Human

Performance In
Aviation
Maintenance
Introduction
 HUMAN FACTORS - THE PROGRAM
1. The need to take human factors into account.
2. What is “Human Factors”?
3. Human Performance and Limitations
3.1. Biological and physiological factors.
3.2. Information processing & Decision Making
4. The Social Environment
5. Personality and behaviour.
6. Communication.
7. Team Working.
8. Factors Affecting Work Performance.
8.1. Alcohol, Medications, fitness, health
8.2. Time Pressure and Deadlines.
8.3. Workload
8.4. Stress
8.5. Sleep, Fatigue and Shift work
9. Physical Environment and Tasks
10. Hazards In The Workplace
11. Human Error & Avoiding and Managing Errors
 HUMAN FACTORS
FIRST THEME
1. The need to take human factors into account;
• Introduction.
• History.
• Statistics on aviation accidents.
• Incidents and accidents attributable to Human Factors/Human Error.
• Chain of errors.
• "Murphy's Law".
• Disciplines studying human factors.
 The Need To Take
Human Factors Into
Account
 Why Human Factors
• An understanding of the importance of human
factors to aircraft maintenance engineering is
essential to anyone considering a career as a
aircraft engineer.

The fundamental reason for applying human factors

is to IMPROVE SAFETY and help to PREVENT
ACCIDENTS.
 Objectives
• Understand the role of human factors
in aviation mishaps.
• To raise awareness of human error and develop
ways to prevent or reduce the occurrence and
consequences of human error in aviation.
• Help you and your Team :
• UNDERSTAND
• PREDICT, and
• CONTROL PERFORMANCE
 Expectations
• Understand nature of Human Error

• Learn how to ID Human Error problems

• ID strategies for reducing Human Error
Statistics Flight
Safety
 In the early days of aviation
• With the aircraft came
aircraft accidents.
• Many aircraft
accidents were
caused by equipment
failure or
• by other factors
outside the control of
the pilots.
 2003 – 100 Aviation
Anniversary

• The first air crash in, 17 th of

September 1908 г.
 Historical Overview

• First licensed aircraft engineer in

military aviation was W. Kelly –
1919
• Convention for the Regulation of
Air Navigation – Paris October in
1919
• Giving engineering technical
permission after World War II
• Providing safety starts from
individual competence to the
responsibility of the entire
organization - Safety system
 Aviation Accidents

100
90
80
70 Human Error

60
% 50
40
30
20
10 Machine Error
0
1903 Present Day
 Since the Second World War

• It has been human error

or
• Human failing
• Over the last 30 - 40
years the major cause
has been human factors
Development of the understanding of
the safety

TECHNICAL FACTORS

HUMAN FACTORS

–TODAY
ORGANIZATIONAL
FACTORS

–1950s –1970s –1990s –2000s

 First international
organizations involved in HF
• 1949 - THE SOCIETY FOR ERGONOMIC
• USA - in 1939 at the University of
Maryland - aviation psychology was
introduced as a separate discipline
• 1957 - THE SOCIETY FOR RESEARCH
INTO HUMAN FACTORS
• In Ohio, the headquarters of an
INTERNATIONAL ORGANIZATION OF
AVIATION PSYCHOLOGY
• On July 13, 1956 in Holland
Drs. A.F. Baars and Dr. S.D.
Fokkema early WESTERN
EUROPEAN SOCIETY OF
AVIATION PSYCHOLOGY -
WEAAP
• In 1994 on Conference in
Dublin, Ireland - rename the
Association at European
Association for Aviation
Psychology – EAAP
 ICAO REQURIRMENTS FOR THE STUDY OF
HUMAN FACTOR

