Human Factors in Aircraft Maintenance Engineering Final

HUMAN FACTORS
IN
AIRCRAFT MAINTENANCE
ENGINEERING
Aug 2022 1
Contents
1. General /Introduction to Human Factors
2. Safety Culture / Organizational Factors
3. Human Error
4. Human Performance and Limitations
5. Environment
6. Procedures, Information, tools and Practices
7. Communication
8. Teamwork
9. Professionalism and Integrity
10. Organization’s HF Program
Jan 2005 2
The Aim of Human Factors
The aim of human factors in aviation

maintenance is to optimize the relationship
between maintenance personnel and systems
with a view to improving safety, efficiency
and well-being.
Jan 2005 3
Human Factors Definitions
The technology concerned to optimize the

relationships between people and their
activities by the systematic application of the
human sciences, integrated within the
framework of systems engineering
Elwyn Edwards (1988)
Jan 2005 4
Concept of people in their living and working
situations; about relationship with machines, with
procedures and with the environment about 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 and air traffic control operations
ICAO
Jan 2005 5
Human Factors is the study of the human as a central part

of any system. Human Factors identifies the capabilities
and limitations of human and, then, adapts the human or
the system components accordingly. The science Human
Factors can quantify human performance with measures
like time, units of work, safety, error, and sometimes,
attitudinal change. Such measures help to design or
modify systems for optimal human performance.
Therefore, operational attention to Human Factors can
raise efficiency, effectiveness, and safety in aviation
environments. That translates to cost control and
continuing safety
FAA
Jan 2005 6
Ergonomics
Ergonomics derives from the Greek words

”ergon” (work) and ”nomos” (natural law)
The study of the efficiency of persons in their

working environment
Original concentration on biomechanical and

biophysical aspects of the work environment
Jan 2005 7
Anthropometry
Anthropometry is the science of measurement

and the art of application that establishes the
physical geometry, mass properties, and
strength capabilities of the human body
The name derives from anthropos meaning

human, and metrikos, meaning of or pertaining
to measuring
Jan 2005 8
Biomechanics
The science of Biomechanics addressees

issues of movement, leverage, and strength.
From a biomechanical perspective, the human
body is a series of physical links (bones)
connected at certain points (joints) that allow
various movements
Jan 2005 9
Biomechanics (contd.)
Muscles and tendons provide the motive force

for all movements. The force that can be
applied in any given posture is dependant on
the strength available from muscles and the
mechanical advantage provided by the relative
positions of the load, muscle connections and
joints
Jan 2005 10
Human Factors Genesis
Parallel to aviation development

First identifiable during second world war
Cockpit design
Aircrew performance
Recognized in Europe in 1949
Ergonomics Research Society
Recognized in the US in 1957
Human Factors Society
Jan 2005 11
Early Research Examples
Anthropometrics – Eye datum in cockpit

Biomechanics – strength required in gear retraction
Controls – Tactile handles on flap lever
Displays – Colour coding of speed ranges
Communication – Standardized phraseology
Social Psychology – Crew Resource Management
Jan 2005 12
Human Factors and Ergonomics
Human Factors - US led development

Ergonomics - European led development
Terms now synonymous in aviation context

Two original societies have combined to
become the Human Factors and Ergonomics
Society
Jan 2005 13
Human Factors is Evolving
MRM is defined as:

A general process for improving communication,
effectiveness, and safety in airline maintenance
operations
MRM improves safety by:
Increasing the coordination and exchange of
information between teams of airlines maintenance
crews
MRM programs link and integrate traditional human
factors topics, such as equipment design, human
physiology, workload, and workplace safety
Jan 2005 14
Human – Machine Comparison
Humans are better than Machines in :

Sensory functions
Perceptual abilities
Stimulus generalization
Abstract concepts
Flexibility
Ability to improvise
Judgment
Selective recall
Inductive reasoning
Jan 2005 15
Human – Machine Comparison
Machines are better than Humans in :

Alertness
Speed and power
Sensor detection outside Human Range
Routine work
Computation
Short-term memory storage
Simultaneous Activities
Jan 2005 16
Cost
Safety is the major reason

