1.5 The Meaning of Human Factors: Maintenance

1.
5 THE MEANING OF HUMAN FACTORS

— CONCEPTS AND DEFINITIONS
1.5.1 Human Factors as a term has to be clearly defined because when these words are
used in the vernacular they are often applied to any factor related to humans. One
definition of Human Factors which is accepted by ICAO was proposed by Professor
Elwyn Edwards and declares that “Human Factors is concerned to optimize the
relationship between people and their activities, by the systematic application of human
sciences, integrated within the framework of systems engineering”. Its objectives can be
seen as effectiveness of the system, which includes safety and efficiency, and the well-
being of the individual. Professor Edwards further elaborates on his proposed definition,
indicating that the word “people” includes both sexes, and that “activities” indicates an
interest in communication between individuals and in the behaviour of individuals and
groups. Lately, this has been expanded upon to include the interactions among
individuals and groups and the organizations to which they belong, and to the
interactions among the organizations that constitute the aviation system. The human
sciences study the structure and nature of human beings, their capabilities and
limitations, and their behaviours both singly and in groups. The notion of integration
within systems engineering refers to the Human Factors practitioner’s attempts to
understand the goals and methods as well as the difficulties and constraints under which
people working in interrelated areas of engineering must make decisions. Human
Factors uses this information based on its relevance to practical problems.
1.5.2 A simpler and more practical definition has been published by the United
Kingdom Health and Safety Executive:
“Human Factors refer to environmental, organisational and job factors, and human
and individual characteristics which influence behaviour at work in a way which can
affect health and safety.”
1.5.3 Human Factors is therefore about people in their living and working situations;
about their relationships with 1-7 Chapter 1. Why Human Factors in Aircraft
Maintenance
machines, with procedures and with the environment around them; and also about
their relationships with other people. In aviation, Human Factors involves a set of
personal, medical and biological considerations for optimal aircraft, aircraft
maintenance and air traffic control operations.
1.5.4 It can be helpful to use a conceptual model to aid in the understanding of Human
Factors. One practical diagram to illustrate this conceptual model uses blocks to
represent the different components of Human Factors. The model can then be built up
one block at a time, with a pictorial impression being given of the need for matching the
components.
THE ROLE OF MANAGEMENT
2.3.1 Organizations in socio-technical systems have to allocate resources to two distinct

objectives: production and safety. In the long term, these are clearly compatible goals;
but given that resources are finite, there are likely to be many occasions when there will
be short-term conflicts of interest. Resources allocated to the pursuit of production (see
Figure 2-1) could diminish those available to safety and vice versa. When facing this
dilemma, organizations with inadequate structures may emphasize production
management over safety or risk management. Although a perfectly understandable
reaction, it is ill-advised and contributes to additional safety deficiencies.
2.3.2 As a complex socio-technical system, aviation requires the precise coordination of
a large number of
human and mechanical elements for its functioning. It also possesses elaborate safety
defences. Accidents in such a system are the product of the conjunction of a number of
enabling factors, each one necessary but in itself not sufficient to breach system
defences. With constant technological progress, major equipment failures or operational
personnel errors are seldom the root cause of breakdowns in system safety defences.
Instead, these breakdowns are the consequence of human decision-making failures
which occur primarily within managerial sectors.
2.3.3 Analysis of major accidents in technological systems has clearly indicated that the
preconditions to disasters can be traced back to identifiable organizational deficiencies.
It is typical to find that a number of undesirable events, all of which may contribute to
an accident, define an “incubation period” which is often measured in terms of years,
until a trigger event, such as an abnormal operating condition, precipitates a disaster.
Furthermore, accident prevention activities in sociotechnical systems recognize that
major safety problems do not belong exclusively to either the human or the technical
components. Rather, they emerge from as yet little understood interactions between
people and technology. The environment in which these interactions take place further
influences their complexity.
2.3.4 A superficial management response to organ-izational-induced maintenance errors

is to ask why the procedures are not being followed. The short answer, as provided by
Taylor and Christensen in their book Airline Maintenance Resource Management,
would be as follows:
“If the process isn’t being adhered to, first consider the process design itself to be
faulty, not the individual. Understanding and compliance issues must be included in
the design. Employees are not to blame when the system makes it hard for them to
understand and comply with expectations. The process design needs to be improved.”
2.3.5 People are the most important resource in any aircraft or equipment maintenance
organization. The manner in which management deals with its people will significantly
affect the organization’s output both in terms of production and standards. The ADAMS
project report summarizes this point as follows:
“An organisation, which ignores, or feels threatened by, quality reports, or which
cannot take effective action in response to serious incidents, which reacts punitively
when people make well intentioned mistakes, or which makes unrealistic or
inappropriate demands, will see 2-4 Human Factors Guidelines for Aircraft
Maintenance Manual
ilil/liIlin ies Outages iillin Ifit iifllf liii iitiliDiiifiliiA delcate and compex balancng act
RESOURCES Avaiable money Equipment/plant Personnelexpertise Avaiable tme
DECSION MAKERS SAFETY GOALS Outcome reatively uncertaInjurEvents
Accdents etc. FEEDBACK Defensve fiters Outcome reatively certaPRODUCTON
GOALS Rate Range ProMarket share etc. FEEDBACK Successndicated negatively
Traditonal measures noisy and deceptive Indirect and discontinuous Little reinorcement
vaue of itseOnly achieves high saence after accdent or near-mss Successndicated
posvely Readiy and relably gauged rect and contnuous Obvously reinorcng Saent and
imperative Source: Human Error James Reason. 1990. . Cambridge Universty Press.
Figure 2-1. A summary of some of the “• Marginalised: human factors
factors that contribute to fallible, high- programmes can
level decision making the skill and
professionalism of its people go towards
protecting themselves and not towards become marginalised in a
improving the separate department or
organisation.” specific ‘champion’ who has little
influence when
decisions are taken. A lack of
perceived effective-
An “open” culture which encourages ness leads to the weakening and
upward com ultimate end of the
munication and responds to constructive
programme.
criticism will,
therefore, have a positive effect on the
organization.
“• One sided: many human factors
programmes have
2.3.6 Experience both in Europe and the a single focus, often on training
United for example. When
States has shown that Human Factors people then return to their
initiatives are not previous work environ-
always entirely successful. The European ment after training, disillusion
Community occurs if that
ADAMS project report lists the following environment has not changed and
as the most the old ways of
common reasons: working are still reinforced.
ERGONOMICS AND HUMAN FACTORS
2.7.1 The term ergonomics is used in many States to refer strictly to the study of human-
machine system design issues. However, in many countries the terms ergonomics and
Human Factors are used interchangeably. The Human Factors Training Manual (Doc
9683), Part 1, Chapter 4, defines the difference between the two as one of emphasis.
Human Factors has acquired a wider meaning, including aspects of human performance
and system interfaces which are not generally considered in the mainstream of
ergonomics
POSSIBLE FATIGUE MANAGEMENT INTERVENTIONS

1. INTRODUCTION
1.1 Interventions to minimize the effects of fatigue can be taken by both the individuals
themselves and AMO management.
1.2 Individuals, such as the certifying staff in a maintenance organization, have an obvious
responsibility for their own fitness for work. That fitness can be impaired by various factors
such as illness, prescribed drugs, non-prescribed drugs (legal or non-legal), eyesight, fatigue
and sleep. Some States have passed legislation to regulate these aspects.
1.3 Management and those in supervisory roles in a maintenance organization also have
responsibilities for their staff and the environment in which they work.
2. STEPS TO MINIMIZE EFFECTS OF FATIGUE
The United Kingdom Civil Aviation Authority document Aviation Maintenance Human Factors
(CAP 716) suggests the following steps in order to minimize the effects of fatigue on personnel
when working shifts:
• Avoid excessive working hours;
• Allow as much regular night sleep as possible;
• Minimize sleep loss;
• Give the opportunity for extended rest when night sleep has been disrupted;
• Take into account reduced physical and mental capacity at night;
• Take into account individual circumstances;
• Provide organizational support services;
• Give opportunity for recovery;
• Rotate shifts towards the biological day, i.e. rotate to later rather than earlier shifts;
• Minimize night shifts through creative scheduling;
• Provide longer continuous rest periods when the week includes more than two night
shifts;
• Allocate more critical tasks during day shifts when staff are likely to be more alert;
• Make appropriate (additional) checks on work performed by a night shift; and
• Break down lengthy repetitive tasks into smaller tasks, with breaks in between
Maintenance resource management
Aviation maintenance is a complex and demanding endeavor. Its success, which is

