ICAO 9824-2003 Human Factors Guidelines for Aircraft Maintenance Manual《飞机保养手册人为因素指引 第1版》.pdf

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13、Samyaek Ladprao, Bangkok 10901 United Kingdom. Airplan Flight Equipment Ltd. (AFE), la Ringway Trading Estate, Shadowmoss Road, Manchester M22 5LH 9/03 Catalogue of ICAO Publications and Audio-visual Training Aids Issued annually, the Catalogue lists all publications and audio-visual training aids c

14、urrently available. Monthly supplements announce new publications and audio-visual training aids, amendments, supplements, reprints, etc. Available free from the Document Sales Unit, ICAO. Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo rep

15、roduction or networking permitted without license from IHS-,-,-Doc 9824 AN1450 Human Factors Guidelines for Aircraft Maintenance Manual Approved by the Secretary General and published under his authority First Edition - 2003 Copyright International Civil Aviation Organization Provided by IHS under l

16、icense with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-AMENDMENTS No. The issue of amendments is announced regularly in the ICAO Journal and in the monthly Supplement to the Catalogue of ICAO Publications and Audio-visual Training Ai therefore, in order to

17、 understand human performance in context, the industry needs to capture, through systematic analyses, the mechanisms underlying successful compromises when operating at the limits of the system, rather than those that failed. It is suggested that understanding the human contribution to successes and

18、 failures in aviation can be better achieved by monitoring normal operations, rather than accidents and incidents. 6. Contracting States with large commercial aviation activities have already initiated Human Factors pro- grammes, which include the development and publication of guidance and training

19、 materials and the promotion of Human Factors awareness. This awareness promotion includes not only the aviation maintenance industry but also the personnel of the civil aviation authorities themselves. 7. In addition, recent amendments to Annex 1 and Annex 6 now require civil aviation authorities i

20、n ali the Contracting States to observe standards to reduce the adverse effects of deficiencies in human performance on the maintenance of aircraft. It is intended that this manual will provide authorities with the tools to develop and implement such standards appropriate to their States aviation ac

21、tivities. Table A presents the text of Human Factors Standards and Recommended Practices (SAMs) in the two Annexes that cover the maintenance of aircraft. 8. This manual is a guidance document based on the use of existing published material from numerous sources. The material is quoted, used as exam

22、ples, referenced and or discussed as appropriate. (xiii) Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-(xiv) Human Factors Guidelines for Aircraft Maintenance Manual Table

23、A. Aircraft maintenance-related ICA0 SAMs Annex Annex 1 - Personnel Licensing Annex 6 - Operation of Aircraft Part I - International Commercial Air Transport - Aeroplanes Annex 6 - Operation of Aircraft Part III - International Operations - Helicopters Section II - International Commercial Air Trans

24、port Chapter and Section Chapter 4. Personnel Other than Flight Crew Members 4.2 Aircraft maintenance (technician/ engineerlmechanic) Licences and Ratings for Chapter 8. Aeroplane Maintenance 8.3 Maintenance programme 8.7 Approved maintenance organization Chapter 6. Helicopter Maintenance 6.3 Mainte

25、nance programme Paragraph and Text of the Standard or Recommended Practice 4.2.1.2 Knowledge Human performance . e) human performance relevant to aircraft maintenance. . . . 8.3.1 The operator shall provide, for the use and guidance of maintenance and operational personnel concerned, a maintenance p

26、rogramme, approved by the State of Registry, containing the information required by 11.3. The design and application of the operators maintenance programme shall observe Human Factors principles. . . . 8.7.5.4 The maintenance organization shall ensure that all maintenance personnel receive initial a

27、nd continuation training appropriate to their assigned tasks and responsibilities. The training programme established by the maintenance organization shall include training in knowledge and skills related to human performance, including Co-ordination with other maintenance personnel and flight crew.

28、 . 6.3.1 The operator shall provide, for the use and guidance of maintenance and operational personnel concerned, a maintenance programme, approved by the State of Registry, containing the information required by 9.3. The design and application of the operators maintenance programme shall observe Hu

29、man Factors principles. . . . Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Introduction (xv) 9. This manual is only designed to support the safety objectives and requireme

30、nts of Annex 1 and Annex 6. Some Human Factors materials produced by other bodies include information intended to enhance worker safety, industry efficiency andor career development for indi- viduals. While these are very worthwhile objectives, they are not required by the Annexes and are not indude

31、d in this manual except where they have an influence on aviation safety. 10. This document is designed as follows: Chapter 1. Why Human Factors in Aircraft Main- tenance - Background Information and Justifica- tion: This chapter provides background information on the importance of Human Factors know

