Thursday, January 1, 2009
Cessna’s Human Factors Training In A Class By Itself
Cessna Aircraft, a Textron company, reached a milestone in April 2008 when all employees in its nine Citation Service Centers in the United States completed the first round of a company developed, human factors (HF) training program. More than 1,400 employees, including some 1,100 A&Ps and maintenance technicians, took the four-hour introductory course.
What makes the milestone significant is that it marks the initial phase of one of the first in-house HF training programs approved for Part 145 certified repair stations by the Federal Aviation Administration (FAA). The U.S. agency advises that Part 145 repair stations adopt human factors training, and it provides guidelines for what it calls "maintenance management resource" training in AC 120-72. But the agency does not require HF training for centers maintaining general aviation aircraft. In fact, it doesn’t require the training even for those that work on aircraft flown by Part 121 carriers or operating under Part 135. The European Aviation Safety Agency (EASA) does require human factors training in all Part 145 facilities (under Part 145.A.30 [e] and CAP 716) and grants compliance to service centers that follow FAA guidelines.
To learn about Cessna’s human factors training, AM traveled to Wichita, Kan., and met with Stan Younger, vice president of service facilities, and Phillip Watkins Jr., manager of EHS (environmental health and safety) regulatory and training. Their offices are in Cessna’s largest service center, a 477,000-square-foot (44,315-square-meter) facility that can take in more than 100 Citation business jets simultaneously. It is located next to Cessna headquarters and not far from the sight of the manufacturer’s Citation Columbus design and assembly facility now under construction.
One Down, Four to Go
The recent HF training represents the first of a five-module program. The four succeeding modules will be held one each year. All of Cessna’s service center employees, including contracted workers, took the first module, which gives a broad overview of the five-year training program. According to Watkins, module one, which is FAA approved, also covers the "dirty dozen," an often-referenced list of human conditions that contribute to aircraft maintenance errors. (See list on page 13.) Citation Service Center employees are now taking the second HF module, covering three of the dirty dozen factors. The following module will cover three more of the dirty dozen; by module five, all of the dirty dozen will have been covered. "We didn’t want to have just one course and then call it done," says Watkins.
"If you feed too much information at one time, you remember little," adds Younger, explaining the program’s five-year length. "But if you stress a little over time, you tend to remember more." To reinforce positive human factors, Cessna issues badge cards that list the dirty dozen to all of its service-center employees, and it places dirty dozen posters on each facility’s walls.
When AM visited Cessna in late November, the second module had not yet received FAA certification from the agency’s FAASTeam. (The FAA Safety Team is a group of aviation specialists assembled within each of the agency’s eight Flight Standards regions; it succeeds the Aviation Safety Program).
"It takes time to get a module approved," says Watkins. But, he adds, the FAA regional manager has assured the company that approval from agency headquarters in Washington, D.C., is "on its way," and told Cessna, "Continue teaching it. Don’t stop now."
Meanwhile, Cessna is preparing to launch HF training at its European Citation Service Center, at Le Bourget airport near Paris. Employees in the European facility had been receiving HF training from a vendor but will switch to in-house training, though Cessna officials have yet to determine a start date. "They just received the first module 30 days ago [in early November]," Watkins explains. "And now we have to translate it."
In preparation for HF training at Le Bourget, Cessna recently provided train-the-trainer instruction to the facility’s quality assurance manager and EHS manager, crediting them to administer the five-part program. Each U.S. Citation Service Center has at least one trainer — the EHS manager — approved to conduct HF training; some have the quality assurance manager qualified, as well. All told, 14 trainers are qualified to conduct the HF program.
Training more than 1,400 employees took a year’s time because instead of emptying shops for one large HF instruction, Cessna chose instruction in small groupings, usually about 10 people. Each grouping represents a cross section of company personnel, even including the receptionist. "We mix the classes so management and technicians and staff learn from each other," says Watkins.
