Human Factors and FAR Part 145.163 'Training Program'

[Don Palmer]

Aircraft Accident Report
Aloha Airlines, flight 243, Boeing 737-200,
N73711, near Maui, Hawaii
April 28, 1988
NTSB Number AAR-89/03
NTIS Number PB89-910404

Executive Summary: On April 28, 1988, at 1346, a Boeing 737-200, N73711, operated by Aloha Airlines Inc., as flight 243, experienced an explosive decompression and structural failure at 24,000 feet, while en route from Hilo, to Honolulu, Hawaii. Approximately 18 feet from the cabin skin and structure aft of the cabin entrance door and above the passenger floor line separated from the airplane during flight. There were 89 passengers and 6 crewmembers on board. One flight attendant was swept overboard during the decompression and is presumed to have been fatally injured; 7 passengers and 1 flight attendant received serious injuries. The flight crew performed an emergency descent and landing at Kahului Airport on the Island of Maui.

The National Transportation Safety Board determines that the probable cause of this accident was the failure of the Aloha Airlines maintenance program to detect the presence of significant disbonding and fatigue damage which ultimately led to failure of the lap joint a S-10L and the separation of the fuselage upper lobe. Contributing to the accident were the failure of Aloha Airlines management to supervise properly its maintenance force; the failure of the FAA to require Airworthiness Directive 87-21-08 inspection of all the lap joints proposed by Boeing Alert Service Bulletin SB 737-53A1039; and the lack of a complete terminating action (neither generated by Boeing nor required by the FAA) after the discovery of early production difficulties in the B-737 cold bond lap joint which resulted in low bond durability, corrosion, and premature fatigue cracking.

• The Safety issues raised in this report include:
  
• The quality of air carrier maintenance programs and the FAA surveillance of those programs.
  
• The engineering design, certification, and continuing airworthiness of the B-737 with particular emphasis on multiple site fatigue cracking of the fuselage lap joints.

The human factors aspects of air carrier maintenance and inspection for the continuing airworthiness of transport category airplanes, to include repair procedures and the training, certification and qualification of mechanics and inspectors.

Recommendations concerning these issues were addressed to the Federal Aviation Administration, Aloha Airlines, and the Air Transport Association.

It took the FAA a few years to get a mandated training program requirement in the regulations, but the time has come. It's here now.

My MRO organization has a formal documented training program, including 'Human Factors Training', ready to submit to the FAA FSDO for approval. Are there others here having the same requirement, getting close to being ready? The FAR Part 145.163 rule takes effect on April 6, 2006.

Sidenote for the non-aerospace industry folk: Our sector of aviation has been receiving all kinds of documented training for years. The difference here is in the detail of the FAA APPROVED TRAINING PROGRAM.

[Craig H.]

Originally Posted by Muleskinner

It took the FAA a few years to get a mandated training program requirement in the regulations, but the time has come. It's here now.

My MRO organization has a formal documented training program, including 'Human Factors Training', ready to submit to the FAA FSDO for approval. Are there others here having the same requirement, getting close to being ready? The FAR Part 145.163 rule takes effect on April 6, 2006.

Sidenote for the non-aerospace industry folk: Our sector of aviation has been receiving all kinds of documented training for years. The difference here is in the detail of the FAA APPROVED TRAINING PROGRAM.

OK, I see where human factors would be involved in the incident, but what would human factors training "look like? What topics would be covered?

[Steve Prevette]

Originally Posted by Craig H.

OK, I see where human factors would be involved in the incident, but what would human factors training "look like? What topics would be covered?

"Human Performance Improvement" is becoming a big buzzword in the nuclear industry and the Department of Energy. INPO (Institute of Nuclear Power Operations) has been leading a charge in this lately, and it has spread to Hanford. It is fairly closely related to Human Factors, and somewhat to error-proofing. Generally looking for error-precursors and setting up systems that help the operator, and also are less susceptible to one human error causing a big crisis.

One article on the internet is http://www.alwaysimproving.com/train...ITto%20HPT.htm

Here is one company's course (happened to come up first in Google)
https://mis.doe.gov/ess/training_cat...85&skey=194871

[Justin]

Originally Posted by Craig H.

OK, I see where human factors would be involved in the incident, but what would human factors training "look like? What topics would be covered?

Fish Bone it. Then you will know what your human factors are that relate to each process. It is always different for each organization. I even add human factors to my FMEA's.

[Cari Spears]

Originally Posted by Muleskinner

My MRO organization has a formal documented training program, including 'Human Factors Training', ready to submit to the FAA FSDO for approval.

What do you guys repair/maintenance at your facility?

[Don Palmer]

Great input and questions.

Craig,
The FAA won't prescribe what human factor elements to include, but the elements we as an MRO choose, should obviously focus on aviation maintenance, and safety related issues. Our PMI has instructed that approval of the training will be based on (standard) training process documentation, initial/recurrent training schedule, method of accomplishing training, record keeping, etc.

Human factors training programs are for us (the MRO) to decide but must address training specifics and qualifications process.

Here's a simplified list of covered topics:

General introduction to human factors
Statistics
Safety culture / organizational factors
Human error
Types of errors in mainenance tasks
Human reliability
Human performance and limitations
Vision, Hearing, Stress
Substance abuse
Situation awareness
Workload management

As you can see this list is very basic, but it's a place to start. FAA must APPROVE repair station 'training programs' of all certificated MRO organizations in the United States within a relatively short period of time. No doubt the list will grow and the program will become more complex as time goes by.

Steve,
Yes, just as "Human Performance Improvement" is becoming a big buzzword in the nuclear industry and the Department of Energy; "Human Factors Training" is becoming the big buzzword in the aerospace MRO industry. Thanks for sharing the links. I've bookmarked them for reference and possible use in the future.

Justin,
Yes, no doubt plugging human factors statistics into FMEA is a good idea. An interesting side note to this FAA mandate for 'human factors' training is that it's way behind on the timeline for implementation compared to EU/EASA(JAA) MROs and other industries well established and mature because of ISO 9000/AS9100 etc.

Cari,
Our facilities have full/limited class ratings in airframe, aircraft accessory, engine/apu, avionics/instrument/radio. We also perform specialized services such as NDT Inspection and Welding. We pretty much have capability and hold ratings to do it all.

[Cari Spears]

Originally Posted by Muleskinner

Our facilities have full/limited class ratings in airframe, aircraft accessory, engine/apu, avionics/instrument/radio. We also perform specialized services such as NDT Inspection and Welding. We pretty much have capability and hold ratings to do it all.

Cool - that sounds like an interesting place to work!

[Don Palmer]

Originally Posted by Cari Spears

Cool - that sounds like an interesting place to work!

OK!?! I thought you had purpose in asking your original question. Guess not, and that's ok by me. I do appreciate the pleasantry