MS CHADEMOYO

HUMAN FACTORS
What is human factors?

 It refers to the study if human capabilities and

limitations in the workplace.
 The interaction of maintenance personnel
 Equipment they use
 The written and verbal procedures they use
and the rules they follow
 And environmental conditions of any system
Definitions

 Airplane accident – an occurrence associated

with the operation of an airplane that takes
place between the times any person boards
the airplane with the intention of flight and
such a time as all such persons have
disembarked in which;
 Airplane sustains substantial damage,
 Death or serious injury results from;
 Being in or upon the airplane
 Direct contact with the airplane or anything
attached thereto
 Direct exposure to jet blast
HULL LOSS

 Airplane damage that is substantial and is

beyond economic repair.
 Hull loss also includes events in which,
1. Airplane is missing
2. Search for the wreckage has been terminated
without it being located
3. Airplane is substantially damaged and
inaccessible
Substantial damage

 Damage or structural failure that adversely

affects the structural strength, performance
or flight characteristics of the aircraft and
would normally require major repair or
replacement of the affected component
Substantial damage is not

 Engine failure or damage limited to an engine

if only one engine fails or is damaged.
 Bent aerodynamic fairings
 Dents in the skin
 Damage to landing gear
 Damage to wheels
 Damage to tyres
 Damage to flaps
Fatal accident

 An accident that results in fatal injury

Fatal injury

 An injury that results in death within 30days

as a result of an accident
Serious injury

 An injury in an accident that;

 Requires hospitalization for more than 48
hours that begins within 7 days of the date of
injury
 Results in fracture of any bone( except simple
fractures of fingers toes or nose).
 Produces lacerations that result in severe
haemorrhage or nerve, muscle or tendon
damage
 Involves injury to an internal organ
 Involves 2nd or 3rd degree burns over 5% or
more of the body
 Involves verified exposure to infectious
substance or injurious radiation
Excluded events

 Fatal and non fatal injuries from natural causes

 Fatal and non fatal self inflicted injuries.
 Fatal and non fatal injuries of stowaways.
 Experimental test flight accidents
 Nonfatal injuries resulting from atmospheric
turbulence, manoeuvring, loose objects, boarding,
dis-embarking, evacuation and maintenance and
servicing
 Nonfatal injuries to persons not on-board the
aircraft
Regional identification

 Events are identified by the operators

national domicile and by event location
Airplane collisions

 Events involving two or more airplanes are

counted as separate events, one for each
airplane.
 For example , destruction of two airplanes in
a collision is considered two separate hull loss
accidents.
Accidents rates

 It is a measure of accidents per million

departures
Human factors

 This chapter examines the relationship

between human factors and incidents largely
in terms of human error and “ Murphy’s Law”
(i.e. if it can happen, one day it will).
 It is also known as crew resource
management
 Or ergonomics
 It can be described as fitting the man to the
job and the job to the man.
Human factors

 Why do smart people do dangerous / dumb

things?
Its attributes

 Human physiology, psychology (including

perception, cognition, memory, social
interaction, error, etc.);
 Work place design
 Environmental conditions
 Human machine interface
 Anthropometrics (the scientific study of
measurements of the human body)
Contribution of human
factors
Who does Human Factors?

 Multi-Disciplinary HF Specialists
 Some:
1. Psychologists
2. Engineers
3. Doctors
4. Kinesiologists
5. Retrained Subject Matter Experts … Yes, it is
possible to retrain engineers (pilots and doctors)
6. Scientists
Goal of human factors
training
 To provide practical Human factors guidance
based on issues concerned with aircraft
maintenance and inspection.
 To show how human capabilities and
limitations can influence task performance
and safety within the maintenance and
inspection environments
What is not Human Factors?

 “Just applied common sense”

 Training people to accommodate poor design
 Blaming the user - “Pilot error”
 Designers projecting their skills onto users - If
it’s easy for the designer it must be easy for
the end user
 Human Resources
SHEL

 Thanks to modern design aircraft are

becoming more amore reliable.
 However it is not possible to redesign the
human being, we have to accept the fact that
humans are intrinsically unreliable.
 We can work around that unreliability by
providing good training, procedures, tools,
duplicate inspections etc.
Examples of accidents

 Accident to Boeing 737 (Aloha flight 243),

Maui, Hawaii, April 28 1988
 BAC One-Eleven, G-BJRT (British Airways
flight 5390), over Didcot, Oxford shire, 10
June 1990
 Airbus A32o, G-KMAM at London Gatwick
Airport, 26 August 1993
 Boeing 737, G-OBMM near Daventry, 23
February 1995
Human error

 Estimates of human error contribution to

accidents has increased over the years, from a
low of 20% in the 1960s to values in excess of
80% in the 1990s
STATISTICS

 Pilot deviated from basic operational procedures 33

 Inadequate cross-check by second crew member 26

 Design faults 13

 Maintenance & inspection deficiencies 12

 Absence of approach guidance 10

 Captain ignored crew inputs 10

STATISTICS (Cont’d)

 Air traffic control failures or errors 9

 Improper crew response during abnormal conditions 9

 Insufficient or incorrect weather information 8

 Runaways hazards 7

 ATC/crew communication deficiencies 6

 Improper decision to land 6

Class work

 Identify human factors within the control of

the individual and those which are not
Accidents caused by human
factors

?
THE DIRTY DOZEN

 Lack of teamwork
 Fatigue
 Lack of parts/resources
 Pressure
 Lack of assertiveness
 Stress
 Lack of awareness
 Norms
 Lack of knowledge
 Lack of communication
 Complacency
Safety culture and Org
factors
 It is based on what actually goes on within an
organisation on a day to day basis, and not on
rhetoric or superficial, short term safety
initiatives.
Safety culture and Org
factors
Safety culture and Org
factors
 The culture of an organisation can be
described as “the way we do things here”. It is
a group or company norm.
Definition

