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    • Abstract: MANAGING HUMAN FACTORS IN AIRCRAFT MAINTENANCE THROUGH APERFORMANCE EXCELLENCE FRAMEWORKbyAdrian J. XavierA Graduate Research ProjectSubmitted to the Extended Campusin Partial Fulfillment of the Requirements of the Degree of

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Adrian J. Xavier
A Graduate Research Project
Submitted to the Extended Campus
in Partial Fulfillment of the Requirements of the Degree of
Master of Aeronautical Science
Embry-Riddle Aeronautical University
Extended Campus
Hill AFB Resident Center
March 2005
Adrian J. Xavier
This Graduate Research Project
was prepared under the direction of the candidate’s Research Committee Member,
Dr. Wendell Smith, Associate Professor, Extended Campus,
and the candidate’s Research Committee Chair,
Dr. Roger Lee, Associate Professor, Extended Campus, and has been
approved by the Project Review Committee. It was submitted
to the Extended Campus in partial fulfillment of
the requirements for the degree of
Master of Aeronautical Science
Dr. Wendell Smith, J.D.
Committee Member
Dr. Roger Lee, Ph.D.
Committee Chair
The researcher would like to express appreciation to his wife Sharon, his
colleagues in the USAF Technical Coordination Group, his International Officer friends
at Hill AFB and especially Mr. Gordon Dupont, CEO, System Safety Services whose
expertise, advice and tutorledge have been the foundation for this research.
Researcher: Adrian J. Xavier
Title: Managing Human Factors in Aircraft Maintenance through a
Performance Excellence Framework.
Institution: Embry-Riddle Aeronautical University
Degree: Master of Aeronautical Science
Year: 2004
U.S. statistics indicate that 80% of aviation accidents are due to human errors with 50%
due to maintenance human factor problems. Current human factor management programs
have not succeeded to the degree desired. Many industries today use performance
excellence frameworks such as the Baldrige National Quality Award framework to
improve over-all organizational effectiveness, organizational culture and personal
learning and growth. A survey administered to a sample population of senior aviation
maintainers in 18 countries revealed a consistent problem with aviation human factors
and the need for a more integrated framework to manage human factor problems in
aviation maintenance.
Background of the Problem 1
Human Factors History 3
Current Human Factor programs in Aircraft Maintenance 5
Performance Excellence Framework 6
Researcher’s Work Setting and Role 7
Statement of the Problem 7
Human Factor Errors in Aircraft Maintenance Statistics 8
Current Human Factor Programs in Aircraft Maintenance 13
Aviation Performance Excellence Framework 12
Statement of Research Question 18
Research Design 19
Research Model 19
Survey Population 19
Source of Data 20
Pilot Study 20
The Data Gathering Device 21
Distribution Method 22
Instrument Reliability 22
Instrument Validity 22
Treatment of Data and Procedures 23
Human Factor Programs and Management 24
Most Common Outcomes of Safety Occurrences 25
Survey Feedback 28
Table Page
1 Boeing Field Test with MEDA 8
2 1997 Survey by Australian Transportation Safety Bureau 9
3 Asian Study survey comparison between 1999 and 2003 11
4 Several UK Maintenance Error Management System (MEMS) data 12
5 Survey Demography 20
6 Survey coverage and objectives 21
7 Human Factors Management Survey 24
8 Most common Outcomes of Safety Occurrences 25
9 Most common Outcomes of Safety Occurrences 26
10 Top HFIM drivers that need reviewing 26
11 Performance Excellence Framework in relation to HFIM 40
Figure Page
1 The role played by human performance in civil aircraft accidents 2
2 Human Factors History 4
3 Maintenance Error Decision Aids 6
4 “The Dirty Dozen” 13
5 Misfortune Muphy’s Slot Machine. 15
6 Baldridge Criteria for Performance Excellence Framework 16
7 Influence of experience on human factor management survey 27
8 Breakdown of results of those who “strongly agree” that they have a 27
structured HFIM program
9 Human Performance X’cellence Model 37
10 Human Performance Excellence Model 39
Background of the Problem
Imagine you are a member of an aviation organization, such as the military, and you
have just been told that you will need to work over the weekend because there has been a
fleet grounding issue on your F-16 aircraft. You will need to work to get all the aircraft
inspected by Monday morning. You have just put in close to 60 hours of work that week
and you are really tired. Your organization has sent you for Human Factors (HF) training
and workshops and your management has told you to call for time-out when you feel
tired yet they say there is an urgent need to get the aircraft inspected over the weekend.