With 23,000 customers to serve this year, the Citation Service Center couldn’t afford to shut down for a company-wide training session. But the small groupings were established for another reason. "We want a lot of one-on-one interaction," says Watkins. "That’s why the modules are small and instructor-led, not CD-ROM-based." The intent is to have employees relate conditions they have witnessed on the shop floor or in their workspace.
Watkins says a module also includes videos and case studies, such as the infamous Aloha Airlines flight 243 disaster in Hawaii in April 1988, in which a Boeing 737’s fuselage tore apart. The cause of that accident was attributed to metal fatigue and corrosion — and the failure of maintenance personnel to perform key inspections.
"We read NTSB [National Transportation Safety Board] reports in the class and then try to piece together what we think happened," says Watkins, describing other HF training activities. "We also have exercises, applying, for example, the ‘Swiss cheese’ model." With this commonly used model, participants learn how HF errors can line up, like holes in Swiss cheese, in sequence to cause critical maintenance errors to occur.
Cessna developed its HF training program, in part, to satisfy EASA requirements, but it also was motivated by other considerations. "The program fits hand-in-glove with our Diamond Award initiative," says Younger, referring to the FAA’s honor bestowed on service centers reporting 100-percent employee participation in advanced levels of training. Cessna actively seeks the Diamond Award. Its Wichita facility has earned the honor six years in a row.
"Last year , our service-center employees received 77,500 man hours of training," Younger reports. That equates to an annual average of 56 training hours per employee.
Beyond awards, Cessna has identified still more benefits from its HF program. "We’ve surveyed our customers to see what their satisfaction level is, and our customer satisfaction has increased this year significantly," says Watkins. "And we have mitigated our safety events this year. Our total, recordable incident rate has fallen by about 15 percent."
While it is the largest producer of general aviation aircraft, delivering 387 Citation jets in 2007, Cessna isn’t the only bizjet manufacturer providing HF training at service centers. In fact, Bombardier, too, conducts a dedicated HF course to the technicians and management staff at its six factory-owned service centers across the United States. Meeting FAA standards, the course material is based on U.S. Department of Defense human factors training, germane FAA material and courses provided by other maintenance, repair and overhaul (MRO) companies, according to a company spokesperson. Bombardier instructors provide the training. The company repeats the course at least every two years.
Dassault Falcon Jet personnel at the company’s three service centers — in Little Rock, Ark., Wilmington, Del., and Paris — receive training from FlightSafety International and CAE Simuflite, and the company "makes sure human factors is included in the training curriculum," according to Dean Anderson, director of service network and maintenance training.
"Because our aircraft are type certificated under EASA in Europe, Dassault Falcon also must report any maintenance malfunctions under Part 21.3," he adds. "And to improve human factors, we advance that same information to our training providers and support network. It helps prevent errors."
Gulfstream Aerospace, too, provides HF training for personnel at its 11 U.S. service centers and one in England. "We may not bundle our training into a single package," says a company spokesman. "But we have communications training, training on stress management and computerized training in ergonomics. Also, teamwork is an integral part of our training program, and we also have a health-and-safety newsletter for our employees."
Being multi-modular, Cessna’s HF training remains unique, however, and was developed as such "because human factors is such a new, broad subject." Watkins comments. Younger adds, "We didn’t just look at what we had in place and say, OK, how can we just enhance that. We wanted to bring more clarity and light to human factors for our employees."
When Cessna first considered dedicated HF training, it looked at outside vendors. "But their training was cookie-cutter, generic," says Watkins. "It wasn’t molded for Cessna."
So, in 2006 the company established a three-person team: an in-house manufacturing trainer, an in-house customer-service trainer and a consultant with a PhD in human factors and aviation experience. The three men first examined NTSB reports, safety studies and data from EASA, the military, Air Canada and other organizations relating to human factors, and then developed a program that was rolled out Jan. 1, 2007. The consultant also worked with Watkins to train and certify the 14 trainers.
A Long History
Human factors issues are not new in aviation. John (Jay) Hiles, an FAA aviation safety inspector specializing in maintenance HF, often points out in speeches that since aviation began in 1903, machine causes of accidents have gone down markedly, while human causes have escalated dramatically. FAA reports that human error causes eight of 10 aviation accidents.