 A set of beliefs, norms, attitudes, roles and

social and technical practices concerned with
minimizing exposure of employees,
managers, customers and members of the
general public to conditions considered
dangerous or hazardous.
 It is judged by what is done not what is said.
Social culture

 It considers at an individuals background or

heritage.
 Internal pressures and conflicts can be driven
by underlying social cultural differences (e.g.
different nationalities, different political
views, different religious beliefs, etc.)
Social culture

 Safety culture is an amalgamation of the

attitude, beliefs and actions of all the
individuals working for the org and each
person should take responsibility for their
own contribution towards this culture,
ensuring that it is positive contribution rather
than negative.
MEMS

 The CAA is declaring its policy on

Maintenance Error Management Systems
such that maintenance organizations, in
particular those maintaining large
commercial aircraft, are encouraged to adopt
the concept.
 They should contain the following elements
 Clearly identified aims and objectives
 Demonstrate corporate commitment with
responsibilities for the MEMS clearly
identified
 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.

 The aim of the system is to identify the

factors contributing to incidents, and to make
the system resistant to similar errors.
Maintenance error

 It is considered to have occurred when the

system , including the human element, fails
to perform in the manner expected in order
to achieve its safety objectives.
Human error

 “It is the nature of man to err”. Cicero, Roman

philosopher.
 “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 change
agency.” Prof James Reason
Error models and theories

 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”
Design versus operator induced errors

 Errors may be made by aircraft designers.

 It may be maintained well but safety is still
compromised
 Flawed procedures put in place by an airline
or MO or ATC management may lead to
problems
Variable versus constant errors

 Variable errors are random in nature

 Constant errors follow a consistent
systematic (yet erroneous) pattern
 Constant errors are predictable
 Variable errors cannot be predicted
Reversible versus irreversible errors

 If a pilot miscalculates the fuel he should

carry, he may have to divert to a closer
airfield, but if he dumps his fuel, he may not
have many options open to him.
 A well designed system or procedure should
mean that errors made by maintenance
engineers are reversible.
Slips, lapses and mistakes

 Slips can be thought of as actions not carried

out as intended or planned, e.g. ‘transposing
digits when copying out numbers, or
misordering steps in a procedure.
 Lapses are missed actions or omissions e.g.
forgetting to replace an engine cowling.
 Mistakes are errors brought about by a faulty
plan/intention, i.e. doing something believing
it to be correct when it was, In fact wrong.
Skill, rule and knowledge based behaviours and associated errors

 Skill based behaviours are those that rely on

routines or motor programmes that have
been learned and may be executed without
conscious thought.
 Rule based behaviours are those for which a
routine procedure has been learned
 Knowledge based behaviour are those for
which knowledge and experience are used to
solve a problem. No procedure has been
established.
The ‘Swiss Cheese Model’

 There are defences set up against human

error.
 Examples are;
1. Duplicate inspection
2. Pilot pre-flight functional checks etc., which help
to ‘trap’ human errors, reducing likelihood of
negative consequences.
3. These defences have been portrayed as slices of
cheese.
Types of errors

 Errors in industry
 In aircraft maintenance they take two specific
forms;
1. Errors that result in a specific a/c problem that
was not there before but the maintenance task
was initiated
2. An error that results in an unwanted or unsafe
condition remaining undetected while
performing a maintenance task designed to
detect a/c problems, i.e. something is missed.
Errors during regular and less frequent maintenance tasks

 Frequently performed tasks are prone to

complacency, environmental capture and rule
based errors.
 however, errors if engineers do not keep up-to-
date with any changes that occur to frequently
used procedures.
 In less frequently performed tasks, there is a
possibility of error of judgement.
 An engineer may mistakenly select the wrong
procedure or parts
Violation

 Routine violation
 Situational violation
 Optimizing violation
 Exceptional violation
Routine violation

 ‘The normal way of doing things’, within the

person’s workgroup.
 Engineers may believe that procedures may
be over prescriptive and violate them in order
to simplify a task (cutting corners), to save
time and effort.
Situational violation

 Occur due to particular factors that exist at

the time, such as time pressure, high
workload, unworkable procedures and poor
working conditions.
 These occur when, in order to get the job
done, engineers consider that a procedure
cannot be followed.
Optimizing violation

 Involve breaking the rule for ‘kicks’. These are

often quite unrelated to the actual task.
 The person just uses the opportunity to
satisfy a personal need.
Exceptional violation

 Are typified by particular tasks or operating

circumstances that make violations
inevitable, no matter how well intentioned
the engineer might be.
Errors due to individual practices and
habits

 Where procedures allow some leeway,

aircraft maintenance engineers often develop
their own strategies or preferred way of
carrying out a task.
 Often a good rule or principle is one that has
been successfully used in the past. They then
become rules of thumb for everyday use.
 Problems occur when the rule or principle is
wrongly applied.
Visual errors

 Type 1 errors – occur when a good item is

incorrectly identified as faulty
 Type 2 errors – when a faulty item is missed,
these are the dangerous ones.
Causes of accidents

 Omissions 56%
 Incorrect installation 30%
 Wrong parts 8%
 Other 6%
Reason’s bolt and nuts
example
 Omissions can occur for many reasons either
deliberate or accidental.
 Incorrect installation is unsurprising, as there
is usually only one way in which something
may be taken apart but many possible ways
in which it can be reassembled.
The Iceberg Model

 Accidents are the observable manifestations

of error.
 Like an iceberg which has most of its mass
beneath the waterline, the majority of errors
do not result in actual accidents.
Incidents