• HUMAN PERFORMANCE REFERD TO AS

HUMAN FACTORS is relevant wherever and
whenever the human being is involved in
aviation.
• It plays fundamental and vital role to promote
efficiency and safety in every face of aviation
industry
• HF can be summarized as the Safety and
efficiency of the operation and Well/being of the
individual.
 History of human factors in aviation
organisations
• The introduction of HF into aviation organisations was concerned with
airline pilots, as international statistics revealed a significant contribution of
piloting errors in accidents at that time.
• The first to take these HFconcepts into account as early as the late 80s,
• The regulatory obligation to apply HF principles for technical crews was
formally introduced in the OPS Regulation at the end of the 90s under the
concept of Crew Resource Management (CRM).
• As regards maintenance activities, certain HF concepts have been
introduced in the first of the JAR145 Regulation (e.g.: Working conditions,
recurrent training in human factors for certifying staff...) and in JAR66 (e.g.:
Human Factors Assessment — Module 9).
• The concept of HF in maintenance activities appeared more generally and
formally in 2003 with Regulation (EC) No 2042/2003 Part 145 of Regulation
(EC) No, subsequently amended under reference (EU) No 1321/2014. The
revision of Regulation (EU) No 1321/2014 of March 2020 now incorporates
HF for Continuing Airworthiness Management Organisations; Part CAMO.
Concept of Human Factors in Regulation
(EU) No 1321/2014
 Incidents and Accidents Attributable To
Human Factors / Human Error
• In 1940 - 70% of all
aircraft accidents were
attributable to man’s
performance.
• 35 years later IATA
found, that there had
been no reduction in
the human error
component of
• accident statistics
Aircraft accident rates were extremely
high post WWII to the 1970’s
 Aircraft accident rates

• Between 85 and 90% of aviation accidents are due to

human factors

• 70% of aviation accidents and incidents can be attributed

to human error in flight cabin.(Foushee,1984).

• Report of 1998 indicates that if the trend in accidents

and the expected increase in air traffic, then by 2015
every day will be a big disaster somewhere in the world
… traffic increases!
 Anticipation: A doubling of traffic by
2020
–7.0 million flights –199 –8.0 million flights –2000
7

–Traffic triples over 25 years

–11.1 million flights –2010 –16.0 million flights –2020

–Traffic doubles over 20 years

 The phases of flight most prone to
accidents
• Intermediate and
Final Approach
• Landing
• Take-off
• descent
Causes of aircraft accidents
 Causes in 93 aircraft accidents.
Causes/ major contributory factors
A study in 1986 , % of accidents in
which this was a
factor
Pilot deviated from basic operational procedures 33
Inadequate cross-check by second crew member 26
Design faults 13
Maintenance and inspection deficiencies 12
Absence of approach guidance 10
Captain ignored crew inputs 10
Air traffic control failures or errors 9
Improper crew response during abnormal conditions 9
Insufficient or incorrect weather information 8
Runways hazards 7
Air traffic control/crew communication deficiencies 6
Improper decision to land 6
Errors in maintenance staff 1990 - 2000
 Maintenance errors can impose
significant financial costs
• Boeing 747-400, a flight cancellation can cost the airline
around USD $140,000, while a
• delay at the gate can cost an average of USD $17,000 per
hour.
Examples of Incidents and
Accidents
Accident to Boeing 737, (Aloha
flight 243), Maui, Hawaii, April
28 1988
• British Airways
BAC-111, 1990
• Air Midwest,
Beech 1900D, 2003
• The Beech 1900 involved in
the accident. Right, the cable
adjustment turnbuckles on
the elevator control cables.
• UK in August 1993
involved an Airbus 320
• In February 1995, a
Boeing 737-400
 Examples of Accidents Related to
Maintenance
Japan Airlines Boeing 747
1985

The repair to the

rear pressure
bulkhead as
specified in the
repair instructions
(at left), and repair
as actually carried
out (on right).
 Eastern Airlines L-1011, 1983The
Lockheed L-1011

• The magnetic chip detector

plug and housing on the RB-
211-22B engine
• Source: Marx & Graeber (1994
 In all of incidents:
• The engineers involved were well qualified, competent and
reliable employees
• There were staff shortages;
• Time pressures existed;
• All the errors occurred at night;
• Shift or task handovers were involved;
• They all involved supervisors doing long hands-on tasks;
• There was an element of a “can-do” attitude;
• Interruptions occurred;
• There was some failure to use approved data or company
procedures;
• Manuals were confusing;
• There was inadequate pre-planning, equipment or spares.
 The Error Chain

If we can break just one

link of the chain, the
accident does not
happen
 Maintenance errors contribute
to what percentage of aircraft
accidents/incidents?

