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Risk management of technology and maintenance failures in aviation industry essay

As with the chief pilot, the mechanic acts as an advocate for operator or repair station counterparts. The appointment of a chief mechanic grew out of the recognition that the maintenance community contributes significantly to the success of airline operations in both safety and on-time performance. Drawing on the experience of airline and production mechanics, reliability and maintainability engineers, and human factors specialists, the chief mechanic oversees the implementation of all maintenance-related features.

Computer-based maintainability design tools. Beginning with the 777 program, Boeing stopped building full-scale airplane mockups, which in the past helped determine whether a mechanic could reach an airplane part for removal and reinstallation.

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Now, using a computer-aided three-dimensional interactive application CATIABoeing makes this type of determination using a human model. In addition to ensuring access and visibility, human factors specialists conduct ergonomic analyses to assess the human capability to perform maintenance procedures under different circumstances.

For example, when a mechanic needs to turn a valve from an awkward position, it is important that the force required to turn the valve must be within the mechanic's capability in that posture. For another example, when a maintenance operation must be accomplished in poor weather at night, secure footing and appropriate handling forces are necessary to protect the mechanic from a fall or from dropping a piece of equipment.

Fault information team FIT. Human factors considerations in maintenance also led to the formation of the FIT. The FIT charter has since expanded to promote consistency in maintenance processes and design across all systems and models.

  1. Due to this necessity of ensuring safety in this particular field, government regulations became a necessity and therefore have a critical role in the safety of aviation maintenance. Although no lives were lost and the property damage was confined to the reactor itself, the incident came very close to resulting in a nuclear meltdown.
  2. To prevent such errors in the future, those contributing factors must be identified and, where possible, eliminated or mitigated. Boeing developed the CIRA process to better understand how flight crews use the data and cues they are given.
  3. For instance, human factors specialists collaborated with engineers in various studies during 767-400ER program design. A more proactive approach is needed if we are to move forward.

The goal is to enable mechanics to maintain all Boeing commercial airplanes as efficiently and accurately as possible. This cross-functional team has representatives from maintenance, engineering, human factors, and operators. For the text of these displays, Boeing has created templates that provide for common fault menus for all systems.

The interface should look the same to the mechanic regardless of the vendor or engineering organization that designs the component. The FIT reviews all information used by the mechanic, including placards, manuals, training, and size, location, and layout of controls and indicators, and works with the engineers to develop effective, consistent displays. The team also provides input and updates to Boeing design standards and requirements. In the early 1990s, Boeing formed a maintenance human factors group.

The group also helps maintenance engineers improve their maintenance products, including Aircraft Maintenance Manuals, fault isolation manuals, and service bulletins. As maintenance support becomes more electronically based, human factors considerations have become an integral part of the Boeing design process for tools such as the Portable Maintenance Aid.

In addition, the group is developing a human factors awareness training program for Boeing maintenance engineers to help them benefit from human factors principles and applications in their customer support work. However, the industry lacks insight into why such errors occur.

To date, the industry has not had a systematic and consistent tool for investigating such incidents. To improve this situation, Boeing has developed human factors tools to help understand why the errors occur and develop suggestions for systematic improvements.

Two of the tools operate on the philosophy that when airline personnel either flight crews or mechanics make errors, contributing factors in the work environment are part of the causal chain. To prevent such errors in the future, those contributing factors must be identified and, where possible, eliminated or mitigated. The tools are Procedural Event Analysis Tool. Maintenance Error Decision Aid.

This tool, for which training began in mid-1999, is an analytic tool created to help the airline industry effectively manage the risks associated with flight crew procedural deviations. PEAT assumes that there are reasons why the flight crew member failed to follow a procedure or made an error and that the error was not intentional. Based on this assumption, a trained investigator interviews the flight crew to collect detailed information about the procedural deviation and the contributing factors associated with it.

PEAT is the first industry tool to focus on procedurally related incident investigations in a consistent and structured manner so that effective remedies can be developed see below.

This tool began as an effort to collect more information about maintenance errors. It developed into a project to provide maintenance organizations with a standardized process for analyzing contributing factors to risk management of technology and maintenance failures in aviation industry essay and developing possible corrective actions see "Boeing Introduces MEDA" in Airliner magazine, April-June 1996, and " Human Factors Process for Reducing Maintenance Errors " in Aero no.