 Errors that do not cause accidents but still

cause a problem are called incidents.
 They do not become serious because of
defences built into the maintenance system.
 They are important as the may warn of a
potential future accident should the error
occur in different circumstances.
 All maintenance incidents are to be reported.
Error detection

 Errors made by maintenance engineers are

spotted almost immediately they are made
and corrected.
 The engineer may detect his error, or
colleagues, supervisors or quality control.
Blame

 The engineer who last worked on the aircraft

is usually considered to be at fault.
 Blame does not necessarily act as a positive
force in maintenance – it discourages
engineers from ‘coming clean’ about their
errors.
Avoiding and managing errors

 Error management seeks to

1. Prevent errors from happening
2. Eliminate or mitigate the bad effects of errors
 Two components of error management
1. Error containment
2. Error reduction
Error prevention

 To prevent errors, it is necessary to predict

when they are most likely to occur and put
measures against them.
 Incident reporting schemes such as MORS do
this for the industry as a whole.
 Within an organization, data on incidents,
errors and accidents should be captured on a
safety management system.
Error management measures

 Minimize error liability of individual or team.

 Reduce error vulnerability of particular tasks
or task element.
 Discover, assess and eliminate error
producing factors.
 Diagnose org factors that create error
producing factors within the individual, team
the task or workplace
 Enhance error detection
 Increase the error tolerance.
 Make latent conditions more visible to those
who operate and manage the system.
 Improve the Org intrinsic resistance to human
fallibility.
Minimizing errors

 Since errors cannot be totally eliminated they

should be kept at a minimum.
 Engineers must make sure to follow
procedures.
 Procedures should be correct and usable,
presented in a user friendly manner,
appropriate to the task and context that
engineers are encouraged to follow
procedures an not cut corners.
Compromise

 Maintenance Org have to compromise between

implementing measures to prevent, reduce or
detect errors and making a profit.
 Some measures cost little, others cost a lot.
 Incidents tend to result in short term error
mitigation measures but if an organization has no
incident s for a long time, there is danger of
complacency setting in and cost reduction
strategies eroding defences against error.
 ‘The unrocked boat’
‘The unrocked boat’
Error defences

 Its important orgs balance profit and costs

and try to ensure that defences put in place
are the most cost effective in terms of
trapping errors and preventing catastrophic
outcomes.
Maintenance Eng
responsibilities
 It is the responsibility of maintenance Engs to
take every possible care in his work and be
vigilant for error.
 Maintenance Engs are very conscious of the
importance of their work typically expend
considerable effort to prevent injuries,
prevent damage, and to keep the aircraft
they work on safe.
Recent techniques (MEDA,
MESH)
 Maintenance Error Decision Aid (MEDA) is
used to investigate errors that have already
been committed.
 It thoroughly evaluates all the factors that
contributed to the error and recommends
changes to mitigate those factors.
 It can identify systemic elements that
contribute to a broad range of errors.
MESH

 Managing Engineering Safety Health (MESH)is a

proactive technique aimed at identifying
conditions that favour committing errors.
 It solicits anonymous ratings from maintenance
workers regarding the shortcomings of various
local factors known to contribute to errors.
 It is meant to monitor those factors that
contribute to errors and correct them before they
stray outside of acceptable ranges
Human reliability

 A performance shaping factor (PSF)is

anything that can affect human performance
either positive or negative.
 PSFs are either internal or external.
 External PSFs are outside the individual
worker or user , usually some characteristic of
the workplace , the task, or the Org. eg. Poor
workspace layout, poorly designed tools,
inadequate training, etc.
Internal PSFs

 These come from within the person and are

typically related to skills, stress, or other
physiological, psychological or social
element, eg. High stress, a disruptive social
environment, and low skill
Managing identified hazards

 A risk assessment should made of the causes

and contributory factors and a decision made
as to whether action is required.
 Action may be in the form of a change or
merely monitoring the situation to determine
the risk that is controlled.
 Changes should address both the root causes
of hazards and the detection and trapping of
problems before they can jeopardize flight
safety.
Human performance and limitations

 This chapter provides an overview of those

key physical and mental human performance
characteristics which are likely to affect an
aircraft maintenance Eng in his/her working
environment, such as vision, hearing,
information processing, attention and
perception, memory, judgement and decision
making.
Vision

 Basic function of the eye – the eye is similar

to a camera. Light enters the eye through the
cornea, then passes through the iris and the
lens and falls on the retina.
 Here the light stimulates the light sensitive
cells on the retina (rods and cones) and these
pass small electrical impulses by way of the
optic nerve to the visual cortex in the brain.
Here electrical impulses are interpreted an
image is perceived.
The human eye
The cornea

 It is a clear window at the front of the eye.

 It acts as a fixed focusing device.
 The focusing is achieved by the shape of the
cornea bending the incoming light rays.
 The cornea is responsible for between 70%
and 80% of the total focusing ability
(refraction) of the eye.
The iris and pupil

 The iris (coloured part of the eye) controls the

amount of light that is allowed to enter the
eye.
 It does this by varying the size of the pupil
(the dark area in the centre of the iris).
 The size of the pupil can be changed very
rapidly to cater for changing light.
 The amount of light can be adjusted by a
factor of 5:1
The lens

 Its shape is changed by muscles surrounding

it which results in the final focusing
adjustment to place a sharp image on the
retina.
The retina

 It contains two types of light sensitive cells.

 Cones – function in good light and are
capable of detecting fine detail and are colour
sensitive. This means the human eye can
distinguish about 1000 different shades of
colour.
Rods.

