Human Factors Contribute to Near Mishap


Accidents happen all the time in the workplace. The aviation world is no exception, with countless possibilities and situations that can cause damage to equipment and hazards to personnel. According to the Federal Aviation Administration about 80 percent of accidents happen due to human factors. The FAA has identified 12 human-factor situations and has named them the “dirty dozen.”

The dirty dozen are categories of the 12 most common human error conditions that could lead to an accident or incident. These categories include:

1. Lack of Communication – Poor transmitters and receivers can cause dangerous situations in the workplace. Use of logbooks and pass downs are a good start to avoid lack of communication, but clear and accurate pass downs avoid confusion and potential errors.

2. Complacency – When a situation becomes habitual, the level of caution and situational awareness is diminished.

3. Lack of Knowledge – Having someone complete a task without the understanding, proper training, or incorrect knowledge of how to complete the task correctly and safely.

4. Distraction – This could be anything that takes the attention away from the current task.

5. Lack of Teamwork – In certain situations tasks may need multiple personnel to complete. If someone isn’t contributing fully on the task, this could lead into a dangerous situation.

6. Fatigue – Physical or mental tiredness. Being chronically fatigued can lead to poor concentration, remembering, and decision making. Additionally, as maintainers at VR-61, we experience flexible missions requiring multiple shift changes to maintenance personnel.

7. Lack of Resources – The necessary equipment is not available or utilized to complete the job safely.

8. Pressure – Each person can handle different amounts of pressure. Pressure can be created by the amount of work someone can handle, how much time they need, or even lack of resources.

9. Lack of Assertiveness – By allowing oneself to become intimidated can cause a dangerous situation, i.e., not communicating all the information clearly or cutting corners to avoid conflict.

10. Stress – There are many different types and levels. From environment, to personal, and health, those are just a few examples from dozens of forms of stress.

11. Lack of Awareness – A person can be so focused on a task he may be oblivious to the environment around him or her.

12. Norms – Statements like “It’s just the way we do things around here,” are unwritten rules around the workplace. Some norms are force of habit and/or peer pressure.

In late September 2016, VR-61 at Naval Air Station Whidbey Island experienced a near mishap. VR-61 operates C-40A aircraft conducting Navy Unique Fleet Essential Airlift missions around the world.

The morning of the event, maintenance control tasked three highly motivated airframers to align two fire bottle carts positioned in the back of VR-61’s hangar. The team consisted of two second class petty officers as observers, handlers, and guides; and a third class petty officer as the support equipment operator. The equipment used for this evolution included an A/S32A-48 tow tractor and two commercially obtained AFFF fire bottle trailers. These trailers each weigh approximately 12,000 pounds and support firefighting requirements when conducting offsite aircraft maintenance. Before the evolution, the team reviewed the location and desired placement of the trailers. The movement of the first trailer was successfully completed without any issues. The second trailer movement was the greater challenge based on its initial position inside the hangar.

Slowly, safely, and as a team they pushed the second trailer outside the hangar until they gained enough clearance to maneuver the trailer into its final position. Once they had the appropriate clearance, they carefully shifted the tow tractor into drive to execute a near 90-degree turn of the trailer to align it with the first one. Once the trailer was in its correct location, the team moved to the next step of removing the tow bar.

Before the trailer could be disconnected from the tow tractor, one of the observers slowly jacked down the tongue jack. Once the tongue jack was fully retracted and appeared to be secured, the petty officer moved to the front of the tow bar to demonstrate and assist the other petty officer with unlatching the tow tractor’s locking mechanism from the trailer tow hitch. Unknowingly, the locking pin on the tongue jack had not been installed and upon release of the locking mechanism, the fire bottle trailer’s front end hit the deck and the entire cart rolled backwards. Both petty officers investigated the unintended movement and discovered the locking pin for the tongue jack was never installed. The weight of the trailer and the unrestrained condition created a potential hazard of property damage and a danger to personnel.

While no personnel injuries or property damage were reported, the incident could easily have been prevented.

During the post-evolution hot wash, the team concluded that personnel should have ensured the locking pin was securely in place, and chocks were installed to prevent the trailer from rolling backwards when unlatching the tow tractor’s locking mechanism. The team also made great recommendations including the installation of a spring-loaded locking mechanism on the tongue jack and/or affix a warning placard to properly install the locking pin to secure the jack in place.

The human errors in this incident or any can be caused by a single dirty dozen infraction or multiple ones. Hazards like these can be identified and mitigated by practicing operational risk management (ORM), which is key to preventing mishaps. By applying the principles of ORM to each task, personnel can recognize hazards and create actionable plans to mitigate potential injury to personnel and property damage.

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