Although your body tells you that you can no longer take it, your mind tells you that you
must keep going and be a team player or else the whole team will fail in this important
mission. As you console yourself on your way home, you are reminded of how many
times this year you have been doing this and the close encounters you have had with
making an error of judgment. You are immediately reminded of that famous lecture you
heard during HF training that “the chain is only as strong as its weakest link.” The next
morning, before you go to work, you hear that one of your friends the night before had hit
and damaged the aircraft nose landing gear with a Harlan tractor and now management
has called for an urgent safety briefing to remind everyone of the need to be vigilant and
aware of such lapses in judgment. You immediately recall how one of your colleagues
had been screaming to remove the Harlan tractor or Toyota tractor because they both had
exactly the opposite reverse gears, in one you push the lever forward and the other
backward. Does this sound far too familiar?
Today, more than ever, the aviation world is faced with the constant challenge of
addressing human factors in maintenance. While there have been several advances to the
study and implementation of human factors programs, there are still several
inconsistencies to the way these programs are implemented and hence the varied results.
Aircraft maintenance work encompasses fast turnaround, high pressure with
possibly hundreds of tasks being performed by large numbers of personnel on highly
complex and technologically advanced systems in a confined area. It is very easy for
information and tasks to fall through the safety net. Events around the world in the late
1970s, 1980s and early 1990s, involving crashes or serious accidents with aircraft, alerted
the aviation world to the fact that although the aircraft were becoming much more
reliable, the human being in the process had the potential to obliterate any of these
technological advances. The role played by human performance can be found below.
Figure 1: The role played by human performance in civil aircraft accidents.(IATA, 1975)
In this research project we will analyze the top human factor problems in aviation
maintenance and evaluate a holistic solution to addressing these problems through a
performance excellence framework. We will start with a brief look at the history of HF
programs and the changes that have taken place over the years. We will also explore the
current HF programs adopted by several organizations and try to understand why HF
error occur, and how comprehensive, the solutions currently adopted. Then finally, we
will look at the Baldridge national quality program and criteria for performance
excellence to see if we can formulate a more comprehensive solution to managing HF in
maintenance. In essence, we would be looking at a more systemic solution to HF
management as HF is more than just about people.
Human Factors History
In the late 1970s, Cockpit Resource Management (CRM) featured prominently in pilot
training. The term was used to apply to the process of training flight crews to reduce pilot
error by making better use of the resources on the flight deck. A change in name was
made from Cockpit to Crew Resource Management (CRM) to change the emphasis of
training to focus on cockpit group dynamics. Some airline programs dealt with specific
topics such as team building, briefing strategies, situational awareness and stress
management. (Byrnes and Black, 1993). In the early 1990s, CRM training began to
reflect the many factors, such as organizational culture, within the aviation system in
which the crew must function which can determine safety.
Similarly, but much later, it was not until in the 90s that Maintenance Resource
Management (MRM) was made available to maintenance personnel. After years of
accidents, many caused by HF errors, nothing significant was really done to determine
the HF root causes. Unlike CRM, MRM was very new to the aviation maintainers and it
was not until June 10, 1990 when a cockpit window blew out at 16,000 feet, and a pilot
almost went with it, that an in depth look at the contributing factors to a maintenance
error were examined. (System Safety Services, 2000). David King, from the United
Kingdom is one of the first to look at HF in the same light it is looked at today.
Operations (Pilots)
Training Ops-Logs Interaction
Crew Resource Maintenance
Management for Resource
Pilots Management
Timescale CRM Spate of Birth of HFIM
68 70s 80s 90s 98
FAA began a
Spate of series of
• 1st Human Factors
Useful accidents Symposium (CAA,
meetings to
caused by FAA, Trans Canada)
Lessons deal with HFIM
• ICAO amends
chapter 6 to include
HF training (JAR 66,
More attention paid Module 9)
by Investigators on
maintenance errors
Figure 2: Human Factors History. From Xavier.A , 2005.