 They cannot detect colour. They are poor at

distinguishing fine detail, but good at
detecting movement in the edge of the visual
field (peripheral vision).
 They are much more sensitive at lower levels.
 As light decreases, the sensing task is passed
from the cones to the rods. This means in
poor light we only see in black and white and
shades of grey.
Factors affecting clarity

 The eye is very sensitive in the right

conditions (clear air, good light). It is 2 times
more sensitive than the ear.
 Visual acuity is the ability to discriminate
sharp detail at varying distances.
 A person with an acuity of 20/20 vision should
be able to see at 20 ft that which the so called
normal person is capable of seeing at this
range.
Factors affecting clarity

 Physical factors such as physical

imperfections in one or both eyes (short
sightedness, long sightedness) and age
 Influence of ingested foreign substances i.e.
1. Drugs
2. Medication
3. Alcohol
4. Cigarettes.
Factors affecting clarity

 Environmental factors i.e.

1. Amount of light available
2. Clarity of the air.
 Factors associated with object being viewed
such as;
1. Size and contours of the object
2. Contrast of the object
3. Relative motion of the object
4. Distance of the object from the viewer
5. The angle of the object from the viewer
Physical factors

 Hypermetropia – long sight is caused by a

shorter than normal eyeball which means
that the image is formed behind the retina
Short sight

 Also known as Myopia is where the eyeball is

longer than normal causing the image to be
formed in front of the retina.
Physical factors

 Other visual problems include;

1. Cataracts – clouding of the lens
2. Astigmatism– a misshapen cornea causing
objects to appear irregularly shaped;
3. Glaucoma – a build up of pressure of the fluid
within the eye which can cause damage to the
optic nerve and even blindness.
4. Migraine –severe headaches that can causes
visual disturbances.
Physical factors

 As a person grows older the lens becomes less

flexible this is known as Presbyopia and is a form
of long sightedness.
 After the age of 40, spectacles may be needed for
near vision, especially in poor light conditions.
 With foreign substances i.e. Smoking, CO which
builds up in the bloodstream allows less O₂ to be
carried in the blood to the eyes.
 This is known as Hypoxia. Alcohol has similar
effects.
Environmental factors

 Vision can be increased by increasing the

lighting levels. Also increased light could
result in increased glare.
 Human eyes take time to adapt to a different
lighting environment 7 minutes for cones and
30 minutes for rods.
 When moving between a bright hanger to a
dark apron area at night an engineer must
wait for his eyes to adjust (adapt).
Environmental factors

 Any airborne particles such as dust, can

interfere with transmission of light through
the air, distorting what is seen.
 This can be worse with spectacles as they can
dirty, wet, misted or scratched.
Colour vision

 Good colour vision for maintenance

engineers is important for;
1. Recognizing components
2. Distinguishing between wires
3. Using various diagnostic tools
4. Recognizing various light on the airfield
 Colour defective vision is usually hereditary
and occurs more commonly on men.
Are the lines crooked or straight?
Say the colour of the word, not the word itself

Why is it hard?
Vision and the Maintenance
Eng
 It is important to have adequate vision to
meet task requirements particularly for one
involved in inspection tasks.
Visual inspection

 It is a primary method used in a/c

maintenance.
 Tools may be used e.g. magnifiers,
borescopes, to enhance visual capabilities.
 The engineer may use his other senses
(touch, hearing, smell etc.) to manipulate the
element being inspected to make further
judgements about its condition.
Steps for visual inspection

 He should ensure that he understands the area,

component or system asked to inspect.
 Locate the corresponding area, component or
system on the aircraft.
 Make sure the environment is conducive to the
task to ensure all parts are inspected.
 Examine thoroughly any potential degradation
or defect and make a decision
 Record any problem found and search even
further
Visual inspection

 Engineers may find it beneficial to take short

breaks between discrete visual inspection
tasks.
Hearing; the human ear

 The ear is used for detecting sounds by

receiving vibrations.
 It is also used for balance and sensing
acceleration.
 it has three parts.
Human ear
Human ear

 Outer ear – it directs sounds down the

auditory canal and on to the eardrum. The
sound waves will cause the eardrum to vibrate.
 Middle ear – it transmits vibrations from the
eardrum by way of three small bones known as
ossicles to the fluid in the inner ear.
 Inner ear – this is where vibrations in the fluid
are converted to electrical signals which are
transmitted to the brain.
Performance and limitations of an ear

 The ears performance depends on pitch

(frequency), and the volume.
 Audible frequency is 20 Hz to 20 000Hz, with
greatest sensitivity at 3000hz
 Volume is measured in Decibels
Sound levels
Impact of noise

 Annoying
 Interfere with verbal communication
 Cause accidents by masking warning signals
or messages.
 Fatiguing and affect concentration, decision
making etc.
 Damage workers hearing
(permanently/temporarily)
Hearing impairment

 Hearing loss which results from exposure to

noise is known as Noise Induced Hearing Loss
(NIHL).
 It can be from a few seconds, a few days or
permanent.
 Temporary – short exposure or very large
sound
 Permanent – long/regular exposure thus
damaging hearing cells.
Hearing impairment

 At 85 decibels, employer must

1. Assess risk to employees hearing
2. Tell employees about risk and precautions and
provide safety gear
 At 90 dB,
1. Signs to restrict entry
2. Mark zones where noise levels are high
3. Provide hearing protection
 140 dB, the noise causes pain.
Hearing impairment

 Exposure to any sound over 80db constitutes

a noise dose and can be measured over the
day as an 8 hour Time Weighted Average
sound level (TWA).
 Permanent hearing loss may occur if TWA is
above recommended maximum.
Hearing protection

 Noise levels can be reduced by up to 20 db

using ear plugs and 40 db using ear muffs.
 However, using ear protection will tend to
interfere with verbal communication.
 It must be used consistently and as instructed
to be effective.
 Hearing loss due to aging is called
presbycusis
Information processing

 It is the process of receiving information

through the senses, analysing it and making it
meaningful.
Attention and reception

 Attention can be thought of as the

concentration of mental effort on sensory or
mental events.
 It can deal with one item at a time and can
take the form of;
1. Selective attention
2. Divided attention
3. Focused attention
4. Sustained attention.
Selective attention

 It occurs when a person is monitoring several

sources of input, with greater attention being
given to one or more sources which appear
more important.
 Also called the cocktail party effect.
 Distraction is the negative side of selective
attention.
Divided attention

 Its where people are required to do more than

one thing at the same time.
 Usually one task suffers at the expense of the
other, more so if they are similar in nature.
 It is also referred to as time sharing.
Focused attention

 Is merely a skill of focusing ones attention

upon a single source avoiding distraction.
Sustained attention.