Industry estimates
vary between
6% and 25%
SOME EXAMPLES OF MAINTENANCE
ERRORS
• parts installed
incorrectly,
• missing parts, and
• necessary checks
not being performed

These mistakes are present but not visible and

have the potential to remain latent, affecting the
safe operation of aircraft for longer periods of
time.
However everybody is convinced that
Human Factors is a central, crucial and
decisive element in pursuing safe,
effective and efficient operation – whether
it’s aviation, medicine or nuclear industry.
 POTENTIAL ROOT ISSUES Score
Design & Maintenance Interface 57
Planning 51
Fatigue 51
Provision of Resources 50
Commercial Pressures 49
Working Conditions 49
Training 47
Roles & Responsibility 41
 A model of accident and
incident causation

The main causal elements involved in accidents and incidents. It is

an adaptation of the ‘Swiss Cheese’ model originally developed by
James Reason
 Understanding operational
errors
• Human error is considered
contributing factor in most aviation
occurrences.
• Even competent personnel commit
errors.
• Errors must be accepted as a
normal component of any system
where humans and technology
interact.
 The Heinrich Ratio

–Fatal accident
–1
–Accidents
–10
–Reportable
incidents
–30
–Incidents
–600
 Human Error
• We all commit errors
• Any time an action does not produce
the desired result
• Something we do
• Something we fail to do
• THINGS THAT INTERFERE
WITH OUR PERFORMANCE
 Murphys Law

• “If something can go wrong, it will.”!

• “it will never happen to me”

 What is Human Error?

• “To err is human!”

• “To err is human; to persist is of the Devil!”
• Man makes mistakes unintentionally!
• We learn from our mistakes but nobody can
make all the possible mistakes so that he can
learn everything!
Errors are defined as action or lack of action
which lead to deviation from intentions or our
expectations.
(Helmreich,Klinect, Wilhelm)
Any action (or inaction) that potentially results in
negative system effects, given the situation that
other possibilities were available. This includes
any deviation from operating procedures, good
working practice or intentions.
 Human error
• Human error is involved in
– 70 per cent of aircraft accidents, as well as
– 80 per cent of shipping accidents,
– and at least 58 per cent of medical misadventures.
 Human Error
• The use of the term ‘human error’ should
not imply that we have a problem with
people.
• Maintenance errors are only symptoms of
underlying problems within the
organisation.
• They are unwanted events.
• Errors are valuable opportunities to
identify improvements.
• Human error is the starting point rather than the
stopping point in accident investigation and
prevention
• The term “Human error” indicate WHERE in the
system a breakdown occurred.
• It provides no WHY it occurred.
• We must identify the elements affecting human
performance, understand the predictable
aspects of human capabilities and limitations
and seek ways of minimizing or preventing
human errors.
 Human Error
Human errors vary widely depending on the task
and many other factors such as:

Fatigue
Sleep loss
Lack of skill
Misunderstanding
Lack of information
Motivation
Distraction
 2.What is Human Factors?
1. What is “Human Factors”?
• Models describing Human Factors.
• The SHELL Model.
• Characteristics of the main elements of
the SHELL model.
• Interactions between the elements.
• Interfaces between the human and the
other elements of the SHELL model.
 "Human factors"
• "Human factors" refers to the
study of human capabilities and
limitations in the workplace.

• Human factors researchers

study system performance.

• They study the interaction of

maintenance personnel, the
equipment they use, the written
and verbal procedures and rules
they follow, and the
environmental conditions of any
system.
 "Human factors"
• The aim of human
factors is to optimise
the relationship
between maintenance
personnel and
systems with a view
to improving safety,
efficiency and well-
being”.
Definitions of the Human FactorsAccording
to Regulation (EU) No 1321/2014
• The concept of “Human Factors” means
principles which apply to aeronautical design,
certification, training, operation and maintenance
and which seek safe interface between the
human and other system components by proper
consideration of human performance.
• ‘Human performance’ means human capabilities
and limitations which have an impact on the
safety and efficiency of aeronautical operations.
 Human error is most often
attributable to

• Pilots
• Maintenance
personnel
• Air traffic controllers
Human Factors is about people:
• It is about people in
their working and
living environments,
and
• It is about their
relationship with
equipment,
procedures and the
environment
• It is about relationship
with other people
• Human Factors seeks to optimize the performance of
people by the systematic application of the human
sciences, often integrated within the framework of
system engineering.
• Its twin objectives can be seen as safety and efficiency.
ICAO Human Factors Digest № 1,
1989

