M15. Human Factors-1

Training Handbook
Basic Aircraft Maintenance Airframe Powerplant

Module 15 – Human Factors
Manual No. : BCT-0011/M15 For Training Purpose Only Rev. 0: Aug 19, 2015
Basic Aircraft Maintenance Training Manual
Module 15 – Human Factor
Module 15
Human Factor
for
Basic Aircraft Maintenance
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Module 15 Chapters
15.1. General
15.2. Human Performance and Limitations
15.3. Social Psychology
15.4. Factors Affecting Performance
15.5. Physical Environment
15.6. Tasks
15.7. Communication
15.8. Human Error
15.9. Hazards in the Workplace
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Module 15
Human Factor
15.1 General
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Knowledge Levels — Category A, B1, B2 and C Aircraft Maintenance Licence
Basic knowledge for categories A, B1 and B2 are indicated by the allocation of knowledge levels indicators (1, 2 or 3) against each applicable
subject. Category C applicants must meet either the category B1 or the category B2 basic knowledge levels.
The knowledge level indicators are defined as follows:
LEVEL 1
• A familiarisation with the principal elements of the subject.
Objectives: The applicant should be familiar with the basic elements of the subject.
• The applicant should be able to give a simple description of the whole subject, using common words and examples.
• The applicant should be able to use typical terms.
LEVEL 2
• A general knowledge of the theoretical and practical aspects of the subject.
• An ability to apply that knowledge.
Objectives: The applicant should be able to understand the theoretical fundamentals of the subject.
• The applicant should be able to give a general description of the subject using, as appropriate, typical examples.
• The applicant should be able to use mathematical formulae in conjunction with physical laws describing the subject.
• The applicant should be able to read and understand sketches, drawings and schematics describing the subject.
• The applicant should be able to apply his knowledge in a practical manner using detailed procedures.
LEVEL 3
• A detailed knowledge of the theoretical and practical aspects of the subject.
• A capacity to combine and apply the separate elements of knowledge in a logical and comprehensive manner.
Objectives: The applicant should know the theory of the subject and interrelationships with other subjects.
• The applicant should be able to give a detailed description of the subject using theoretical fundamentals and specific examples.
• The applicant should understand and be able to use mathematical formulae related to the subject.
• The applicant should be able to read, understand and prepare sketches, simple drawings and schematics describing the subject.
• The applicant should be able to apply his knowledge in a practical manner using manufacturer's instructions.
• The applicant should be able to interpret results from various sources and measurements and apply corrective action where appropriate.
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Table of Contents
Module 15.1 General ______________________________________________________________________________________________ 5
The Need To Take Human Factors Into Account _______________________________________________________________________ 5
What is "Human Factors"? __________________________________________________________________________________________ 5
The SHEL Model __________________________________________________________________________________________________ 7
Incidents and Accidents Attributable To Human Factors I Human Error ___________________________________________________ 8
Examples of Incidents and Accidents ______________________________________________________________________________ 10
Incidents and Accidents - A Breakdown in Human Factors _____________________________________________________________ 13
Murphy's Law ____________________________________________________________________________________________________ 14
Dr James Reason _________________________________________________________________________________________________ 15
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Module 15.1 Enabling Objectives
Objective Reference Level
The need to take human factors into account 9.1 2
Incident attributable to human factors/ human error
Murphy's Law
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Module 15.1 General
This chapter introduces human factors and explains its importance to the aviation industry. It examines the relationship between human
factors and incidents largely in terms of human error and "Murphy's Law" (i.e. if it can happen, one day it will).
The Need To Take Human Factors Into Account

In the early days of powered flight, the design, construction and control of aircraft predominated. The main attributes of the first pilots were
courage and the mastery of a whole new set of skills in the struggle to control the new flying machines.
As the technical aspects of flight were overcome bit by bit, the role of the people associated with aircraft began to come to the fore. Pilots
were supported initially with mechanisms to help them stabilise the aircraft, and later with automated systems to assist the crew with tasks
such as navigation and communication. With such interventions to complement the abilities of pilots, aviation human factors was born.
An understanding of the importance of human factors to aircraft maintenance engineering is essential to anyone considering a career as a
licensed aircraft engineer. This is because human factors will impinge on everything they do in the course of their job in one way or another.
What is "Human Factors"?

The term "human factors" is used in many different ways in the aviation industry..
The term is, perhaps, best known in the context of aircraft cockpit design and Crew Resource Management (CRM). However, those activities
constitute only a small percentage of aviation-related human factors, as broadly speaking it concerns any consideration of human
involvement in aviation.
The use of the term "human factors" in the context of aviation maintenance engineering is relatively new. Aircraft accidents such as that to
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the Aloha aircraft in the USA in 1988 and the BAC 1-11 windscreen accident in the UK in June 1990 brought the need to address human
factors issues in this environment into sharp focus. This does not imply that human factors issues were not present before these dates nor
that human error did not contribute to other incidents; merely that it took an accident to draw attention to human factors problems and
potential solutions.
Before discussing how these accidents were related to human factors, a definition of human factors is required. There are many definitions
available. Some authors refer to the subject as `human factors' and some as èrgonomics'. Some see "human factors" as a scientific discipline
and others regard it as a more general part of the human contribution to system safety. Although there are simple definitions of human
factors such as: "Fitting the man to the job and the job to the man", a good definition in the context of aviation maintenance would be:
"Human factors" refers to the study of human capabilities and limitations in the workplace. Human factors researchers study system
performance. That is, they study the interaction of maintenance personnel, the equipment they use, the written and verbal procedures and
rules they follow, and the environmental conditions of any system. The aim of human factors is to optimise the relationship between
maintenance personnel and systems with a view to improving safety, efficiency and well-being".
Thus, human factors include such attributes as:
• human physiology ;
• psychology (including perception, cognition, memory, social interaction, error);
• work place design;
• environmental conditions;
• human-machine interface;
• Anthropometrics (the scientific study of measurements of the human body).
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The SHEL Model
It can be helpful to use a model to aid in the understanding of human factors, or as a framework around which human factors issues can be
structured. A model which is often used is the SHEL model, a name derived from the initial letters of its components:
Software (e.g. maintenance procedures, maintenance manuals, checklist layout, etc.);
Hardware (e.g. tools, test equipment, the physical structure of aircraft, design of flight decks, positioning and operating sense of controls
and instruments, etc.);
Environment (e.g. physical environment such as conditions in the hangar, conditions on the line, etc. and work environment such as work
patterns, management structures, public perception of the industry, etc.);
Liveware (i.e. the person or people at the centre of the model, including maintenance engineers, supervisors, planners, managers, etc.).
Figure 1.1: SHEL Model.
Human factors concentrates on the interfaces between the human (the 'L' in the centre box) and the other elements of the SHEL model (see
Figure 1.1), and - from a safety viewpoint - where these elements can be deficient, e.g.:
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S: misinterpretation of procedures, badly written manuals, poorly designed checklists, untested or difficult to use computer
software.
H: not enough tools, inappropriate equipment, poor aircraft design for maintainability.
E: uncomfortable workplace, inadequate hangar space, extreme temperatures, excessive noise, poor lighting.
L: relationships with other people, shortage of manpower, lack of supervision, lack of support from managers.
As will be covered in this document, man, the "Liveware" - can perform a wide range of activities. Despite the fact that modern aircraft are
now designed to embody the latest self-test and diagnostic routines that modern computing power can provide, one aspect of aviation
maintenance has not changed: maintenance tasks are still being done by human beings. However, man has limitations. Since Liveware is at
the centre of the model, all other aspects (Software, Hardware and Environment) must be designed or adapted to assist his performance
and respect his limitations. If these two aspects are ignored, the human - in this case the maintenance engineer - will not perform to the
best of his abilities, may make errors, and may jeopardize safety.
Thanks to modern design and manufacturing, aircraft are becoming more and more reliable. However, it is not possible to re-design the
human being: we have to accept the fact that the human being is intrinsically unreliable. However, we can work around that unreliability by
providing good training, procedures, tools, duplicate inspections, etc. We can also reduce the potential for error by improving aircraft
design such that, for example, it is physically impossible to reconnect something the wrong way round.
Incidents and Accidents Attributable To Human Factors / Human Error

In 1940, it was calculated that approximately 70% of all aircraft accidents were attributable to man's performance, that is to say human error.
When the International Air Transport Association (IATA) reviewed the situation 35 years later, they found that there had been no reduction
in the human error component of accident statistics (Figure 1.2).
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Figure 1.2: The dominant role played by human performance in civil aircraft accidents
A study was carried out in 1986, in the USA, looking at significant accident causes in 93 aircraft accidents. These were as follows:
Causes/major contributory factors % of accidents in which this was a factor
• Pilot deviated from basic operational procedures 33

• Inadequate cross-check by second crew member 26
• Design faults 13
• Maintenance and inspection deficiencies 12
• Absence of approach guidance 10
• Captain ignored crew inputs 10
• Air traffic control failures or errors 9
• Improper crew response during abnormal conditions 9
• Insufficient or incorrect weather information 8
• Runways hazards 7
• Air traffic control/crew communication deficiencies 6
• Improper decision to land 6
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As can be seen from the list, maintenance and inspection deficiencies are one of the major contributory factors to accidents.
The UK CAA carried out a similar exercise in 1998 looking at causes of 621 global fatal accidents between 1980 and 1996. Again, the area
"maintenance or repair oversight /error /inadequate" featured as one of the top 10 primary causal factors.
It is clear from such studies that human factors problems in aircraft maintenance engineering are a significant issue, warranting serious
consideration.
Examples of Incidents and Accidents
• Accident to Boeing 737, (Aloha flight 243), Maui, Hawaii, April 28 1988;
• Accident to BAC One-Eleven, (British Airways flight 5390), over Didcot, Oxfordshire on 10 June 1990;
• Incident involving Airbus A320, G-KMAM at London Gatwick Airport, on 26 August 1993;
• Incident involving Boeing 737, G-OBMM near Daventry, on 23 February 1995.
Aloha flight 243

The accident involving Aloha flight 243 in April 1988 involved 18 feet of the upper cabin structure suddenly being ripped away in flight due
to structural failure. The Boeing 737 involved in this accident had been examined, as required by US regulations, by two of the engineering
inspectors. One inspector had 22 years experience and the other, the chief inspector, had 33 years experience. Neither found any cracks in
their inspection. Post-accident analysis determined there were over 240 cracks in the skin of this aircraft at the time of the inspection. The
ensuing investigation identified many human-factors-related problems leading to the failed inspections.
As a result of the Aloha accident, the US instigated a programme of research looking into the problems associated with human factors and
aircraft maintenance, with particular emphasis upon inspection.
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British Airways flight 5390

On June 10th 1990 in the UK, a BAC1-11 (British Airways flight 5390) was climbing through 17,300 feet on departure from Birmingham
International Airport when the left windscreen, which had been replaced prior to flight, was blown out under the effects of cabin pressure
when it overcame the retention of the securing bolts, 84 of which, out of a total of 90, were smaller than the specified diameter. The
commander was sucked halfway out of the windscreen aperture and was restrained by cabin crew whilst the co-pilot flew the aircraft to a
safe landing at Southampton Airport.
The 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 storeman 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). 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.
There were several human factors issues contributing to this incident, including perceptual errors made by the SMM when identifying the
replacement bolts, poor lighting in the stores area, failure to wear spectacles, circadian effects, working practices, and possible
organizational and design factors.
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G-KMAM
An incident in the UK in August 1993 involved an Airbus 320 which, during its first flight after a flap change, exhibited an undemanded roll
to the right after takeoff. The aircraft returned to Gatwick and landed safely. The investigation discovered that during maintenance, in order
to replace the right outboard flap, the spoilers had been placed in maintenance mode and moved using an incomplete procedure;
specifically the collars and flags were not fitted. The purpose of the collars and the way in which the spoilers functioned was not fully
understood by the engineers. This misunderstanding was due, in part, to familiarity of the engineers with other aircraft (mainly 757) and
contributed to a lack of adequate briefing on the status of the spoilers during the shift handover. The locked spoiler was not detected
during standard pilot functional checks.
G-OBMM
In the UK in February 1995,a Boeing 737-400 suffered a loss of oil pressure on both engines. The aircraft diverted and landed safely at Luton
Airport. The investigation discovered that the aircraft had been subject to borescope inspections on both engines during the preceding
night and the high pressure (HP) rotor drive covers had not been refitted, resulting in the loss of almost all the oil from both engines during
flight. The line engineer was originally going to carry out the task, but for various reasons he swapped jobs with the base maintenance
controller.
The base maintenance controller did not have the appropriate paperwork with him. The base maintenance controller and a fitter carried out
the task, despite many interruptions, but failed to refit the rotor drive covers. No ground idle engine runs (which would have revealed the oil
leak) were carried out. The job was signed off as complete.
In all three of these UK incidents, the engineers involved were considered by their companies to be well qualified, competent and reliable
employees. All of the incidents were characterized by the following:
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• There were staff shortages;

• Time pressures existed;
• All the errors occurred at night;
• Shift or task handovers were involved;
• They all involved supervisors doing long hands-on tasks;
• There was an element of a "can-do " attitude;
• Interruptions occurred;
• There was some failure to use approved data or company procedures;
• Manuals were confusing;
• There was inadequate pre-planning, equipment or spares.
Incidents and Accidents - A Breakdown in Human Factors

In all of the examples above, the accident or incident was preventable and could have been avoided if any one of a number of things had
been done differently. In some cases, a number of individuals were involved and the outcome could have been modified if any one of them
had reacted or queried a particular action. In each situation however, the individuals failed to recognize or react to signs of potential
hazards, did not react as expected of them, or allowed themselves to be diverted from giving their attention to the task in hand, leaving
themselves open to the likelihood of committing an error.
As with many incidents and accidents, all the examples above involved a series of human factors problems which formed an error chain (see
Figure 1.3).If any one of the links in this `chain' had been broken by building in measures which may have prevented a problem at one or
more of these stages, these incidents may have been prevented.
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Maintenance
Figure 1.3: The Error Chain.
Murphy's Law
There is a tendency among human beings towards complacency The belief that an accident will never happen to "me " or to "my Company "
can be a major problem when attempting to convince individuals or organizations of the need to look at human factors issues, recognize
risks and to implement improvements, rather than merely to pay `lip-service 'to human factors.
"Murphy's Law " can be regarded as the notion: "If something can go wrong, it will ."
If everyone could be persuaded to acknowledge Murphy's Law, this might help overcome the "it will never happen to me" belief that many
people hold. It is not true that accidents only happen to people who are irresponsible or `sloppy '.The incidents and accidents described
show that errors can be made by experienced, well-respected individuals and accidents can occur in organizations previously thought to be
"safe".
Dr James Reason
James Reason is considered the leading authority on the study of human error. Many of the theories described in these notes were
propounded by him.
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James Reason is professor of psychology at the University of Manchester, United Kingdom. His primary research interest
is human performance in hazardous systems. In 1999, Professor Reason was a member of the chief medical officer's
expert group on 'learning from experience' and was also adviser to the Bristol Royal Infirmary Inquiry. In 1995, he
received the Distinguished Foreign Colleague Award from the United States Human Factors and Ergonomics Society.
From 1962 to 1977, Dr. Reason worked at the Royal Airforce Institute of Aviation Medicine, the United States Naval Aerospace Medical
Institute and the University of Leicester. He has published books on motion sickness, transport human factors, absent-mindedness, human
error, and on managing the risks of organizational accidents. He is a fellow of the British Psychological Society, the Aeronautical Society, and
the British Academy. Professor Reason holds a Ph.D. in psychology and physiology from the University of Leicester, United Kingdom.
The Choice is Very Simple (Dr. Reason)

"Either you manage human error or human error will manage you."
Another way of putting it is to say:
'If you're not part of the solution, then you're part of the problem'
There is bad news and good news:
The bad news
If some evil genius were given the job of designing a task guaranteed to produce an abundance of errors, he or she would come up with
something like aircraft maintenance:
• frequent removal and replacement of many parts

• often in cramped and poorly lit spaces
• often with less than adequate tools
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• often under severe time pressure.
Maintenance-related activities are so error-provoking that it is hard to believe that they have not been contrived by some malign
mastermind.
Additional refinements
• People who write the manuals and procedures hardly ever do the job for real.
• People who start on a job are not necessarily the ones to finish it.
• Several groups work on same aircraft at same time and/or sequentially.
"Small wonder, then, that maintenance attracts more than its fair share of errors"
The good news
• Maintenance-related errors are not random events.

• They fall into recurrent patterns, shaped by situation and task factors characteristic of maintenance activities in general.
• Different people in different organizations keep on making the same blunders.
• Can focus limited resources to maximum remedial effect.
Many people regard errors as random occurrences, events that are so wayward and unpredictable as to be beyond effective control. But this
is not the case. While it is true that chance factors play their part and that human fallibility will never be wholly eliminated, the large majority
of slips, lapses and mistakes fall into systematic and recurrent patterns. Far from being entirely unpredictable happenings, maintenance
mishaps fall mostly into well-defined clusters shaped largely by situation and task factors that are common to maintenance activities in
general. That these errors are not committed by a few careless or incompetent individuals is evident from the way that different people in
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different kinds of maintenance organizations keep on making the same blunders. One of the basic principles of error management is that
the best people can make the worst mistakes.
So the good news boils down to this: the maintenance error problem can be managed in the same way that any well-defined business risk
can be managed. And because most maintenance errors occur as recognizable and recurrent types, limited resources can be targeted to
achieve maximum remedial effect. It should be stressed, however, that there is no one best way of limiting and containing human error.
Effective error management requires a wide variety of counter-measures directed at different levels of the system: the individual, the team,
the task, the workplace and the organization as a whole.
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Module 15
Human Factor
15. 2 Human Performance and Limitations
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LEVEL 1
LEVEL 2
LEVEL 3
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Table of Contents
Module 15.2 Human Performance and Limitations ____________________________________________________________________ 6
Human Performance as Part of the Maintenance Engineering System ____________________________________________________ 6
Vision ___________________________________________________________________________________________________________ 7
The Basic Function of the Eye ______________________________________________________________________________________ 7
Components of the Eye ___________________________________________________________________________________________ 8
Factors Affecting Clarity of Sight ___________________________________________________________________________________ 10
Physical Factors _________________________________________________________________________________________________ 12
Environmental Factors ___________________________________________________________________________________________ 1
The Nature of the Object Being Viewed ______________________________________________________________________________ 12
Colour Vision ___________________________________________________________________________________________________ 12
Vision and the Aircraft Maintenance Engineer_________________________________________________________________________ 13
Hearing _________________________________________________________________________________________________________ 14
The Basic Function of the Ear ______________________________________________________________________________________ 14
Components of the Ear ___________________________________________________________________________________________ 15
Impact of Noise on Performance ___________________________________________________________________________________ 16
Hearing Impairment _____________________________________________________________________________________________ 16
High and Low Tone Deafness ______________________________________________________________________________________ 17
Hearing Protection ______________________________________________________________________________________________ 18
Presbycusis_____________________________________________________________________________________________________ 18
Hearing and the Aircraft Maintenance Engineer _______________________________________________________________________ 18
Information Processing ____________________________________________________________________________________________ 19
An Information Processing Model __________________________________________________________________________________ 20
Sensory Receptors and Sensory Stores_______________________________________________________________________________ 20
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Attention and Perception _________________________________________________________________________________________ 20

Decision Making ________________________________________________________________________________________________ 21
Memory _______________________________________________________________________________________________________ 22
Motor Programmes ______________________________________________________________________________________________ 24
Situation Awareness _____________________________________________________________________________________________ 25
Information Processing Limitations _________________________________________________________________________________ 26
Attention and Perception _________________________________________________________________________________________ 26
Decision Making, Memory, and Motor Programmes ____________________________________________________________________ 28
Summary ______________________________________________________________________________________________________ 30
Claustrophobia, Physical Access and Fear of Heights __________________________________________________________________ 30
Physical Access and Claustrophobia_________________________________________________________________________________ 31
Fear of Heights __________________________________________________________________________________________________ 31
Other Phobias __________________________________________________________________________________________________ 32
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Vision 9.2 2
Hearing
Information processing
Attention and Perception
Memory
Claustrophobia and physical access
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Module 15.2 Human Performance and Limitations
The intention of this chapter is to provide an overview of those key physical and mental human performance characteristics which are likely
to affect an aircraft maintenance engineer in his working environment, such as his vision, hearing, information processing, attention and
perception, memory, judgment and decision making.
Human Performance as Part of the Maintenance Engineering System

Just as certain mechanical components used in aircraft maintenance engineering have limitations, engineers themselves have certain
capabilities and [imitations that must be considered when looking at the maintenance engineering `system '. For instance, rivets used to
attach aluminium skin to a fuselage can withstand forces that act to pull them apart. It is clear that that these rivets will eventually fail if
enough force is applied to them. While the precise range of human capabilities and limitations might not be as well-defined as the
performance range of mechanical or electrical components, the same principles apply in that human performance is likely to degrade and
eventually 'fail ' under certain conditions (e.g. stress).
Mechanical components in aircraft can, on occasion, suffer catastrophic failures. Man, can also fail to function properly in certain situations.
Physically, humans become fatigued, are affected by the cold, can break bones in workplace accidents, etc. Mentally, humans can make
errors, have limited perceptual powers, can exhibit poor judgment due to lack of skills and knowledge, etc. In addition, unlike mechanical
components, human performance is also affected by social and emotional factors. Therefore failure by aircraft maintenance engineers can
also be to the detriment of aircraft safety.
The aircraft engineer is the central part of the aircraft maintenance system. It is therefore very useful to have an understanding of how
various parts of his body and mental processes function and how performance limitations can influence his effectiveness at work.
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Vision
The Basic Function of the Eye

In order to understand vision, it is useful first to know a little about the anatomy of the eye (see L Figure 2.1). The basic structure of the eye is
similar to a simple camera with an aperture (the iris), a lens, and a light sensitive surface (the retina). Light enters the eye through the
cornea, then passes through the iris and the lens and falls on the retina. Here the light stimulates the light-sensitive cells on the retina (rods
and cones) and these pass small electrical impulses by way of the optic nerve to the visual cortex in the brain. Here, the electrical impulses
are interpreted and an image is perceived.
Figure 2.1: The human eye
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Components of the Eye
The Cornea
The cornea is a clear `window' at the very front of the eye. The cornea acts as a fixed focusing device. The focusing is achieved by the shape
of the cornea bending the incoming light rays. The cornea is responsible for between 70% and 80% of the total focusing ability (refraction)
of the eye.
The Iris and Pupil

The iris (the coloured part of the eye) controls the amount of light that is allowed to enter the eye. It does this by varying the size of the
pupil (the dark area in the centre of the iris). The size of the pupil can be changed very rapidly to cater for changing light levels. The amount
of light can be adjusted by a factor of 5:1.
The Lens
After passing through the pupil, the light passes through the lens. Its shape is changed by the muscles (cillary muscles) surrounding it which
results in the final focusing adjustment to place a sharp image onto the retina. The change of shape of the lens is called accommodation. In
order to focus clearly on a near object, the lens is thickened. To focus on a distant point, the lens is flattened. The degree of accommodation
can be affected by factors such as fatigue or the ageing process.
When a person is tired accommodation is reduced, resulting in less sharp vision (sharpness of vision is known as visual acuity).
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The Retina
The retina is located on the rear wall of the eyeball. It is made up of a complex layer of nerve cells connected to the optic nerve. Two types of
light sensitive cells are found in the retina - rods and cones The central area of the retina is known as the fovea and the receptors in this area
are all cones. It is here that the visual image is typically focused. Moving outwards, the cones become less dense and are progressively
replaced by rods, so that in the periphery of the retina, there are only rods.
Cones function in good light and are capable of detecting fine detail and are colour sensitive. This means the human eye can distinguish
about 1000 different shades of colour.
Rods cannot detect colour. They are poor at distinguishing fine detail, but good at detecting movement in the edge of the visual field
(peripheral vision). They are much more sensitive at lower light levels. As light decreases, the sensing task is passed from the cones to the
rods. This means in poor light levels we see only in black and white and shades of grey.
At the point at which the optic nerve joins the back of the eye, a 'blind spot' occurs. This is not evident when viewing things with both eyes
(binocular vision), since it is not possible for the image of an object to fall on the blind spots of both eyes at the same time. Even when
viewing with one eye (monocular vision), the constant rapid movement of the eye (saccades) means that the image will not fall on the blind
spot all the time. It is only when viewing a stimulus that appears very fleetingly (e.g. a light flashing), that the blind spot may result in
something not being seen. In maintenance engineering, tasks such as close visual inspection or crack detection should not cause such
problems, as the eye or eyes move across and around the area of interest (visual scanning).
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Factors Affecting Clarity of Sight

The eye is very sensitive in the right conditions (e.g. clear air, good light, etc.). In fact, the eye has approximately 1.2 million nerve cells
leading from the retinas to the area of the brain responsible for vision, while there are only about 50,000 from the inner ears -making the
eye about 24 times more sensitive than the ear.
Before considering factors that can influence and limit the performance of the eye, it is necessary to describe visual acuity.
Visual acuity is the ability of the eye to discriminate sharp detail at varying distances.
An individual with an acuity of 20/20 vision should be able to see at 20 feet that which the socalled 'normal' person is capable of seeing at
this range. It may be expressed in metres as 6/6 vision. The figures 20/40 mean that the observer can read at 20 feet what a `normal ' person
can read at 40 feet.
Various factors can affect and limit the visual acuity of the eye. These include:
Physical factors such as:
• physical imperfections in one or both eyes (short sightedness, long sightedness),

• age.
The influence of ingested foreign substances such as-
• drugs,
• medication,
• alcohol,
• cigarettes.
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Environmental factors such as:
• amount of light available,

• clarity of the air (e.g. dust, mist, rain, etc.).
Factors associated with object being viewed such as:
• size and contours of the object,

• contrast of the object with its surroundings,
• relative motion of the object,
• distance of the object from the viewer,
• the angle of the object from the viewer.
Each of these factors will now be examined in some detail.
Blind Spot
Occurs at the point where the optic nerve enters the retina (between the rods & cones). Facial features such as the nose also contribute to
this problem.
Hold picture away and focus on the circle with the right eye. Move the page slowly to the face and at some point the triangle shall
disappear.. the blind spot.
Figure 2.2: Standard test for the "blind spot"
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Physical Factors
Long sight - known as Hypermetropia - is caused by a shorter than normal eyeball which means that the image is formed behind the retina
(Figure 2.3). If the cornea and the lens cannot use their combined focusing ability to compensate for this, blurred vision will result when
looking at close objects.
Figure 2.3: Farsighted focus
A convex lens overcomes long sightedness by bending light inwards before it reaches the cornea.
Short sight - known as Myopia - is where the eyeball is longer than normal, causing the image to be formed in front of the retina (Figure 2.4).
If the accommodation of the lens cannot counteract this then distant objects are blurred.
Figure 2.4: Nearsighted focus
A concave lens overcomes shortsightedness by bending light outwards before it reaches the cornea.
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Other visual problems include:
• cataracts - clouding of the lens usually associated with ageing;
• astigmatism - a misshapen cornea causing objects to appear irregularly shaped;
• glaucoma - a build up in pressure of the fluid within the eye which can cause damage to the optic nerve and even blindness;
• migraine - severe headaches that can cause visual disturbances.
Finally as a person grows older, the lens becomes less flexible meaning that it is unable to accommodate sufficiently. This is known as
presbyopia and is a form of long sightedness. Consequently, after the age of 40, spectacles may be required for near vision, especially in
poor light conditions. Fatigue can also temporarily affect accommodation, causing blurred vision for close work.
Foreign Substances
Vision can be adversely affected by the use of certain drugs and medications, alcohol, and smoking cigarettes. With smoking, carbon
monoxide which builds up in the bloodstream allows less oxygen to be carried in the blood to the eyes. This is known as hypoxia and can
impair rapidly the sensitivity of the rods. Alcohol can have similar effects, even hours after the last drink.
Environmental Factors
Vision can be improved by increasing the lighting level, but only up to a point, as the law of diminishing returns operates. Also, increased
illumination could result in increased glare. Older people are more affected by the glare of reflected light than younger people. Moving
from an extremely bright environment to a dimmer one has the effect of vision being severely reduced until the eyes get used to less light
being available. This is because the eyes have become light adapted. If an engineer works in a very dark environment for a long time, his
eyes gradually become dark adapted allowing better visual acuity. This can take about 7 minutes for the cones and 30 minutes for the rods.
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As a consequence, moving between a bright hanger (or the inside of an aircraft) to a dark apron area at night can mean that the
maintenance engineer must wait for his eyes to adjust (adapt). In low light conditions, it is easier to focus if you look slightly to one side of
an object. This allows the image to fall outside the fovea and onto the part of the retina that has many rods.
Any airborne particles such as dust, rain or mist can interfere with the transmission of light through the air, distorting what is seen. This can
be even worse when spectacles are worn, as they are susceptible to getting dirty, wet, misted up or scratched. Engineers who wear contact
lenses (especially hard or gas-permeable types) should take into account the advice from their optician associated with the maximum wear
time -usually 8 to 12 hours - and consider the effects which extended wear may have on the eyes, such as drying out and irritation. This is
particularly important if they are working in an environment which is excessively dry or dusty, as airborne particles may also affect contact
lens wear. Goggles should be worn where necessary.
The Nature of the Object Being Viewed

Many factors associated with the object being viewed can also influence vision. We use information from the objects we are looking at to
help distinguish what we are seeing. These are known as visual cues. Visual cues often refer to the comparison of objects of known size to
unknown objects. An example of this is that we associate small objects with being further away. Similarly, if an object does not stand out
well from its background (i.e. it has poor contrast with its surroundings), it is harder to distinguish its edges and hence its shape. Movement
and relative motion of an object, as well as distance and angle of the object from the viewer, can all increase visual demands.
Colour Vision
Although not directly affecting visual acuity, inability to see particular colours can be a problem for the aircraft maintenance engineer.
Amongst other things, good colour vision for maintenance engineers is important for:
• Recognising components;
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• Distinguishing between wires;
• Using various diagnostic tools;
• Recognising various lights on the airfield (e.g. warning lights).
Colour defective vision is usually hereditary, although may also occur as a temporary condition after a serious illness.
Colour defective vision (normally referred to incorrectly as colour blindness, Daltonism') affects about 8% of men but only 0.5% of women.
The most common type is difficulty in distinguishing between red and green. More rarely, it is possible to confuse blues and yellows.
There are degrees of colour defective vision, some people suffering more than others.
Individuals may be able to distinguish between red and green in a well-lit situation but not in low light conditions. Colour defective people
typically see the colours they have problems with, as shades of neutral grey.
Ageing also causes changes in colour vision. This is a result of progressive yellowing of the lens, resulting in a reduction in colour
discrimination in the blue-yellow range. Colour defective vision and its implications can be a complex area and care should be taken not to
stop an engineer from performing certain tasks merely because he suffers from some degree of colour deficient vision. It may be that the
type and degree of colour deficiency is not relevant in their particular job. However, if absolutely accurate colour discrimination is critical for
a job, it is important that appropriate testing and screening be put in place.
Colour Loss at Night

At night or in dim light central vision is poor under low illumination. Better results are obtained by looking slightly to one side of the object,
rather than directly at them. This permits better use of the peripheral vision by using rods instead of the central cones. This effect can be
demonstrated by counting a group of faint lights in the distance when looking directly at them. Then by looking some 10 degrees to one
side. It will be possible to see more lights.
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A further point to bear in mind is that some people who have perfect day vision may be myopic (near sighted) at night. Night myopia is little
recognized but can present a significant hazard, particularly because of the false confidence instilled from having good vision by day.
The reason for night myopia lies in the differing frequency of colours that prevail by night, and the varying ability of the eyes lens to focus
them. Red and orange predominate by day and a lens whether natural or artificial, which is easily capable of focusing these wavelengths
can be found wanting.
When it tries to focus the more violet colours that prevail at night. In dim conditions the lens has enough elasticity to focus the light from
near objects (thus near sightedness) but cannot focus properly on objects further away.
Vision and the Aircraft Maintenance Engineer

It is important for an engineer, particularly one who is involved in inspection tasks, to have adequate vision to meet the task requirements.
As discussed previously, age and problems developing in the eye itself can gradually affect vision. Without regular vision testing, aircraft
maintenance engineers may not notice that their vision is deteriorating.
In the UK, the CAA have produced guidance (CAAIP Leaflet 15-6, previously published as Airworthiness Notice 47) which states:
"A reasonable standard of eyesight is needed for any aircraft engineer to perform his duties to an acceptable degree. Many maintenance
tasks require a combination of both distance and near vision. In particular, such consideration must be made where there is a need for the
close visual inspection of structures or work related to small or miniature components. The use of glasses or contact lenses to correct any
vision problems is perfectly acceptable and indeed they must be worn as prescribed. Frequent checks should be made to ensure the
continued adequacy of any glasses or contact lenses. In addition, colour discrimination may be necessary for an individual to drive in areas
where aircraft manoeuvre or where colour coding is used, e.g. in aircraft wiring.
Organisations should identify any specific eyesight requirement and put in place suitable procedures to address these issues."
Often, airline companies or airports will set the eyesight standards for reasons other than aircraft maintenance safety, e.g. for insurance
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purposes, or for driving on the airfield.
Ultimately, what is important is for the individual to recognise when his vision is adversely affected, either temporarily or permanently, and
to consider carefully the possible consequences should they continue to work if the task requires good vision.
Hearing
The Basic Function of the Ear

The ear performs two quite different functions. It is used to detect sounds by receiving vibrations in the air, and secondly, it is responsible
for balance and sensing acceleration. Of these two, the hearing aspect is more pertinent to the maintenance engineer, and thus it is
necessary to have a basic appreciation of how the ear works.
As can be seen in Figure 2.5, the ear has three divisions: outer ear, middle ear and inner ear. These act to receive vibrations from the air and
turn these signals into nerve impulses that the brain can recognise as sounds.
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Figure 2.5: The human ear
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Components of the Ear
Outer Ear
The outer part of the ear directs sounds down the auditory canal, and on to the eardrum The sound waves will cause the eardrum to vibrate.
Middle Ear
Beyond the eardrum is the middle ear which transmits vibrations from the eardrum by way of three small bones known as the ossicles , to
the fluid of the inner ear. The middle ear also contains two muscles which help to protect the ear from sounds above 80 dB by means of the
acoustic or aural reflex, reducing the noise level by up to 20 dB. However, this protection can only be provided for a maximum of about 15
minutes, and does not provide protection against sudden impulse noise such as gunfire. It does explain why a person is temporarily
`deafened' for a few seconds after a sudden loud noise. The middle ear is usually filled with air which is refreshed by way of the eustachian
tube which connects this part of the ear with the back of the nose and mouth. However, this tube can allow mucus to travel to the middle
ear which can build up, interfering with normal hearing.
Inner Ear
Unlike the middle ear, the inner ear is filled with fluid. The last of the ossicles in the middle ear is connected to the cochlea This contains a
fine membrane (the basilar membrane) covered in hair-like cells which are sensitive to movement in the fluid. Any vibrations they detect
cause neural impulses to be transmitted to the brain via the auditory nerve.
The amount of vibration detected in the cochlea depends on the volume and pitch of the original sound.
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Performance and Limitations of the Ear

The performance of the ear is associated with the range of sounds that can be heard - both in terms of the pitch (frequency) and the volume
of the sound.
The audible frequency range that a young person can hear is typically between 20 and 20,000 cycles per second (or Hertz), with greatest
sensitivity at about 3000 Hz.
Volume (or intensity) of sound is measured in decibels (dB). Table 2.1 shows intensity levels for various sounds and activities.
Activity Approximate Intensity level (Decibels)
Rusting of leaves / Whisper 20

Conversation at 2 m 50
Typewriter at 1 m 65
Car at 15 m 70
Lorry at 15 m 75
Power Mower at 2 m 90
Propeller aircraft at 300 m 100
Jet aircraft at 300 m 110
Standing near a propeller aircraft 120
Threshold of pain 140
Immediate hearing damage result 150
Table 2.1 Typical sound levels for various activities
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Impact of Noise on Performance

Noise can have various negative effects in the workplace. It can:
• be annoying (e.g. sudden sounds, constant loud sound, etc.);

• interfere with verbal communication between individuals in the workplace;
• cause accidents by masking warning signals or messages;
• be fatiguing and affect concentration, decision making, etc.;
• damage workers' hearing (either temporarily or permanently).
Intermittent and sudden noise are generally considered to be more disruptive than continuous noise at the same level. In addition, high
frequency noise generally has a more adverse affect on performance than lower frequency. Noise tends to increase errors and variability,
rather than directly affect work rate.
Hearing Impairment
Hearing loss can result from exposure to even relatively short duration noise. The degree of impairment is influenced mainly by the intensity
of the noise. Such damage is known as Noise Induced Hearing Loss (NIHL). The hearing loss can be temporary -lasting from a few seconds to
a few days -or permanent. Temporary hearing loss may be caused by relatively short exposure to very loud sound, as the hair-like cells on
the basilar membrane take time to recover'. With additional exposure, the amount or recovery gradually decreases and hearing loss
becomes permanent. Thus, regular exposure to high levels of noise over a long period may permanently damage the hair-like cells in the
cochlea, leading to irreversible hearing impairment.
UK `Noise at Work' regulations stipulate three levels of noise at which an employer must act:
85 decibels (if normal speech cannot be heard clearly at 2 metres), employer must;
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• assess the risk to employees' hearing,,

• tell the employees about the risks and what precautions are proposed,
• provide their employees with personal ear protectors and explain their use. 90 decibels (if normal speech cannot be heard clearly at 1
metre), employer must;
• do all that is possible to reduce exposure to the noise by means other than by providing hearing protection,
• mark zones where noise reaches the second level and provide recognized signs to restrict entry.
140 decibels (noise causes pain).
The combination of duration and intensity of noise can be described as noise dose.
Exposure to any sound over 80 dB constitutes a noise dose, and can be measured over the day as an 8 hour Time Weighted Average sound
level (TWA).
For example, a person subjected to 95 decibels for 3.5 hours, then 105 decibels for 0.5 hours, then 85 decibels for 4 hours, results in a TWA of
93.5 which exceeds the recommended maximum TWA of 90 decibels.
Permanent hearing loss may occur if the TWA is above the recommended maximum.
It is normally accepted that a TWA noise level exceeding 85 dB for 8 hours is hazardous and potentially damaging to the inner ear. Exposure
to noise in excess of 115 decibels without ear protection, even for a short duration, is not recommended.
High and Low Tone Deafness

The normal human ear is sensitive to frequencies between about 20 Hz and 20,000 Hz, being particularly sensitive in eth range 1000 Hz to
4000 Hz and progressively less sensitive at higher and lower frequencies.
This is very important when measuring noise since two sounds of equal intensity, but of different frequency, may appear subjectively to be
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of different loudness.
In the cochlea there are 23,000 nerve cells and each has about 100 sensory hairs. These hairs sense the vibration of the ossicles.
There are two sizes of hair; long; which detect low frequencies, and short; which detect high frequencies. Deterioration of the sensory hairs
occurs with over exposure to high levels of noise.
Hearing Protection
Hearing protection is available, to a certain extent, by using ear plugs or ear defenders.
Noise levels can be reduced (attenuated) by up to 20 decibels using ear plugs and 40 decibels using ear muffs. However, using ear
protection will tend to adversely interfere with verbal communication. Despite this, it must be used consistently and as instructed to be
effective.
It is good practice to reduce noise levels at source, or move noise away from workers.
Often this is not a practical option in the aviation maintenance environment. Hearing protection should always be used for noise, of any
duration, above 115 dB. Referring again to Table 1,this means that the aviation maintenance engineer will almost always need to use some
form of hearing protection when in reasonably close proximity (about 200-300m) to aircraft whose engines are running.
Presbycusis
Hearing deteriorates naturally as one grows older. This is known as presbycusis. This affects ability to hear high pitch sounds first, and may
occur gradually from the 30’s onwards. When this natural decline is exacerbated by Noise Induced Hearing Loss, it can obviously occur
rather sooner.
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Hearing and the Aircraft Maintenance Engineer

The UK CAA makes the following recommendations (Leaflet 15-6, previously published as Airworthiness Notice 47) regarding hearing:
"The ability to hear an average conversational voice in a quiet room at a distance of 2 metres (6 feet) from the examiner is recommended as
a routine test. Failure of this test would require an audiogram to be carried out to provide an objective assessment. If necessary, a hearing
aid may be worn but consideration should be given to the practicalities of wearing the aid during routine tasks demanded of the
individual."
It is very important that the aircraft maintenance engineer understands the limited ability of the ears to protect themselves from damage
due to excessive noise. Even though engineers should be given appropriate hearing protection and trained in its use, it is up to individuals
to ensure that they actually put this to good use. It is a misconception that the ears get used to constant noise: if this noise is too loud, it will
damage the ears gradually and insidiously.
Information Processing
The previous sections have described the basic functions and limitations of two of the senses used by aircraft maintenance engineers in the
course of their work. This section examines the way the information gathered by the senses is processed by the brain. The limitations of the
human information processing system are also considered.
Information processing is the process of receiving information through the senses, analysing it and making it meaningful.
An Information Processing Model

