Rajesh M9 Notes

MESH​- managing engineering safety health

NIHL- noise induced hearing loss
MEDA- maintenance error decision aid
ADaMS- aircraft dispatch and maintenance safety
MEMS- ​maintenance error management system (investigate all incidents and accident)

Reason model​ (or)​Swiss cheese model- ​based on​ defense's.

REASON MODEL- preventive measures

Task and procedure ​checked from maintenance manual

Accident prevention manual is collection of ​all accidents and originates.

Light and noise ​result in intended​ respect of nervous system.

Hazardous substances- tank sealant , ………… structural chemicals

Toxic substance : Sealent.

Potential hazard- X ray as NDT

Above 110 db- ​not exceed 12 min , in 8 hr period.

Hangars lightening area- ​ceiling mount unit

Task lighting :200 - 500 foot candle

Area lighting( hangar) : 100-150 foot candle
Facility Lighting: not brightness than 20 lux

Through SHEl and reason model it is not difficult​ to see​ why and where ​error was occurred.

SHEL ​environment​- work pattern, management structure and public perception to industry

Sleep }
Diet. }. Have determinal effect of
Physical exercise}. such effect on performance
Intake of caffeine}

Environmental stress can result in ​physical and mental impairment.

Handover or turnover ​is identified as the most contribute cause in several accidents.

Safety audit ​- minimise or prevent error

Argonomics relate to human being is ​liveware-workplace & workplace-working.

Human body Measurement , dimensions- ​Anthropometry

Movement, strength, length, leabrag - ​Biomechanics

Reason model based upon ​defence.

Load and intense sound- ​result in lightening response of nervous system.

--When working with bright light consideration given to ​Glare.

-- to focus ​near object​ lens must be ​thickened
--​ human eye can differentiate ​1000 colours

Shape of lens can be altered to produce sharp image on retina by action of ​Ciliary Muscles

--Cornea- 70-80% focusing

- Light enter through cornea
--Iris - ​controls the amount of light to enter
--Rods- peripheral vision
--Retina- back of eye with optic nerve
Centre of retina is fovea
Image formed on retina is inverted related to viewers normal perception of image, ​the viewer
will behave and feel normal

- hypermyopia: shorter than normal eyeball

( Behind retina image form)
Convex lens
Long sightedness

Max allowable noise dose- ​any combination of noise and time which exceed 90dB TWA

Iconic memory- storage of visual information up to ½ second

Echoic memory- storage of sound and last upto 2 seconds

--Ultra short memory- up to ​2 seconds

--Short term memory- ​end of the series.
Motor memory ( short term memory) - 10 to 20 seconds.
7 chunks of information
Susceptible to interference from external influences
7+-2 ( 9-15)

--Long term memory- storage ​unlimited

Long term improved by training and instruction.
Information in Long Term Memory is easily lost
Episodic memory refers to memory of special

Motor Programme- stores as working rules in long term memory

Motor programme- ​learned behaviour that does not require concious thought
Motor Programme - Skill Based

--Selective attention- general background noise can be filtered out.

Cocktail party
Distraction is negative side of selective attention

--Divided attention- ​person monitor several sources of input.

Cycle of sleep- ​every 90 min

Phase ¾ sleep- most beneficial for body.

Risk management decision- ​risk can be taken by managerial person.

Viewing distance
Main panel : 71-78 cm
Over head panel : 20 cm
Lateral system. : 2 m

Task analysis​ - actual and end user, common source of error.

Accidentally mostly happen due to not only single cause/ error - ​Human Action and Machine
Failure/ Latent failure.

Active and latent failure - ​human system and management

Active and latent failure- often beach defence

Active and latent failure well guarded - not often breach defence

--failure caused by direct contact with system is ​Active failure​ .

Active Failure- ​error and violation, having an immediate adverse effect.

Eg:
1) a man ​is there tow buck ,
2) he drive at high speed and hit the aircraft structure
3) Tow tractor did not apply brake
4) Tow tractor fitted from ramp and aircraft
5) Does not brake and Tyres and crashed into another aircraft causing damage
6) Person while taxing the aircraft is driving to fast and into another aircraft causing
damage

Latent Failure- ​decision or action which may remain dormant for long time.