ultimately measured by the safety of the flying public, depends on communication and
teamwork. Aviation maintenance operations are most successful when crews function as
integrated, communicating teams -- rather than as a collection of individuals engaged in
independent actions.
Over the past decade, the importance of teamwork in the maintenance setting has been
widely recognized.1,2,3,4,5,6,7,8 The result has been the emergence of human factors training,
Maintenance Resource Management (MRM) programs, and other team-centered activities
within
the aviation maintenance community.
Maintenance Resource Management is a general process for improving communication,
effectiveness, and safety in airline maintenance operations. Effectiveness is measured through
the reduction of maintenance errors, and improved individual and unit coordination and
performance. MRM is also used to change the "safety culture" of an organization by
establishing a pervasive, positive attitude toward safety. Such attitudes, if positively reinforced,
can lead to changed behaviors and better performance.
Safety is typically measured by occupational injuries, ground damage incidents, reliability,
and airworthiness. MRM improves safety by increasing the coordination and exchange of
information between team members, and between teams of airline maintenance crews.
The details of MRM programs vary from organization to organization. However, all MRM
programs link and integrate traditional human factors topics, such as equipment design, human
physiology, workload, and workplace safety. Likewise, the goal of any MRM program is to
improve work performance and safety. They do this by reducing maintenance errors through
improved coordination and communication.
Not surprisingly, a prerequisite for implementing successful MRM is the will to do so. As
with any program intended to be diffused throughout an organization, MRM must have the
positive, explicit, and demonstrated support of senior management.
A typical MRM training program addresses each of the following components:
1. Understanding the maintenance operation as a system
2. Identifying and understanding basic human factors issues
3. Recognizing contributing causes to human errors
4. Situation awareness
5. Decision-making; Leadership
6. Assertiveness (how to effectively speak up during critical times)
7. Peer-to-peer work performance feedback techniques
8. Stress management and fatigue
9. Coordination and planning
10. Teamwork and conflict resolution
11. Communication (written and verbal)
12. Norms
In this chapter, we describe the background and evolution of MRM. We discuss current
practices and describe some real-life implementation experiences. We present a systems
approach to designing and developing an MRM training program. Finally, we provide a generic
MRM course outline with examples of activities designed to promote the use of MRM skills.
Shift handover
Task and Shift Handovers
The primary objective of handovers is to ensure that all necessary information is
communicated between the out-going and in-coming personnel. Effective task and
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
persons and a place and time for such exchanges to take place.
Organisations should have a recognised procedure for task and shift handovers which
all staff understand and adhere to. This procedure should be listed in the MOE.
Ideally the procedure should provide for sufficient time to be made available by way
of a shift overlap, depending on the complexity of task(s) to be handed over. As a
guideline, 20 to 30 minutes could be considered good human factors practise.
It would also be good practice for the outgoing shift supervisor to leave a contact
telephone number with the incoming shift, in case they have any queries after a
handover has taken place.
Further detailed information is provided in Appendix T concerning task and shift
handovers, and appropriate ways of recording information for handover. Whilst all
essential information (especially the detailed status of tasks) should be recorded in
written form, it is also important to pass this information verbally in order to reinforce
it. This is known as redundancy, or the ‘belt and braces’ approachA
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 appendix
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:
a) The outgoing person’s ability to understand and communicate the important
elements of the job or task being passed over to the incoming person.
b) The incoming person’s ability to understand and assimilate the information being
provided by the outgoing person.
c) A formalised process for exchanging information between outgoing and incoming
people and a place for such exchanges to take place.
18 December 2003
CAP 716 Aviation Maintenance Human Factors (EASA / JAR145 Approved Organisations)
Appendix T Page 5
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 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.
a) 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.
b) 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.
c) 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 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.
d) 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.
18 December 2003
Appendix T Page 6
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.
a) 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.
b) 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?)
c) 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.
d) 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
18 December 2003
Appendix T Page 7
thinking about, and recording, what information should be included in their handover
to the next person or shift.
Table 1 lists the sort of topics that should be covered in the managers’/supervisors’
handover meeting
Table 1 Topics for managers’ shift 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
Problems
Outstanding/in 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
Table 1 Topics for managers’ shift 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
Problems
Solved
Information
AD’s, SB’s, etc.
Company technical notices
Company policy notices
18 December 2003
Appendix T Page 8
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 jobs on the hangar floor or at the workplace. A mutual inspection
and discussion of this nature is called a “Walkthrough
Sign-offs
Research indicates that many maintenance tasks are signed off unseen. In order to
prevent omissions, mis-installations, etc., every maintenance task or group of tasks
should be signed-off. To ensure the task or group of tasks is completed, sign-off
should only take place after completion and appropriate checks. Work by noncompetent
personnel (i.e. temporary staff, trainee, etc.) should be checked by
authorised personnel before they sign-off. The grouping of tasks for the purpose of
signing-off should allow critical steps to be clearly identified.
18 December 2003
Chapter 7 Page 2
NOTE: A “sign-off” is a statement by the competent person performing or supervising the
work, that the task or group of tasks has been correctly performed. A sign-off relates
to one step in the maintenance process and is therefore different to the release to
service of the aircraft.
Signing off small groups of tasks will help prevent situations where a technician is
called away from one task to do another, and the person picking up the previous task
has no record of what has been completed and what has not. If there are accepted
break points at frequent intervals during each main task (ie. the sign-off points),
technicians should be encouraged to continue with the task up to the next break point
without interruption, and only after the sign-off allow themselves to be diverted onto
another task if this is required.
Sign-off points would be determined by the maintenance organisation as appropriate
to the nature of their work.
Sign-offs should be considered a mechanism for helping to ensure that all steps have
been carried out, and carried out correctly, and not primarily as a mechanism for
identifying the responsible person in the event of something going wrong. It is
understood that, in some cases, the person signing-off the task or groups of tasks will
be unable to view or inspect, in detail, the work which has been carried out, but it is
important that that person has a high degree of confidence that the work has been
carried out correctly. If sign-offs end up as purely a paper exercise, where the person
signing off the tasks has little idea whether they have been carried out correctly, the
whole point of the sign-off mechanism will have been lost. It is appreciated that
signing off tasks generates a certain workload, but considered that the safety benefits
outweigh the disbenefits
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
Table 2 Topics for the Supervisors/Certifying Staff Walkthrough Meeting
Jobs/tasks in progress
Workcards being used
Last step(s) completed
Problems encountered
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.
18 December 2003
Appendix T Page 9
way through and it is not certain who will pick this up at a later stage. This section on
task handover should be read in conjunction with the section on Non-Routine Tasks
and Process Sheets.
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 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 1 is an example of a
Task Card.
18 December 2003
Appendix T Page 10
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:
Figure 2 Supplementary Card
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.
GO FAST AIRWAYS
A/C type: B737 MP ref: MS/B737/668
Aircraft Reg: G-OFST
Flight Controls
Additional work card raised: Yes/No
27-00-56 Flap synchronising system Mechanic Inspector
a) Check the cable tensions are correct (mm 27-50-02) B Bloggs 􀁩
stamp
b) With the flaps selected up, disconnect the operating
link from one transmitter gearbox only.
B Bloggs 􀁩
stamp
c) Pressurise the hydraulic system and select flaps down B Bloggs 􀁩
stamp
d) Make sure that the flaps start to move and then the
system cuts out.
B Bloggs 􀁩
stamp
e) Depressurise the hydraulic system and connect the
transmitter operating link.
f) Pressurise the hydraulic system and make sure that
the flaps operate correctly.
Figure 1 Task Card
Defect Action Taken Mechanic Inspector
Reference card 27-00-56.
Card completed fully up to
stage d). Hydraulic system
depressurised but the
transmitter operating link is
not reconnected. Operating
link to be reconnected prior to
performing stage f).
18 December 2003
Appendix T Page 11
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). CAA Airworthiness Notice No. 12 Appendix No. 53
endorses the use of these as a good maintenance practice and necessary to comply
with Part-145.A.50(b). However 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 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.
5 Non-routine Task and Process Sheets
Airworthiness Notice No. 12 Appendix No. 53 was issued as a result of a serious
incident1 where inaccurate and incomplete maintenance documentation was cited as
a contributing factor. It highlights the need to prepare complete documentation prior
to the work being accomplished which clearly and accurately defines the nonscheduled
maintenance task(s) to be undertaken.
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 break down 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.
This Section of the Appendix describes the types of tasks that need Non-Routine Task
Cards or Process Sheets, and what the goals are from a human factors perspective.
1. AAIB report 2/95
18 December 2003
Appendix T Page 12
Developing Non-routine Task Cards or Process Sheets
If a task contains any one of the attributes in the left hand column then an Operator
or maintenance organisation should develop pre-printed task cards; or process sheets
if the task stages are particularly numerous or lengthy. The right hand column
provides the reasons and goals that are to be achieved by the documentation.
Table 3 Non-routine Task Cards
Task Attributes Reason and Goals to be Achieved
Task is Complex 1. Helps to structure the sequence that the various sub tasks will be
performed.
2. Identifies the significant stages in the process.
3. Provides cues and prompts.
4. Helps prevent errors of omission because:-
• The greater the amount of information in a procedural step, the
more likely that items within the step will be omitted.
• Procedural steps that are not obviously cued by preceding actions,
or that do not follow in a direct linear sequence are more likely to be
omitted.
Task involves
multiple Trade
disciplines
1. Identifies what tasks require specialist task disciplines to perform
and certify the work.
2. Ensures that specialist trades are called upon to perform their task
at the correct point in the process.
3. Provides evidence that the specialist task has been performed.
Task that could
extend over shifts
1. Provides clear evidence of what tasks have been performed and
what is outstanding.
2. Compliments the task or shift handover process.
3. Helps prevent errors of omission because:-
• The larger the number of discrete steps in an action sequence, the
greater the probability that one or more will be omitted.