But it is very difficult to quantify
The cost effectiveness is the second
major reason because:
Engineering delays to operations are costly
Incidents and Accidents are very costly
And these aspects are very easy to quantify
Jan 2005 17
Human Factors Models
SHEL Model
SHELL Model
SCHELL Model
Jan 2005 18
SHEL Model
Liveware
Software Hardware
Environment
Jan 2005 19
SHELL Model
H
S L E
L
Jan 2005 20
SHELL Model
Hardware
Software -Tools
- Procedures -Aircraft
- Policies/Rules Liveware (people) -Equipment
- Manuals - Physical
- Placards - Knowledge
- Attitudes Liveware (teams)
- cultures - Teamwork
Environment - Stress -
Communication
- Physical - Leadership
- Organizational - Norms
- Economic
Jan 2005 21
SCHELL Model
S C L E
Jan 2005 22
Statistics
Human Factors
Machine Causes
1903 Today
Jan 2005 23
Statistics
Jan 2005 24
Statistics
33% Pilot deviated from basic operational procedures
26% Inadequate cross-check by second crew member
13% Design faults
12% Maintenance and inspection deficiencies
10% Absence of approach guidance
10% Captain ignored crew inputs
9% Air Traffic Control failures or errors
9% Improper crew response during abnormal
conditions
8% Insufficient or incorrect weather information
8% Runways hazards
7% Air Traffic Control/Crew communication
deficiencies
6% Improper decision to land
Jan 2005 25
Incidents – Portland Oregon
United Airlines Flight 173 –DC8 aircraft

Landing gear light out on finals
Circling away from the airfield while
troubleshooting
Ran out of fuel
10 fatalities
Similar to Eastern Airlines L1011 Everglades
accident in 1972
Jan 2005 26
Cockpit Resource Management
United Airlines commenced CRM workshops

Concentration on communication
Taken up by other airlines
Included further HF subject areas
Jan 2005 27
Incidents - Kegworth
British Midland B737-400 [almost brand new]

Climb out from LHR to Belfast
Engine damage on #1
Flight crew shut down #2 engine
Aircraft eventually crashed on the M1
motorway
Jan 2005 28
Incidents – Kegworth –Contributing Factors
The combination of heavy engine vibration,

noise, shuddering and an associated smell of
fire were outside their training and experience
They reacted to the initial engine problem
prematurely and in a way that was contrary to
their training
They did not assimilate the indications on the
engine instrument display before they throttled
back the #2 engine
Jan 2005 29
Incidents – Kegworth –Contributing Factors
As the #2 engine was throttled back the noise

and shuddering associated with the surging of
the#1 engine ceased, persuading them that
they had correctly identified the defective
engine.
They were not informed of the flames which
had emanated from #1 engine and which had
been observed by many on board including
three cabin staff
Jan 2005 30
Incidents – The convertible 737
Jan 2005 31
Incidents – The convertible 737
Jan 2005 32
Incidents – The convertible 737 - Investigation
Examination of the aircraft revealed dis-

bonding and fatigue damage which led to the
failure of the lap joint and the separation of
the fuselage upper skin.
NTSB determined the probable causes of this
accident/incident as follows:
FUSELAGE, ATTACHMENT … FATIGUE
FUSELAGE, ATTACHMNET… SEPARATION
Jan 2005 33
Incidents – The convertible 737 – Contributing Factors
Maintenance, Inspection – Improper

Company maintenance personnel supervision
– inadequate
Company/operator management – inadequate
surveillance of operation
Jan 2005 34
Incidents – Evolution
CCC HPIM
HPIM MRM
Jan 2005 35
Incidents
THE HUMAN FACTORS ELEMENTS

THAT CAN EVIDENT WHEN
CARRYING OUT SPECIFIC AIRCRAFT
MAINTENANCE TASKS SUCH AS
INSPECTION OF AGING AIRCRAFT
AND OTHER REPETITIVE AND
BORING ACTIVES
Jan 2005 36
The Dirty Dozen
 Lack of communication  Lack of resources

 Complacency  Pressure
 Lack of assertiveness
 Lack of knowledge
 Stress
 Distraction  Lack of awareness
 Lack of teamwork  Norms
 Fatigue
Jan 2005 37
The Error Chain
Jan 2005 38
Murphy’s Law
If anything can go wrong, it will.

If there is a possibility of several things going
wrong, the one that will cause the most
damage will be the one to go wrong.
Corollary: if there is a worse time for
something to go wrong, it will happen then.
If anything just cannot go wrong, it will
anyway
Jan 2005 39
Murphy’s Law – contd.
If an individual perceives that there are four

possible ways in which something can go
wrong, and circumvent these, then a fifth way ,
unprepared for , will promptly develop.
Left to themselves, things tend to go from bad
to worse.
If everything seems to be going well,
something obviously had been overlooked.
Nature always sides with the hidden flaw.
Jan 2005 40
2. SAFETY CULTURE /
ORGANIZATIONAL
FACTORS
Jan 2005 41
What is Safety Culture?
Beliefs, Attitudes and Values – of an