Latent failure ​result of decision or action well before an accident .

Latent Failure- ​cause other than human action that lead to an accident. ( Also known as human
error)
Active to latent failure ratio is 1:3

Risk management-
1) Hazard assessment
2) Risk assessment
3) Hazard elimination
4) Hazard reduction

Safety is judged , not measured.

ICAO consideration- ​accident system regardless of their origin

Positive Environment- ​open system

Dynamic display- ​Altimeter

Static display-. Placard, boards

According to SHEl all components should have ​interface mismatch.

In sHEL model, ​Liveware cannot be controlled substance, difficult to protect from error by
“designing out” or “working around”.

Eye position guidance- ​risk of visual illusion can be alleviated

MEDA:
1) vibration that make instrument reading difficult or induce fatigue for hands or
arms
2) Insufficient lightning for reading instructuions or placard. Conduction visual
inspection on performing task.

Skill base mistake - daily base

- In computer system called as “fat figuring”

Ambient temperature​ is the most important environment factor for AME.

HF syllabus contain - ​Theoretical or practical based.

Communication ​causes most a/c accidents

?????​ Maintenance related accident continuing factors:

A) A/c design
B) Communication
C) Improper procedure and task
D) All. ✓

--Alcohol ​“‘increase mental and physical reaction time “and “decrease body temperature
and quality of sleep”

--Blood Alcohol Ratio - 0.02 & greater.

-- a person may not fit to go on duty ​even 8 hours a

​ fter drinking large amounts

Operators develop safety for ​continued operations.

Error Capturing ​include​ ​post task inspection.

Accident/ incident report causes of accident attribute to organisation ​inadequate safety

oversight.

Corporate culture - 3

Guidance for HF Training - ​ICAO doc 9683

Error tolerance- ​ability of system to accept an error without a catastrophic failure

Insomnia- ​have difficulty in sleeping or poor quality of sleep.
Clinical Insomnia: caused by CAFFEINE
Primary insomnia- when occurring under normal conditions and in phase with body rhythms.

Hyperthermia- ​decrease in body temperature

( If someone is hypothermic , ​warm then up ​)
Hyperventilation- ​short of oxygen and rate of breathing

Hypoxia- ​less oxygen carried in blood to eyes

Hypoxia impair the sensitivity of rods and hence have determinal effect on eyesight

CAA standard for vision - ​acceptable corrected vision

--Troubleshooting - ​rule based.

--Visual inspection by experienced engineers is ​knowledge and rule based behaviour
--Experienced engineer fits the wrong seal during routine component change - ​Rule based
-- ​Engineer working on wing , kicks spanner off into engine cowl and breaks sensor - ​Skilled
Based Error
-- ​engineer forgets to fit a seal to engine drain plug - ​made error of omission

--Mistake- ​unintentional error

--Violation - deliberate departure from rules
--Violation- usually carried out with best intentions from a genuine desire to get job done
-- ​violation quite unrelated to actual task- ​optimising violation

Circadian rhythm- ​the cycle of body temperature , sleep requirement and alertness.
-varies by 1.5°F.
Circadian rhythm ​control ​body temperature
( 24 hr cycle) and ( 25 hr in man )

Working outside and temperature at 55°F will have a effect on hand dexterity ​around 50%.

--Human eye most of the refraction required to bring an image into focus on retina as
accomplised by ​Cornea.
--​light enter ratio​ 5:1
-- presbyopia - 40 age ( presbycusis - 30 age)
Person with presbyopia , ​wear spectacle when reading or carrying out close work.
-- cones - 7 min
Roda - 30 min
-- ​colour blindness​ - difficult to identify red
and green
 - Almost 1 men out of 10

CAA standard for vision- ​Acceptable corrected vision

Effective group- ​everyone contributes in same way.

--AWN 3 - ​responsibility of licensed AME

--AWN 47 - ​Influence of AME of drink or drug ( or) does not report for work if unfit.
-- AWN 47 does not mention Melatonin

Peer Pressure- ​your collegue exerting pressure so that they can go home
- It is the perceived pressure to conform what u believe your colleagues expect of u.
- Confirmation bias : ​subconscious attention to evidence which confirms an engineer
believes and an attention to evidence which contradict his beleif.