 The ability to maintain attention and remain

alert over long periods of time, often on one
task.
 Attention is influenced by arousal level and
stress. This can improve attention or damage
it depending on circumstances.
Perception

 Involves organisation and interpretation of

sensory data in order to make it meaningful,
discarding non-relevant data i.e. transforming
data into information.
 It is a sophisticated mechanism requiring
existing knowledge and experience.
 It is the process of assembling sensations into
usable mental representation of the world.
 Perception creates faces, melodies, works of
art.
Decision making

 It is the generation of alternative courses of

action based on available information,
knowledge, prior experience, expectation,
context, goals etc. and selecting one
preferred option.
 It is also described as thinking, problem
solving and judgement.
Decision making

 Good decisions are based on knowledge

supplemented by written information and
procedures, analysis of observed symptoms,
performance indications etc.
Memory

 It is the ability to act consistently and learn

new things.
 Without memory we could not capture a
stream of information reaching our senses or
draw on past experience and apply this
knowledge when making decisions.
 It is storage of info, experiences and
knowledge as well as ability to retrieve this
info
Memory depends on

 Registration – the input of info into memory

 Storage – the retention of info
 Retrieval – the recovery of info
Memory types

 Ultra short memory

 Short term memory
 Long term memory
Ultra short memory

 It has a duration of up to 2 seconds (sensory

storage) and is used as a buffer, giving us time
to attend to sensory input.
Short term memory

 Duration of short term memory can be

enhanced by rehearsal
Long term memory

 Its capacity is unlimited, it is used to store

info that is currently not being used,
including;
1. Knowledge of the physical world
2. Personal experiences
3. Beliefs about people, social norms, values etc.
4. Motor programmes, problem solving skills and
plans for various activities
5. Abilities such as language comprehension
Motor programmes

 If a task is performed often enough, it may

eventually become automatic and the
required skills and actions are stored in long
term memory.
 The motor programmes are ingrained
routines established through practice.
 They allow us to carry simultaneous activities
such as having a conversation whilst driving.
Situation awareness

 It is a synthesis of an accurate and up to date

‘mental model’ of one’s environment and
state, and the ability to use this to make
predictions of possible future states.
 Feedback improves situation awareness by
informing us of our mental models and their
predictive power.
Situation awareness

 Can be summarized as;

1. The status of the system the engineer is working
on
2. The relationship between the reported defect
and the intended rectification.
3. The possible effect on this work on other
systems
4. The effect of this work on that being done by
others and the effect of their work on this work.
Information processing
limitations
 Because info processing has limitations, the
aircraft engineer, like other skilled
professionals, requires support such as
reference to written material (manuals).
Attention and perception

 A proportion of ‘sensed’ data may be lost

without being perceived.
 When some data is missing, the danger is that
people fill in the gaps with information from
their own store of knowledge or experience,
and this may lead to wrong conclusion.
 They are many well known visual illusions
which illustrate the limits of human perception
Decision making memory and motor
programmes

 Attention and perception impinge on decision

making.
 It is important to bear in mind that human
memory is fallible , so that information
1. May not be stored
2. May be stored incorrectly
3. May be difficult to retrieve
 All these may be referred to as forgetting
which occurs when info is unavailable or
inaccessible
Claustrophobia and other
phobias
 Physical access and claustrophobia
 People may experience various levels of physical
or psychological discomfort when in an enclosed
or small space, which is generally considered to be
quite normal.
 When this discomfort becomes extreme, it is
known as claustrophobia
 Also known as abnormal fear of being in an
enclosed space.
Acrophobia

 It is an abnormal fear of heights.

 Working at significant heights can also be
problem for some aircraft engineers,
especially when doing ‘ crown’ inspections.
 Ultimately, if an engineer finds working high
up brings up phobic symptoms they should
avoid such situations for safety’s sake.
Motivation and demotivation

 It is a basic human drive that arouses, directs

and sustains all human behaviour.
 Generally we say a person is taking action to
achieve something.
 Motivation can either be positive or negative
De-motivation

 Highly motivated people tend to show the

following characteristics.
 High performance and results being consistently
achieved;
 The energy, enthusiasm and determination to
succeed;
 Unstinting co-operation in overcoming problems;
 Willingness to accept responsibility;
 Willingness to accommodate change.
De-motivation

 De-motivated people have the following

characteristics:
 Apathy and indifference to the job, including reduced,
regard for safety whilst working;
 A poor record of time keeping and high absenteeism;
 An exaggeration of the effects/difficulties
encountered in problems, disputes and grievances;
 A lack of co-operation in dealing with problems;
 Unjustified resistance to change.
 Some could be signs of stress
Fitness and health

 Fitness and health of a maintenance engineer

is a factor since the work may be physically
demanding.
Stress; domestic and work
related
 Stress is inescapable to all of us.
 It is defined as any force that when applied to
a system, causes some significant
modification of its form, where forces can be
physical, psychological or due to social
pressures.
Causes and symptoms