Information processing can be represented as a model. This captures the main elements of the process, from receipt of information via the
senses, to outputs such as decision making and actions. One such model is shown in Figure 2.6.
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Figure 2.6: A functional model of human information processing
Sensory Receptors and Sensory Stores

Physical stimuli are received via the sensory receptors (eyes, ears, etc.) and stored for a very brief period of time in sensory stores (sensory
memory). Visual information is stored for up to half a second in iconic memory and sounds are stored for slightly longer (up to 2 seconds) in
echoic memory. This enables us to remember a sentence as a sentence, rather than merely as an unconnected string of isolated words, or a
film as a film, rather than as a series of disjointed images.
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Having detected information, our mental resources are concentrated on specific elements - this is attention.
Attention can be thought of as the concentration of mental effort on sensory or mental events.
Although attention can move very quickly from one item to another, it can only deal with one item at a time. Attention can take the form of:
• selective attention,
• divided attention,
• focused attention
• sustained attention.
Selective attention occurs when a person is monitoring several sources of input, with greater attention being given to one or more sources
which appear more important. A person can be consciously attending to one source whilst still sampling other sources in the background.
Psychologists refer to this as the `cocktail party effect 'whereby you can be engrossed in a conversation with one person but your attention
is temporarily diverted if you overhear your name being mentioned at the other side of the room, even though you were not aware of
listening in to other people 's conversations. Distraction is the negative side of selective attention.
Divided attention is common in most work situations, where people are required to do more than one thing at the same time. Usually, one
task suffers at the expense of the other, more so if they are similar in nature. This type of situation is also sometimes referred to as time
sharing.
Focused attention is merely the skill of focusing one's attention upon a single source and avoiding distraction.
Sustained attention as its name implies, refers to the ability to maintain attention and remain alert over long periods of time, often on one
task. Most of the research has been carried out in connection with monitoring radar displays, but there is also associated research which has
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concentrated upon inspection tasks.
Attention is influenced by arousal level and stress. This can improve attention or damage it depending on the circumstances.
Perception involves the organisation and interpretation of sensory data in order to make it meaningful, discarding non-relevant data, i.e.
transforming data into information. Perception is a highly sophisticated mechanism and requires existing knowledge and experience to
know what data to keep and what to discard, and how to associate the data in a meaningful manner.
Perception can be defined as the process of assembling sensations into a useable mental representation of the world. Perception creates
faces, melodies, works of art, illusions, etc. out of the raw material of sensation.
Examples of the perceptual process:
1 the image formed on the retina is inverted and two dimensional, yet we see the world theright way up and in three dimensions;
2 if the head is turned, the eyes detect a constantly changing pattern of images, yet we perceive things around us to have a set location,
rather than move chaotically.
Decision Making
Having recognised coherent information from the stimuli reaching our senses, a course of action has to be decided upon. In other words
decision making occurs.
Decision making is the generation of alternative courses of action based on available information, knowledge, prior experience, expectation,
context, goals, etc, and selecting one preferred option. It is also described as thinking, problem solving and judgment.
This may range from deciding to do nothing, to deciding to act immediately in a very specific manner. A fire alarm bell, for instance, may
trigger a well-trained sequence of actions without further thought (i.e. evacuate); alternatively, an unfamiliar siren may require further
information to be gathered before an appropriate course of action can be initiated.
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We are not usually fully aware of the processes and information which we use to make a decision. Tools can be used to assist the process of
making a decision. For instance, in aircraft maintenance engineering, many documents (e.g. maintenance manuals, fault diagnosis
manuals), and procedures are available to supplement the basic decision making skills of the individual. Thus, good decisions are based on
knowledge supplemented by written information and procedures, analysis of observed symptoms, performance indications, etc. It can be
dangerous to believe that existing knowledge and prior experience will always be sufficient in every situation as will be shown in the section
entitled 'Information Processing Limitations '.
Finally, once a decision has been made, an appropriate action can be carried out. Our senses receive feedback of this and its result. This
helps to improve knowledge and refine future judgment by learning from experience.
Memory
Memory is critical to our ability to act consistently and to learn new things. Without memory, we could not capture a 'stream' of information
reaching our senses, or draw on past experience and apply this knowledge when making decisions.
Memory can be considered to be the storage and retention of information, experiences and knowledge, as well as the ability to retrieve this
information.
Memory depends on three processes:
• registration - the input of information into memory;

• storage - the retention of information;
• retrieval - the recovery of stored information.
It is possible to distinguish between three forms of memory:
• ultra short-term memory (or sensory storage);

• short term memory (often referred to as working memory)
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• long term memory.
Ultra short-term memory has already been described when examining the role of sensory stores. It has a duration of up to 2 seconds
(depending on the sense) and is used as a buffer, giving us time to attend to sensory input.
Short term memory receives a proportion of the information received into sensory stores, and allows us to store information long enough to
use it (hence the idea of 'working memory'). It can store only a relatively small amount of information at one time, i.e. 5 to 9 (often referred
to as 7 ±2) items of information, for a short duration, typically 10 to 20 seconds. As the following example shows, capacity of short term
memory can be enhanced by splitting information in to `chunks' (a group of related items).
A telephone number, e.g. 01222555234, can be stored as 11 discrete digits, in which case it is unlikely to be remembered. Alternatively, it
can be stored in chunks of related information, e.g. in the UK, 01222 may be stored as one chunk, 555 as another, and 234 as another, using
only 3 chunks and therefore, more likely to be remembered. In mainland Europe, the same telephone number would probably be stored as
01 22 25 55 23 4, using 6 chunks. The size of the chunk will be determined by the individual's familiarity with the information (based on prior
experience and context), thus in this example, a person from the UK might recognise 0208 as the code for London, but a person from
mainland Europe might not.
The duration of short term memory can be extended through rehearsal (mental repetition of the information) or encoding the information
in some meaningful manner (e.g. associating it with something as in the example above).
The capacity of long-term memory appears to be unlimited. It is used to store information that is not currently being used, including:
• knowledge of the physical world and objects within it and how these behave;
• personal experiences;
• beliefs about people, social norms, values, etc.;
• motor programmes, problem solving skills and plans for achieving various activities;
• abilities, such as language comprehension.
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Information in long-term memory can be divided into two types:
• Semantic memory refers to our store of general, factual knowledge about the world, such as concepts, rules, one's own language, etc. It
is information that is not tied to where and when the knowledge was originally acquired.
• Episodic memory refers to memory of specific events, such as our past experiences (including people, events and objects). We can
usually place these things within a certain context. It is believed that episodic memory is heavily influenced by a person's expectations of
what should have happened, thus two people's recollection of the same event can differ.
Summary
Figure 2.7: Sections of the memory
Motor Programmes
If a task is performed often enough, it may eventually become automatic and the required skills and actions are stored in long term
memory. These are known as motor programmes and are ingrained routines that have been established through practice. The use of a
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motor programme reduces the load on the central decision maker. An often quoted example is that of driving a car: at first, each individual
action such as gear changing is demanding, but eventually the separate actions are combined into a motor programme and can be
performed with little or no awareness.
These motor programmes allow us to carry out simultaneous activities, such as having a conversation whilst driving.
Situation Awareness
Although not shown explicitly in Figure 8, the process of attention, perception and judgment should result in awareness of the current
situation.
Situation awareness is the synthesis of an accurate and up-to-date 'mental model' of one's environment and state, and the ability to use this
to make predictions of possible future states.
Situation awareness has traditionally been used in the context of the flight deck to describe the pilot's awareness of what is going on
around him, e.g. where he is geographically, his orientation in space, what mode the aircraft is in, etc. In the maintenance engineering
context, it refers to:
• the perception of important elements, e.g. seeing loose bolts or missing parts, hearing information passed verbally;
• the comprehension of their meaning, e.g. why is it like this? Is this how it should be?
• the projection of their status into the future, e.g. future effects on safety, schedule, airworthiness.
An example is an engineer seeing (or perceiving) blue streaks on the fuselage. His comprehension may be that the lavatory fill cap could be
missing or the drainline leaking. If his situation awareness is good, he may appreciate that such a leak could allow blue water to freeze,
leading to airframe or engine damage.
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As with decision making, feedback improves situation awareness by informing us of the accuracy of our mental models and their predictive
power. The ability to project system status backward, to determine what events may have led to an observed system state, is also very
important in aircraft maintenance engineering, as it allows effective fault finding and diagnostic behaviour.
Situation awareness for the aircraft maintenance engineer can be summarised as:
• the status of the system the engineer is working on;
• the relationship between the reported defect and the intended rectification;
• the possible effect on this work on other systems;
• the effect of this work on that being done by others and the effect of their work on this work.
This suggests that in aircraft maintenance engineering, the entire team needs to have situation awareness - not just of what they are doing
individually, but of their colleagues' activities as well.
Information Processing Limitations

The basic elements of human information processing have now been explored. It is important to appreciate that these elements have
limitations. As a consequence, the aircraft engineer, like other skilled professionals, requires support such as reference to written material
(e.g. L manuals).

A proportion of `sensed' data may be lost without being `perceived'. An example with which most people are familiar is that of failing to
perceive something which someone has said to you, when you are concentrating on something else, even though the words would have
been received at the ear without any problem. The other side of the coin is the ability of the information processing system to perceive
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something (such as a picture, sentence, concept, etc.) even though some of the data may be missing. The danger, however, is that people
can fill in the gaps with information from their own store of knowledge or experience, and this may lead to the wrong conclusion being
drawn.
Once we have formed a mental model of a situation, we often seek information which will confirm this model and, not consciously, reject
information which suggests that this model is incorrect.
There are many well-known visual ìllusions' which illustrate the limits of human perception. Figure 2.8 shows how the perceptual system
can be misled into believing that one line is longer than the other, even though a ruler will confirm that they are exactly the same.
Figure 2.8: The Muller-Lyer Illusion
Figure 2.9 illustrates that we can perceive the same thing quite differently (i.e. the letter "B" or the number "13"). This shows the influence of
context on our information processing.
Figure 2.9: The importance of context.
In aviation maintenance it is often necessary to consult documents with which the engineer can become very familiar. It is possible that an
engineer can scan a document and fail to notice that subtle changes have been made. He sees only what he expects to see (expectation). To
illustrate how our eyes can deceive us when quickly scanning a sentence, read quickly the sentence below in Figure 2.10.
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Figure 2.10: The effects of expectation
At first, most people tend to notice nothing wrong with the sentence. Our perceptual system sub-consciously rejects the additional "THE".
As an illustration of how expectation, can affect our judgment, the same video of a car accident was shown to two groups of subjects. One
group was told in advance that they were to be shown a video of a car crash; the other was told that the car had been involved in a `bump'.
Both groups were asked to judge the speed at which the vehicles had collided. The first group assessed the speed as significantly higher
than the second group.
Expectation can also affect our memory of events. The study outlined above was extended such that subjects were asked, a week later,
whether they recalled seeing glass on the road after the collision. (There was no glass). The group who had been told that they would see a
crash, recalled seeing glass; the other group recalled seeing no glass.
Decision Making, Memory, and Motor Programmes

Attention and perception shortcomings can clearly impinge on decision making. Perceiving something incorrectly may mean that an
incorrect decision is made, resulting in an inappropriate action. Figure 8 also shows the dependence on memory to make decisions. It was
explained earlier that sensory and short-term memory have limited capacity, both in terms of capacity and duration. It is also important to
bear in mind that human memory is fallible, so that information:
• may not be stored;

• may be stored incorrectly;
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• may be difficult to retrieve.
All these may be referred to as forgetting, which occurs when information is unavailable (not stored in the first place) or inaccessible (cannot
be retrieved). Information in short-term memory is particularly susceptible to interference, an example of which would be trying to
remember a part number whilst trying to recall a telephone number.
It is generally better to use manuals and temporary aides-memoires rather than to rely upon memory, even in circumstances where the
information to be remembered or recalled is relatively simple. For instance, an aircraft maintenance engineer may think that he will
remember a torque setting without writing it down, but between consulting the manual and walking to the aircraft (possibly stopping to
talk to someone on the way), he may forget the setting or confuse it (possibly with a different torque setting appropriate to a similar task
with which he is more familiar). Additionally, if unsure of the accuracy of memorised information, an aircraft maintenance engineer should
seek to check it, even if this means going elsewhere to do so. Noting something down temporarily can avoid the risk of forgetting or
confusing information. However, the use of a personal note book to capture such information on a permanent basis can be dangerous, as
the information in it may become out-of-date.
In the B737 double engine oil loss incident, the AAIB report stated:
"Once the Controller and fitter had got to T2 and found that this supportive material [Task Cards and AMM extracts] was not available in the
workpack, they would have had to return to Base Engineering or to have gone over to the Line Maintenance office to get it. It would be, in
some measure, understandable for them to have a reluctance to re-cross the exposed apron area on a winter's night to obtain a description
of what they were fairly confident they knew anyway. However, during the course of the night, both of them had occasion to return to the
Base Maintenance hangar a number of times before the task had been completed. Either could, therefore, have referred to or even drawn
the task descriptive papers before the job was signed off. The question that should be addressed, therefore, is whether there might be any
factors other than overconfidence in their memories, bad judgment or idleness which would dispose them to pass up these opportunities
to refresh their memories on the proper and complete procedures."
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Summary
Figure 2.11: Summary of information processing
Claustrophobia, Physical Access and Fear of Heights

Although not peculiar to aircraft maintenance engineering, working in restricted space and at heights is a feature of this trade. Problems
associated with physical access are not uncommon. Maintenance engineers and technicians often have to access, and work in, very small
spaces (e.g. in fuel tanks), cramped conditions (such as beneath flight instrument panels, around rudder pedals), elevated locations (on
cherry-pickers or staging), sometimes in uncomfortable climatic or environmental conditions (heat, cold, wind, rain, noise).This can be
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aggravated by aspects such as poor lighting or having to wear breathing apparatus. The physical environments associated with these
problems are examined further in Chapter 5.
Physical Access and Claustrophobia

There are many circumstances where people may experience various levels of physical or Lr psychological discomfort when in an enclosed
or small space, which is generally considered to be quite normal. When this discomfort becomes extreme, it is known as claustrophobia.
Claustrophobia can be defined as abnormal fear of being in an enclosed space.
It is quite possible that susceptibility to claustrophobia is not apparent at the start of employment. It may come about for the first time
because of an incident when working within a confined space, e.g. panic if unable to extricate oneself from a fuel tank. If an engineer suffers
an attack of claustrophobia, they should make their colleagues and supervisors aware so that if tasks likely to generate claustrophobia
cannot be avoided, at least colleagues may be able to assist in extricating the engineer from the confined space quickly, and
sympathetically.
Engineers should work in a team and assist one another if necessary, making allowances for the fact that people come in all shapes and sizes
and that it may be easier for one person to access a space, than another. However, this should not be used as an excuse for an engineer who
has put on weight, to excuse himself from jobs which he would previously have been able to do with greater ease!
Fear of Heights
Working at significant heights can also be a problem for some aircraft maintenance engineers, especially when doing `crown' inspections
(top of fuselage, etc.).Some engineers may be quite at ease in situations like these whereas others may be so uncomfortable that they are far
more concerned about the height, and holding on to the access equipment, than they are about the job in hand. In such situations, it is very
important that appropriate use is made of harnesses and safety ropes. These will not necessarily remove the fear of heights, but will
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certainly help to reassure the engineer and allow him to concentrate on the task in hand. The FAA's hfskyway website provides practical
guidance to access equipment when working at height. Ultimately, if an engineer finds working high up brings on phobic symptoms (such
as severe anxiety and
panic), they should avoid such situations for safety's sake. However, as with claustrophobia, support from team members can be helpful.
Shortly before the Aloha accident, during maintenance, the inspector needed ropes attached to the rafters of the hangar to prevent falling
from the aircraft when it was necessary to inspect rivet lines on top of the fuselage. Although unavoidable, this would not have been
conducive to ensuring that the inspection was carried out meticulously (nor was it, as the subsequent accident investigation revealed). The
NTSB investigation report stated:
"Inspection of the rivets required inspectors to climb on scaffolding and move along the upper fuselage carrying a bright light with them; in
the case of an eddy current inspection, the inspectors needed a probe, a meter, and a light. At times, the inspector needed ropes attached
71 to the rafters of the hangar to prevent falling from the airplane when it was necessary to inspect rivet lines on top of the fuselage.
Even if the temperatures were comfortable and the lighting was good, the task of examining the area around one rivet after another for
signs of minute cracks while standing on scaffolding or on top of the fuselage is very tedious. After examining more and more rivets and
finding no cracks, it is natural to begin to expect that cracks will not be found."
Managers and supervisors should attempt to make the job as comfortable and secure as reasonably possible (e.g. providing knee pad rests,
ensuring that staging does not wobble, providing ventilation in enclosed spaces, etc.) and allow for frequent breaks if practicable.
Other Phobias
There is a name for almost every fear. Some rare, others are common, many are irrational, but many are rational fears. There are far too many
to list here.
See http://phobialist.com for the full list.
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Module 15
Human Factor
15.3 Social Psychology
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Basic knowledge for categories A, B1 and B2 are indicated by the allocation of knowledge levels indicators (1, 2 or 3) against each applicable subject. Category C
applicants must meet either the category B1 or the category B2 basic knowledge levels.
LEVEL 1
LEVEL 2
LEVEL 3
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Table of Contents
Chapter 15.3 Social Psychology ____________________________________________________________________ 6
The Social Environment __________________________________________________________________________________________ 6
Responsibility: Individual and Group _______________________________________________________________________________ 8
Motivation and De-motivation ____________________________________________________________________________________ 11
Introduction __________________________________________________________________________________________________ 12
External and Internal Motivation __________________________________________________________________________________ 11
Reward and Punishment: Effects on Behaviour ______________________________________________________________________ 13
Maslow's Hierarchy of Needs _____________________________________________________________________________________ 13
De-motivation _________________________________________________________________________________________________ 15
Peer Pressure ___________________________________________________________________________________________________ 16
Experiments in Conformity ______________________________________________________________________________________ 17
Countering Peer Pressure and Conformity __________________________________________________________________________ 18
Culture Issues ___________________________________________________________________________________________________ 19
Safety Culture __________________________________________________________________________________________________ 20
Social Culture _________________________________________________________________________________________________ 22
Engineering a Just Culture (Dr.Reason) _____________________________________________________________________________ 22
The Blame Cycle _______________________________________________________________________________________________ 25
David Marx Scenarios ___________________________________________________________________________________________ 29
The Substitution Test ___________________________________________________________________________________________ 32
The Blame Scale _______________________________________________________________________________________________ 33
Summary _____________________________________________________________________________________________________ 33
Personality Types _______________________________________________________________________________________________ 34
Five Factor Model ______________________________________________________________________________________________ 34
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"Accident Prone" _______________________________________________________________________________________________ 35

Team Working __________________________________________________________________________________________________ 35
The Concept of a Team __________________________________________________________________________________________ 35
Some Advantages and Disadvantages of Team Working _______________________________________________________________ 36
Important Elements of Team Working ______________________________________________________________________________ 37
Management, Supervision and Leadership _________________________________________________________________________ 38
The Management Role __________________________________________________________________________________________ 39
The Supervisory Role ___________________________________________________________________________________________ 39
Characteristics of a Leader _______________________________________________________________________________________ 40
Maintenance Resource Management (MRM) ________________________________________________________________________ 42
CRM and MRM _________________________________________________________________________________________________ 43
The Dirty Dozen _______________________________________________________________________________________________ 45
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Vision 15.2 2
Hearing
Information processing
Memory
Claustrophobia and physical access
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Chapter 15.3 Social Psychology

This chapter draws together issues relating to the social context in which the aircraft maintenance engineer works. This includes the
responsibilities may be delegated, motivation, and aspects of team working, supervision and leadership.
The Social Environment

Aircraft maintenance engineers work within a `system'. As indicated in Figure 3.1, there are various factors within this system that impinge
on the aircraft maintenance engineer, ranging from his knowledge, skills and abilities (discussed in the previous chapter),the environment
in which he works (dealt with in Chapter 5), to the culture of the organisation for which he works. Even beyond the actual company he
works for, the regulatory requirements laid down for his trade clearly impact on his behaviour. As will be seen in Chapter 8 on Human Error,
all aspects of this system may contribute towards errors that the engineer might make.
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Maintenance Engineer
Wider Environment
Figure 3.1: The maintenance system. Source: Boeing
The vast majority of aircraft maintenance engineers work for a company, either directly, or as contract staff. It is important to understand
how the organisation in which the engineer works might influence him. Every organisation or company employing aircraft maintenance
engineers will have different "ways of doing things".
This is called the organisational culture. They will have their own company philosophy, policies, procedures, selection and training criteria,
and quality assurance methods. Culture will be discussed further in a separate section in this chapter.
The impact of the organisation may be positive or negative. Organisations may encourage their employees (both financially and with career
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incentives), and take notice of problems that their engineers encounter, attempting to learn from these and make changes where necessary
or possible. On the negative side, the organization may exert pressure on its engineers to get work done within certain timescales and
within certain budgets. At times, individuals may feel that these conflict with their ability to sustain the quality of their work. These
organisational stresses may lead to problems of poor industrial relations, high turnover of staff, increased absenteeism, and most
importantly for the aviation industry, more incidents and accidents due to human error.
Responsibility: Individual and Group
Being an aircraft maintenance engineer is a responsible job. Clearly, the engineer plays a part in the safe and efficient passage of the
travelling public when they use aircraft.
If someone is considered responsible, they are liable to be called to account as being in charge or control of, or answerable for something.
Within aircraft maintenance, responsibility should be spread across all those who play a part in the activity. This ranges from the
accountable manager who formulates policy, through management that set procedures, to supervisors, teams of engineers and individuals
within those teams. Flight crew also play a part as they are responsible for carrying out preflight checks and walk around and highlighting
aircraft faults to maintenance personnel.
Working as an Individual or as a Group
Traditionally, in the maintenance engineering environment, responsibility has been considered in terms of the individual rather than the
group or team. This is historical, and has much to do with the manner in which engineers are licensed and the way in which work is certified.
This has both advantages and disadvantages. The main advantage to individual responsibility is that an engineer understands clearly that
one or more tasks have been assigned to him and it is his job to do them (it can also be a strong incentive to an engineer to do the work
correctly knowing that he will be the one held responsible if something goes wrong). The main disadvantage of any emphasis upon
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personal responsibility is that this may overlook the importance of working together as a cohesive team or group to achieve goals.
In practice, aircraft maintenance engineers are often assigned to groups or teams in the workplace. These may be shift teams, or smaller
groups within a shift. A team may be made up of various engineering trades, or be structured around aircraft types or place of work (e.g. a
particular hangar). Although distinct tasks may be assigned to individuals within a team, the responsibility for fulfilling overall goals would
fall on the entire team.
Individual Responsibility
All aircraft maintenance engineers are skilled individuals having undertaken considerable training. They work in a highly professional
environment and generally have considerable pride in their work and its contribution to air safety.
All individuals, regardless of their role, grade or qualifications should work in a responsible manner. This includes not only Licensed Aircraft
Engineers (LAE's), but non-licensed staff. Leaflet 15-2 (previously published as Airworthiness Notice No. 3) details the certification
responsibilities of LAE's. This document states that "The certifying engineer shall be responsible for ensuring that work is performed and
recorded in a satisfactory manner...".
Likewise, non-certifying technicians also have a responsibility in the maintenance process. An organisation approved in accordance with
EASA Part-145 must establish the competence of every person, whether directly involved in hands-on maintenance or not. The CAA has
previously ruled that an organisation can make provision on maintenance records or work sheets for the mechanic(s) involved to sign for
the work. Whilst this is not the legally required certification under the requirements of ANO Article 12 or EASA Part-145.50, it provides the
traceability to those who were involved in the job. The LAE is then responsible for any adjustment or functional test and the required
maintenance records are satisfied before making the legal certification.
Group or Team Responsibility
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Group responsibility has its advantages and disadvantages. The advantages are that each member of the group ought to feel responsible
for the output of that group, not just their own output as an individual, and ought to work towards ensuring that the whole `product' is safe.
This may involve cross-checking others' work (even when not strictly required), politely challenging others if you think that something is not
quite right, etc.
The disadvantage of group responsibility is that it can potentially act against safety, with responsibility being devolved to such an extent
that no-one feels personally responsible for safety (referred to as diffusion of responsibility). Here, an individual, on his own, may take action
but, once placed within a group situation, he may not act if none of the other group members do so, each member of the group or team
assuming that `someone else will do it'. This is expanded upon further in the section on peer pressure later in this chapter.
Social psychologists have carried out experiments whereby a situation was contrived in which someone was apparently in distress, and
noted who came to help. If a person was on their own, they were far more likely to help than if they were in a pair or group. In the group
situation, each person felt that it was not solely his responsibility to act and assumed that someone else would do so.
Other recognised phenomena associated with group or team working and responsibility for decisions and actions which aircraft
maintenance engineers should be aware of are:
Intergroup Conflict in which situations evolve where a small group may act cohesively as a team, but rivalries may arise between this team
and others (e.g. between engineers and planners, between shifts, between teams at different sites, etc.). This may have implications in terms
of responsibility, with teams failing to share responsibility between them. This is particularly pertinent to change of responsibility at shift
handovers, where members of the outgoing shift may feel no 'moral' responsibility for waiting for the incoming shift members to arrive and
giving a verbal handover in support of the written information on the workcards or task sheets, whereas they might feel such responsibility
when handing over tasks to others within their own shift.
Group Polarisation is the tendency for groups to make decisions that are more extreme than the individual members' initial positions. At
times, group polarization results in more cautious decisions. Alternatively, in other situations, a group may arrive at a course of action that is
riskier than that which any individual member might pursue. This is known as risky shift. Another example of group polarisation is
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groupthink in which the desire of the group to reach unanimous agreement overrides any individual impulse to adopt proper, rational (and
responsible) decision making procedures.
Social Loafing has been coined to reflect the tendency for some individuals to work less hard on a task when they believe others are
working on it. In other words, they consider that their own efforts will be pooled with that of other group members and not seen in
isolation.
Responsibility is an important issue in aircraft maintenance engineering, and ought to be addressed not only by licensing, regulations and
procedures, but also by education and training, attempting to engender a culture of shared, but not diffused, responsibility.
Figure 3.2: Social Loafing
Motivation and De-motivation

Introduction
Motivated behaviour is goal-directed, purposeful behaviour, and no human behaviour occurs without some kind of motivation
underpinning it. In aircraft maintenance, engineers are trained to carry out the tasks within their remit. However, it is largely their motivation
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which determines what they actually do in any given situation. Thus, "motivation reflects the difference between what a person can do and
what he will do".
Motivation can be thought of as a basic human drive that arouses, directs and sustains all human behaviour. Generally we say a person is
motivated if he is taking action to achieve something.
Motivation is usually considered to be a positive rather than a negative force in that it stimulates one to achieve various things. However
just because someone is motivated, this does not mean to say that they are doing the right thing. Many criminals are highly motivated for
instance. Motivation is difficult to measure and predict. We are all motivated by different things, for example, an artist might strive over
many months to complete a painting that he may never sell, whereas a businessman may forfeit all family life in pursuit of financial success.
With respect to aviation safety, being appropriately motivated is vital. Ideally, aircraft maintenance engineers ought to be motivated to
work in a safe and efficient manner. However, many factors may cause conflicting motivations to override this ideal. For instance, the
motivation of some financial bonus, or de-motivation of working outdoors in extreme cold weather might lead to less consideration of
safety and increase the likelihood of risk taking, corner cutting, violating procedures and so on. Aircraft maintenance engineers should be
aware of conflicting motivations that impinge on their actions and attempt to examine their motivations for working in a certain way.
External and Internal Motivation
• External: System rewards & punishments.

• Internal: Do it because we want to.
• What people want from work:-
o To feel valued and competent
o To feel in control (to a degree)
• External sticks and carrots far less effective than internal motivation.
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Intrinsic motivation (doing things because you want to rather than because someone else has told you to) is far more effective than extrinsic
sticks and carrots. Punishing (or even rewarding inappropriately) people who are intrinsically motivated can be counter-productive.
Reward and Punishment: Effects on Behaviour
Figure 3.3 summarises what psychologists know about the effects of reward and punishment in the workplace. Rewards are the most
powerful means of changing behaviour, but they are only effective if delivered close in time and place to the behaviour that is desired.
Delayed punishments have negative effects: they don't lead to improved behaviour and they make people resentful.
Figure 3.3: Punishment and reward
The cells labelled 'doubtful effects' mean that, in each case, there are opposing forces at work.Hence, the results are uncertain.
Maslow's Hierarchy of Needs
Possibly one of the most well known theories which attempts to describe human motivation is Maslow's hierarchy of needs. Maslow
considered that humans are driven by two different sets of motivational forces:
• those that ensure survival by satisfying basic physical and psychological needs;
• those that help us to realise our full potential in life known as self-actualisation needs (fulfilling ambitions, etc.).
Figure 3.4 shows the hypothetical hierarchical nature of the needs we are motivated to satisfy. The theory is that the needs lower down the
hierarchy are more primitive or basic and must be satisfied before we can be motivated by the higher needs. For instance, you will probably
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find it harder to concentrate on the information in this document if you are very hungry (as the lower level physiological need to eat
predominates over the higher level cognitive need to gain knowledge). There are always exceptions to this, such as the mountain climber
who risks his life in the name of adventure. The higher up the hierarchy one goes, the more difficult it becomes to achieve the need. High
level needs are often long-term goals that have to be accomplished in a series of steps.
Figure 3.4: Maslow's hierarchy of needs.
An aircraft maintenance engineer will fulfill lower level needs by earning money to buy food, pay for a home and support a family. They may
well be motivated by middle level needs in their work context (e.g. social groups at work, gaining status and recognition). It is noteworthy
that for shift workers, tiredness may be a more powerful motivator than a higher order need (such as personal satisfaction to get the job
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done in time or accurately).
An interesting experiment on motivation was carried out in 1924 at the Hawthorne Works of the Western Electric Company in Chicago.
Here, the management altered various factors such as rest periods, lighting levels, working hours, etc. and each time they did so,
performance improved, even when the apparent improvements were taken away! This suggested that it was not the improvements
themselves which were causing the increased production rates, but rather the fact that the staff felt that management were taking notice of
them and were concerned for their welfare. This phenomenon is known as the Hawthorne effect.
De-motivation
Highly motivated people tend to show the following characteristics:
• high performance and results being consistently achieved;

• the energy, enthusiasm and determination to succeed;
• unstinting co-operation in overcoming problems;
• willingness to accept responsibility;
• willingness to accommodate change.
People who are de-motivated lack motivation, either intrinsically or through a failure of their management to motivate the staff who work
for them. De-motivated people tend to demonstrate the following characteristics:
• apathy and indifference to the job, including reduced regard for safety whilst working;
• a poor record of time keeping and high absenteeism;
• an exaggeration of the effects/difficulties encountered in problems, disputes and grievances;
• a lack of co-operation in dealing with problems or difficulties;
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• unjustified resistance to change.
However, care should be taken when associating these characteristics with lack of motivation, since some could also be signs of stress.
There is much debate as to the extent to which financial reward is a motivator. There is a school of thought which suggests that whilst lack
of financial reward is a demotivator, the reverse is not necessarily true. The attraction of the extra pay offered to work a 'back to back shift'
can be a strong motivator for an individual to ignore the dangers associated with working when tired.
The motivating effects of job security and the de-motivating impact of lack of job security is also an area that causes much debate. The 'hire
and fire' attitude of some companies can, potentially, be a major influence upon safety, with real or perceived pressure upon individuals
affecting their performance and actions. It is important that maintenance engineers are motivated by a desire to ensure safety (Maslow's
`self esteem/self respect'), rather than by a fear of being punished and losing their job (Maslow's 'security'). It is possible that the "can do"
culture, which is evident in some areas of the industry, may be generated by the expectancy that if individuals do not 'deliver', they will be
punished (or even dismissed) and, conversely, those who do `deliver' (whether strictly by the book or not, finding ways around lack of time,
spares or equipment) are rewarded and promoted. This is not motivation in the true sense but it has its roots in a complex series of
pressures and drives and is one of the major influences upon human performance and human error in maintenance engineering.
Peer Pressure
In the working environment of aircraft maintenance, there are many pressures brought to bear on the individual engineer. We have already
discussed the influence of the organisation, of responsibility and motivational drives. In addition to these, there is the possibility that the
aircraft maintenance engineer will receive pressure at work from those that work with him. This is known as peer pressure.
Peer pressure is the actual or perceived pressure which an individual may feel, to conform to what he believes that his peers or colleagues
expect.
For example, an individual engineer may feel that there is pressure to cut corners in order to get an aircraft out by a certain time, in the
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belief that this is what his colleagues would do under similar circumstances. There may be no actual pressure from management to cut
corners, but subtle pressure from peers, e.g. taking the form of comments such as "You don't want to bother checking the manual for that.
You do it like this..." would constitute peer pressure.
Peer pressure thus falls within the area of conformity. Conformity is the tendency to allow one's opinions, attitudes, actions and even
perceptions to be affected by prevailing opinions, attitudes, actions and perceptions.
Experiments in Conformity
Asch carried out several experiments investigating the nature of conformity, in which he asked people to judge which of lines A, B & C was
the same length as line X. (see Figure 3.5). He asked this question under different conditions:
• where the individual was asked to make the judgment on his own;
• where the individual carried out the task after a group of 7-9 confederates of Asch had all judged that line A was the correct choice. Of
course, the real participant did not know the others were "stooges"
B is the same length as X
Figure 3.5: Experiment to illustrate conformity (S. Asch 1951)
In the first condition, very few mistakes were made (as would be expected of such a simple task with an obvious answer). In the latter
condition, on average, participants gave wrong answers on one third of the trials by agreeing with the confederate majority. Clearly,
participants yielded to group pressure and agreed with the incorrect 'group' finding (however, it is worth mentioning that there were
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considerable individual differences: some participants never conformed, and some conformed all the time).
Further research indicated that conformity does not occur with only one confederate (as then it is a case of 'my word against yours').
However, it is necessary to have only three confederates to one real participant to attain the results that Asch found with 7- 9 confederates.
The degree to which an individual's view is likely to be affected by conformity or peer pressure, depends on many factors, including:
• culture (people from country x tend to conform more than those from country y);
• gender (men tend to conform less than women);
• self-esteem (a person with low self-esteem is likely to conform more);
• familiarity of the individual with the subject matter (a person is more likely to conform to the majority view if he feels that he knows less
about the subject matter than they do);
• the expertise of the group members (if the individual respects the group or perceives them to be very knowledgeable he will be more
likely to conform to their views);
• the relationship between the individual and group members (conformity increases if the individual knows the other members of the
group, i.e. it is a group of peers).
Countering Peer Pressure and Conformity
The influence of peer pressure and conformity on an individual's views can be reduced considerably if the individual airs their views publicly
from the outset. However, this can be very difficult: after Asch's experiments, when asked, many participants said they agreed with the
majority as they did not want to appear different or to look foolish.
Conformity is closely linked with 'culture' (described in the next section). It is highly relevant in the aircraft maintenance environment where
it can work for or against a safety culture, depending on the attitudes of the existing staff and their influence over newcomers. In other
words, it is important for an organisation to engender a positive approach to safety throughout their workforce, so that peer pressure and
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conformity perpetuates this. In this instance, peer pressure is clearly a good thing. Too often, however, it works in reverse, with safety
standards gradually deteriorating as shift members develop practices which might appear to them to be more efficient, but which erode
safety. These place pressure, albeit possibly unwittingly, upon new engineers joining the shift, to do likewise.
Culture Issues
There can be a degree of mistrust of anything new in the workplace, (e.g. an individual joining a company whose expertise has not yet been
proven, or contracting out maintenance to another company, etc.). There may be a tendency for groups within organisation and the
organisation itself to think that their own methods are the best and that others are not as good. This viewpoint is known as the group's or
organisation's culture.
The culture of an organisation can be described as `the way we do things here'. It is a group or company norm.
Figure 3.6 indicates that there can be an overall organisational culture, and a number of different `sub-cultures', such as safety culture,
professional/technical culture, etc.
It is possible for cultural differences to exist between sites or even between shifts within the same organisation. The prevailing culture of the
industry as a whole also influences individual organisations.
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Figure 3.6: The influences on an organisation's culture.
Culture is not necessarily always generated or driven from the top of an organization (as one might think), but this is the best point from
which to influence the culture.
Safety Culture
The ICAO Human factors Digest No. 10, "Human Factors, Management and Organisation" (Circular 247), discusses corporate culture and the
differences between safe and unsafe corporate cultures.
ICAO HF Digest 10 describes a safety culture as "a set of beliefs, norms, attitudes, roles and social and technical practices concerned with
minimising exposure of employees, managers, customers and members of the general public to conditions considered dangerous or
hazardous"
Gary Eiff from Purdue University discusses safety culture in his paper "Organizational Culture and its Effect on Safety". He suggests that "A
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safety culture exists only within an organisation where each individual employee, regardless of their position, assumes an active role in error
prevention", stressing that "Safety cultures do not ...spring to life simply at the declaration of corporate leaders".
The culture of an organisation can best be judged by what is done rather than by what is said. Organisations may have grand `mission
statements' concerning safety but this does not indicate that they have a good safety culture unless the policies preached at the top are
actually put into practise at the lower levels. It may be difficult to determine the safety culture of an organisation by auditing the procedures
and paperwork; a better method is to find out what the majority of the staff actually believe and do in practice.
A method for measuring attitudes to safety has been developed by the Health and Safety Executive utilising a questionnaire approach.
Examples of the statements which employees are asked the extent to which they agree are:
1. It is necessary to bend some rules to achieve a target;
2. Short cuts are acceptable when they involve little or no risk;
3. I often come across situations with which I am unfamiliar;
4. I sometimes fail to understand which rules apply;
5. I am not given regular break periods when I do repetitive and boring jobs;
6. There are financial rewards to be gained from breaking the rules.
The results are scored and analysed to give an indication of the safety culture of the
organisation, broken down according to safety commitment, supervision, work conditions, logistic support, etc. In theory, this enables one
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organisation to be objectively compared with another.
Professor James Reason describes the key components of a safety culture, summarised as follows:
• The èngine' that continues to propel the system towards the goal of maximum safety health, regardless of the leadership's personality or
current commercial concerns;
• Not forgetting to be afraid;
• Creating a safety information system that collects, analyses and disseminates information from incidents and near-misses as well as from
regular proactive checks on the system's vital signs;
• A good reporting culture, where staff are willing to report near-misses;
• A just culture - an atmosphere of trust, where people are encouraged, even rewarded, for providing essential safety related information -
but in which they are clear about where the line must be drawn between acceptable and unacceptable behaviour;
• A flexible culture;
• Respect for the skills, experience and abilities of the workforce and first line supervisors;
• Training investment;
• A learning culture - the willingness and the competence to draw the right conclusions from its safety information system, and the will to
implement major reforms when their need is indicated.
Social Culture
The influence of social culture (an individual's background or heritage) can be important in determining how an individual integrates into
an organisational culture. The way an individual behaves outside an organisation is likely to have a bearing on how they behave within it.
Internal pressures and conflicts within groups at work can be driven by underlying social cultural differences (e.g. different nationalities,
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different political views, different religious beliefs, etc.). This is an extremely complex subject, however, and in-depth discussion is beyond
the scope of this text.
Whilst safety culture has been discussed from the organisational perspective, the responsibility of the individual should not be overlooked.
Ultimately, safety culture is an amalgamation of the attitude, beliefs and actions of all the individuals working for the organisation and each
person should take responsibility for their own contribution towards this culture, ensuring that it is a positive contribution rather than a
negative one.
Engineering a Just Culture (Dr.Reason)
In complex, well-defended systems, like aircraft maintenance organisations, culture is crucial because it reaches into all parts of the system.
It is probably the only single factor that can influence the quality of the defences for good or ill, because they too are scattered widely
throughout the system.
An effective safety culture is an informed culture, one that knows where the 'edge' is without having to fall over it. But incidents and
accidents are still relatively rare. They are not enough to steer by. To achieve that, we need people to report their errors and near misses. But
they won't do that unless they trust the system and its bosses. And they certainly won't confess their errors if they get disciplined for it. So,
an effective reporting culture depends upon having a just culture. That is, an organisation in which people clearly understand where the line
must be drawn between acceptable and unacceptable actions. In short, a just culture lies at the heart of a safe culture.
Culture: A workable definition
Shared values (what is important) and beliefs (how things work) that interact with an organization's structure and control systems to
produce behavioural norms (the way we do things around here).
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The significance of culture
• Defences, barriers and safeguards take many different forms and are widely distributed throughout the system.
• Perhaps the only factor that can have a systematic and far-reaching effect upon defences (for good or ill) is the organisational culture.
Culture: Two aspects
• Something an organisation is: shared values and beliefs.

