller with other controllers, flight crews,
engineers and maintenance personnel, management and administration people - within in
the system.
Figure 2.4: Liveware
The critical focus of the model is the human participant, or live ware, the most critical as well as
the most flexible component in the system. The edges of this block are not simple and straight,

and so the other components of the system must be carefully matched to them if stress in the
system and eventual breakdown are to be avoided.
However, of all the dimensions in the model, this is the one which is least predictable and most
susceptible to the effects of internal (hunger, fatigue, motivation, etc.) and external (temperature,
light, noise, workload, etc.) changes.
Human Error is often seen as the negative consequence of the live ware dimension in this
interactive system. Sometimes, two simplistic alternatives are proposed in addressing error: there
is no point in trying to remove errors from human performance, they are independent of training;
or, humans are error prone systems, therefore they should be removed from decision making in
risky situations and replaced by computer controlled devices. Neither of these alternatives are
particularly helpful in managing errors [9].
2.6.1 Liveware-Liveware (The interface between people and other people)
Figure 2.5: Liveware Liveware
This is the interface between people. In this interface, we are concerned with leadership, co-
operation, teamwork and personality interactions. It includes programmes like Crew Resource
Management (CRM),

2.6.2 Liveware-Software (The interface between people and software)
Figure 2.6: Liveware Software
Software is the collective term which refers to all the laws, rules, regulations, orders, standard
operating procedures, customs and conventions and the normal way in which things are done.
Increasingly, software also refers to the computer-based programmes developed to operate the
automated systems.
In order to achieve a safe, effective operation between the liveware and software it is important
to ensure that the software, particularly if it concerns rules and procedures, is capable of being
implemented. Also attention needs to be shown with phraseologies which are error prone,
confusing or too complex. More intangible are difficulties in symbology and the conceptual
design of systems. [9]
2.6.3 Liveware-hardware (The interface between people and hardware)
Figure 2.7: Liveware Hardware

Another interactive component of the SHELL model is the interface between liveware and
hardware. This interface is the one most commonly considered when speaking of human-
machine systems: design of seats to fit the sitting characteristics of the human body, of displays
to match the sensory and information processing characteristics of the user, of controls with
proper movement, coding and location.
Hardware, for example in Air Traffic Control, refers to the physical features within the
controlling environment, especially those relating to the work stations. As an example the press
to talk switch is a hardware component which interfaces with liveware. The switch will have
been designed to meet a number of expectations, including the probability that when it is pressed
the controller has a live line to talk. Similarly, switches should have been positioned in locations
that can be easily accessed by controllers in various situations and the manipulation of equipment
should not impede the reading of displayed information or other devices which might need to be
used at the same time [9].
2.6.4 Live ware – Environment (The interface between people and the environment)
Figure 2.8: Liveware Environment
The liveware - environment interface refers to those interactions which may be out of the direct
control of humans, namely the physical environment - temperature, weather, etc., but within
which aircraft operate. Much of the human factor development in this area has been concerned
with designing ways in which people or equipment can be protected, developing protective
systems for lights, noise, and radiation. The appropriate matching of the liveware -
environmental interactions involve a wide array of disparate disciplines, from environmental
studies, physiology, psychology through to physics and engineering [9].

2.7. ERROR AND ERROR MANAGEMENT
Error is an unavoidable part of human being. Identifying a human error is a starting point, not a
conclusion. If our aim is to learn from the error and to lessen the chances of its happening again,
we need to consider the organizational context that surrounded the person’s action: including
equipment, procedure, people, the environment and management. There are two aspects to
managing error [1].
 Reducing the probability the people will make error.

 Making sure that the system is prepared to deal with errors when they occur.
The use of the term human error does not mean we have a problem with people. Human error
generally points us to systems problems. Although error can lead to unwanted events, it also can
provide valuable opportunities to identify and implement system improvements.
TYPES OF ERROR
Human errors can be divided into two basic categories, unintended actions and intended
actions[1].
Slips
Unintentional
actions
Lapses
Error
Mistakes
Intentional
actions
Violation
Figure 2.9: Reason model of error.

Slips: it occurs when we perform a routine action that was out of place in the situation, usually
because we are distracted and habit takes over. Many slips in maintenance are slips of the pen,
where a signature is out in a wrong place. Slips also occur when using tools and when activating
cockpit controls [1].
Lapses: it occurs when we forget to complete an action we had been intending to perform.
Examples are forgetting to remove tools or rigging devices at the end of the job, forgetting to
close hatches or leaving nuts figure tight. One of the most widely reported lapses in maintenance
is failing to replace oil caps. Many lapses occur when a technician has been interrupted by other
task, often called away to a more urgent job [1].
Mistakes: mistakes are a type of error where the problem has occurred during thinking rather
than doing. The person carries out their actions as planned, except that what they planned to do
was not right for the situation. Reason describes two types of mistakes, rule based and
knowledge based.
Rule based mistakes occur in familiar situation where engineer has a pre existing rule or
guideline they use to guide their actions. This need not necessarily be a formal rule; it could be a
procedure or work habit that they usually follow in that situation. The mistake happens when the
rule no longer fits the situation, or the engineer miss identifies the situation.
Knowledge based mistakes reflect the lack of necessary knowledge, or a lack of awareness of
where to find the necessary information. This is not most likely to occur when a person is
performing an unfamiliar task, or is dealing with a non routine situation [1].
Violations: they are intentional deviation from procedures or good practice. In most cases
violation occurs because the engineer is trying to get the job done, not because they want to
break rules.
Routine violations are the everyday deviation from procedures made to keep things moving and
get the job done. Examples are not using a torque wrench, instead judging torque by feel; or
referring a personal source of maintenance data instead of going to the maintenance manual.

Exceptional violations are often well intentioned attempts to get the job done, despite problems
such as missing document or shortage of parts.
Sabotage is an extremely rare event in aircraft maintenance.
2.8. SUMMARY AND GAPS IDENTIFIED
to detail. Maintenance technicians commonly spend more time preparing for a task than actually
carrying it out. The work requires good communication and coordination, yet verbal
communication can be difficult due to noise levels and the use of hearing protection. The work
frequently involves fault diagnosis and problem solving in the presence of time pressures,
particularly at the gate [8].
From the Literature the SHELL model focuses on the interaction between the software, live ware,
environment and the hard ware in the maintenance environment. And in other way the PEAR
model focuses on the People, environment, Action and Resources in the maintenance
environment. The two models help the main body of this thesis and they were the practical
causes observed in the Ethiopian MRO. Most of the causes of human error identified in
Ethiopian MRO are part those theories. Both principles are talking about the same issues and
they are related in the following figure
P S
E H
A E
L
R
L
Figure 2.10: Relationship between PEAR and SHELL models

As per (ICAO Digest No. 12) the causes of human factor are mainly depends on maintenance
activity of the technician, mainly equipment incorrect installation, omissions and wrong parts but
it does not consider any other parameters. But as per (Civil Aviation Authority of Australia, 2013)
the human error causes are lack of team work, lack of communication, poor decision making,
fatigue and poor instruction. In contrast to the first paper the second paper is highly related with
the work of this thesis and also related with the data analysis output.
“Human factors in aircraft maintenance by Cilin G.Drury” this paper provides only a sampling of
the research performed and products made available from human factors in aviation maintenance
and inspection research programs. The first issue in developing a human factors program on an
airline or other maintenance organization is to recognize that human error will not be eliminated
by blame, motivation or even most training. True system intervention requires an integrated
approach of all the elements in the SHELL system. Organization should now have sufficient data
and incentive to undertake human factors program. This paper gives a logical approach to error
reduction, combining error investigation and task analysis based approach.
“A Human Error Analysis of Commercial Aviation Accidents Using the Human Factors Analysis
and Classification System (HFACS)”, by Douglas A.Wiegmann. This investigation demonstrates
that the HFACS frame work, originally developed for and proven in the military, can be used to
reliably identify the underlying human factors problems associated with commercial aviation
accidents. Furthermore, the results of this study highlight critical areas of human factors in need
of further safety research and provide the foundation upon which to build a larger civil aviation
safety program. Ultimately, data analyses such as that presented here will provide valuable
insight aimed at the reduction of aviation accidents through data-driven investment strategies and
objective evaluation of intervention programs. The HFACS framework may also prove useful as
a tool for guiding future accident investigations in the field and developing better accident
databases, both of which would improve the overall quality and accessibility of human factors
accident data. Different from the others this paper is not promising to use it everywhere, because
the nature and cause of maintenance human factor in different areas have their own
characteristics.
The value added to the existing body of knowledge is a data that observed from the literature and
different reference paper used are discussed, and identified the causes of maintenance human

error practically observed in the specified airline. The nature, the management and the skill level
of the technicians in Ethiopian MRO has its own unique characteristics. Therefore as per the
assessed different journals and the literature the causes of human factor causes in Ethiopian
MRO is designed.

