Dirty Dozen Human Factors Aviation Maintenance

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The "Dirty Dozen" in Aviation Maintenance -

Explanations Safety nets available

Caption says "I guess day shift can finish Communicate, to remove doubt.
screwing on the panel." Discuss w ork to be done and w hat
Lack of com m unication is depicted as has been completed to the one taking
the w orker is going to leave the panel of over from you.
an aircraft unfinished w ithout Never assume anything, alw ays
communicating this to the next w orker in check.
any w ritten or verbal form, assuming that
the next w orker know s w hich part of the
aircraft is left unfinished.

Caption says "I've looked back there 1,000


times and never found anything wrong."
Complacency is depicted w hereby a
maintenance personnel has finished
signing an inspection sheet w hilst telling Train yourself to expect to find a fault
himself that he has checked at the aircraft and to consistently look out for these
part a thousand times w ithout ever faults or hazards.
finding anything w rong; Never sign for anything you didn't
This is despite the fact that a component do.
of the aircraft has a spoilt cable. Never assume anything, alw ays
Hence, by performing a routine task over check.
and over again, overconfidence due to
increasing proficiency could lead lead to
complacency setting in and errors in
judgment can appear.
The "Dirty Dozen" in Aviation Maintenance -
Explanations Safety nets available

Caption says "This is the third one to bend!


What's going on?"
Lack of knowledge is depicted in w hich a
maintenance personnel cannot fathom
how a helicopter part could be bent for a
third time even though he has kept w Don't rely on memory and consult
orking on it, demonstrating that there is a the relevant up to date manuals.
possibility there is a lack of certain type of Alw ays ask if you are in doubt.
know ledge in how he is remedying the Get training on type.
helicopter part. This could be also due the
rapid pace at w hich technology is evolving
and hence increased know ledge is
needed w hen performing the task.

Alw ays finish the job or unfasten the


connection.
Caption says "Hey, Y our wife is on the Document and handover the
phone." uncompleted w ork.
Distraction is depicted as the personnel is When you return to the job,re-
informed of an urgent call from his w ife, inspect by another or alw ays go
hence taking him away from focusing on back three steps by yourself.
his job which could potentially lead to Use a detailed check sheet.
errors later as his concentration has been
affected.
The "Dirty Dozen" in Aviation Maintenance -
Explanations Safety nets available

Caption says "I thought you wanted him to


turn left right here!" Discuss w hat, w ho and how a job is
Lack of team work in w hich two to be done.
marshallers are trying to guide an aircraft Be sure that everyone understands
in opposite directions show s a and agrees through good
fundamental lack of cooperation and communications and co-ordination w
communication w hich are essential in its team members.
performing certain difficult tasks Look out for one another.
especially w hen more people are
involved.

Be aw are of the symptoms and look


for them in yourself and others.
Plan to avoid complex tasks w hen
Caption says "I'm glad this double shift is
you are physically exhausted.
over."
Sleep and exercise regularly.
Fatigue is depicted w ith a maintenance
Ask others to check your w ork.
personnel blissfully unaw are that he is
If you are fatigued, take a break.
reaching the end of the horizontal
stabilizer as he has become fatigued
after w orking a double shift.
The "Dirty Dozen" in Aviation Maintenance -
Explanations Safety nets available

Caption says "We have nil stock of left


skids so I guess this will have to do."
Lack of resources is depicted w ith a Check suspect areas at the beginning
maintenance personnel standing in front of the inspection.
of a helicopter w ith tw o different Order and stock anticipated parts
components; before they are required.
a float on the left and a skid on the right; Know all available parts sources and
obviously one of the essential parts is arrange for pooling or loaning.
insufficient and he has fixed a totally Maintain a standard and if in doubt
different part on and still w ants the ground the aircraft.
helicopter to continue to fly. Preserve all equipment through
Hence, there are times w hen there a lack proper maintenance.
of resources, a decision must be made not
to fly for safetys sake.

Caption says "Hurry up or we're going to be


Be sure the pressure isn't self-
late again!"
induced.
Pressure is depicted w ith an aircraft
Communicate your concerns.
captain w ho is averse to being late,
Request for assistance.
rushing a maintenance personnel to finish
Just say No.
closing up a panel and w hilst doing so, he
misses seeing a component jutting out.
The "Dirty Dozen" in Aviation Maintenance -
Explanations Safety nets available

Caption says "Listen, I own the aircraft and Be assertive and provide clear
I say it's not a bad leak!" feedback w hen danger is perceived.
Lack of assertiv eness is show n w ith the If it's not critical, record it in the
maintenance personnel being badgered journey log book and only sign for w
by the ow ner of the aircraft and not hat is serviceable.
asserting himself and backing dow n by Refuse to compromise your
telling him that the plane is indeed standards.
suffering from a bad oil leak. Hence by Allow team members to give their
allow ing himself to be intimidated and not opinions and accept criticisms
speaking up, it could potentially lead to positively
an accident.

Caption says "We lost our best aircraft! Be wary of the effects of stress on
How are they going to pay my wages? your performance.
What if I'm sued?" Stress is depicted w Stop and look rationally at the
ith a maintenance personnel pulling his problem.
cart of tools tow ards the moving Determine a rational course of action
propeller and his overstressed at having and follow it.
lost his best aircraft and the fact that he Take time off or at least have a short
might be sued. Hence, the stress build break.
up has exceeded his limits and he cant Discuss it w ith someone. Ask fellow
think rationally and perform his task w orkers to monitor your w ork.
right. Exercise your body. Ensure sufficient
rest at all times
The "Dirty Dozen" in Aviation Maintenance -
Explanations Safety nets available

Caption says "All the regulation said was,


'Install Where it is Easily Accessible." Think of w hat may occur in the event
of an accident.
Lack of awareness is depicted as an Check to see if your w ork w ill conflict
aftermath in this incident w hereby a w ith an existing modification or repair.
passenger has hit his head against a fire Ask others if they can see any
extinguisher during an emergency as the problem w ith the w ork done by
maintenance personnel w ho had installed checking periodically to ensure correct
the fire extinguisher there show ed a lack w ork procedures.
of awareness by not using common sense
and vigilance by putting it at a place that
though easily accessible could potentially
hurt someone.

Caption says "Never mind the


Maintenance Manual. Its quicker the
Alw ays comply w ith defined w ork
way we do it here." Norm s are depicted
procedures. Be aw are that "norms"
w ith a forklift used to install a jet engine
don't make it right.
demonstrating how this procedure w as
conducted at this
maintenance facility, that even though it
is a flaw ed manner has become a norm
as the majority performs in this w ay.

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