• Something an organisation has: structures, practices, systems.
• Changing practices is much easier than changing values and beliefs.
There can be no doubt that it is extremely difficult to change adult attitudes directly. Think how long it has taken to reduce the number of
smokers to a relatively small group. It has taken around 30 years to achieve this. Smokers have known throughout all of this time that
smoking could kill them. But this knowledge alone did not significantly change their behaviour. Now, most buildings have outlawed
smoking. To satisfy their need, smokers have to indulge outside the front door or in dark dirty rooms set aside for the purpose. This practice
has greatly reduced their desire to smoke. They are also tired of being treated as pariahs. In short, changing practices has changed attitudes.
Engineering a safety culture
Figure 3.7 spells out in diagrammatic form the message of getting people to change the way they do things (by changing organisational
practices) eventually changes the way they think and believe.
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Figure 3.7: Getting people to change
Safety culture = Informed culture
• An informed culture means not forgetting to be afraid in the absence of bad accidents.
• An informed culture means collecting data about incidents and near misses.
• An informed culture is one in which those who manage the system know where the 'edge' is without falling over it.
Above all else, a safe culture is one that does not forget to be afraid. In order to keep up the proper level of intelligent wariness, we need to
understand the hazards and risks that beset our operation. In short, we need to know where the 'edge' is. Many organisations do not
discover this until they fall over it. It is better to know in advance. But how do we find out? Aviation does not have that many accidents, and,
in aviation engineering, only the more dramatic incidents tend to get reported. We need people to tell us about their errors, near misses and
free lessons. In short, we need to operate a reporting culture. NASA's Aviation Safety Reporting System (ASRS) has achieved this through
clever social engineering--much of which has to do with the issue of sanctions and immunity. Around the world, there are many other,
confidential Human Factors reporting schemes with similar objectives.
But an informed culture can only grow from a just culture
• An adequate reporting system depends on people reporting near misses, errors and incidents.
• But they won't do that if they don't trust the system.
• And they certainly won't do it if they are disciplined because of what they report.
The Blame Cycle
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Figure 3.8: The blame cycle
Why are we so inclined to blame people rather than situations? The answer comes in two parts:
• The first of these is what psychologists call the `fundamental attribution error'. When we see or hear of someone performing less than
adequately, we tend to attribute this to the person's character or ability. We say he or she was silly, careless, stupid, incompetent, reckless
or thoughtless. But if we were to ask the person why they did it, they would almost certainly tell you how the circumstances forced them
to act that way. The truth, of course, lies somewhere in between.
• The second part of the answer relates to the ìllusion of free will'. It is this that makes the attribution error so fundamental to human
nature. People, especially in western cultures, place great value in the belief that they are free agents, the masters of their own fate. They
can become mentally ill when they are deprived of this sense of personal freedom by illness, old age or enforced confinement. Feeling
ourselves to be capable of free choice naturally leads us to assume that other people are the same. They are also seen as free agents,
able to choose between right and wrong, and between correct and erroneous courses of action. People are assumed to be the least
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constrained factor causing an accident. Their actions are seen as more avoidable than situational conditions. It is this, together with the
illusion of free will, that drives the fruitless Blame Cycle.
Avoiding the Blame Cycle
• Recognise that human actions are almost always affected by factors outside a person's control.
• Recognise that people cannot easily avoid those actions they did not intend in the first place.
• Recognise that errors are consequences rather than causes. The beginning of search rather than end.
• Recognise that in a well-trained and well-motivated workforce, situations are easier to fix than people.
Of course, people can behave carelessly and stupidly. We all do so at some time or another. But a stupid or careless act does not necessarily
make a stupid or careless person. Everyone is capable of a wide range of actions, sometimes inspired and sometimes silly, but mostly
somewhere in between.
An important point to emphasise here is the third bullet about errors being consequences rather than causes. Many investigations stop as
soon as they have identified human errors. These are then called the causes of the incident or accident. But the errors, just as much as their
bad outcomes, are consequences rather than causes. They are a chapter in a long history of prior error-provoking factors. Finding errors,
therefore, should mark the beginning rather than the end of the search for causal factors.
Common sense would suggest that people are easier to fix than circumstances. People, after all, are capable of wide variability. They can be
retrained, punished, advised or warned (it is believed) in ways that will make them behave more appropriately in the future. But, in this
regard, common sense is wrong. Yes, we can change individual behaviour up to a point, but we cannot change human nature. And it is
human nature to go wrong occasionally. Situations and even organisations are actually easier to change than human nature. And that is
where the main focus of error management must lie: in changing the conditions that provoke errors rather than trying to change
humankind.
Engineering a just culture
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• A'no blame' culture is neither feasible nor desirable.

• Some unsafe acts deserve sanctions.
• A 'just' culture depends on:
 the trust of the workforce
 knowing the difference between acceptable and unacceptable behaviour.
Decades ago, most maintenance organisations were punitive cultures: people got punished if they caused damage to the aircraft without
regard to the nature of the actions involved. In the 1980s, the phrase `blame-free' culture came along. But that is equally inappropriate.
Some actions deserve punishment. The important thing that everyone must understand is where the line should be drawn between
acceptable and unacceptable actions, between blameworthy and blameless behaviour.
Can the law help?
• Negligence: involves bringing about a bad consequence that a 'reasonable and prudent person' would have foreseen and avoided.
Actions do not need to be intended. Mainly an issue for civil law.
• Recklessness: involves taking a deliberate and unjustifiable risk. Mainly an issue for criminal law.
The law identifies two kinds of actions: those that are merely negligent and those that are reckless. The latter clearly deserve some kind of
sanction, even dismissal.
Errors Vs violations?
• Should all unintended actions (errors) be exempt from disciplinary action?

• Should all deliberate violations be punished?
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• Unfortunately, it's not as simple as that.
How do we draw a line between innocent negligence and deliberate recklessness? It is not easy.
The underlying conduct
• We can't assume that all errors are 'blame free', nor that all procedural violations areblameworthy.
• It all depends on what the person was doing when the error or violation was committed.
• Consider the following two scenarios.
David Marx Scenarios
David Marx, a former Boeing engineer who has taken a law degree, now spends a good deal of his time helping aircraft maintenance
organisations to establish fair and just disciplinary systems. He argues that the important thing to determine is the nature of the underlying
conduct. What was the person doing when he/she made the error? What was his/her motivation? Marx created the next two scenarios to
help clarify the important issues.
Scenario 1
• A maintainer is assigned to inspect for cracks in an aircraft's wings.

• In accordance with procedures, he/she gets the appropriate workstand and lights then carries out a close inspection
• Despite this, he/she misses a crack that could have seriously endangered the aircraft.
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Here a maintainer did everything he/she should have done to carry out a proper inspection. Yet he/she still missed a dangerous crack.
Scenario 2
• As before, a maintainer is assigned to check for cracks in a wing.

• This time, however, he/she doesn't bother to fetch the stand and lights.
• He/she merely walks beneath the aircraft using a hand-held flashlight.
• Once again, a dangerous crack is missed.
In this case, the underlying conduct is quite different. The maintainer deliberately failed to comply established and appropriate procedures.
He/she did so because he/she couldn't be bothered to do the job properly. In so doing, he/she also misses a dangerous crack.
Who is most to blame?
• Both maintainers committed the same unintended error: missing the crack.
• But, in scenario 2, the maintainer's actions made this error far more likely.
• He/she deliberately engaged in behaviour that significantly and unjustifiably increased the risk of error (recklessness).
On the face of it, the difference between the two scenarios is clear. The first person followed procedures, the second person deliberately
failed to comply. In so doing, he/she greatly increased the chances of missing a crack.
Compliance versus non-compliance?
• It could be that the main difference was that one person complied with procedures and the other did not.
• In other words, the issue of blame could hinge on compliance or non-compliance said.
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• But even that is too simple. Consider Scenario 3.
Unfortunately, it does not hinge neatly on the question of compliance or non-compliance. As we shall see in the next scenario, some
violations are not the fault of the person. They are created by system problems.
Scenario 3
• The situation is basically as before.

• But this time the maintainer discovers that the proper workstand is broken.
• Pressed for time, the maintainer does a walk-under inspection using a flashlight.
• As before, a dangerous crack is missed.
This situational violation (or necessary violation) shows how important it is not to assume that all violations are down to human weakness.
Many are created by the system, and it is the system that must be corrected.
Differences between Scenarios 2 and 3
• In Scenario 2, the maintainer deliberately decides to short-cut the appropriate procedures re: workstand.
• In Scenario 3, the maintainer is forced to commit a situational violation because the appropriate equipment is either unserviceable or
missing.
Again, this reiterates the distinction between deliberate short cuts and system-induced violations. Many necessary violations happen
because a person feels that some action is better than none, even though it does not comply with procedures.
Where should the line be drawn?
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Figure 3.9: Drawing the line
Figure 3.9 poses the question again: Where should we draw the line? David Marx's research has shown that, in general, only about 10% of
unsafe acts fall clearly into the culpable category. The vast majority are blameless, and so could be safely reported--if the reporters really
trusted the system.
The Substitution Test
• Question to peers: 'Given the circumstances, could you be sure that you would not have made the same or a similar error?'
• If answer is 'no', then blame probably inappropriate.
• The best people can make the worst mistakes.
Neil Johnston, an Aer Lingus captain, has come up with this very useful substitution test. After an unsafe act has been committed, the
perpetrator's peers are asked whether or not it could have happened to them. We all recognise human fallibility. We all know that we have
made mistakes in the past. If the peers say it could have happened to them, then the act is probably blameless.
The history of maintenance-related accidents shows us very clearly that well-trained, well-intentioned and experienced people with
blameless records can sometimes make the worst mistakes. This means that maintenance errors are not just created by a few incompetent
or reckless people. Blaming individuals rarely leads to effective remedial action -- except, of course, when blaming and then dismissing
someone removes a dangerous 'cowboy' from the work force.
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The Blame Scale
Figure 3-10: The blame scale
Summary
• A safety culture is an informed culture: one that knows where the 'edge' is without falling over it.
• An informed culture depends on trust. The workforce will not report errors and near misses if they are punished for it.
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• Thus a safety culture depends critically upon 'engineering' a just culture.
By now, you should have a clear idea of the importance of disciplinary proceedings in shaping a safe culture. The issue of justice (or
apparent injustice) lies at the heart of aviation engineering human factors. There are no black and white answers. Each organisation has to
work out the solutions for itself. But this is not an issue that can be either dodged or fudged.
This module is rich in discussion material. How do these issues apply to your organisation. Experience has shown that people are happy to
argue about these matters for many hours.
Personality Types
Five Factor Model
The Big Five factors and their constituent traits can be summarized as follows:
• Openness - appreciation for art, emotion, adventure, unusual ideas, curiosity, and variety of experience.
• Conscientiousness - a tendency to show self-discipline, act dutifully, and aim for achievement; planned rather than spontaneous
behaviour.
• Extraversion - energy, positive emotions, surgency, and the tendency to seek stimulation and the company of others.
• Agreeableness - a tendency to be compassionate and cooperative rather than suspicious and antagonistic towards others.
• Neuroticism - a tendency to experience unpleasant emotions easily, such as anger, anxiety, depression, or vulnerability; sometimes
called emotional instability.
When scored for individual feedback, these traits are frequently presented as percentile scores. For example, a Conscientiousness rating in
the 80th percentile indicates a relatively strong sense of responsibility and orderliness, whereas an Extraversion rating in the 5th percentile
indicates an exceptional need for solitude and quiet. Although these trait clusters are statistical aggregates, exceptions may exist on
individual personality profiles. On average, people who register high in Openness are intellectually curious, open to emotion, interested in
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art, and willing to try new things. A particular individual, however, may have a high overall Openness score and be interested in learning
and exploring new cultures. Yet he or she might have no great interest in art or poetry. Situational influences
"Accident Prone"
Personality can be described along two personality dimensions lying at right angles to one another. The traits listed in each cell show the
characteristics associated with various combinations of the two main personality dimensions. Accident proneness is associated with
unstable extraverts.
Figure 3.11: "Accident prone" personality
Team Working
The Concept of a Team
A lot has been written on the concept of a team, and it is beyond the scope of this document to give anything but a flavour of this.
Whereas individualism encourages independence, teams are associated with interdependence and working together in some way to
achieve one or more goals.
Teams may comprise a number of individuals working together towards one shared goal. Alternatively, they may consist of a number of
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individuals working in parallel to achieve one common goal. Teams generally have a recognised leader and one or more follower(s). Teams
need to be built up and their identity as a team needs to be maintained in some way.
A team could be a group of engineers working on a specific task or the same aircraft, a group working together on the same shift, or a group
working in the same location or site. There are natural teams within the aircraft maintenance environment. The most obvious is the
supervisor and the engineers working under his supervision. A team could also be a Licensed Aircraft Engineer (LAE) and unlicensed
engineers working subject to his scrutiny. A team may well comprise engineers of different technical specialities (e.g. sheet/metal structures,
electrical/electronics/avionics, hydraulics, etc.).
There has been a great deal of work carried out on teamwork, in particular "Crew Resource Management (CRM)" in the cockpit context and,
more recently, "Maintenance Resource Management (MRM)" in the maintenance context. The ICAO Human Factors Digest No. 12 "Human
Factors in Aircraft Maintenance and Inspection" (ICAO Circular 253), includes a Chapter on team working, to which the reader is directed for
further information. MRM is addressed separately (section 8) since it covers more than just teamwork.
Some Advantages and Disadvantages of Team Working
The discussion on motivation suggests that individuals need to feel part of a social group. In this respect, team working is advantageous.
However, the work on conformity suggests that they feel some pressure to adhere to a group's views, which may be seen as a potential
disadvantage.
Working as part of a team has a number of potential benefits which include:
• individuals can share resources (knowledge, tools, etc.);

• they can discuss problems and arrive at shared solutions;
• they can check each others' work (either "officially" or "unofficially").
Teams can be encouraged to take ownership of tasks at the working level. This gives a team greater responsibility over a package of work,
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rather than having to keep referring to other management for authorisation, support or direction. However, groups left to their own devices
need proper leadership. Healthy competition and rivalry between teams can create a strong team identity and encourage pride in the
product of a team. Team identity also has the advantage that a group of engineers know one another's capabilities (and weaknesses).
If work has to be handed over to another group or team (e.g. shift handover), this can cause problems if it is not handled correctly. If one
team of engineers consider that their diligence (i.e. taking the trouble to do something properly and carefully) is a waste of time because an
incoming team's poor performance will detract from it, then it is likely that diligence will become more and more rare over time.
Important Elements of Team Working
For teams to function cohesively and productively, team members need to have or build up certain interpersonal and social skills. These
include communication, cooperation, co-ordination and mutual support.
Communication
Communication is essential for exchanging work-related information within the team.
For example, a team leader must ensure that a team member has not just heard an instruction, but understood what is meant by it. A team
member must highlight problems to his colleagues and/or team leader. Furthermore, it is important to listen to what others say. This is
covered in greater depth in Chapter 7.
Co-operation
`Pulling together' is inherent in the smooth running of a team. Fairness and openness within the team encourage cohesiveness and mutual
respect. Disagreements must be handled sensitively by the team leader.
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Co-ordination
Co-ordination is required within the team to ensure that the team leader knows what his group members are doing. This includes
delegation of tasks so that all the resources within the team are utilised. Delegated tasks should be supervised and monitored as required.
The team leader must ensure that no individual is assigned a task beyond his capabilities. Further important aspects of co-ordination are
agreement of responsibilities (i.e. who should accomplish which tasks and within what timescale), and prioritisation of tasks.
Mutual Support
1. Mutual support is at the heart of the team's identity. The team leader must engender this in his team. For instance, if mistakes are made,
these should be discussed and corrected constructively.
2. It is worth noting that in many companies, line engineers tend to work as individuals whereas base engineers tend to work in teams. This
may be of significance when an engineer who normally works in a hangar, finds himself working on the line, or vice versa. This was the
case in the Boeing 737 incident involving double engine oil pressure loss, where the Base Controller took over a job from the Line
Maintenance engineer, along with the line maintenance paperwork. The line maintenance paperwork is not designed for recording work
with a view to a handover, and this was a factor when the job was handed over from the Line engineer to the Base Controller.
Management, Supervision and Leadership

The previous section made frequent reference to the team leader. Management, supervision and leadership are all skills that a team leader
requires. Of course, management is also a function within an organisation (i.e. those managers responsible for policy, business decisions,
etc.), as is the supervisor (i.e. in an official role overseeing a team).
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Managers and supervisors have a key role to play in ensuring that work is carried out safely. It is no good instilling the engineers and
technicians with 'good safety practice' concepts, if these are not supported by their supervisors and managers.
The Management Role
Line Managers, particularly those working as an integral part of the `front line' operation, may be placed in a situation where they may have
to compromise between commercial drivers and ìdeal' safety practices (both of which are passed down from 'top management' in the
organisation). For example, if there is a temporary staff shortage, he must decide whether maintenance tasks can be safely carried out with
reduced manpower, or he must decide whether an engineer volunteering to work a "back to back shift," to make up the numbers will be
able to perform adequately. The adoption of Safety Management Principles may help by providing Managers with techniques whereby they
can carry out a more objective assessment of risk.
The Supervisory Role
Supervision may be a formal role or post (i.e. a Supervisor), or an informal arrangement in which a more experienced engineer 'keeps an eye
on' less experienced staff. The Supervisor is in a position not only to watch out for errors which might be made by engineers and
technicians, but will also have a good appreciation of individual engineer's strengths and weaknesses, together with an appreciation of the
norms and safety culture of the group which he supervises. It is mainly his job to prevent unsafe norms from developing, and to ensure that
good safety practices are maintained. There can be a risk however, that the Supervisor becomes drawn down the same cultural path as his
team without realising. It is good practice for a Supervisor to step back from the day-to-day work on occasion and to try to look at his
charges' performance objectively.
It can be difficult for supervisory and management staff to strike the right balance between carrying out their supervisory duties and
maintaining their engineering skills and knowledge (and appropriate authorisations), and they may get out of practice. In the UK Air
Accidents Investigation Branch (AAIB) investigation reports of the BAC 1- 11, A320 and B737 incidents, a common factor was: "Supervisors
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tackling long duration, hands-on involved tasks". In the B737 incident, the borescope inspection was carried out by the Base Controller, who
needed to do the task in order to retain his borescope authorisation. Also, there is unlikely to be anyone monitoring or checking the
Supervisor, because: of his seniority;
• he is generally authorised to sign for his own work (except, of course, in the case where a duplicate inspection is required);
• he may often have to step in when there are staff shortages and, therefore, no spare staff to monitor or check the tasks;
• he may be 'closer' (i.e. more sensitive to) to any commercial pressures which may exist, or may perceive that pressure to a greater extent
than other engineers.
It is not the intention to suggest that supervisors are more vulnerable to error; rather that the circumstances which require supervisors to
step in and assist tend to be those where several of the 'defences' (see Chapter 8 - Error) have already failed and which may result in a
situation which is more vulnerable to error.
Characteristics of a Leader
There are potentially two types of leader in aircraft maintenance: the person officially assigned the team leader role (possibly called the
Supervisor), an individual within a group that the rest of the group tend to follow or defer to (possibly due to a dominant personality, etc.).
Ideally of course, the official team leader should also be the person the rest of the group defer to.
A leader in a given situation is a person whose ideas and actions influence the thought and the behaviour of others.
A good leader in the maintenance engineering environment needs to possess a number of qualities:
• Motivating his team;

• Reinforcing good attitudes and behaviour;
• Demonstrating by example;
• Maintaining the group;
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• Fulfilling a management role.
These will now be examined in a little more detail:
Motivating the Team
Just as the captain of a football team motivates his fellow players, the leader of a maintenance team must do likewise. This can be done by
ensuring that the goals or targets of the work which need to be achieved are clearly communicated and manageable. For instance, the team
leader would describe the work required on an aircraft within a shift. He must be honest and open, highlighting any potential problems and
where appropriate encouraging team solutions.
Reinforcing Good Attitudes and Behaviour
When team members work well (i.e. safely and efficiently), this must be recognized by the team leader and reinforced. This might be by
offering a word of thanks for hard work, or making a favourable report to senior management on an individual. A good leader will also make
sure that bad habits are eliminated and inappropriate actions are constructively criticised.
Demonstrating by Example
A key skill for a team leader is to lead by example. This does not necessarily mean that a leader must demonstrate that he is adept at a task
as his team (it has already been noted that a Supervisor may not have as much opportunity to practise using their skills). Rather, he must
demonstrate a personal understanding of the activities and goals of the team so that the team members respect his authority. It is
particularly important that the team leader establishes a good safety culture within a team through his attitude and actions in this respect.
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Maintaining the Group
Individuals do not always work together as good teams. It is part of the leader's role to be sensitive to the structure of the team and the
relationships within it. He must engender a 'team spirit' where the team members support each other and feel responsible for the work of
the team. He must also recognise and resolve disputes within the team and encourage co-operation amongst its members.
Fulfilling a Management Role
The team leader must not be afraid to lead (and diplomatically making it clear when necessary that there cannot be more than one leader in
a team). The team leader is the link between higher levels of management within the organisation and the team members who actually
work on the aircraft. He is responsible for coordinating the activities of the team on a day-to-day basis, which includes allocation of tasks
and delegation of duties. There can be a tendency for team members to transfer some of their own responsibilities to the team leader, and
he must be careful to resist this.
Skilled management, supervision and leadership play a significant part in the attainment of safety and high quality human performance in
aircraft maintenance engineering.
In terms of the relationship between managers, supervisors and engineers, a `them and us' attitude is not particularly conducive to
improving the safety culture of an organisation. It is important that managers, supervisors, engineers and technicians all work together,
rather than against one another, to ensure that aircraft maintenance improves airworthiness.
Maintenance Resource Management (MRM)

Although not part of the EASA Part-66 Module 9 syllabus, Maintenance Resource Management (MRM) is nevertheless included as a specific
topic because it is implicit in many of the areas covered in this chapter, such as team working, communication, responsibility, shift
handovers. The discussion of MRM in this text is intended only as an introduction to the basic concepts. For in-depth information
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concerning MRM, the reader is referred to the "Maintenance Resource Management Handbook" produced on behalf of the FAA.
MRM is not about addressing the individual human factors of the engineer or his manager; rather, it looks at the larger system of human
factors concerns involving engineers, managers and others, working together to promote safety.
CRM and MRM
The term `Maintenance Resource Management' became better known after the Aloha accident in 1988, when researchers took Crew
Resource Management (CRM) concepts and applied them to the aircraft maintenance environment. CRM concerns the process of managing
all resources in and out of the cockpit to promote safe flying operations. These resources not only include the human element, but also
mechanical, computer and other supporting systems. MRM has many similarities to CRM, although the cockpit environment and team is
somewhat different from that found in aircraft maintenance. The FAA MRM handbook highlights the main differences between CRM and
MRM, and these are summarised in Table 3.2.
CRM MRM
Human error
Errors tend to be “active” in that their consequences follow on The consequences of an engineer’s error are often not immediately
immediately after the error. apparent, and this has implications for training for error avoidance.
Communication
Much of flight operations are characterised by synchronous, “face-to- Maintenance operations tend to be characterized by “asynchronous”
face” communications, or immediate voice communications (e.g. with communications such as technical manuals, memos. Advisory Circulars,
ATC) over the radio. Airworthiness Directives, workcards and other non-immediate formats.
Much of the information transfer tends to be of a non-non verbal nature.
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"Team" composition
Flight crews are mostly homogenous by nature, in that they are similar in Maintenance staff are diverse in their range of experiences and education
education level and experience, relative to their maintenance and this needs to be taken into account in a MRM programme.
counterparts.
Teamwork
Flight deck crew team size is small – two or three members; although the Maintenance operations are characterised by large teams working on
wider team is obviously larger (i.e. flight deck crew + cabin crew, flight disjointed tasks, spread out over a hangar. In addition, a maintenance
crew + ATC, ground crew, etc) task may require multiple teams (hangar, planning department, technical
library, management) each with their own responsibilities.
Situation awareness
The flight environment is quickly changing, setting the stage for the The maintenance environment, thought hectic, changes slowly relative
creation of active failures. Situation awareness in CRM is tailored to avoid to flight operations. In terms of situation awareness, engineers must have
these errors; Line Oriented Flight Training (LOFT) simulations provide the ability to extrapolate the consequences of their errors over hours,
flight crews with real-time, simulations to improve future situation days or even weeks. To do this, the situation awareness cues that are
awareness. taught must be tailored to fit the maintenance environment using MRM-
specific simulations.
Leadership
Similar to teamwork issues, leadership skills in CRM often focus mainly on Because supervisors or team leaders routinely serve as intermediaries
intra-team behaviours or “how to lead the team”, as well as followership among many points of the organisation, engineer leaders must be skilled
skills. Inter-team interaction is somewhat limited during flight. not only in intra-team behaviours, but in handling team “outsiders”
(personnel from other shifts, managers outside the immediate
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workgroup, etc) during any phase of the maintenance problem. These

outsiders also vary widely in experience, mannerisms, etc. A good MRM
programme should take these into account.
Table 3.2: Examples of the Differences Between CRM and MRM Highlighted in the FAA Maintenance Resource Management Handbook.
The Dirty Dozen
One of the early MRM training programmes was developed by Gordon Dupont for Transport Canada. It introduced "The Dirty Dozen", which
are 12 areas of potential problems in human factors. A series of posters has been produced, one for each of these headings, giving a few
examples of good practices or "safety nets" which ought to be adopted. These are summarised in Table 3.3 and addressed in most
maintenance human factors programmes.
Problem Example Potential Solutions
Lack of communication Use logbooks, worksheet, etc. to communicate and remove doubt. Discus work to be done or what has been completed.
Never assume anything.
Complacency Train your self to expect to find a faults. Never sign for anything you didn’t do [or see done]
Lack of Knowledge Get training on type

Use up to date manuals
Ask a technical representative or someone who knows
Distraction Always finish the job or unfasten the correction

Mark the uncompleted work
Lockwire where possible or use torque-seal
Double inspect by another or self
When you return to the job, always go back three steps.
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Use a detailed check sheet
Lack of Teamwork Discuss what, who and how a job is to be done. Be sure that everyone understands and agrees
Fatigue Be aware of the symptons and look for them in your self and others. Plan to avoid complex task at the bottom of your
circadian rhythm, sleep and exercise regularly. Ask others to check your work.
Lack of Parts Check suspect areas at the beginning of the inspection and AOG the required parts. Order and stock anticipated parts
before they are required. Know all available parts sources and arrange for pooling or loaning. Maintain a standard and if
in doubt ground the aircraft.
Pressure Be sure the pressure isn't self-induced.

Communicate your concerns.
Ask for extra help.
Just say 'No'.
Lack of assertiveness If it's not critical, record it in the journey log book and only sign for what is serviceable. Refuse to compromise your
stands.
Stress Be aware of how stress can affect your work. Stop and look rationally at the problem. Determine a rational course of
action and follow it. Take time off or at least have a short break. Discuss it with someone. Ask fellow workers to monitor
your work. Exercise your body.
Lack of awareness Think of what may occur in the event of an accident. Check to see if you work will conflict with an existing modification
or repair. Ask others if they can see any problem with the work done.
Norms Always work as per the instruction or have the instruction changed. Be aware the "norms" don't make it right.
Table 3.3: Examples of Potential Human Factors Problems from the "Dirty Dozen"
The UK Human Factors Combined Action Group (UK-HFCAG) have suggested a generic MRM syllabus which organisations may wish to
adopt. MRM training programmes have been implemented by several airlines and many claim that such training is extremely successful.
There has been work carried out to evaluate the success of MRM and the reader is directed in particular at research by Taylor, which looks at
the success of MRM programmes in various US airlines.
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Module 15
Human Factor
15.4 Factors Affecting Performance
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LEVEL 1
LEVEL 2
LEVEL 3
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Table of Contents
Chapter 15.4 Factors Affecting Performance _________________________________________________________________________ 6
Fitness and Health _______________________________________________________________________________________________ 6
Pre-employment Disposition _____________________________________________________________________________________ 7
Day-to-Day Fitness and Health ____________________________________________________________________________________ 7
Positive Measures ______________________________________________________________________________________________ 9
Stress __________________________________________________________________________________________________________ 9
Causes and Symptoms __________________________________________________________________________________________ 10
Domestic Stress ________________________________________________________________________________________________ 11
Work Related Stress _____________________________________________________________________________________________ 11
Stress Management _____________________________________________________________________________________________ 12
Time Pressure and Deadlines ______________________________________________________________________________________ 14
The Effects of Time Pressure and Deadlines __________________________________________________________________________ 14
Managing Time Pressure and Deadlines ____________________________________________________________________________ 15
Workload - Overload and Underload _______________________________________________________________________________ 16
Arousal _______________________________________________________________________________________________________ 16
Factors Determining Workload ____________________________________________________________________________________ 18
Overload _____________________________________________________________________________________________________ 19
Underload ____________________________________________________________________________________________________ 20
Workload Management _________________________________________________________________________________________ 20
Sleep, Fatigue and Shift Work _____________________________________________________________________________________ 22
What Is Sleep? _________________________________________________________________________________________________ 22
Circadian Rhythms______________________________________________________________________________________________ 23
Fatigue _______________________________________________________________________________________________________ 25
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Shift Work_____________________________________________________________________________________________________ 28
Sleep, Fatigue, Shift Work and the Aircraft Maintenance Engineer _______________________________________________________ 29
Alcohol, Medication and Drug Abuse _______________________________________________________________________________ 36
Alcohol _______________________________________________________________________________________________________ 36
Railways and Transport Safety Act 2003 _____________________________________________________________________________ 37
Alcohol and Sleep ______________________________________________________________________________________________ 45
Alcohol and Attention ___________________________________________________________________________________________ 48
Medication ____________________________________________________________________________________________________ 48
Drugs ________________________________________________________________________________________________________ 50
Non-Prescribed Drugs ___________________________________________________________________________________________ 50
Diet and Nutrition _______________________________________________________________________________________________ 52
Eating Habits/Patterns __________________________________________________________________________________________ 52
Culture _______________________________________________________________________________________________________ 52
Nutrition ______________________________________________________________________________________________________ 52
Glycaemic Index (GI) ____________________________________________________________________________________________ 53
Drinking Habits ________________________________________________________________________________________________ 58
Dehydration ___________________________________________________________________________________________________ 59
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Finess/health; 9.4 2
Stress: Domestic and Work related;
Tim pressure and deadlines;
Workload : overload and underload;
Sleep and fatigue, shiftwork;
Alcohol, medication, drug abuse
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Chapter 15.4 Factors Affecting Performance

The performance abilities and limitations of aircraft maintenance engineers have been described in Chapter 2. Other factors may also
impinge on the engineer, potentially rendering him less able to carry out his work and attain the levels of safety required. These include
fitness and health, stress, time pressures, workload, fatigue and the effects of medication, alcohol and drugs. These subjects are discussed in
this chapter.
Fitness and Health

The job of an aircraft maintenance engineer can be physically demanding. In addition, his work may have to be carried out in widely varying
physical environments, including cramped spaces, extremes of temperature, etc. (as discussed in the next chapter). There are at present no
defined requirements for physical or mental fitness for engineers or maintenance staff. ICAO Annex 11 states:
"An applicant shall, before being issued with any licence or rating [for personnel other than flight crew members], meet such requirements
in respect of age, knowledge, experience and, where appropriate, medical fitness and skill, as specified for that licence or rating."
In the UK, the ICAO requirements are enforced through the provision of Article 13 (paragraph 7) of the Air Navigation order (ANO). This
states:
"The holder of an aircraft maintenance engineer's licence shall not exercise the privileges of such a licence if he knows or suspects that his
physical or mental condition renders him unfit to exercise such privileges."
There are two aspects to fitness and health: the disposition of the engineer prior to taking on employment and the day-to-day well being of
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the engineer once employed.
Pre-employment Disposition
Some employers may require a medical upon commencement of employment. This allows them to judge the fitness and health of an
applicant (and this may also satisfy some pension or insurance related need). There is an obvious effect upon an engineer's ability to
perform maintenance or carry out inspections if through poor physical fitness or health he is constrained in some way (such as his freedom
of movement, or his sight). In addition, an airworthiness authority, when considering issuing a licence, will consider these factors and may
judge the condition to be of such significance that a licence could not be issued. This would not, however, affect the individual's possibility
of obtaining employment in an alternative post within the industry where fitness and health requirements are less stringent.
Day-to-Day Fitness and Health

Fitness and health can have a significant affect upon job performance (both physical and cognitive). Day-to-day fitness and health can be
reduced through illness (physical or mental) or injury.
EASA Part-66.50 imposes a requirement that "certifying staff must not exercise the privileges of their certification authorisation if they know
or suspect that their physical or mental condition renders them unfit."
Responsibility falls upon the individual aircraft maintenance engineer to determine whether he is not well enough to work on a particular
day. Alternatively, his colleagues or supervisor may persuade or advise him to absent himself until he feels better. In fact, as the CAA's
CAAIPs Leaflet 15-6 (previously published as Airworthiness Notice 47) points out, it is a legal requirement for aircraft maintenance engineers
to make sure they are fit for work:
"Fitness: In most professions there is a duty of care by the individual to assess his or her own fitness to carry out professional duties. This has
been a legal requirement for some time for doctors, flight crew members and air traffic controllers. Licensed aircraft maintenance engineers
are also now required by law to take a similar professional attitude. Cases of subtle physical or mental illness may not always be apparent to
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the individual but as engineers often work as a member of a team any substandard performance or unusual behaviour should be quickly
noticed by colleagues or supervisors who should notify management so that appropriate support and counseling action can be taken."
Many conditions can impact on the health and fitness of an engineer and there is not space here to offer a complete list. However, such a list
would include:
• Minor physical illness (such as colds, 'flu, etc.);

• More major physical illness (such as HIV, malaria, etc.);
• Mental illness (such as depression, etc.);
• Minor injury (such as a sprained wrist, etc.);
• Major injury (such as a broken arm, etc.);
• Ongoing deterioration in physical condition, possibly associated with the ageing process (such as hearing loss, visual defects, obesity,
heart problems, etc.);
• Affects of toxins and other foreign substances (such as carbon monoxide poisoning, alcohol, illicit drugs, etc.).
This document does not attempt to give hard and fast guidelines as to what constitutes 'unfit for work'; this is a complex issue dependent
upon the nature of the illness or condition, its effect upon the individual, the type of work to be done, environmental conditions, etc.
Instead, it is important that the engineer is aware that his performance, and consequently the safety of aircraft he works on, might be
affected adversely by illness or lack of fitness.
An engineer may consider that he is letting down his colleagues by not going to work through illness, especially if there are ongoing
manpower shortages. However, he should remind himself that, in theory, management should generally allow for contingency for illness.
Hence the burden should not be placed upon an individual to turn up to work when unfit if no such contingency is available. Also, if the
individual has a contagious illness (e.g. 'flu), he may pass this on to his colleagues if he does not absent himself from work and worsen the
manpower problem in the long run. There can be a particular problem with some contract staff due to loss of earnings or even loss of
contract if absent from work due to illness. They may be tempted to disguise their illness, or may not wish to admit to themselves or others
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that they are ill. This is of course irresponsible, as the illness may well adversely affect the contractor's standard of work.
Positive Measures
Aircraft maintenance engineers can take common sense steps to maintain their fitness and health. These include:
• Eating regular meals and a well-balanced diet;

• Taking regular exercise (exercise sufficient to double the resting pulse rate for 20 minutes, three times a week is often recommended);
• Stopping smoking;
• Sensible alcohol intake (for men, this is no more than 3 - 4 units a day or 28 per week, where a unit is equivalent to half a pint of beer or a
glass of wine or spirit);
• Finally, day-to-day health and fitness can be influenced by the use of medication, alcohol and illicit drugs. These are covered later.
Stress
Stress is an inescapable part of life for all of us.
Stress can be defined as any force, that when applied to a system, causes some significant modification of its form, where forces can be
physical, psychological or due to social pressures.
From a human viewpoint, stress results from the imposition of any demand or set of demands which require us to react, adapt or behave in
a particular manner in order to cope with or satisfy them. Up to a point, such demands are stimulating and useful, but if the demands are
beyond our personal capacity to deal with them, the resulting stress is a problem.
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Causes and Symptoms

Stress is usually something experienced due to the presence of some form of stressor, which might be a one-off stimulus (such as a
challenging problem or a punch on the nose), or an ongoing factor (such as an extremely hot hangar or an acrimonious divorce). From
these, we get acute stress (typically intense but of short duration) and chronic stress (frequent recurrence or of long duration) respectively.
Different stressors affect different people to varying extents. Stressors may be:
• Physical - such as heat, cold, noise, vibration, presence of something damaging to health (e.g. carbon monoxide);
• Psychological - such as emotional upset (e.g. due to bereavements, domestic problems, etc.), worries about real or imagined problems
(e.g. due to financial problems, ill health, etc.);
• Reactive - such as events occurring in everyday life (e.g. working under time pressure, encountering unexpected situations, etc.).
Types of stressors
• Physical: heat, noise, vibration, etc.
• Social: anxiety, incentives, group pressures.
• Drugs: alcohol, nicotine, medication, etc.
• Work: boredom, fatigue, sleep deprivation too much to do in too little time.
• Body clock: shift changes, jet lag.
• Personal: domestic worries, aches and pains, feeling under the weather, etc.
CAAIPs Leaflet 15-6 (previously published as Airworthiness Notice 47) points out that:
"A stress problem can manifest itself by signs of irritability, forgetfulness, sickness absence, mistakes, or alcohol or drug abuse. Management
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have a duty to identify individuals who may be suffering from stress and to minimise workplace stresses. Individual cases can be helped by
sympathetic and skilful counseling which allows a return to effective work and licensed duties."
In brief, the possible signs of stress can include:
• Physiological symptoms - such as sweating, dryness of the mouth, etc.;

• Health effects - such as nausea, headaches, sleep problems, diarrhea, ulcers, etc.;
• Behavioural symptoms - such as restlessness, shaking, nervous laughter, taking longer over tasks, changes to appetite, excessive drinking,
etc.;
• Cognitive effects - such as poor concentration, indecision, forgetfulness, etc.;
• Subjective effects - such as anxiety, irritability, depression, moodiness, aggression, etc.
It should be noted that individuals respond to stressful situations in very different ways. Generally speaking though, people tend to regard
situations with negative consequences as being more stressful than when the outcome of the stress will be positive (e.g. the difference
between being made redundant from work and being present at the birth of a son or daughter).
Domestic Stress
When aircraft maintenance engineers go to work, they cannot leave stresses associated with home behind. Pre-occupation with a source of
domestic stress can play on one's mind during the working day, distracting from the working task. Inability to concentrate fully may impact
on the engineer's task performance and ability to pay due attention to safety.
Domestic stress typically results from major life changes at home, such as marriage, birth of a child, a son or daughter leaving home,
bereavement of a close family member or friend, marital problems, or divorce.
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Work Related Stress

Aircraft maintenance engineers can experience stress for two reasons at work: because of the task or job they are undertaking at that
moment, or because of the general organisational. environment. Stress can be felt when carrying out certain tasks that are particularly
challenging or difficult. This stress can be increased by lack of guidance in this situation, or time pressures to complete the task or job
(covered later in this chapter). This type of stress can be reduced by careful management, good training, etc.
Within the organisation, the social and managerial aspects of work can be stressful.
Chapter 3 discussed the impact on the individual of peer pressure, organizational culture and management, all of which can be stressors. In
the commercial world that aircraft maintenance engineers work in, shift patterns, lack of control over own workload, company
reorganisation and job uncertainty can also be sources of stress.
Stress Management
Once we become aware of stress, we generally respond to it by using one of two strategies: defense or coping.
Defense strategies involve alleviation of the symptoms (taking medication, alcohol, etc.) or reducing the anxiety (e.g. denying to yourself
that there is a problem (denial), or blaming someone else).
Coping strategies involve dealing with the source of the stress rather than just the symptoms (e.g. delegating workload, prioritizing tasks,
sorting out the problem, etc.).
Coping is the process whereby the individual either adjusts to the perceived demands of the situation or changes the situation itself.
Unfortunately, it is not always possible to deal with the problem if this is outside the control of the individual (such as during an emergency),
but there are well-published techniques for helping individuals to cope with stress. Good stress management techniques include:
• Relaxation techniques;
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• Careful regulation of sleep and diet;

• A regime of regular physical exercise;
• Counseling - ranging from talking to a supportive friend or colleague to seeking professional advice.
There is no magic formula to cure stress and anxiety, merely common sense and practical advice.
Stress is part of our lifestyle. It is inevitable but manageable. Management of stress is relatively easy once learnt. But we each have to learn a
way that best suits us. We need to find the particular technique that tickles our own fancy. The objective is not to confront stress head on.
Like a kite it will climb against the wind and become even more challenging. The idea is to defuse it, to divide it into bite-size chunks, and
remind yourself that it is temporary. It will pass and there is a future. Alcohol does not defuse stress, it defers it and then it is added to the
next days lot.
Coping/defusing techniques include:
• Exercise /sports Physical demand takes your mind of mental problems and is good for you. Physical demand that also demands mental
concentration is even better i.e. golf, or sailing, is more diverting than jogging.
• Fresh air The wide world around us keeps everything in perspective and reinforces our hope and realisation that we are both small, and
large in the scheme of things;
• Diversions/hobbies Mental and manipulative occupation is a marvelous relaxant something that requires total concentration.
• Relaxation therapy and meditation These use the same technique of mental occupation and diversion so that the build-up of stress is
deflated by inattention. It is not the same as lying in the sun and snoozing as the brain dwells on the problem. They are effective and
easy-to-learn techniques for focusing the single-channel processor of the conscious mind on a trivial routine symbol.
Summary - Fatigue and stress
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• Upsets timing of skilled performance.