MEDA is intended to help airlines shift from blaming maintenance personnel for making errors to systematically investigating and understanding contributing causes. In maintenance practices, those factors typically include misleading or incorrect information, design issues, inadequate communication, and time pressure. Boeing maintenance human factors experts worked with industry maintenance personnel to develop the MEDA process.

Once developed, the process was tested with eight operators under a contract with the U.

Since the inception of MEDA in 1996, the Boeing maintenance human factors group has provided on-site implementation support to more than 100 organizations around the world. A variety of operators have witnessed substantial safety improvements, and some have also experienced significant economic benefits because of reduced maintenance errors. Three other tools that assist in managing error are Crew information requirements analysis.

Improved use of automation. Crew information requirements analysis CIRA.

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Boeing developed the CIRA process to better understand how flight crews use the data and cues they are given. It provides a way to analyze how crews acquire, interpret, and integrate data into information upon which to base their actions. CIRA helps Boeing understand how the crew arrived or failed to arrive at an understanding of events. Since it was developed in the mid-1990s, CIRA has been applied internally in safety analyses supporting airplane design, accident and incident analyses, and research.

Boeing has applied its human factors expertise to help develop training aids to improve flight safety. Boeing proposed and led a training tool effort with participation from line pilots in the industry.

The team designed and conducted scientifically based simulator studies to determine whether the proposed training aid would be effective in helping crews cope with this safety issue.

Similarly, the controlled flight into terrain training aid resulted from a joint effort by flight crew training instructor pilots, human factors engineering, and aerodynamics engineering. Both human factors scientists and flight crews have reported that flight crews can become confused about the state of advanced automation, such as the autopilot, autothrottle, and flight management computer.

This condition is often referred to as decreased mode awareness. The Boeing Human Factors organization is involved in a number of activities to further reduce or eliminate automation surprises and to ensure more complete mode awareness by flight crews. The primary approach is to better communicate the automated system principles, better understand flight crew use of automated systems, and systematically document skilled flight crew strategies for using automation.

Boeing is conducting these activities in cooperation with scientists from the U. National Aeronautics and Space Administration fig. When complete, Boeing will use the results to improve future designs of the crewmember-automation interface and to make flight crew training more effective and efficient.

Human factors principles usually associated with the flight deck are now being applied to examine human performance functions and ensure that cabin crews and passengers are able to do what they need or want to do.

Some recent examples illustrate how the passenger cabin can benefit from human factors expertise applied during design. These include Automatic overwing exit. Human performance and ergonomics methods played important roles in both its design and testing. Computer analyses using human models ensured that both large and small people would be able to operate the exit door without injury.

The handle was redesigned and tested to ensure that anyone could operate the door using either single or double handgrips.

Then, approximately 200 people who were unfamiliar with the design and who had never operated an overwing exit participated in tests to verify that the average adult can operate the exit in an emergency. The exit tests revealed a significantly improved capability to evacuate the airplane.

This major benefit was found to be unique to the 737 configuration. The human factors methodology applied during test design and data analysis contributed significantly to refining the door mechanism design for optimal performance. Working with payloads designers, human factors specialists also evaluated cabin crew and passenger reach capability, placard comprehension, emergency lighting adequacy, and other human performance issues.

Because of the focus on human capabilities and limitations, the analyses and design recommendations were effective in reducing potential errors and in increasing usability and satisfaction with Boeing products. More general issues of human usability have also been addressed. For instance, human factors specialists collaborated with engineers in various studies during 767-400ER program design. The reach and visibility of the passenger service units components were reviewed so cabin crews could use them more easily and effectively.

The glare ratio on the sidewalls was analyzed and improved for increased passenger comfort. An essential part of this philosophy is continuous improvement in designs and flight crew training and procedures.

Integral to this effort is an ongoing attempt to better address human performance concerns as they relate to design, usability, maintainability, and reliability. By continuously studying the interface between human performance and commercial airplanes, Boeing continues to help operators apply the latest human factors knowledge for increased flight safety.

Success depends on having sufficient data to do so. A more proactive approach is needed if we are to move forward. Unfortunately, it is difficult to obtain insightful data in an aviation system that focuses on accountability. Flight and maintenance crews are often unduly exposed to blame because they are the last line of defense when unsafe conditions arise.

We must overcome this "blame" culture and encourage all members of our operations to be forthcoming after any incident. We must be careful not to limit data collection to any one segment of the safety chain. Boeing believes that if we, the aviation community, hope to further reduce the overall accident rate, we must continue to promote and implement proactive, nonpunitive safety reporting programs designed to collect and analyze aviation safety information.