The need for a change in approach to human errors and their reporting was
reinforced during the CAA sponsored 12th Symposium on Human Factors in Aviation
Maintenance that was held in Gatwick Airport, England, on 10-12 March 1998. It was
the first of the international symposiums involving the CAA, FAA and Transport Canada.
The foundation of Human Factors training as a modern aviation tool was probably
initiated in the United States at a workshop sponsored by the National Aeronautics and
Space Administration (NASA) in 1979. This workshop was the development of NASA
research into the causes of air transport accidents. The International Civil Aviation
Organization, (ICAO) now requires organizations to include HFIM training. HF training
which helps our fellow maintenance personnel to avoid an error he/she never intends to
make had finally arrived (System, n.d).
Current Human Factor Programs in Aircraft Maintenance
MRM which later evolved into Human Factors in Maintenance (HFIM) was
developed to provide primarily the training required to understand and prevent HF errors
from occurring. The main breakthrough that was achieved in recent years is the emphasis
given by senior management in organizations to HF programs. Many consultants and
companies have enjoyed this upward focus on HF. Gordon Dupont, formerly of
Transport Canada, is one such consultant whose excellent “Dirty Dozen” classification of
HF root causes has been widely adopted by several aviation organizations. Other
organizations like Boeing have developed their own in-house Maintenance Error and
Decision Analysis (MEDA) programs with more in depth analysis including the
background of personnel that commit these HF errors to better understand the extent of
solutions necessary. Most of these programs are designed to identify the HF errors,
educate the personnel on their causal potential, suggest ways to contain and correct the
problem and create a HF error-free environment. While many of these programs have
truly made the aviation work environment safer, many of them still look at HF from a
‘people’ perspective rather than “an organization” perspective. There may be a need to
develop programs that improve the performance of all areas of an organization as a whole
which will provide long term solutions to HFIM.
Figure 3: Maintenance Error Decision Aids. From SIA, 2000.
Performance Excellence Framework
Performance Excellence Framework (PEF) has been used in several countries and in
several sectors such as Education, Healthcare, Tourism and Housing. Most recently, the
Defense industry has been using such framework to gauge its quality health. One of the
first of such frameworks, established in 1988, is the Malcom Baldridge National Quality
Award (MBNQA) framework which covers all areas of a business such as Process
Management, Information Management, Strategic Planning, Human Resource
Development and the Use of Results (Hertz, 2004). The key thrust for performance
excellence is to establish a culture of continuous improvement and innovation that builds
upon a strong foundation of quality, professionalism and team excellence always.
Researcher’s Work Setting and Role
The researcher has been an officer of the Republic of Singapore Air Force (RSAF)
for 10 years. The researcher has held the equivalent rank of Major since 2001. The
researcher has held positions as a deputy Officer Commanding Quality Assurance and a
Flight Commander at an F-16 Air Force Base in Singapore. Currently the researcher is
the Senior National Representative of the Republic of Singapore Air Force at the Ogden
Air Logistics Centre (OO-ALC), Hill AFB, Utah. The researcher received his Bachelor of
Engineering in Mechanical Engineering with specialization in Advanced Aerospace
Materials from Bristol University, United Kingdom in 1995.
Statement of Problem
U.S. statistics indicate that 80% of aviation accidents are due to human errors
with 50% due to maintenance human factor problems. Most programs currently
implemented are designed to identify the HF errors, educate the personnel on their causal
potential, suggest ways to contain and correct the problem and create a HF error-free
environment. However, the percentage of HF errors in aviation mishaps is on the rise
today. There is a need for a more integrated and holistic approach to HF management.
Limitations and Assumptions
Due to the limited funding and time, this researcher will limit the surveys to the
Senior National Representatives (SNR) in OO-ALC/YPX to provide a summary of their
countries perspectives on HFIM Management. Research results of the survey will be
assumed to be representative of possible results from similar units within their respective
Air Force.
