HUMAN ERRORS

Error is defined as:

“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”.

ERROR MODELS AND THEORIES

Design- versus operator-induced errors
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.

Chap 8, pg 1
HUMAN ERRORS

Variable Versus Constant Errors

• Variable errors are random in nature, whereas the constant errors
follow some kind of consistent, systematic (yet erroneous) pattern.
• Constant errors may be predicted and therefore controlled.
• Variable errors cannot be predicted and are much harder to deal with.

Reversible Versus Irreversible Errors

• Reversible errors can be recovered from.
• Irreversible errors typically cannot be.
• A well designed system or procedure should mean that errors made by
aircraft maintenance engineers are reversible.

Chap 8, pg 3
HUMAN ERRORS

Slips, Lapses and Mistakes

• Slips can be thought of as actions not carried out as intended or planned,
e.g. ‘transposing digits when copying out numbers, or misordering steps in
a procedure.

• Lapses are missed actions and omissions, i.e. when somebody has failed to
do something due to lapses of memory and/or attention or because they
have forgotten something, e.g. forgetting to replace an engine cowling.

• Mistakes are a specific type of error brought about by a faulty plan /

intention, i.e. somebody did something believing it to be correct when it was, in fact,
wrong, e.g. an error of judgement such as mis-selection of bolts when fitting an aircraft
windscreen.

Slips typically occur at the task execution stage, lapses at the storage
(memory) stage and mistakes at the planning stage.
Chap 8, pg 4
HUMAN ERRORS

Violations
• Sometimes appear to be human errors,
• 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).

Skill-, Rule- and Knowledge-Based Behaviours and Associated Errors

• 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.
• Rule-based errors are related to the use of the wrong rule or procedure.
• Errors at the knowledge-based performance level are related to
incomplete or incorrect knowledge or interpreting the situation incorrectly.
HUMAN ERRORS

The ‘Swiss Cheese Model’

• Some failures are latent, meaning that they have been made at some
point in the past and lay dormant.
• Errors made by front line personnel, such as aircraft maintenance
engineers, are ‘active’ failures.

Chap 8, pg 6
HUMAN ERRORS

Violation in Aircraft Maintenance

There are four types of violations:
• Routine violations - are things which have become ‘the normal way of
doing something’ within the person’s work group (e.g. a maintenance
team).
• 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.
• Optimising violations - involve breaking the rules for ‘kicks’.
• Exceptional violations - are typified by particular tasks or operating
circumstances that make violations inevitable, no matter how well
intentioned the engineer might be.

Chap 8, pg 8
HUMAN ERRORS

Reason’s Study of Aviation Maintenance Engineering

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%)
Omissions can occur for a variety of reason, such as forgetting, deviation
from a procedure (accidental or deliberate), or due to distraction. 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.
How many ways can this be
disassembled? (the answer being 1) and
(b) how many ways can it be
reassembled? (the answer being about
40,000, excluding errors of omission!).
HUMAN ERRORS

Implications of Errors (i.e. Accidents)

 In the worst cases, human errors in aviation maintenance can and do

cause aircraft accidents.
 However, 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.
HUMAN ERRORS

Avoiding and Managing Errors

All maintenance organisations should aim to ‘manage’ errors.

Error management seeks to:

• prevent errors from occurring;
• eliminate or mitigate the bad effects of errors

The two components of error management as: (i) error containment and
(ii) error reduction.

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.

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.
RECOGNISING AND AVOIDING HAZARDS

 There are may potential hazards in the aircraft maintenance industry.

Physical hazards may include:
• very bright lights (e.g. from welding);
• very loud sounds (sudden or continuous);
• confined or enclosed areas;
• working at significant heights;
• noxious substances (liquids, fumes, etc.);
• excessive temperature (i.e. too cold or too hot);
• moving equipment, moving vehicles and vibration.

In brief, a maintenance organisation has a duty under health and safety

legislation to:
• identify hazards in the workplace; • remove them where possible;
• mitigate the risks to employees.
RECOGNISING AND AVOIDING HAZARDS

 If hazards cannot be removed from the workplace, employees should

be made aware that they exist and how to avoid them. To be effective,
warnings signs must:
• clearly identify the hazard(s);
• describe the danger (i.e. electric shock, radiation, etc);
• inform employees what to do or not to do.

 The sign must attract an engineer’s attention, it must be visible and it

must be understandable to the people it is aimed at.

DANGER denotes that the hazard is immediate and could cause grave,
irreversible damage or injury. DANGER signs use red, black and white.

CAUTION indicates a hazard of lesser magnitude. The sign should also

detail how to avoid or manage the risk. CAUTION signs are generally
yellow and black.
RECOGNISING AND AVOIDING HAZARDS
Engineer’s Individual Responsibilities

 The legislation notes that every individual in a workplace also

has health and safety responsibilities.

Every aircraft maintenance engineer should be aware that he

can influence the safety of those with whom he works.