Well practised,
routine tasks where
the consequence of
error is
unacceptably high
(safety or economic
impact).
1. Well practised or routine tasks are susceptible to ‘slips’ and
‘lapses’. Errors of omission are most common in these
circumstances. Examples are:
• Distraction causing the person to ‘lose his place’ upon resumption
of the task. People tend to think they are further along in the task
than they actually are and therefore miss a step out.
• Premature exit. This is moving on to the next job before the previous
one is complete. The last activity in the task is frequently the one
omitted. We are particularly vulnerable to this sort of error when
under time pressure. Examples are not torque tightening a pipe
coupling, wire locking or calling up an engine run for leak checks
2. Written sheets serve as ‘mind joggers’ to prevent forgetting a step
Task involves the
recording of
measurements or
calculations
1. Measurements which are required to be recorded are more likely
to be captured if pre-supplied paperwork is readily available with
the facility to do so. It makes compliance easy.
2. Provides a prompt that recording of data is required.
3. If calculations are required, as in the case of taking measurements
and then selecting shims. Recording the measurements and
providing a place for doing the calculation augments the limited
capacity of the working memoryA
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.
Source: Reason, 19901
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 quotation2 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.
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”.
1. Reason, J.T. (1990) Human Error. New York: Cambridge University Press.
2. Drury, C.G. (1991) Errors in Aviation Maintenance: Taxonomy and Control. In: Proceedings
of the Human Factors Society
35th Annual Meeting, pp. 42-46. Available from http://hfskyway.faa.gov
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CAP 715 An Introduction to Aircraft Maintenance Engineering Human Factors for JAR 66
Chapter 8 Page 2
Further Reading:
a) Reason, J.T. (1990) Human Error. New York: Cambridge University Press.
b) Maddox, M.E. (Ed.) (1998) Human Factors Guide for Aviation Maintenance 3.0.
Washington DC: Federal Aviation Administration/Office of Aviation Medicine -
Chapter 14: Human Error. Available from http://hfskyway.faa.gov
c) Reason, J.T. (1997) Managing the Risks of Organisational Accidents. Aldershot:
Ashgate.
d) Human Factors Digest No. 12: (1995) Human Factors in Aircraft Maintenance and
Inspection (ICAO Circular 253)
1 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’.
1.1 Design-Versus Operator-Induced Errors
1.1.1 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.
1.1.2 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.
1.1.3 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.
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1.2 Variable Versus Constant Errors
1.2.1 In his book “Human Error”, Professor Reason discusses two types of human error:
variable and constant. It can be seen in Figure 22 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.
1.2.2 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.
1.3 Reversible Versus Irreversible Errors
1.3.1 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.
1.3.2 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.
Figure 22 Variable versus Constant Errors.
Target patterns of 10 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 aligning
the rifle sight). Chapanis, 1951
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Chapter 8 Page 4
1.4 Slips, Lapses and Mistakes
1.4.1 Reason highlights the notion of ‘intention’ 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?
1.4.2 Reason then suggests an error classification based upon the answers to these
questions as shown in Figure 23.
Figure 23 Error types based on intention. Source: Reason, 19901
1.4.3 The most well-known of these are slips, lapses and mistakes.
1.4.4 Slips typically occur at the task execution stage, lapses at the storage (memory) stage
and mistakes at the planning stage.
1. Reason, J.T. (1990) Human Error. New York: Cambridge University Press
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
judgement such as mis-selection of bolts when fitting an aircraft windscreen.
Was there intention
in the action?
Was there a prior
intention to act?
Did the actions
proceed as planned?
SUCCESSFUL ACTION
Involuntary or nonintentional
action
Spontaneous or
subsidiary action
Unintentional action
- slip or lapse
Intentional but
mistaken action
YES
YES
YES
NO
NO
NO
NO
YES
Did the actions
achieve the desired
end?
22 January 2002
Chapter 8 Page 5
1.4.5 Violations sometimes appear to be human errors, but they differ from slips, lapses
and mistakes because they are deliberate ‘illegal’ actions, i.e. somebody did
something knowing it to be against the rules (e.g. deliberately failing to follow proper
procedures). Aircraft maintenance engineers may consider that a violation is wellintentioned,
i.e. ‘cutting corners’ to get a job done on time. However, procedures
must be followed appropriately to help safeguard safety.
1.5 Skill-, Rule- and Knowledge-Based Behaviours and Associated Errors
1.5.1 The behaviour of aircraft maintenance engineers can be broken down into three
distinct categories: skill-based, rule-based and knowledge-based behaviour.
1.5.2 Each of these behaviour types have specific errors associated with them.
1.5.3 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 24 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.
1.5.4 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).
1.5.5 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.
Green et al define these:
“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.”
Figure 24 Example of an Action Slip
Correct
decision
Wrong skill
applied
Aircraft
maintenance
engineer is
distracted
Aircraft
maintenance
engineer fails
to monitor
ERROR
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Chapter 8 Page 6
1.5.6 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.
1.5.7 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).
1.6 The ‘Swiss Cheese Model’
1.6.1 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
diagramatically, as several slices of Swiss cheese (and hence the model has become
known as Professor Reason’s “Swiss cheese” model) (see Figure 25).
Figure 25 Reason’s Swiss Cheese Model. Source: Reason, 19901
1. Reason, J.T. (1990) Human Error. New York: Cambridge University Press.
22 January 2002
Chapter 8 Page 7
1.6.2 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. 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.
1.6.3 Defences in aircraft maintenance engineering will be considered further in Section 4.
2 Types of Error in Maintenance Tasks
2.1 As aircraft maintenance engineers are human, errors in the industry are inevitable.
2.2 Examples of errors highlighted in (i) in the box above are incorrect installation of
linereplaceable
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. Examples of errors in (ii) are 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. The actual error type
responsible can be any of those highlighted in the previous section of this document.
2.3 Errors During Regular and Less Frequent Maintenance Tasks
2.3.1 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, Section 2
“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.
2.3.2 When undertaking less frequently performed tasks, there is the possibility of errors
of judgement. 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.
2.4 Violation in Aircraft Maintenance
2.4.1 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
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:
i) an error that results in a specific aircraft problem that was not there before the
maintenance task was initiated;
ii) 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.
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Chapter 8 Page 8
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.
2.4.2 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.
2.4.3 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.
2.4.4 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.
2.4.5 Exceptional violations are typified by particular tasks or operating circumstances
that make violations inevitable, no matter how well intentioned the engineer might
be.
2.4.6 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.
Examples of routine violations are not performing an engine run after a borescope
inspection (“it never leaks”), or not changing the ‘O’ 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
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Chapter 8 Page 9
2.5 Errors Due to Individual Practices and Habits
2.5.1 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.
2.5.2 In addition, engineers may pick up some ‘bad rules’, leading to bad habits during their
working life, as a driver does after passing his driving test. An example of applying a
bad rule is the British Rail technician in the Clapham train accident who had acquired
the practice of bending back old wires rather than cutting them off and insulating
them.
2.6 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 1 errors and Type 2 errors. A Type 1 error
occurs when a good item is incorrectly identified as faulty; a 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).
2.7 Reason’s Study of Aviation Maintenance Engineering
2.7.1 Reason analysed1 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%)
2.7.2 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 B7372
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 26), asking the questions (a) how many ways can this be
1. Reason, J.T. (1997) Managing the Risks of Organizational Accidents. Aldershot: Ashgate.
2. AAIB (1996) Report on the incident to a Boeing 737-400, GOBMM near Daventry on 25
February 1995. Aircraft Accident
report 3/96
22 January 2002
Chapter 8 Page 10
disassembled? (the answer being 1) and (b) how many ways can it be reassembled?
(the answer being about 40,000, excluding errors of omission!).
2.7.3 In the BAC1-111 accident in June 1990, the error was fitting the wrong bolts to the
windscreen. This illustrates well the category of ‘wrong parts’.
Further Reading:
a) Ashworth, W. (1998) Error Management in a 3rd Party Repair Station. In:
Proceedings of 12th Symposium on Human Factors in Aviation Maintenance.
March 1998. Available from http://hfskyway.faa.gov
3 Implications of Errors (i.e. Accidents)
3.1 In the worst cases, human errors in aviation maintenance can and do cause aircraft
accidents. However, as portrayed in Figure 27, 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.
Figure 27 The “Iceberg Model” of Accidents
3.2 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.
Figure 26 Reason’s Bolt and Nuts Example. Source: Reason, 19971
1. Reason, J.T. (1997) Managing the Risks of Organisational Accidents. Aldershot: Ashgate.
1. AAIB (1992) Report on the accident on BAC 1-11, GBJRT over Didcot, Oxfordshire on 10
June 1990. Aircraft Accident
report 1/92.
ABCDEFGH
22 January 2002
Sea level
Minor events
Incidents
Errors
Serious Incidents
Accidents
Iceberg
Chapter 8 Page 11
3.3 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, Section
2 “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 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.
3.4 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.
3.5 When an error occurs in the maintenance system of an airline, the engineer who last
worked on the aircraft is usually considered to be ‘at 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).
3.6 The UK Civil Aviation Authority has stressed in Airworthiness Notice No. 71 (Issue 1,
20 March 2000) 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.).
b) CAA (1999) CAP455: Airworthiness Notices. AWN71. UK Civil Aviation Authority.
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.
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4 Avoiding and Managing Errors
4.1 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.
4.2 Reason refers to the two components of error management as: (i) error containment
and (ii) error reduction.
4.3 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.
4.4 According to Reason1, 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;
• improve the organisation’s intrinsic resistance to human fallibility.
4.5 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.
4.6 Ultimately, maintenance organisations have to compromise between implementing
measures to prevent, reduce or detect errors, and making a profit. Some measures
Error management seeks to:
• prevent errors from occurring;
• eliminate or mitigate the bad effects of errors
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.
22 January 2002
Chapter 8 Page 13
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. Reason1 refers to this as “the unrocked boat” (Figure 28).
Figure 28 The lifespan of a hypothetical organisation through the production -
protection space. Reason, 1997
4.7 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.
4.8 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, Section
1). 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.
Implications of Errors (i.e. Accidents)