Discussion of maintenance human factors frequently adverts to the Aloha flight 243 accident, but plenty of other examples exist. Indeed, the accident in Hawaii may be superceded in reference by the Aug. 20, 2008, crash of Spanair flight JK5022 in which the MD82 broke apart near Madrid Barajas airport, killing 154 on board. Faulty maintenance and inspection are suspected factors, which prompted a Spanish judge to conduct an independent investigation and charge three maintenance technicians of manslaughter.
A Learjet official comments, "human factors, while well understood, are rarely taught." But that appears to be changing.
FAA contracted FlightSafety International to train about 1,000 air safety investigators (ASIs) in maintenance resource management (which can be defined as comparable but less broad based than human factors). The ASIs took a three-day course.
FlightSafety also offers HF training through a business relationship with Connecticut-based Global Jet Services, and it includes human factors as one of the soft-skills trained in its Master Technician Training Programs. Launched in 1992, Global Jet Services offers several of its own HF programs, as does Grey Owl Aviation Consultants, in Canada, which specializes in human factors.
In addition, in March 2008 FAA’s Flight Standards Service introduced an educational DVD titled Maintenance Human Factors Presentation System (MHFPS). It includes about 170 PowerPoint presentations, 38 animations, 11 FAA videos and seven presentations addressing fatigue, error and other HF topics.
In addition to the dirty dozen, human factors have been dissected for closer examination in various ways. FAA officials often refer to the PEAR acronym, in reference to people, environment, actions (job tasks) and resources. EASA and other agency enumerate by using more academic terms such as psychology and phsycosocial. And listings are often subdivided further to include age, gender, lifestyle, physical fitness, performance standards, lighting, and crew structure, even weather, among others.
Regardless, human-factors issues can generally be resolved by better communication and greater human awareness.
An FAA report perhaps summed it best, saying: "The goal of a human factors training program is to let employees become familiar with and understand why errors are committed, and to develop awareness and the strategy to diminish error behavior."
The key word here may be "diminish," even though the ideal would be to "eliminate" error behavior. Recognizing that "to error is human," Capt. Daniel Maurino, coordinator of the International Civil Aviation Organization’s (ICAO’s) Flight Safety and Human Factors Program and coauthor of the book "Beyond Aviation Human Factors," said in a paper, HF training "should not be restricted to attempt to avoid errors, but rather to make them visible and trap them before they produce damaging consequences."
Matter of Communication
Of the dirty dozen, poor communication is often cited as the human factor most likely to cause maintenance errors. "It’s the root of most human factors issues," says Keith McGann, FlightSafety’s director of professional development. "We often forget about all the interaction that goes into maintenance. So many things factor into communications."
Specifically, shift-task turnover, the communication between maintenance crews during a shift change, "is the single most problematic issue in aviation," Younger contends. A common reference to shift-change problem is the 1991 crash of a Continental Express Embraer EMB 120 near Houston, in which the NTSB cited the airline management’s failure "to ensure compliance with the approved maintenance procedures."
Younger says Cessna initially thought of resolving the shift-change issue by having two shifts overlap, allowing 30 minutes for the on-duty crew to relay eye-to-eye its progress in maintaining an aircraft to the following crew. Instead the company chose an electronic approach, placing computerized kiosks around the aircraft — four to six per bay — on which technicians print off each task to sign off during task completion. (See cover photo.)
The kiosks are hooked to a network, allowing access to electronic manuals and other sources. But they largely serve as standalone units in which technicians log their "shift-to-shift tie-ins," reporting the work completed. The benefit sought from these electronic tie-ins, according to Watkins, is "mistake proofing," or assuring that no task is omitted and that one task is successfully completed before proceeding with the appropriate succeeding task.
Younger admits the electronic tie-in process can be "cumbersome," involving considerable paper printouts for signatures, detailed reports and instruction to facilitate shift transition. "Cessna’s goal is to become totally electronic," he adds. "The FAA allows electronic signatures and electronic documentation. We just need the medium [software and hardware] to get there."