 Physical – such as heat, cold, noise, vibration,

presence of something damaging to health.
 Psychological – such as emotional upset,
worries about real or imagined problems.
 Reactive – such as events occurring in
everyday life (eg. Working under time
pressure, encountering unexpected
situations.)
Stress management

 Once we become aware of stress, we generally

respond to it by one of two strategies; defence or
coping.
 Defence involves alleviation of the symptoms or
reducing the anxiety
 Coping involves dealing with source of stress rather
than just symptoms e.g. delegating tasks, prioritizing
tasks etc.
 Coping is whereby the individual adjusts to the
perceived demands of the situation or changes the
situation itself
Arousal

 It refers to readiness of a person for

performing work.
 To achieve optimum level of task
performance, it is necessary to have a certain
level of stimulation or arousal
Factors determining workload

 The degree of stimulation exerted on an

individual caused by a task is generally
referred to as workload and can be separated
into physical and mental workload.
 As the workload of the engineer may vary he
may experience periods of overload and
under load. This is a particular feature in some
areas like line maintenance.
Overload

 It occurs at very high levels of workload

(when the engineer becomes over aroused).
 Error rates increase.
Underload

 It occurs at low levels of workload (when the

engineer becomes under aroused).
 It cause a deterioration in performance and
an increase in errors such as missed
information.
 It can result from a task an engineer finds
boring, very easy or indeed a lack of tasks
Sleep, fatigue and shift
work
 Sleep
 Sleep is a natural state of reduced consciousness
involving changes in body and brain physiology
which is necessary to man to restore and replenish
the body and brain.
 Sleep can be resisted for a time, but various parts
of the brain ensure that sooner or later sleep
occurs.
 It has five stages
Stages of sleep

 Stage 1 – this is transition between waking

and sleeping. The heart rate slows and
muscles relax. It is easy to wake up someone.
 Stage 2 – this is a deeper level of sleep, but it
is fairly easy to wake someone.
 Stage 3 – sleep is even deeper and sleeper
unresponsive to external stimuli and difficult
to wake. Heart rate, blood pressure and body
temperature continue to drop.
Stages of sleep

 Stage 4 – this is the deepest stage of sleep

and it is very difficult to wake someone up.
 Rapid Eye Movement or REM sleep. This
stage is characterized by brain activity of
someone who is awake, but it is more difficult
to wake the person than in stage 4. it is
known a paradoxical sleep. Muscles are
totally relaxed and eyes rapidly dart back and
forth under the eyelids. It is thought
dreaming occurs during REM sleep.
Stages of sleep

 Stages 1-4 are known as non-REM (NREM) sleep.

 Stages 2-4 are categorized as slow-wave sleep
and appear to relate to body restoration, whereas
REM sleep seems to aid the strengthening and
organization of memories.
 Sleep deprivation experiments suggest that if a
person is deprived of stage 1-4 sleep or REM he
will show rebound effects.
 This means he will make up the deficit in that
particular type of sleep
Circadian rhythm

 They 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).
Fatigue

 It can either be physiological or subjective.

 Physiological reflects the body’s need for
replenishment and restoration. It is tied in with
factors such as recent physical activity, current
health, consumption of alcohol and with
circadian rhythms. It can only be satisfied by
sleep and rest.
 Subjective fatigue is and individuals perception
of how sleepy they feel. This is affected by
degree motivation.
Symptoms of fatigue

 Diminished perception and general lack of awareness

 Diminished motor skills
 Problems with short memory
 Channelled concentration- fixation on a single
unimportant issue.
 Easily distracted
 Poor judgement and decision making leading to
more mistakes
 Abnormal moods – erratic mood changes, depression
 Diminished of own work standards
 It is always sensible to monitor ones
performance, especially when working
additional hours. Performance decrements
can be gradual, and first signs of chronic
fatigue may be moodiness, headaches or
finding that familiar tasks seem more
complicated than usual.
Alcohol, medication and drug abuse

 The performance of an engineer will be

affected by alcohol, medication or illicit
drugs.
 The holder of an aircraft maintenance
engineer’s license shall not, when exercising
the privileges of such a license be under the
influence of drink or a drug to such an extent
as to impair his capacity to exercise such
privileges.
Alcohol

 It acts as a depressant on the central nervous

system, dulling the senses and increasing
mental and physical reaction times.
 As a general rule , aircraft maintenance
engineers should not work for at least eight
hours after drinking even small quantities of
alcohol and increase this time if more has
been drunk.
Medication

 Engineers should be careful when taking

medicine for the first time and should ask the
doctor whether any prescribed drug will
affect his/her work performance.
Drugs

 Illicit drugs affect the central nervous system

and impair mental function. They have
significant effects upon performance and
have no place in aviation maintenance
environment..
 Smoking cannabis can subtly impair
performance for up to 24 hours. In particular
it affects the ability to concentrate, retain
information and make reasoned judgement
especially on difficult tasks
Tasks

 Blindly starting a task without planning how

best to do it is the best way to invite
problems.
 Repetitive tasks can be tedious and reduce
arousal, it may cause people engineers to
cease to consult the maintenance manual or
to use job cards.
 If something about a task is changed they wil
not notice.
Physical environment

 This chapter considers the impact of noise,

fumes, illumination, climate and
temperature, motion and vibration as well as
the requirement to work in confined spaces
and issues associated with the general
working environment.
Noise

 It can thought of as any unwanted sound,

especially if it is loud, unpleasant and
annoying.
 Noise can be annoying, can interfere with
verbal communication and mask warnings
and it can damage workers’ hearing.
 For problematic noise , some form of hearing
protection is used by maintenance engineers
Fumes

 Fumes can cause problems for engineers as a

result of inhalation, but they can also cause
eye irritation.
 It might be appropriate to use breathing
apparatus.
Climate and temperature