CHAPTER THREE
3. METHODOLOGY
3.1. INTRODUCTION
In this study both primary and secondary information source is used. Primary source contain raw,
original, non-interpreted and unevaluated information. The secondary data sources are technical
documents and annual reports that help to cross check the official information and to get details
concerning the study. Discussion, interview and questionnaires are techniques that are used for
gathering primary information and relevant data for the study.
Data collection is in both qualitative and quantitative nature. Quantitative means anything that
exists in a certain quantity and can be measured. The methodology has a quantitative nature
because there are quantifiable measures of variables and hypotheses can be formulated, and
conclusions drawn from samples to populations. However some of the data are not inherently
quantitative that is they do not necessarily have to be expressed in numbers, and so it has also a
qualitative nature.
3.2. PRIMARY DATA
The data required for the study is identified and collected by communicating with maintenance
staffs of the Ethiopian MRO and safety office. In collecting the data’s, the safety office has detail
records of the human related accidents and incidents. And the maintenance personal knows the
detail causes and the human related error performed. Thus the causes of the accidents and
incidents are grouped under different categories and tried to identify the human factor related
errors.
Interview conducted for both the team leaders and the technicians. The content and depth of the
questions on the interview is based on Boeing MEDA interview format. From the interview the
causes of human factor are identified properly. The interview output was analyzed by using
Boeing MEDA analysis.

Questionnaire is also prepared and given to the team leaders, the technicians and the
management of the organization. The questioners are collected, analyzed and the causes of
human related errors are identified.
A total of 60 questioners are distributed, 56 (93%) of them are collected back. So from the
questioners it is understood that, most of the technicians replied that time pressure and workload,
professionalism, poor instructions, lack of using proper procedure, lack of good communication,
poor leadership, lack of team work, complacence, and lack of proper skill are the main reasons of
human error in aviation maintenance.
There was also a focal group discussion with company safety office and senior technician’s staffs
in the company. In this regard two things are observed, the safety department of the company is
highly stressed on the inefficiency of the technicians and their work behaviors, and they are
mentioning that the technicians are not using proper maintenance procedure; and they do not
have good communication and good team work. On the other hand the senior maintenance stuffs
are mentioning both their inefficiencies and the bad side of the management.
Since the author was practically working as an aircraft technician, on his daily work experience
different incidents and accidents are observed. And this will really guides to know the real causes
of human factor in aviation maintenance. In addition with the basic information collection
mechanisms, on job experience helps to identify the causes of the human factors.
3.3. SECONDARY DATA
The secondary data sources are technical documents and annual reports that help to cross check
the official information and to get details concerning the study. For the literature part different
related websites that are done on aviation maintenance human factors, articles, journals and text
books are referred.
3.4. PROPOSED SOFTWARE
After the primary and secondary data’s were collected, different aircraft accidents are identified
and categorized under different causes. In order to support the causes different practical cases are
taken. Those cases are practical cases that are happened in the airline. Each accident is briefed

properly, regarding their cost effect, injuries on human being and their economic and brand
drawbacks on the airline are accessed.
After those causes are discussed a proposed solution was raised. The solution is to propose
software that has different inputs about the person who assigned on the aircraft. Before every
technician is going to perform a specific task, they have to login in this software and accept the
task given to them.
This software indentifies weather the person assigned on the aircraft is fatigued or not, weather
the task needs more than one person or not, it has also an input from quality assurance
department about the technician and the aircraft on which he/she trained, the other input is
weather the technician takes different short term safety training and also warns the technician
weather the safety trainings are going to expire and if they are expired it denies the task. Also the
software opens the maintenance procedure, and it doesn’t let you pass the page in minimum time.
It has a pause on a specific page to let the technician read the procedures, cautions and the
warnings.

3.5. RESEARCH METHODOLOGY FRAME WORK
Problem description and

Objective Formulation
Literature Review
Data collection
Interview Questioner Experience Secondary data
Chec
Data analysis and software k
development
Conclusion and
Recommendation
Figure 3.1: The research methodology framework

CHAPTER FOUR
4. DATA ANALYSIS AND FINDING

4.1. DATA ANALYSIS
4.1.1. INTERVIEW ANALYSIS USING MEDA
The Boeing Maintenance Error Decision Aid (MEDA) provides the basis for a maintenance
safety program as it focuses on documenting human error-based factors that contribute to an
event. By adopting a structured, impartial analysis of undesirable events, properly identifying
causal factors, and creating a database system, effective preventive measures can be produced
and carried out. [12] The MEDA analysis has the following basic guide lines,
A. The MEDA Event Analysis Model
The earliest and simplest form of the MEDA event (error) model is shown in Figure 4.1
Contributing Error Event

Factor
Figure 4.1: Initial MEDA Error Model

In this simple model, one or more contributing factor causes an error that causes an event. In
MEDA the term “contributing factor” is used to describe conditions that contribute to an error or
a violation. Or more simply a contributing factor is anything that affects how a maintenance
technician or inspector does his/her job.
The MEDA philosophy is explained using the final MEDA event model (see Figure 4.1 above).
The fundamental philosophy behind MEDA is: [11]
 A maintenance-related event can be caused by an error, by a violation, or by an
error/violation combination
 Maintenance errors are not made on purpose
 Maintenance errors are caused by a series of contributing factors
 Violations, while intentional, are also caused by contributing factors

In a more advanced analysis, with more number of contributing factors (CF), the MEDA error
model will be described on Figure below.
CF CF CF
CF CF
CF
Error and/or System

CF CF Failure
Violation
Event
CF CF CF Violation
Figure 4.2: Final MEDA event model.

B. The MEDA Investigation Process
1. Event occurs, 4. Interview involved personnel

2. Investigation
e.g Cancellation, 3. Determine using MEDA result analysis form
reveals Event
Diversion, A/c who made to
caused by
Grounding or In the error  Find contributing factors
maintenance
Flight shut down  Get idea for process
error
improvement
7. Provide
5. Obtain additional 6. Design process
Finally, as per feedback to all
contributing factors improvements based
the contributing Employees about
information as on contributing factors
factors Identified the process
required, of the Events.
and Analyzed improvements.
Figure 4.3: The MEDA Investigation Process

C. MEDA Results Analysis Form
MEDA Results Analysis Form (Appendix I) is a 4 page interview form consisting of six sections:
1. Section I, General Information
2. Section II, Event
3. Section III, Maintenance System Failure
4. Section IV, Chronological Summary of the Event
5. Section V, Summary of Recommendations
6. Section VI, Contributing Factors Checklist
Sections I, II, and III establish what happened (the event), Section IV provides a summary of the
whole event in a chronological order, Section V lists recommendations for prevention strategies
to prevent the errors and violations from occurring, and Section VI establishes why the event
happened through listing all contributing factors [11].
Therefore, as per the MEDA interview guide line on Appendix I, interview was conducted for 46
maintenance technicians and supervisors of the airline and the result was concluded below.
Table 4.1: Contributing factors identified from the Interview
No. Contributing factors %

1 Time pressure and Workload 64.5
2 Fatigue 55.3
3 Professionalism and Skill 44.8
4 Team work and Communication 36.9
5 Leadership and Poor Decision 32.8
6 Complacency 32.2
7 Stress 28.3
8 Lack of Training 10.6
9 Working Environment 10.1
10 Poor documentation/Information 9.2
11 Destructions 8.0
12 Proper tool not used 6.0
13 Unrealistic deadline 5.3
14 Part unavailable 5.2
15 Confined space 5.2
16 Unreliable tool calibration 5.0
17 Not enough staff 3.9
18 Others 10.3

The above contributing factors are the cause of maintenance errors according to the maintenance
technicians and supervisors.
A Pareto diagram is a bar graph used to arrange information in such a way that priorities for
process improvement can be established. It is used to display the relative importance of data and
to direct efforts to the biggest improvement opportunity by highlighting the vital few in contrasts
to the useful many.
Figure 4.4: Pareto diagram of contributing factors
The fundamental idea behind the use of Pareto diagrams for improvement is that the first few
contributing causes to a problem usually account for the majority of the result. Thus, targeting
these major causes for eliminating human error, results in the most effective improvement
scheme. Therefore using Pareto diagram the interview response is analyzed and the following are
the main contributing factors for the maintenance errors or they are almost 80% of the cause of
maintenance errors. The main contributing factors according to the Pareto diagram are integrated
according to their similarities on the table below.

