1、 _ ICAO CRCULAR*253 -AN/LSL * 4YLYLb 0063739 LO4 CIRCULAR 253-Awl51 ICAO CIRCULAR 1995 HUMAN FACTORS DIGEST No. 12 HUMAN FACTORS IN AIRCRAFT MAINTENANCE AND INSPECTION Approved by the Secretary General and published under his authority INTERNATIONAL CIVIL AVIATION ORGANIZATION MONTREAL CANADA COPYRI
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9、Despacho 3. 11,28027 Madrid. 37 Gratton Road, Cheltenham, Clos., GL50 2BN. The Catalogue of ICAO Publications and Audio Visual Training Aids Issued annually, the Caflogue lists-all publications and audio visual training aids currently available. Monthly supplements announce new publications and audi
10、o visual training aids, amendments, supplements, reprints, etc. Available free from the Document Sales Unit, ICAO COPYRIGHT International Civil Aviation OrganizationLicensed by Information Handling ServicesICA0 CIRCULAR*253 -AN/151 * 4841416 0063721 862 TABLE OF CONTENTS Page introduction . Chapter
11、1 . Human Factors . Aircraft Maintenance and Inspection . Contemporary maintenance problems TheSHELModel . The Reason Model . Human error Chapter 2 . Human Error in Aircraft Maintenance and Inspection (an organizational perspective) . Chapter 3 . Human Factors Issues affecting Aircraft Maintenance I
12、nformation exchange and communication . Training . The aircraft maintenance technician . Facilities and work environment Chapter 4 . Teams and Organizational issues in Aircraft Maintenance Teamwork . Jobdesign . Rewardsystems . Selection and staffing Training . Chapter 5 . Automation and Advanced Te
13、chnology Systems Automation and computerization Advanced job aid tools 1 10 19 19 21 23 25 28 28 30 30 31 31 32 32 32 Chapter 6 . Error Prevention Considerations and Strategies . 35 Appendix 1 . List of Recommended Reading 41 COPYRIGHT International Civil Aviation OrganizationLicensed by Information
14、 Handling ServicesICA0 CIRCULAR*253 -AN/35L * H 4843436 0063722 7T9 INTRODUCTION 1. 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
15、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 systems safety net. There is no question that human error in aircraft maintenance
16、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. From a Human Factors perspective, important truths have been uncovered during the inves
17、tigation of these occurrences. 2. The objectives of this digest are to provide practical Human Factors guidance - based on those truths - to those concerned with aircraft maintenance and inspection and to introduce the non-specialist to Human Factors issues in aircraft maintenance and inspection. It
18、 is intended to show how human capabilities and limitations can influence task performance and safety within the maintenance and inspection environ- ments. This digest also identifies sources of Human Factors knowledge and information. The target audience includes aircraft maintenance technicians/en
19、gineers/mechanics, aircraft airworthiness inspectors, maintenance designers and planners, civil aviation and airline management personnel, operational personnel as well as those responsible for maintenance organizations. 3. Throughout the digest and consistent with the series of ICA0 Human Factors d
20、igests, both the SHEL model and the Reason model are presented and repeatedly referred to in order to demonstrate the relevance of Human Factors to aviation safety and effectiveness. Information on aircraft accidents in which maintenance error has been identified is included to illustrate the issues
21、 discussed. The digest advocates the importance of information exchange, the sharing of experience in maintenance operations among operators and the safety benefits to be gained therefrom. The need to adhere to established maintenance procedures by all concerned is emphasized and the negative aspect
22、s of non-adherence are explained using real-life examples. New and improved training methods for aircraft maintenance personnel are briefly reviewed and possible advantages addressed. 4. This digest also discusses the safety and efficiency gains from the provision of proper facilities and work envir
23、onment. Job design, reward systems and selection and training of staff are also examined, emphasizing these gains. Obviously, a job design that works for one organization does not necessarily work for another. This digest, therefore, stresses that each organizations culture must be considered separa
24、tely if and when assigning work teams. It also introduces the reader to existing advanced job aids and to those expected to be available in the near future. The need to introduce new advanced technology vis-vis the gains to be had from their introduction - not only financjally but, most importantly,
25、 in the enhancement of safety standards - is discussed. Although acknowledging advantages from advanced job aids, it nevertheless cautions that introduction of automation or new technology should take into consideration the capabilities and limitations of the operators who will use it. Automation sh
26、ould be designed to assist humans in performing their normal duties in a more efficient and safe manner. 5. This digest comprises the following: e Chapter 7 discusses Human Factors in aircraft maintenance and inspection. Chapter 2 examines human error in aircraft maintenance and inspection. COPYRIGH
27、T International Civil Aviation OrganizationLicensed by Information Handling ServicesICAO CIRCULAR*253 -AN/L5L * = 484L41b 0063723 b35 = 2 ICAO Circular 253-ANA51 O Chapter 3 presents the issues affecting aircraft maintenance. O Chapter 4 considers teams and organizational issues in maintenance opera
28、tions. O Chapter 5 deals with automation and advanced technology systems in aircraft maintenance. Chapter 6 addresses the challenges for the future through error prevention considerations and strategies. O Appendix 7 provides a list of references and recommended reading. 6. This digest was produced
29、with the assistance of the ICAO Flight Safety and Human Factors Study Group, developed from an initial draft prepared by Study Group Member Dr. William T. Shepherd. Other sources of reference include Human Error in Aircraft Maintenance by David A. Marx and R. Curtis Graeber, Human Error by Professor