 Humans can work within quite a wide range

of temperatures and climatic conditions but
performance can be adversely affected at the
extremes of these.
 When it is either too cold and or wet or too
hot and or humid, performance diminishes.
The working environment

 It comprises the physical environment, social

environment and the tasks that need to be
carried out.
 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
Conformity

 The degree to which an individual’s view is

likely to be affected by conformity or peer
pressure, depends on many factors, including
1. Culture
2. Gender
3. Self esteem
4. Familiarity of the subject matter
5. The expertise of the group members
6. The relationship between the individual and the
group members
Conformity

 When asked many people agree with the

majority as they did not want to appear
different or to look foolish.
 It is closely linked to culture. It might be a
good thing but it might work in reverse with
safety standards gradually deteriorating as
shift members develop practices which might
appear to them more efficient, but which
erode safety.
Effects of time pressure and deadlines

 There is no industry without time pressure and

deadlines.
 Time pressure is stimulating and may actually
improve task performance.
 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 may lead to accidents.
Managing time pressure and deadlines

 Those responsible for setting deadlines and

allocating tasks should consider;
1. Prioritizing various pieces of work that need to
be done
2. The actual time available to carry out work
3. The personnel available throughout the whole
job
4. The most appropriate utilization of staff
5. Availability of parts and spares.
Hazards in the workplace

 All workplaces have hazards and aircraft

maintenance engineering is no exception.
 Physical hazards may include;
1. Very bright lights
2. Very loud sounds
3. Confined or enclosed areas
4. Working at significant heights
5. Noxious substances
6. Excessive temperature
7. Moving equipment, moving vehicles and vibration.
Relevant legislation and the MOs
responsibilities

 They should have a health and safety policy

that should;
1. Carry out assessments including inspections to
determine health and safety risks
2. Provide safe working practices and procedures for
plant, machinery, work equipment, materials and
substances.
3. Inform employees and other persons including
temporary workers of any risk
4. Provide suitable training and/or instruction to
meet health and safety risks.
 Develop and introduce practices and
procedures to reduce risks to health and
safety including the provision of special
protective devices and personal protecting
equipment.
 Provide for the welfare of employees.
 Discuss with and consult employee
representatives on health and safety
measures.
Org should appoint someone
to
 Identify hazards in the workplace
 Remove them where possible
 Mitigate the risk to employees
 If hazards cannot be removed effective signs
must be placed which
1. Clearly identify hazards
2. Describe the danger
3. Inform employees what to do or not do
 Every aircraft maintenance engineer should
be aware that he can influence the safety of
those with whom he works.
Dealing with emergencies

 Emergencies may include;

1. An injury to oneself or to a colleague
2. A situation that is inherently dangerous, which
has the potential to cause injury( fire or escape
of noxious gases)
Actions in emergency

 Stay calm and asses the situation

 Observe what happened
 Look for dangers to oneself and others
 Never put oneself at risk
 Make the area safe
 Protect any casualties from further danger
 Remove the danger if it is safe to do so
 Be aware of ones own limitations
 Assess all casualties to the best of ones
abilities
 Call for help
 Summon help from those nearby
 Call for local emergency equipment
 Call for emergency services
 Provide assistance as far as one feels
competent to.
Procedures, information, tools and
practices

 Procedures fall into two categories;

1. Those produced by the manufacturer
2. Those within the control of the maintenance
organisation.
Inaccuracies, ambiguities
and gaps
 Some aircraft manuals offer scope for
improvement, in addition the information
manual may not necessarily always in an
appropriate form to be used in a maintenance
environment and some translation may be
required to make this data more usable.
 Maintenance organisations must have a
procedure whereby such inaccuracies ,
ambiguities or missing information are recorded
and reported to the type certificate holder.
 It is good human factors practice for
manufacturers to ensure that maintenance
manuals are correct, complete, unambiguous
and ‘user friendly’, both from the outset and
on a continuing basis.
Procedures and work
instructions
 A work instruction is what you should do,
whereas a procedure is how you should do it.
 Job cards are usually work instructions;
procedures generally originate from the
maintenance manual.
Writing procedures and work instructions

 There is a better way of writing or presenting

technical procedures and work instructions
which are produced by and used within an
organization.
 Fundamental elements should not deviate
from the manufacturers requirement.
Work logging and recording

 This is one of the most critical aspects of

communication within aviation maintenance,
since inadequate logging and recording of
work has been cited as a contributor to
accidents.
 Even if engineers think that they are going to
complete a task they should always keep the
record up-to-date just in case the job has to
be handed over.
Written communication

 It is the duty of all persons to ensure that an

adequate record of work done is maintained.
 This is particularly important where such work
carries on beyond a working period or shift, or
handed over from one person to another.
 The work completed, particularly if only
disassembly or disturbance of components or
aircraft systems, should be recorded as the work
progresses or prior to undertaking a dissociated
task.
Written communication

 A certificate of release to service shall only be

issued when the signatory is satisfied that the
work has been properly carried out and
accurately recorded.
Procedures-practices/mismatch/norms

 A/c 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.
 Problems occur when the rule or principle is
wrongly applied.
 In addition engineers may pick up some bad
rules leading to bad habits
Violations

 Violations are deviations from safe operating

procedures;
 It can be seen that;
1. Errors are unintended. Violations are deliberate
(the act not the bad occasional bad
consequences).
2. Violations are any deliberate deviations from the
rules, procedures, instructions and regulations
Error vs. Violation

Error Violation
 Unintended  Usually deliberate
 Over normal span of  Arise mainly from
working life, error motivational factors
proneness is largely  The tendency to violate is
demographic factors such clearly related to age,
as age and gender gender. Young men violate,
 Arise mainly from old women generally do
informational problems; not violate.
incorrect or incomplete
knowledge
Violations