3.1 In the worst cases, human errors in aviation maintenance can and do cause aircraft
accidents. However, as portrayed in Figure 27, 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.
Figure 27 The “Iceberg Model” of Accidents
3.2 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.
Figure 26 Reason’s Bolt and Nuts Example. Source: Reason, 19971
1. AAIB (1992) Report on the accident on BAC 1-11, GBJRT over Didcot, Oxfordshire on 10
report 1/92.
ABCDEFGH
Iceberg
Chapter 8 Page 11
3.3 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, Section
2 “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 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.
3.4 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.
3.5 When an error occurs in the maintenance system of an airline, the engineer who last
worked on the aircraft is usually considered to be ‘at 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).
3.6 The UK Civil Aviation Authority has stressed in Airworthiness Notice No. 71 (Issue 1,
20 March 2000) 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.).
Occurrence Management System (OMS)

concepts
Introduction
An occurrence management system is a generic name given to any system which
enables the reporting and follow-up of safety related events or hazards, whether
minor or major, whether voluntarily or mandatory, whether anonymous or attributable
and whether computerised or not. The aim of such a system is to learn from events,
and to either prevent them from happening again, or to ensure that they are unlikely
to result in adverse outcomes (in the extreme case, aircraft accidents).
Occurrence management is more than just occurrence reporting; it also includes
investigation of reported occurrences to an appropriate level of detail in order to
discover their root causes, and follow up in terms of action and feedback to reportees.
An occurrence management system should be closed-loop.
Occurrence Management System Examples
There are many schemes, mechanisms and databases which fall within the
description of an occurrence management system, the majority of which are
described in the Global Aviation Information Network (GAIN) report (issue 2). There
are many more which are just reporting schemes, and do not include investigation of
occurrences, identification of remedial action, follow-up or feedback mechanisms.
Maintenance organisations will probably already have a system for reporting
mandatory occurrences to the CAA, and a system for reporting quality discrepancies
internally. If these systems incorporate some form of investigation of those
occurrences and discrepancies, and follow up action, they will fall into the description
of occurrence management systems.
This CAP is concerned specifically with internal company schemes which provide a
mechanism for reporting and investigating those occurrences which might not
otherwise be reported and/or investigated, in particular those where the contributory
factors are likely to have been human factors related. Such schemes may also be
expanded to be proactive as well as reactive, and include reporting and investigation
of hazards which have not (yet) resulted in an incident or event. Alternatively,
organisations may have separate proactive schemes for the identification of hazards,
e.g. the Maintenance Error Safety Health (MESH) scheme developed by Professor
Jim Reason for British Airways. (Such schemes are not discussed further in this
appendix).
The UK CAA Mandatory Occurrence Reporting (MOR) scheme is an example of an
occurrence management system. Organisations report occurrences to the CAA. Each
reported occurrence is assessed to determine whether it warrants further
investigation or not. Investigation occurs to determine root causes. Results are
recorded, and action is taken where considered appropriate. Finally, information is
fedback to reportees in the form of summary data.
Internal company OMSs can go further than the MOR scheme in several respects:
i) reporting and investigating lower level occurrences, as well as those meeting
the MOR criteria
18 December 2003
Appendix J Page 2
ii) more thorough investigation of occurrences and determination of root causes
iii) tailoring remedial action to the root causes
iv) using the results from investigated incidents within human factors training
v) feeding back information to company employees in an appropriate form
The term Maintenance Error Management System (MEMS) was developed by the
CAA to describe the key elements of an occurrence management system in a
maintenance context.
The Maintenance Error Decision Aid (MEDA), developed by Boeing and industry, has
become the most commonly used type of Maintenance Error Management System
across the world, in aviation maintenance. MEDA is described further in this chapter,
and a copy of the MEDA form is included in Appendix K.
Maintenance Error Management System (MEMS) concepts
The elements of a Maintenance Error Management System are described in AN71
(Appendix H). They are:
• Clearly identified aims and objectives
• Demonstrable corporate commitment with responsibilities for the MEMS clearly
defined .
• Corporate encouragement of uninhibited reporting and participation by individuals
• Disciplinary policies and boundaries identified and published
• An event investigation process
• The events that will trigger error investigations identified and published
• Investigators selected and trained
• MEMS education for staff, and training where necessary
• Appropriate action based on investigation findings
• Feedback of results to workforce
• Analysis of the collective data showing contributing factor trends and frequencies
A MEMS does not prescribe the use of any one particular taxonomy or method for
investigating incidents. However, the MEDA system1, and MEDA derivatives, are
consistent with MEMS principles, and considered an appropriate mechanisms for
investigating incidents.
Maintenance Error Decision Aid (MEDA)2
The following text has been adapted from an article published in Boeing AERO
magazine, issue 03, with permission.
1. MEDA was designed for aircraft maintenance organisations. A version suitable for
component maintainers is available
from BainesSimmons Ltd.
2. Whilst Boeing encourages organisations to use MEDA, and even provides its customers with
free MEDA training, it had
copywrited the term 'MEDA' in order to prevent organisations selling on possibly inappropriate
adaptations of MEDA
training. Contact Boeing for further details.
18 December 2003
Appendix J Page 3
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 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
18 December 2003
Appendix J Page 4
union, and the U.S. Federal Aviation Administration. The result was a basic five-step
process for operators to follow
• Event.
• Decision.
• 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.
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.
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
1. Appoint a manager in charge of MEDA and assign a focal organization.
2. Decide which events will initiate investigations.
3. Establish a plan for conducting and tracking investigations.
4. Assemble a team to decide which prevention strategies to implement.
5. Inform the maintenance and engineering workforce about MEDA before
implementation.
18 December 2003
Appendix J Page 5
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.
Maintenance error management system (MEMS)
The overall culture of the organisation must embrace the objectives of the MEMS. It
is particularly important that the most senior members of management openly
endorse the programme and this acceptance is demonstrated by all levels of
management through their active participation in the process whenever appropriate.
Staff should be encouraged to report errors, hence the need for a disciplinary code
that recognises this element of management policy. The two elements of
organisational policy, MEMS and disciplinary procedures, must, however, be clearly
separate.
Errors can be caused by human failings alone. However, most frequently a procedural
or system fault/error can induce the apparent human failure. It is important therefore
to ensure the root causes of a maintenance error are identified and rectified. The
rectification process should apply to systems and procedures as well as to individuals.
The Process
1) A formal company procedure should be produced that outlines the general
principles of the MEMS, the objectives of the procedure and the benefits to the
individual and to the organisation. Responsibilities of individuals for operating the
MEMS process should be clearly defined. A flow chart is useful in clarifying the
process.
2) All staff should be aware of the MEMS in their organisation, its aims and
objectives, through a process of education. A training programme for all staff to
be subject to the process is now a requirement of JAR-145. Senior management
participation in this training will demonstrate their support for the System.
3) A core of staff members with appropriate communications skills should receive
additional training in interviewing staff involved in incidents and compiling
documentation. This is necessary to ensure that the maximum, accurate,
information is obtained from the individuals involved. It also ensures consistency
of application of the procedures and acquisition and treatment of data from the
process. These individuals must be seen to be impartial in carrying out their
duties in the programme. They should span Line, Base and Outstations as
appropriate.
4) Events that will trigger an investigation should be defined and publicised to all
staff involved directly in the maintenance of aircraft.
5) The reporting format to be used for MEMS should be the Maintenance Error
Decision Aid, MEDA, originated by Boeing, to the latest revision standard: CHIRP
has produced a CD1 for the purpose. This is a structured process to determine
1. Contact either CHIRP or osdhf@srg.caa.co.uk for a free copy.
18 December 2003
Appendix L Page 3
factors and root causes when investigating maintenance errors and determining
possible corrective actions for the future.
6) By using the CHIRP software, completed reports from participating organisations
can be readily transmitted to CHIRP and collected into a common, disidentified,
database for use by all the participants in the Programme. In this way individual
company performance can be compared with a wider spectrum of data; overall
trends can be identified and actions to remedy problems highlighted.
7) Maintenance errors should be reported initially within a defined timescale to the
person with overall responsibility for the MEMS. These reports may use a
common report form with MORs
8) The investigation and interview process should be directed by, and the declared
responsibility of, a senior manager in the maintenance department. This is often
the manager responsible for airworthiness or the Quality department manager.
9) Timescales for commencing the investigation and interview process should be
part of the procedure.
10) Staff with a thorough, up-to-date, knowledge of the work area involved should be
engaged in the investigation and interview process.
11) Interviews should be conducted in a calm and quiet atmosphere, free from
interruptions. It is important to put the interviewee at ease and not led into a
defensive posture. Where it is determined that the company disciplinary
procedure should be invoked, the interview should be terminated, the
interviewee advised, and the disciplinary procedure started by a member of
management who has had no previous involvement with that particular inquiry.
12) Actions designed to correct identified causes of error need to be practical and
effective and the results capable of being measured, wherever possible. A named
individual should be responsible for their implementation with agreed timescales.
13) Recommendations from an investigation should be subject to a further
independent review, within a stated timescale, at a senior, impartial, level of
management for endorsement, implementation and subsequent reassessment
as to the effectivity of the corrective actions taken.
14) Safety information and lessons learned from finalised reports should be widely
disseminated within the organisation especially to those working in maintenance
areas.
15) A company database of the information acquired in the course of carrying out
these investigations should be built from the outset. This should be capable of
analysis to determine significant causes of error and trends. Periodic review and
comparisons with the wider CHIRP database may produce information leading to
additional action to correct longer-term trends.
16) As part of an overall review of company performance, senior management, and
in particular the Accountable Manager, should review periodically the results of
database analyses.
Peer Pressure
4.1 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.
4.2 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 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.
4.3 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.
4.4 Experiments in Conformity
4.4.1 Asch1 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 14). He asked this question under different conditions:
• where the individual was asked to make the judgement 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”
4.4.2 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 considerable
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.
1. Asch, S. (1951) Effects of Group Pressure upon the Modification and Distortion of
Judgement. in Groups, Leadership and
Men (Ed.) Guetzkow, M H. (1951). Pittsburgh: Carnegie
(B is the same length as X)
Figure 14 An experiment to illustrate conformity. Source: Asch, 1951
XABC
22 January 2002
Chapter 3 Page 9
individual differences: some participants never conformed, and some conformed all
the time).
4.4.3 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.
4.4.4 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).
4.5 Countering Peer Pressure and Conformity
4.5.1 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.
4.5.2 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 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.
Time Pressure and Deadlines