Summary of Relevant Data
Human Factor Errors in Aircraft Maintenance Statistics
In the United Kingdom (UK) between 1982 and 1991, there were 1,270 Mandatory
Occurrence Reports (MOR) which involved maintenance errors submitted to the CAA
Safety Data Department (CAA, 1992). Of these, only 230 resulted in an unexpected or
undesirable occurrence that interrupts normal operating procedures that may cause an
accident or incident. The CAA concluded that there was no significant risk to the public.
In the period 1992-1994, however, there were 230 MORs and in 1995 to 1996 there were
534. The number of reported errors was occurring at a greater frequency. Similarly a
study by Boeing in 1993 of 122 occurrences between 1989 to 1991 revealed that 56% of
human factors errors resulted in omissions with a further 30% resulting in incorrect
In a field test by Boeing in 1994 to 1995 with nine maintenance organizations, the
main types, causes and results of errors are summarized below (Boeing, 1996).
Table 1
Boeing field test with MEDA
1. 2. 3.
Operational Events Maintenance Error Types Contributing Factors
3 Top Items :-
Flight Delay Improper Installation Information
(30%) (35%) (50%)
Aircraft Damage (23%) Improper testing Communication
(15%) (42%)
Air Turn Back Improper servicing Job/Task/Environment
(15%) (12%) (40%)
In 1998, the Australian Transport Safety Bureau (Hobbs & Williamson, 1998)
surveyed close to 1400 Licensed Aircraft Maintenance Engineers (LAMEs). The most
common outcomes for airline related maintenance occurrences were:
1. Systems operated unsafely during maintenance
2. Towing events
3. Incomplete installation
The most common outcomes of non-airline occurrences were:
1. Incorrect assembly or orientation
2. Incomplete installation
3. Persons contacting hazards
The most common causes to these unsafe acts are summarized below.
Table 2
1997 Survey by Australian Transportation Safety Bureau
Occurrence Causes and Airline Non-airline
Contributory factors
Pressure 21% 23%
Fatigue 13% 14%
Coordination 10% 11%
Training 10% 16%
Supervision 9% 10%
Lack of Equipment 8% 3%
Environment 5% 1%
Poor Documentation 5% 4%
Poor procedure 4% 4%
A ground crew attitude survey in the military in Asia (classified source, n.d)
revealed similar findings to that of the Australian Transport and Safety Board. The
surveys were conducted bi-annually from 1999 to 2003 on approximately 2500 aviation
technicians. In the survey conducted in 1999, the top three violations were:
1. Servicing without a checklist
2. Speeding
3. Omitting job steps
Approximately 20% of those surveyed disclosed that they would violate rules daily
or once a week. The top three reasons for these violations were:
1. Too much work, too little time
2. Insufficient manpower
3. Time pressure to complete duties
In 2003, when the survey was conducted again, several key initiatives had been
implemented to address HFIM such as :
1. Implementing a Human Factor training program initiated by Mr. Gordon
Dupont, Chief Executive Officer (CEO), System Safety Services in 1999.
2. Training 100% of the licensed aircraft engineers in Human Factors
3. Implementing a MEDA type Human Error Analysis Tool (HEAT).
4. Embracing a local version of the Malcom Baldridge Performance Excellence
Framework for the military over six years from 1998.
5. Embracing additional performance excellence measurement tools such as the
Balanced Score Card and Enhanced Value Organization principles.
The survey results comparison between 1999 and 2003 revealed the following
significant improvements.
Table 3
Asian Study survey comparison between 1999 and 2003.
Survey Coverage Results
99% agreed that the organization placed strong
emphasis on safety and quality. Personnel also agreed
Safety Culture (new) that management (96.43%), supervisors (97.30%) and
personnel (94.38%) showed strong emphasis and take
safety / quality seriously.
Top 4 reasons remain unchanged. “Easy way out
(taking short cuts)”, which registered an increase of
Reasons for Violations × 11% (13% to 24%), has emerged as the 5th reason.
"Lack of proper tools", the 6th reason, registered a
significant increase of 14% (7% to 21%).
Overall reduction of 4% (14% to 10%) was noted for
Types of Violations the 6 common types of violations observed everyday
and once a week.