Table 4.2: Main contributing factors
No. Contributing Factors

1 Time pressure, Fatigue and Workload
2 Skill (Professionalism) and Complacency

3 Poor decision making and Leadership
4 Lack of Team work and Communication
In addition as per the Final MEDA event model the contributing factors and the corresponding
human errors are summarized on the next figure,
Contributing factor
(Human error Producing Condition)
Human
Errors
Part Poor Events

Unavailabl decision
e Wrong
part
Work Loaded Fatigued Installation
 Damage on
Aircraft, and
Time Forgot to
Stressed Destruction Equipments and
pressure close access
Injury on
panels
Personnel
 Air turn back,
Procedure Diversion and
Skill Complacency Gate return
Violation
Physical
Lack of Team Communication damage on
Work barrier the
Aircraft
Figure 4.5: Final MEDA event model summaries

4.1.2. QUESTIONER ANALYSIS
The results of the Human Factor Management Survey carried out can be found below. A total of
60 questioners are distributed, 56 (93%) of them are collected back. The results are broken down
to the four parts of the survey questionnaire. The survey can be found in Appendix III.
A. Human Factor Programs and Management
Table 4.3: Human Factors Management Survey

Human Factor Survey (%) Strongly Agree Disagree Strongly
Agree Disagree
1.1 There is a structured Human Factors Program in your 18.1 36 29.6 16.3
Maintenance Department? 54.1 45.9
1.2 If yes, how many years has it been in existence? >10years 5-10years <5years
48.2 41.4 10.4
1.3 If no, is it important to have one? 100 0 0 0
100 0
2.1 The HFIM programs currently implemented have 10.7 53.6 19.8 15.9
improved the management of human factor errors in your 64.3 35.7
organization?
2.2 The training and tools currently available in your 9.8 26.7 50 13.5
organization are sufficient to manage HFIM? 36.5 63.5
2.3 More needs to be done to manage HFIM errors in 66.5 24.1 6.2 3.2
maintenance? 90.6 9.4
Of the department surveyed, 54.1% have a structured Human Factors Maintenance Program. Of
these departments that have a structured program, 89% have had it for more than five years.
Most departments agree that the programs in their organizations have improved human factor
error management. The responses on the effectiveness of tools and training to manage human
factor errors in maintenance were mixed in that 36.5% thought they were adequate while 63.5%
thought otherwise. However, a good majority, or 90.6% of those surveyed clearly felt that
“More needs to be done to manage HFIM Errors”

B. Most Common Outcomes of Safety Occurrences
The most common outcome of HFIM safety occurrences were “System operated unsafely during
maintenance”. This was followed closely by “Incorrect assembly or orientation of part”. These
were the top two outcomes of safety occurrences in their organization. And this indicates that the
maintenance system that is used in this airlines need to be improved.
Table 4.4: Most common Outcomes of Safety Occurrences
In your opinion, which of these are the most common outcomes of HFIM safety occurrences?
Please select 1 or more that are the most common outcomes for this section
Outcomes %
1 System operated unsafely during maintenance 65.7
2 Incorrect assembly or orientation of part 53.2
3 Part/aircraft damaged during repair 40.8
4 Tool lost on aircraft/in maintenance facility 33.9
5 Material left on aircraft 28.8
6 Injury to personnel 28.6
“Time Pressure and workload” was the top most likely reason for the occurrence of safety
violations. “Pressure” together with the “Fatigue” was the two top reasons for safety violations.
Table 4.5: Most common reasons for the occurrence of the outcomes
The most likely reason for the occurrence of these outcomes?

Outcomes %
1 Time pressure and Workload 64.5
2 Fatigue 55.3
3 Professionalism and Skill 44.8
4 Team work and Communication 36.9
5 Leadership and Poor Decision 32.8
6 Complacency 32.2
7 Lack of Training 24.2
8 Environment 19.1
In the opinion of those surveyed, more than 50% listed the “Processes Improvement” and
“Organizational Culture” as the top factors that need to be reviewed to better manage human
factor errors in maintenance.

Table 4.6: Top HFIM drivers that need reviewing
In your opinion, HFIM errors can be managed better by reviewing…?

Outcomes %
1 Processes Improvement 55.3
2 Organizational Culture 52.6
3 Attitudes of personnel 44.9
4 Training Effectiveness 41.6
5 Leadership 33.9
6 Management of Information 29.6
C. SURVEY FEEDBACK
Several senior officers that were surveyed, most of whom had been maintenance team leaders in
their previous appointment, had very good comments and feedback during the survey. Some of
these comments were:
1. The main issue in my opinion is “complacency”. A lot is due to repeated jobs over and over.
Not paying attention to the little details.
2. Managers and Supervisors need to be more patient when shops get a lot of work. Most
mistakes are made when technicians get interrupted during their tasks to do other jobs and
feel pressure to always get done quickly. It is hard to do tasks that may be quite complicated
when you are always in a rush.
3. To improve or reduce HFIM management need:
a. Effective implementation of supervisory training
b. Aircraft system training for all maintenance crews.
c. Timely sharing of information (incidents/accidents)
d. Motivation at all levels
e. Implement different controlling mechanisms.
f. Involvement of leaders and supervisors with the subordinates
4. Personnel should be trained and watched by supervisors to make sure they are gaining an
understanding of correct processes and staying to the procedures.
5. I think pressure and fatigue is special human error producer. I think generally, the air lines
have to consider a rest time for technicians just like the rest time valid for crew members.

6. As a 16 years aircraft maintenance officer to me the most problematic area for HFIM
management in aircraft maintenance are:
i. Norms of the maintenance people
ii. Night shifts (you’d better check the effectiveness of shifts and their
change over consequences in A/C maintenance)
4.1.3. SECONDARY DATA ANALYSIS
The secondary data sources are technical documents, different journals and annual reports that
help to cross check the official information and to get details concerning the study. Different
related websites that are done on aviation maintenance human factors, recent articles, journals
and text books are referred.
Among the secondary data analyzed, Civil Aviation Authority of Australia, Human factor
handbook, 2013 was one of the main references of this paper. Similar to the output of this thesis,
the mentioned hand book has described the human error producing conditions with practical
incidents and accidents in the same way. And also the references that are used on the literature
part describe the causes of maintenance human errors and their sources.
4.2. FINDINGS AND HUMAN ERROR PRODUCING CONDITIONS
4.2.1. STRESS, WORKLAD AND TIME PRESSURE
Aviation maintenance is a stressful task due to many factors. Aircraft must be functional and
flying in order for airlines to make money, which means that maintenance must be done within a
short timeframe to avoid flight delays and cancellations.
Stress is the high level of emotional arousal typically associated with an overload of mental and
physical activity. Stress is often associated with anxiety, fear, fatigue and hostility. It can also
arise as a result of feeling of inadequacy, where we may feel we don’t have the appropriate
experience, knowledge or capability to complete our allocated tasks. All these feelings can have
a direct and negative impact on an engineer’s performance [1].
Stress is an inevitable and necessary part of life. It can motivate us and heighten our response to
meeting the challenge we face. In fact, our performance will generally improve with the onset of