organization’s membership regarding safety
Structures, Practices, Controls, and Policies

that an organization possesses and employs
Jan 2005 42
A safe culture
is the engine that continues to drive the
organization towards the goal of maximum
attainable safety
Reminds the members to respect the operational
hazards, and to expect that people and equipment
will fail
Is an informed culture, one that knows where the
edge is without having to fall over it
Jan 2005 43
An informed culture
is just culture that has agreed and understood the
distinction between blame-free and culpable acts.
A safe culture
Is a learning culture in which both reactive and
proactive measures are used to guide continuous
and wide-reaching system improvements
Jan 2005 44
Safety Culture – interlocking parts
Just Culture
Reporting Culture
Learning Culture
Jan 2005 45
Can safety culture be engineered?
Most organizations would seek to change

through various motivational measures:
Fear appeals
Sticks and carrots (mostly sanctions)
Making an example of those who commit unsafe
acts – naming, blaming, shaming, retraining
Writing another procedure
Better changing Practices
Jan 2005 46
Can safety culture be engineered?
Changing collective values of adult people in

an intended direction is extremely difficult, if
not impossible - Greet Hofstede
Values, beliefs and attitudes can be changed,

but not necessarily by a direct assault
Introducing practices and structures that are
seen to work effectively have a way of
bringing people’s values into line with them
Jan 2005 47
Creating a just culture
Is the first critical step in socially engineering

a safe culture
A just culture hinges critically on a collective
agreed and clearly understood distinction
being drawn between acceptable and
unacceptable behaviour
Jan 2005 48
2. Safety Culture / Organizational
Factors
Creating a just culture –getting the balance right
Zero tolerance for reckless conduct

Creating a wide spread confidence that the
vast majority of unintended unsafe acts will go
unpunished
Difference between bad acts and honest errors
Natural justice works two ways:
Punishments for the few culprits
Protect the innocence of the many
Jan 2005 49
Factors
Creating a Reporting Culture
Psychological and Organizational Barriers

Natural disinclination to confess one’s blunders
Suspicion that such reports might go on the record
and count against
Scepticism – will management take necessary
measures
Why should we bother – writing the report take
time and effort
Jan 2005 50
Factors
Characteristics of successful reporting programs

De-identification – complete anonymity or
confidentiality
Protection – indemnity against disciplinary
procedures
Separation of functions – separate agency to collect
and analyse reports
Feedback – rapid, useful, accessible and intelligible
feedback to the reporting community
Ease of making the report – report formats,
Jan 2005 51
Factors
Value of a safety information system lies in its

ability to identify recurrent event patterns,
error traps, and gaps or weaknesses in the
defences.
Jan 2005 52
Factors
Creating a Learning Culture
Reporting culture is a prerequisite for a

learning culture
Types of organizational learning
Single loop
Double loop
Jan 2005 53
Factors
Assumptions
Actions Single – loop

Double – learning
loop learning
Actual results
Results gap
Desired results
Jan 2005 54
Factors
Four stage model of organizational learning

Local stage – learning is mainly single loop
Control stage – sanctions, incentives, SOPs and
formal routines
Open stage – early stage of double loop learning
Deep learning stage – increasing tolerance for
short-term difficulties
John Carroll - MIT
Jan 2005 55
Factors
Types of Safety Culture
Three kinds of Safety Culture – the way that

an organization handles safety-related
information
Ron Westrum
Generative – deep learning
Pathological - avoid collective responsibility
Bureaucratic - the large majority – lie
somewhere in between
Jan 2005 56
Factors
Types of Safety Culture
Patrick Hudson of Leiden University has extended this
three-part classification into five stages, each of which needs
to be passed through before the next level can be achieved
Pathological – ‘who cares as long as we don’t get caught’
Reactive – ‘safety is important; we do a lot every time we
have an accident’
Calculate – ‘we have systems in place to manage all
hazards’
Proactive – ‘we work hard on the problems we still find’
Generative – ‘we know that achieving safety is difficult’
Jan 2005 57
Relationships Among Organizational Theory, Structure,
Culture, Design and Change
Jan 2005 58
3. HUMAN ERROR
Jan 2005 59
3. Human Error
Definitions
“It is the nature of man to err”