Hearing test- ​able to hear conversation in quite room at ​2 meter ( 6 ft )

Aural reflex - protect for 15 min

Written communication- most effective.

Iconic - upto ½ seconds

Echoic - upto 2 seconds

First stage in information processing is​ perception.

Concentration of mental effort on sensory or mental events is ​Attention.

Large caffeine - ​cause anxiety, headache and stress

Symptoms of stress- ​irritability, forgetfulness, sickness, absence from work drug and alcohol
abuse.

Sleeping tablet - ​slow reaction time and dull senses

Up to 200- 300 metres ​proximity an a/c with engines running in use of protection recommended
for maintenance personnel.

--Airside ramp vehicle driver​ get deaf at ​right ear.

-- high pitch sound ​is​ ​usually impaired with onset of presbycusis.
Mistake - planning
Slip - execution
Lapse - memory/ storage.

Symptoms of de motivation is ​stress.p

Ergonomics audit AMO in a task done ​pre maintenance and post maintenance

Hypoxia, Hyperventilation, Anoxia lead to fatal consequences.

Optical support ​can minimise visual illusion

​ otice to minimum visual error notice should place

N
1 ) below shoulders
2) above shoulder
3) shoulder level ✓
4) above heal​.

As per SHEL model and REASoN, ​one tune maintenance ​contribute error.

--Natural culture- ​different language but different use of same language.

--Country culture-

In hangar after sweating the temperature is ​37°C.

Constant body temperature our body is trying to maintain​ed during maintenance work - ​37°C.

Being Subconscious - ​Lack of Awareness.

In a/c accident, in maintenance point of view ​_____​shall be taken.

1) Error analysis ✓✓✓
2) Misbehavior analysis
3) Manipulating analysis

●
In maintenance a complete maintenance involve ​broad range of tools.

Supervisor should consider ​suitable lighting ​for AME.

Error:
1) Induced​ by poor design
2) May result from normal reaction of person to particular decision
3) Negligence or poor design
Information is processed and analyse ​commercial consideration .

Social Loafing​ - they consider that their own efforts will be pooled with that of other group
members and not seen in insolation.

Physiological effect- ​Alcohol, diet, health and fitness.

A man takes complete nutrition and diet but still absorb alcohol and tobacco , his problem is
Psychological

As a review person u can improve u can improve AMP by ​consulting senior person of
management.

Communication ​is the maintenance related most contributing error

In Aviation meeting involving management and line worker should be ​good atmosphere , any
topic brought to table should be discussed openly, and it should be logical.

Omission ​is the main cause of incident.

---omission 56%
Incorrect installation 30%
Wrong parts. 8%
Others. 6%

Class of strategies is ​Error reduction rate.

In HF dangerous means ​risky and dangerous

Most important in safety program and feedback system is ​implementation, continued

operations and visible support of company safety programme.

Meeting of Management authority and line operation should be ​good atmosphere and any
topic on table

Lack of communication between airline and maintenance organisation ​very serious impact on
airline operation.

If you want to change something and design factor- ​Practical Approach

Regular behaviour of individual is ​Habit

Human error category -

 1) Error reduction
2) Error capturing
3) Error tolerance
4) All​ ​✓✓✓✓✓

Human error caused by low body temperature.

Employers must provide their employees with personal care protection if ​noise level exceed
85dB.

--When a composition of function of a system is harder to conceptualize for engineer it's

opaque to engineer
-- Complex system in terms of one person conception is said to be ​OPAQUE

--Perforated ear drum - less than 8000 Kz

--Frequency injurious to hand- 100 to 150 Hz
--Greatest sensitivity-. 3000Hz
--Ear detect ​Acceleration
--Conductive deafness caused by damage to ​Cochlea

Intensity level of propeller a/c at 300m is ​100dB

Intensity of jet a/c is ​110 dB
Threshold pain- 140 dB
Immediate hearing damage - 150 dB

BMI
Below 18.5- underweight
18.5 - 24.9 - healthy
25- 29.9 -. Over weight
Above 30 - obese

Doom wath time :. 2-4 am

Mode of communication are ​information, ideas, feelings, and attitudes/ beleif

Spiral orientation- visual inspection

Reduce human error by “training”

Statistics​ can be understanding the nature of accident and devising preventive measures.
Hf performance depends upon sensing and processing ​ability to remember

Ability to remember is
1) Limited source called memory
2) Essential for information processing ✓✓✓✓
3) Both

On the basis of HF , error management programme ​actions are most always constrained

High pitch sound​ - person most susceptible to injury or damage

Large organisations classification of individual is as per ​APTITUDE

Earplug - passive device

Ear muffs - active device

Attributes related to safety issues of an individual ​motivation,skill level and violence

Ambiguity and uncertainty may occur when this sensed information is processed by brain and
combined with ​emotional factor, past learning, expectation / experience.