stress, but will peak and then begin to degrade rapidly as stress levels exceed our adaptive
abilities to handle the situation. High level of stress is a problem for maintenance team and it is
difficult to handle its consequences.
Any changes in personal circumstances such as divorce, marital separation, or financial concerns
can lead to stress and affect our emotional state. Then there is also work related stress, which
may include real or imagined commercial pressure, unattainable deadlines to get the aircraft on
line after maintenance, carrying out tasks that are new, or very challenging, lack of standard
procedures, lack of guidance or supervision and other related things will cause stress.
Workload or work overload occurs when there is a lot of work to be done and the individual’s or
team’s workload exceeds their ability to cope. As performance deteriorates, we are forced to
shed tasks and focus on key information. In these situations error rates may also increase.
Specific task allocation between maintenance team members can reduce the likelihood of one
person within the team being overloaded.
Time pressure, Aviation maintenance tasks require individuals to perform in an environment

with constant pressure to do things better and faster without making mistakes and letting things
fall through the cracks. Unfortunately, these types of job pressures can affect the capabilities of
maintenance workers to get the job done right [7].
Ethiopian Airlines have strict financial guidelines, as well as tight flight schedules, that forces
the mechanics to be under pressure and work loaded to identify and repair mechanical problems
quickly so that the airline can keep moving. Most of the aircrafts has no enough ground time
between flights.
Consequence of, stress, workload, and time pressure on maintenance technicians are:
 Poor judgment
 Loss of alertness
 Preoccupation with a single task at the expense of others
 Forgetting or omitting procedural steps
 Greater tendency towards missing things

 Misreading maintenance manuals and procedural steps

 Loss of time perception
 Loss of situational awareness
 Poor task planning
4.2.2. LACK OF COMMUNICATION
Communication is possibly the most important Human Factors issue in aircraft maintenance.
Without communication among maintenance managers, manufacturers, dispatchers, pilots, the
public, the government and others, safety standards would be difficult to maintain. In the
maintenance realm there is an enormous volume of information that must be created, conveyed,
assimilated, used and recorded in keeping the fleet airworthy [1].
Lack of communication is a key human factor that can result in incorrect or faulty maintenance.
Communication occurs between the AMT and many people (i.e., management, pilots, parts
suppliers, aircraft servicers). Each exchange holds the potential for misunderstanding or
omission. But communication between AMTs may be the most important of all.
Lack of communication between technicians could lead to a maintenance error and result in an
aircraft accident. This occurs in this airline, especially true during procedures where more than
one technician performs the work on the aircraft. It is critical that accurate, complete information
be exchanged to ensure that all work is completed without any step being omitted. Knowledge
and speculation about a task must be clarified and not confused. Each step of the maintenance
procedure must be performed according to approved instructions as though only a single
technician did the work [4].
Regardless of whether you work in a one person operation or a large organization, effective
communication is a critical part of maintenance work. Misunderstandings and communication
failures cost money, and at worst, can compromise safety. Clear communication can be the
difference between getting a job right the first time, or expensive re work; doing the job safety,
or injury to maintenance personnel; and of course, safe flight or aircraft accidents.
It is most important that maintenance information be understandable to the target audience. The
primary members of this audience are the inspectors and technicians who undertake scheduled

aircraft maintenance and diagnose and repair aircraft malfunctions. New manuals, service
bulletins, job cards and other information to be used by this audience should be tested before
distribution to make sure that they will not be misunderstood or misinterpreted.
4.2.3. PROFFESIONALISM (SKILL) AND COMPLACENCY
Professionalism is the underpinning character of the aircraft maintenance engineer. It is

combination of specialist skills, personal feelings and our attitude to the work we do. Aviation
maintenance safety depends on all those who perform the work required to enable aircraft to
operate, especially those involved in repairs and inspection to determine the airworthiness and
safety of the product, whether aircraft , engines or component [1].
A lack of knowledge when performing aircraft maintenance can result in a faulty repair that can
have catastrophic results. All maintenance must be performed to standards specified in approved
instructions. These instructions are based on knowledge gained from the engineering and
operation of the aircraft equipment. Technicians must be sure to use the latest applicable data and
follow each step of the procedure as outlined. They must also be aware that differences exist in
the design and maintenance procedures on different aircraft. It is important for technicians to
obtain training on different types of aircraft. When in doubt, a technician with experience on the
aircraft should be consulted [7]. If one is not available, or the consulted technician is not familiar
with the procedure, a manufacturer’s technical representative should be contacted. It is better to
delay a maintenance procedure than to do it incorrectly and cause an accident.
There are several factors that play into the cause of aircraft accidents and some of these factors
are known as human factors. The study of how humans can most efficiently interact with
technology is known as human factors. According to Boeing, the world’s largest aircraft
manufacturer, human error accounts for 70% of commercial airplane accidents. In order to
decrease the number of accidents caused by maintenance-related human factors, awareness and
training in the field of human factors is critical.
Complacency is a human factor in aviation maintenance that typically develops over time. As a
technician gains knowledge and experience, a sense of self satisfaction and false confidence may
occur. A repetitive task, especially an inspection item, may be overlooked or skipped because the

technician has performed the task a number of times without ever finding a fault. The false
assumption that inspection of the item is not important may be made. However, even if rare, a
fault may exist. When a technician finds him or herself performing work without documentation,
or documenting work that was not performed, it is a sign that complacency may exist.
But in case of this airline the company does not want to train all the technicians on specific
aircraft on which they perform, they think the technicians will left the airline for better job
abroad. In addition most of the technicians in the airline does not follow standard working
procedure and works everything by heart. And this will lead them to perform a wrong
maintenance action.
Effective aviation maintenance professionals demonstrate professionalism by their:
 Discipline: they follow approved procedure to perform a given task.

 Communication
 Teamwork: they work together well to resolve problems and maintain control
 Knowledge: they have a deep understanding of aircraft systems and their operation
 Expertise: they retain and transfer knowledge and skills.
 Situational awareness: they know what’s going on around them.
 Experience: they call upon prior training and knowledge to assess new situations.
 Decision making: they take decisive actions.
 Resource management: they allocate resources wisely.
 Goal prioritization: they prioritize safety above personal concerns.
4.2.4. FATIGUE
Fatigue is a threat to aviation safety because it can have a negative effect on performance.
Perhaps one of the most dangerous aspects of fatigue is that when we are fatigued, we are often
unable to recognize that we are fatigued, that our performance is deteriorating and that we should
act accordingly. For engineers, who are often shift workers, fatigue is an important issue.

The reduced performance caused by fatigue imposes a burden on the aviation industry not only
in terms of flight safety, but also in financial costs through delays, the need for re-work, and
other inefficiencies [1].
Certain conditions in the workplace can make the effects of fatigue more severe. These include:
 Low light, a work environment with low illumination reduces alertness and makes it
harder for a fatigued person to fight the urge to sleep. Maintenance and inspection tasks
performed beneath aircraft structures and within confined spaces pose difficult lighting
problems. The structure shades work points from area lighting and, similarly, cramped
equipment compartments will not be illuminated by ambient hangar lighting. Special
task lighting should be provided for these situations. Affordable portable lighting units
which can be positioned near work areas or attached to adjacent structures for the
performance of specific tasks are available in various sizes and ranges. The use of such
lighting systems could help alleviate some of the problems which may result from a
liveware-environment mismatch. [8]
 Passive activities, tasks that do not involve physical activity, or are performed while
seated, are more likely to be affected by fatigue.
 Boring tasks, tasks requiring continues monitoring or long tedious inspections tend to be
more susceptible to fatigue-related errors.
 Worm temperature, a fatigued person will find it even harder to stay alert if their work
environment is warm.
 Noise: Noise is another important work environment factor. Aircraft maintenance
operations are usually intermittently noisy due to activities such as riveting, machinery
operation inside hangars, or engine testing or run-up on ramps. Noise can cause speech
interference and can also have health implications. Loud or intense noise tends to result
in heightened response of the human autonomic nervous system. One of the results can
be fatigue. Perhaps more important is the effect of noise on hearing. Regular exposure to
loud noise can result in permanent hearing loss. Lower-intensity noise can cause
temporary hearing loss which can have safety implications in the workplace. Missed or
misunderstood communication resulting from noise interference or hearing loss can have
serious consequences. Actions that can be taken by operators to deal with noise problems

