Investigasi Kecelakaan Pesawat Terbang

SEMESTER VII/3SKS/ TP45060

Oleh:

Ir. Prasetyo Edi, MSc., PhD.

PROGRAM STUDI TEKNIK DIRGANTARA FAKULTAS

TEKNOLOGI KEDIRGANTARAAN INSTITUT
TEKNOLOGI DIRGANTARA ADISUTJIPTO
YOGYAKARTA
Tahun 2021/2022
HUMAN FACTOR
IN
AVIATION SAFETY
 4.5. Causes of Human Factor Error

Civil airline industry usually uses "Dupont's

Dirty Dozen" to categorize human errors

1) Lack of Communication 7) Lack of Resources

2) Lack of assertiveness 8) Pressure
3) Complacency 9) Lack of knowledge
4) Distraction 10) Stress
5) Lack of Teamwork 11) Lack of Awareness
6) Fatigue 12) Norms
 Causes of Human Factor Error

1) Lack of Communication
Communication is the process of exchanging information from one party
to another. Lack of communication represents a lack of clear direct
statements and good, active listening skills. In aircraft maintenance
LACK OF GOOD COMMUNICATION can be seen mostly in the
following forms:

• Inadequate usage of manuals

• Non-standard hand signals
• Insufficient communication between the shifts or teams
 Causes of Human Factor Error

2) Lack of assertiveness
Assertiveness : The genuine, complete & direct
communication of facts, ideas & needs. Briefly, it is
telling the truths, facts or problems that you are facing
honestly.

assertive : disposed to or characterized by bold or confident statements and behavior <an assertive
leader>
 Causes of Human Factor Error

3) Complacency
Complacency means not paying attention what you are
doing.

Complacency is the result of three main factors:

• Fatigue,
• Too many things happening simultaneously, and
• Too few things happening.

Fatigue affects one’s ability to pay attention.

 Causes of Human Factor Error

4) Distraction
Distraction is the situation where your attention is
drawn away.
 Causes of Human Factor Error

5) Lack of Teamwork
Lack of working together to achieve a common goal.

Potential ways to improve team-working are:

• Discuss what, who and how a job is to be done.
• Be sure that everyone understands and agrees.
 Causes of Human Factor Error

6) Fatigue
Weariness from labor or nervous exhaustion which may
result in temporary loss of power to respond.

Potential solutions for fatigue problem are:

• Sleep and exercise regularly
• Ask others to check your work
 Causes of Human Factor Error

7) Lack of Resources
Lack of resources means failure to obtain or use the
appropriate tools, equipment, information and the
procedures for the task at hand. (Such as not having
enough spare parts, not having an equipment to do a job,
etc.)
 Causes of Human Factor Error

8) Pressure
Pressure is a situation which creates a sense of urgency
or haste. In aviation, particularly time pressure affects
the flight crew or maintenance people.
 Causes of Human Factor Error

9) Lack of knowledge
It represents lack of experience or training in the task at
hand.

Potential solutions may include providing

engineers/technicians with:
• Training on type of aircraft
• Use of Up-to-date manuals
 Causes of Human Factor Error

10) Stress
Stress is mental, emotional or physical tension, strain, or
distress.

Potential solutions are:

• Be aware how stress can affect the work
• Take short break
 Causes of Human Factor Error

11) Lack of Awareness

It represents the lack of ability to maintain awareness of
what is happening around as well as the primary task.

Potential solutions may include:

• Think of what may occur in the event of an accident
• Ask others if they can see any problem with the work
done.
 Causes of Human Factor Error
12/10/2014 17/10/2016
12/3/2017

12) Norms
Norms are informal work practices or unwritten rules
that are accepted by the group. Norms fall into two
categories:
• Positive norms
• Negative norms
Positive norms have an overall positive effect on the organization.
Example: Checking all nuts by hand after the job is done

Negative norms have a negative effect on the organization and have the potential to
cause errors. These types of norms are unsafe. We act in accordance with them
because they generally save us time and steps, and get the job done faster.
Example: Completing the job from memory
 4.6 Human Factors in Aircraft Maintenance and Inspection

Why do we need to study human factor in

maintenance?
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 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 net.
 4.6 Human Factors in Aircraft Maintenance and Inspection

There is no question that human error in aircraft

maintenance and inspection has been a causal factor in
recent air carrier/military accidents. Whenever humans are
involved in an activity, human error is a certain sequel.

According to statistics, the number of maintenance concern

accidents and incidents to public transport and military
aircraft has increased significantly.
 Why do human errors increase
in maintenance operations?
There are many possible reasons for the dramatic increase in
human errors in aircraft maintenance, but the following three are
the most referred ones:
• The reliability of mechanical and electronic components
has increased markedly over the past thirty years.
People have stayed the same.
• Aircraft have become more automated and more
complex. The current generation of Boeing 747-400s
and Airbus A340s has duplicated or triplicated flight
management systems. This may have reduced the
burden on the flight crew but it has placed a greater
demand on aircraft maintenance technicians.
• Increased aviation system complexity, tight flight
schedules put increased pressure and demands upon
maintenance
 4.6 Human Factors in Aircraft Maintenance and Inspection

Traditionally, Human Factors studies have been directed towards

flight crew performance (and, to a lesser extent, towards the
performance of air traffic controllers). As a result of this, various
methods (Crew Resource management, HFACS, etc) have been
developed and adapted to address safety and teamwork issues in
the cockpit. Until recently, there was a little consideration of the
Human Factors issues which are related to aircraft maintenance
personnel who inspect and repair aircraft.