3.1 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 selfimposed,
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).
3.2 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.
3.3 The Effects of Time Pressure and Deadlines
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.
Source: AAIB, 19921
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.
1. AAIB (1992) Report on the accident to BAC 1-11, G-BJRT over Didcot, Oxfordshire on 10
Report 1/92.
22 January 2002
Chapter 4 Page 7
Source: NTSB, 19891
3.4 Managing Time Pressure and Deadlines
3.4.1 One potential method of managing time pressures exerted on engineers is through
regulation. For example, FAA research has highlighted the need to insulate 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).
3.4.2 Those responsible for setting deadlines and allocating tasks should consider:
• 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.
.
Circadian Rhythms
5.2.1 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.
5.2.2 Although, circadian rhythms are controlled by the brain, they are influenced and
synchronised by external (environmental) factors such as light.
5.2.3 Figure 18 shows the circadian rhythm for body temperature. This pattern is very
robust, meaning that 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.
1. Gross, R. (1996) Psychology: The Science of Mind and Behaviour (3rd edition). London:
Hodder and Stoughton.
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).
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.
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Chapter 4 Page 13
5.2.4 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
A conceptual Model of Human Factors

4.1 It is helpful to use a model to aid in the understanding of Human Factors, as this
allows a gradual approach to comprehension. One practical diagram to illustrate this
conceptual model uses blocks to represent the different components of Human
Factors. The model can then be built up one block at a time, with a pictorial impression
being given of the need for matching the components. The SHEL concept (the name
being derived from the initial letters of its components, Software, Hardware,
Environment, Liveware) was first developed by Edwards in 1972, with a modified
diagram to illustrate the model developed by Hawkins in 1975. For those familiar with
the long-established concept of ”man-machine-environment” (now referred to as
”human-machine-environment”), the following interpretations are suggested:
liveware (human), hardware (machine) and software (procedures, symbology, etc.),
environment (the situation in which the L-H-S system must function). This building
block diagram does not cover the interfaces which are outside Human Factors
(hardware-hardware; hardware-environment; software-hardware) and is only
intended as a basic aid to understanding Human Factors.
4.2 Liveware. In the centre of the model is a person, the most critical as well as the most
flexible component in the system. Yet people are subject to considerable variations
in performance and suffer many limitations, most of which are now predictable in
general terms. The edges of this block are not simple and straight, and so the other
components of the system must be carefully matched to them if stress in the system
and eventual breakdown are to be avoided.
Figure 1 The SHEL model as modified by Hawkins
H
LE
L
S
S = Software (procedures,
symbology, etc.)
H = Hardware (machine)
E = Environment
L = Liveware (human)
In this model the match or
mismatch of the blocks (interface)
is just as important as the
characteristics of the blocks
themselves. A mismatch can be
a source of human error.
15 February 2002
CAP 719 Fundamental Human Factors Concepts
Chapter 1 Page 4
4.3 In order to achieve this matching, an understanding of the characteristics of this
central component is essential. Some of the more important characteristics are the
following:
a) Physical size and shape. In the design of any workplace and most equipment, a
vital role is played by body measurements and movements, which will vary
according to age and ethnic and gender groups. Decisions must be made at an
early stage in the design process, and the data for these decisions are available
from anthropometry and biomechanics.
b) Physical needs. People’s requirements for food, water and oxygen are available
from physiology and biology.
c) Input characteristics. Humans have been provided with a sensory system for
collecting information from the world around them, enabling them to enable him
to respond to external events and to carry out the required task. But all senses are
subject to degradation for one reason or another, and the sources of knowledge
here are physiology, sensory psychology and biology.
d) Information processing. These human capabilities have severe limitations. Poor
instrument and warning system design has frequently resulted from a failure to
take into account the capabilities and limitations of the human information
processing system. Short- and long-term memory are involved, as well as
motivation and stress. Psychology is the source of background knowledge here.
e) Output characteristics. Once information is sensed and processed, messages
are sent to the muscles to initiate the desired response, whether it be a physical
control movement or the initiation of some form of communication. Acceptable
control forces and direction of movement have to be known, and biomechanics,
physiology and psychology provide such knowledge.
f) Environmental tolerances. Temperature, pressure, humidity, noise, time of day,
light and darkness can all be reflected in performance and also in well-being.
Heights, enclosed spaces and a boring or stressful working environment can also
be expected to influence behaviour and performance. Information is provided here
by physiology, biology and psychology.
4.4 The Liveware is the hub of the SHEL model of Human Factors. The remaining
components must be adapted and matched to this central component.
4.5 Liveware-Hardware. This interface is the one most commonly considered when
speaking of human-machine systems: design of seats to fit the sitting characteristics
of the human body, of displays to match the sensory and information processing
characteristics of the user, of controls with proper movement, coding and location.
The user may never be aware of an L-H deficiency, even where it finally leads to
disaster, because the natural human characteristic of adapting to L-H mismatches will
mask such a deficiency, but will not remove its existence. This constitutes a potential
hazard to which designers should be alert.
4.6 Liveware-Software. This encompasses humans and the non-physical aspects of the
system such as procedures, manual and checklist layout, symbology and computer
programmes. The problems are often less tangible in this interface and are
consequently more difficult to resolve (for example, misinterpretation of checklists or
symbology).
4.7 Liveware-Environment. The human-environment interface was one of the earliest
recognized in flying. Initially, the measures taken all aimed at adapting the human to
the environment (helmets, flying suits, oxygen masks, anti-G suits). Later, the trend
was to reverse this process by adapting the environment to match human
15 February 2002
CAP 719 Fundamental Human Factors Concepts
Chapter 1 Page 5
requirements (pressurization and air-conditioning systems, soundproofing). Today,
new challenges have arisen, notably ozone concentrations and radiation hazards at
high flight levels and the problems associated with disturbed biological rhythms and
related sleep disturbance and deprivation as a consequence of the increased speed
of transmeridian travel. Since illusions and disorientation are at the root of many
aviation accidents the L-E interface must consider perceptual errors induced by
environmental conditions, for example, illusions during approach and landing phases.
The aviation system operates within the context of broad political and economical
constraints, and those aspects of the environment will interact in this interface.
Although the possibility of modifying these influences is beyond Human Factors
practitioners, their incidence is central and should be properly considered and
addressed by those in management with the possibility to do so.
4.8 Liveware-Liveware. This is the interface between people. Aircrew training and
proficiency testing have traditionally been done on an individual basis. If each
individual crew member was proficient, then it was assumed that the team consisting
of these individuals would also be proficient and effective. This is not always the case,
however, and for many years attention has increasingly turned to the breakdown of
teamwork. Flight crews function as groups and group influences play a role in
determining behaviour and performance. In this interface, we are concerned with
leadership, crew co-operation, teamwork and personality interactions. CAP 720
(previously Human Factors ICAO Digest No. 2) describes current industry approaches
to deal with this interface, and concerns cockpit resource management (CRM) and
line-oriented flight training (LOFT) programmes. Staff/management relationships are
also within the scope of this interface, as corporate climate and company operating
pressures can significantly affect human performance. CAP 720 also demonstrates
the important role of management in accident prevention.
Planning, Preparation and Teamwork
1 Planning and Preparation
Planning is critical to human factors in that it should aim to ensure that there are
adequate appropriately qualified and alert personnel, tools, equipment, material,
maintenance data and facilities at the right place, at the right time, for the scheduled
(and, as far as is possible, unscheduled) tasks. Indeed, Part-145 states that an
organisation may only maintain an aircraft (or aircraft component) when all necessary
facilities, equipment, tooling, material, maintenance data and certifying staff are
available.
It is not the purpose of this CAP or of Part-145 to tell planners how to do their jobs
but, rather, to highlight some of the human factors issues which they should be taking
into account in the planning process, such as human performance limitations when
working shifts and long hours.
Depending on the amount and complexity of work generally performed by the
maintenance organisation, the planning system may range from a very simple
procedure to a complex organisational set-up including a dedicated planning function
in support of the production function.
The production planning function includes two complimentary elements:
• scheduling the maintenance work ahead, to ensure that it will not adversely
interfere with other maintenance work as regards the availability of all necessary
personnel, tools, equipment, material, maintenance data and facilities.
• during maintenance work, organising maintenance teams and shifts and provide all
necessary support to ensure the completion of maintenance without undue time
pressure.
When establishing the production planning procedure, AMC-145.A.47(a)(3) states
that consideration should be given to the following:
• logistics;
• inventory control;
• square meters of accommodation;
• hangar availability;
• man-hours estimation;
• man-hours availability;
• preparation of work;
• co-ordination with internal and external suppliers, etc.;
• scheduling of safety-critical tasks during periods when staff are likely to be most
alert, and avoiding periods when alertness is likely to be very low, such as early
mornings on night shifts.
Further information concerning fatigue and shiftwork can be found in chapter 4.
Part-145 requires an organisation to have a maintenance man-hour plan showing that
the organisation has sufficient staff to plan, perform, supervise, inspect and quality
monitor the organisation. In addition, the organisation must have a procedure to
18 December 2003
Chapter 8 Page 2
reassess work intended to be carried out when actual staff availability is less than the
planned level for any particular work shift or period.
It is important that planners attend human factors training, in order to better
appreciate how good or bad planning can potentially affect human performance and,
ultimately, safety and airworthiness.
Factors Associated with the Individual