include controlling noise sources by enclosing or insulating machinery, isolating noisy

activities so that fewer people are exposed, providing workers with hearing protection
and requiring its use, reducing engine run-up or testing to the minimum acceptable and
measuring noise levels in work areas. Noise monitoring can identify where problems
exist, thereby enabling management to take corrective actions. The serious consequences
of noise exposure should be stressed so that the workers see the need for hearing
protection and for controlling noise wherever possible [8].
In this airline since the number of qualified technicians on specific aircraft are very small in
number, most technicians are forced to work for consecutive shifts, in addition with
uncomfortable working conditions. Also the management focuses only on on-time completion of
the task. It is very clear that fatigue cannot be eliminated, but the risks associated with it can be
managed through a partnership between employer and employees. Some of the causes of fatigue
originate with company policies and practice; for example, hours of work, workload, the extent
to which work is performed during the night, and the predictability of work schedules. Other
causes stem from the employee’s personal situation, including commuting time, sleep duration,
family and social responsibilities, and the demand of second jobs.
4.2.5. POOR LEADERSHIP & DECISION MAKING
Ideally a leader should have infinite flexibility. That means they can adopt their leader ship style
according to the situation and status of the team. Leadership is not power, authority, status and
management. Leadership is about helping to ensure that people will work safely, leaders
provides consistent feedback to people when they are doing the right kinds of things around
safety , they make safety meetings, they model safe behaviors in all they do, they balance
between production, quality and safety, and they celebrate successes [1] [18].
Aviation maintenance often requires the skills of a good leader in situations that present the
individuals and team with various challenges.
Ethiopian airlines technicians often work with different types of equipment, processes and
personnel. They deal with routine and non routine tasks, and regularly work with in controlled
schedules and ever present deadlines. Their work involves dealing with people within their own

organization, supplier and contractors, and in some cases, directly with the customer. These
conditions can sometimes lead to poor decisions, resulting in compromised safety.
Also Technicians confronted with unexpected situations when maintaining aircrafts. Few
industries have more constant pressure than aviation maintenance to get jobs done on time.
Various factors can shape the effectiveness of our decision making, such as our knowledge and
experience, communication effectiveness, stress, time pressure and fatigue.
 Previous experience and knowledge will shape the extent to which individuals are able to
know what information or feedback is relevant and how to make sense of it.
 The quality of communication used in order to gather information and inform your
decision will also affect the quality of decision making.
 Fatigue can affect cognitive performance, reducing the ability to fully process all
available information and increasingly the possibility that essential information is missed.
 Stress and time pressure may encounter individuals or teams.
4.2.6. LACK OF TEAM WORK
Aviation maintenance is based mainly on maintenance teams carrying out a great number of
tasks in cooperation with supporting management and regulatory structures. Effective teamwork
is especially important for aviation maintenance, because it can help to avoid breakdown in
communication, defuse conflict and coordinate activity.
Few maintenance workers work completely alone, and to perform their work successfully, they
must coordinate with other operational personnel. Coordination problems such as
misunderstandings, ineffective communication, and incorrect assumptions feature in many
maintenance incidents [8].
Successful teamwork is achieved when the output of the team is greater than the output that
could be achieved by the sum of the efforts of the individual team members acting in isolation.
Interaction between maintenance team members creates a positive environment, increasing
efficiency and productivity. This interaction is not usually occurring in this airline, unless all
individual members of the team fully understand their role within the group, and how this role
might vary depending on circumstances [1].

Consequently, good communications within the group; a high degree of situational awareness;
and a comprehensive understanding of the decision-making process by all members, are pre-
requisites for creating synergy and effective performance of the team as a whole. Sound
teamwork in aviation maintenance is a vital error management tool. There are many examples
where maintenance teamwork failures have been found to be major contributing factors in
aviation accidents.

4.3. FISHBONE DIAGRAM
Figure 4.6: Fishbone diagram of maintenance human error causes.

4.4. SUMMARY
The PEAR and SHELL model discussed in the literature part was the source and basic structure
of this thesis finding. The relationship of the two models and the human error producing
condition are described below as a summary.
Human Error Producing Conditions
Lack of Communication
L
P Lack of Team Work
Time Pressure
E Work Load E
PEAR SHELL
Model Fatigue Model
Boring Tasks
A Poor Decision
S
Poor Leadership
Poor Documentation
Lack of Proper tools
R H
Lack of proper Equipment
Figure 4.7: PEAR and SHELL model relationship with the Thesis finding.

CHAPTER FIVE
5. PROPOSED SOFTWARE DEVELOPMENT
5.1. INTRODUCTION
In the previous chapter different human factor that causes aircraft maintenance accidents and
incidents are discussed, and also different practical cases that are happened in the airline are seen.
This chapter tries giving solution to the causes of maintenance accidents.
The solution is to propose software that has different inputs. Before every technician is going to
perform a specific task, they have to login in this software and accept the task given to them.
5.2. ABOUT THE SOFTWARE

The software can assist the current working software used in the company. Currently for
performing the maintenance and other related tasks Ethiopian MRO uses Maintenix (MXi
Technologies Ltd). The current software in operation does not have any controlling mechanism.
Anyone who has given a user ID can perform any task on any aircraft without any limit. But the
designed software has different controlling mechanisms; its inputs are discussed below. The
designed software “Aircraft Maintenance Control” is not fully operational, in this thesis the
software is used only for demonstration.
The software was made by Visual studio.
5.3. ASSUMPTIONS OF SOFTWARE DEVELOPMENT
The software is planning to control the person who is assigned on the aircraft. It has the above
listed inputs about the technician. The following are the assumptions used
• The normal working hour is eight (8) hours, and if the technician exceeds 8 hours the
warning will come and will let him to exit.
• If it is required to work overtime the schedule of the technician will be edited with
authorization with his/her supervisor.

• Different skill levels have different capabilities, and if the software assumes he/she is
work loaded as per the skill level, the software will not let them do the job
• Every technician has his/her own password to login and perform the task.
• There is a quality control department which controls every data entry on the software
• The software retrieves the maintenance manual, forces the technician to read it.
• The Expiry date of every course is two years from the day it was taken.
• One person can be trained and work on different model aircrafts.
5.4. SOFTWARE INPUTS
5.4.1 SHIFT AND CLOCK IN TIME
The shift and also the clock in time of the technician has been loaded on a central server and
when the technician login to accept and performs the task it denies or let the technician to
perform a task. This identifies weather the technician assigned on a specific task is fatigued or
not. Fatigue is a major human factor that has contributed to many maintenance errors resulting in
accidents. Fatigue can be mental or physical in nature. Emotional fatigue also exists and effects
mental and physical performance. A person is said to be fatigued when a reduction or
impairment in any of the following occurs: cognitive ability, decision-making, reaction time,
coordination, speed, strength, and balance. Fatigue reduces alertness and often reduces a person’s
ability to focus and hold attention on the task being performed.
5.4.2 SYSTEM COURSE TAKEN
All maintenance must be performed to standards specified in approved instructions. These

instructions are based on knowledge gained from the engineering and operation of the aircraft
equipment. Technicians must be sure to use the latest applicable data and follow each step of the
procedure as outlined. They must also be aware that differences exist in the design and
maintenance procedures on different aircraft. It is important for technicians to obtain training on
specific types of aircraft on which he/she performs the task. This software has been loaded on
central server or retrieves the data from quality assurance department and when the technician
tries to perform on the aircraft he/she is not trained on; the software denies them to perform a
task.