30、 James Reason and ICAO Human Factors Digests No. 7 - Investigation of Human factors in Accidents and Incidents and No. 10 - Human Factors, Management and Organization. Other digests in this series include: Digest No. 1 - fundamental Human factors Concepts (Circular 216); Digest No. 2 - Flight Crew T
31、raining: Cockpit Resource Management (CRM) and Line- Oriented flight Training (LOFT) (Circular 21 7); Digest No. 3 - Training of Operational Personnel in Human Factors (Circular 227); Digest No. 4 - Proceedings of the ICAO Human Factors Seminar (Circular 229); Digest No. 5 - Operational Implications
32、 of Automation in Advanced Technology Flight Decks (Circular 234); Digest No. 6 - Ergonomics (Circular 238); Digest No. 7 - Investigation of Human Factors in Accidents and Incidents (Circular 240); Digest No. 8 - Human Factors in Air Traffic Control (Circular 241); Digest No. 9 - Proceedings of the
33、Second CAO Flight Safety and Human factors Global Symposium (Circular 243); Digest No. 1 O - Human Factors, Management and Organization (Circular 247); and Digest No. 11 - Human factors in CNS/ATM Systems (Circular 249). COPYRIGHT International Civil Aviation OrganizationLicensed by Information Hand
34、ling ServicesICA0 CIRCULAR*253 -AN/L5L * = 484L4Lb 0063724 571 Chapter 1 HUMAN FACTORS - AIRCRAFT MAINTENANCE AND INSPECTION Contemporary Maintenance Problems 1.1 There is no question that human error in aircraft maintenance and inspection has been a causal factor in several recent air carrier accid
35、ents. Whenever humans are involved in an activity, human error is a certain sequel. According to one source, the number of maintenance concern accidents and incidents to public transport aircraft has increased significantly. This source defines maintenance concern as one which is not necessarily a m
36、aintenance error (it may be a design error) but one which is of concern to the maintenance personnel as frontline managers of technical problems in daily operations. The same source states that in the first half of the 1980s, there were 17 maintenance concern-related accidents and incidents, involvi
37、ng aircraft belonging only to Western operators and excluding all “routine” technical failures (engine, landing gear, systems, structure, component separations, ramp accidents, etc). All these accidents and incidents had serious consequences (fatal, serious damage, significant previous occurrences,
38、significant airworthiness implications, etc). In the second half of the 1980s, the same source enumerates 28 accidents of maintenance concern, an increase of 65% over the first half of the decade. In the same period, traffic movements (flight departures, scheduled and non-scheduled) increased by 22%
39、. In the first three years of the 1990s there were 25 accidents involving maintenance concerns. This compares with seven in the first three years of the 1980s. 1.2 Whether maintenance concern-related occurrences are a “new” phenomenon in aviation or whether they have always existed but have only rec
40、ently been validated by statistics may be a matter of debate. Indeed, the awareness of the importance of maintenance to aviation safety may be the logical consequence of the gradual acceptance of broader, systemic approaches to aviation safety. Whatever the case may be, the increase in the rate of a
41、ccidents and incidents involving maintenance concerns appears to be at least statistically significant. In the last ten years, the annual average has increased by more than 100% while the number of flights has increased by less than 55%. 1.3 Traditionally, Human Factors endeavours have been directed
42、 towards flight crew performance and, to a lesser extent, towards the performance of air traffic controllers. Until recently, available literature showed little consideration of the Human Factors issues which could affect aircraft maintenance personnel who inspect and repair aircraft. This has been
43、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. 1.4 Aircraft maintenance and inspection duty can be very complex and varied in an enviro
44、nment where opportunities for error abound. Maintenance personnel - at least in the most developed aviation systems - frequently work under considerable time pressures. Personnel at the maintenance base and at the flight line stations realize the importance of meeting scheduled departure times. Oper
45、ators have increased aircraft utilization in order to counteract the economic problems that plague the industry. Aircraft maintenance technicians are also maintaining a fleet that is increasing in age. It is not uncommon to find 20 to 25 year old 1. TechLog - “is There a Maintenance Problem.” AEROSP
46、ACE, June 1993. 3 COPYRIGHT International Civil Aviation OrganizationLicensed by Information Handling ServicesICAO CIRCULAR*253 -AN/LSL * D 484141b O063725 408 4 ICAO Circular 253-ANh51 aircraft in many airline fleets, including those of major operators. In addition, many operators intend to keep so
47、me of these aircraft in service in the foreseeable future, perhaps beyond the turn of the century. Engine hush kits will make some older narrow-body aircraft economically and environmentally viable. However, these aircraft are maintenance-intensive. The old airframes require careful inspection for s
48、igns of fatigue, corrosion and general deterioration. This places an increased burden on the maintenance workforce. It creates stressful work situations, particularly for those engaged in inspection tasks, because additional maintenance is required and because the consequences may be serious if the
49、signs of aging, which are frequently subtle, remain undetected. 1.5 While maintenance of these aging aircraft is ongoing, new technology aircraft are entering the fleets of many of the worlds airlines, thus increasing the demands on aircraft maintenance. These new aircraft embody advanced technology such as composite material structures, “glass cockpits”, highly automated systems and built-in diagnostic and test equipment. The need to simultaneously maintain new and old fleets requires aircraft maintenance technicians to be more knowledgeable and adept in the