• Causes tired person to do more work to achieve same results (involves more effort).
• Tired people tend to focus on one out of many sources of information.
• Tired people do not always notice these changes and assume that their performance is as good as ever.
This outlines how skilled performance breaks down as the result of fatigue or stress. As indicated previously, the direction of this breakdown
process is in the opposite direction to skill acquisition.
Time Pressure and Deadlines

There is probably no industry in the commercial environment that does not impose some form of deadline, and consequently time pressure,
on its employees. Aircraft maintenance is no exception. It was highlighted in the previous section that one of the potential stressors in
maintenance is time pressure. This might be actual pressure where clearly specified deadlines are imposed by an external source (e.g.
management or supervisors) and passed on to engineers, or perceived where engineers feel that there are time pressures when carrying out
tasks, even when no definitive deadlines have been set in stone. In addition, time pressure may be self-imposed, in which case engineers set
themselves deadlines to complete work (e.g. completing a task before a break or before the end of a shift).
Management have contractual pressures associated with ensuring an aircraft is released to service within the time frame specified by their
customers. Striving for higher aircraft utilisation means that more maintenance must be accomplished in fewer hours, with these hours
frequently being at night. Failure to do so can impact on flight punctuality and passenger satisfaction. Thus, aircraft maintenance engineers
have two driving forces: the deadlines handed down to them and their responsibilities to carry out a safe job. The potential conflict between
these two driving pressures can cause problems.
The Effects of Time Pressure and Deadlines
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As with stress, it is generally thought that some time pressure is stimulating and may actually improve task performance. However, it is
almost certainly true that excessive time pressure (either actual or perceived, external or self-imposed), is likely to mean that due care and
attention when carrying out tasks diminishes and more errors will be made. Ultimately, these errors can lead to aircraft incidents and
accidents.
It is possible that perceived time pressure would appear to have been a contributory factor in the BAC 1-11 accident described in Chapter 1.
Although the aircraft was not required the following morning for operational use, it was booked for a wash. The wash team had been
booked the previous week and an aircraft had not been ready. This would have happened again, due to short-staffing, so the Shift Manager
decided to carry out the windscreen replacement task himself so that the aircraft would be ready in time.
An extract from the NTSB report on the Aloha accident refers to time pressure as a possible contributory factor in the accident: "The majority
of Aloha's maintenance was normally conducted only during the night. It was considered important that the airplanes be available again for
the next day's flying schedule. Such aircraft utilization tends to drive the scheduling, and indeed, the completion of required maintenance
work. Mechanics and inspectors are forced to perform under time pressure. Further, the intense effort to keep the airplanes flying may have
been so strong that the maintenance personnel were reluctant to keep airplanes in the hangar I any longer than absolutely necessary."
Managing Time Pressure and Deadlines

One potential method of managing time pressures exerted on engineers is through regulation. For example, FAA research has highlighted
the need to isolate aircraft maintenance engineers from commercial pressures. They consider this would help to ensure that airworthiness
issues will always take precedence over commercial and time pressures. Time pressures can make `corner-cutting' a cultural norm in an
organisation. Sometimes, only an incident or accident reveals such norms (the extract from the Aloha accident above exemplifies this).
Those responsible for setting deadlines and allocating tasks should consider:
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• Prioritising various pieces of work that need to be done;

• The actual time available to carry out work (considering breaks, shift handovers, etc.);
• The personnel available throughout the whole job (allowing a contingency for illness);
• The most appropriate utilisation of staff (considering an engineer's specialisation, and strengths and limitations);
• Availability of parts and spares.
It is important that engineering staff at all levels are not afraid to voice concerns over
inappropriate deadlines, and if necessary, cite the need to do a safe job to support this. As highlighted in Chapter 3, within aircraft
maintenance, responsibility should be spread across all those who play a part. Thus, the aircraft maintenance engineer should not feel that
the `buck stops here'.
Workload - Overload and Underload

The preceding sections on stress and time pressure have both indicated that a certain amount of stimulation is beneficial to an aircraft
maintenance engineer, but that too much stimulation can lead to stress or over-commitment in terms of time. It is noteworthy that too little
stimulation can also be a problem.
Arousal
Arousal in its most general sense, refers to readiness of a person for performing work. To achieve an optimum level of task performance, it is
necessary to have a certain level of stimulation or arousal. This level of stimulation or arousal varies from person to person. There are people
who are overloaded by having to do more than one task at a time; on the other hand there are people who appear to thrive on stress, being
happy to take on more and more work or challenges. Figure 4.1 shows the general relationship between arousal and task performance.
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Figure 4.1: Optimum arousal leads to best task performance
At low levels of arousal, our attentional mechanisms will not be particularly active and our performance capability will be low (complacency
and boredom can result). At the other end of the curve, performance deteriorates when arousal becomes too high. To a certain extent, this
is because we are forced to shed tasks and focus on key information only (called narrowing of attention). Best task performance occurs
somewhere in the middle. In the work place, arousal is mainly influenced by stimulation due to work tasks. However, surrounding
environmental factors such as noise may also influence the level of arousal.
Summary
Level of arousal has an important influence upon performance. The best performance is associated with an intermediate level of arousal.
This is sometimes called the inverted U-curve; reflecting how performance varies with arousal level.
• Arousal is the body's reaction to stresses, drives and motivation.
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• Sleep (low arousal) -- Panic (high arousal)

• Too little or too much arousal causes poor performance.
• Low arousal: focus on task-irrelevant cues.
• High arousal: neglect task relevant cues.
Factors Determining Workload

An individual aircraft maintenance engineer can usually identify what work he has to do quite easily. It is more difficult to assess how that
work translates into workload.
The degree of stimulation exerted on an individual caused by a task is generally referred to as workload, and can be separated into physical
workload and mental workload.
As noted in the section on information processing in Chapter 2, humans have limited mental capacity to deal with information. We are also
limited physically, in terms of visual acuity, strength, dexterity and so on. Thus, workload reflects the degree to which the demands of the
work we have to do eats into our mental and physical capacities. Workload is subjective (i.e. experienced differently by different people) and
is affected by:
The nature of the task, such as the:
• physical demands it requires (e.g. strength required, etc.);

• mental demands it requires (e.g. complexity of decisions to be made, etc.).
The circumstances under which the task is performed, such as the:
• standard of performance required (i.e. degree of accuracy);

• time available to accomplish the task (and thus the speed at which the task must be carried out);
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• requirement to carry out the task at the same time as doing something else;
• perceived control of the task (i.e. is it imposed by others or under your control, etc.);
• environmental factors existing at time (e.g. extremes of temperature, etc.).
The person and his state, such as his:
• skills (both physical and mental);

• his experience (particularly familiarity with the task in question);
• his current health and fitness levels;
• his emotional state (e.g. stress level, mood, etc.).
As the workload of the engineer may vary, he may experience periods of overload and underload. This is a particular feature of some areas
of the industry such as line maintenance.
Overload
Overload occurs at very high levels of workload (when the engineer becomes over aroused). As highlighted previously, performance
deteriorates when arousal becomes too high and we are forced to shed tasks and focus on key information. Error rates may also increase.
Overload can occur for a wide range of reasons based on the factors highlighted above. It may happen suddenly (e.g. if asked to remember
one further piece of information whilst already trying to remember a large amount of data), or gradually. Although EASA Part-145 states that
"The Part-145 approved maintenance organisation must employ sufficient personnel to plan, perform, supervise and inspect the work in
accordance with the approval", and "the Part-145 organisation should have a production man hours plan showing that it has sufficient man
hours for the work that is intended to be carried out", this does not prevent individuals from becoming overloaded. As noted earlier in this
section, it can be difficult to determine how work translates into workload, both for the individual concerned, and for those allocating tasks.
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How we cope with overload

These are the ways in which we shed informational overloads. Each of the bullet points on the slide shows a progression of steps for coping
with overload, starting by ignoring selected inputs and ending by abandoning the task altogether. Unlike machines that tend to break
down suddenly, human performance degrades gracefully under conditions of overload.
• Ignore selected inputs.

• Trade-off accuracy for speed.
• Postpone things until quieter times.
• Reduce level of discrimination
• Redistribute the work if possible
• Abandon the task altogether
Underload
Underload occurs at low levels of workload (when the engineer becomes under aroused). It can be just as problematic to an engineer as
overload, as it too causes a deterioration in performance and an increase in errors, such as missed information. Underload can result from a
task an engineer finds boring, very easy, or indeed a lack of tasks. The nature of the aircraft maintenance industry means that available work
fluctuates, depending on time of day, maintenance schedules, and so forth. Hence, unless stimulating 'housekeeping' tasks can be found,
underload can be difficult to avoid at times.
Workload Management
Unfortunately, in a commercial environment, it is seldom possible to make large amendments to maintenance schedules, nor eliminate time
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pressures. The essence of workload management in aircraft maintenance should include:
• ensuring that staff have the skills needed to do the tasks they have been asked to do and the proficiency and experience to do the tasks
within the timescales they have been asked to work within;
• making sure that staff have the tools and spares they need to do the tasks;
• allocating tasks to teams or individual engineers that are accomplishable (without cutting corners) in the time available;
• providing human factors training to those responsible for planning so that the performance and limitations of their staff are taken into
account;
• encouraging individual engineers, supervisors and managers to recognise when an overload situation is building up.
If an overload situation is developing, methods to help relieve this include:
• seeking a simpler method of carrying out the work (that is just as effective and still legitimate);
• delegating certain activities to others to avoid an individual engineer becoming overloaded;
• securing further time in order to carry out the work safely;
• postponing, delaying tasks/deadlines and refusing additional work.
Thus, although workload varies in aircraft maintenance engineering, the workload of engineers can be moderated. Much of this can be
done by careful forward planning of tasks, manpower, spares, tools and training of staff.
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Sleep, Fatigue and Shift Work
What Is Sleep?
Man, like all living creatures has to have sleep. Despite a great deal of research, the purpose of sleep is not fully understood.
Sleep is a natural state of reduced consciousness involving changes in body and brain physiology which is necessary to man to restore and
replenish the body and brain.
Sleep can be resisted for a short time, but various parts of the brain ensure that sooner or later, sleep occurs. When it does, it is characterised
by five stages of sleep:
• Stage 1: This is a transitional phase between waking and sleeping. The heart rate slows and muscles relax. It is easy to wake someone up.
• Stage 2: This is a deeper level of sleep, but it is still fairly easy to wake someone.
• Stage 3: Sleep is even deeper and the sleeper is now quite unresponsive to external stimuli and so is difficult to wake. Heart rate, blood
pressure and body temperature continue to drop.
• Stage 4: This is the deepest stage of sleep and it is very difficult to wake someone up.
• Rapid Eye Movement or REM Sleep: Even though this stage is characterised by brain activity similar to a person who is awake, the person
is even more difficult to awaken than stage 4. It is therefore also known as paradoxical sleep. Muscles become totally relaxed and the eyes
rapidly dart back and forth under the eyelids. It is thought that dreaming occurs during REM sleep.
Stages I to 4 are collectively known as non-REM (NREM) sleep. Stages 2-4 are categorised as slow-wave sleep and appear to relate to body
restoration, whereas REM sleep seems to aid the strengthening and organisation of memories. Sleep deprivation experiments suggest that
if a person is deprived of stage 1-4 sleep or REM sleep he will show rebound effects. This means that in subsequent sleep, he will make up
the deficit in that particular type of sleep. This shows the importance of both types of sleep.
As can be seen from Figure 4.2, sleep occurs in cycles. Typically, the first REM sleep will occur about 90 minutes after the onset of sleep. The
cycle of stage 1 to 4 sleep and REM sleep repeats during the night about every 90 minutes. Most deep sleep occurs earlier in the night and
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REM sleep becomes greater as the night goes on.
Figure 4.2: Typical cycle of stage 1-4 (NREM) sleep and REM sleep in the course of a night.
Circadian Rhythms
Apart from the alternation between wakefulness and sleep, man has other internal cycles, such as body temperature and hunger/eating.
These are known as circadian rhythms as they are related to the length of the day.
Circadian rhythms are physiological and behavioural functions and processes in the body that have a regular cycle of approximately a day
(actually about 25 hours in man).
Although, circadian rhythms are controlled by the brain, they are influenced and synchronised by external (environmental) factors such as
light.
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An example of disrupting circadian rhythms would be taking a flight that crosses time zones.
This will interfere with the normal synchronisation with the light and dark (day/night). This throws out the natural link between daylight and
the body's internal clock, causing jet lag, resulting in sleepiness during the day, etc. Eventually however, the circadian rhythm readjusts to
the revised environmental cues.
Figure 4.3 shows the circadian rhythm for body temperature. This pattern is very robust, even if the normal pattern of wakefulness and sleep
is disrupted (by shift work for example), the temperature cycle remains unchanged. Hence, it can be seen that if you are awake at 4-6 o'clock
in the morning, your body temperature is in a trough and it is at this time that is hardest to stay awake. Research has shown that this drop in
body temperature appears to be linked to a drop in alertness and performance in man.
Figure 4.3: The Circadian Rhythm for Internal Body Temperature
Although there are many contributory factors, it is noteworthy that a number of major incidents and accidents involving human error have
either occurred or were initiated in the pre-dawn hours, when body temperature and performance capability are both at their lowest. These
include Three Mile Island, Chernobyl, and Bhopal, as well as the BAC1-11, A320, and B737 incidents summarised in Chapter 1.
The engineer's performance at this `low point' will be improved if he is well rested, feeling well, highly motivated and well practised in the
skills being used at that point.
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Fatigue
Fatigue is a loss of alertness and a feeling of tiredness that can be caused by a lack of sleep, a change in your work schedule due to working
overtime or working second shift, or trying to fit too many things in a 24-hour period. The National Transportation Safety Board (NTSB) has
found fatigue to be a causal or contributory factor in accidents in every mode of transportation and has issued almost 80 fatigue-related
safety recommendations since 1972. The National Aeronautics and Space Administration (NASA) Ames Fatigue Countermeasures program
has addressed fatigue in aviation through research and other activities since 1980.
A look at the causes

Our internal clock or circadian clock controls immune function, digestion, performance, alertness, and mood. The lowest point occurs
around 3 to 5 a.m. each day making this time period one of the lowest levels of performance activity, although sometimes it can be
anywhere from midnight to 6 a.m. A second period of sleepiness occurs around 3 to 5 p.m. These low circadian levels are associated with
decreased performance and alertness. And these time periods can become more relevant if there is an accident and a follow-up
investigation.
Fatigue is most often associated with being extra tired and the usual cause and effect scenario leads one to consider sleep (or
sleeplessness). Eight hours of sleep is considered the norm for the average person, although it can vary by the individual and range from six
to ten hours. Sleep loss can be acute, the amount of sleep loss in a 24-hour period, and cumulative, sleep loss over several days. Recovery
from cumulative sleep loss requires more deep sleep and not an hour-for-hour exchange.
How long an individual remains awake is a factor that can affect performance and alertness. Studies have examined the lengths of shifts and
the results on performance. NTSB data has shown an increased risk beyond 12 hours. And at 16 hours of work, a national occupation-injury
database revealed an accident/injury rate three times greater than a nine-hour shift. Seventeen hours or longer of prolonged wakefulness
can be similar to changes experienced with alcohol consumption.
Research has shown that the effects of fatigue are similar to moderate alcohol consumption. On-the-job performance loss for every hour of
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wakefulness between 10 and 26 hours is equivalent to a 0.004 percent rise in blood alcohol concentration. Eighteen hours of wakefulness
are usually considered to be equivalent to a blood alcohol concentration of 0.05 percent. A person who has been awake for this length of
time will act and perform as if he or she has consumed one glass of beer. The result is significantly delayed response and reaction times,
impaired reasoning, reduced vigilance, and impaired hand-eye coordination.
Tied in with the study of circadian rhythms is the effect of light. The National Lighting Bureau (NLB) reveals that research shows that lighting
supports more than visual needs, it affects health. The amount of light needed to influence health tends to be about 10 times greater than
for vision, according to John Bachner of the NLB. Studies have shown that a lack of light can cause certain forms of cancer. And having
greater amounts of light can reduce the risk of colon and prostate cancer; prevent myopia; counteract airborne disease transmission; and
cure psoriasis, seasonal affective disorder, and sleep disorders.
Other factors that influence fatigue include stress, drugs, medications, illness, large temperature variations, noise, boredom, vibration, and
dehydration (See sidebar on page 85).
Sources of fatigue can be very easy to underestimate. Who reads the packages of cold and sinus medication? Caution: This drug may cause
drowsiness and impair the ability to drive or operate machinery. So even a runny nose could affect your job performance.
Effect on performance
Some of the most common effects due to fatigue are feeling lethargic, becoming withdrawn, having difficulty concentrating, and a reduced
attention span. Other effects include short-term memory loss (what was I working on?); complacency (it doesn't matter); lack of awareness
affected by hearing and eyesight; loss of coordination; lack of good judgment and decision making; and lengthened reaction time. All of
these conditions increase the possibility of reduced safety and increased risk.
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Solutions
So what can you do? The best solution is to be aware of your performance level. If you think there is a problem take a break; a short walk, a
glass of water, or a snack might give you the burst of energy you need. Talk to your co-workers; it will increase your awareness of things
around you. Research has shown that a short nap can also improve alertness and performance. Other solutions concern your lifestyle. Try
and get adequate sleep, exercise regularly, eat a balanced diet, and drink at least eight glasses of water a day.
The typical cup of coffee can improve alertness but only for a limited time. Coffee is a stimulant and causes a temporarily increased level of
alertness, but fatigue is a symptom of its withdrawal. And it's a diuretic, which causes the body to discharge more fluid than it is taking in,
resulting in dehydration, which can also cause fatigue.
If your schedule is too hectic to eat a balanced diet, you can always take vitamins andsupplements to fight fatigue. To make up for
deficiencies in your diet consider vitamins A, B complex, C, E, zinc, iron, potassium, and calcium. Use carefully and check with a physician
about use and possible side effects.
Work conditions and practices also need to be considered. A culture that supports safety and conducts human factors training so you are
more aware of factors that influence performance is one that will help prevent fatigue or injuries from occurring.
Management should have adequate staff to handle tasks,this includes having the right experience levels as well as the manpower. And
when designing and planning work schedules, circadian rhythms should be taken into consideration.
Other management practices should include additional inspections, rotating shifts, and longer rest periods following night shifts. If possible
more critical tasks should be allocated for day shifts. Procedures should be documented so that there is a record of what has been done.
This will ensure tasks are completed or indicate where someone left off in case someone else has to follow up to complete maintenance
procedures.
Know your own limits and adjust your behaviour in areas that you can, such as hours of sleep, proper diet, and exercise. And if work affects
your energy level, see what steps you can take or recommend to make work procedures safe and productive.
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Shift Work
Most aircraft movements occur between 6 a.m. and 10 p.m. to fit in with the requirements of passengers. Aircraft maintenance engineers
are required whenever aircraft are on the ground, such as during turn arounds. However, this scheduling means that aircraft are often
available for more significant maintenance during the night. Thus, aircraft maintenance engineering is clearly a 24 hour business and it is
inevitable that, to fulfill commercial obligations, aircraft maintenance engineers usually work shifts. Some engineers permanently work the
same shift, but the majority cycle through different shifts. These typically comprise either an 'early shift', a `late shift' and a night shift', or a
'day shift' and a 'night shift' depending on the maintenance organisation.
Advantages and Disadvantages of Shift Work

There are pros and cons to working shifts. Some people welcome the variety of working different times associated with regular shift work
patterns.
Advantages may include more days off and avoiding peak traffic times when traveling to work. The disadvantages of shift working are
mainly associated with:
• working ùnsociable hours', meaning that time available with friends, family, etc. will be disrupted;
• working when human performance is known to be poorer (i.e. between 4 a.m and 6 a.m.);
• problems associated with general desynchronisation and disturbance of the body's various rhythms (principally sleeping patterns).
Working At Night
Shift work means that engineers will usually have to work at night, either permanently or as part of a rolling shift pattern. As discussed
earlier in this chapter, this introduces the inherent possibility of increased human errors. Working nights can also lead to problems sleeping
during the day, due to the interference of daylight and environmental noise. Blackout curtains and use of ear plugs can help, as well as
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avoidance of caffeine before sleep.
In the B737 double engine oil loss incident, the error occurred during the night shift. The accident investigation report commented that: "It
is under these circumstances that the fragility of the self monitoring system is most exposed because the safety system can be jeopardised
by poor judgment on the part of one person and it is also the time at which people are most likely to suffer impaired judgment".
Rolling Shift Patterns

When an engineer works rolling shifts and changes from one shift to another (e.g. 'day shift' to `night shift'), the body's internal clock is not
immediately reset. It continues on its old wake-sleep cycle for several days, even though it is no longer possible for the person to sleep
when the body thinks it is appropriate, and is only gradually resynchronised. However, by this time, the engineer may have moved onto the
next shift. Generally, it is now accepted that shift rotation should be to later shifts (i.e. early shift --* late shift -->night shift or day shift -).
night shift) instead of rotation towards earlier shifts (night shift late shift - early shift).
Sleep, Fatigue, Shift Work and the Aircraft Maintenance Engineer

Most individuals need approximately 8 hours sleep in a 24 hour period, although this varies between individuals, some needing more and
some happy with less than this to be fully refreshed. They can usually perform adequately with less that this for a few days, building up a
temporary sleep `deficit'. However, any sleep deficit will need to be made up, otherwise performance will start to suffer.
A good rule of thumb is that one hour of high-quality sleep is good for two hours of activity.
As previously noted, fatigue is best tackled by ensuring adequate rest and good quality sleep are obtained. The use of blackout curtains if
having to sleep during daylight has already been mentioned. It is also best not to eat a large meal shortly before trying to sleep, but on the
other hand, the engineer should avoid going to bed hungry. As fatigue is also influenced by illness, alcohol, etc., it is very important to get
more sleep if feeling a little unwell and drink only in moderation between duties (discussed further in the next section). Taking over-the-
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counter drugs to help sleep should only be used as a last resort.
When rotating shifts are worked, it is important that the engineer is disciplined with his eating and sleeping times. Moreover, out of work
activities have to be carefully planned. For example, it is obvious that an individual who has been out night-clubbing until the early hours of
the morning will not be adequately rested if rostered on an early shift.
Shift working patterns encountered by aircraft maintenance engineers may include three or four days off after the last night shift. It can be
tempting to work additional hours, taking voluntary overtime, or another job, in one or more of these days off. This is especially the case
when first starting a career in aircraft maintenance engineering when financial pressures may be higher. Engineers should be aware that
their vulnerability to error is likely to be increased if they are tired or fatigued, and they should try to ensure that any extra hours worked are
kept within reason.
It is always sensible to monitor ones performance, especially when working additional hours. Performance decrements can be gradual, and
first signs of chronic fatigue may be moodiness, headaches or finding that familiar tasks (such as programming the video recorder) seem
more complicated than usual.
Finally, it is worth noting that, although most engineers adapt to shift working, it becomes harder to work rotating shifts as one gets older.
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Figure 4.4: The effect of successive days without Zietberg clues
Figure 4.5: Timing planned sleep
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Figure 4.6: Jet lag - flying East and flying West
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Age & Sleep
• Ageing brings major changes in sleep requirements.

• New born babies may sleep up to 23 hours per day (of which the majority is REM)
• As people get older they sleep less but at the same time, become less flexible about when sleep is
taken.
• Shift work becomes more difficult with age as it is much harder to re-programme the body clock.
• Women tend to sleep longer than men but report more sleep problems.
Naps
• A nap is a short period of sleep taken at any hour.

• The time of day, the duration of the nap and the sleep credit/deficit of the individual will
determine through which sleep stages the individual will pass.
• The restorative properties of naps will vary from one individual to another
• With the increase in extended flight times there is debate about allowing a crew member to take
20 to 30 minute naps in the seat in an effort to keep him/her fresh.
• It is not unknown for one of the pilots to be taking a nap and the other pilot to fall asleep.
• After napping it may take some minutes to collect one’s thoughts and they will have slow
responses and reactions for up to 5 minutes after being roused.
• The minimum duration for a nap to be restorative appears to be not less than 10 minutes.
Figure 4.7: Age, sleep, naps
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Microsleeps
• Microsleeps are very short periods of sleep lasting from a fraction of a second to two to three seconds.
• Although their existence can be confirmed by EEG readings, the individual may be unaware of their
occurrence which makes them particularly dangerous.
• They occur most often in conditions of fatigue but are of no assistance in reducing sleepiness.
Planning Shift Work Sleep
• An engineer rostered for night duty will attempt to get some sleep during the afternoon prior to
reporting for duty.
• However, it will be difficult to get any satisfactory sleep due to having a good sleep credit assuming a
normal night’s sleep had been achieved the night before, plus an increasing body temperature does
not facilitate sleep.
• There are basically two options in this case:
- Firstly, one could go to bed early the previous night and set the alarm for an early call so that by
the afternoon the body will be approaching sleep deficit and be ready to sleep.
- Second alternative would be to go to bed late the previous night, sleep late, relax in the
afternoon and still have a good sleep credit for the night duty.
Figure 4.8: Microsleeps and shift work sleep
Sleep Disorders
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• Narcolepsy
• An inability to stop falling asleep even when in sleep credit.
• Specialists believe that this is associated with the inability of the brain to distinguish between wakefulness and REM sleep.
• Apnoea
• A cessation of breathing whilst asleep.
• A common condition and the subject will normally either wake up or restart breathing after a short time.
• It becomes a more serious problem when the breathing stoppage lasts for up to a minute and the frequency of stoppages increases.
• The frequent awakenings will disturb the normal sleep pattern and the individual may experience excessive daytime sleepiness.
• Sleepwalking (Somnambulism)
• This condition, as well as talking in one’s sleep, is more common in childhood, but does occur later in life.
• It may happen more frequently in those operating irregular hours or those under some stress.
• The condition should not cause difficulty in healthy adults unless the sleep walker is involved in an accident whilst away from his bed.
• Insomnia
• This is simply the term for difficulty in sleeping.
• Clinical insomnia – a person has difficulty in sleeping under normal, regular conditions in phase with the body rhythms (an inability to sleep when
the body’s systems are calling for sleep)
- Clinical insomnia is rarely a disorder within itself, it is normally a symptom of another disorder.
- For this reason the common and symptomatic treatment with sleeping drugs or tranquilliser is inappropriate unless treatment for the underlying
cause is also undertaken.
• Situational insomnia – an inability to sleep due to disrupted work/rest patterns, or circadian dysrhythmia
- This often occurs when one is required to sleep but the brain and body are not in the sleeping phrase.
- This condition is the one most frequently reported by aircrew
Figure 4.9: Sleep disorders
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Alcohol, Medication and Drug Abuse

It should come as no surprise to the aircraft maintenance engineer that his performance will be affected by alcohol, medication or illicit
drugs. Under both UK and JAA legislation it is an offence for safety critical personnel to carry out their duties whilst under the influence of
alcohol or drugs.
Article 13 of the UK ANO, states:
"The holder of an aircraft maintenance engineer's licence shall not, when exercising the privileges of such a licence, be under the influence
of drink or a drug to such an extent as to impair his capacity to exercise such privileges."
The current law which does not prescribe a blood/alcohol limit, is soon to change. There will be new legislation permitting police to test for
drink or drugs where there is reasonable cause, and the introduction of a blood/alcohol limit of 20 milligrams of alcohol per 100 millilitres of
blood for anyone performing a safety critical role in UK civil aviation (which includes aircraft maintenance engineers).
Alcohol
Alcohol acts as a depressant on the central nervous system, dulling the senses and increasing mental and physical reaction times. It is
known that even a small amount of alcohol leads to a decline in an individual's performance and may cause his judgment (i.e. ability to
gauge his performance) to be hindered.
Alcohol is removed from the blood at a fixed rate and this cannot be speeded up in any way (e.g. by drinking strong coffee). In fact, sleeping
after drinking alcohol can slow down the removal process, as the body's metabolic systems are slower.
CAAIP Leaflet 15-6 (previously Airworthiness Notice 47) provides the following advice concerning alcohol:
"Alcohol has similar effects to tranquillisers and sleeping tablets and may remain circulating in the blood for a considerable time, especially
if taken with food. It may be borne in mind that a person may not be fit to go on duty even 8 hours after drinking large amounts of alcohol.
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Individuals should therefore anticipate such effects upon their next duty period. Special note should be taken of the fact that combinations
of alcohol and sleeping tablets, or anti-histamines, can form a highly dangerous and even lethal combination."
As a general rule, aircraft maintenance engineers should not work for at least eight hours after drinking even small quantities of alcohol and
increase this time if more has been drunk.
The affects of alcohol can be made considerably worse if the individual is fatigued, ill or using medication.
Even small quantities of alcohol in the blood can impair one's performance, with the added danger of relieving anxiety so that the person
thinks he is performing marvelously. Alcohol severely affects a person's judgment and abilities; high altitudes, where there is less oxygen,
worsens the effect. Alcohol is a depressant. It lowers the body's natural sensitivities, cautions and fears (showing as over-confidence) and, at
the same time, it lowers capabilities; a deadly combination as we know by the road accident statistics. It also represses social mores and
allows emotions, that would otherwise be controlled, to run free. Hence loudness, aggression, anger, passion, violence, showing-off and
risk-taking. In some personalities it actually causes depression and low self-esteem. The World Health Organisation defines an alcoholic as
someone whose excessive drinking repeatedly damages their physical, mental or social life. (I would add their professional life also.) It takes
time for the body to remove alcohol.
After heavy drinking, alcohol may still be in the blood 24 hours later. Having coffee, soup or water between drinks only helps if they are
taken instead of an alcoholic beverage. Otherwise, the body receives the same total amount of alcohol in the same time; it takes the same
time for it to be discarded and for its effects to be removed. Also of concern are the long-term effects of alcohol consumption, such as
dependency and damage to kidneys, liver and brain. Studies suggest that females who drink 14-21 standard drinks per week, or less, and
males who drink 21-28 per week, or less, should not suffer long-term problems. A standard drink contains 10 grams of alcohol.
Railways and Transport Safety Act 2003

The CAA have adopted the Railways and Transport Safety Act of 2003 as their stand on the use of alcohol and drugs. It is summarised in
CAAIP Leaflet 15-5 (previously issued as Airworthiness Notice 45). It is as follows:
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1. Introduction
a. The information contained in this Leaflet has been developed in conjunction with the Department for Transport, the Home Office and
the Police, and is consistent with thecriteria contained in the Police Protocol. It is anticipated that this will facilitate a consistent
approach by relevant parties.
b. The aim of this Leaflet is to inform Licensed Aircraft Maintenance Engineers of this new legislation and how it affects them in the
performance of their duties.
2. Legislative Background
a. The effect of intoxication, through alcohol or drugs, on aviation personnel has significant safety implications. The Air Navigation Order
(ANO), which is the main aviation safety regulatory legislation, provides that no member of an aircraft's crew, a licensed aircraft
maintenance engineer or an air traffic control officer shall be under the influence of alcohol or drugs to such an extent as to impair
his/her capacity to carry out their duties. The ANO, however, does not set a blood alcohol limit nor does it require a person who is
suspected of an alcohol or drugs offence to be subjected to a test.
b. In 1996, the Government issued a Consultation Paper on alcohol and drug testing for aircraft crew and other safety critical civil aviation
personnel, which proposed the introduction of a blood/alcohol limit for certain aviation personnel, together with corresponding
Police powers of enforcement. Responses to the consultation were broadly supportive of the Government's approach. Part 5 of the
Railways and Transport Safety Act 2003 www.legislation.hmso.gov.uk/acts/acts2003/20030020.htm represents the first suitable
legislative opportunity to take forward these proposals and now brings aviation into line with other transport modes in seeking to
tackle alcohol or drug misuse among key personnel. The Police testing and enforcement powers broadly mirror those currently
applied on our roads and railways and are based on an officer's reasonable suspicion that an offence either has been, or is in the
process of being, committed.
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c. The blood/alcohol limit for aviation personnel is lower than that in shipping or on our roads or railways, but for pilots reflects the Joint
Aviation Requirement on Commercial Air Transportation (JAR-OPS) - adopted by the Joint Aviation Authorities (JAA) in 1996 -which
requires that crew members of commercial aircraft should not commence a flight duty period with a blood/alcohol level in excess of
20mg of alcohol per 100ml of blood. The adoption of this limit will go towards the harmonisation of standards across most of Europe.
d. Enforcement of the provisions of the Act is the responsibility of the Police and the Crown Prosecution Service. There is no provision for
random testing.
3. Implementation
Part 5 of the Act was brought into force on 30 March 2004.
4. Summary of Part 5 of The Railways and Transport Safety Act 2003 and Commentary on Enforcement
This Part extends to the flight and cabin crew of an aircraft, air traffic controllers and licensed aircraft maintenance engineers in the
United Kingdom. It also applies to the crew of an aircraft registered in the United Kingdom wherever it may be in the world.
An Explanatory Note may be found at: www.legislation.hmso.gov.uk/acts/en/03en20-b.htm.
5. Offences - Being Unfit for Duty (Section 92)
Section 92 makes it an offence to perform an aviation function or an ancillary activitywhilst impaired through alcohol or drugs.
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6. Offences - Prescribed Limit (Section 93)

a. This Section makes it an offence to perform or prepare to perform certain aviation related functions with more than a prescribed
level of alcohol in the body.
b. The prescribed blood/alcohol alcohol limits are 20 milligrammes of alcohol per 100 millilitres of blood for those activities carried out
by aircrew and air traffic controllers, and 80 milligrams per 100 millilitres for licensed aircraft maintenance engineers. The different
limits reflect the fact that although licensed aircraft maintenance engineers perform a safety critical role in aviation, they do not
necessarily require the same speed of reaction as aircrew or air traffic controllers may need in an emergency situation. The equivalent
limits in respect of breath and of urine are also set out in this section.
c. Detailed limits are:
a. When:
• acting as a pilot, cabin crew, flight engineer, flight navigator or flight radiotelephony operator of an aircraft during flight;
• attending the flight deck of an aircraft during flight to give or supervise training, to administer a test, to observe a period of
practice or to monitor or record the gaining of experience; or • acting as an air traffic controller in pursuance of a licence
granted under or by virtue of an enactment (other than a licence granted to a student): the prescribed limit of alcohol is:
I. In the case of breath: 9 microgrammes of alcohol in 100 millilitres.
II. In the case of blood: 20 milligrammes of alcohol in 100 millilitres.
III. In the case of urine: 27 milligrammes of alcohol in 100 millilitres.
b. When acting as a licensed aircraft maintenance engineer the prescribed limit of alcohol in respect of the above is:
I. In the case of breath: 35 microgrammes of alcohol in 100 millilitres.
II. In the case of blood: 80 milligrammes of alcohol in 100 millilitres.
III. In the case of urine: 107 milligrammes of alcohol in 100 millilitres.
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7. Aviation Functions (Section 94)

a. This section applies the offences of being either over the limit or unfit, to people preparing to carry out an aviation function or
otherwise holding themselves ready to carry out one of those functions by virtue of being on duty or standby.
b. An activity shall be treated as an ancillary function if it is undertaken by a person commencing a period of duty in respect of the
function, and as a requirement of, for the purpose of or in connection with the performance of the function during the period of
duty. For example, the pre-flight briefing of the flight and cabin crew and any post-flight activity such as filing reports is considered
to be an àncillary' function.
8. Testing Under the Act

a. Preliminary test (i.e. a breathalyser test)
The Act provides that the power to require a person to co-operate with a preliminary test shall apply where:
• a constable in uniform reasonably suspects that the person is over the prescribed limit,
• a constable in uniform reasonably suspects that the person has been over the prescribed limit and still has alcohol or a drug in
his body or is still under the influence of a drug,
• an aircraft is involved in an accident and a constable reasonably suspects that the person was undertaking an aviation function,
or an activity ancillary to an aviation function, in relation to the aircraft at the time of the accident, or
• an aircraft is involved in an accident and a constable reasonably suspects that the person has undertaken an aviation function, or
an activity ancillary to an aviation function, in relation to the aircraft.
b. A person who, without reasonable excuse, fails to provide a specimen when required to do so in pursuance of this section is guilty of
an offence.
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c. A person commits an offence under the Act if he/she performs an aviation function, or an activity that is ancillary to an aviation
function, at a time when his/her ability to perform the function is impaired because of alcohol or drugs. This means that a person can
be tested at any time after commencing duty, including standby.
d. The Police will determine when to test. As noted above this will in essence be when there are reasonable grounds for suspicion that
someone is over the prescribed limit, or when an accident has occurred.
e. The Police are empowered to breathalyse and to perform subsequent tests (i.e. blood and urine tests). Police officers have been
advised to exercise their powers under the Act as discreetly as circumstances allow and, if possible, in private, particularly where
passenger aircraft are concerned. Overtly or insensitively exercising these powers in certain circumstances could have detrimental
affect on passenger perception and confidence, and could have commercial implications and liabilities. The preliminary drug test is
dependent on factors not yet finalised.
f. Testing following an accident
An accident for these purposes is defined as an unintended event with adverse physical effect. It is unlikely that every accident
involving an aircraft will warrant Police exercising any or all of their power under this Act.
9. Reasonable Grounds for Suspicion

a. Reasonable grounds for suspicion depend upon the circumstances in each case. There must be an objective basis for that suspicion
based on facts, information and/or intelligence that are relevant to the likelihood of an offence. Reasonable suspicion cannot be
based on generalisations or stereotypical images of certain groups or categories of people as more likely to be involved in criminal
activity.
b. Reasonable suspicion can sometimes exist without specific information or intelligence band on the basis for some level of
generalisation stemming from the behaviour of a person. Reasonable suspicion should normally be linked to accurate and current
intelligence or information. For example, evidence of impairment from witnesses or from the result of a primary test of an employee
by an employer could be sufficient.
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10. Procedure in the Event of a Positive Breathalyser Test

a. If, as a result of an initial Police breath test, an officer has reasonable cause to suspect that a person has more than the prescribed
proportion of alcohol in their body, then they can expect to be arrested and taken to a Police station. There, they will be asked to
provide a further specimen of breath, blood or urine for laboratory analysis. In practice, this will usually be a specimen of blood,
taken by a Police doctor. Failure to provide a specimen without reasonable cause is an offence. Where a sample of blood or urine is
taken, he/she will be entitled to request a part of the sample for themselves. He/she will be supplied with a booklet of analysts where
they can have their specimen privately analysed if they wish.
b. Once a blood sample has been taken he/she will probably be released from the Police station on a condition to return at a later date,
by which time the Police part of the sample will have been analysed. If the sample is under the limit he/she will probably be told not
to attend. If, when he/she attends, the results of the analysis of the sample shows that he/she was over the limit, he/she will be
charged with the offence and be given a date to attend court.
c. After giving a specimen, the Police may detain the individual at the Police station until it appears to the officer that there is no
likelihood of them carrying out, or attempting to carry out, an aviation function of the kind for which they have provided a sample,
whilst still over the prescribed limit or otherwise impaired through alcohol or drugs.
11. Advice to Engineers
This Leaflet should be read in conjunction with CAP 562 Leaflet 15-6, that contains further information on the Licensed Aircraft
Maintenance Engineer's responsibilities when medically unfit or under the influence of alcohol or drugs.
12. Penalties and Enforcement Powers (Sections 95, 97 and 98)

a. Section 95: Penalty
The penalties set out in section 95 are set at the same level as those currently applying to aircrew and air traffic controllers under
Article 148 of the ANO 2005 (as amended). This section will bring the penalty for licensed maintenance engineers under the
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influence of alcohol or drugs into line with them.