 They are shaped mainly by attitude, beliefs,

group norms and safety culture.
 Most stem from genuine desire to do a good
job. Seldom are they acts of sabotage or
vandalism.
 They present a significant threat to safety
systems.
Examples of Violations

 Speeding
 Parking
 ‘Do not walk on the grass’
 Using pirate or unauthorised software.
Cause of violations at work

 Created by management
 Accepted by management
 Condoned as normal working practice.
Routine violations

 These involve cutting corners in order to take

the path of least effort between two task –
related points.
 They occur at skill-based level of performance
and eventually can become part of a person’s
repertoire of largely automatic actions.
 Are violations which have become the normal
way of doing something within the person’s
workgroup.
Necessary violations

 These are violations which are done in order

to get the work done and occur due to
1. Unrealistic deadlines
2. High workload
3. Unworkable procedures
4. Inadequate tooling
5. Poor working conditions
Intentions to violate

 Attitudes to behaviour ( I can do it)

 Subjective norms (they would do it)
 Perceived behavioural control (I can’t help it)
 Optimizing violations – these are breaking
rules for kicks.
COMMUNICATION

 This is the transmission of something from

one location to another. This can be a
message, signal, a meaning etc. Both the
sender and the recipient must share a
common code so that the meaning or
information contained in the message may be
interpreted without error
Types of Communication

 VERBAL/SPOKEN
 NON-VERBAL
1. WRITTEN/TEXTUAL
2. GRAPHIC
3. SYMBOLIC
4. BODY LANGUAGE
VERBAL/WRITTEN

 Channel of communication----the medium

used to convey the message.
 Language ---- message coding used by the
sender is understood by the recipient so that
he/she can decode the message accurately.
 Meaning -------content of message clear and
unambiguous
NON-VERBAL

 Can accompany verbal communication

 Can occur independently
 Used where verbal communication is
impossible
 Systems communicate their status
nonverbally.
 Body language
COMMUNICATION (Cont’d

 Communication within a team

 Communication between teams
 Communication problems;
 Lack of communication
 Poor communication
 Assumption.
 Always keep the record of work up to date.
 Always keep knowledge and skills up-to-date
TEAM WORKING

 ADVANTAGES
 DISADVANTAGES
 ELEMENTS OF TEAM WORKING
1. Communication, co-operation, co-ordination
and mutual support.
2. Management, Supervision and Leadership.
DECISION MAKING

 Effective decision making refers to the ability

to choose a course of action using logical and
sound judgement to make decisions based on
available information. This includes;
1. Assessing the problem
2. Verifying the problem
3. Identifying solutions
4. Anticipating solutions
5. Informing others of decision and rationale
6. Evaluating decisions
Factors affecting good decision making

 Teamwork
 Extra time to make a decision
 Alert maintenance personnel
 Decision strategies and experience
Barriers to good decision
making
Barriers How to overcome
 Time  Use SOPs and select the
best decision using
available information.
 Cross check data
 Inaccurate or ambiguous
data
 Pressure to perform  Evaluate rationale
 Rank difference  Use assertive behaviours
 Personal attitudes  Be aware of negative
attitude traps
Defective decision making

 Two principles emerge that are caused by

defective decision making;
1. One bad decision leads to another in a ‘snow ball
effect’.
2. A series of bad decisions reduces the
alternatives for continued safety. As time goes
by, available alternatives decrease.
Recognition of poor
judgement
 Feedback – asking for feedback from another
engineer may be difficult because of hesitancy
to admit an error. Yet feedback is necessary to
break the poor judgement chain quickly.
 Stress – stress levels are high
 Challenge – identify hazardous situations
resulting from poor judgements and rectify
 Review – a review of the original bad decision
should be made as soon as possible.
Traps in decision making

 ‘do something fast’ – jumping to conclusions and

solutions.
 ‘can do’ – macho attitude. Risk taking to impress
others, being afraid to voice and share uncertainty or
overload.
 Not being willing to challenge ‘Experts’.
 Complacency, invulnerability, denial, ‘it can’t happen
to me’.
 Anti authority – ‘don’t tell me what to do’
 Resignation – ‘what’s the use? Nothing I do makes any
difference’
Key points

 Don’t assume you don’t have time. Time

spent on diagnosis is time well spent.
 Consultation is not a sign of weakness – use
your resources and consult other
maintenance crew members.
 Decisions should always be reviewed.
 Changing a decision is not indecision.
DECISION MAKING

 THE DODAR CONCEPT;

 D - diagonise
 O - options
 D - decision
 A - assign
 R - review
Professionalism and
Integrity.
 Professionalism is a matter of attitude and
behaviour and means not just knowing your
job, but showing a willingness to learn, co-
operating, respecting, living up to your
commitments and avoiding many kinds of
behaviours that can cause errors.
Good and Bad Professionalism

GOOD BAD
 Management discovers corner  Management condoning corner
cutting and are prepared to ground cutting to get the job done
a/c till proper checks are done.
 Refusing to sign off tasks not seen  Signing off tasks not seen
 Admitting to be fatigued and asking  Turning up for work and accepting
for a change to work on non critical an additional shift or overtime when
areas. fatigued.
 Turning up for work fully rested  Not getting enough rest before
 Limiting alcohol intake work
 Use of documentation  Overindulgence in alcohol
 Planning work  Reliance on memory
 Not enough planning
HF PROGRAMME

 The HUMAN factors programme should

include;
1. Initial training
2. Continuous training
3. CHIRP
4. MEDA
5. HF audits
6. Reporting inaccuracies and ambiguities
7. Just culture/disciplinary policy
8. Error management.
Thank you