5.4.3 SHORT TERM TRAININGS
The following short term trainings are given for aircraft maintenance technicians to help them to
perform their task safely. Those trainings are very useful, and given to maintenance technicians
every two years. But most technicians are not properly took those trainings on time, most of
them are expired but no one stops them from performing the task. The trainings are as follows;
 FUEL TANK SAFETY
It is a training given to every technicians to aware them about the safety that is needed while
working on the fuel tanks. Since fuel is very explosive great safety has be given. When working
on fuel tank, electrical wires have to be routed away from the tank and also any other materials
that causes explosive have to be given care. And this training helps them to remind the
precautions while working on the fuel tank.
 AVIATION REGULATION
Aircraft maintenance is highly regulated. The primary objectives of Federal Aviation

Regulations FAR’s are ensuring safe aviation procedures and programs. Besides protecting
aviation employees and the general public, FARs also protect the national security of the United
States. Aviation maintenance technicians seeking to work in the aviation industry will also need
to adhere to high safety standards. Since Ethiopian is following both American and European
every technicians has to follow standard procedures and rules while performing their task.
 LEGISLATION
This training was almost the same with FAR but it was intended for people under training to gain
authorisation to certify, to European Aviation Safety Agency (EASA) standards, the release to
service of aircraft or aeronautical maintenance or repair.
 EWIS (ELECTRICAL WIRE INSTALLATION SYSTEM)
This training helps the technician to route a safe way of electrical wires installation on the
aircraft. Since electrical wire is a source of fire if wrongly routed, great caution has to be given.

 HUMAN FACTOR
Human factors awareness can lead to improved quality, an environment that ensures continuing
worker and aircraft safety, and a more involved and responsible work force. More specifically,
the reduction of even minor errors can provide measurable benefits including cost reductions,
fewer missed deadlines, reduction in work related injuries, reduction of warranty claims, and
reduction in more significant events that can be traced back to maintenance error.
5.4.4 MAINTENANCE MANUAL
The software also retrieves a maintenance manual for the specific task that the maintenance
technician is going to work on. This lets the maintenance technician to follow a standard
procedure while performing their tasks. In addition the software has a pause on the maintenance
procedures, cautions and warnings and will not let them pass simply. This input helps the
technicians to follow standard maintenance manual while performing a task.
5.4.5 MAN POWER
The software has also ability to ask for additional man power by analyzing the scope and
workload of the task. In order to do that the senior technician who is assigned on the task has to
request other junior or senior technicians to work with. When he requested, the other technician
has to login and accept the request and see the procedures carefully. If not, the software will not
let you to precede the task. Also when the task is closed all technicians who assigned on the task
has to confirm for the senior who took the task. If the other technician who assigned on the
aircraft did not reply for the senior technician during completion the software denies completing
the task and considers the aircraft is not ready for dispatch. This input facilitates team work,
communication and avoids workload.
5.4.6 COMPLETION TIME
The software sets minimum completion time for different routine and non routine tasks and
different removal and installations. If the technician simply sits on the computer and tries to
close the task it denies the completion of the task. This helps weather the task is properly
performed on the aircraft or not. This helps to avoid poor decisions and wrong data’s.

CHAPTER SIX
6. CONCLUSION AND RECOMMENDATION
6.1. CONCLUSION
The aviation industry could not function without the contribution of maintenance personnel, yet
maintenance error is a significant and continuing threat to aviation safety. In the past,
maintenance errors were often viewed as nothing more than failures of individuals to perform
their assigned tasks, and organizations often responded with punishment or dismissal. There is
now worldwide recognition that maintenance errors reflect the interplay of personal, workplace,
and organizational factors. While maintenance technicians must still take responsibility for their
actions, managing the threat of maintenance error requires a system-level response.
In comparison to many other threats to aviation safety, the mistakes of maintenance personnel
can be more difficult to detect, and have the potential to remain latent, affecting the safe
operation of aircraft for longer periods of time. While acknowledging that maintenance
personnel are responsible for their actions, it must also be recognized that, in many cases, the
errors of maintenance technicians are the visible manifestation of problems with roots deep in the
organization. A careful examination of each error, combined with a preparedness to inquire into
why the error occurred, can help to identify underlying organizational problems.
to detail. The work requires good communication and coordination, yet verbal communication
can be difficult due to noise levels and the use of hearing protection. The work frequently
involves fault diagnosis and problem solving in the presence of time pressures, particularly at the
gate.
In the paper it was clearly stated that, time pressure and workload, lack of communication, lack
of team work, professionalism, lack of good decision making and fatigue are the main causes of

maintenance human factor that are observed in this airline. Also software that helps to minimize
the problems was developed. The software has different inputs about the person who perform
the task and other necessary parameters. And it will help to decrease the human related error if it
was applied.
6.2. RECOMMENDATION
Based on the major findings of the research the following recommendations are forwarded to the
Ethiopian MRO.
• The airline has to train its entire technician at least on one of its specific aircraft and
assign them according to their skills.
• The safety trainings have to be given without fail, before it expires.
• The airline has to monitor the environment of the work area and give immediate solution
for the observed human factor causes.
• The airline has to have necessary serviceable tools and parts on hand.
• It is necessary to conduct a detailed study for the causes of human factors
• If it will be applied, the proposed software controls technician from performing
maintenance error.
• It is also necessary to develop other controlling mechanisms by performing a detailed
analysis.
6.3. FUTURE RESEARCH AREA
This study was conducted in Ethiopian MRO and a new software model was developed, the
software was designed with limited inputs as compared with the vast majority of the causes of
human errors. There are a number of human error causes that resulted in accidents/incidents in
aviation maintenance; in this research all areas are not covered. In the future better software that
controls the maintenance activity can be designed. This paper can help as a starting point for
future reference for the researchers who are planning to perform in this specific area.

REFERENCES
1. Australian government, Civil Aviation Safety Authority, Safety Behaviors: Human
Factors for Engineers, ISBN978-1-921475-34-4, 2013
2. Department of Transportation U.S; FAA, Aviation Maintenance Technician Handbook,
chapter 14, 2008
3. ICAO, Human Factors in Aircraft Maintenance and Inspection Human Factors in Aircraft
Maintenance and Inspection ISBN 0 86039 836 6 , 2002
4. Colin G. Drury, Human Factors in Aircraft Maintenance, State University of New York
Department of Industrial Engineering, 342 Bell Hall Buffalo, NY 14260, USA, 2003
5. ICAO journal, Human Factors Guidelines for Aircraft Maintenance Manual, First
Edition 2003
6. Andrea M. Georgiou, The Effect of Human Factors in Aviation Maintenance Safety,
Middle Tennessee State University, 2009
7. TAKAHIRO SUZUKI, TERRY L. VON THADEN, WILLIAM D. GEIBEL, Influence
of time pressure on aircraft maintenance errors, University of Illinois, 2007
8. Australian government , Australian transport safety bureau, An overview of human factor
on aviation maintenance, Aviation Research and Analysis AR-2008-055, 2008
9. PEREZGONZALEZ Jose D [Ed] (2009) ICAO: fundamental human factors concepts,
SHELL model, Circular 216-AN31. ISSN 2324-4399), pages 4-7, 2012.
10. Kara A. Latorella, Prasad V. Prabhu , International Journal of Industrial Ergonomics, A
review of human error in aviation maintenance, Department of Industrial Engineering,
State University of New York at Buffalo, Buffalo, 161GA 30345, USA, 2011.