b. Arrest without a warrant (Section 97)
A constable may arrest a person without a warrant if the constable reasonably suspects that the person is committing an offence
under Section 92 (being unfit for duty), or has committed an offence under that Section and is still under the influence of alcohol or
drugs.
c. Right of entry (Section 98)
• A Police constable in uniform may board an aircraft if he/she reasonably suspects that he/she may wish to exercise a power by
virtue of Section 96 (power to administer tests, etc.) or under Section 97 (arrest without a warrant) in respect of a person who is
or may be on the aircraft.
• A Police constable in uniform may enter any place if he/she reasonably suspects that he/she may wish to exercise a power by
virtue of Section 96 (power to administer tests, etc.) or under Section 97 (arrest without a warrant) in respect of a person who is
or may be in that place.
• For the purpose of boarding an aircraft or entering a place under this Section, a Police constable may use reasonable force or
may be accompanied by one or more persons, e.g. airline personnel, additional Police constables, etc. Officers not used to
working on airports or in aircraft and not trained to consider the relevant aspects of health and safety may wish to be
accompanied by an agent of the airport or the operator as appropriate.
13. Disclosure of Information

a. In exercising their powers under this Act, the Police may acquire information that gives cause for serious concern that a person
performing a safety critical aviation function is unsuited to hold that position of trust. This acquisition may occur even before their
sample of blood or urine has been analysed or they have been charged, for example, where such a person has provided a positive
preliminary test.
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b. Such information may be passed to that person's employer or professional body on grounds of public safety or for the prevention or
detection of crime. This will only be carried out with the authority of an officer of Assistant Chief of Police rank.
• Any disclosure should provide only that information required to determine whether the offender should continue in their
present role pending trial.
• If authority to disclose is refused, Police should provide for the analysis of samples to be fast-tracked by the Forensic Science
Service and for the offender to be charged, if appropriate, at the earliest opportunity.
c. In reality it is likely that if an individual is tested positive whilst on a duty, this will have an immediate impact on their ability to
perform their function and will quickly come to the attention of the employer.
14. CAA Protocol in Suspected Alcohol or Drug Misuse
In cases where a licensed engineer may be misusing alcohol or drugs, a decision will be made whether there is alcohol or drug
dependency that could be a risk to flight safety. If so, the licence may be suspended, or where the licence has been issued by another
state, a recommendation to suspend will be sent to the issuing authority. If that is so, he/she will then be invited to take part in a
treatment and rehabilitation schedule. If that is successful, the suspension will be lifted. For non-UK licence holders a recommendation
will be sent to the issuing authority that a rehabilitation schedule was completed.
Alcohol and Sleep

Alcohol has a detrimental effect on both the quality of sleep and on daytime attention. Sleep problems are common in alcoholics and also in
some people who have completely stopped drinking. The effects of alcohol on sleep and attention are complicated to define and
haveconsiderable variability in individuals.
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Disturbance of paradoxical (REM) sleep/slow wave sleep cycle

Alcohol seems to accelerate falling asleep, at least in subjects who do not tend to fall asleep immediately. The negative effects arise later
and affect the quality and duration of sleep. Sleep is a complex phenomenon in which there are alternating phases of deep sleep, called
paradoxical or REM sleep during which the subject dreams, and slow wave sleep. Undisturbed progression of these two phases of sleep is
essential for an individual's well being. Alcohol disturbs or interrupts the sequence of paradoxical sleep and light sleep. Thus alcoholics and
some people who have stopped drinking complain about disturbed and fragmented sleep, frightening dreams and insomnia.
The disruptive effects of alcohol last well into the night, even when alcohol has been eliminated. This is not a phenomenon specific to
alcohol, it is seen with other sedative products. Snoring is abnormally frequent after taking alcoholic drinks in the evening before going to
bed. This is due to the relaxing effects of alcohol on the pharyngeal muscles.
Daytime repercussions of alcohol's effects on sleep

Disturbed sleep or sleep deprivation exacerbate the sedative effects of alcohol during the day. Alcohol consumed late in the evening will
noticeably reduce the performance of a subject (attention, dexterity,...) during the following morning. By producing an accumulation of
nights of poor sleep, alcohol can disrupt the normal sleep/wake cycle, which is also essential for health and well being. Hence the negative
effects of alcohol can have repercussions on daytime performance.
Research on Alcohol and Sleep
From: National Institute on Alcohol Abuse and Alcoholism

Insomnia as a Pathway to Alcoholism
In healthy subjects, acute alcohol in doses of 0.16 - 1.0 g/kg suppresses REM sleep and increases deep non-rapid eye movement sleep (non
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REM). Initial latency to sleep is reduced, but paradoxically, wake time during the latter half of the sleep period is increased. The reduced time
to fall asleep produced by alcohol may encourage continued use of alcohol at bedtime.
Epidemiological studies have found that 28 percent of those who complain of insomnia reported using alcohol to help them sleep, and
further, individuals who reported having two weeks or more of insomnia were more likely to have met diagnostic criteria for alcoholism at
one year follow-up. A recent study found that insomniacs were more likely to self-administer ethanol before bedtime than non-insomniacs.
Furthermore, a low dose of ethanol before bedtime made subtle improvements in the insomniacs' sleep and mood, suggesting that ethanol
may be more reinforcing for insomniacs. Therefore, the degree to which ethanol use in insomniacs extends beyond the therapeutic context
into daytime use is an important line of research. Tolerance development to low doses of alcohol in insomniacs is also a possibility, which
could lead to increased doses, although this has not been investigated. Finally, for the elderly who use alcohol at bedtime to counteract
insomnia, there is increased risk for falls during the night. Thus, whether insomnia precedes the development of alcohol abuse, and the
clinical significance of the sequencing of these two disorders particularly with respect to age and gender are important research questions.
Extract from the NIAAA Alcohol Alert
Alcohol and Sleep in Those Without Alcoholism

Alcohol consumed at bedtime, after an initial stimulating effect, may decrease the time required to fall asleep. Because of alcohol's sedating
effect, many people with insomnia consume alcohol to promote sleep. However, alcohol consumed within an hour of bedtime appears to
disrupt the second half of the sleep period. The subject may sleep fitfully during the second half of sleep, awakening from dreams and
returning to sleep with difficulty. With continued consumption just before bedtime, alcohol's sleep-inducing effect may decrease, while its
disruptive effects continue or increase. This sleep disruption may lead to daytime fatigue and sleepiness. The elderly are at particular risk,
because they achieve higher levels of alcohol in the blood and brain than do younger persons after consuming an equivalent dose. Bedtime
alcohol consumption among older persons may lead to unsteadiness if walking is attempted during the night, with increased risk of falls
and injuries.
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Alcohol and Attention

The sedative action of alcohol has variable degrees of effect on attention, reducing it and producing diminished performance. This action is
particularly noticeable in subjects who lack sleep or who tend to be lethargic. Alcohol seems to reduce the ability of an individual to waken,
even if consumed in moderate amounts, to the point where driving ability is affected, not just in the hours after consumption, but
sometimes for days afterwards.
Medication
Any medication, no matter how common, can possibly have direct effects or side effects that may impair an engineer's performance in the
workplace.
Medication can be regarded as any over-the-counter or prescribed drug used for therapeutic purposes.
There is a risk that these effects can be amplified if an individual has a particular sensitivity to the medication or one of its ingredients.
Hence, an aircraft maintenance engineer should be particularly careful when taking a medicine for the first time, and should ask his doctor
whether any prescribed drug will affect his work performance. It is also wise with any medication to take the first dose at least 24 hours
before any duty to ensure that it does not have any adverse effects.
Medication is usually taken to relieve symptoms of an illness. Even if the drugs taken do not affect the engineer's performance, he should
still ask himself whether the illness has made him temporarily unfit for work.
Various publications, and especially CAAIP Leaflet 15-6 (previously published as Airworthiness Notice 47) give advice relevant to the aircraft
maintenance engineer on some of the more common medications. This information is summarised below, however the engineer must use
this with caution and should seek further clarification from a pharmacist, doctor or their company occupational health advisor if at all unsure
of the impact on work performance.
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Analgesics are used for pain relief and to counter the symptoms of colds and 'flu. In the UK, paracetamol, aspirin and ibuprofen are the
most common, and are generally considered safe if used as directed. They can be taken alone but are often used as an ingredient of a 'cold
relief medicine. It is always worth bearing in mind that the pain or discomfort that you are attempting to treat with an analgesic (e.g.
headache, sore throat, etc.) may be the symptom of some underlying illness that needs proper medical attention.
Antibiotics (such as Penicillin and the various mycins and cyclines) may have short term or delayed effects which affect work performance.
Their use indicates that a fairly severe infection may well be present and apart from the effects of these substances themselves, the side-
effects of the infection will almost always render an individual unfit for work.
Anti-histamines are used widely in 'cold cures' and in the treatment of allergies (e.g. hayfever). Most of this group of medicines tend to
make the user feel drowsy, meaning that the use of medicines containing anti-histamines is likely to be unacceptable when working as an
aircraft maintenance engineer.
Cough suppressants are generally safe in normal use, but if an over-the-counter product contains anti-histamine, decongestant, etc., the
engineer should exercise caution about its use when working.
Decongestants (i.e. treatments for nasal congestion) may contain chemicals such as pseudoephedrine hydrochloride (e.g. 'Sudafed') and
phenylphrine. Side-effects reported, are anxiety, tremor, rapid pulse and headache. AWN47 forbids the use of medications containing this
ingredient to aircraft maintenance engineers when working, as the effects compromise skilled performance.
`Pep' pills are used to maintain wakefulness. They often contain caffeine, dexedrine or benzedrine. Their use is often habit forming. Over-
dosage may cause headaches, dizziness and mental disturbances. CAAIP Leaflet 15-6 (previously published as Airworthiness Notice 47)
states that "the use of `pep' pills whilst working cannot be permitted. If coffee is insufficient, you are not fit for work."
Sleeping tablets (often anti-histamine based) tend to slow reaction times and generally dull the senses. The duration of effect is variable
from person to person. Individuals should obtain expert medical advice before taking them.
Melatonin (a natural hormone) deserves a special mention. Although not available without a prescription in the UK, it is classed as a food
supplement in the USA (and is readily available in health food shops). It has been claimed to be effective as a sleep aid, and to help promote
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the resynchronisation of disturbed circadian rhythms. Its effectiveness and safety are still yet to be proven and current best advice is to
avoid this product.
If the aircraft maintenance engineer has any doubts about the suitability of working whilst taking f medication, he must seek appropriate
professional advice.
Drugs
Don't touch them.
Illicit drugs such as ecstasy, cocaine and heroin all affect the central nervous system and impair mental function. They are known to have
significant effects upon performance and have no place within the aviation maintenance environment. Of course, their possession and use
are also illegal in the UK.
Smoking cannabis can subtly impair performance for up to 24 hours. In particular, it affects the ability to concentrate, retain information and
make reasoned judgments, especially on difficult tasks.
Non-Prescribed Drugs
Don't touch them.
Tobacco
Nothing good can be said about smoking. Smoking is detrimental to good health, both in the short term and in the long term. Smoking also
significantly decreases a person's capacity to perform by reducing the amount of oxygen carried in the blood, replacing it with the useless
and potentially poisonous by-products of cigarette smoke. A person does not have to be the active smoker to suffer the effects; smoke from
any person in the cockpit (or anywhere in the aircraft, if it is small) will affect everyone.
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Carbon monoxide, which is present in cigarette smoke, is absorbed into the blood in preference to oxygen. The maximum blood oxygen
concentration for a smoker is 90 per cent of that for a non-smoker. This means that, at sea level, a smoker is already as hypoxic as a non-
smoker at an altitude of about eight thousand feet. A smoker's night vision is affected by hypoxia, even at sea level. Any oxygen deficiency
reduces the body's ability to produce energy (and it affects brain functions).
The level of carbon monoxide in the blood is measured by the carboxyhaemoglobin level (COHb). Smokers with a COHb of 5% are already
equivalent to an altitude of 8,000 feet and, at an actual cabin altitude of 5,000 feet, are at a personal altitude of 10,000 feet. (They should
already be on oxygen.) An average smoker will have a COHb level of 4-10%. A passive smoker may be as high as 5%. It is now recognisedthat
cigarette smoking plays a significant role in cardiovascular (heart) diseases, cancer and other mental and physical diseases.
Most doctors will now tell you that whatever else you do for your health do not smoke. Besides, it is unfair to threaten the health of those
who choose not to. If you must smoke, smoke alone.
Figure 4.10: Carboxyhaemoglobin
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Diet and Nutrition

We are what we eat. Diet concerns what we eat, how much and in what proportions. It receives much attention in the media these days
because in Western society our dietary intake is poorly managed: too much animal fat, too much processed sugar, too few vegetables,
cereals and fruit. In all, too much quantity and too little activity.
Eating Habits/Patterns
We are habitual eaters. The suggested eating pattern is to have small, varied serves often rather than sporadic large serves. Snacks, such as
fruit, yoghurt, muesli bars and cereals keep the hunger at bay and avoid the temptation to eat a large meal too quickly. Eating slowly allows
the digestive system to process the food and to feel satisfied with a lesser quantity.
Culture
We are heavily influenced by the diet of our culture and our forebears. Some are very favourable. Some are damaging. Our cuisine, style of
cooking and the frequency and size of meals are related to our upbringing. All affect our health, energy and well-being. The Mediterranean
cuisine is currently assessed as best: seafoods, salads, olive oil, fruit and time spent enjoying it.
Nutrition
Nutrition is fuel for the body and mind. We have discussed the importance of oxygen for generation of energy, and there is a need for fuel in
the form of nutrients, which the body converts from the food we eat, and roughage, which is important for internal hygiene.
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Glycaemic Index (GI)

There is much discussion regarding the natural sugar content of foods. A rating called the glycaemic index (GI) has been adopted and may
appear on the packaging of foods in future, similar to the fat and cholesterol content. High GI foods give a quick but short-lived boost
followed by a depressed level of energy and focus. OK for sprint athletes; not so good for long-haul flight crew.
Elements of Our Diet
Fats
Intake of animal fat, in any form, should be carefully controlled. Meat does not necessarily mean fat, nor does milk. There are lean choices for
both.
Meat
Choose lean lamb, beef and chicken, no skin on the chicken. Keep fatty bacon to a minimum. Do not be too heavy on the sauces. Minimise
preserved or processed meats, such as sausages and hams. Women don't eat enough meat. Lean meat is the best source of protein and iron.
Fish
Oily fish/bluefish, sardines, kippers, herrings, salmon and tuna are marvelous. All grilled, steamed or poached fish is great. Avoid fried,
battered or crumbed as the coating collects the fats and the calories.
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Oils
Vegetable and fish oils are good. Olive oil is best but don't overheat when cooking. Limit coconut and palm oils.
Legumes
Peas, and all types of beans, are good for you (pulsars). Lentils are a good source of protein.
Salad
Any salad is wonderful if raw, fresh and clean. If you are sure of the source, eat lots. Watch the dressings though. Light oil and vinegar is
good. Mayonnaise not so moderate. The additives such as cheese, bacon, potatoes and eggs. Salad, fruit and vegetables protect against
cancers and heart disease.
Vegetables
Vegetables should be undercooked and undressed, and steamed or stir-fried rather than boiled to death - crunchy is good. Eat lots of them.
Go.overboard. Spinach or silver beet is a good source of iron. Have many different-coloured vegetables on your plate. Brighter-coloured
vegetables contain greater levels of anti-oxidants. These neutralise free radicals, the ageing and health-threatening agents that encourage
cancers and heart disease. Soups are a wonderful way to serve fresh vegetables as the juices remain in the serve. Don't add too much salt.
Potatoes boost energy but only in the short term (that GI again). Rice has the same effect. Avoid bulk quantities of either.
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Fruit
Eat unlimited amounts, if fresh. Fruit is the best source of vitamins, energy and water and also acts as anti-oxidants, especially red fruits,
strawberries, and tomatoes. However, tropical fruits increase blood supply quickly (GI) and lead to an immediate uplift that is short-lived. It
is followed by a loss of energy and concentration. They provide short-lived energy.
Nuts
Nuts should be eaten sparingly - watch the oil and salt.
Carbohydrates - Fibre/Cereals/Grains/Rice
Bread is the staff of life Granular and unprocessed is best with oil rather than butter. Rice and potatoes are good - steamed or boiled rather
than fried. However, large amounts of rice or potatoes act to rapidly build the glycaemic level (blood sugar), but there follows a sudden let-
down. Ever feel hungry and weak not long after a rice meal? It is doubly negative when it happens halfway into a long flight sector.
Additionally, watch the sauce, cheese and butter.
Milk and Dairy Products

Choose the low-fat/high-calcium versions. Restrict intake to small amounts of good cheese. Use vegetable oil or margarine in preference to
butter. Low-salt, low-fat versions should be selected.
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Yoghurt
Yoghurt is excellent. Natural unsweetened varieties are best. Acidophilus is an important element in the functioning of the bowel. Some
yoghurts culture forms of this essential bacterium (e.g. lactobacillus).
Eggs
Cholesterol is high in egg yolk so keep to only two or three eggs a week. Poached or boiled is better than fried. Omelettes and custards can
be high in egg content. Nevertheless, eggs are good food.
Desserts, Cakes, Sweets, Chocolates

Fruits are better than sweet snacks but avoid adding sugar and serve the fruit with yoghurt rather than cream or ice cream. Biscuits, cakes,
puddings, sauces, custards and chocolates should be a special (rare) treat.
Snacks
Fresh fruit is best, or vegetables (celery, carrots, etc.), yoghurt, dry biscuits, or small amounts of nuts or seeds. Health bars are okay. No chips,
hot or cold, in any guise.
Undercooking versus Overcooking

Always steam or poach rather than boil, and grill rather than fry. Undercooked. Is better for most foods, but some personal taste must be
allowed, and also the source of the food. In some areas, well-cooked food, stewed or curried, is safest provided it is not reheated, nor
presented in full public view to customers and to flies.
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Minerals, Vitamins and Nutrients

Previously, we could assume that a daily intake of calories, in the form of a varied diet, would automatically ensure that we had sufficient
vitamins and minerals. Later research is suggesting that, in modern society, the food value and eating habits are not the same as they were
and that supplementary vitamins and minerals may be essential. The body does not store all vitamins and so a daily need has to met by a
daily supply. The general recommendation is that we take supplementary multi-vitamins. We are also only beginning to understand the
roles of various elements, minerals and anti-oxidants.
Salt (Sodium Chloride)

We no longer need to preserve meat or fish in salt and so our taste must change to value food without salt. We have grown accustomed to
salt in and on our meals but our diet contains too much. It does take time to lower the salt level as meals initially taste less flavoured. It's like
giving up sugar or stopping smoking: our taste buds adjust and we eventually appreciate the taste of the actual ingredients. There is
enough salt naturally in all food. If there is a need for supplementary salt to replace that lost by perspiration, for example, in the tropics or
when exercising severely, then the doctor will prescribe it.
Minerals and Mineral Salts

Calcium, iron, magnesium and other elements are essential in our diet. They are inherent in a balanced diet. Iron deficiency is common in
women and specific advice should be sought for your individual cycles. New dairy products include high-calcium, low-fat alternatives.
Sugar
Minimise your intake of unprocessed sugar - preferably none. Eat sweet fruit rather than chocolate. Bananas are great.
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Fast Foods/Take-Away
So much to eat in so little time.
• Chinese and Thai - yes but choose those with no MSG and avoid deep fried meals. Steamed rice rather than fried or noodles - in small
quantities.
• Indian - okay if high turnover and not reheated - but watch out for the fat in curries.
• Western - burgers are not so good on a regular basis but quite okay occasionally.
Have lots of salad or coleslaw and less of the bread, butter and fries. Tomato sauce is good. Have chicken without the skin. Sandwiches are
good if you choose the right contents. Grainy bread and no butter is ideal.
• Seafood plus salad - good.

• Fish and chips - not so good. Crumbed, or grilled, fish and chips cooked in vegetable oil is much better, Potato cakes, dim-sims and pluto-
pops is not so good.
• Chicken - better without skin and with salad, or coleslaw, rather than mashed potato and gravy.
Drinking Habits
Fruit and Vegetable Juices and Water

Good, good, good. Water is best. Drink lots of it. Don't wait until you feel thirsty. Drink regularly. The colour of your urine should be light
straw or paler. Any darker means potential dehydration. Too much fruit juice can cause bowel problems and also adds calories.
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Soft Drinks
The mineral-enriched health drinks are for athletes. Use them for severe exercise; otherwise, drink straight mineral water. Avoid sweet,
sticky, sugary soft drinks. They make you even thirstier.
Tea and Coffee

Caffeine is a drug and a stimulant. Coffee has most (especially expresso). Excess caffeine increases pulse rate, prevents sleep, increases
urination and therefore fluid loss (it is a diuretic), causes headaches and increases the level of stress. It may wake you up but it won't let you
rest. Keep caffeine to a minimum (one or two cups a day) and drink plenty of water.
Dehydration
A Hidden Source of Fatigue

By Gordon Dupont - February 2001
Fatigue is an industry problem that we are finally just beginning to come to grips with. It is a problem that our industry has vastly
underestimated and that we have vastly overestimated our ability to cope with.
Well, now it appears that we have a further problem that both we and the industry are totally ignorant of --- at least I sure was - dehydration.
Dehydration has the ability to induce fatigue with the resulting reduction in judgment - all without us even being aware of it. Let's start with
a few interesting facts:
1. Our body is made up of about 60 percent water (women a little less than men for some reason).
2. Our brain is made up of 85 percent water and requires a very narrow range of water content to remain at its peak.
3. We lose about 8 to 10 cups, or just over 2 litres of water per normal day through breathing, urinating, perspiring, and bowel movements.
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4. Without water, we can live about 3 days.

5. If working outside on a hot day, we can lose about two pounds or one litre of water per hour.
6. Doctors now say that a whopping 75 percent of people don't have enough water, which translates to - dehydration.
What are the symptoms?

Surprisingly, thirst is not at the top of the list. We depend on feeling thirsty to keep us from becoming dehydrated and it has been shown to
be a poor indicator.
Dr. F. Batmanghel, in his book Your Body's Many Cries for Water, states that in over one-third of us (37 percent), the thirst mechanism is so
weak that it's often mistaken for hunger. It is only when we are moderately dehydrated, (6 to 10 percent) that we begin to pay attention to
our thirst. By that time, our mental alertness has dropped dramatically. As dehydration becomes severe, the person slips into a coma and if
the cardiovascular system collapses, the person dies.
Only two percent

As little as a two percent drop in body water can begin to affect mental alertness as the brain reacts to the fluid loss. Dr. Susan M. Kleiner,
author of Power Eating, states "... this two percent triggers fuzzy, short-term memory; particularly, trouble with basic math and focusing on
the problems on the printed page or computer screen. The problem is, we are becoming dehydrated and we may not even feel thirsty yet.
We will begin to feel fatigued as our metabolism begins to slow down."
Putting two percent into perspective: A 150 lb. person would need to lose only 1.8 lbs. of water to be two percent dehydrated. On a hot day,
you can lose that in less than an hour. If, as they say, 75 percent of us are chronically dehydrated, then we may be looking at a major
contributing factor to maintenance errors -- and we don't even know it!
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Cold weather preservation

In cold climates, we often don't think of drinking water, choosing rather, a cup of hot coffee or tea. Humidity is very low in cold conditions
and we still lose water through breathing and other body functions. The unknown dehydration leads to a feeling of fatigue and decreased
mentalalertness with never a thought that a simple glass of water will make us feel better.
The formula
Unlike fatigue, the solution is simple - drink lots of water. The old eight, 8-oz. glasses of water per day isn't very accurate because it doesn't
take into account body weight, climate, or activity.
A more accurate figure calls for taking your body weight in pounds and dividing that number in half. That result is the ounces of water that
you require daily. To that, add 12- to 16-oz. for hot, dry weather and a further 12- to 16-oz. if you are doing strenuous physical work.
This is considered a minimum to be sure that you are not dehydrated. Drinking more than that will do no harm as the kidneys maintain the
correct water content and will simply "expel" the excess. This excess is thought to help flush out the toxins or at least dilute them, and can
reduce the chances of colon cancer by possibly 45 percent and bladder cancer by 50 percent.
Perspiring heavily will require replenishment of some essential body salts that are being lost -sodium, potassium, calcium bicarbonate and
phosphate. Salt tablets will help, as will some vitamin tablets.
There are many sport drinks on the market that offer replenishment of these salts. If you want to make your own "tonic," here is a recipe that
will work:
1 litter (or quart) of water
Pinch of salt
75 ml (1/3cup) of sugar*
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100 ml (1/2 cup) of orange juice
*Add an optional drink crystal packet of any flavour you want. If it has sugar already added, then skip the sugar listed above. If you have a
blender, you can even blend in a banana to help balance the potassium.
Now, if you're working out in the heat, you will need to drink at least one of these per hour just to keep balanced. You should also be
drinking fluid about every 20 minutes in these conditions.
Fruits with your labour

Another often forgotten source of fluid as well as some those missing salts are fresh fruits and vegetables. They are made up of up to 90
percent water and are, as we know, good for you.
Diuretics
By fluid, we mean, the "tonic," water, milk, juice, mineral water, flavoured seltzers but NOT tea, coffee, soft drinks with caffeine, or alcohol.
Tea, coffee, and alcohol are diuretics and cause the kidneys to release more water, resulting in greater dehydration. If you are going to drink
coffee, tea, alcohol and to a lesser extent affricated soft drinks, then you better add a water chaser to them just to counteract their diuretic
effect.
Give this article some serious thought and remember; if we are to reduce maintenance errors we have to use all means possible.
Dehydration is an easy one to fix - let's at least eliminate this potential source of error. While the industry may not, at least your body will
thank you for it.
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By the numbers...
As little as two percent loss in water content begins to cause the brain to lose alertness and the body to feel fatigued.
2% to 5% - Mild dehydration but sufficient to influence how the body will react. 6% to 10% Moderate dehydration and is cause for
immediate concern.
11 % to 15% - Severe. Hospitalisation and intravenous will likely be required. Beyond 15% - Can end in death.
Some Common Indicators of Dehydration
Lips and later mouth feel dry
Heart rate and breathing increases
Blood pressure begins to drop
Begin to feel fatigued
Nagging headache that becomes progressively worse Decreased urine output
Begin to feel thirsty
Eyes begin to become sunken
Become mentally irritated and depressed
Skin begins to become wrinkled
May develop a stomach ache
May begin to experience lower back pain
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Become dizzy
Become mentally confused
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Module 15
Human Factor
15.5 Physical Environment
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LEVEL 1
LEVEL 2
LEVEL 3
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Table of Contents
Chapter 15.5 Physical Environment_____________________________ __________________________________________________ 5
Noise_________________________________________________________ ________________________________________________ 5
Fumes______________________________________________________ ___________________________________________________ 6
Illumination____________________________________________________________________________________________________ 7
Climate and Temperature_______________________________________ _________________________________________________ 9
Motion and Vibration____________________________________________ ______________________________________________ 11
Confined Spaces_______________________________________________ ________________________________________________ 12
Working Environment__________________________________________ ________________________________________________ 12
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Noise and fumes 9.5 1
Illumination
Climate and temperature
Motion and vibration
Working environment
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Module 15.5 Physical Environment

The aircraft maintenance engineer can expect to work in a variety of different environments, from `line' (generally outside the hangar) to
`base' (usually inside a hangar or workshop), in all types of weather and climatic conditions, day and night. This depends largely on the
company he works for, and the function he fulfils in the company. Both physical environments have their own specific features or factors
that may impinge on human performance. This chapter considers the impact of noise, fumes, illumination, climate and temperature, motion
and vibration, as well as the requirement to work in confined spaces and issues associated with the general working environment.
Noise
The impact of noise on human performance has already been discussed in Chapter 2, when examining `hearing'. To recap, noise in the
workplace can have both short-term and long-term negative effects: it can be annoying, can interfere with verbal communication and mask
warnings, and it can damage workers' hearing (either temporarily or permanently). It was noted that the ear is sensitive to sounds between
certain frequencies (20 HZ to 20 KHz) and that intensity of sound is measured in decibels (dB), where exposure in excess of 115 dB without
ear protection even for a short duration is not recommended. This equates to standing within a few hundred metres of a moving jet aircraft.
Noise can be thought of as any unwanted sound, especially if it is loud, unpleasant and annoying.
General background noise can be 'filtered out' by the brain through focused attention (as noted in Chapter 2). Otherwise, for more
problematic noise, some form of hearing protection (e.g. ear plugs and ear muffs) is commonly used by aircraft maintenance engineers,
both on the line and in the hangar, to help the engineer to concentrate.
The noise environment in which the aircraft maintenance engineer works can vary considerably. For instance, the airport ramp or apron
area is clearly noisy, due to running aircraft engines or auxiliary power units (APUs), moving vehicles and so on. It is not unusual for this to
exceed 85 dB - 90 dB which can cause hearing damage if the time of exposure is prolonged. The hangar area can also be noisy, usually due
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to the use of various tools during aircraft maintenance. Short periods of intense noise are not uncommon here and can cause temporary
hearing loss. Engineers may move to and from these noisy areas into the relative quiet of rest rooms, aircraft cabins, stores and offices.
It is very important that aircraft maintenance engineers remain aware of the extent of the noise around them. It is likely that some form of
hearing protection should be carried with them at all times and, as a rule of thumb, used when remaining in an area where normal speech
cannot be heard clearly at 2 metres.
In their day-to-day work, aircraft maintenance engineers will often need to discuss matters relating to a task with colleagues and also, at the
end of a shift, handover to an incoming engineer. Clearly, in both cases it is important that noise does not impair their ability to
communicate, as this could obviously have a bearing on the successful completion of the task (i.e. safety). Common sense dictates that
important matters are discussed away from noisy areas.
Fumes
By its nature, the maintenance of aircraft involves working with a variety of fluids and chemical substances. For instance, engineers may
come across various lubricants (oils and greases), hydraulic fluids, paints, cleaning compounds and solder. They will also be exposed to
aircraft fuel and exhaust. In fact, there is every possibility that an engineer could be exposed to a number of these at any one time in the
workplace. Each substance gives off some form of vapour or fumes which can be inhaled by the aircraft maintenance engineer. Some fumes
will be obvious as a result of their odour, whereas others have no smell to indicate their presence. Some substances will be benign most of
the time, but may, in certain circumstances, produce fumes (e.g. overheated grease or oils, smoldering insulation).
Fumes can cause problems for engineers mainly as a result of inhalation, but they can also cause other problems, such as eye irritation. The
problem may be exacerbated in aircraft maintenance engineering by the confined spaces in which work must sometimes be carried out
(e.g. fuel tanks). Here the fumes cannot dissipate easily and it may be appropriate to use breathing apparatus.
It may not always be practical to eradicate fumes from the aircraft maintenance engineer's work place, but where possible, steps should be
taken to minimise them. It is also common sense that if noxious fumes are detected, an engineer should immediately inform his colleagues
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and supervisor so that the area can be evacuated and suitable steps taken to investigate the source and remove them.
Apart from noxious fumes that have serious health implications and must be avoided, working in the presence of fumes can affect an
engineer's performance, as he may rush a job in order to escape them. If the fumes are likely to have this effect, the engineer should
increase the ventilation locally or use breathing apparatus to dissipate the fumes.
Illumination
In order that aircraft maintenance engineers are able to carry out their work safely and efficiently, it is imperative that their work be
conducted under proper lighting conditions. It was noted in Chapter 2, that the cones in the retina of the eye require good light to resolve
fine detail. Furthermore, colour vision requires adequate light to stimulate the cones. Inappropriate or insufficient lighting can lead to
mistakes in work tasks or can increase the time required to do the work.
Illumination refers to the lighting both within the general working environment and also in the locality of the engineer and the task he is
carrying out. It can be defined as the amount of light striking a surface.
When working outside during daylight, the engineer may have sufficient natural light to see well by. It is possible however that he may be in
shadow (possibly caused by the aircraft) or a building. Similarly, cramped equipment compartments will not be illuminated by ambient
hangar lighting. In these cases, additional local artificial lighting is usually required (known as task lighting). At night, aerodromes may
appear to be awash with floodlights and other aerodrome lighting, but these are unlikely to provide sufficient illumination for an engineer
to be able to see what he is doing when working on an aircraft. These lights are not designed and placed for this purpose. Again, additional
local artificial lighting is needed, which may be nothing more than a good torch (i.e. one which does not have a dark area in the centre of
the beam). However, the drawback of a torch, is that it leaves the engineer with only one hand available with which to work. A light
mounted on a headband gets round this problem.
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A torch can be very useful to the engineer, but Murphy's Law dictates that the torch batteries will run down when the engineer is across the
airfield from the stores. It is much wiser to carry a spare set of batteries than `take a chance' by attempting a job without enough light.
Within the hangar, general area lighting tends to be some distance from the aircraft on which an engineer might work, as it is usually
attached to the very high ceiling of these buildings. This makes these lights hard to reach, meaning that they tend to get dusty, making
them less effective and, in addition, failed bulbs tend not to be replaced as soon as they go out. In general, area lighting in hangars is
unlikely to be as bright as natural daylight and, as a consequence, local task lighting is often needed, especially for work of a precise nature
(particularly visual inspection tasks).
An extract from the NTSB report on the Northwest Airlines accident at Tokyo, 1994, illustrates these points:
"The Safety Board believes that the "OK to Close" inspector was hindered considerably by the environment of the pylon area. He indicated,
for example, that the combination of location of the scaffolding (at a level just below the underside of the wing that forced him into unusual
and uncomfortable physical positions) and inadequate lighting from the base of the scaffolding up toward the pylon, hampered his
inspection efforts. Moreover, the underside of the pylon was illuminated by portable fluorescent lights that had been placed along the floor
of the scaffolding. These lights had previously been used in areas where airplanes were painted, and, as a result, had been covered with the
residue of numerous paint applications that diminished their brightness. These factors combined to cause the inspector to view the fuse pin
retainers by holding onto the airplane structure with one hand, leaning under the bat wing doors at an angle of at least 300, holding a
flashlight with the other hand pointing to the area, and moving his head awkwardly to face up into the pylon area."
It is also important that illumination is available where the engineer needs it (i.e. both in the hangar and one the line). Any supplemental
task lighting must be adequate in terms of its brightness for the task at hand, which is best judged by the engineer. When using task
lighting, it should be placed close to the work being done, but should not be in the engineer's line of sight as this will result in direct glare. It
must also be arranged so that it does not reflect off surfaces near where the engineer is working causing indirect or reflected glare. Glare of
either kind will be a distraction from the task and may cause mistakes.
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Poor ambient illumination of work areas has been identified as a significant deficiency during the investigation of certain engineering
incidents. It is equally important that lighting in ancillary areas, such as offices and stores, is good.
The AAIB report for the BAC 1-11 accident says of the unmanned stores area: "The ambient illumination in this area was poor and the Shift
Maintenance Manager had to interpose himself between the carousel and the light source to gain access to the relevant carousel drawers.
He did not use the drawer labels, even though he now knew the part number of the removed bolt, but identified what he thought were
identical bolts by placing the bolts together and comparing them." He also failed to make use of his spectacles.
Relying on touch when lighting is poor is no substitute for actually being able to see what you are doing. If necessary, tools such as mirrors
and borescopes may be needed to help the engineer see into remote areas.
Climate and Temperature

Humans can work within quite a wide range of temperatures and climatic conditions, but performance is adversely affected at extremes of
these. Thus, as can be seen in Figure 5.1, when it is either too cold and/or wet or too hot and/or humid, performance diminishes.
As has been noted throughout this document, aircraft maintenance engineers routinely work both within the hangar and outside. Clearly,
exposure to the widest range of temperature and climate is likely to be encountered outdoors. Here, an engineer may have to work in direct
summer sun, strong winds, heavy rain, high humidity, or in the depths of winter. Although hangars must exclude inclement weather, they
can be cold and draughty, especially if the hangar doors have to remain open.
EASA Part-145 AMC 145.25 (c) states: "Hangars used to house aircraft together with office accommodation should be such as to ensure the
working environment permits personnel to carry out work tasks in an effective manner. Temperatures should be maintained such that
personnel can carry out required tasks without undue discomfort."
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Figure 5.1 : The relationship between climate, temperature and performance
Engineers cannot be expected to maintain the rigorous standards expected in their profession in all environmental conditions. EASA Part-
145 Acceptable Means of Compliance (AMC) 145.25(c) requires that environmental conditions be adequate for work to be carried out,
stating:
"The working environment for line maintenance should be such that the particular maintenance or inspection task can be carried out
without undue distraction. It therefore follows that where the working environment deteriorates to an unacceptable level in respect of
temperature, moisture, hail, ice, snow, wind, light, dust/other airborne contamination, the particular maintenance or inspection tasks should
be suspended until satisfactory conditions are re-established"
Unfortunately, in reality, pressure to turn aircraft round rapidly means that some maintenance tasks are not put off until the conditions are
more conducive to work.
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There was an instance in Scotland, where work on an aircraft was only suspended when it became so cold that the lubricants being used
actually froze.
Environmental conditions can affect physical performance. For example, cold conditions make numb fingers, reducing the engineer's ability
to carry out fiddly repairs, and working in strong winds can be distracting, especially if having to work at height (e.g. on staging). Extreme
environmental conditions may also be fatiguing, both physically and mentally.
There are no simple solutions to the effects of temperature and climate on the engineer. For example, an aircraft being turned around on
the apron cannot usually be moved into the hangar so that the engineer avoids the worst of the weather. In the cold, gloves can be worn,
but obviously the gloves themselves may interfere with fine motor skills. In the direct heat of the sun or driving rain, it is usually impossible
to set up a temporary shelter when working outside.
Motion and Vibration

Aircraft maintenance engineers often make use of staging and mobile access platforms to reach various parts of an aircraft. As these get
higher, they tend to become less stable. For example when working at height on a scissors platform or'cherry picker', applying force to a
bolt being fixed to the aircraft may cause the platform to move away from the aircraft. The extent to which this occurs does not just depend
on the height of the platform, but its design and serviceability. Any sensation of unsteadiness may distract an engineer, as he may
concentrate more on keeping his balance than the task. Furthermore, it is vitally important that engineers use mobile access platforms
properly in order to avoid serious injury.
Vibration in aircraft maintenance engineering is usually associated with the use of rotating or percussive tools and ancillary equipment,
such as generators. Low frequency noise, such as that associated with aircraft engines, can also cause vibration. Vibration between 0.5 Hz to
20 Hz is most problematic, as the human body absorbs most of the vibratory energy in this range.
The range between 50-150 Hz is most troublesome for the hand and is associated with
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Vibratory-induced White Finger Syndrome (VWF). Pneumatic tools can produce troublesome vibrations in this range and frequent use
can lead to reduced local blood flow and pain associated with VWF. Vibration can be annoying, possibly disrupting an engineer's
concentration.
Confined Spaces
Chapter 2 highlighted the possibility of claustrophobia being a problem in aircraft maintenance engineering. Working in any confined
space, especially with limited means of entry or exit (e.g. fuel tanks) needs to be managed carefully. As noted previously, engineers should
ideally work with a colleague who would assist their ingress into and egress out of the confined space. Good illumination and ventilation
within the confined space will reduce any feelings of discomfort. In addition, appropriate safety equipment, such as breathing apparatus or
lines must be used when required.
Working Environment
Various factors that impinge upon the engineer's physical working environment have been highlighted in this chapter. Apart from those
already discussed, other physical influences include:
• workplace layout and the cleanliness and general tidiness of the workplace (e.g. storage facilities for tools, manuals and information, a
means of checking that all tools have been retrieved from the aircraft, etc.);
• the proper provision and use of safety equipment and signage (such as non-slip surfaces, safety harnesses, etc.);
• the storage and use of toxic chemical and fluids (as distinct from fumes) (e.g. avoiding confusion between similar looking canisters and
containers by clear labeling or storage in different locations, etc.).
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To some extent, some or all of the factors associated with the engineer's workplace may affect his ability to work safely and efficiently. EASA
Part-145.25(c) - Facility Requirements states:
"The working environment must be appropriate for the task carried out and in particular special requirements observed. Unless otherwise
dictated by the particular task environment, the working environment must be such that the effectiveness of personnel is not impaired."
This is expanded upon in AMC 145.25(c).
The working environment comprises the physical environment encapsulated in this chapter, the social environment described in Chapter 3
and the tasks that need to be carried out (examined in the next chapter). This is shown in Figure 5.2. Each of these three components of the
working environment interact, for example:
• engineers are trained to perform various tasks;
• successful task execution requires a suitable physical environment;
• an unsuitable or unpleasant physical environment is likely to be de-motivating.
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Figure 5.2: Components of the 'working environment'
Aircraft maintenance engineering requires all three components of the working environment to be managed carefully in order to achieve a
safe and efficient system
It is important to recognise that engineers are typically highly professional and pragmatic in their outlook, and generally attempt to do the
best work possible regardless of their working environment. Good maintenance organisations do their best to support this dedication by
providing the necessary conditions for safe and efficient work.
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Module 15
Human Factor
15.6 Tasks
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LEVEL 1
LEVEL 2
LEVEL 3
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Table of Contents
Chapter 15.6 Tasks _____________________________________________ _____________________________________________ 5

Physical Work_________________________________________________ _________________________________________________ 6
Planning_______________________________________________________ ______________________________________________ 6
Physical Tasks______________________________________________________ ___________________________________________7
Repetitive Tasks_______________________________________________ _________________________________________________ 8
Visual Inspection_______________________________________________ ________________________________________________ 9
Complex Systems_______________________________________________ _______________________________________________ 11
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Physical Work 9.6 1
Repetitive Task
Visual Inspection
Complex system
Memory
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Chapter 15.6 Tasks