1 Introduction
CAP 715 addresses human performance an limitations, therefore this chapter will not
go into too much detail in these areas except where topics are particularly relevant to
organisational human factors (e.g. taking into account fatigue when planning
maintenance tasks), or to specific requirements in Part-145.
Error and violations, whilst factors associated with the individual, are covered
separately in Chapter 3, but again from an organisational perspective rather than from
a theoretical human performance and limitations perspective. Further information on
the theory of error may be found in CAP 715.
Generally when we talk about factors associated with the individual, we are talking
about influences which may lead to a person making errors or mistakes. These factors
can be both internal and external, and include influences such as physical fitness,
fatigue, stressors, noise, distraction, etc. There are also factors which may possibly
be associated with violations, such as personality type, assertiveness, etc.
Factors potentially influencing performance include:
• physical fitness;
• physiological characteristics such as visual acuity, colour vision, hearing, etc.;
• personality;
• attitude, professional integrity, motivation;
• arousal level, low arousal (boredom), excessively high arousal (stress), stressors;
• alertness, fatigue, tiredness, shiftwork, sleep, circadian rhythms;
• distractability, attention span, concentration, multi-tasking ability, situation
awareness;
• information processing capability, memory, perception, intelligence
• knowledge level, awareness of knowledge level, experience, recency;
• cultural influences, company culture, national culture, norms.
Further information concerning most of these factors may be found in basic textbooks
on human factors and psychology and in CAP715. However, a couple of the topics are
discussed in greater detail below (and in the associated appendices), where they are
particularly pertinent to organisational human factors and safe operations.
2 Fitness for Work
Certifying staff working on a JAR66/Part-66 license “must not exercise the privileges
of their certification authorisation if they know or suspect that their physical or mental
condition renders them unfit to exercise such privileges”. This includes blood-alcohol
level, drugs & medication, eyesight, colour vision and psychological integrity.
Worth of particular mention is that there is now UK legislation1 in place to allow police
to conduct drink and drugs tests on anyone performing a safety critical role in UK civil
1. http://www.railways.dft.gov.uk/safetybill/pdf/safetybill.pdf
18 December 2003
Chapter 4 Page 2
aviation, including flight crew, air traffic controllers and licensed aircraft engineers.
The limit for aircraft maintenance engineers is 80 milligrams of alcohol per 100
millilitres of blood, ie. the same as the blood/alcohol limit for driving a car.
Readers are referred to Appendix N which contains a copy of AN47. Note: AN47 may
be updated from time to time therefore readers are advised to consult CAP 455, or
the CAA website, for the latest issue of AN47.
3 Shiftwork and Fatigue
Fatigue has been reported as one of the factors contributing towards maintenance
errors.
Part-145 requires planners to take into account human performance limitations when
organising shifts and planning work. AMC-145.A.47(a) includes "scheduling of safety
critical tasks during periods when staff are likely to be most alert" as one of the items
which should be taken into account during planning. The AMC also states that
"Limitations of human performance, in the context of planning safety related tasks,
refers to the upper and lower limits, and variations, of certain aspects of human
performance (circadian rhythm/ 24 hour body cycle) which personnel should be aware
of when planning work and shifts."
The JAA MHFWG report provides some limited guidelines for minimising fatigue and
its impact. More comprehensive guidance is also provided in Appendix P of CAP 716,
and in CAP715.
The UK implementation of the EU Working Time Directive applies to the majority of
aviation maintenance personnel (non mobile workers) and provides working time
limitations including limits on:
• maximum hours per week (48);
• night work;
• rest time and holiday.
However, staff may agree to opt out of these limits under certain circumstances and
to work longer hours if they wish. Further details are given in Appendix P, but readers
are referred to the primary legislation for definitive information.
NOTE: It should be remembered that the EU Directive was based upon health and social
needs, and not upon aviation safety needs.
The CAA recently sponsored a study concerning best practice for shiftwork and work
hours. This study was carried out by Professor Simon Folkard, and the results have
been published in CAAP 2002/06 "Work Hours of Aircraft Maintenance Personnel"
(March 2003), and are summarised in Appendix P.
At the time of writing this document, Transport Canada were in the process of
drafting an NPA on management of fatigue within the context of a Safety
Management System. Further details will be available, in due time, on www.tc.gc.ca.
Fatigue and shiftwork are discussed further below, much of the information having
been extracted and adapted from some of the sources referenced in Appendix Z.
18 December 2003
Chapter 4 Page 3
3.1 Fatigue
The term ‘fatigue’ has many meanings1 and can include physical fatigue (e.g. muscle
soreness, oxygen debt, or extreme tiredness caused by sleep deprivation, illness or
poor nutrition), mental fatigue (e.g. associated with tasks demanding intense
concentration, rapid or complex information processing and other high level cognitive
skills) or emotional fatigue (the wearying effect of working under trying conditions or
performing psychologically disagreeable tasks). There is often no clear distinction
between these types of fatigue, and it is probably more useful to look at fatigue in
terms of the various criteria by which it is recognised.
The concept of fatigue is more easily understood through common experiences than
through quantitative research. It is not possible to measure fatigue directly, as one
might measure blood pressure or the length of a person's hand. Fatigue is indirectly
measurable through its effects. For example, you can measure the number of errors
committed per unit time on a particular task. If the person doing that task continues
without rest long enough, the number of errors he or she commits increases. At
some point, you would conclude that the person is fatigued. Working long hours,
working during normal sleep hours, and working on rotating shift schedules all
produce fatigue-like effects, although the mechanisms are different for each
situation.
Symptoms of fatigue (in no particular order) may include:
• a lack of awareness;
• diminished motor skills;
• diminished vision;
• slow reactions;
• short-term memory problems;
• channelled concentration - fixation on a single possibly unimportant issue, to the
neglect of others and failing to maintain an overview;
• easily distracted by unimportant matters, or, in the other extreme, impossible to
distract;
• increased mistakes;
• poor judgement;
• poor decisions, or no decisions at all;
• abnormal moods - erratic changes in mood, depressed, periodically elated and
energetic;
• diminished standards.
AN 47 (Appendix N) provides the following advice concerning fatigue:
“Fatigue: Tiredness and fatigue can adversely affect performance. Excessive hours
of duty and shift working, particularly with multiple shift periods or additional
overtime, can lead to problems. …Individuals should be fully aware of the dangers of
impaired performance due to these factors and of their personal responsibilities.”
1. Stokes, A., Kite, K. Flight Stress: Stress, Fatigue and Performance in Aviation. 1994.
18 December 2003
Chapter 4 Page 4
The best cure for acute fatigue is sleep - and this means restful sleep, not disturbed
by the effects of alcohol or caffeine. Chronic long-term fatigue may take longer to
eliminate, and may require professional advice.
3.2 Shiftwork
The central problem in aviation maintenance is that many, perhaps most, routine
tasks are performed during night-time hours, when people are more prone to errors,
so that the aircraft can fly and produce revenue during the daytime. In addition,
maintenance tasks often span more than one shift, requiring information to be passed
from one shift to the next. Shift handover is the source of many errors.
The length of each work period also affects the error-producing effects of fatigue. In
some industries, work periods are longer than in others. For example, workers in
nuclear power plants are commonly scheduled to work 12-hour shifts. Whilst longer
shifts may result in greater fatigue, the disadvantages may be offset by the fact that
fewer shift changeovers are required (ie. only 2 handovers with 2 twelve hour shifts,