Improvement of 22% (21% to 43%) that violations
Frequency of Violations
observed were “very infrequent.”
Reduction by 11% (50% to 39%) in holding back to
Calling Timeout
call timeout.
Reduction by 16% (49% to 33%) in frequency
Overtime Management
(weekly) of overtime.
Improvement of 16% (66% to 82%) that open
Open Reporting Culture reporting is being practiced widely in the
98% (an improvement of 8%) agreed that
Safety/Quality information are readily available.
Safety / Quality
Management are also conducting briefings and
disseminating safety/quality information more
frequently, matching closely to that desired in the
previous survey.
Several UK maintenance organizations have pooled their Maintenance Error
Management System (MEMS) data, using a common MEDA taxonomy. The initial
results were presented at a MEMS-MEDA seminar in the UK in May 2003, a selection of
which is listed below.
Table 4
Several UK Maintenance Error Management System (MEMS) data
1. 2. 3.
Improper Installation Improper Fault Isolation Improper Servicing
3 Top Items :-
Incomplete Installation System not Re/Deactivated Service not performed
Wrong Orientation Not properly tested System not Re/Deactivated
System not Re/Deactivated Not properly inspected Insufficient fluid
3 Top Factors :-
Individual performance Individual performance Information
factors factors
Information Information Communications
Technical Communications Individual performance
knowledge/Skills factors
The maintenance error trends in US, Australia, Asia and United Kingdom from 1982
to 2003 are alarmingly similar and they continue to plague the aviation industry and in
some areas of aviation such as in the military. The trends in maintenance human factor
errors have continued to increase. A closer look at the statistics indicate that these trends
are due mainly to lapses in the organizational operational culture and business processes.
Time pressure seems to be the main factor due to lack of manpower and excess workload.
In recent years, HF training has focused on these lapses in rules and the detrimental
consequences of such actions. There is still an uptrend of these maintenance errors and
violations in the aviation maintenance field.
Current Human Factor Programs in Aircraft Maintenance
Several HFIM courses have evolved since ICAO required HFIM training which
include those by the UK CAA, FAA as well as JAR compliant courses to ensure
consistency and conformance to minimum standards set out by the governing bodies. A
typical HFIM course such as the one developed to comply with JAR145-12 includes:
1. A General introduction to Human Factors
2. Safety Culture/Organizational factors overview
3. Human Performance, limitations and Human Error models
4. Environmental issues impacting Human Performance
5. Procedures, Information, Tools and Practices
6. Professionalism, Integrity, Communication and Teamwork
7. Organization HF program including the management of HF errors
Gordon Dupont, formerly from Transport Canada, now CEO of System Safety
Services, is a renowned human factors proponent and conducts several of his HPIM
courses all around the world in the aviation sectors. He is best known for his “Dirty
Dozen” posters which depict the most common 12 human factor errors in maintenance.
Figure 4: “The Dirty Dozen.” From Gordon Dupont, System Safety Services.
Gordon conducts three workshops, HPIM Part One to Part Three, and covers areas
such as the background to HFIM behaviors and errors through case studies,
organizational culture and risk management and ways to manage them.
As can be seen from the typical course structures above, current HFIM courses
generally adopt the three E’s or Educate personnel, Equip personnel with the tools
necessary to contain, correct and prevent HF errors and Evaluate the management of
HFIM programs. This in essence is the main coverage for most HFIM courses and
programs adopted by commercial airline and other aviation industries.
Professor James Reason and his “Swiss Cheese” model propounds that there are
several latent conditions prior to an active failure or unsafe act. These failed or absent
defenses line up to cause a mishap or injury waiting to happen. Interestingly, one of the
first lapses in defenses in his model starts at organizational influences as can be seen
from the model below. Gordon Dupont, CEO, System Safety Services modified James
Reason’s “Swiss Cheese model” incorporating his famous “Dirty Dozen” human error
factors as the preconditions to unsafe acts which could eventually cause an
accident/incident. Gordon attributes 70% of accident causation to fallible decisions by
management, deficiencies in line management and the preconditions which are the “Dirty
Dozen” human error factors. (G. Dupont, n.d)
Active &
Active Failures
Incident Drip Tray
Latent Conditions
Latent Conditions
Latent Conditions
Figure 5: Misfortune Muphy’s Slot Machine. James Reason’s Model of Accident
Causation modified by G. Dupont.