Licensed aircraft engineering is a specialist occupation undertaken by men and women who have received appropriate training. The
possible paths into the profession are shown in Figure 6.1.
Figure 6.1: Routes to becoming a Licensed Aircraft Engineer
As a self starter, training is obtained mainly on-the-job, whereas an approved course is largely classroom-based with a condensed on-the-
job element. Given the varied nature of the maintenance tasks in aircraft maintenance, few engineers are `jacks of all trades'. Most engineers
opt to specialise in the tasks they carry out, either as an Airframe and Powerplant specialist, or as an Avionics specialist (both disciplines
include Electrical tasks).
When working within an aircraft maintenance organisation, an engineer will also be sent on `type courses'. These courses provide the
engineer with requisite skills and knowledge to carry out tasks on specific aircraft, engines or aircraft systems.
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The rest of this chapter examines the nature of the tasks that aircraft maintenance engineers carry out, looking at the physical work,
repetitive tasks, visual inspection and the complex systems that they work on.
Physical Work
Planning
Blindly starting a task without planning how best to do it is almost certainly the best way to invite problems. Before commencing a task, an
individual engineer, engineering team or planner should ask themselves a number of questions. These may include-
• Do I/we know exactly what the task is that has to be done?
• Are the resources available to do it effectively (safely, accurately and within the time permitted)? Where resources include:
o personnel;
o equipment/spares;
o documentation, information and guidance;
o facilities such as hangar space, lighting, etc.
• Do I/we have the skills and proficiency necessary to complete the task?
Information about specific tasks should be detailed on job cards or task sheets. These will indicate the task (e.g. checks or inspection, repair,
replacement, overhaul) and often further details to aid the engineer (such as maintenance manual references, part numbers, etc.).
If the engineer is in any doubt what needs to be done, written guidance material is the best resource. Colleagues may unintentionally give
incorrect or imprecise direction (the exception to this is discussing problems that arise that are not covered in the guidance material).
It is generally the shift supervisor's job to ensure that the resources are available for his staff to carry out their tasks. As noted in Chapter 3,
('Time Pressure and Deadlines'), it is likely that, within a shift or a team, various sub-tasks are allocated to individuals by the supervisor.
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Alternatively, he may encourage a team to take ownership of the tasks that need to be completed, giving them the discretion to manage a
package of work (as noted in Chapter 3, ('Team Working'). Exactly 'who does what' is likely to be based on factors such as individuals'
specialisation (i.e. mechanical or avionics) and their experience with the task.
Although management have a responsibility to ensure that their engineers have suitable training, at the end of the day, it is up to the
individual engineer to decide whether he has the necessary skills and has the proficiency and experience to do what he has been asked to
do. He should not be afraid to voice any misgivings, although it is recognised that peer and management pressure may make this difficult.
Physical Tasks
Aircraft maintenance engineering is a relatively active occupation. Regardless of the job being done, most tasks tend to have elements of
fine motor control, requiring precision, as well as activities requiring strength and gross manipulation.
From a biomechanical perspective, the human body is a series of physical links (bones) connected at certain points (joints) that allow
various movements. Muscles provide the motive force for all movements, both fine and gross. This is known as the musculoskeletal system.
The force that can be applied in any given posture is dependent on the strength available from muscles and the mechanical advantage
provided by the relative positions of the load, muscle connections, and joints.
As an engineer gets older, the musculoskeletal system stiffens and muscles become weaker. Injuries become more likely and take longer to
heal. Staying in shape will minimize the effects of ageing, but they still occur.
It is important that maintenance tasks on aircraft are within the physical limitations of aircraft maintenance engineers. Boeing use a
computerised tool, based on human performance data (body sizes, strengths, leverages, pivots, etc.), to ensure that modern aircraft are
designed such that the majority of maintenance engineers will be able to access aircraft equipment, apply the necessary strength to loosen
or tighten objects, etc. (i.e. designed for ease of maintainability).
Clearly we are all different in terms of physical stature and strength and as a consequence, our physical limitations vary. Attempting to lift a
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heavy object which is beyond our physical capabilities is likely to lead to injury. The use of tools generally make tasks easier, and in some
situations, may make a task achievable that was hitherto outside our physical powers (e.g. lifting an aircraft panel with the aid of a hoist).
As noted in Chapter 4, ('Fatigue'), physical work over a period of time will result in fatigue. This is normally not a problem if there is adequate
rest and recovery time between work periods. It can, however, become a problem if the body is not allowed to recover, possibly leading to
illness or injuries. Hence, engineers should try to take their allocated breaks.
Missing a break in an effort to get a job done within a certain time frame can be counterproductive, as fatigue diminishes motor skills,
perception, awareness and standards. As a consequence, work may slow and mistakes may occur that need to be rectified.
As discussed at some length in Chapter 4, (Day-to-Day Fitness and Health'), it is very important that engineers should try to ensure that their
physical fitness is good enough for the type of tasks which they normally do.
Repetitive Tasks
Repetitive tasks can be tedious and reduce arousal (i.e. be boring). Most of the human factors research associated with repetitive tasks has
been carried out in manufacturing environments where workers carry out the same action many times a minute. This does not generally
apply to maintenance engineering.
Repetitive tasks in aircraft maintenance engineering typically refer to tasks that are performed several times during a shift, or a number of
times during a short time period, e.g. in the course of a week. An example of this would be the checking life jackets on an aircraft during
daily inspections.
Some engineers may specialise in a certain aspect of maintenance, such as engines. As a result, they may possibly carry out the same or
similar tasks several times a day.
The main danger with repetitive tasks is that engineers may become so practised at such tasks that they may cease to consult the
maintenance manual, or to use job cards. Thus, if something about a task is changed, the engineer may not be aware of the change.
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Complacency is also a danger, whereby an engineer may skip steps or fail to give due attention to steps in a procedure, especially if it is to
check something which is rarely found to be wrong, damaged or out of tolerance. This applies particularly to visual inspection, which is
covered in greater detail in the next section.
In the Aloha accident report, the NTSB raised the problem of repetitive tasks:
"The concern was expressed about what kinds of characteristics are appropriate to consider when selecting persons to perform an
obviously tedious, repetitive task such as a protracted NDI inspection. Inspectors normally come up through the seniority ranks. If they have
the desire, knowledge and skills, they bid on the position and are selected for the inspector job on that basis. However, to ask a technically
knowledgeable person to perform an obviously tedious and exceedingly boring task, rather than to have him supervise the quality of the
task, may not be an appropriate use of personnel..."
Making assumptions along the lines of 'Oh I've done that job dozens of times!' can occur even if a task has not been undertaken for some
time. It is always advisable to be wary of changes to procedures or parts, remembering that `familiarity breeds contempt'.
Visual Inspection
Visual inspection is one of the primary methods employed during maintenance to ensure the aircraft remains in an airworthy condition.
Visual inspection can be described as the process of using the eye, alone or in conjunction with various aids to examine and evaluate the
condition of systems or components of an aircraft.
Aircraft maintenance engineers may use magnifiers and borescopes to enhance their visual capabilities. The engineer may accompany his
visual inspection by examining the element using his other senses (touch, hearing, smell, etc.). He may also manipulate the element being
inspected to make further judgments about its condition. For instance, he might feel a surface for unevenness, or push against it to look for
any unanticipated movement.
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As highlighted in Chapter 2, ("Vision and the Aircraft Maintenance Engineer"), good eyesight is of prime importance in visual inspection, and
it was noted that the UK CAA have provided some guidance on eyesight in CAAIP Leaflet 15-6 (previously published as Airworthiness Notice
47). Amongst other things, this calls for glasses or contact lenses to be used where prescribed and regular eyesight checks to be made.
Visual inspection is often the principal method used to identify degradation or defect in systems or components of aircraft. Although the
engineer's vision is important, he also has to make judgments about what he sees. To do this, he brings to bear training, experience and
common sense. Thus, reliable visual inspection requires that the engineer first sees the defect and then actually recognises that it is a defect.
Of course, experience comes with practice, but tell tale signs to look for can be passed on by more experienced colleagues.
Information such as technical bulletins is important as they prime the inspector of known and potential defects and he should keep abreast
of these. For example, blue staining on an aircraft fuselage may be considered insignificant at first sight, but information from a Technical
Bulletin of `blue ice' and external toilet leaks may make the engineer suspicious of a more serious problem
There are various steps that an engineer can take to help him carry out a reliable visua inspection. The engineer should:
• ensure that he understands the area, component or system he has been asked to inspect (e.g. as specified on the work card);
• locate the corresponding area, component or system on the aircraft itself;
• make sure the environment is conducive to the visual inspection task (considering factors described in Chapter 5 - "Physical
Environment", such as lighting, access, etc.);
• conduct a ystematic visual search, moving his eyes carefully in a set pattern so that all parts are inspected;
• examine thoroughly any potential degradation or defect that is seen and decide whether it constitutes a problem;
• record any problem that is found and continue the search a few steps prior to where he left off.
Visual inspection requires a considerable amount of concentration. Long spells of continuous inspection can be tedious and result in low
arousal. An engineer's low arousal or lack of motivation can contribute to a failure to spot a potential problem or a failure in recognising a
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defect during visual inspection. The effects are potentially worse when an inspector has a very low expectation of finding a defect, e.g. on a
new aircraft.
Engineers may find it beneficial to take short breaks between discrete visual inspection tasks, such as at a particular system component,
frame, lap joint, etc. This is much better than pausing midway through an inspection.
The Aloha accident highlights what can happen when visual inspection is poor. The accident report included two findings that suggest
visual inspection was one of the main contributors to the accident:
"There are human factors issues associated with visual and non-destructive inspection which can degrade inspector performance to the
extent that theoretically detectable damage is overlooked."
"Aloha Airlines management failed to recognise the human performance factors of inspection and to fully motivate and focus their
inspector force toward the critical nature of lap joint inspection, corrosion control and crack detection... ."
Finally, non-destructive inspection (NDI) includes an element of visual inspection, but usually permits detection of defects below visual
thresholds. Various specialist tools are used for this purpose, such as the use of eddy currents and fluorescent penetrant inspection (FPI).
Complex Systems
All large modern aircraft can be described as complex systems. Within these aircraft, there are a myriad of separate systems, many of which
themselves may be considered complex, e.g. flying controls, landing gear, air conditioning, flight management computers. Table 6.1 gives
an example of the breadth of complexity in aircraft systems.
Any complex system can be thought of as having a wide variety of inputs. The system typically performs complex modifications on these
inputs or the inputs trigger complex responses. There may be a single output, or many distributed outputs from the system.
The purpose, composition and function of a simple system is usually easily understood by an aircraft maintenance engineer. In other words,
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the system is transparent to him. Fault finding and diagnosis should be relatively simple with such systems (although appropriate manuals
etc. should be referred to where necessary).
Type of Aileron Nature of system
Simple aileron Direct connection from control column to control

surface; direct movement
Servo tab aileron Direct connection from control column to servo tab;
aerodynamic movement of surface
Powered aileron Connection from control column to servo valve via

input; hydraulic movement of surface; feed back
mechanism; position and indication.
Powered aileron/roll spoiler As above but with interface to spoiler input system to
provide additional capability.
Fly-by-wire aileron system No connection from control column to surface.

Electrical command signal to electro-hydraulic servo
valve on actuator, signal modified and limited by
intermediate influence of flight control computer.
Table 6.1: Example of increasing complexity - the aileron system
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With a complex system, it should still be clear to an aircraft maintenance engineer what the system's purpose is. However, its composition
and function may be harder to conceptualise - it is opaque to the engineer.
To maintain such complex systems, it is likely that the engineer will need to have carried out some form of system-specific training which
would have furnished him with an understanding of how it works (and how it can fail) and what it is made up of (and how components can
fail). It is important that the engineer understands enough about the overall functioning of a large, complex aircraft, but not so much that
he is overwhelmed by its complexity. Thus, system-specific training must achieve the correct balance between detailed system knowledge
and analytical troubleshooting skills.
With complex systems within aircraft, written procedures and reference material become an even more important source of guidance than
with simple systems. They may describe comprehensively the method of performing maintenance tasks, such as inspections, adjustments
and tests. They may describe the relationship of one system to other systems and often, most importantly, provide cautions or bring
attention to specific areas or components. It is important to follow the procedures to the letter, since deviations from procedures may have
implication on other parts of the system of which the engineer may be unaware.
When working with complex systems, it is important that the aircraft maintenance engineer makes reference to appropriate guidance
material. This typically breaks down the system conceptually or physically, making it easier to understand and work on.
In modern aircraft, it is likely that the expertise to maintain a complex system may be distributed among individual engineers. Thus, avionics
engineers and mechanical engineers may need to work in concert to examine completely a system that has an interface to the pilot in the
cockpit (such as the undercarriage controls and indications).
A single modern aircraft is complex enough, but many engineers are qualified on several types and variants of aircraft. This will usually mean
that he has less opportunity to become familiar with one type, making it even more important that he sticks to the prescribed procedures
and refers to the reference manual wherever necessary. There is a particular vulnerability where tasks are very similar between a number of
different aircraft (e.g. spoiler systems on the A320, B757 and B767), and may be more easily confused if no reference is made to the manual.
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Module 15
Human Factor
15.7 Communication
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LEVEL 1
LEVEL 2
LEVEL 3
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Table of Contents
Chapter 15.7 Communication _____________________________________________________________________ 5

Within and Between Teams ______________________________________________________________________________________ 5
Modes of Communication_______________________________________________________________________________________ 5
Transactional Analysis (TA) ______________________________________________________________________________________ 6
The Freudian Approach________________________________________________________________________________________ 10
Verbal and Written Communication ______________________________________________________________________________ 13
Non-verbal Communication ____________________________________________________________________________________ 14
Communication Within Teams __________________________________________________________________________________ 14
Communication Between Teams ________________________________________________________________________________ 15
Shift Handover _______________________________________________________________________________________________ 16
Communication Problems___ __________________________________________________________________________________ 28
Work Logging and Recording ____________________________________________________________________________________ 29
Keeping Up-to-Date, Currency ___________________________________________________________________________________ 30
Dissemination of Information ___________________________________________________________________________________ 32
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Within and between teams;

9.7 2
Work logging and recording;
Keeping up-to-date currency;
Dissemination of information;
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Chapter 15.7 Communication

Good communication is important in every industry. In aircraft maintenance engineering, it is vital. Communication, or more often a
breakdown in communication, is often cited as a contributor to aviation incidents and accidents. It is for this very reason that it has its own
section in the EASA Part-66 Module 9 for Human Factors. This chapter examines the various aspects of communication that affect the
aircraft maintenance engineer.
Communication is defined in the Penguin Dictionary of Psychology as:
"The transmission of something from one location to another. The `thing' that is transmitted may be a message, a signal, a meaning, etc. In
order to have communication both the transmitter and the receiver must share a common code, so that the meaning or information
contained in the message may be interpreted without error".
Within and Between Teams

As noted in previous chapters, aircraft maintenance engineers often work as teams. Individuals within teams exchange information and
need to receive instructions, guidance, etc. Moreover, one team will have to pass on tasks to another team at shift handover. An engineer
needs a good understanding of the various processes of communication, as without this, it is impossible to appreciate how communication
can go wrong.
Modes of Communication
We are communicating almost constantly, whether consciously or otherwise. An aircraft maintenance engineer might regularly
communicate:
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• information;
• ideas;
• feelings;
• attitudes and beliefs
As the sender of a message, he will typically expect some kind of response from the person he is communicating with (the recipient), which
could range from a simple acknowledgement that his message has been received (and hopefully understood), to a considered and detailed
reply. The response constitutes feedback.
• As can be seen in the above definition, communication can be:

• verbal/spoken - e.g. a single word, a phrase or sentence, a grunt;
• written/textual - e.g. printed words and/or numbers on paper or on a screen, hand written notes;
• non-verbal -
• graphic - e.g. pictures, diagrams, hand drawn sketches, indications on a cockpit instrument;
• symbolic - e.g. `thumbs up', wave of the hand, nod of the head;
• body language - e.g. facial expressions, touch such as a pat on the back, posture.
Transactional Analysis (TA)

Transactional Analysis (or TA as it is often called) is a model of people and relationships that was developed during the 1960s by Dr. Eric
Berne. It is based on two notions: first that we have three parts or'ego-states' to our 'personality. The other assumption is that these
converse with one another in 'transactions' (hence the name). TA is a very common model used in therapy and study of human interactions
and there is a great deal written about it.
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Parent, Adult and Child

We each have internal models of parents, children and also adults, and we play these roles with one another in our relationships. We even
do it with ourselves, in our internal conversations.
Parent
There are two forms of Parent we can play.
• The Nurturing Parent is caring and concerned and often may appear as a mother-figure (though men can play it too). They seek to keep
the Child safe and offer unconditional love, calming them when they are troubled.
• The Controlling (or Critical) Parent, on the other hand, tries to make the Child do as the parent wants them to do, perhaps transferring
values or beliefs or helping the Child to understand and live in society. They may also have negative intent, using the Child as a
whipping-boy or worse.
Adult
The Adult in us is the'grown up' rational person who talks reasonably and assertively, neither trying to control nor reacting. The Adult is
comfortable with themselves and is, for many of us, our'ideal self.
Child
There are three types of Child we can play.
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• The Natural Child is largely un-self-aware and is characterized by the non-speech noises they make (yahoo, etc.). They like playing and are
open and vulnerable.
• The cutely-named Little Professor is the curious and exploring Child who is always trying out new stuff (often much to their Controlling
Parent's annoyance). Together with the Natural Child they make up the Free Child.
• The Adaptive Child reacts to the world around them, either changing themselves to fit in or rebelling against the forces they feel.
Communications (Transactions)
When two people communicate, each exchange is a transaction. Many of our problems come from transactions which are unsuccessful.
Figure 7.1: Transactions between ego states
Parents naturally speak to Children, as this is their role as a parent. They can talk with other Parents and Adults, although the subject still
may be about the children.
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The Nurturing Parent naturally talks to the Natural Child and the Controlling Parent to the Adaptive Child. In fact these parts of our
personality are evoked by the opposite. Thus if I act as an Adaptive Child, I will most likely evoke the Controlling Parent in the other person.
We also play many games between these positions, and there are rituals from greetings to whole conversations (such as the weather) where
we take different positions for different events. These are often 'pre-recorded' as scripts we just play out. They give us a sense of control and
identity and reassure us that all is still well in the world. Other games can be negative and destructive and we play them more out of sense
of habit and addiction than constructive pleasure.
Conflict
Complementary transactions occur when both people are at the same level. Thus Parent talking to Parent, etc. Here, both are often thinking
in the same way and communication is easy. Problems usually occur in Crossed transactions, where the other person is at a different level.
The parent is either nurturing or controlling, and often speaks to the child, who is either adaptive or 'natural' in their response. When both
people talk as a Parent to the other's Child, their wires get crossed and conflict results.
The ideal line of communication is the mature and rational Adult-Adult relationship.
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Ego States
• There are no "good" nor "bad " ego states.

• A healthy personality comprises of all three them
• What is decisive, is to be able to choose the suitable
ego state in a difficult situation.
• Unfortunately, in a such a situation we often tend to
react with one of the other ego states which usually
does'nt solve the problem
• As a rule, communication can go on as long as the
people involved use the same ego states.
• If this is not the case, we will get luck
• A new common basis will have to be found
Figure 7.2: Ego states
The Freudian Approach

Sigmund Freud described several components which have been very influential in understanding personality and communication.
Three levels of awareness

Freud identified three different parts of the mind, based on our level of awareness.
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Conscious mind
The conscious mind is where we are paying attention at the moment. It includes only our current thinking processes and objects of
attention, and hence constitutes a very large part of our current awareness.
Preconscious mind
The preconscious includes those things of which we are aware, but where we are not paying attention. We can choose to pay attention to
these and deliberately bring them into the conscious mind.
We can control our awareness to a certain extent, from focusing in very closely on one conscious act to a wider awareness that seeks to
expand consciousness to include as much of preconscious information as possible.
Subconscious mind
At the subconscious level, the process and content are out of direct reach of the conscious mind. The subconscious thus thinks and acts
independently.
One of Freud's key findings was that much behavior is driven directly from the subconscious mind. This has the alarming consequence that
we are largely unable to control our behavior, and in particular that which we would sometimes prefer to avoid.
More recent research has shown that the subconscious mind is probably even more in charge of our actions than even Freud had realized.
Three components of personality

Clinical psychologist Don Bannister has described Freud's position on the human personality as being:
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"...basically a battlefield. He is a dark-cellar in which a well-bred spinster lady (the superego) and a sex-crazed monkey (the id) are forever
engaged in mortal combat, the struggle being refereed by a rather nervous bank clerk (the ego)."
Thus an individual's feelings, thoughts, and behaviors are the result of the interaction of the id, the superego, and the ego.
This creates conflict, which creates anxiety, which leads to Defense Mechanisms.
Id
The Id contains our primitive drives and operates largely according to the pleasure principle, whereby its two main goals are the seeking of
pleasure and the avoidance of pain.
It has no real perception of reality and seeks to satisfy its needs through what Freud called the primary processes that dominate the
existence of infants, including hunger and self-protection. The energy for the Id's actions come from libido, which is the energy storehouse.
Ego
Unlike the Id, the Ego is aware of reality and hence operates via the reality principle, whereby it recognizes what is real and understands that
behaviors have consequences. This includes the effects of social rules that are necessary in order to live and socialize with other people. It
uses secondary processes (perception, recognition, judgment and memory) that are developed during childhood.
The dilemma of the Ego is that it has to somehow balance the demands of the Id and Super ego with the constraints of reality.
The Ego controls higher mental processes such as reasoning and problem-solving, which it uses to solve the Id-Super ego dilemma,
creatively finding ways to safely satisfy the Id's basic urges within the constraints of the Super ego.
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Super ego
The Super ego contains our values and social morals, which often come from the rules of right and wrong that we learned in childhood from
our parents (this is Freud, remember) and are contained in the conscience.
The Super ego has a model of an ego ideal and which it uses as a prototype against which to compare the ego (and towards which it
encourages the ego to move).
The Super ego is a counterbalance to the Id, and seeks to inhibit the Id's pleasure-seeking demands, particularly those for sex and
aggression.
Verbal and Written Communication

Generally speaking, verbal and written communication are purposeful. For a spoken or written message to be understood, the sender has to
make sure that the receiver:
• is using the same channel of communication;

• ecognises and understands his language;
• is able to make sense of the message's meaning;
The channel of communication is the medium used to convey the message. For spoken communication, this might be face-to-face, or via
the telephone. Written messages might be notes, memos, documents or e-mails.
In the UK it is expected that aircraft maintenance engineers will communicate in English. However, it is also vital that the message coding
used by the sender is appreciated by the recipient so that he can decode the message accurately. This means that engineers must have a
similar knowledge of technical language, jargon and acronyms.
Assuming the channel and language used are compatible, to extract meaning, the engineer has to understand the content of the message.
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This means that it has to be clear and unambiguous. The message must also be appropriate to the context of the workplace and preferably
be compatible with the receiver's expectations. Where any ambiguity exists, the engineer must seek clarification.
Non-verbal Communication
Non-verbal communication can accompany verbal communication, such as a smile during a face-to-face chat. It can also occur
independently, for instance a colleague may pass on his ideas by using a sketch rather than the use of words. It can also be used when
verbal communication is impossible, such as a nod of the head in a noisy environment.
Non-verbal communication is also the predominant manner by which systems communicate their status. For instance, most displays in the
aircraft cockpit present their information graphically.
Body language can be very subtle, but often quite powerful. For example, the message "No" accompanied by a smile will be interpreted
quite differently from the same word said whilst the sender scowls.
Communication within Teams

Individual aircraft maintenance engineers need to communicate:
• before starting a task - to find out what to do; during a task - to discuss work in progress, ask colleagues questions, confirm actions or
• intentions, or to ensure that others are informed of the maintenance state at any particular time;
• at the end of a task - to report its completion and highlight any problems.
Spoken communication makes up a large proportion of day-to-day communication within teams in aircraft maintenance. It relies both on
clear transmission of the message (i.e. not mumbled or obscured by background noise) and the ability of the recipient of the message to
hear it (i.e. active listening followed by accurate interpretation of the message). Good communication within a team helps to maintain
group cohesion.
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Spoken messages provide considerable flexibility and informality to express work-related matters when necessary. The key to such
communication is to use words effectively and obtain feedback to make sure your message has been heard and understood.
It is much less common for individuals within teams to use written communication. They would however be expected to obtain pertinent
written information communicated by service bulletins and work cards and to complete documentation associated with a task.
Communication Between Teams

Communication between teams is critical in aircraft maintenance engineering. It is the means by which one team passes on tasks to another
team. This usually occurs at shift handover. The information conveyed will include:
• tasks that have been completed;

• tasks in progress, their status, any problems encountered, etc.;
• tasks to be carried out;
• general company and technical information.
Communication between teams will involve passing on written reports of tasks from one shift supervisor to another. Ideally, this should be
backed up by spoken details passed between supervisors and, where appropriate, individual engineers. This means that, wherever
necessary, outgoing engineers personally brief their incoming colleagues. The written reports (maintenance cards, procedures, work orders,
logs, etc.) and warning flags / placards provide a record of work completed and work yet to be completed - in other words, they provide
traceability. Furthermore, information communicated at shift handover ensures good continuity.
It is important that handovers are not rushed, so as to minimise omissions.
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Shift Handover
It is universally recognised that at the point of changing shift, the need for effective communication between the out-going and in-coming
personnel in aircraft maintenance is extremely important. The absence of such effective communication has been evident in many accident
reports from various industries, not just aircraft maintenance. Well known examples are the Air Accidents Investigation Branch (AAIB) report
2/95 on the incident to Airbus A320 G-KMAM at Gatwick in 1993 which highlighted an inadequate handover, and the Cullen Report for the
Piper Alpha disaster which concluded that one of the factors which contributed to the disaster was the failure to transmit key information at
shift handover.
Whilst history is littered with past experiences of poor shift handover contributing to accidents and incidents there is little regulatory or
guidance material regarding what constitutes a good handover process relevant to aircraft maintenance. This section attempts to provide
guidelines on such a process and is drawn from work performed by the UK Health and Safety Executive (HSE), US Department of Energy
(DOE) and the Federal Aviation Administration (FAA).
Concepts
Effective shift handover depends on three basic elements:
• The outgoing person's ability to understand and communicate the important elements of the job or task being passed over to the
incoming person.
• The incoming person's ability to understand and assimilate the information being provided by the outgoing person.
• A formalised process for exchanging information between outgoing and incoming people and a place for such exchanges to take place.
The DOE shift handover standards stress two characteristics that must be present for effective shift handover to take place: ownership and
formality. Individuals must assume personal ownership and responsibility for the tasks they perform. They must want to ensure that their
tasks are completed correctly, even when those tasks extend across shifts and are completed by somebody else. The opposite of this mental
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attitude is "It didn't happen on my shift", which essentially absolves the outgoing person from all responsibility for what happens on the
next shift.
Formality relates to the level of recognition given to the shift handover procedures. Formalism exists when the shift handover process is
defined in the Maintenance Organisation Exposition (MOE) and managers and supervisors are committed to ensuring that cross-shift
information is effectively delivered. Demonstrable commitment is important as workers quickly perceive a lack of management
commitment when they fail to provide ample shift overlap time, adequate job aids and dedicated facilities for the handovers to take place.
In such cases the procedures are just seen as the company covering their backsides and paying lip service as they don't consider the matter
important enough to spend effort and money on.
Aids to Effective Communication at Shift Handover

Research has shown that certain processes, practices and skills aid effective communication at shift handover.
• People have to physically transmit information in written, spoken or gestured (nonverbal or body language) form. If only one medium is
used there is a risk of erroneous transmission. The introduction of redundancy, by using more than one way of communicating i.e.
written, verbal or non verbal, greatly reduces this risk.
• For this reason information should be repeated via more than one medium. For example verbal and one other method such as written or
diagrams etc.
• The availability of feedback, to allow testing of comprehension etc. during communication increases the accuracy. The ability for two-
way communication to take place is therefore important at shift handover.
• A part of the shift handover process is to facilitate the formulation of a shared mental model of the maintenance system, aircraft
configuration, tasks in work etc.
Misunderstandings are most likely to occur when people do not have this same mental 'picture' of the state of things. This is particularly
true when deviations from normal working has occurred such as having the aircraft in the flight mode at a point in a maintenance check
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when this is not normally done. Other considerations are when people have returned following a lengthy absence (the state of things
could have changed considerably during this time) and when handovers are carried out between experienced and inexperienced
personnel (experienced people may make assumptions about their knowledge that may not be true of inexperienced people). In all
these cases handovers can be expected to take longer and should be allowed for.
• Written communication is helped by the design of the documents, such as the handover log, which consider the information needs of
those people who are expected to use it. By involving the people who conduct shift handovers and asking them what key information
should be included and in what format it should be helps accurate communication and their 'buy-in' contributes to its use and
acceptance of the process.
Barriers To Effective Communication At Shift Handover

Research has also shown that certain practices, attitudes and human limitations act as barriers to effective communication at shift handover.
• Key information can be lost if the message also contains irrelevant, unwanted information. We also only have a limited capability to
absorb and process what is being communicated to us. In these circumstances it requires time and effort to interpret what is being said
and extract the important information. It is important that only key information is presented, and irrelevant information excluded.
• The language we use in everyday life is inherently ambiguous. Effort therefore needs to be expended to reduce ambiguity by:
I. carefully specifying the information to be communicated e.g. by specifying the actual component, tooling or document.
II. facilitating two-way communication which permits clarification of any ambiguity (e.g. do you mean the inboard or out board wing
flap?)
• Misunderstandings are a natural and inevitable feature of human communication and effort has to be expended to identify, minimise
and repair misunderstandings as they occur. Communication therefore has to be two-way, with both participants taking responsibility
for achieving full and accurate communication.
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• People and organisations frequently refer to communication as unproblematic, implying that successful communication is easy and
requires little effort. This leads to over-confidence and complacency becoming common place. Organisations need to expend effort to
address complacency by:
I. emphasising the potential for miscommunication and its possible consequences
II. developing the communication skills of people who are involved in shift handovers
Guidelines
In considering the theories of communication and the research that has been performed the following guidelines apply for operations that
are manned on multiple shifts to allow for continuous 24 hour maintenance. When shifts are adopted which do not cover a full 24 hour
period, for example early and late shifts with no night shift, the handover where face to face communication is not possible posses an
inherent risk. In such cases organisations should be aware that the potential for ineffective and inefficient communication is much higher.
Shift Handover Meetings

It could be said that the primary objective of the shift handover is to ensure accurate, reliable communication of task-relevant information
across the shifts. However this does not recognise the users needs for other information which may also be required to enable a complete
mental model to be formed which will allow safe and efficient continuation of the maintenance process.
Examples of such information could be manning levels, Authorisation coverage, staff sickness, people working extended hours (overtime),
personnel issues etc.
An important aspect related to individual shift handover is when it actually begins. The common perception is that shift handover occurs
only at the transition between the shifts. However, DOE shift handover standards make the point that shift handover should really begin as
soon as the shift starts. Throughout their shift people should be thinking about, and recording, what information should be included in their
handover to the next person or shift.
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The following lists the sort of topics that should be covered in the managers'/supervisors' handover meeting.
• Status of the Facility

 Workstands/Docking
 Visitors
 Construction work
 Health & Safety issues
• Work Status
 Aircraft being worked
 Scheduled aircraft incoming/departing
 Deadlines
 Aircraft status against planned status
• Manning Levels and Status

 Authorisation coverage
 Certifying staff
 Non certifying staff
 Numbers and names of personnel working overtime
 Numbers and names of contract staff
 Sickness
 Injuries
 Training
 Other personnel issues
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• Problems
 Outstandinglin work/status
 Solved
• Information
 AD's, SB's, etc.
 Company technical notices
 Company policy notices
The shift handover process should comprise at least two meetings. It starts with a meeting between the incoming and outgoing shift
managers/supervisors. This meeting should be conducted in an environment free from time pressure and distractions.
Shift managers/supervisors need to discuss and up-date themselves on tactical and managerial matters affecting the continued and timely
operation of the maintenance process. The purpose of this meeting is therefore to acquaint themselves with the general state of the facility
and the overall status of the work for which they are responsible. Outgoing managers/supervisors should summarise any significant
problems they have encountered during their shift, especially any problems for which solutions have not been developed or are still in
progress.
Walkthroughs
After the meeting between shift managers, and assignment of tasks, there is a need for
Supervisors and certifying staff to meet and exchange detailed information related to individual jobs and tasks. The most effective way to
communicate this information is for the affected incoming and outgoing personnel to go over the task issues while examining the actual
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jobs on the hangar floor or at the workplace. A mutual inspection and discussion of this nature is called a "Walkthrough".
The following lists the sort of topics that should be covered in the supervisors/certifying staffs walkthrough meeting.
• Jobs/tasks in progress
• Workcards being used
• Last step(s) completed
• Problems encountered
• Outstanding/in work/status
• Solved
• Unusual occurrences
• Unusual defects
• Resources required/available
• Location of removed parts, tooling etc.
• Parts and tools ordered and when expected
• Parts shortages
• Proposed next steps
• Communication with Planners, Tech Services, workshops
• Communication with managers etc.
• task handover should be read in conjunction with the section on Non-Routine Tasks
• and Process Sheets.
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Task Handover
The handing over of tasks from one person to another does not always occur at the point of changing shifts. Tasks are frequently required to
be handed over during a shift. This Section deals with two common situations. When a task is being handed over to someone who is present
at the time, and when a job is being stopped part
Handing Over A Task Directly To Another Person

When the task is being directly handed over to someone who is present at the time the process and concepts are the same as for a
Walkthrough described in the Shift Handover Section of this handbook. That is to say it is done face to face using verbal and written
communication. In these cases the written element is normally by ensuring that the task cards or non routine process sheets are accurately
completed clearly identifying at what stage in the task the job has reached. Any deviations from normal working practices or procedures
must be clearly highlighted during the Walkthrough. An example of this would be if in changing a valve, a clamp, not required to be
removed by the maintenance manual, is disturbed to aid removal and installation. Many mishaps have occurred in these circumstances as
the person taking over the job assumes that the task was being performed as per the maintenance manual, drawings, procedures etc. It is a
CAA requirement that this deviation is recorded by the outgoing person, and it is essential from a communication effectiveness point of
view that this is reinforced during the Walkthrough.
Handing Over a Task for Somebody to Complete at a Later Stage

It is not uncommon that a job is left incomplete during a shift, say in the case of someone being called away to attend to a more urgent task
on another aircraft. In these cases it is often not known who will eventually pick up the job of completing and certifying the release to
service. These situations present a far greater risk and challenge to effectively communicate the stage of task accomplishment and what is
required to complete the job. Face to face communication is not possible therefore total reliance has to be placed on written
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communication, a single medium with no redundancy and opportunity to question and test a true understanding by the person expected
to finish the job.
Scheduled Tasks
The paperwork normally associated with scheduled tasks are the Task Cards that are issued at the beginning of the maintenance input.
These may have been written by the manufacturer, maintenance organisation or the operator of the aircraft. In all cases the card and
associated task breakdown written on it, assume that the same person will start and finish the job. It was not designed to be used as a
handover document.
That is not to say that it could not be the handover, or that it could not form part of one. It really depends on the circumstances.
Task Cards break down jobs in to discrete stages, and ideally jobs should always be stopped at one of these stages so that the last sign off
on the card is the exact stage of the job reached. In this case the card is the handover. However, a job is sometimes stopped at a point which
is between the stages identified on the card, the stage sequencing has not been followed, or a deviation from normal working has occurred
(such as in the example of disturbing the additional clamp to aid removal and installation of a valve). When this occurs additional written
information must be used to clearly identify the point of exit from the task and what is required to complete the job and restore
serviceability. Non-routine cards or sheets should then be used to record and transmit the relevant information necessary. Figure 7.3 is an
example of a Task Card.
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GO FAST AIRWAYS
A/C type : B 737 MP ref : MS/B737/668
Aircraft Reg : G-OFST
Flight Control
Additional work card raised : Yes or no
27-00-56 Flap synchronising system Mechanic Inspector
a) check the cable tensions are correct (mm 27-50- B Bloggs 7 stamp
02)
b) With the flaps selected up, disconnect the B Bloggs 7 stamp

operating link from one transmitter gearbox only.
c) Pressurise the hydraulic system and select flpas B Bloggs 7 stamp

down
d) Make sure that the flaps start to move and then B Bloggs 7 stamp
the system cuts out
e) Depressurise the hydraulic system and connect

the transmitter operating link
f) Pressurise the hydraulic system and make sure

the flaps operate correctly
Figure 7.3: Typical Task Card
In the case above, the job has been accomplished fully up to stage d), but the hydraulics have been depressurised therefore only part of
stage e) has been accomplished. A supplementary card, worksheet or non routine sheet (the terminology will vary from one company to
another) must be raised to communicate that the Task Card does not reflect the true state of the aircraft. In this case the wording could be:
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Defect Action Taken Mechanic Inspection
Reference card 27-00-56. Card

completely fully up to stage d)
hydraulic system depressurised but
the transmitter operating link is not
reconnected prir to performing
stage f)
Figure 7.4: Worksheet
The combination of both documents provides sufficient information for the person picking up the job to know what stage the work is up to
and what is required to complete it.
Non-scheduled Tasks
Complex or lengthy non-scheduled tasks should always be broken down in to a number of discrete steps using stage or process sheets (the
terminology will vary from one company to another). Many incidents have occurred when people have started a straight forward job but
had to exit the task part way through without anybody to handover to. These situations by their nature are unplanned and are normally
associated with time pressure or emergency situations.
In spite of this it is vital that time is taken by the person leaving the job to comprehensively record what activities have taken place and what
is required to complete the job. This would be recorded on stage sheets and should emphasis any deviations from the normal or expected
way of working. Management and supervisors have a responsibility to ensure that adequate time is given to maintenance staff to record
their work if they require tasks to be suspended for any reason.
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Non-routine Task and Process Sheets

Task Cards for scheduled maintenance are an everyday document for aircraft engineers. They not only identify the job to be performed, but
they also break down the task in to stages to allow for individuals to sign or certify the various stages The reasons for breaking down the job
in to discrete tasks is often wrongly seen as record keeping, and of being able to identify who did what part of a job so that if there is an
incident the employer or regulator can take action against the person. Whilst it does confer accountability for the work this could be
achieved by other means. The primary purpose of a job card is to identify the task to be performed but then act as a job aid to help the
engineer plan, complete the task fully, and in the correct sequence.
Maintenance Programmes today are frequently based on the principles of Condition Monitoring. Most components on the aircraft therefore
have no specific period defined as to when they will be removed for repair, overhaul etc. The time to remove them is determined by a
reliability programme or scheduled inspections which assess their serviceability. Operator's Task Cards are normally derived, or copied from
those provided by the aircraft manufacturer. Unfortunately these are usually only the required tasks and do not include those tasks which
have to be performed as a consequence. An example of this is an engine change. The manufacturer will have written cards describing the
breakdown of various inspections such as borescope, oil sampling and magnetic chip detectors but not a card on changing the engine. This
had led to the situation whereby many jobs, often long and complex, have no pre-printed task cards or process sheets which break down
the job in to stages and so help the engineers.
Shift and task handover systems: A review across industries

Effective shift handovers should be:
• conducted face-to-face
• two-way, with both participants taking responsibility for accurate communication
• via verbal and written means
• based on analysis of information needs of incoming staff
• given as much time as is necessary for accurate communication.
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Communication Problems
There are two main ways in which communication can cause problems. These are lack of communication and poor communication. The
former is characterised by the engineer who forgets to pass on pertinent information to a colleague, or when a written message is mislaid.
The latter is typified by the engineer who does not make it clear what he needs to know and consequently receives inappropriate
information, or a written report in barely legible handwriting. Both problems can lead to subsequent human error.
Communication also goes wrong when one of the parties involved makes some kind of assumption. The sender of a message may assume
that the receiver understands the terms he has used. The receiver of a message may assume that the message means one thing when in fact
he has misinterpreted it. Assumptions may be based on context and expectations, which have already been mentioned in this chapter.
Problems with assumptions can be minimised if messages are unambiguous and proper feedback is given.
Basic rules of thumb to help aircraft maintenance engineers minimise poor communication are:
• think about what you want to say before speaking or writing;
• speak or write clearly;
• listen or read carefully;
• seek clarification wherever necessary.
Major risk areas for poor communication
• Work that continues over a shift change.

• When safety systems have been over-ridden.
• During deviations from normal working.
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• Following a lengthy absence from work.

