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ZENG YANG

FAIDHI
ROHIT
SHOFIYAH

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Contents Page
• Problem Statement
• What are Human Factors?
• What is SHEL? Or SHELL?
• Elements of SHELL
• What is Error Chain?
• Murphy’s Law?
• Human factors that led to the Incident
• What the Investigators Found/ Conclusion
• The End

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Problem Statement
• Your task today is to investigate the human
factors issues that could have caused this
incident.

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Human Factors
 In general, a human factor is a physical or cognitive property of an
individual or social behaviour which is specific to humans and
influences functioning of technological systems as well as human-
environment equilibriums.

Rohit- http://www.usernomics.com/human-factors.html

http://en.wikipedia.org/wiki/Human_factors

http://www.mtr.com.hk/eng/sustainability/sustainrpt/2005rpt/sia-hfs.html 4
What is SHEL? Or SHELL?
• This concept has originated from the ‘SHEL Model’ by
Edwards in 1972, which the name was derived from the
initials of its components:
(Software, Hardware, Environment, and Liveware).

• The most different point between Edwards’s SHEL Model


(1972) and Hawkins’s SHELL Model (1975) is that Hawkins
urged for the necessity of another ‘Liveware’ (the person)
and diagrammed to illustrate the interactions between the
central Liveware and each of other four systems
http://wikiofscience.wikidot.com/sci (ZENG YANG)
ence:shell-model-of-human-factors 5
SHELL Diagram

http://lamoureux-cse.com/hf/ (ZENG YANG) 6


Elements of SHEL
• SOFTWARE (procedures , documentation , symbology , etc )
• the Software comprehends all non-physical
resources, which are for organically operation, like
organizational policies/rules, procedures, manuals
and placards.

• HARDWARE (machines and equipment )


• Various equipments, tools, aircraft, workspace,
buildings and other physical resources without
human elements in aviation constitute the
Hardware. http://wikiofscience.wikidot.com/science:s
(ZENG YANG)
hell-model-of-human-factors
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Elements of SHEL(II)
Environment (internal and external )
• The Environment includes not only the factors
which influence where people are working such as
climate, temperature, vibration and noise, but also
socio-political and economic factors.

Liveware (Human Factors)


• The Liveware includes factors like teamwork,
communication, leadership and norms.

http://wikiofscience.wikidot.com/science:s
(ZENG YANG)
hell-model-of-human-factors
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Hawkins(Central Liveware)
• The Liveware, which is in the centre of the SHELL
Model, can be defined as human elements such as
knowledge, attitudes, cultures and stress. This
Liveware is regarded as the core of the SHELL
Model and other components match with the
Liveware as the central figure .

http://wikiofscience.wikidot.com/science:s
hell-model-of-human-factors (ZENG YANG) 9
Chain of event or Error chain
• term referring to the concept that many contributing factors typically lead to an
accident, rather than one single event.
• contributing actions typically stem from human factor related mistakes and pilot
error, rather than mechanical failure.

• For today problem, if the SMM to the work by the book following the step and
not judging by himself which lead to the different size of bolt use for the
windscreen. And why the procedures not requiring a pressure check or
duplicated check. This lead to an accident waiting to occur.

• The SMM must ensure to perform each and every function safely and by the
book, no shortcuts.
• If we can break just one link in the chain, the accident will not happen.

• And also, A study conducted by Boeing found that 55% of airline accidents
between 1959 and 2005 were caused by such human related factors, while only
17% of accidents were caused by mechanical issues with the aircraft.
Faidhi
http://en.wikipedia.org/wiki/Chain_of_events_%28aviation%29
Murphy’s Law
• “Murphy’s Law” can be regarded as the notion: “If
something can go wrong, it will.”

• The engineer replace the bolt without referencing


to the maintenance documents

• He replaces it on a like for like basis as he thinks


that it could not go wrong as it is the same type of
bolt.
Human factors issues that had
resulted to this incident.
• Shift Maintenance Manager (SMM), short-handed on a
night shift, had decided to carry out the windscreen
replacement himself. He consulted the Maintenance
Manual (MM) and concluded that it was a
straightforward job.

• He decided to replace the old bolts and, taking one of


the bolts with him (a 7D), he looked for replacements.
The store man advised him that the job required 8Ds,
but since there were not enough 8Ds, the SMM
decided that 7Ds would do (since these had been in
place previously)
The problem start...
• However, he used sight and touch to match
the bolts and, erroneously, selected 8Cs
instead, which were longer but thinner.
• He failed to notice that the countersink was
lower than it should be, once the bolts were in
position.
• He completed the job himself and signed it
off, the procedures not requiring a pressure
check or duplicated check.
• Accident investigators found that a replacement windscreen had been installed
27 hours before the flight, and that the procedure had been approved by the
Shift Maintenance Manager.

• However, 84 of the 90 windscreen retention bolts were 0.026 inches (0.66


mm) too small in diameter, while the remaining six were 0.1 inches (2.5 mm)
too short.

• The investigation revealed that the previous windscreen had been fitted with
incorrect bolts, which had been replaced on a "like for like" basis by the Shift
Maintenance Manager without reference to the maintenance documentation.

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