Human Error and The “Dirty Dozen” (Part Three)

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Lack of Assertiveness

Assertiveness is the ability to express your feelings, opinions, beliefs, and needs in a positive, productive manner and should not be confused with being aggressive. [Figure 14-28]

It is important for AMTs to be assertive in issues relating to aviation repair rather than choosing not to or not being allowed to voice their concerns and opinions. Not being assertive could ultimately cost people their lives. The following are examples of how a lack of assertiveness can be offset:

Address managers and supervisors directly by stating the problem.
- Example: “John, I have a concern with how this repair is being rushed.”
Explain what the consequences will be.
- Example: “If we continue, the result will be that the part will break sooner rather than later.”
Propose possible solutions to the problem.
- Example: “We could try doing things another way or you may want to try this way.”
Always solicit feedback and include other opinions.
- Example: “John, what do you think?”

When being assertive with co-workers or management, deal with one issue at a time rather than trying to tackle a number of problems at once. It is also important to have documentation and facts to back up your argument, which can give people a visual account of what you are trying to explain. A lack of assertiveness in failing to speak up when things do not seem right has resulted in many fatal accidents. This can easily be changed by promoting good communication between co-workers and having an open relationship with supervisors and management. Maintenance managers must be familiar with the behavior styles of the people they supervise and learn to utilize their talents, experience, and wisdom.

As the employees become aware of behavior styles and understand their own behavior, they see how they unwittingly contribute to some of their own problems and how they can make adjustments. Assertive behavior may not be a skill that comes naturally to every individual, but it is a critical skill to achieve effectiveness. AMTs should give supervisors and management the kind of feedback required to ensure that they will be able to assist mechanics in doing their job.

Stress

Aviation maintenance is a stressful task due to many factors. [Figure 14-29]

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. Fast-paced technology that is always changing can add stress to technicians. This demands that AMTs stay trained on the latest equipment. Other stressors include working in dark, tight spaces, lack of resources to get the repair done correctly, and long hours. The ultimate stress of aviation maintenance is knowing that the work they do, if not done correctly, could result in tragedy.

Everyone handles stress differently and particular situations can bring about different degrees of difficulty for different people. For example, working under a strict timeline can be a stressor for one person and normal for another. The causes of stress are referred to as “stressors” and are categorized as physical, psychological, or physiological. Following is a list of each and how they may affect maintenance.

Physical Stressors

Physical stressors add to a person’s workload and make his or her work environment uncomfortable.

Temperature—high temperatures in the hangar increase perspiration and heart rate causing the body to overheat. Low temperatures can cause the body to feel cold, weak, and drowsy.
Noise—hangers that have high noise levels (due to aircraft taking off and landing close by) can make it difficult for maintenance personnel to focus and concentrate.
Lighting—poor lighting within a work space makes it difficult to read technical data and manuals. Likewise, working inside an aircraft with poor lighting increases the propensity to miss something or to repair something incorrectly.
Confined spaces—small work spaces make it very difficult to perform tasks, as technicians are often contorted into unusual positions for a long period of time.

Psychological Stressors

Psychological stressors relate to emotional factors, such as a death or illness in the family; business worries; poor interpersonal relationships with family, co-workers, or supervisors; and financial worries.
Work-related stressors—over anxiousness can hinder performance and speed while conducting maintenance if there is any apprehension about how to do a repair or concerns about getting it done on time.
Financial problems—impending bankruptcy, recession, loans, and mortgages are a few examples of financial problems that can create stressors.
Marital problems—divorce and strained relationships can interfere with one’s ability to perform his or her job correctly.
Interpersonal problems—problems with superiors and colleagues due to miscommunication or perceived competition and backstabbing can cause a hostile work environment.

Physiological Stressors

Physiological stressors include fatigue, poor physical condition, hunger, and disease.

Poor physical condition—trying to work when ill or not feeling well can force the body to use more energy fighting the illness, leaving less energy to perform vital tasks.
Proper meals—not eating enough, or eating foods lacking the proper nutrition, can result in low energy and induce symptoms like headaches and shaking.
Lack of sleep—a fatigued AMT is unable to perform to standard for long periods of time and can become sloppy with repairs and make significant mistakes.
Conflicting shift schedules—the effect of changing sleep patterns on the body’s circadian cycle can lead to a degradation of performance.