This has been a serious oversight, since it is quite clear that human
error in aircraft maintenance has indeed had as dramatic an
effect upon the safety of flight operation as the errors of pilots
and air traffic controllers.
4.6 Human Factors in Aircraft Maintenance and Inspection

There is at present a growing awareness of the importance

of Human Factors issues in aircraft maintenance and
inspection.

The safety and effectiveness of airline operations are also

becoming more directly related to the performance of
the people who inspect and service the aircraft fleets.
 What are the human errors
made in maintenance
operations?

Errors in maintenance may be in two forms:

Errors resulting in aircraft discrepancy

• An error that results in a specific aircraft problem that
was not there before the maintenance task was initiated.
(Ex: failure to remove a protective cap from a hydraulic
line before reassembly, incorrect installation, etc.)

Errors resulting in unsafe condition

• An error that results in an unwanted or unsafe condition
remaining undetected while performing a maintenance
task designed to detect aircraft problems, i.e. something
is missed. (Ex: a structural crack unnoticed during a
visual inspection task)
 Top 8 maintenance errors

Studies indicate that the leading maintenance

errors may be listed as follows:

1. Incorrect installation of components

2. The fitting of wrong parts
3.Electrical wiring discrepancies (including cross
connections)
4. Loose objects (tools, etc.....) left in aircraft
5. Inadequate lubrication
6.Cowlings, access panels and fairings not secured
7.Fuel/oil caps and refuel panels not secured
8.Landing gear ground lock pins not removed before
departures
4.6.3 Characteristics of Human Error
in the Maintenance Environment

There are unique characteristics which shape human error in the

maintenance environment differently than in other operational
environments, such as the flight deck or the ATC room.
Followings are some of them.
• Pilot or ATC controller’s error is “REAL TIME” error. Pilot and
controller see the effect of their error. These people are always at
the scene at the time of accident. But, Maintenance error can not
be identified at the time of error made.

• It is not easy to identify “why maintenance error is made”. But,

cockpit voice recorders, flight data recorders, control tower tapes
provides information why pilot or controller makes error.

• Human factor issues are different for maintenance people and

pilots or controllers because of the content of their works.
 Differences between Flight crew and Maintenance
crew human factor considerations
Flight Crew
Human error
Errors tend to be ‘active’ in that their
consequences follow on immediately
after the error.
Communication
Much of flight operations are
characterised by “face-to face”
communications, or immediate voice
communications (e.g. with ATC) over
the radio. It has verbal nature.
Maintenance Crew
The consequences of an engineer’s error
are often not immediately apparent
(latent)
Maintenance operations tend to be
characterized by communications such
as technical manuals, memos,
Advisory Circulars, Airworthiness
Directives, workcards and other non-
immediate formats. Much of the
information transfer tends to be of a
non-verbal nature.
 Differences between Flight crew and Maintenance
crew human factor considerations
Team composition
Flight crews are mostly homogenous by
nature, in that they are similar in
education level and experience, relative to
their maintenance counterparts.
MRM =
Teamwork
MAINTEN
Flight deck crew team size is small – two
or three members; although the wider
team is obviously larger (i.e. flight deck
crew + cabin crew, flight crew + ATC,
ground crew, etc.)
Maintenance staff are diverse in their
range of experiences and education and
this needs to be taken into account in a
MRM programme.
ANCE RESOURCE MANAGEMENT
Maintenance operations are
characterised by large teams working
on disjointed tasks, spread out over a
hangar. In addition, a maintenance task
may require multiple teams (hangar,
planning department, technical library,
management) each with their own
responsibilities. Therefore MRM places
equal emphasis on inter-team teamwork
skills.
 Differences between Flight crew and Maintenance
crew human factor considerations

Situational awareness
The flight environment is quickly
changing, creating conditions for
active failures. Situation awareness in
CRM is tailored to avoid these errors
The maintenance environment changes
slowly relative to flight operations. In
terms of situation awareness, engineers
must have the ability to extrapolate
the consequences of their errors over
hours, days or even weeks.

CRM = Crew Resource Management = Cockpit Resource Management

Leadership 24/9/2012 2/3/2013

Similar to teamwork issues, leadership Maintenance engineer leaders must be

skills in CRM often focus mainly on
intrateam (within the team)
behaviours or ‘how to lead the team’.
Interteam (between teams) interaction
is somewhat limited during flight.
skilled not only in intra-team
behaviours, but in handling team
‘outsiders’ (personnel from other
shifts, managers outside the immediate
workgroup, etc.) during any phase of
the maintenance problem.
 4.6 Control of Human
Errors

On the understanding that errors are normal in human behavior,

the total elimination of human error would be an unrealistic
goal. The challenge then is not merely to prevent errors, but to
learn to safely manage the inevitable errors.

Three strategies for managing human errors are briefly

discussed below. Such strategies are relevant in flight
operations, air traffic control or aircraft maintenance.

• Error Reduction
• Error Capturing
• Error Tolerance
 Control of human
errors

• Error Reduction
Error reduction are the activities directed at the source of the error
to reduce or eliminate the contributing factors to the error. Examples:
- Minimizing error in employee selection
- Controlling of operating environment (physical, procedural, etc)
- Provide better training
- Use of monitoring/alerting systems
• Error Capturing
• Error Capturing assumes the error has already been made. Its purpose
is to capture the error before any adverse consequences of the error
are felt (Example: functional checks of equipments)
• Error Tolerance
• Error Tolerance refers to the ability of a system to accept an error
without serious consequence. (Example : Usage of multiple hydraulic
systems in aircraft)
Conclusion

Know your people

Enforce rules
Be Approachable
Be Proactive
Use outside Help