11. William Rankin, Rebecca Hibit, Jerry Allen, Robert Sargent, International Journal of
Industrial Ergonomics “Development and evaluation of the Maintenance Error Decision
Aid (MEDA) process Boeing Commercial Airplane Group, USA April 2013
12. User’s Guide Boeing, “Maintenance Error Decision Aid (MEDA)” Maintenance Human
Factors Boeing Commercial Aviation Services, Sep 2013
13. Daniel Kitaw “Industrial management and Engineering Economy.” Addis Ababa
University Press. 2009.
14. Deborah M. Licht and Donald J. Polzella “Human Factors, Ergonomics, and Human
Factors Engineering” Armstrong Aerospace Medical Research Laboratory, 2011
15. Health and Safety Executive, “Ergonomics and Human factor at work” A brief guide,
university of Massachusetts, 2010.
16. D.J Pennie and N. Brook-Carter “HUMAN FACTORS GUIDANCE FOR

MAINTENANCE” University of Birmingham, UK, March 2007.
17. U.S department of transportation, “Aviation maintenance technician handbook” Federal

Aviation Administration, 2012
18. Judith Orasanu and Lynne Martin “Errors in Aviation Decision Making: A Factor in
Accidents and Incidents” NASA-Ames Research Center, 2011
19. Robert Sumwalt, National Transportation Safety board, Board Member, “Human Error in
the Context of Accidents” Society of Experimental Test Pilots April , 2009
20. ZAHARIA Sorin Eugen and Florin NECULA “CAPTURING HAZARDS AND
ERADICATING HUMAN ERRORS IN AIRCRAFT MAINTENANCE” Polytechnic
University of Bucharest, Romania, 2015
21. Sonja Biede, HF Specialist “Airbus Human Factors Design Process” Airbus France
Engineering, April 2014.
22. www.ethiopianairlines.com , 12 Sept, 2016

APPENDIX I
THE MEDA RESULTS ANALYSIS FORM
Section I. General Information

Reference #_________________________ Interviewer’s Name__________________
Airline_____________________________ Interviewer’s Tel. #___________________
Station of maintenance Failure__________ Date of Investigation__________________
Aircraft type________________________ Date of Event________________________
Engine type_________________________ Time of event________________________
Reg. #_____________________________ Shift of Failure______________________
Fleet Number_______________________ Type of Maintenance, Circle one
ATA #_____________________________ 1. Line, type____________________
Aircraft Zone_______________________ 2. Base, type____________________
Ref. # of previous related event_________
Section II. Event

Please select the event (Check all that apply)
1. Operational Process Event
( ) a. Flight delay. ____days ____hrs ____mints
( ) b. Flight Cancellation
( ) c. Gate Return ( ) 2. Aircraft Damage event
( ) d. In Flight shut down ( ) 3. Personal Injury Event
( ) e. Air Turn Back ( ) 4. Rework
( ) f. Diversion ( ) 5. Other Event (Explain Below)
( ) g. Other (Explain Below)
Describe the incident/degradation/failure (e.g., could not pressurize) that caused the event.

Section III. Maintenance Error
1. Installation Error ( ) 3. Repair Error (e.g., component 7. Personal Injury Error

( ) a. Equipment/part not or structural repair)
installed structural repair) ( ) a. Slip/trip/fall
4. Fault Isolation/Test/Inspection
( ) b. Wrong equipment/part Error ( ) b. Caught in/on/between
installed
( ) a. Did not detect fault ( ) c. Struck by/against
( ) c. Wrong orientation
( ) b. Not found by fault ( ) d. Hazard contacted
( ) d. Improper location isolation (e.g., electricity, hot or cold
surfaces, and sharp
( ) e. Incomplete installation ( ) c. Not found by surfaces)
operational/functional
( ) f. Extra parts installed ( ) e. Hazardous substance
( ) d. Not found by exposure (e.g., toxic or
( ) g. Access not closed
inspection noxious substances) ( ) a.
( ) h. System/equipment not Not enough fluid
( ) e. Access not closed
( ) i. Damaged on installation ( ) f. Hazardous thermal
( ) f. System/equipment not environment (heat, cold, or
( ) j. Cross connection deactivated/reactivated humidity)
( ) k. Other (explain below) ( ) g. Other (explain below) ( ) g. Other (explain below)

5. Foreign Object Damage Error
2. Servicing Error ( ) a. Material left in ( ) 8. Other (explain below)

( ) a. Not enough fluid aircraft/engine
( ) b. Too much fluid ( ) b. Debris on ramp
( ) c. Wrong fluid type ( ) c. Debris falling into

open systems
( ) d. Required servicing not
performed ( ) d. Other (explain below)
( ) e. Access not closed
( ) f. System/equipment not
deactivated/reactivated
( ) g. Other (explain below)

Describe the specific maintenance error (e.g., auto pressure controller installed in wrong location).
Section IV. Chronological summary of the Event

Includes how some contributing factors lead to additional contributing factors.
Section V. Summary of Recommendations

Section VI. Contributing Factors Checklist

This checklist will help the analyst identify the contributing factors that contributed to the system
failure. [Remember, if two or more systems failures combined to cause the event, it is important to
identify which factors relate to which system failures.] There are ten major categories of contributing
factors in the checklist:
1. Information 2. Ground support equipment, tools, and safety
o Not understandable equipment
o Unavailable/inaccessible o Unsafe
o Incorrect o Unreliable
o Too much/conflicting information o Layout of controls or display
o Out of calibration
o Update process is too long/complicated
o Unavailable in stock
o Incorrectly modified manufacturer's MM/SB
o Inappropriate for the task
o Information not used
o Inadequate o Cannot use in untended environment
o uncontrolled o No instructions
o Too complicated
o Incorrectly labeled
o Not used but available
o Incorrectly used
o Inaccessible
o Past expiration date
3. Aircraft design, configuration, parts, equipment, 4. Job or task
and consumables o Repetitive
o Complex o Complex/confusing
o Inaccessible o New task or task change
o Aircraft configuration variability o Different from other similar tasks
o Parts/equipments unavailable
o Parts/equipments incorrectly labeled
o Easy to install incorrectly
o Not used, using interchangeable part
o Not user friendly
o Consumable unavailable, or expired

5. Knowledge and skills 6. Individual factors

o Technical skills o Physical health
o Task knowledge o Fatigue
o Task planning o Time pressure
o Airline process knowledge o Peer pressure
o Aircraft system knowledge o Complacency
o English language proficiency o Body size/ strength
o Team work skills o Personal event
o Computer skills o Task distraction/interruptions
o Memory lapse
o Visual perception
o Assertiveness
o Stress
o Situational awareness
o Work/task saturation
7. Environment and facilities 8. Organizational factors

o High noise o Quality of support from technical
o Hot organization
o Cold o Company policies
o Humidity o Not enough staff
o Rain o Corporate change/restructuring
o Snow o Union action
o Lighting o Work process and procedure not
o Wind followed
o Vibration o Team building
o Cleanliness
o Hazardous/toxic substances
o Power sources
o Inadequate ventilation
o Markings
o Labels/placards
o Confined space
9. Leadership and supervision 10. Communication

o Planning/organization of tasks o Between departments
o Prioritization of work o Between mechanics
o Delegation/assignment of tasks o Between shifts
o Unrealistic attitude/expectation o Between maintenance crew and lead
o Between flight crew and maintenance
o Amount of supervision

APPENDIX II
KEY POINTS FOR MEDA INTERVIEW AND SIX RULES OF CAUSATION
I. Interviewing Outline
1. Introduction at start of interview, develop good rapport.
a) Introduce self/team
b) Tell them why you are doing this interview.
c) Ask what they know about the MEDA process. Explain to them the MEDA
philosophy.
d) Say something like, “You are the person who knows all of the important
information. So, you will be doing most of the talking. I will be asking you some
questions, but I would like you to volunteer information whenever you think of it,
tell me about the event in your own words, and be as specific as possible. You can
ask me questions at any time. OK?”
2. Ask for a general account of the task/event
a) Say something like, “What I would like is for you to tell me the sequence of
events as you remember them. Start from wherever you think is relevant. Before
starting, just try to put yourself back in the same situation. Do not say anything
yet—just think about the situation that you were in.”
b) After 5 to 10 seconds, say something like, “OK, would you please tell me
everything that you can remember.”
c) While they are talking, listen for them to mention contributing factors. Write this
information down on the MEDA form or on a blank piece of paper.
3. Ask for detailed accounts of parts of the task/event.
a) Use the paraphrase (I think I heard you say that…) and open-ended questions
(can’t be answered “yes” or “no”), to ask for more detailed information about
potential contributing factors brought up during the interviewee’s general account
of the task/event.
b) Ask about other MEDA contributing factors categories that were not mentioned
during the general account.
c) Review your understanding of everything that you have heard.

d) Deal with minor discrepancies here.