New resources can solve some HF problems, but Cessna officials recognize that many of the dirty dozen must be resolved through a culture change within the company and by amplifying employees’ awareness of their own dispositions and behavior, as well as those of fellow workers.
Does the training entail consciousness raising? "Absolutely," Watkins stresses. Problems at home can affect a person’s work, and problems at work can affect life at home, Younger adds. "People have things going on in their lives that can cause their minds to wander away from the task at hand," he explains. The results can be consequential; a 2002 FAA study found that installation errors is the number one maintenance problem, followed by inspection failures.
The key is to recognize stress, fatigue or less-than-normal behavior when it occurs and then take action. In such a case, the service center management "may have a technician do something different," says Younger, "like pulling panels from the airplane instead of putting the back end of an engine together, which requires magnifying glasses and much concentration."
Beyond worker/worker communications, the Cessna HF program encourages management, too, to enhance its interaction among workers and staff — which is a key reason why Cessna’s HF modules include a cross section of its staff. Such interaction, for example, could help spot an employee’s lack of assertiveness, indicating that he is not happy with his job. "In this case, we’ll either redirect the employee within the facility, put him on a job he can engage in, or we’ll have a critical discussion about his future," says Younger.
Although Cessna placed significant effort in developing its HF training and officials believe the program is a success, they have no plans to market the program to independent service centers. "We could market it, but that’s not what we’re about," says Younger. "We’re in the business of servicing airplanes with the best tools and best technology available...and that supports our slogan: "Safe People, Safe Planes."
The Dirty Dozen
Almost everyone in aviation knows that the "dirty dozen" is not just a 1967 World War II movie starring Lee Marvin. Since 1993, when Transport Canada identified conditions contributing to human errors in aircraft maintenance, the dirty dozen has been the fundamental ingredient in human factors training and discussion. Those 12 contributors to human error are:
It started with 12 demonstration pilots at Bombardier’s Learjet facility in Wichita, Kan. In 12 years it ballooned to become a successful annual seminar drawing as many as 600 attendees. Today the Safety Standdown, which is free and has been open to the public for the last eight years, draws Learjet customers, operators of competitive bizjets and military personnel operating small passenger jets. The Learjet demo pilots still coordinate the Safety Standdown, a seminar dedicated to skill-based and knowledge-based training in human factors (HF); however, they now have more backing. To help organize the seminar, Learjet partnered with parent company Bombardier in 2006 and with FAA, NTSB, National Business Aircraft Association (NBAA), European Business Aircraft Association (EBAA) and Embry-Riddle Aeronautical University the following year. Top officials from these organizations regularly attend the Safety Standdown.
In addition, for the third year Learjet has sponsored a comparable one-day seminar in Geneva, Switzerland, to extend HF awareness to the growing international business jet market. (Seventy percent of Learjet’s aircraft sales currently are non-U.S.) The last European Standdown was held in May, and the Wichita event was held in October; they are scheduled to follow EBACE (European Business Aviation Conference and Exhibition) and the NBAA Conference and Exhibition, respectively. The Safety Standdown in the United States essentially takes over a hotel. In addition to setting aside hotel rooms and meeting space, seminar coordinators devise simulations — for example, water ditchings in the hotel pool and cabin fire evacuations in the parking lot. The Geneva event doesn’t yet include simulations. Both events include experts in human factors who discuss HF-related topics, such as psychology, professionalism and stress management. And for the past two years, the Safety Standdown has employed consultants from Grey Owl Aviation Consultants to administer a workshop titled "Human Factors for Maintenance Managers." A dinner with guest speakers, such as astronaut Eugene Cernan, commander of Apollo 17 (the last mission to the moon), allows time for camaraderie among attendees. A Bombardier spokesman stressed that the company does not showcase its products and services at the seminar. "We don’t bombard you with Bombardier marketing," she laughs. Rather, according to the seminar’s slogan, the Safety Standdown is meant to wage, not unlike the Bush presidency’s battle against violent extremism, "The War on Error."