• In aviation, Human factors involves a set of personal,

medical and biological consideration for optimal aircraft
operations.
 Human capabilities and limitations
Human factors are the underlying human traits that support human
performance, i.e. the human capabilities and limitations involved in
continuing airworthiness activities.
• Perception,
• Reasoning,
• Actions,
• Memorisation,
• Communication,
• Moving,
• Handling tools and materials with dexterity
• Resilience in a range of working environments (noise, extremes of
heat, humidity etc)…
The level of capabilities and limitations varies from person to person.
It varies according to age, build, health, biological rhythms adopted,
situations experienced, life events (marriages, births but also
deaths, conflict, pain, stress…).
• The human sciences study the
structure and nature of human
beings, their capabilities and
limitations, and their behaviours
both singly and in groups.
 Human Sciences are:
• Anthropometrics
• Biomechanics
• Aviation Physiology
• Aviation Psychology
• Biology
• Ergonomics
Anthropometrics
• Anthropometrics is
the study of the
dimensions and
abilities of the human
body.
Anthropometrical data
and an enormous of
information is
available to the
aircraft designer, the
large of size of
potential pilots, crew
and passengers.
Biomechanics
• Biomechanics study
physical control of
movement, forces
and direction.
 Aviation Physiology
• Aviation Physiology study
how the human body functions
under normal condition and
during the flight under the
condition of stress, altitude and
variation of “g” forces.
• Medicine is the science and
HYP
10,000 MSL
XIA art of healing. It encompasses
• a variety of health care
practices evolved to maintain
and restore health by the
prevention and treatment of
illness.
Biology

• Biology – body’s
diurnal (or circadian)
rhythms, Circadian
Desynchronization
 Aviation Psychology
• Aviation Psychology –
perception, cognition, information
processing, decision making,
memory capacity, personality,
behavior, group interaction, and
et.
• Organizational Psychology
Organizational psychologists are
concerned with relations
between people and work,
organizational structure and
organizational change, workers’
–Educational Psychology – productivity and job satisfaction,
consumer behavior, and the
how people learn and design the methods selection, placement, training,
and materials used to educate people of and development of personnel.
all ages.
 Cognitive Science
• Cognitive Goal:
• Minimize Mental Fatigue
• Digital versus analog
displays
• Placement and font of text
• Appropriate symbol shapes
and colors
• Is the interdisciplinary scientific
study of minds as information
processors.
• It includes research on
• how information is processed
(in faculties such as
perception, language,
reasoning, and emotion),
represented,
• and transformed in a nervous
system or machine
(e.g.,computer).
Computer Science
Is the study of the theoretical
foundations of information and
computation
and of practical techniques for
their implementation and
application in computer
systems.
Medical Science
 Ergonomics-
• Ergonomics
Workspace
specification and
design

Ergonomic Goal:
Minimize Physical Fatigue
Form and fit to the human
body
Comfortable environment
(temp and lighting)
 History of Human Factors
• Around 1487, Leonardo
DiVinci began research in the
• Area of anthropometrics.
• He also began to
• study the flight of birds.
 History of Human Factors
• 1452 – 1519 Leonardo DiVinci
began research in the area .of
anthropometrics.
• he also began tostudy the flight of
birds.
• Industrial engineers Frank Lillian
Gilbreth – 1868 – 1924 were trying
to reduce human error in medicine.
• They developed the concept of
• using call backs when
communicating in the operating
room.
• That is called the challenge-
response system.
• In the early 1900s, Orville and
Wilbur Wright were the first to
fly a powered aircraft and also
pioneered many human factors
considerations.
• Devil Hills, near Kitty Hawk,
North Carolina, to develop the
first practical human interactive
controls for aircraft pitch, roll,
and yaw.
• On December 17, 1903, they
made four controlled powered
flights over the dunes at Kitty
Hawk with their Wright Flyer.
• They later developed practical
in-flight control of engine
power, plus an angle of attack
sensor and stick pusher that
reduced pilot workload.
 Evolution of Maintenance
Human Factors
• With the onset of World War I (1914–1918), more
sophisticated equipment was being developed and the
inability of personnel to use such systems led to an increased
interest in human capability.
• The focus of aviation psychology was on:
– the pilot,
– the focus shifted onto the aircraft.
– design of the controls and displays, the effects of altitude, and
environmental factors on the pilot.
• The war brought on the need for aeromedical research and the
• need for testing and measurement methods.
• By the end of
• World War I, two aeronautical labs were established, one at Brooks
Air Force Base, Texas, and the other at Wright Field outside of
Dayton, Ohio.
 After World War II
• With the onset of World War II (1939–1945), it was becoming
increasingly harder to match individuals
• The design of equipment had to take into account human limitations
and take advantage of human capabilities.
• There was a lot of research to be done to determine the human
capabilities and limitations that had to be accomplished.
• The beginning of the Cold War led to a major expansion of
Department of Defense supported research laboratories, and many
of the labs established during the war started expanding
• In the civilian industry, the focus shifted from research to
participation through advice to engineers in the design of equipment.
 Human Factors
• “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/or safety.”
MODELS of HUMAN FACTORS
 The Pear Model
• People who do the job.
• Environment in which they work.
• Actions they perform.
• Resources necessary to complete the job.
 The SHELL Model
Adopted by ICAO to differentiate between the basic
sub-systems of the aviation system

