I was perusing through the August AMT issue and read with interest Doctor Bill Johnson’s article on human factors training; a really good article and well worth revisiting. Now I’ve known Dr. Bill for a long, long time … well, we actually first met last January. But in all that time I’ve never known him to exaggerate … ever! Well, OK, there’s that marlin he ‘caught’ (dropped anchor on a sea trout he said was the size of a Buick). But he’s a great resource, a fun person to talk to, and a title holder in the lost sport of emu wrestling.
His article mentioned the benefits of human factors training. Human factors and ergonomics: my understanding is that ergonomics is the science of improving conditions, e.g. tool design or office equipment; while human factors skews toward studying human environmental conditions, e.g. workplace lighting or work hours. These sciences have grown in importance over the last four decades. For instance, in the early '70s Douglas engineered the DC-10 with minimal ergonomic designs for mechanics, while in the early '90s Boeing used virtual technicians to ergonomically design the B777.
It has been my experience – and opinion – that maintenance triggered accidents can be classified in two ways: as a weak link or as a domino principle. A weak link is when one mistake breaks the safety chain, causes confusion, and the safety ‘house of cards’ collapses; it might be bad procedures, poor management, or utter confusion. A domino principle is when one event feeds another, cascading out of control to the scene of the accident.
During a particular accident investigation in early 2003, the NTSB’s human factors investigator and I honed our mechanic interviewing skills – a first for the NTSB. One would think my interviews generated ‘gotcha’ moments; that the discussions led anxious technicians blindly into admissions of guilt, except … I already knew where the mistakes were made.
The interviews were eye opening; they illuminated maintenance minefields the mechanics were forced to dance around. The discussions revealed: volumes about work environments; inconsistencies in management; the resources available/not available to technicians on shift; incompatibilities of multiple corporate cultures in one hangar; and the technicians’ abilities to identify who was actually in charge. Identifying a single person’s error fixes one problem; discovering errors that affect dozens of people, fixes many problems.
Later that year I investigated another accident; it involved the same model aircraft with the same flight control system as the probable cause. The two certificate holders: different; the accident causing errors: different; yet each accident would require I remove my socks to count all the human factors errors that were discovered; errors that were the result of infamous catalysts, e.g. complacency. Both accidents could have been prevented if the certificate holders took the time to be proactive, make simple workplace improvements, and elicit feedback from the workforce. Both accidents’ probable causes could both be funneled into one highlighted finding: Training issues.
At the Sunshine meeting for the first accident I explained to then-Member Carmody, training is presented in three different ways, all of which I’ve experienced: stand-up (teacher taught), computerized instruction, and on-the-job training (OJT). She had asked if one or more is ineffective; I responded that they are all effective, if done right.
In both cases the certificate holders provided OJT; a method that’s been effective since Barney taught Bam-Bam how to change a stone wheel. If done poorly, OJT can pave the way for mistakes down the line. In these accidents three things happened: One – the maintenance program’s procedures for OJT weren’t followed; Two – the student was never properly monitored while being trained; and, Three – the instructor demonstrated poor maintenance techniques that lacked basic concepts, but employed short-cuts.
How does this relate to human factors? It speaks to both the learning and working environments; it spotlights training quality. For example: one learning mechanic used masking tape to maintain tension on greasy cables during a component replacement; here the student was not monitored. Although this was the first domino, it was actually the last error found because I started from the accident’s cause and traced backwards. There were a total of five dominoes, each with a catching moment that was missed; each domino represented another failure; each failure was blaringly obvious – the equivalent of Uranium 238 painted luminescent colors, bathed in neon and strobe lights – to those following procedures.
How important is human factors today? Many airlines require human factors training. The late Bill O’Brien and the late Tom Hendershot recognized years ago the importance of human factors and the effects subpar working conditions have on general aviation. They introduced and pressed these concepts in writing (O’Brien) and renewal seminars (Hendershot); Ron Donner continues the tradition at IA seminars; he highlights speakers like Doctor Bill who spread the word.
If you think about it, ergonomics has been an important staple on the Operations side for many years; cockpit resource management was one brainchild of the ergonomic wave. When I joined the NTSB, human factors in maintenance was not given serious attention; they felt ergonomics and human factors were not practical maintenance issues; it was often an uphill battle to get comprehensive fixes entered in any maintenance report. Fortunately John Goglia expected pushback and ran interference for me and the maintenance workforce. I was even willing to overlook having to wash his car and pick up his dry cleaning in return for his support. Do you know how many suits that guy has?
I want everyone reading this to exploit the human factors training the good Doctor spoke of. Ergonomics are not an entitlement program; it does not give one an excuse to avoid responsibility. Instead it’s a valuable tool to keep in your roll-around that’ll make you a better technician. There’s a reason for calling it human factors: they’re factors affecting human health and reliability, so all you humans can take advantage.
But if you’re an emu, watch out. Doctor Bill’s not giving up the title.
