Communication, Knowledge, and Complacency

14-15 THE DIRTY DOZEN Twelve human factors for aircraft maintenance proficiency Lack of Teamwork Fatigue Lack of Resources

Pressure

Lack of Assertiveness

Stress

Lack of Awareness Norms Complacency Lack of Knowledge Distraction Lack of Communication MITIGATING THE RISK Properly use logbooks and worksheets to communicate work accomplishments. Never assume that the work has been completed. Ensure that maintenance personnel are discussing exactly what has been and needs to be completed to the next shift. Maintainers must communicate with one another and explain what work has and has not been completed when changing shifts. on the aircraft should be consulted. If one is not available, or the consulted technician is not familiar with the procedure, a manufacturer’s technical representative should be contacted.

It is better to delay a maintenance procedure than to do it incorrectly and cause an accident. Distraction A distraction while performing maintenance on an aircraft may disrupt the procedure. [Figure 14-21] When work resumes, it is possible that the technician skips over a detail that needs attention. It is estimated that 15 percent of maintenance related errors are caused by distractions. Distractions can be mental or physical in nature. They can occur when the work is located on the aircraft or in the hangar. They can also occur in the psyche of the technician independent of the work environment. Something as simple as a cell phone call or a new aircraft being pushed into the 14-16 hangar can disrupt the technician’s concentration on a job.

Less visible is a difficult family or financial matter or other personal issues that may occupy the technician’s thought process as work is performed. This can make performance of the required maintenance less effective. Whatever their nature, numerous distractions can occur during the course of maintaining an aircraft. The technician must recognize when attention to the job at hand is being diverted and assure that work continues correctly. A good practice is to go back three steps in the work procedure from when distraction occurred and resume the job from that point. Using of a detailed step-by-step written procedure and signing off each step only after it is completed also helps. Incomplete work can be marked or tagged, especially when the technician is pulled from the work by a distraction, and it is unknown when work will be resumed and by whom. Disconnect any connector and leave it plainly visible if an installation is not complete. There is a tendency to think a job is finished when a component is “hooked up.” Similarly, when a step in the maintenance procedure is complete, be sure to immediately lock wire or torque the fasteners if required. This can be used as an indication that all is well up to that point in the procedure.

Lack of Teamwork A lack of teamwork may also contribute to errors in aircraft maintenance. [Figure 14-22] Closely related to the need for communication, teamwork is required in aviation maintenance in many instances. Sharing of knowledge between technicians, coordinating maintenance functions, turning work over from shift to shift, and working with flight personnel to troubleshoot and test aircraft are all are executed better in an atmosphere of teamwork. Often associated with improved safety in the workplace, teamwork involves everyone understanding and agreeing on actions to be taken. A gear swing or other operational check involves all the members of a team working together. Multiple technicians contribute to the effort to ensure a single outcome. They communicate and look out for one another as they do the job. A consensus is formed that the item is airworthy or not airworthy.

The technician primarily deals with the physical aspect of the aircraft and its airworthiness. Others in the organization perform their roles and the entire company functions as a team. Teams can win or lose depending on how well everyone in the organization works together toward a common objective. A lack of teamwork makes all jobs more difficult and, in maintenance, could result in a miscommunication that affects the airworthiness of the aircraft. Fatigue Fatigue is a major human factor that has contributed to many maintenance errors resulting in accidents. [Figure 14-23] Fatigue can be mental or physical in nature. Emotional fatigue also exists and affects mental and physical performance. A person is said to be fatigued when a reduction or impairment in any of the following occurs: cognitive ability, decision-making, reaction time, coordination, speed, strength, or balance. Fatigue reduces alertness and often reduces a person’s ability to focus on the task being performed.

Symptoms of fatigue can also include short-term memory problems, channeled concentration on unimportant issues while neglecting more important ones, and failure to maintain a situational overview. A fatigued person may be easily distracted or may be nearly impossible to distract. They may experience abnormal mood swings. Fatigue results in an increase in mistakes, poor judgment, and poor decisions or perhaps no decisions at all. A fatigued person may also lower their standards. Tiredness is a symptom of fatigue. However, sometimes a fatigued person may feel wide awake and engaged in a task. The primary cause of fatigue is a lack of sleep. Good restful sleep, free from drugs or alcohol is a human necessity to prevent fatigue. Fatigue can also be caused by stress and overworking. A person’s mental and physical state also naturally cycles through various levels of performance each day. Variables such as body temperature, blood pressure, heart rate, blood chemistry, alertness, and attention rise and fall in a pattern daily. This is known as circadian rhythm.

[Figure 14-24] A person’s ability to work (and rest) rises and falls during this cycle, and performance counter to circadian rhythm can be difficult. Until it becomes extreme, a person may be unaware that they are fatigued. It is easier recognized by another person or in the results of tasks being performed. This is particularly dangerous in aviation maintenance since the lives of people depend on maintenance procedures performed at a high level of proficiency. Working alone when fatigued is particularly dangerous. The best remedy for fatigue is to get enough sleep on a regular basis. The technician must be aware of the amount and quality of sleep obtained. Time off is justified when too little sleep has occurred and errors are probable during maintenance. Countermeasures to fatigue are often used, but their effectiveness can be short lived and many can make fatigue worse. Caffeine is a common fatigue countermeasure.

Pseudoephedrine found in sinus medicine and amphetamines are also used. While they can be effective for short periods, the underlying fatigue remains and due to this drug use, the person may have trouble getting the rest needed once off the job. Suggestions to help mitigate the problems caused by fatigue include looking for symptoms of fatigue in oneself and in