Aviation Performance Excellence Framework
More than 66 business excellence awards in 43 countries have been established
adopting similar frameworks to the MBNQA framework. One of the many objectives of
this framework is to create the values desired by businesses and customers and build a
system which can sustain a competitive edge for an extended period of time. Most of
these performance excellence frameworks have seven main criteria areas namely:
1. Leadership
2. Strategic Planning
3. Measurement, Analysis and Knowledge Management
4. Human Resource Focus
5. Process Management
6. Customer and Market Focus
7. Business Results
Figure 6: MBNQA Criteria for Performance Excellence Framework
One of the main objectives of the framework criteria is to motivate an organization
into creating strategies, systems and methods of achieving excellence, stimulating
innovation and building knowledge and capabilities. Achieving the highest levels of
business performance requires a well-executed approach to organizational and personal
learning. This will result in not only better products but also move toward being more
responsive, adaptive, innovative and efficient thus giving an organization marketplace
sustainability and performance advantages while it gives employees the satisfaction and
motivation to excel (Hertz, 2004).
Today, the main focus in many businesses is the relentless pursuit for innovation.
Innovation means making meaningful change to improve an organization’s products,
services and processes and to create a new value for the organization. Organizations
should be led and managed so that innovation becomes part and parcel of the learning
culture and is integrated into daily work. The use of a balanced composite of leading and
lagging performance indicators measures the effective means to communicate short and
long term priorities. It also helps monitor performance and provides a clear basis for
improving results. The adoption of this framework constitutes a systemic approach to
managing an organization and is proposed in this paper as a necessary means for reducing
significantly aviation’s “Dirty Dozen” maintenance human factor issues. Several defense
related organizations have adopted this framework and tailored it to their needs. Some of
the key realigned objectives from the framework can be found below. The MBNQA
framework has been adopted by many sectors in the industry namely health, education
and most recently in the defense industry in Asia over the last 10 years. The framework
provides excellent criteria for organizations to follow to permeate a culture of excellence.
Most relevant for the defense industry, and to human factor management, are the four
main areas of the framework namely:
1. Leadership and Organizational Culture
2. Measurement, Analysis and Knowledge Management
3. Human Resource Focus
4. Process Management
The key objectives for the Malcom Baldridge National Quality Award framework
for performance excellence can be translated to key objectives for a successful Human
Factor program.
Statement of Research Question
Since the dawn of aviation, the aviation maintenance community has been constantly
motivated to reduce human factor errors and its operational/organizational impact. Most
programs currently implemented are designed to identify the HF errors, educate the
personnel on their causal potential, suggest ways to contain and correct the problem and
create a HF error-free environment. While many of these programs have truly made the
aviation work environment safer, human factor errors still continue to persist today.
There is a need for a more integrated and holistic approach to human factor management.
Research Design
The research design used for this study was the self-report descriptive research
method. A quantitative descriptive approach will be used to collect and assess the data.
Survey results were the sole source of data collection for this study.
Research Model
The researcher has collected a wealth of HFIM data and results from organizations
in Asia, Australia and the United States to understand the current state of HFIM and the
initiatives currently implemented. The researcher used a survey that will be e-mailed to
25 OO-ALC/YPX Senior National Representatives (SNR) representing close to 18
countries with military ranks ranging from Major to Brigadier General at Hill AFB. The
survey was administered to ascertain the effectiveness of human factor management
through various programs and initiatives adopted.
Survey Population
The survey population for this study is 25 SNRs. The sample population for this
study is 25 SNRs assigned to the OO-ALC/YP, which is located at Hill Air Force Base,
Utah. The SNRs with ranks from Major – Brigadier General represent 18 countries
namely :
1. FMS countries – Pakistan, Oman, Korea, Greece, Thailand, Israel, Turkey, Italy,
Singapore, Venezuela, Taiwan and Egypt .
2. EPAF (European participating) countries – Belgium, Norway, Holland,
Denmark, Portugal and Germany.

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