Identify how their interaction is influenced by human

capabilities

It also helps to illustrate the various interfaces

between different sub-systems in operational
practice
It use a model to aid in the understanding of human
factors, or
as a framework around which human factors issues
can be structured
People and safety – SHEL
model
◼ Software
S ◼ Hardware
H L L ◼ Environment
◼ Liveware
E ◼ Liveware, other
persons
–*
 SHELL Model
What is Liveware?

•Other components must fit

Hub of L •Physical size and shape
•Physical needs
Model Input characteristics
•Information processing
•Output characteristics
•Environmental tolerances
 SHELL Model

S
What is Software?
•Procedures
•Checklists
•Simbology
•Computer programs
•Manual layout
 SHELL Model

H
What is Hardware?
• How does human fit
• Design of seats
• Design of controls
• Movement of
controls
 SHELL Model

E
◼Measures taken
to adapt human
to the environment
What is Environment? • Helmets
• Oxygen masks
• Pressurization
systems
• etc.
 SHELL Model

•Interface between
people
•Group performance
•Leadership
•Teamwork
L
•Crew cooperation

What is Liveware – Liveware?

 People and Safety – SHELL Model
1972, Edwards; 1975 –Capt. Franc Hawkins

• Software - PROCEDURES
H SYMBOLS
DOCUMENTS

• Hardware - AIRCRAFTS
S L E • Environment
• Liveware - HUMAN
L • Liveware - OTHER
PERSONS

IN THIS MODEL THE MATCH OR MISMATCH OF THE BLOCKS IS JUST

AS IMPORTANT AS THE CHARACTERISTICS OF THE BLOCKS
THEMSELVES. A MISMATCH CAN BE A SOURCE OF HUMAN ERROR. *
 How SHELL Model elements
can be deficient
– S: misinterpretation of procedures, badly written
manuals, poorly designed checklists,
untested or difficult to use computer softwar
– H: not enough tools, inappropriate equipment,
– poor aircraft design for maintainability
– E: uncomfortable workplace, inadequate hangar
space, extreme temperatures, excessive, noise,
poor lighting
– L: relationships with other people, shortage of
manpower, lack of supervision, lack of support
from managers
Human-Machine Comparison
• HUMANS SURPASS MACHINES IN:
• Ability to detect small amount of visual and acoustic energy.
• Ability to perceive patterns of light or sound.
• Ability to improvise and use flexible procedures.
• Ability to store very large amounts of information for long periods
and to recall relevant facts at the appropriate time.
• Ability to reason inductively.
• Ability to exercise judgment.
• MACHINES SURPASS HUMANS IN:
• Ability to respond quickly to control signals, and to apply great force
smoothly and precisely.
• Ability to perform repetitive, routine tasks.
• Ability to store information briefly and then to erase it completely.
• Ability to reason deductively, including computational ability.
• Ability to handle highly complex operations--to do many different
things at once.
 Human-Machine Differences

• Machines can be modified, redesigned, and retrofit -- humans

cannot. Humans are born with innate, genetically determined
differences that are shaped by the environment. Innate aptitudes or
abilities are developed through education and training.
• Machines can be manufactured to be identical--with identical, or
nearly identical, output or performance. Humans are not identical
and vary across all sensory, cognitive, physical, and performance
characteristics. Specific aspects of human performance can be
made more equal through education and training.