e) Get the interviewee’s input on how to improve the contributing factors that were
uncovered during the interview.
4. Background information
a) Collect background information, especially from witnesses to the event.
5. Conclusion
a) Make sure that you and the team have asked all of your questions.
b) Deal with large discrepancies here.
c) Provide a positive ending.
6. Post-interview evaluation and follow-up
a) Finish your paperwork
b) Call the interviewee back if you have any questions.
II. General Principles of Interviewing

1. Minimize distractions during the interview.
2. Develop and maintain good rapport—Avoid arguments, judgmental comments, and criticism.
3. Respond to their statements in a positive manner. Say such things as,
a. “I know what you mean.”
b. “I have done that myself”
c. “Sometimes those procedures are hard to understand and follow.”
d. “I agree with you that are an error-prone task.”
4. Do NOT asking “leading” questions like?
a. “At that point you probably asked for help, didn’t you?”
b. “Then you probably did…”
5. Do NOT say things that would put the interviewee on the defensive, such as:
a. “You did WHAT?!?”
b. “I can’t believe that you did that.”
c. “You didn’t use the calibrated tool for that task?”
d. “A good mechanic/engineer would not have done that.”
6. Try NOT to ask questions that can be answered with a simple “yes” or “no” response.
7. Go into the interview with no biases regarding culpability/blame.

III. Rules of Causation

1. Each human error must have a preceding cause.
2. Each procedural deviation (violation) must have a preceding cause.
3. Causal statements must clearly show the “cause and effect” relationship.
4. Negative descriptors (such as poorly or inadequate) may not be used in causal statements.
5. Failure to act is only causal when there is a pre-existing duty to act.
6. Causal searches must look beyond that which is within the control of the investigator.

APPENDIX III
QUESTIONER DATA COLLECTION DEVICE:
My name is Getnet Bacha and I am doing my thesis with a title “Aviation Maintenance Human
Error Identification and Management” for completing my Masters degree in Industrial
engineering from Addis Ababa University Institute of technology. So the following discussion
points are prepared for you to answer, which helps me a lot in doing my thesis.
Thank you for your time and help. If you would like an executive summary of my findings,
please provide your name and address below (your personal information will not be used nor
reflected in my report):
Name: _________________________________________________________________
Address: ________________________________________________________________
________________________________________________________________________
Getnet Bacha
HUMAN FACTORS MANAGEMENT SURVEY

Personal Details
Name Years in >20years 10-15 Years <10years Job
(Optional) Organization Description
Rank: HFIM Poor Average Good Excellent Involved in Y/N
Awareness maintenance
Human Factors (HF) Fact:
U.S. statistics indicate that 80% of aviation accidents are due to human errors with 50% due to
maintenance human factor problems. Most programs currently implemented are designed to identify the
HF errors, educate the personnel on their causal potential, suggest ways to contain and correct the
problem; and create a HF error-free environment. However, HFIM errors are still on the rise today.

Please mark your response in boxes

Strongly Agree Strongly Disagree
6 5 4 3 2 1
1. Human Factors Programs
1.1 There is a structured Human Factors Program in your
Maintenance Department?
1.2 If yes, how many years has it been in existence? >10years 5-10years <5years
1.3 If no, is it important to have one?
2. Human Factors Management
2.1 The HFIM programs currently implemented have improved the
management of human factor errors in your organization?
2.2 The training and tools currently available in your organization
are sufficient to manage HFIM?
2.3 More needs to be done to manage HFIM errors in maintenance?
3. Most Common Outcome of Safety Occurrences (check all that apply)
3.1 In your opinion, which of these are the most common outcomes of HFIM safety occurrences?
o Incorrect assembly or orientation of part
o Injury to personnel
o Tool lost on aircraft / in maintenance facility
o Part/aircraft damaged during repair
o Material left on aircraft
o System operated unsafely during maintenance
3.2 The most likely reason for the occurrence of these outcomes
o Time Pressure
o Fatigue and Workload
o Professionalism and Skill
o Complacency
o Environment
o Lack of training
o Supervision and Decision
o Lack of equipment
o Environment
o Lack of Team work and communication
3.3 In your opinion, HFIM errors can be managed better by reviewing it’s
o Leadership
o Processes Improvement
o Management of information
o Organizational culture (not just safety)
o Attitudes of personnel
o Training effectiveness

4. Do you have any additional comments or suggestions to improve or reduce HFIM

management/errors?
Thank you for your time.

Getnet Bacha
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HUMAN ERROR IDENTIFICATION AND MANAGEMENT IN AVIATION

Book · March 2016

Kassu Jilcha Daniel Kitaw

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HUMAN ERROR IDENTIFICATION AND MANAGEMENT IN

By: Getnet Bacha

A Thesis Submitted to Addis Ababa University Institute of Technology,

Advisor: Professor Daniel Kitaw

SCHOOL OF MECHANICAL AND INDUSTRIAL ENGINEERING,

“HUMAN ERROR IDENTIFICATION AND MANAGEMENT IN

Getnet Bacha ____________________ _____________________

Student Name Signature Date

Approved by Board of Examiners:

1. _______________ ____________________ _____________________

Chairman, SMIE Signature Date

2. Professor Daniel Kitaw ____________________ ____________________

Supervisor Signature Date

3. Mr. Kassu Jilcha ____________________ ____________________

Co-Advisor Signature Date

4. Dr. Ir. Eshetie Berhan _____________________ _____________________

Internal Examiner Signature Date

5. Dr. Shewit Woldegebriel ____________________ _____________________

External Examiner Signature Date

Getnet Bacha Date

Professor Daniel Kitaw (Advisor) Date

Mr. Kassu Jilcha (Co-Advisor) Date

AAiT School of Mechanical and Industrial Engineering Page i

AAiT School of Mechanical and Industrial Engineering Page ii

AAiT School of Mechanical and Industrial Engineering Page ii

CONTENTS ............................................................................................................................................... iii

LIST OF TABLE ....................................................................................................................................... vi

LIST OF FIGURES .................................................................................................................................. vii

LIST OF ACRONYM.............................................................................................................................. viii

1. INTRODUCTION AND BACKGROUND ........................................................................................... 1

1.1. INTRODUTION ....................................................................................................................... 1

1.2. PROBLEM FORMULATION AND IDENTIFICATION ....................................................... 2

1.3. OBJECTIVE ............................................................................................................................. 5

1.4. SCOPE AND LIMITATION OF THE PAPER ........................................................................ 5

1.5. SIGNIFICANCE OF THE RESEARCH PAPER ..................................................................... 6

1.6. ORGANIZATION OF THE PAPER ........................................................................................ 6

2. LITRATURE REVIEW ..................................................................................................................... 7

2.1. INTRODUCTION .................................................................................................................... 7

2.2. DEFINITION OF HUMAN FACTOR ..................................................................................... 8

2.3. ELEMENTS OF HUMAN FACTORS ..................................................................................... 9

2.4. HISTORY OF HUMAN FACTORS ...................................................................................... 13

2.5. THE PEAR MODEL .............................................................................................................. 15

2.6. SHELL MODEL ..................................................................................................................... 20

2.7. ERROR AND ERROR MANAGEMENT.............................................................................. 24

2.8. SUMMARY AND GAPS IDENTIFIED ................................................................................ 26

3.1. INTRODUCTION .................................................................................................................. 29

3.2. PRIMARY DATA .................................................................................................................. 29

AAiT School of Mechanical and Industrial Engineering Page iii

3.3. SECONDARY DATA ............................................................................................................ 30

3.4. PROPOSED SOFTWARE ...................................................................................................... 30

3.5. RESEARCH METHODOLOGY FRAME WORK ................................................................ 32

4. DATA ANALYSIS AND FINDING ................................................................................................ 33

4.1. DATA ANALYSIS ................................................................................................................. 33

4.1.1. INTERVIEW ANALYSIS USING MEDA ........................................................................ 33

Getnet Bacha _

1. _ _______

2. Professor Daniel Kitaw

3. Mr. Kassu Jilcha

4. Dr. Ir. Eshetie Berhan _ _

5. Dr. Shewit Woldegebriel _