• When handovers are between experienced and inexperienced staff.
Work Logging and Recording

This is one of the most critical aspects of communication within aviation maintenance, since inadequate logging or recording of work has
been cited as a contributor to several incidents.
In the B737 double engine oil loss incident in February 1995, for instance, one of the AAIB conclusions was:
"...the Line Engineer... had not made a written statement or annotation on a work stage sheet to show where he had got to in the
inspections".
The reason for this was because he had intended completing the job himself and, therefore, did not consider that detailed work logging was
necessary. However, this contributed towards the incident in that:
"the Night Base Maintenance Controller accepted the tasks on a verbal handover [and] he did not fully appreciate what had been done and
what remained to be done".
Even if engineers think that they are going to complete a job, it is always necessary to keep the record of work up-to-date just in case the job
has to be handed over. This may not necessarily be as a result of a shift change, but might be due to a rest break, illness, the need to move
to another (possibly more urgent) task, etc.
The exact manner in which work should be logged tends to be prescribed by company procedures. It is usually recorded in written form.
However, there is no logical reason why symbols and pictures should not also be used to record work or problems, especially when used for
handovers. There are many cases where it may be clearer to draw a diagram rather than to try to explain something in words (i.e. 'a picture is
worth a thousand words').
The key aspects of work logging and recording are captured in the CAA's CAAIPs Leaflet 15-2 (previously published as Airworthiness Notice
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No. 3). This states:
"In relation to work carried out on an aircraft, it is the duty of all persons to whom this Notice applies to ensure that an adequate record of
the work carried out is maintained. This is particularly important where such work carries on beyond a working period or shift, or is handed
over from one person to another. The work accomplished, particularly if only disassembly or disturbance of components or aircraft systems,
should be recorded as the work progresses or prior to undertaking a disassociated task. In any event, records should be completed no later
than the end of the work period or shift of the individual undertaking the work. Such records should include òpen' entries to reflect the
remaining actions necessary to restore the aircraft to a serviceable condition prior to release. In the case of complex tasks which are
undertaken frequently, consideration should be given to the use of pre-planned stage sheets to assist in the control, management and
recording of these tasks. Where such sheets are used, care must be taken to ensure that they accurately reflect the current requirements and
recommendations of the manufacturer and that all key stages, inspections, or replacements are recorded."
New technology is likely to help engineers to record work more easily and effectively in the future. ICAO Digest No.12: "Human Factors in
Aircraft Maintenance and Inspection", refers to hand-held computers and an Integrated Maintenance Information System (IMIS). It points
out that these devices are likely to encourage the prompt and accurate recording of maintenance tasks.
Modern technology is also being implemented to improve the transfer of information in maintenance manuals to worksheets and
workcards. These help to communicate pertinent information to engineers in an accessible and useable format. A contributory factor in the
B737 double engine oil loss incident was that the information which should have prompted the engineer to carry out a post-inspection idle
engine run to check for leaks was in the maintenance manual but not carried over to the task cards.
Keeping Up-to-Date, Currency

As discussed in Chapter 6, aircraft maintenance engineers undertake an approved course to obtain the knowledge and basic skills to enter
the profession. This training is followed by instruction in more specific areas, such as maintenance of individual aircraft and specific systems
(as discussed in Chapter 6, on "Complex Systems"). However, the aviation industry is dynamic: operators change their aircraft, new aircraft
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types and variants are introduced, new aircraft maintenance practices are introduced. As a consequence, the engineer needs to keep his
knowledge and skills up-to-date.
To maintain his currency, he must keep abreast of pertinent information relating to:
• new aircraft types or variants;

• new technologies and new aircraft systems;
• new tools and maintenance practices;
• modifications to current aircraft and systems he works on;
• revised maintenance procedures and practices.
Engineers are likely to keep up-to-date by:
• undertaking update courses;

• reading briefing material, memos and bulletins;
• studying maintenance manual amendments
Responsibility for maintaining currency lies with both the individual engineer and the maintenance organisation for which he works. The
engineer should make it his business to keep up-to-date with changes in his profession (remembering that making assumptions can be
dangerous). The organisation should provide the appropriate training and allow their staff time to undertake the training before working on
a new aircraft type or variant. It should also make written information easily accessible to engineers and encourage them to read it. It is, of
course, vital that those producing the information make it easy for engineers to understand (i.e. avoid ambiguity).
Anecdotal evidence describes a case where a certain maintenance procedure was "proscribed" (i.e. prohibited) in a service bulletin. The
technician reading this concluded that the procedure was "prescribed" (i.e. defined, laid down) and proceeded to perform the forbidden
action.
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From a human factors point of view, small changes to the technology or procedures concerning existing aircraft carry potentially the
greatest risk. These do not usually warrant formal training and may merely be minor changes to the maintenance manual. Although there
should be mechanisms in place to record all such changes, this presumes that the engineer will consult the updates. It is part of the
engineer's individual responsibility to maintain his currency.
Dissemination of Information
As highlighted in the previous section, both the individual engineer and the organisation in which he works have a shared responsibility to
keep abreast of new information. Good dissemination of information within an organisation forms part of its safety culture (Chapter 3).
Typically, the maintenance organisation will be the sender and the individual engineer will be the recipient.
It was noted in Chapter 6, "Planning", that an aircraft maintenance engineer or team of engineers need to plan the way work will be
performed. Part of this process should be checking that all information relating to the task has been gathered and understood. This includes
checking to see if there is any information highlighting a change associated with the task (e.g. the way something should be done, the tools
to be used, the components or parts involved).
It is imperative that engineers working remotely from the engineering base (e.g. on the line) familiarise themselves with new information
(on notice boards, in maintenance manuals, etc.) on a regular basis.
There should normally be someone within the maintenance organisation with the responsibility for disseminating information. Supervisors
can play an important role by ensuring that the engineers within their team have seen and understood any communicated information.
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Poor dissemination of information was judged to have been a contributory factor to the Eastern Airlines accident in 1983. The NTSB
accident report stated:
"On May 17, 1983, Eastern Air Lines issued a revised work card 7204 [master chip detector installation procedures, including the fitment of
O-ring seals]. .. theaterial was posted and all mechanics were expected to comply with the guidance. However, there was no
supervisory follow-up to insure that mechanics and foremen were incorporating the training material into the work requirements... Use of
binders and bulletin boards is not an effective means of controlling the dissemination of important work procedures, especially when there
is no accountability system in place to enable supervisors to ensure that all mechanics had seen the applicable training and procedural
information."
Communication is an active process whereby both the organisation and engineer have to play their part.
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Module 15
Human Factor
15.8 Human Error
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LEVEL 1
LEVEL 2
LEVEL 3
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Table of Contents
Chapter 15.8 Human Error ________________________________________________________________________________________ 5

Error Models and Theories ________________________________________________________________________________________ 6
Design Vs Operator - Induced Errors ____________________________________________________________________________ 6
Variable Vs Constant Errors ___________________________________________________________________________________ 7
Reversible Vs Irreversible Errors ________________________________________________________________________________ 8
Slips, Lapses and Mistakes ____________________________________________________________________________________ 8
Skill-, Rule- and Knowledge-Based Behaviours and Associated Errors _________________________________________________ 10
The 'Swiss Cheese Model'_____________________________________________________________________________________ 16
Failures ___________________________________________________________________________________________________ 17
Three Common Mistakes in Aircraft Maintenance _________________________________________________________________ 25
Summarising Error Types _____________________________________________________________________________________ 29
Types of Error in Maintenance Tasks ________________________________________________________________________________ 29
Violation in Aircraft Maintenance ______________________________________________________________________________ 31
Errors Associated With Visual Inspection ____________________________________________________________________________ 39
Implications of Errors (i.e. Accidents) ___________________________________________________________________________ 41
Avoiding and Managing Errors ____________________________________________________________________________________ 43
Error Management __________________________________________________________________________________________ 46
Maintenance Error Decision Aid (MEDA) _________________________________________________________________________ 55
Safety and Risk _____________________________________________________________________________________________ 59
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Error models and theories; 9.8 2
Types of error in maintenance tasks;
Implications of errors (i.e. accidents);
Avoiding and managing errors;
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Chapter 15.8 Human Error
It has long been acknowledged that human performance is at times imperfect. Nearly two thousand years ago, the Roman philosopher
Cicero cautioned "It is the nature of man to err". It is an unequivocal fact that whenever men and women are involved in an activity, human
error will occur at some point.
In his book "Human Error", Professor James Reason defines error as follows:
"Error will be taken as a generic term to encompass all those occasions in which a planned sequence of mental or physical activities fails to
achieve its intended outcome, and when these failures cannot be attributed to the intervention of some chance agency".
It is clear that aircraft maintenance engineering depends on the competence of engineers. Many of the examples presented in Chapter 1
"Incidents Attributable to Human Factors / Human Error" and throughout the rest of this document highlight errors that aircraft
maintenance engineers have made which have contributed to aircraft incidents or accidents.
In the past, aircraft components and systems were relatively unreliable. Modern aircraft by comparison are designed and manufactured to
be highly reliable. As a consequence, it is more common nowadays to hear that an aviation incident or accident has been caused by "human
error".
The following quotation illustrates how aircraft maintenance engineers play a key role in keeping modern aircraft reliable:
"Because civil aircraft are designed to fly safely for unlimited time provided defects are detected and repaired, safety becomes a matter of
detection and repair rather than one of aircraft structure failure. In an ideal system, all defects which could affect flight safety will have been
predicted in advance, located positively before they become dangerous, and eliminated by effective repair. In one sense, then, we have
changed the safety system from one of physical defects in aircraft to one of errors in complex human-centred systems"
The rest of this chapter examines some of the various ways in which human error has been conceptualised. It then considers the likely types
of error that occur during aircraft maintenance and the implications if these errors are not spotted and corrected. Finally, means of
managing human error in aircraft maintenance are discussed.
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Error Models and Theories

To appreciate the types of error that it is possible to make, researchers have looked at human error in a number of ways and proposed
various models and theories. These attempt to capture the nature of the error and its characteristics. To illustrate this, the following models
and theories will be briefly highlighted:
• design- versus operator-induced errors;
• variable versus constant errors;
• reversible versus irreversible errors;
• slips, lapses and mistakes;
• skill-, rule- and knowledge-based behaviours and associated errors;
• the `Swiss Cheese Model'.
• failures
Design Vs Operator - Induced Errors

In aviation, emphasis is often placed upon the error(s) of the front line operators, who may include flight crew, air traffic controllers and
aircraft maintenance engineers.
However, errors may have been made before an aircraft ever leaves the ground by aircraft designers. This may mean that, even if an aircraft
is maintained and flown as it is designed to be, a flaw in its original design may lead to operational safety being compromised. Alternatively,
flawed procedures put in place by airline, maintenance organisation or air traffic control management may also lead to operational
problems.
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It is common to find when investigating an incident or accident that more than one error has been made and often by more than one
person. It may be that, only when a certain combination of errors arises and error `defences' breached (see the 'Swiss Cheese Model') will
safety be compromised.
Variable Vs Constant Errors

In his book "Human Error", Professor Reason discusses two types of human error:
Variable and constant. It can be seen in Figure 8.1 that variable errors in (A) are random in nature, whereas the constant errors in (B) follow
some kind of consistent, systematic (yet erroneous) pattern. The implication is that constant errors may be predicted and therefore
controlled, whereas variable errors cannot be predicted and are much harder to deal with. If we know enough about the nature of the task,
the environment it is performed in, the mechanisms governing performance, and the nature of the individual, we have a greater chance of
predicting an error.
Figure 8.1: Variable versus Constant Errors
Target patterns of 4 shots fired by two riflemen. Rifleman A's pattern exhibits no constant error, but large variable errors; rifleman B's pattern
exhibit's a large constant error but small variable errors. The latter would, potentially, be easier to predict and to correct (e.g. by correctly
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aligning the rifle sight). Chapanis, 1951
However, it is rare to have enough information to permit accurate predictions; we can generally only predict along the lines of "re-assembly
tasks are more likely to incur errors than dismantling tasks", or "an engineer is more likely to make an error at 3 a.m., after having worked 12
hours, than at 10 a.m. after having worked only 2 hours". It is possible to refine these predictions with more information, but there will
always be random errors or elements which cannot be predicted.
Reversible Vs Irreversible Errors

Another way of categorising errors is to determine whether they are reversible or irreversible. The former can be recovered from, whereas
the latter typically cannot be. For example, if a pilot miscalculates the fuel he should carry, he may have to divert to a closer airfield, but if he
accidentally dumps his fuel, he may not have many options open to him.
A well designed system or procedure should mean that errors made by aircraft maintenance engineers are reversible. Thus, if an engineer
installs a part incorrectly, it should be spotted and corrected before the aircraft is released back to service by supervisory procedures in
place.
Slips, Lapses and Mistakes

Reason highlights the notion of ìntention' when considering the nature of error, asking the questions:
• Were the actions directed by some prior intention?
• Did the actions proceed as planned?
• Did they achieve their desired end?
Reason then suggests an error classification based upon the answers to these questions as shown in Figure 8.2.
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Figure 8.2 : Error types based on intention. Source: Reason, 1990
The most well-known of these are slips, lapses and mistakes.
Slips can be thought of as actions not carried out as intended or planned, e.g. `transposing digits when copying out numbers, or
misordering steps in a procedure.
Lapses are missed actions and omissions, i.e. when somebody has failed to do something due to lapses of memory and/or attention or
because they have forgotten something, e.g. forgetting to replace an engine cowling.
Mistakes are a specific type of error brought about by a faulty plan/intention, i.e. somebody did something believing it to be correct when it
was, in fact, wrong, e.g. an error of judgment such as mis-selection of bolts when fitting an aircraft windscreen.
Slips typically occur at the task execution stage, lapses at the storage (memory) stage and mistakes at the planning stage.
Violations sometimes appear to be human errors, but they differ from slips, lapses and mistakes because they are deliberate ìllegal' actions,
i.e. somebody did something knowing it to be against the rules (e.g. deliberately failing to follow proper procedures). Aircraft maintenance
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engineers may consider that a violation is well intentioned, i.e. `cutting corners' to get a job done on time. However, procedures must be
followed appropriately to help safeguard safety.
Skill-, Rule- and Knowledge-Based Behaviours and Associated Errors

The behaviour of aircraft maintenance engineers can be broken down into three distinct categories: skill-based, rule-based and knowledge-
based behaviour.
Skill-based behaviours are those that rely on stored routines or motor programmes that have been learned with practice and may be
executed without conscious thought.
Rule-based behaviours are those for which a routine or procedure has been learned. The components of a rule-based behaviour may
comprise a set of discrete skills.
Knowledge-based behaviours are those for which no procedure has been established. These require the [aircraft maintenance engineer] to
evaluate information, and then use his knowledge and experience to formulate a plan for dealing with the situation.
Each of these behaviour types have specific errors associated with them.
Examples of skill-based errors are action slips, environmental capture and reversion.
Action slips as the name implies are the same as slips, i.e. an action not carried out as intended. The example given in Figure 8.3 may consist
of an engineer realising he needs a certain wrench to complete a job but, because he is distracted by a colleague, picks up another set to
the wrong torque and fails to notice that he has tightened the bolts incorrectly.
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Figure 8.3: Example of an Action Slip
Environmental capture may occur when an engineer carries out a certain task very frequently in a certain location. Thus, an engineer used to
carrying out a certain maintenance adjustment on an Airbus A300, may inadvertently carry out this adjustment on the next A300 he works
on, even if it is not required (and he has not made a conscious decision to operate the skill).
Reversion can occur once a certain pattern of behaviour has been established, primarily because it can be very difficult to abandon or
unlearn it when it is no longer appropriate. Thus, an engineer may accidentally carry out a procedure that he has used for years, even
though it has been recently revised. This is more likely to happen when people are not concentrating or when they are in a stressful
situation.
Rule-based behaviour is generally fairly robust and this is why the use of procedures and rules is emphasised in aircraft maintenance.
However, errors here are related to the use of the wrong rule or procedure. For example, an engineer may misdiagnose a fault and thus
apply the wrong procedure, thus not clearing the fault. Errors here are also sometimes due to faulty recall of procedures. For instance, not
remembering the correct sequence when performing a procedure.
Errors at the knowledge-based performance level are related to incomplete or incorrect knowledge or interpreting the situation incorrectly.
An example of this might be when an engineer attempts an unfamiliar repair task and assumes he can `work it out'. Once he has set out in
this way, he is likely to take more notice of things that suggest he is succeeding in his repair, while ignoring evidence to the contrary (known
as confirmation bias).
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Three basic error types
Figure 8.4: The three categories of error
Figure 8.4 shows the three categories of error linked to three human performance levels: the skill-based (SB), rule based (RB) and
knowledge-based (KB) levels.
The SB level involves the largely automatic control of habitual task in routine surroundings.
The RB level switches in when we encounter some trained-for or familiar problem.
The KB level only occurs when we are faced with an entirely novel situation.
Errors can thus be sub-divided into three distinct categories:
• Skill based (SB) slips and lapses.
• Rule based (RB) mistakes.
• knowledge-based (KB) mistakes.
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The next set of diagrams deal with skill-based slips and lapses. Thereafter we will focus on mistakes, most particularly on the three varieties
of rule-based mistake.
Rule based (RB) mistakes arise from: -
• Misapplication of good rules.
• Application of bad rules.
• Non-application of good rules (violations).
Knowledge-based (KB) mistakes are more varied. They arise when people have to improvise in a novel situation. However, as the next slide
shows, KB mistakes are fairly rare occurrence in aircraft engineering, so we will not consider them in the further( hence the cross beside this
category in the slide).
Maintenance error types (classified by performance level)
Figure 8.5: Variable versus Constant Errors
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Figure 8.5 shows an analysis of the performance levels involved in the Hobbs critical incident study. It shows that Knowledge Based errors
occur very rarely in aircraft maintenance activities. Hence, we will not discuss them any further. We will focus only on the Skill Based slips
and lapses and the Rule Based mistakes.
Slips & lapses: Three main types
• Recognition failures
• Memory failures
• Attentional failures
This sets out the major sub-divisions of slips and lapses. Each one is linked to a different mental function: perception (i.e., taking in and
interpreting relevant sensory inputs), remembering to carry out the actions (i.e., prospective memory), deploying the limited attentional
resource over the various actions in an appropriate manner (as we shall see, various misdirections of attention are a major factor in the
production of slips and lapses), and selecting the pre-programmed actions that are to be carried out (in skilled action, this selection process
is largely automatic and outside of consciousness).
Recognition failures
• The misidentification of objects, messages, signals, etc.
• The non-detection of problem states (inspection or monitoring failures).
Recognition failures break down into two main groups: misidentifications and non-detections (false-negatives).
A third class is wrongly detecting defects that were not actually present (false-positives). These are logically possible and do actually occur,
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but they are unlikely to carry a major safety penalty. Maintenance systems are designed to be fairly tolerant of false-positives (better to be
safe than sorry), but they are highly intolerant of false-negatives.
Causes of misidentifications
• Similarity (in appearance, location, function, etc.) between right and wrong objects.
• Indistinctness: poor illumination and signal-to-noise ratios.
• Expectation: we tend to see what we want to see (confirmation bias).
• Habit: in well-practised and familiar tasks, perceptions become less precise.
Misidentifications involve putting the wrong mental interpretation upon the evidence gathered by our senses. These errors have been the
cause of many serious accidents. They include train drivers who misread a signal aspect and pilots who misinterpret the height information
provided by their instruments.
A major factor in misidentifications is the similarity (in appearance, location, function, etc.) between the right and wrong objects. This can be
made worse by poor signal-to-noise ratios (i.e., poor illumination, static, inaccessibility and the like).
Misidentifications are also strongly influenced by expectation: we tend to see what we expect to see. What we perceive is derived from two
types of information: the evidence of our senses and knowledge structures stored in long-term memory. The weaker or more ambiguous
the sensory evidence, the more likely it is that our perceptions will be dominated by expectation, or the stored knowledge structures. This is
termed `confirmation bias' or `mindset' Once we have formed an impression or hunch about what is going on, we tend to select information
that will confirm this hunch, even when there is contradictory evidence available.
Strong habits are also like expectations: we sometimes accept a crude match to what is expected, even when it is wrong.
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The `Swiss Cheese Model'

In his research, Reason has highlighted the concept of `defences' against human error within an organisation, and has coined the notion of
'defences in depth'. Examples of defences are duplicate inspections, pilot pre-flight functional checks, etc., which help prevent to 'trap'
human errors, reducing the likelihood of negative consequences. It is when these defences are weakened and breached that human errors
can result in incidents or accidents. These defences have been portrayed diagrammatically, as several slices of Swiss cheese (and hence the
model has become known as Professor Reason's "Swiss cheese" model) (see Figure 8.6).
Figure 8.6: Reason's Swiss Cheese Model
Some failures are latent, meaning that they have been made at some point in the past and lay dormant. This may be introduced at the time
an aircraft was designed or may be associated with a management decision. Errors made by front line personnel, such as aircraft
maintenance engineers, are 'active' failures. The more holes in a system's defences, the more likely it is that errors result in incidents or
accidents, but it is only in certain circumstances, when all holes `line up', that these occur. Usually, if an error has breached the engineering
defences, it reaches the flight operations defences (e.g. in flight warning) and is detected and handled at this stage.
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However, occasionally in aviation, an error can breach all the defences (e.g. a pilot ignores an in flight warning, believing it to be a false
alarm) and a catastrophic situation ensues.
Failures
Memory failures
• Memory can fail at one or more of three information-processing stages:-
• input: Insufficient attention is given to the to-be-remembered material. Lost from short-term memory.
• storage: Material decays or suffers interference in long-term memory.
• retrieval: Known material not recalled at the appropriate time.
Here we move on to the second major heading in the overall 'wrong actions' category: memory failures.
There are three basic memory processes:
• Encoding-taking information into memory.
• Storage-keeping it there
• Retrieval-calling information to mind when it is needed.
Failures in each of these processes can cause forgetting. Input failures
• Forgetting instructions, names, etc. Essentially a failure of attention at the time of presentation.
• Forgetting past actions, where tools were left, etc. During routine actions, mind is often on other things. Actions not attended to.
o place-losing (forget where you are in a sequence.)
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o time-gap experience ('wake up' to find past actions a blank.)
What are we most likely to forget on being introduced to someone? The name. Why? Because the name is part of a flood of new information
about this person and often fails to get taken in unless we make a special effort to focus on the name (then we often cannot remember what
they looked like or what they did for a living). This tells us that giving just the right amount of attention to something is an important
precondition for being able to remember it later.
The second kind of input failure is the forgetting of previous actions. Again, this is due to a failure of attention. When we are doing very
familiar and routine tasks, our minds are almost always on something other than the job in hand. That's a necessary feature for the task to
be done smoothly. The result is that we "forget' where we put our tools down, or find ourselves walking around looking for something that
we are still carrying.
Some other consequences of this kind of forgetting are:
a) Losing our place in a series of actions: we 'wake up' and don't know immediately where we are in the sequence.
b) The time-gap experience: we can't remember things about where we've been walking or driving in the last few minutes, or what we've
been doing exactly. For example, we can be in the shower and can't remember whether or not we've put shampoo on our hair. The
evidence (if there was any) has been washed away, and we have been thinking about something else. In short, we've not been attending
to the routine details.
Storage failures
• Forgetting the plan-a vague feeling that you should be doing something, but can't recall what.
• What-am-l-doing-here?' experience-find yourself in front of open drawer or cupboard, but can't recall what you came to get.
• Forgetting items in a plan-necessary steps omitted.
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An intention to do something is rarely put into action immediately. Usually, it has to be held in memory until the right time and place for its
execution. Memory for intentions is called prospective memory, and it is particularly prone to forgetting or sidetracking, so that the action is
not carried out as intended. It is, of course, possible to forget an intention completely, so that no trace of it remains. More usually, the
forgetting occurs in degrees.
Almost forgetting the plan entirely turns into the vague 'I should be doing something' feeling. Here, you have a vague and uneasy sense
that you should be doing something, but you can't remember what, or where and when it should be done.
Another fairly common experience is that you remember the intention and start out to carry it through, but somewhere along the line
(usually because you are preoccupied with something else) you forget what it is that you came to some place to do. The place could be a
shop or you could find yourself standing in front of an open drawer or cupboard. You simply can't recall what it is you came to fetch. This is
the 'what-am-I-doing?' or 'what-am-I-doing here?' feeling.
The third possibility is that you set out to perform a plan of action, think you have completed it, but later discover that you've left something
out. A common experience is to return home to find a letter you intended to post.
Retrieval failures
• Fail to recall something you know you know. Often a name, a word or a fact.
• Frequently, the memory search is blocked by some other word or name that you know to be wrong, but which keeps coming to mind.
• TOT states ended by further search, pop-ups {just comes to mind later) or external prompts.
Retrieval failures are among the commonest ways that your memory can let you down, and increasingly so as you grow older.
At its most acute, it shows itself as the 'tip-of-the-tongue' (TOT) state when you realise that you can't call to mind a name or a word that you
know you know. The searched-for word seems tantalizingly close - on the tip of your tongue, in fact. The problem is usually made worse
because some word or name comes into your mind, but you know it's not the one you are trying to find. However, you have a strong sense
that somehow it's close to the target item, you may feel it sounds similar, or has the same number of syllables, or is a name that belongs to
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someone who is related to or works with the person whose name you are trying to find.
Research on TOT states has shown that these painful searches get resolved in one of three ways:
a) The lost word or name appears as the result of a deliberate search, though this could be one of many attempts,
b) The searched-for name or word just pops into your mind out of the blue, usually when you are doing some routine job like washing up,
c) A TV programme or newspaper or some other external source mentions the word or name and you recognise it as the one you have
been hunting for. Each of these three methods of concluding a memory search is equally likely.
It is unlikely that TOT states are much involved in maintenance errors. They are mentioned here for two reasons:
a) They are a common everyday experience,
b) They complete the trio of memory stages mentioned earlier.
Attentional failures
• Attention is a limited resource.
• Direct it to one thing and it is withdrawn from another (attentional capture).
• When this happens, actions often proceed unintentionally along some well-trodden pathway: strong habit intrusions.
It would be useful to explaining what attention is and what it does:-
• Attention is closely bound up with conscious awareness.
• It can vary in both direction and intensity
• It selects some part of a much larger array of information for further processing.
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• It has limited capacity.
• It is necessary for effective information-processing.
Two kinds of attentional problems:-
• Inattention at critical decision points in an action sequence. The attentional investment is necessary to direct actions along their currently
intended pathways. This is especially important when there has been some change, either in the customary plan or in the surroundings.
• We can also have the opposite: too much attention given to routine or pre-programmed segments of action that are best left to run their
course automatically. These periods of over-attention usually follow times when you have been thinking about something other than the
job in hand and 'wake up' to ask yourself where you are in the sequence. Too much attention given to these automatic runs of action can
be highly disruptive, as will be discussed later.
A typical pattern
Figure 8.7: A typical failure pattern
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Figure 8.7 represents the makings of a typical absent-minded slip.
Imagine that you are carrying out a highly practised action routine, like boiling an electric kettle preparatory to making a beverage. Imagine
also that you have a guest who has asked for tea, while you are a habitual coffee-drinker.
You go to the kitchen, fill the kettle and set it to boil. In the meantime, you start thinking about something else. As a result you miss the
choice point and fill both cups with instant coffee and pour on the water.
In this case, the kettle sequence is the fat arrow on the left. The fatter of the two arrows on the right is the coffee-making routine. The
thinner arrow is the tea-making routine. You miss the choice point and your actions run, as on rails, along the familiar route. But this time,
because of a change in circumstances, it is an absent-minded slip.
Slips of action (attentional failures)
• Strong habit intrusions
• Omissions following interruptions
• Premature exits
Strong habit intrusions
• Make tea instead of coffee. You are a tea drinker, but guest asks for coffee.
• Drive to work on Saturday morning when you meant to go to elsewhere.
• Intend to stop off to buy groceries on the way home, but drive straight past.
Branching slips, as the name indicates, involve actions where two different outcomes have an initial common pathway. Boiling a kettle of
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water, for example, is the first stage in achieving a variety of goals: making tea, making coffee, speeding up the cooking of vegetables, etc.
The defining feature of these slips is that the wrong route (i.e., the one not currently intended) is taken. This 'wrong route' is almost
invariably more familiar and frequently traveled than the one that was currently intended. The slip is triggered by a change in plan (see tea-
making slip described earlier)
Omissions following interruptions
• The failure to make the proper attentional check on progress is caused by distraction:-
o Intend to collect manual, but on removing it from shelf other books fall down. You replace books but depart without the manual.
• Actions associated with the interruption can get unconsciously 'counted in' as part of the intended sequence.
This is another type of slip that is a relatively common occurrence in aircraft engineering. They are also a frequent error type in everyday life.
On some occasions, the interruption causes the person to 'forget' the subsequent actions, or allows him or her to get sidetracked into
something else. On others, the actions involved in dealing with an interruption get unconsciously counted in as part of the original action
sequence. For example, a person is making tea and finds that the tea caddy is empty. They go to the cupboard and put fresh tea into the
caddy. Then they pour boiling water into an empty teapot having omitted to put the tea in.
Premature exits
• Terminate job before all fastenings are attached, or oil/fluid replaced, or caps secured, or all tools and foreign objects removed. Actual
examples:-
o Nuts left finger tight and not torqued.
o Centre P2 instrument panel slid out on takeoff.
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o Pre-flight checks revealed that control column could not be moved backwards. 3 cm hole cutter found wedged between balance
weight and a/c structure.
Another name for undershoots is 'premature exits'. That is, departing from an action sequence before all the component actions are carried
out. Slips of this kind feature very commonly among aircraft engineering quality lapses.
General factors promoting wrong actions
• The performance of a routine, habitual task in familiar surroundings.
• Attentional capture by preoccupation or distraction.
• Change, either in the plan of action or in the surroundings.
Several studies of everyday absent-minded actions, in which people kept diaries of the occasions when their actions did not go as planned,
have shown that there are a number of conditions that are invariably associated with these wrong actions.
a) Paradoxically, absent-mindedness is the penalty we pay for being skilled; that is, for being able to control our routine actions in a largely
automatic fashion. It is therefore natural that slips and lapses are most likely to occur during the execution of well-practised habitual
tasks in familiar surroundings. Of course, we do commit errors when we are learning a new skill (like using a computer keyboard), but
these errors are most likely to be fumbles and mishits due to inexperience and lack of motor coordination.
b) Attention is a limited commodity. If it is given to one thing it is necessarily withdrawn from other things. Attentional `capture' happens
when almost all of this limited attentional resource is devoted to one thing. If it is an internal worry, we call it preoccupation; if it is
something happening externally in our immediate vicinity, we call it distraction. The evidence shows very clearly that attentional capture,
of one kind or another, is an indispensable condition for an absent-minded (AM) slip or lapse.
c) Many action slips involve carrying out a set of actions that is highly usual or habitual in that situation, but was not what was wanted or
intended at the time. The trigger for the slip was some kind of change, either in the plan or in the surroundings. If that change had not
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occurred then the actions would have run along their accustomed tracks as intended. Thus, change of any kind is a powerful error-
producer.
Slips versus mistakes
• Installation problems (omissions) are the largest class of maintenance errors.
• While many of them are due to slips, this is not the whole story.
• Omissions can also occur because of mistakes: having the wrong idea about something, or using the wrong procedure.
• Slips are hardly ever repeated, but mistakes are.
Three Common Mistakes in Aircraft Maintenance
• Misapply a good rule
• Apply a bad rule
• Fail to apply a good rule (violation)
This identifies the three main classes of rule-based mistakes:
• We can misapply a normally good rule: that is, we can use it in a situation for which it is not appropriate because of some changed
circumstance.
• We can apply a bad rule that may get the job done but can have unwanted consequences.
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• Logically, there is also a third class: we can fail to apply a good rule that was appropriate and should have been followed. These are
violations, rule-bendings and non-compliances.
The next few examples look at examples of misapplying good rules and applying bad rules.
Misapplying good rules
• A 'good rule or principle' is one that has been generally useful in the past.
• But sometimes the rule/principle is wrongly applied:-
o Ina situation that shares many common features with the one for which rule was intended.
o But where the differences are overlooked.
This explains what is meant by a `good rule'. It also spells out some of the situations in which a good rule can be wrongly applied.
The business of applying problem-solving rules is often complicated by the fact that different problems can share common features. In
other words, it is possible that a given problem presents both indications suggesting that the common rule (common because it's a useful
rule) should be applied as well as counter-indications directing the person to apply a less commonly-used rule.
Here is an example. A family doctor is holding surgery during winter time in, say, the UK. A mother comes in with a baby that has a runny
nose and a high fever. The doctor sees a lot of patients with influenza in Northern European winters and prescribes penicillin. But the baby
actually has meningitis that does not respond that dosage of penicillin. The counter-indications are a bad headache and a stiff neck, but
these are difficult to establish in a young child who doesn't talk and doesn't have much of a neck. The consequence of this RB mistake is that
the child either dies or suffers severe brain damage.
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Misapplication: BAC 1-11
• Engineer involved in 1-11 accident ignored storeman's comment that the required bolt was an 8D-a slightly longer bolt than the 7D that
he was searching for.
• A general rule-of-thumb in maintenance is to replace like with like.
• In this case, the IPC called for 8Ds. But he did not consult [PC (a violation) and had used 7Ds in the past. The a/c had flown safely with 7Ds
for past 4 years.
Misapplication: B747 Incident
• During 'C' check, NDT inspector marked work card steps covering replacement of secondary fuse pin retainers as 'N/A' (not applicable).
• He did not believe that secondary retainers were required on this aircraft and thus did not realise that they had been removed.
• Only 7 of airline's fleet of forty one 747s required secondary retainers.
This example is drawn from the 747 dropped engine incident, and explains why the inspector failed to spot the missing retainers. Since
only 7 of the airline's fleet of forty one 747s were fitted with these secondary retainers, he did not expect them to be present.
Applying bad rules
• Most people pick up some 'bad rules' (bad habits) when learning a job.
• They are 'bad' because they can lead to something going wrong at a later time, even though they might serve their immediate purpose
on many occasions.
• Such 'bad rules' become established as part of the person's 'toolbag'.
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Bad rules can become established as part of our normal behaviour for a number of reasons:-
• No one corrects us at the time.
• Applying the bad rule seems to get the job done.
• And most of the time, there are no bad consequences.
Bad rules: Clapham Jct.
• British Rail technician had acquired the habit of bending back old wire rather than removing it when rewiring a signal box.
• Old wire made a false connection causing signal to fail unsafe (green aspect). Commuter train crashed into back of a stationary train
contributing to worst British railway accident for 40 years (Clapham Junction disaster, 1987).
The British Rail (BR) technician was a very keen and hard-working person who had never (in his 12 years of service) received any proper
training. He had picked up the job by watching other people and trying things out for himself.
The other part of the story is that the system had procedures for checking on the quality of signal wiring work, but these were not put into
operation at this time. The person who was supposed to have done the checks was very busy with the Waterloo rewiring scheme and the
checks simply fell out of his list of things to be done. Managerial and supervisory oversights are very common. It's not necessarily the case
that these people are lazy or incompetent. It is often that they are just very busy with other things.
Someone has called the Clapham accident 'the case of the unrocked boat'. BR had had seven years without a passenger fatality and the
normal checks and balances had grown imperceptibly slack.
The second example is a case of 'naive physics' in which a large proportion of intelligent students assumed - as they did in ancient times -
that the trajectory of a moving body reflects the shape of the structure that ejected it. Nearly all of us have got some misconceptions about
the world. Most of the time, they have no consequences; but, occasionally, they can lead to bad outcomes.
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Summarising Error Types
• Slips and lapses fall into three groups:
o Recognition failures
o Memory failures
o Attentional failures
• Mistakes can arise from:-
o misapplying good rules
o applying bad rules
o not applying good rules (violations)
Types of Error in Maintenance Tasks

As aircraft maintenance engineers are human, errors in the industry are inevitable.
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Any maintenance task performed on an aircraft is an opportunity for human error to be

introduced. Errors in aircraft maintenance engineering tend to take two specific forms:
• an error that results in a specific aircraft problem that was not there before the
maintenance task was initiated (e.g. installation of line replaceable units, failure
to remove a protective cap from a hydraulic line before reassembly or damaging
an air duct used as a foothold while gaining access to perform a task.);
• an error that results in an unwanted or unsafe condition remaining undetected

while performing a maintenance task designed to detect aircraft problems, i.e.
something is missed (a structural crack unnoticed during a visual inspection task
or a faulty avionics box that remains on the aircraft because incorrect diagnosis of
the problem led to removal of the wrong box).
Errors During Regular and Less Frequent Maintenance Tasks

A large proportion of maintenance tasks are fairly routine, such as regular, periodic checks on aircraft. Thus, engineers will use a certain set
of procedures relatively frequently and, as noted in the previous section, slips and lapses can occur when carrying out procedures in the
busy hangar or line environment. Chapter 6 "Repetitive Tasks" noted that engineers will often become so accustomed to doing a regular,
often repeated task, that they will dispense with written guidance altogether. It would be unrealistic and unnecessarily time consuming to
expect them to constantly refer to familiar guidance material. However, errors may occur if they do not keep up-to-date with any changes
that occur to these frequently used procedures. These routine tasks are also prone to complacency, environmental capture and rule-based
errors.
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When undertaking less frequently performed tasks, there is the possibility of errors of judgment. If the engineer does not familiarise or
refamiliarise himself properly with what needs to be done, he may mistakenly select the wrong procedure or parts.
Violation in Aircraft Maintenance