as opposed to 3 handovers with 3 eight hour shifts). However, if personnel rotate
between shifts, shorter shifts may allow for greater flexibility in shift rotation, than
longer shifts.
There is a great deal of research on shiftwork and what are good and bad shifts from
the purely scientific perspective. However, one must take into account the whole
context when considering shift patterns, including what is acceptable to the staff and
management within an organisation, the trade-off between length of shift and
number of handovers, the pattern of work to be done, etc. There is no single ideal
shift system. Organisations must select whatever shift system is most appropriate to
Table 1 Fatigue Management
Shift personnel fatigue may be minimised by:
• Avoiding excessive working hours
• Allowing as much regular night sleep as possible;
• Minimising sleep loss;
• Giving the opportunity for extended rest when night sleep has been disrupted;
• Taking into account reduced physical and mental capacity at night;
• Taking into account individual circumstances;
• Providing organisational support services;
• Giving the opportunity for recovery.
• Rotating shifts toward the biological day, i.e., rotate to later rather than earlier shifts.
• Minimising night shifts through creative scheduling
• Providing longer rest periods following night shifts
• Within a week providing longer continuous rest periods when the week includes more
than 2 night shifts
The impact of fatigue may be minimised by:
• Allocating more critical tasks during day shifts when staff are likely to be more alert
• Ensuring that appropriate checks are carried out after night shift work
• Breaking up lengthy repetitive tasks into smaller tasks, with breaks in between
18 December 2003
Chapter 4 Page 5
the company and staff, but should take into account the scientific advice which is
available.
The EU Working Time Directive states:
“..research has shown that the human body is more sensitive at night to
environmental disturbances and also to certain burdensome forms of work
organization and that long periods of night work can de detrimental to the health of
workers and can endanger safety at the workplace.”
The connections among shiftwork, morale, productivity and safety are not simple.
The shift patterns which would appear to be the best ‘scientifically’, may be unpopular
among workers and the poor morale which may arise if these are implemented may
outweigh the benefits to the individual in terms of physiological adaptation. However,
safety should always be the overriding factor when choosing shift patterns and
rosters, taking into account all possible factors which may affect vulnerability to error.
It is important that organisations and shift workers fully appreciate this.
From a human factors perspective, we are especially interested in shift- and schedulerelated
problems that are reflected in degraded maintenance performance. Listed
below are some of the most common issues and problems which may occur. It is
stressed that these issues and problems are neither necessarily nor entirely caused
by shiftwork or scheduling. Many work-related and personal factors can contribute to
most of the items described below.
Higher Absentee Rate
Particular shifts and schedules can cause workers to be away from work more often
than people who work on more "normal" schedules. There are several factors that
contribute to higher absenteeism. Shift workers tend to have more health problems
than non-shift workers. A fairly innocuous cold, when coupled with the increased
fatigue due to night work, can cause increased use of sick leave. Family-related
issues, such as childcare and companionship, can cause workers to take short periods
of time off. More serious incidents, such as an extended sickness in the family, can
force shiftworkers to juggle their personal and work lives.
Higher Error Rate
Elevated error rates are directly associated with mental and physical fatigue.
Shiftwork and shift schedules can contribute to fatigue by disrupting normal wakesleep
cycles, forcing extended working hours, and increasing personal and familyrelated
stress. The first abilities to be compromised by fatigue are those related to
cognitive processing, decision making, and judgement. Unfortunately, these are the
very abilities that come into play when making safety-related maintenance decisions.
In addition, the fact that aviation maintenance organisations tend to be 24-hour
operations means that some tasks are inevitably distributed across multiple shifts.
Poor shift turnover procedures, especially the communication aspect of shift
turnover, has been implicated in a number of serious aviation accidents. The fatigue
that accompanies working on the night shift causes shift handover procedures to
assume added importance.
The unavoidable fact is that most aviation maintenance occurs during night-time
hours, which we know to be especially conducive to human error. There is nothing
we can do to fundamentally alter human physical and psychological responses to
night work, at least in the long term. We should expect, therefore, to experience
many human errors and must tailor our procedures to provide ample opportunities to
catch and fix these errors before they affect our workers or the flying public.
18 December 2003
Chapter 4 Page 6
Physical and Psychological Problems
There are many studies linking shiftwork, especially rotating shiftwork and especially
working at night, to a variety of physical, emotional, and psychological problems.
Because aviation maintenance workers tend to be permanently assigned to a specific
shift, it is reasonable to be concerned about the long-term effects of night work.
Unfortunately, we have very few answers in this regard. We can't even say with
certainty that working on the night shift causes the problems with which it is
statistically associated.
About the best we can do to address this issue is to provide coping processes that
allow night-time workers to maintain a semblance of normal sleeping patterns and
then closely monitor their physical and psychological conditions.
Increased Injuries
Most athletes understand that their risk of injury increases when they are tired or not
paying attention. This is also true for industrial workers. Just as cognitive (thinking)
errors increase with increased fatigue, so do physical errors, which result in personal
injuries. All of the elements that we described above, such as loss of judgement,
contribute to the increased likelihood that a worker will be injured.
Dissatisfaction and Poor Morale
The combination of long hours, disrupted wake-sleep cycles, increased instances of
domestic conflict, and higher workloads is an obvious source of poor morale and
dissatisfaction among shift workers. As a performance shaping factor, emotional
issues are potent causes of poor job performance.
Lower Productivity
One of the primary reasons for working on shifts and longer hours on each shift is to
utilise human and capital resources more efficiently. For example, expensive hangar
and maintenance equipment isn't earning a return if it is idle. Also, working slightly
longer shifts reduces the amount of non-productive time at the beginning and end of
each shift. It is somewhat ironic that engaging in a practice that can increase
productivity when used sparingly can actually decrease productivity when used
excessively. To use an extreme example, people cannot produce twice as much
output if they work 24 instead of 12 hours. Planning and production managers should
take this into account.
Higher Attrition Rate
Humans can only take so much physical and mental stress. Many workers may opt
to simply go elsewhere rather than endure a shift schedule that causes constant
fatigue and family stress. It is costly and wasteful to lose skilled aviation maintenance
workers.
4 Fatigue and shiftwork models
A few models have been developed, based on sound scientific principles and
research, which attempt to highlight when workers are likely to reach unacceptable
levels of fatigue. They generally require, as an input, roster details. The model
developed by the Centre for Sleep Research (University of Southern Australia) is one
example. Further details can be obtained from www.unisa.edu.au/sleep and a
demonstration copy of the fatigue model can be downloaded from http://
www.interdyne.com.au.
18 December 2003
Chapter 4 Page 7
There is also a CAA sponsored1 fatigue model which has been developed by the
Centre for Human Sciences, at QinetiQ, primarily for flight crew. The "System for
Aircrew Fatigue Evaluation" may also be applicable to ground personnel, but at the
time of writing this document, the model had only been applied to, and validated on,
flight crew and flight operations, nor had it yet been formally released for use.
Dirty Dozens
Due to a large number of aircraft accidents or incidents related to maintenance, transport