People cope with stress in many different ways. Specialists say that the first step is to identify stressors and the symptoms that occur after exposure to those stressors. Other recommendations involve development or maintenance of a healthy lifestyle with adequate rest and exercise, a healthy diet, limited consumption of alcoholic drinks, and avoidance of tobacco products.

Lack of Awareness

Lack of awareness is defined as a failure to recognize all the consequences of an action or lack of foresight. [Figure 14-30]

In aviation maintenance, it is not unusual to perform the same maintenance tasks repeatedly. After completing the same task multiple times, it is easy for technicians to become less vigilant and develop a lack of awareness of what they are doing and what is around them. Each time a task is completed it must be treated as if it were the first time.

Norms

Norms is short for “normal,” or the way things are normally done. [Figure 14-31]

They are unwritten rules that are followed or tolerated by most organizations. Negative norms can detract from the established safety standard and cause an accident to occur. Norms are usually developed to solve problems that have ambiguous solutions. When faced with an ambiguous situation, an individual may use another’s behavior as a frame of reference around which to form his or her own reactions. As this process continues, group norms develop and stabilize. Newcomers to the situation are then accepted into the group based on adherence to norms. Very rarely do newcomers initiate change in a group with established norms.

Some norms are unsafe in that they are non-productive or detract from the productivity of the group. Taking shortcuts in aircraft maintenance, working from memory, or not following procedures are examples of unsafe norms. Newcomers are better able to identify these unsafe norms than long-standing members of the group. On the other hand, the newcomer’s credibility depends on his or her assimilation into the group. The newcomer’s assimilation, however, depends on adherence to the group norms. Everyone should be aware of the perceptiveness of newcomers in identifying unhealthy norms and develop a positive attitude toward the possibility that norms may need to be changed. Finally, as newcomers become assimilated into the group structure, they build credibility with others. Once this has been done, a relative newcomer may begin to institute change within the group. Unfortunately, such actions are often difficult to do and rely heavily on the group’s perception of the newcomer’s credibility.

Norms have been identified as one of the dirty dozen in aviation maintenance and a great deal of anecdotal evidence points to the use of unsafe norms on the line. The effect of unsafe norms may range from the relatively benign, such as determining accepted meeting times, to the inherently unsafe, such as signing off on incomplete maintenance tasks. Any behavior commonly accepted by the group, whether as a standard operating procedure (SOP) or not, can be a norm. Supervisors need to ensure that everyone adheres to the same standards and that unsafe norms are not tolerated. AMTs should pride themselves on following procedure, rather than unsafe norms that may have been adopted as regular practice.

Example of Common Maintenance Errors

In an effort to identify the most frequently occurring maintenance discrepancies, the United Kingdom Civil Aviation Authority (CAA) conducted in-depth studies of maintenance sites on aviation maintenance operations. The following list is what they found to be the most common occurring maintenance errors.

Incorrect installation of components.
Fitting of wrong parts.
Electrical wiring discrepancies to include crossing connections. [Figure 14-32]
Figure 14-32. A description of a Lufthansa Airbus A320 that almost crashed due to reversed wiring of the flight controls.
Forgotten tools and parts.
Failure to lubricate. [Figure 14-33]
Figure 14-33. A description of Alaska Airlines Flight 261 that crashed due to insufficient lubrication of the jackscrew assembly.
Failure to secure access panels, fairings, or cowlings.
Fuel or oil caps and fuel panels not secured.
Failure to remove lock pins. [Figure 14-34]
Figure 14-34. Lock pins located on the wheels of an aircraft.

All of the maintenance discrepancies listed above can be avoided if the proper procedures are followed on the job card that is being used. [Figure 14-35]

Figure 14-35. A sample picture of a maintenance job card that explains the steps of each maintenance task.

Regardless of how many times the task has been completed, each time you pick up a job card, treat it like it is the first time you have ever completed the task, and complete it with diligence and complete accuracy.

Historically, twenty percent of all accidents are caused by a machine failure, and eighty percent by human factors.

[Figure 14-36]

Originally focusing on the pilot community, human factors awareness has now spread into the training sphere of maintenance technicians. An in-depth review of an aviation incident reveals time and again that a series of human errors (known also as a chain of events) was allowed to build until the accident occurred. If the chain of events is broken at the maintenance level, the likelihood of the accident occurring can be drastically decreased. Figure 14-37 is a list of maintenance-related incidents/accidents and their causes. It is easy to see how many of the “Dirty Dozen” contributed to the causes or were considered contributing factors.

Figure 14-37. A list of maintenance-related incidents/accidents and their causes.

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