It is an unfortunate fact of life that violations occur in aviation maintenance. Most stem from a genuine desire to do a good job. Seldom are
they acts of vandalism or sabotage. However, they represent a significant threat to safety as systems are designed assuming people will
follow the procedures. There are four types of violations:
• Routine violations;
• Situational violations;
• Optimising violations;
• Exceptional violations.
Routine violations are things which have become `the normal way of doing something' within the person's work group (e.g. a maintenance
team). They can become routine for a number of reasons: engineers may believe that procedures may be over prescriptive and violate them
to simplify a task (cutting corners), to save time and effort.
Situational violations occur due to the particular factors that exist at the time, such as time pressure, high workload, unworkable procedures,
inadequate tooling, poor working conditions. These occur often when, in order to get the job done, engineers consider that a procedure
cannot be followed.
Optimising violations involve breaking the rules for 'kicks'. These are often quite unrelated to the actual task. The person just uses the
opportunity to satisfy a personal need.
Exceptional violations are typified by particular tasks or operating circumstances that make violations inevitable, no matter how well
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intentioned the engineer might be.
Examples of routine violations are not performing an engine run after a borescope inspection ("it never leaks"), or not changing the Ò' seals
on the engine gearbox drive pad after a borescope inspection ("they are never damaged").
An example of a situational violation is an incident which occurred where the door of a B747 came open in-flight. An engineer with a tight
deadline discovered that he needed a special jig to drill off a new door torque tube. The jig was not available, so the engineer decided to
drill the holes by hand on a pillar drill. If he had complied with the maintenance manual he could not have done the job and the aircraft
would have missed the service.
An example of an optimising violation would be an engineer who has to go across the airfield and drives there faster than permitted.
Time pressure and high workload increase the likelihood of all types of violations occurring. People weigh up the perceived risks against the
perceived benefits, unfortunately the actual risks can be much higher.
Mental èconomics' of violations
(A) Benefits exceed costs. Violation likely.
(B) Costs exceed benefits. Violation unlikely.
Figure 8.8: Relationship of benefits to cost of violations
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Unlike errors, violations are deliberate acts. People weigh up the costs and benefits of an act of non-compliance and when the benefits
exceed the possible costs they are likely to violate. The effects of `mental economics' have been shown in a wide variety of work and
everyday situations.
The violation `balance sheet'
Benefits are immediate. Costs are remote from experience, and-in the case ofaccidents-seem unlikely.
Table 8.1: Perceived benefits and Perceived costs of violations
Table 8.1 shows the factors that might lie on the plus and minus sides of the mental balance sheet relating to violations.
For many acts of non-compliance, however, experience shows that violating is an easier way of working and brings no obvious bad effects.
In short, the benefits of non-compliance are often seen to outweigh the costs.
The challenge here is not so much to increase the costs of violating (by stiffer penalties, etc.) but to try to increase the perceived benefits of
compliance. And that means having procedures that are workable and that describe what are obviously the quickest and most efficient
ways of doing the job. Any lack of trust caused by inappropriate or clumsy procedures will increase the perceived benefits of violating.
Indeed, some jobs can only be done by deviating from the procedures.
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Why people violate good rules
• "I can handle it."
• "I can get way with it."
• "I can't help it."
• "Everyone does it."
• "It's what they want."
• "They'll turn a blind eye."
These are some of the beliefs that lead people to violate. A number of them relate to the widely held attitude that violating is the
prerogative of the skilled person. Their skill shows them how to bend the rules and get away with it.
Other beliefs have to do with the fact that violations may be going on all over the worksite. Consequently people feel powerless to avoid
them. Indeed, they might feel that violations are expected of them. They may also be aware that managers turn a blind eye to violations that
get the job done and so meet tight deadlines.
Bad procedures
• Violations are only half the problem.
• The other half (or more) arises from bad procedures.
• In the nuclear power industry, 67% of all human performance problems have been traced to bad (incorrect, absent or unworkable)
procedures.
It would be a mistake to think that most violations were due to bloody-mindedness on the part of the workforce. As we have already seen,
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situational or necessary violations arise because
a) People want to get the job done,
b) The tools or the situation make it impossible to do the job when following the procedures to the letter.
In the nuclear industry, for example, nearly 70 per cent of all human performance problems have been traced to bad procedures. That is,
procedures that gave the wrong information, or were inappropriate or unworkable in the present situation, or were not known about, or
were out of date, or that could not be found, or that could not be understood, or that simply had not been written to cover this job.
Bad, absent or unworkable documentation is not a monopoly of the nuclear power industry.
Situational factors
• Time pressure
• High workload
• Unworkable procedures
• Inadequate equipment
• Bad working conditions
• Supervisors turn blind eye
These are some of the situational factors that promote violations. Several of the factors also crop up on the list of local error-producing
factors.
Removing or moderating these local error- and violation-producing factors is a major part of managing unsafe acts.
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Use of informal procedures ('black books')
• Operators (56%)
• Managers (51%)
In many highly-proceduralised industries, it is common for the workforce to write their own procedures as to how jobs should be done.
These are jealously guarded and passed on to new members of the workgroup. They are generally known as 'black books'.
Notice from this slide that over half of both operators and managers use these `black books'. These results come from the procedure-usage
survey introduced on the previous slide.
Reasons for not following procedures
• If followed to the letter, job wouldn't get done.
• People are not aware that procedure exists.
• People prefer to rely on own skills and experience.
• People assume they know what is in the procedure.
These are some the reasons given why workers for not following procedures. These are universal reasons for not following procedures and
manuals. Any attempt at improving compliance must address these problems.
Violation types
• Corner-cutting violations
• Thrill-seeking violations
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• Violations to get job done
This shows a preliminary break down of violation types.
• Corner-cutting-or routine violations-are committed to avoid unnecessary effort or to circumvent clumsy or inappropriate procedures.
• Thrill-seeking or optimising violations are committed for 'kicks' or to avoid boredom.
• Violations to get the job done-or necessary violations-occur in circumstances where it is impossible to get the job done by sticking to the
rules.
Cutting corners: Example
• B747 was about to make first flight after servicing in which oil lines on one engine had been changed.
• Finding oil leaks on engine run, technicians tightened suspect oil lines.
• Skipped additional engine run because tug had arrived.
• Tech's followed a/c to terminal where they performed an engine dry spin. No oil leaks were found.
• Oil leak from engine caused IFSD and diversion.
Thrill-seeking violations
• Most obvious examples are to be found in the handling of vehicles: speeding, cutting in, tail-gating, `road rage', etc.
• We do these things for the `joy of speed' or to let out angry feelings.
• Many towing and ground contact accidents are due to thrill-seeking.
• Males violate more than females, the young violate more than the old. Similar differences not found for errors.
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Getting job done: Example
Figure 8.9: Violations become the Norm
How violations differ from errors
• Errors are unintended. Violations are deliberate (the act not the occasional bad consequences).
• Errors arise from information problems. Violations are shaped mainly by attitudes, beliefs, group norms and safety culture.
The distinction between errors and violations depends upon the following factors:-
Intentionality: We do not generally intend to make slips, lapses or mistakes. Except when they have become so routinised as to be
automatic, people do generally intend to commit the actions that deviate from procedures. It is important to note, however, that while they
may intend the non-compliant actions, they do not generally intend the occasionally bad consequences. Only saboteurs intend both the act
and its bad consequences.
Information versus motivation: Errors arise as the result of informational problems, either in the head or in the world. In short, errors arise
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from informational problems and are generally corrected by improving the information, either in the person's head or in the workplace.
Violations, on the other hand, arise largely from motivational factors, from beliefs, attitudes, norms and from the organisational culture at
large. These are the things that need to be fixed if we are to reduce the non-compliance to good rules.
Demographics: Men violate more than women and the young violate more than the old. The same does not apply to errors.
Errors Due to Individual Practices and Habits
Where procedures allow some leeway, aircraft maintenance engineers often develop their own strategies or preferred way of carrying out a
task. Often, a 'good' rule or principle is one that has been used successfully in the past. These good rules become `rules of thumb' that an
engineer might adopt for day-to-day use. Problems occur when the rule or principle is wrongly applied. For example, aircraft pipe couplings
are normally right hand threads but applying this 'normally good rule' to an oxygen pipe (having a different thread) could result in damage
to the pipe. Also, there can be dangers in applying rules based on previous experience if, for example, design philosophy differs, as in the
case of Airbus and Boeing. This may have been a factor in an A320 locked spoiler incident, where subtle differences between the operation
of the spoilers on the A320 and those of the B767 (with which the engineers were more familiar) meant that actions which would have been
appropriate on the B767 were inappropriate in the case of the A320.
In addition, engineers may pick up some `bad rules', leading to bad habits during their working life.
Errors Associated With Visual Inspection

There are also two particular types of error which are referred to particularly in the context of visual inspection, namely Type I and Type 2
errors.
• Type 1 error occurs when a good item is incorrectly identified as faulty;
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• Type 2 error occurs when a faulty item is missed.
Type 1 errors are not a safety concern per se, except that it means that resources are not being used most effectively, time being wasted on
further investigation of items which are not genuine faults.
Type 2 errors are of most concern since, if the fault (such as a crack) remains undetected, it can have serious consequences (as was the case
in the Aloha accident, where cracks remained undetected).
Reason's Study of Aviation Maintenance Engineering

Reason analysed the reports of 122 maintenance incidents occurring within a major airline over a 3 year period. He identified the main
causes as being:
• Omissions (56%)
• Incorrect installation (30%)
• Wrong parts (8%)
• Other (6%)
It is likely that Reason's findings are representative for the aircraft maintenance industry as a whole. Omissions can occur for a variety of
reason, such as forgetting, deviation from a procedure (accidental or deliberate), or due to distraction. The B737 double engine oil loss
incident, in which the HP rotor drive covers were not refitted is an example of omission.
Incorrect installation is unsurprising, as there is usually only one way in which something can be taken apart but many possible ways in
which it can be reassembled. Reason illustrates this with a simple example of a bolt and several nuts (see Figure 8.10), asking the questions
(a) how many ways can this be disassembled? (the answer being 1) and (b) how many ways can it be reassembled? (the answer being about
40,000, excluding errors of omission!).
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Figure 8.10: Reason's Bolt and Nuts Example.
In the BAC1-11 accident in June 1990, the error was fitting the wrong bolts to the windscreen. This illustrates well the category of `wrong
parts'.
Implications of Errors (i.e. Accidents)

In the worst cases, human errors in aviation maintenance can and do cause aircraft accidents. However, as portrayed in Figure 8.11,
accidents are the observable manifestations of error. Like an iceberg which has most of its mass beneath the water line, the majority of
errors do not result in actual accidents.
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Figure 8.11: The "Iceberg Model" of Accidents
Thankfully, most errors made by aircraft maintenance engineers do not have catastrophic results. This does not mean that this might not be
the result should they occur again.
Errors that do not cause accidents but still cause a problem are known as incidents. This subject was introduced at the beginning of this
document in Chapter 1, "Incidents Attributable To Human Factors / Human Error", which gave examples of aviation incidents relating to
aircraft maintenance errors. Some incidents are more high profile than others, such as errors causing significant in-flight events that,
fortuitously, or because of the skills of the pilot, did not become accidents. Other incidents are more mundane and do not become serious
because of defences T built into the maintenance system. However, all incidents are significant to the aircraft maintenance industry, as they
may warn of a potential future accident should the error occur in different circumstances. As a consequence, all maintenance incidents have
to be reported to the UK Civil Aviation Authority Mandatory Occurrence Reporting Scheme (MORS). These data are used to disclose trends
and, where necessary, implement action to reduce the likelihood or criticality of further errors. In the UK, the Confidential Human Factors
Incident Reporting Programme (CHIRP) scheme provides an alternative reporting mechanism for individuals who want to report safety
concerns and incidents confidentially.
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It is likely that the greatest proportion of errors made by aircraft maintenance engineers are spotted almost immediately they are made and
corrected. The engineer may detect his own error, or it may be picked up by colleagues, supervisors or quality control. In these cases, the
engineer involved should (it is hoped) learn from his error and therefore (it is hoped) be less likely to make the same error again.
It is vital that aircraft maintenance engineers learn from their own errors and from the errors made by others in the industry. These powerful
and persuasive lessons are the positive aspects of human error.
When an error occurs in the maintenance system of an airline, the engineer who last worked on the aircraft is usually considered to be àt
fault'. The engineer may be reprimanded, given remedial training or simply told not to make the same error again. However, blame does not
necessarily act as a positive force in aircraft maintenance: it can discourage engineers from `coming clean' about their errors. They may
cover up a mistake or not report an incident. It may also be unfair to blame the engineer if the error results from a failure or weakness
inherent in the system which the engineer has accidentally discovered (for example, a latent failure such as a poor procedure drawn up by
an aircraft manufacturer - possibly an exceptional violation).
The UK Civil Aviation Authority has stressed in CAAIP Leaflet 11-50 (previously published as Airworthiness Notice No. 71) that it "seeks to
provide an environment in which errors may be openly investigated in order that the contributing factors and root causes of maintenance
errors can be addressed". To facilitate this, it is considered that an unpremeditated or inadvertent lapse should not incur any punitive action,
but a breach of professionalism may do so (e.g. where an engineer causes deliberate harm or damage, has been involved previously in
similar lapses, attempted to hide their lapse or part in a mishap, etc.).
Avoiding and Managing Errors

Whilst the aircraft maintenance engineering industry should always strive towards ensuring that errors do not occur in the first place, it will
never be possible to eradicate them totally. Therefore all maintenance organisations should aim to `manage' errors.
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Error management seeks to:
• prevent errors from occurring;
• eliminate or mitigate the bad effects of errors
Reason refers to the two components of error management as:
1. error containment
2. error reduction.
To prevent errors from occurring, it is necessary to predict where they are most likely to occur and then to put in place preventative
measures. Incident reporting schemes (such as MORS) do this for the industry as a whole. Within a maintenance organisation, data on errors,
incidents and accidents should be captured with a Safety Management System (SMS), which should provide mechanisms for identifying
potential weak spots and error-prone activities or situations. Output from this should guide local training, company procedures, the
introduction of new defences, or the modification of existing defences.
According to Reason, error management includes measure to:
• minimise the error liability of the individual or the team;
• reduce the error vulnerability of particular tasks or task elements;
• discover, assess and then eliminate error-producing (and violation-producing) factors within the workplace;
• diagnose organisational factors that create error-producing factors within the individual, the team, the task or the workplace;
• enhance error detection;
• increase the error tolerance of the workplace or system;
• make latent conditions more visible to those who operate and manage the system;
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• improve the organisation's intrinsic resistance to human fallibility.
It would be very difficult to list all means by which errors might be prevented or minimised in aircraft maintenance. In effect, the whole of
this document discusses mechanisms for this, from ensuring that individuals are fit and alert, to making sure that the hangar lighting is
adequate.
One of the things likely to be most effective in preventing error is to make sure that engineers follow procedures. This can be effected by
ensuring that the procedures are correct and usable, that the means of presentation of the information is user friendly and appropriate to
the task and context, that engineers are encouraged to follow procedures and not to cut corners.
Ultimately, maintenance organisations have to compromise between implementing measures to prevent, reduce or detect errors, and
making a profit. Some measures cost little (such as renewing light bulbs in the hangar); others cost a lot (such as employing extra staff to
spread workload). Incidents tend to result in short term error mitigation measures but if an organisation has no incidents for a long time (or
has them but does not know about them or appreciate their significance), there is a danger of complacency setting in and cost reduction
strategies eroding the defences against error. Reason refers to this as "the unrocked boat" (Figure 8.12).
Figure 8.12: The lifespan of a hypothetical organisation through the production - protection space.
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It is important that organisations balance profit and costs, and try to ensure that the defences which are put in place are the most cost-
effective in terms of trapping errors and preventing catastrophic outcomes.
Ultimately, it is the responsibility of each and every aircraft maintenance engineer to take every possible care in his work and be vigilant for
error (see Chapter 3). On the whole, aircraft maintenance engineers are very conscious of the importance of their work and typically expend
considerable effort to prevent injuries, prevent damage, and to keep the aircraft they work on safe.
Error Management
The purpose is to provide maintenance organisations with a sense of what techniques are available to deal with `here and now' human
performance problems. It is not definitive. It merely provides a sample of what is being used in airline engineering organisations in various
parts of the world. Details are given to enable you to follow up on techniques that you feel could be useful in your company.
It must be stressed that an effective Error Management system involves the whole organisation. Human Factors and Error Management
training is not just for those who get their hands dirty. All the modules are designed to be suitable for all levels of the system.
Comprehension and the judged relevance of this kind of training material has been trialled successfully in a number of
maintenanceorganisations ( British Airways Engineering, Singapore Airlines Engineering Company, Cathay Pacific)
There is no one best Error Management system. Different mixes of techniques and practices suit different organisations. What this package
offers is a set of guiding principles for error management and a `shopping list' of measures and techniques for managing error at different
levels of the system. Of course, another way of looking at this catalogue is as a spur to creating your own home-grown Error Management
system.
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Eight reasons to have an Error Management system
• Flightdeck windscreen blowout, BAC1-11
• Inflight structural break-up, Embraer 120
• Engine and pylon broke away, B747-258
• Un-commanded roll on takeoff, A320
• Engine drop on landing, B747-251
• Oil loss on both engines, B737-400
• Static ports covered with tape, B757-23A
• Oxygen generator fire, DC9-32
They have been selected for two reasons:
• First, they illustrate a range of initiating errors.
• Second, they demonstrate a variety of system failures that allowed these errors to go undetected.
Maintenance error accidents:
• BAC 1-11 (6/90): Left windscreen blown out at 17,300 ft. Capt. half sucked out of a/c. Window installed with wrong bolts.
• Embraer 120 (9191): Fatal crash due to in-flight loss of a partially secured de-ice boot on left leading edge of horizontal stabiliser.
Upper attachment screws missing.
• B747-258 (10/92): # 3 engine and pylon separated from wing. Fuse pin fatigue. Probable cause: System to ensure structural integrity
by inspection failed.
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The B747 accident occurred shortly after takeoff on 4 October 1992. As the aircraft was climbing through 6500 It, the no. 3 engine and pylon
separated from the wing and ollided with the no. 4 engine which was torn off. The flight crew declared a mayday and requested a return to
runway 27. However, the leading edge of the wing was severely damaged and the use of several important flight systems was lost or
limited. The aircraft crashed into a high-rise building. Two primary causes.
The design and certification of the B747 was found to be inadequate to provide the required level of safety.
The system to ensure structural integrity by inspection failed. The event was probably initiated by fatigue in the inboard midspar fuse-pin
on the no. 3 engine and pylon.
• A320-212 (8/93): Undemanded roll to right on takeoff. Re-instatement and functional check of the spoilers after flap fitment was not
carried out.
• B757-23A (10/96): Three static ports on left side obstructed by masking tape. Tape had been applied before washing and polishing of
aircraft prior to crash flight.
The B757 took off at 12.42 on 2 October 1996. Five minutes later, the crew reported instrument problems and requested a return to the
airport. During the initial climb the airspeed and altitude indications were too low and a windshear warning sounded in calm winds. On its
return, the aircraft kept descending and impacted the water with the left wing. Preliminary investigation of the wreckage found masking
tape blocking three static ports on the left side. They had been applied before washing and polishing of the aircraft prior to the accident
flight.
• DC9-32 (5/96): Fire in cargo compartment due to actuation of oxygen generator(s). Among the causes: Failure to oversee contract
maintenance programme.
Six minutes after takeoff on 11 May 1996, the aircraft dropped 815 ft and the [AS decreased 34 kts in 3 seconds. Shortly after smoke filled the
cockpit. Subsequently, the aircraft crashed into the Everglades killing all on board. In the cargo hold were boxes containing oxygen
generators. The accident investigators concluded that accident was due to:
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• Failure prepare, package, identify and track unexpended chemical oxygen generators before handing them over to the airline.
• Failure of the airline to properly oversee its contract maintenance programme.
• Failure of the Regulator to require smoke detection and fire suppression systems in Class D cargo compartments. The regulator also failed
to monitor the airline's contracted maintenance program.
Two common elements of these accidents
• Various unsafe acts and/or equipment states that jeopardised the airworthiness of the aircraft.
• A failure of the s stem to detect and rectif these dangerous conditions before the aircraft was released to the line.
When we hear of maintenance-related accidents such as these, we naturally assume that the primary fault lies with the individual
maintainer(s) at the sharp end, the person or people who actually touched the aircraft. True, these form an important part of the accident
sequence, but they are only the initiating events. For them to have had a bad outcome, it means that the systems designed to check and
correct errors. As we shall see later, systems are easier to manage than people--assuming, as is generally the case, that we have a competent
and wellmotivated workforce.
YOU CAN'T CHANGE THE HUMAN CONDITION, BUT YOU CAN CHANGE THE CONDITIONS UNDER WHICH PEOPLE WORK.
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Error management: What do you aim for?
Figure 8.13: What to aim for?
How do you best reduce errors and limit their bad effects. They are four possible target areas: the person, the task, the workplace and the
organisation as a whole. Most organisations aim for the person because they believe that people are more changeable than situations.
Most organizations go for the person
Figure 8.14: Most organisations go for the person
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Typical responses to engineering quality lapses are as follows:-
Blame and train: 'Carpet' the error-maker, or discipline him, or tell him to be more careful, and then, if necessary, send him for retraining.
Write another procedure: All industries tend to write procedures to prohibit actions that have been implicated in some event or incident.
The result is that the range of permitted actions is often less than the range of actions necessary to get the job done.
Search for the 'missing piece': When these measures fail (and they usually do), managers start looking for psychological ways of finding the
piece that will remove violations and errors. Somewhere out there, they think, is a psychologist who can come up with the 'magic bullet'
solution.
But it's better to aim for...
Figure 8.15: Better to aim for...
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Comprehensive Error Management, however, prefers to focus most of its efforts on:-
• Identifying and correcting error-prone tasks
• Improving error-producing work situations
• Identifying and correcting latent organisational conditions.
Summary: Managing the manageable
• Fallibility is part of the human condition.
• We are not going to change the human condition.
• But we can change the conditions under which people work.
"Changing situations is more effective than trying to change human nature."
Errors are like mosquitoes

Errors are like mosquitoes in at least two important ways:
• First, they are hard to deal with one by one.
• Second, they have their origins elsewhere: in the swamps and marshes in which they breed. In the case of maintenance, the `swamps and
marshes' are the workplace and organisational problems that give rise to unsafe acts. Dealing with these latent conditions goes beyond
the `here and now' and limits the chances of future generations of errors threatening the safety of your aircraft.
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You can swat them and spray them

You can deal with errors one by one, but it is inefficient and ineffective. Swatting them and spraying them kills individual mosquitoes. But it
is usually too late. By the time they have been discovered, they have already caused harm. And, in any case, once you have disposed of the
immediate problems, there are still many more mosquitoes coming to bite you.
Dealing with isolated errors is like dealing with the visible symptoms rather than with the underlying disease. To do this, we have to look
into the future and ask: From where are our next problems likely to come? And what can we do to thwart them before they cause damage
and losses?
The only effective measures are
• To drain the swamps in which they breed.
• And to use various proven defences:
o mosquito netting
o mosquito repellent
o quinine-based pills, etc.
With errors as with mosquitoes, it is crucial to deal with the problem at source. One way is to remove the 'swamps and marshes' in the
workplace and in the system at large. The other is to erect ever more effective defences. The ones listed above have shown themselves
effective against mosquitoes. What can you do that is equally effective against future unsafe acts?
In the case of maintenance errors ...
• The 'swamps' are task, workplace and organisational factors that provoke errors.
• The defences are system safeguards and barriers that detect and recover errors before they can have a bad outcome.
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• Both of these go to make up an effective HERO (Human Error Reduction Operation).
The future-directed measures in the HERO toolbox are aimed at identifying and removing 'swamps' and at creating more effective defences
against those errors that will inevitably escape these measures.
Focusing on individual errors is like .. .

The futility of dealing with errors one by one. In the first place, the damage has usually been done. And, in the second, it is a waste of limited
error management resources. Here, you can take the swatter and the spray can as being equivalent to disciplining someone for an error he
or she did not intend to commit.
Changing the future means.. .
• Learning the right lessons from past incidents: Not `who's to blame?' but what were the task, workplace and organisational factors that
contributed to the incident?
• Identifying task, workplace and organisational problems that could combine to cause some future incident or accident? Being proactive
as well as reactive.
To use the mosquito analogy again, there are two ways of dealing with the underlying and fundamental problems. One way is to trace
mosquitoes (errors) back to their point of origin - to their breeding grounds - and then eliminate them. The other is to use this knowledge to
destroy potential breeding grounds before they create problems.
In what follows, we will review a variety of techniques currently in use in the world's airline maintenance facilities. Some of them start with
an event and then work back into the system to identify and remove their fundamental causes. Others involve regular system 'health
checks' in which potential problems are identified and corrected before they cause trouble.
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Maintenance Error Decision Aid (MEDA)
The MEDA Philosophy

Traditional efforts to investigate errors are often aimed at identifying the employee who made the error. The usual result is that the
employee is defensive and is subjected to a combination of disciplinary action and recurrent training (which is actually retraining). Because
retraining often adds little or no value to what the employee already knows, it may be ineffective in preventing future errors. In addition, by
the time the employee is identified, information about the factors that contributed to the error has been lost. Because the factors that
contributed to the error remain unchanged, the error is likely to recur, setting what is called the "blame and train" cycle in motion again.
To break this cycle, MEDA was developed in order to assist investigators to look for the factors that contributed to the error, rather than
concentrate upon the employee who made the error. The MEDA philosophy is based on these principles:
• Positive employee intent (maintenance technicians want to do the best job
• possible and do not make errors intentionally).
• Contribution of multiple factors (a series of factors contributes to an error).
• Manageability of errors (most of the factors that contribute to an error can be managed).
POSITIVE EMPLOYEE INTENT

This principle is key to a successful investigation. Traditional "blame and train" investigations assume that errors result from individual
carelessness or incompetence. Starting instead from the assumption that even careful employees can make errors, MEDA interviewers can
gain the active participation of the technicians closest to the error. When technicians feel that their competence is not in question and that
their contributions will not be used in disciplinary actions against them or their fellow employees, they willingly team with investigators to
identify the factors that contribute to error and suggest solutions. By following this principle, operators can replace a negative "blame and
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train" pattern with a positive "blame the process, not the person" practice.
CONTRIBUTION OF MULTIPLE FACTORS

Technicians who perform maintenance tasks on a daily basis are often aware of factors that can contribute to error. These include
information that is difficult to understand, such as work cards or maintenance manuals; inadequate lighting; poor communication between
work shifts; and aircraft design. Technicians may even have their own strategies for addressing these factors. One of the objectives of a
MEDA investigation is to discover these successful strategies and share them with the entire maintenance operation.
MANAGEABILITY OF ERRORS
Active involvement of the technicians closest to the error reflects the MEDA principle that most of the factors that contribute to an error can
be managed. Processes can be changed, procedures improved or corrected, facilities enhanced, and best practices shared. Because error
most often results from a series of contributing factors, correcting or removing just one or two of these factors can prevent the error from
recurring.
The MEDA Process

To help maintenance organizations achieve the dual goals of identifying factors that contribute to existing errors and avoiding future errors,
Boeing initially worked with British Airways, Continental Airlines, United Airlines, a maintenance workers' labour process for operators to
follow
• Event.
• Decision.
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• Investigation.
• Prevention strategies.
• Feedback.
EVENT
An event occurs, such as a gate return or air turn back. It is the responsibility of the maintenance organization to select the error-caused
events that will be investigated.
DECISION
After fixing the problem and returning the airplane to service, the operator makes a decision: Was the event maintenance-related? If yes, the
operator performs a MEDA investigation.
INVESTIGATION
Using the MEDA results form, the operator carries-out an investigation. The trained investigator uses the form to record general information
about the airplane, when the maintenance and the event occurred, the event that began the investigation, the error that caused the event,
the factors contributing to the error, and a list of possible prevention strategies.
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PREVENTION STRATEGIES
The operator reviews, prioritises, implements, and then tracks prevention strategies (process improvements) in order to avoid or reduce the
likelihood of similar errors in the future.
FEEDBACK
The operator provides feedback to the maintenance workforce so technicians know that changes have been made to the maintenance
system as a result of the MEDA process. The operator is responsible for affirming the effectiveness of employees' participation and
validating their contribution to the MEDA process by sharing investigation results with them.
Figure 8.16: The MEDA process
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Management Resolve
The resolve of management at the maintenance operation is key to successful MEDA implementation. Specifically, after completing a
program of MEDA support from Boeing, managers must assume responsibility for the following activities before starting investigations:
MEDA is a long-term commitment, rather than a quick fix. Operators new to the process are susceptible to "normal workload syndrome".
This occurs once the enthusiasm generated by initial training of investigation teams has diminished and the first few investigations have
been completed. In addition to the expectation that they will continue to use MEDA, newly trained investigators are expected to maintain
their normal responsibilities and workloads. Management at all levels can maintain the ongoing commitment required by providing
systematic tracking of MEDA findings and visibility of error and improvement trends.
Summary
The Maintenance Error Decision Aid (MEDA) process offered by Boeing continues to help operators of airplanes identify what causes
maintenance errors and how to prevent similar errors in the future. Because MEDA is a tool for investigating the factors that contribute to an
error, maintenance organizations can discover exactly what led to an error and remedy those factors. By using MEDA, operators can avoid
the rework, lost revenue, and potential safety problems related to events caused by maintenance errors.
Safety and Risk
The two faces of safety
• Negative face as revealed by bad events, near misses and the like.
• Positive face = system's intrinsic resistance to its operational hazards.
• Too few bad outcomes to steer by.
• We need to measure the processes contributing to resistance (or vulnerability)
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Most of the time when we speak of 'safety' we are usually referring, either directly or indirectly, to moments of 'unsafety', or their
comparative absence over a given period of time. Safety is usually measured in terms of the number of incidents or accidents that occur
during a given interval of time, say a six- or twelve-month period. Most technical people like these kinds of measures because they can be
quantified fairly easily. But what happens when you start having so few bad events that there is actually more noise present than signal. This
is what has happened in the aviation industry. Yes, there are still accidents and maintenance incidents, but they are comparatively few and
far between. And they tell you very little about the true safety health of your system.
Intrinsic Safety
Figure 8.17: Diagram depicting the effects on safety of a disturbance, for different system types
Figure 8.17 tries to spell out what is meant by the positive face of safety. Imagine a ball bearing resting on three differently-shaped blocks.
Imagine also that each arrangement is being agitated by external forces. These forces are equivalent to the operational hazards of your
business.
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Inspection of the slide shows that in all three arrangements, the ball-bearing could be tipped over the edge. But it is clearly far harder for
this to happen in the bottom configuration, representing a resistant or robust system.
We cannot always prevent the chance combinations of factors that cause accidents, but we can work to make our organisation less
vulnerable to them. This is the true goal of risk management - not zero accidents, an impossible target when gravity, terrain, weather and
human error continue to exist - but achieving the maximum degree of resistance to their bad effects.
The Safety Space
Figure 8.18: The safety space
Following on from the ideas expressed on figure 8.17, we can imagine a cigar-shaped space the safety space - with one end labelled as
'maximum achievable resistance' and the other as èxtreme vulnerability'. Each maintenance (or any other kind of) organisation occupies
some position along this resistant-vulnerable dimension. The space is cigar-shaped because most organisations will lie in the intermediate
zone, with only relatively few at either extreme.
It must also be appreciated that an organisation's position along this resistant-vulnerable dimension need not necessarily be reflected in its
negative outcome measures. Even the most resistant systems can suffer incidents and accidents through bad luck. Similarly, even the most
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`cowboy' organisations can be preserved over given periods of time by good luck. Chance does not make moral judgements. It affects both
good and bad companies.
Navigating the safety space
Figure 8.18: The Zone of Maximum Resistance
Figure 8.18 spells out the realistic safety goal of every organisation: to reach the zone of maximum resistance and then stay there for as long
as possible.
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Two things are needed:
a) driving force supplied by the cultural influences of commitment (a genuine top-level concern with safety issues), competence (the ability
to collect, analyse and act upon the right kind of safety-related information) and cognisance (a correct awareness of the dangers), and
b) navigational aids supplied by both reactive outcome measures (e.g., MEDA) and proactive process measures (e.g., MESH).
Safety is a dynamic non-event
• The fallacy: If we go on doing what we did yesterday, when nothing bad happened, then nothing bad will happen today.
• But that `nothing bad' was achieved by many different people doing many different things to compensate for disturbances.
• To maintain `nothing bad', we have to understand exactly what is happening.
The Safety Loop

This shows the main elements of a safety management system. Such systems have proven track records in a wide range of industries. In
particular, they bring together the important managerial issues outlined in the previous slides.
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The Risk Matrix
Table 8.2: Variable versus Constant Errors
Risk is calculated as a function of both the likelihood of occurrence and the severity of the likely outcome. The Risk Matrix shown in the slide
is based upon the one regularly used by British Airways Safety Services in their monthly safety bulletin 'Flywise'.
Five categories of risk are identified:
A: Severe, a rare incident requiring the highest priority for resources and action.
B: High, incidents of significant concern which take priority over other incidents.
C: Medium, incidents requiring the attention and action of a line department.
D: Low, an incident of low concern which normally requires no further action.
E: Minimal, incidents that are of statistical interest only.
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Module 15
Human Factor
15.9 Hazards in the Workplace
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LEVEL 1
LEVEL 2
LEVEL 3
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Table of Contents
Chapter 15.9 Hazards in the Workplace _______________________________________________________________________ 5
Recognising and Avoiding Hazards ___________________________________________________________________________ 5
Potential Hazards in Aircraft Maintenance Engineering ________________________________________________________________ 5
Relevant Legislation and the Maintenance Organisation's Responsibilities ________________________________________________ 6
Engineer's Individual Responsibilities ______________________________________________________________________________ 8
Safety in the Working Environment ________________________________________________________________________________ 9
Safety When Working On Aircraft __________________________________________________________________________________ 9
Dealing with Emergencies _____________________________________________________________________________________ 9
Risk Assessment ______________________________________________________________________________________________ 11

What is risk assessment? _________________________________________________________________________________________ 11
How to assess the risks in your workplace ___________________________________________________________________________ 11
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Recognising and avoiding hazards; 9.9 2
Dealing with emergencies;
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Chapter 15.9 Hazards in the Workplace
Hazards in the workplace tend to be a health and safety issue, relating to the protection of individuals at work. All workplaces have hazards
and aircraft maintenance engineering is no exception. Health and safety is somewhat separate from human factors and this chapter
therefore gives only a very brief overview of the issues relating the aircraft maintenance engineering.
Recognising and Avoiding Hazards
Potential Hazards in Aircraft Maintenance Engineering

There are many potential hazards in the aircraft maintenance industry and it is impossible to list them all here. However, a thorough health
and safety appraisal will reveal the hazards. Physical hazards may include:
• very bright lights (e.g. from welding);
• very loud sounds (sudden or continuous);
• confined or enclosed areas;
• working at significant heights;
• noxious substances (liquids, fumes, etc.);
• excessive temperature (i.e. too cold or too hot);
• moving equipment, moving vehicles and vibration.
Many of these have been addressed earlier in this document (e.g. Chapter 5 "Physical Environment").
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Relevant Legislation and the Maintenance Organisation's Responsibilities

The UK Health and Safety Executive (HSE) have responsibility for overseeing safety in the workplace. The Health and Safety at Work Act 1974
and accompanying Regulations are the relevant legislation and the HSE produce publications and leaflets summarising various aspects. The
Health and Safety at Work Act 1974 places a responsibility on employers to produce a written statement of general policy with respect to
the Health and Safety at Work of its employees. The employer is also obliged to bring to the notice of all its employees this policy together
with the organisation and arrangements in force for carrying out that policy. Thus, in an aircraft maintenance organisation, the health and
safety policy might include statements applicable to the organisation such as the need to:
• Carry out assessments of work including inspections to determine Health and Safety risks;
• Provide safe working practices and procedures for plant, machinery, work equipment, materials and substances;
• Inform employees and other persons including temporary workers of any risk;
• Provide suitable training and/or instruction to meet any Health and Safety risks;
• Develop and introduce practices and procedures to reduce risks to Health and Safety including the provision of special protective devices
and personal protective equipment;
• Provide for the welfare of employees;
• Discuss with and consult employee representatives on Health and Safety matters.
Maintenance organisations should appoint someone with health and safety responsibilities.
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In brief, a maintenance organisation has a duty under health and safety legislation to:
• identify hazards in the workplace;
• remove them where possible;
• mitigate the risks to employees.
If hazards cannot be removed from the workplace, employees should be made aware that they exist and how to avoid them. This can be
effected through training and warning signs. To be effective, warnings signs must:
• clearly identify the hazard(s);
• describe the danger (i.e. electric shock, radiation, etc);
• inform employees what to do or not to do.
The sign must attract an engineer's attention, it must be visible and it must be understandable to the people it is aimed at. Additionally, in
the maintenance industry, it must be durable enough to remain effective, often for years, in areas where dust and the elements can be
present.
Positive recommendations are more effective than negative ones. For example, the statement 3 "Stay behind yellow line on floor" is better
than "Do not come near this equipment". Warning signs should contain a single word indicating the degree of risk associated with the
hazard: DANGER denotes that the hazard is immediate and could cause grave, irreversible damage or injury. CAUTION indicates a hazard of
lesser magnitude. The sign should also detail how to avoid or manage the risk. CAUTION signs are generally yellow and black. DANGER signs
use red, black and white.
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Figure 9.1: "Caution" and "Danger" signs
Engineer's Individual Responsibilities

The legislation notes that every individual in a workplace also has health and safety responsibilities.
Every aircraft maintenance engineer should be aware that he can influence the safety of those with whom he works.
Thus, in an aircraft maintenance organisation, the health and safety policy might include statements applicable to engineers such as the
need to:
• Take reasonable care of the health and safety of themselves and others who may be affected by their acts or omissions at work;
• Co-operate with the maintenance organisation to ensure that statutory requirements concerning health and safety at work are met;
• Work in accordance with any safety instruction and/or training received;
• Inform their supervisor or management of work situations that represent an immediate or potential danger to health and safety at work
and any shortcomings in protection arrangements;
• Not interfere intentionally or recklessly with, nor misuse, anything provided in the interests of health and safety.
The attitude of an individual engineer, team or maintenance organisation (i.e. organisational culture) can have a significant impact on
health and safety. Individuals who display an antiauthority attitude, are impulsive, or reckless are a danger in aircraft maintenance.
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Safety in the Working Environment

Engineers should ensure that they keep the working environment safe. Clutter, rubbish, etc. is not only a nuisance to others, but can
constitute a danger (e.g. a trip hazard, fire hazard, etc.).
In addition, engineers should be careful when working on the line not to leave objects when a job has been completed. Foreign Object
Damage (FOD) is a risk to aircraft operating at an airfield.
Safety When Working On Aircraft

Before operating or working on aircraft system, an engineer should carry out clearance checks around moveable surfaces (e.g. flying
controls, landing gear, flaps, etc.). Deactivation procedures should be followed (e.g. pull circuit breakers, isolate valves, disconnect power,
etc.). Notification of deactivation through the provision of adequate placard in key locations is essential to inform others of system status.
Dealing with Emergencies

Careful handling of health and safety in the maintenance environment should serve to minimise risks. However, should health and safety
problems occur, all personnel should know as far as reasonably practical how to deal with emergency situations.
Emergencies may include:
• An injury to oneself or to a colleague;
• A situation that is inherently dangerous, which has the potential to cause injury (such as the escape of a noxious substance, or a fire).
Appropriate guidance and training should be provided by the maintenance organisation. The organisation should also provide procedures
and facilities for dealing with emergency situations and these must be adequately communicated to all personnel. Maintenance
organisations should appoint and train one or more first aiders.
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The basic actions in an emergency are to:
• Stay calm and assess the situation
Observe what has happened;
Look for dangers to oneself and others;
Never put oneself at risk.
• Make the area safe
Protect any casualties from further danger;
Remove the danger if it is safe to do so;
Be aware of ones own limitations (e.g. do not fight a fire unless it is practical to do so).
• Assess all casualties to the best of ones abilities (especially if one is a qualified first aider)
• Call for help
Summon help from those nearby if it is safe for them to become involved;
Call for local emergency equipment (e.g. fire extinguisher);
Call for emergency services (ambulance or fire brigade, etc.).
• Provide assistance as far as one feels competent to.
Emergency drills are of great value in potentially dangerous environments. Aircraft maintenance engineers should take part in these
wherever possible. Knowledge of what to do in an emergency can save lives.
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Risk Assessment
A risk assessment is an important step in protecting aircraft maintenance staff, as well as complying with the law. It helps you focus on the
risks that really matter in your workplace - the ones with the potential to cause real harm. In many instances, straightforward measures can
readily control risks, for example ensuring spillages are cleaned up promptly so people do not slip, or cupboard drawers are kept closed to
ensure people do not trip. The law does not expect you to eliminate all risk, but you are required to protect people as far as 'reasonably
practicable'.
This is not the only way to do a risk assessment, there are other methods that work well, particularly for more complex risks and
circumstances. However, this method is the most straightforward for most organisations.
What is risk assessment?

A risk assessment is simply a careful examination of what, in your work, could cause harm to people, so that you can weigh up whether you
have taken enough precautions or should do more to prevent harm. Workers and others have a right to be protected from harm caused by
a failure to take reasonable control measures.
Accidents and ill health can ruin lives and affect your business too if output is lost, machinery is damaged, insurance costs increase or you
have to go to court. You are legally required to assess the risks in your workplace so that you put in place a plan to control the risks.
How to assess the risks in your workplace

Follow the five steps:
• Identify the hazards
• Decide who might be harmed and how
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• Evaluate the risks and decide on precaution
• Record your findings and implement them
• Review your assessment and update if necessary
Do not overcomplicate the process. In many organisations, the risks are well known and the necessary control measures are easy to apply.
You probably already know whether, for example, you have employees who move heavy loads and so could harm their backs, or where
people are most likely to slip or trip. If so, check that you have taken reasonable precautions to avoid injury.
If you run a small organisation and you are confident you understand what's involved, you can do the assessment yourself. You don't have
to be a health and safety expert.
If you work in a larger organisation, you could ask a health and safety adviser to help you. If you are not confident, get help from someone
who is competent. In all cases, you should make sure that you involve your staff or their representatives in the process. They will have useful
information about how the work is done that will make your assessment of the risk more thorough and effective. But remember, you are
responsible for seeing that the assessment is carried out properly.
When thinking about your risk assessment, remember: a hazard is anything that may cause harm, such as chemicals, electricity, working
from ladders, an open drawer etc; the risk is the chance, high or low, that somebody could be harmed by these and other hazards, together
with an indication of how serious the harm could be.
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Training Handbook

Basic Aircraft Maintenance Airframe Powerplant

Basic Aircraft Maintenance

Knowledge Levels — Category A, B1, B2 and C Aircraft Maintenance Licence

Module 15.1 Enabling Objectives

Objective Reference Level

The need to take human factors into account 9.1 2

Incident attributable to human factors/ human error

Module 15.1 General

The Need To Take Human Factors Into Account

What is "Human Factors"?

Thus, human factors include such attributes as:

The SHEL Model

Software (e.g. maintenance procedures, maintenance manuals, checklist layout, etc.);

Figure 1.1: SHEL Model.

Incidents and Accidents Attributable To Human Factors / Human Error

Causes/major contributory factors % of accidents in which this was a factor

• Pilot deviated from basic operational procedures 33

Examples of Incidents and Accidents

• Incident involving Boeing 737, G-OBMM near Daventry, on 23 February 1995.

Aloha flight 243

British Airways flight 5390

• There were staff shortages;

Incidents and Accidents - A Breakdown in Human Factors

Figure 1.3: The Error Chain.

The Choice is Very Simple (Dr. Reason)

Another way of putting it is to say:

There is bad news and good news:

The bad news

• frequent removal and replacement of many parts

• often under severe time pressure.

The good news

• Maintenance-related errors are not random events.

Knowledge Levels — Category A, B1, B2 and C Aircraft Maintenance Licence

Attention and Perception _________________________________________________________________________________________ 20

Module 15.2 Enabling Objectives

Objective Reference Level

Attention and Perception

Claustrophobia and physical access

Module 15.2 Human Performance and Limitations

Human Performance as Part of the Maintenance Engineering System

The Basic Function of the Eye

Figure 2.1: The human eye

Components of the Eye

The Iris and Pupil

Factors Affecting Clarity of Sight

Physical factors such as:

• physical imperfections in one or both eyes (short sightedness, long sightedness),

The influence of ingested foreign substances such as-

Environmental factors such as:

• amount of light available,

Factors associated with object being viewed such as:

• size and contours of the object,

Each of these factors will now be examined in some detail.

Figure 2.2: Standard test for the "blind spot"

Figure 2.3: Farsighted focus

Figure 2.4: Nearsighted focus

Other visual problems include: