new practices and technologies to increase capacity to manage risk and Human Factors with success

1
Trends in Aviation Industry A perspective to
understand Human Factors requirments for
Accident analsysis and Auditing D. Baranzini -
MAHB
new practices and technologies to increase
capacity to manage risk and Human Factors with
success
2
JAR-145 HUMAN FACTORSThe Regulation
Requirements

• Organisations must be in compliance by 1 July
  2005 (amended to 28 November 2006 by Part 145)
• The JAA have published a course syllabus
• The National Aviation Authority (NAA) will not be
  approving the course content
• Adapted from a presentation by
• David Hall
• Deputy Regional Manager Heathrow
• david.hall_at_srg.caa.co.uk

3
Training Syllabus for Initial Human Factors
Training (Appendix 9)

• General / Introduction to human factors
• Safety Culture / Organisational factors
• Human Error
• Human Performance Limitations
• Environment
• Procedures, Information, Tools and Practices
• Communication
• Teamwork
• Professionalism and integrity
• Organisations HF Program

4

• some problem statements

5
1 HF at business level

• A recent ADAMS 2 survey concluded that
  approximately 50 of the check and crew managers
  time was spent correcting or dealing with issues
  that should have been dealt with prior to the
  arrival of the aircraft, or by the support areas
  during the aircraft visit

Source Base Maintenance Discussion Paper 14-07-06
6
Source Base Maintenance Discussion Paper 14-07-06
1 HF at business level

• This equates to 5 of the total labour cost in
  aircraft overhaul. Even if it is only 50
  accurate it still represents a substantial sum
  900.000 Euro approx

7
2 HF at groups level

• Hangar teams depend by the support they receive
• This is a problem of configuration of resources
  (human and technical resources).

8
Most influential Areas of inefficiency impairing
check operations - large site North
Europe (Middle/Top Management internal survey,
Feb-2003)
65.5
34.4
9
3 HF for technicians
10
Recording operational conflict
Team checklist ACROSS all ZONES today
(xx-12-04)

Check Profile
11
Some key points

• A HF problem is operationally relevant when the
  technical process is affected establish the
  relation

12
Does HF relate to Tech?
COMMUNICATION
LATES
13
key points

• HF problems are opportunities to understand
• Sequence of technical processes may define
  priorities to invest in HF

14
upstream failures make downstream disasters real !
A common scenario
NO CO-ORDINATION
DELAY
further conflicts, delays
Where do you invest?
15

• Check Process Profiling
• WHERE is the HF in the process

16
IMMS critical HF affecting the Operation
Header
Primary Task Toolbar
IMMS
HOME
HELP
LOG OUT
PREFERENCES
EDITOR
ANALYSER
Navigation Path
Process Level
Operation level
Tree
HANGAR
Task level
TODAY Highest concentration HF
Tree Toolbar
SAVE
CANCEL
User Name
10.03 AM
HOME gt HHA
Status bar
17

• Integrating Tech. and HF data
• Understand check profile

18
PAGE LAYOUT
Header
Primary Task Toolbar
IMMS
HOME
HELP
LOG OUT
PREFERENCES
EDITOR
ANALYSER
Navigation Path
Tech. KPIs
Manpower effort check XY
SecondaryTask Toolbar
Tree
Contents Area
Tree Toolbar
Always consider WHAT is the technical failure and
WHERE the HF is located
SAVE
CANCEL
User Name
10.03 AM
HOME gt HHA
Status bar
19
IMMS Interfaces for Strategic
ManagersDept. Managersbusiness and benchmarking
20

• Bechmarking
• Is HF and Technical KPIs related?

21
IMMS critical HF affecting the Operation
Header
Primary Task Toolbar
IMMS
HOME
HELP
LOG OUT
PREFERENCES
EDITOR
ANALYSER
Navigation Path
Process Level
8 Worst cases
Locate HFs
Multiple checks
Tree
Tree Toolbar
SAVE
CANCEL
User Name
10.03 AM
HOME gt HHA
Status bar
22
PAGE LAYOUT
Header
Primary Task Toolbar
IMMS
HOME
HELP
LOG OUT
PREFERENCES
EDITOR
ANALYSER
Navigation Path
KPIs
Cross Check variance 2002
SecondaryTask Toolbar
Tree
Contents Area
Tree Toolbar
SAVE
CANCEL
User Name
10.03 AM
HOME gt HHA
Status bar
23
Trends of daily Planned versus Spent m/hrs in 8
checks of 2002 (recovery figure in reported
after the check label)
what problems that week ???
Week 12 (EI-CDF)
24
IMMS
HF constraints
1
2
3
4
5
HF Traceability Week 12 (EI-CDF) E-questionnaire
(VC/Pamela output)
Operational plans and decisions were defined
plans were communicated and acknowledged -
everybody understands operational plans and what
will be happening
Plans States
Importance of task re efficiency / safety
criticality is communicated and acknowledged
everybody importance of the task (e.g. task is
the lead item on the check)
Task Priority
Tasks and activities are communicated and
acknowledged
everybody aware of their role and
responsibilities and knows what to do
Task allocation
Strategies for anticipation of problem situations
are prepared
Possible delays/problems are identified and
contingencies are in place
Anticipation
Tech HF integration
1
2
3
4
5
Poor Observed performance had safety implications
Marginal Observed performance was barely adequate
Good Observed performance was effective
Outstanding Observed performance was truly
noteworthy
Not observed
User Name
HOME gt ADMIN HOME gt USER MANAGEMENT
25

• ..Aggregate data

26
HF competence
Co-ordination
Trust levels
27
Stats and aggregate data do not tell you the
entire story!!
28
HF opportunity over 121 C checks, 2002
HF Opportunity relationship between HF and
Technical data
29
Well thenHow to support Managers with IMMS
data?
30
HF opportunity over 121 C checks, 2002
GATE 2
GATE 1

• Managers could target the most influential
  leverage points according to the process (MCO
  principle)

GATE 3
31
Address any first signal to the left!
high
Impact on KPI
medium
low
GATE 1
GATE 2
GATE 3
HF problems entry
32

• Different velocities
• Real time indicators daily warnings support to
  technicians and supervisors (e.g., oversubscribed
  tasks)
• Short-terms indicators weekly/monthly HF from
  operation managers (capacity management)
• Long-terms indicators dedicated HF tools
  (strategic configuration management )

33

• in practice?

34
Tech. peak
HF peak
BACK
35
Suggestion

• Process Industries demands a process perspective
  to understand Human Factors traceability in
  accident events
• Causal orders of dependencies are telling us
  where to invest in Human Factors
• Lesson learned from accidents reveal richer
  picture than before