Engineers take common sense steps to maintain their health and fitness , known as ​POSITIVE
MEASURES

Which have a detrimental effect on performance, choose the wrong one

1) Diet
2) Abnormal sleep pattern
3) Physical exercise ✓✓
4) Intake of alcoholic substance

When one addresses the error directly ​Error Reduction

Eg : improving access to part, improve lightning and better training for maintenance
technician

There are many types of error occurs related to task which of the following is not true i.e there is
no probability of error :
1) One time task ✓✓
2) Complex task

Semantic is more accurate and long lasting than episodic memory.

Risk assessment- necessary to identify where equipment/ procedure might fail

Risk assessment and management:
Reduction of risk to tolerate level & monitoring situation.

Fascination- high workload, workload is low and tedium prevails

Facility Lighting in hangar should be ​provided by fixed lighting units giving light to shadow
ratio of 3:1

Stall warning using stick shaker is example of ​Tactile display

Auditory system- Omnidirectional

By providing good training we can improve

1) Productivity
2) Workers satisfaction
3) Both ✓✓

Error Management programme - ​Achieved

L-S : conspicuous in accident reports, difficult to solve

Company safety policy- MOE

Human error - 80%

B737 lost oil pressure and had divert- ​HP rotor drive covers of both engines had not been
refitted after boroscopic inspection

Inflight shutdown- ​incomplete installation

Most engineering accident- ​installing components incorrectly

Mindset- ​You are unwilling to change ur mind about something

Poking sharp objects in ear - ​Tympanic Membrane Perforation

Attention getter: ​Get operator full attention

Otolith detect- linear acceleration

Generally true that group decisions are ​better ​than average individual decision within group

Whose responsibly to minimise HF incidents in company:

1) AM
 2) Manager
3) Everyone✓✓

Good team where everyone has ​INPUT

Successful working teams have , ​members participate in team activities but retain their own
individual requirements

Organisation which practice HF there is

1) No blame culture
2) No blame unless there is deliberate violation✓✓✓
3) Punishment for violations

Ideal behaviour of professional a/c engineer

1) Goal directed rather than person directed
2) Both person and goal directed ✓✓
3) Neither person nor goal

Effwct of having Hypertension- ​Stroke

When person gets older , his ​reactions decrease and become more accurate

Absenteeism indicate :
1) Active coping
2) Passive coping ✓✓
3) Cognitive coping

Acute stress: typically​ intense of short duration

Chronic stress: ​frequently​ occurring stress of long duration.

Smoking canabals: ​subtly impact performance up to 24 hrs

Human performance is better with less stress, and in the afternoon

1 unit of alcohol- ½ pint of beer

Presence of something damaging ones health is example of

1) Physical stressor ✓✓
2) Reactive stressor
3) Psychological stressor
---20 milligram of alcohol for 100 milligram of blood for commercial aircrew, air traffic
controller​ and ​80 milligram of alcohol for 100 milligram of blood for maintenance
engineering.

--Error Management programme- measurable and achievable

-- ​Error Management - ​control error and and eliminate the error rather than prevent the
error

-- ​amount of stress experienced with a particular task is ​perceived demand and perceived
ability

To minimise the chances of heart disease , recommend min amount of exercise is ​3 times a
week with heart rate doubling the normal rate for atleast 20 min.

