Human error in maintenance
Why skilled people make errors in the hangar, the Dirty Dozen, error types, workplace, handover, rules, reporting, just culture and MEDA. Part 1 of the Human factors in maintenance series.
What you will be able to do
- ✓ Explain what human factors means in maintenance and use the SHEL and PEAR models and the Dirty Dozen to describe the conditions behind errors.
- ✓ Distinguish slips, lapses, mistakes and violations, explain why omissions dominate, and match each error type to a suitable fix.
- ✓ Describe how lighting, noise, temperature, weather, fatigue and hard-to-use procedures affect maintenance performance, using the official account of the G-DBCD spoiler event.
- ✓ Apply good practice for written and spoken communication, shift handover, interrupted tasks and error-capturing methods.
- ✓ Identify the human factors requirements of ICAO, EASA Part-66 and Part-145, the FAA and a national regulator, and audit training records against them.
- ✓ Explain occurrence and internal reporting, the just culture boundary and the MEDA investigation process.
Course content
Session 1 · Why human factors matter in maintenance
1.1
- Why human factors matter in maintenance · free preview
- Two ways to see the whole picture: SHEL and PEAR
- The Dirty Dozen
- Worked example: reading a year of occurrence data
Session 2 · How maintenance errors happen
1.2
- Slips, lapses, mistakes and violations
- Why steps go missing: omissions and memory
- Latent conditions and layers of protection
- Worked example: four errors, four different fixes
Session 3 · The workplace: environment, fatigue and the task
1.3
- The physical environment: light, noise, heat and weather
- Fatigue and shift work in the hangar
- Procedures, documents and tools
- From the investigation file: the spoiler left in maintenance mode on G-DBCD
Session 4 · Communication and shift handover
1.4
- Communication: written, spoken and assumed
- Shift handover that works
- Interruptions, stage marking and error capture
- Worked example: rewriting a seven-word handover
Session 5 · The rules: ICAO, EASA, FAA and national regulators
1.5
- ICAO: the international starting point
- Europe: Part-66 Module 9 and Part-145 training
- The United States: guidance and voluntary reporting
- Worked example: auditing human factors training records
Session 6 · Reporting, just culture and MEDA
1.6
- Reporting errors and near misses
- Just culture: fair, not blame-free
- MEDA: investigating the event, not the person
- Worked example: a MEDA-style review of an oil cap event
Who this course is for
Course content © Aerospace Garage Limited. All rights reserved.