32、ledge and the justification for its incorporation into the operation of maintenance organizations, including training programmes for their technical staff and aircraft maintenance engineers (AMES)*. Chapter 2. Key Issues Related to Maintenance Errors: This chapter identifies some of the key issues w

33、hich can lead to maintenance errors and contribute to in-flight incidents or accidents. * Annex i also offers the possibility of refemng to these persons as aircraft maintenance technicians or aircraft maintenance mechanics. This manual will refer to them as aircraft maintenance engineers (AMES), ex

34、cept in quoted material where another term is used. . Chapter 3. Countermeasures to Maintenance Errors: This chapter identifies some of the generic features of changes that need to be made to the maintenance organization (including the facility and the training) to reduce maintenance errors. Referen

35、ce is made to various guidance material packages that are available. Chapter 4. Reporting, Analysis and Decision Making: This chapter examines the measurement and analysis of errors and the results of errors, including the determination of new or amended countmeasures intended to “close the loop”. C

36、hapter 5. Training: This chapter addresses the objectives and scope necessary to meet the require- ments of Annex 1 and Annex 6. Examples are given of currently available training packages. Chapter 6. Regulatory Policy, Principles and Solutions: This chapter discusses the options avail- able to a St

37、ates aviation regulatory body to develop its own standards in compliance with the SAWS of Annex 1 and Annex 6. Chapter 7. Additional Reference Material: This chapter contains sources of currently available material on the theories and subjects discussed in this manual. e Copyright International Civi

38、l Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Chapter 1 WHY HUMAN FACTORS IN AIRCRAFT MAINTENANCE - BACKGROUND INFORMATION AND JUSTIFICATION 1.1 EVOLUTION AND INTRODUCTION 1.1.1 Maintenance errors con

39、tribute to a significant proportion of Hiorldwide commercial aircraft accidents and incidents and these occurrences are costly; yet until recently, little was known of the nature of maintenance errors and the factors that promote them. 1.1.2 The human element is the most flexible, adaptable and valu

40、able part of the aviation system, but it is also the most vulnerable to influences which can adversely affect its performance. With the majority of aircraft accidents and incidents resulting from less than optimum human performance, there has been a tendency to merely attribute them to human error.

41、However, the term “human error” is of little help in aircraft accident or incident prevention; although it may indicate WHERE in the system a breakdown occurred, it provides no guidance as to WHY it occurred. 1.1.3 Furthermore, the term “human error” allows concealment of the underlying factors that

42、 must be brought to the fore if accidents are to be prevented. For example, an error attributed to humans in the system may have been induced by inadequate design, inadequate training, badly designed procedures, and/or poor layout of job cards or manuals. In contemporary safety thinking, human error

43、 is the starting point rather than the stopping point in accident investigation and prevention. Ultimately, any safety audit must seek ways of minimizing or preventing human errors of any kind that might jeopardize safety. 1.1.4 Early efforts in Human Factors were directed towards the flight crew an

44、d demonstrated the dangers of ignoring the person as part of the socio-technical system. System-induced human errors, such as misreading alti- meters or mis-selecting cockpit controls, have been reduced through better design to improve the interface between the pilot and the cockpit. Understanding t

45、he predictable aspects of human capabilities and limitations and applying this understanding in operational environments are therefore the primary concerns of Human Factors. Other early Human Factors concerns in aviation were related to the effects on people of noise, vibration, heat, cold and accel

46、eration forces. 1.1.5 The understanding of Human Factors in aviation has progressively been refined and developed to include aircraft maintenance activities. It is now backed by a vast amount of knowledge which can be used to ensure that operators and maintenance organizations reduce errors during m

47、aintenance. 1.1.6 Many factors that can potentially compromise human performance can also jeopardize the safety and well-being of the aviation employee, particularly those per- forming aircraft maintenance tasks. Many of these factors which have implications beyond the prevention of aircraft acciden

48、ts, e.g. industrial safety implications, are cited in this manual. However, notwithstanding the importance of such occupational safety and health (OSH) issues to the long-term effectiveness of the aviation system, the focus of this manual is on understanding how these Human Factors issues affect air

49、craft safety. 1.1.7 The safety and reliability of aircraft mainten- ance operations depend as much upon people as they do on the technical systems of aircraft, parts, tools and equip- ment. Nevertheless, accident and incident reports continue to show that aircraft maintenance engineers (AMES) sometimes make errors, that aircraft maintenance organiz- ations sometimes fail to organi