Environmental Capture- ​same job on same type of aircraft

Which is true:
1) Noise affect the standard of work proportionally with level of noise
2) Noise does effect standard of work with certain people ✓✓
3) Noise does not effect standard of work

Cold stress can be influenced by

1) Insufficient vitamins in diet
2) The wind chill factor ✓✓
3) Drop in body temperature

Environmental stresses in an extreme high temperature and noisy environment causes;

1) Loss of attention and distraction
2) Attention to be disturbed and distributed ✓✓
3) Total loss of attention

Facility lightning in hangar should be ​provided by fixed light units giving light to shadow
ratio of 3:1

Task lighting in hangar is mainly ​portable so that individual task may be will lit.

Difficult type of ice to detect by ground crew is ​Glaze ICE

To Perform visual inspection, best condition set is ​Temperature, light and accessibility.

When describing tasks, the term complex system refers to

1) Fault finding
 2) Involve decision making rather than practical work
3) Broke down into many steps✓✓

Good scan - frequently and small

Good shift handover include details of

1) Task completed, task progress, their status and problems encountered; task to be
carried out and ​general company and technical information

Asynchronous communication- technical manuals, memos Advisory Circular and

Airworthiness Directives

Best handover is ​use of handover logs and breif by shift supervisor

To establish reliable means of communication between teams

1) Detail verbal communication is most effective method
2) Change over logs and verbal communication are essential✓✓
3) Detailed written handover is most effective method

Effective shift handover will comprise of

1) Shift supervisor informing personal of ongoing work
2) Outgoing and incoming personal indivisually handing over on-going task
3) Handing over task in designated area ✓✓

Explicit information= clear information

Important means of communication - ​Written
Effective form of communication - ​Verbal

--During ground run, engine fire, carried fire drill is ​RULE BASED ACTION
--Skill based behaviour - motor programme
-- Skill based mistakes- ​daily base
Torque wrench set incorrect- ​Constant error

Biggest risk of error associated with checklist is ​they invoke automatic response

Dealing with emergency-

Assess, make safe and then summon assistance.

When evacuating casualties ​first move walking wounded

Visual stimuli attract attention slower than auditory , but results in more accurate
response
Spatial Orientation involve visual function and vestibular apparatus of the inner ear

Mitigate adverse effects of noise on hearing, ergonomic

1) Source of transmission
2) Source of receiver
3) Both Tx and Tr. ✓✓

Intelligibility of wanted sound depends on ​signal to noise ratio

Effectiveness of dialogue btw human and machine needs ​proper design and location of
display

--When a/c goes to gate, ​investigation and corporate culture/ search for slow has to be
done
-- ​when a/c goes to gate, ​Event , decision, investigation, corrective action, feedback

Implementation, continued operations and visible support of company safety

programme:: ​SAFETY PROGRAM AND FEEDBACK SYSTEMS

To minimise safety risk, which aspect should bring in it

1) Motivation
2) Skill
3) Violence
4) All ✓✓✓

Attribute related to safety issue of individual:

1) Motivation
2) Skill
3) Violence
4) All. ✓✓✓

How a organisation basic risk management

1) Do not have any risk
2) Management is include for risk management. ✓✓
3) There is no program to management risk

SHEL and Reason model

1) Ontime maintenance
2) Complex maintenance ✓✓✓
3) Confusing maintenance

HF training syllabus- ​Theoretical, Practical or experience based.

Well team working - ​improve performance and improve efficiency

Human aspect and human element in common usage are helpful alternative to avoid
1) Ambiguity
2) Aid comprehension
3) Both. ✓[

W​ork will vary from person to person and depend on

1) Nature of task
2) Condition under which the word is carried out. ✓✓
3) Character of person carrying work

Stage 1- 4 : Non REM sleep

Stage 2-4 : slow wave sleep ( ​body tissue restoration)
Half of our sleep depend on ​REM sleep

LOFT increase situation awareness

Rapid breathing in minute: 70 bis

Human performance
1) Problem oriented
2) Discipline oriented
3) Experience oriented

Max accident takes place at ​Night time

Homogeneous - ​EFFECTIVE COMMUNICATION

For health implications, when more noise is Induced which is wrong statement
Permanent hearing loss

Attributes & facts about human actions and errors are:

1) Cause due to single error
2) Always carried out as intentional
3) Is almost always beyond individuals capacity ✓✓✓

Significant attributes related to accident and which consider error

1) Accident are only due to one case
2) Action performed beyond individua​l​ immediate $$
3) People do action which they do not intended