Canada identified twelve factors that degrade people’s ability to perform effectively and safely.
These factors are known as dirty dozen.
Lack of communication:
Lack of communication is a key human factor that can result in a faulty maintenance.
It can occur during shift change while one technician transfers a partially completed task.
Complacency
Complacency is a human factor that typically develops over time. As a technician gains
experience and knowledge over time, self satisfaction and false confidence may develop. A
repetitive task, particularly inspection item may be overlooked or skipped because the
technician has performed it a number of times without finding a fault.
When a technician performing a task without documentation or documenting a task without
performing it is a sign of comlacancy.
To combat complacency, one should be mentally engaged with the task being performed. All
inspection items must be treated with equal importance. Technician should never sign for any
work that has not been performed.
Lack of knowledge
Lack of knowledge while performing aircraft maintenance can result in a faulty repair that can
have catastrophic results. All the maintenance should be performed to required standard in
accordance with approved instructions.
Distraction
Distraction while performing aircraft maintenance can disrupt the procedure. When work
resumes, technician can skip the details that need attention. A good practice is that one should
go back three steps in the work procedure while distracted and resume work from that point.
Lack of teamwork
Teamwork is required in aviation maintenance in many instances. Teamwork involves everyone
understanding and agreeing on actions to be taken. Lack of teamwork makes all jobs more
difficult.
Fatigue
Fatigue is a major human factor that has contributed to many maintenance errors resulting in
accidents. Fatigue can be both physical and mental in nature. Fatigue reduces cognitive power,
reaction time and decision making power and alertness.
Tiredness is a symptom of fatigue. A remedy for fatigue is to get enough sleep on a regular
basis.
Pressure
Lack of resources
Stress
Lack of awareness
Norms
Norms is short for normal. They are unwritten rules followed by most organizations to solve the
problems. Taking shortcuts in aircraft maintenance, working from memory are unsafe norms.
Lack of assertiveness
Assertiveness is the ability to express your opinions, beliefs and feelings in a positive and
productive manner. For example, addressing your manager and supervisor directly by stating
the problem.
How environmental factors affect stress
The environmental factors such as noise, heat, weather elements impair the effectiveness of
employees and cause stress. Working under extreme cold or hot could cause discomfort to the
individuals. If noise level is high, then it can distract the workers.
Aviation maintenance is a stressful task due to several reasons. Maintenance has to be carried
out within certain time frame to avoid flight delays or cancellations. If maintenance is not done
correctly, it could result in tragedy.

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1.

5 THE MEANING OF HUMAN FACTORS

2.3.1 Organizations in socio-technical systems have to allocate resources to two distinct

2.3.4 A superficial management response to organ-izational-induced maintenance errors

POSSIBLE FATIGUE MANAGEMENT INTERVENTIONS

2. STEPS TO MINIMIZE EFFECTS OF FATIGUE

• Avoid excessive working hours;

• Allow as much regular night sleep as possible;

• Minimize sleep loss;

• Take into account reduced physical and mental capacity at night;

• Take into account individual circumstances;

• Provide organizational support services;

• Give opportunity for recovery;

• Minimize night shifts through creative scheduling;

• Make appropriate (additional) checks on work performed by a night shift; and

Maintenance resource management

Aviation maintenance is a complex and demanding endeavor. Its success, which is

Table 1 Topics for managers’ shift handover meeting

Implications of Errors (i.e. Accidents)

Occurrence Management System (OMS)

Maintenance error management system (MEMS)

Time Pressure and Deadlines

A conceptual Model of Human Factors

Factors Associated with the Individual

Due to a large number of aircraft accidents or incidents related to maintenance, transport

How environmental factors affect stress

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