The Roman philosopher Cicero
People make mistakes, it is part of being human
Making mistakes is all part of the learning process
for humans
Some errors have good outcomes, most have very
little consequences but some have catastrophic
consequences
In aviation, what we cannot tolerate are the bad
effects of errors
Jan 2005 60
3. Human Error
Definitions
“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 ”
Jan 2005 61
3. Human Error
Definitions
“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”
Professor James Reason
Jan 2005 62
3. Human Error
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 errors
The ‘Swiss cheese’ model
Jan 2005 63
3. Human Error
Variable versus constant errors
Jan 2005 64
3. Human Error
Variable versus constant errors
Jan 2005 65
3. Human Error
Error Types
Slips and Lapses

the actions do not go according to plan
Mistakes
The plan itself is inadequate to achieve its objective
Jan 2005 66
3. Human Error
Slips can be thought of as actions not carried out as

intended or planned, e.g. ‘transposing digits when copying
out numbers, or misordering steps in a procedure
Lapses are missed actions and omissions, i.e. when
somebody has failed to do something due to lapses of
memory and/or attention or because they have forgotten
something, e.g. forgetting to replace an engine cowling
Mistakes are a specific type of error brought about by a
faulty plan/intention, i.e. somebody did something
believing it to be correct when it was, in fact, wrong, e.g.
an error of judgment such as mis-selection of bolts when
fitting an aircraft windscreen
Jan 2005 67
3. Human Error
Error Models and Theories – Error Facilitator
Distraction,
Poor lighting, Time pressure, ambiguous
noise etc stress, fatigue, etc procedures etc
Processing,
Sensing Judgment
& Taking
&
Perception Action
Decision
Making
Jan 2005 68
3. Human Error
“Skill-based behaviors are those that rely on stored

routines or motor programs that have been learned with
practice and may be executed without conscious thought.
Rule-based behaviors are those for which a routine or
procedure has been learned. The components of a rule-
based behavior may comprise a set of discrete skills.
Knowledge-based behaviors 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.”
Jan 2005 69
3. Human Error
Example of an action slip
Jan 2005 70
3. Human Error
Reason’s Swiss Cheese Model
Some holes due

to active failures
Defences-
in-Depth
Some holes due

to latent conditions
Jan 2005 71
3. Human Error
Types of Errors in Maintenance Tasks
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.
Jan 2005 72
3. Human Error
Error of Commission (Type 1 Error)

performing the wrong action. E.g. anti-
wire locking a component
Error of Omission (Type 2 Error)
not performing a required action E.g.
forgetting to wire lock the component.
forgetting ( Oil Cap )
Jan 2005 73
3. Human Error
Common Mistakes
 Misapply a good rule or principle

 Apply a bad rule or principle
 Fail to apply a good rule or principle (violation)
Jan 2005 74
3. Human Error
Misapplying Good Rules

 A ‘good rule or principle’ is one that has been
useful in the past.
 These good rules are the ‘rule of thumb’
principles that we use in our every day life
 The problems occur when the rule or principle is
wrongly applied
Jan 2005 75
3. Human Error
Misapplying Good Rules - Example

 Aircraft pipe couplings are normally right hand
threads. We do not check with the Maintenance
Manual because we all know this
 Applying this ‘normally good rule’ to an oxygen
pipe could result in damage to the pipe because
they are an exception to the ‘rule’
Jan 2005 76
3. Human Error
Applying Bad Rules

 We all pick up some ‘bad rules’ (bad habits) as we
go through life
 Although bad, they frequently serve our immediate
purpose and ‘we get away with it’, i.e. no negative
or bad effects
 These are dangerous because the more we ‘get
away with it’ the more we convince ourselves and
other it is a ‘good rule’
Jan 2005 77
3. Human Error
Applying a Bad Rule - Examples

 The British Rail Technician in the Clapham rail
accident had acquired the practice of bending back
old, redundant, wires rather cutting them off and
insulating them
 Changing the DC-10 engine using a fork lift truck
instead of the proper lifting gear
Jan 2005 78
3. Human Error
Errors and Violations
Violations are deliberate acts whereas errors are

unintentional
Jan 2005 79
3. Human Error
Violations
Violations are shaped mainly by attitudes, beliefs,

group norms and safety/company culture
Most stem from a genuine desire to do a good job.
Very seldom are they acts of vandalism or
sabotage
They represent a significant threat to safety as the
maintenance system is designed assuming that
people will follow the procedures
Jan 2005 80
3. Human Error
Violations - Types
Routine violations
Situational violations
Optimizing violations
Exceptional violations
Jan 2005 81
3. Human Error
Violations – Routine Violations
These are violations which have become the

normal way of doing something within the persons
work group
They can become routine for a number of reasons:
- Short cuts saves time and energy
- The procedures may be overly prescriptive
and skilled people tend to think they know best
Jan 2005 82
3. Human Error
Violations – Routine Violations
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”).
Jan 2005 83
3. Human Error
Violations – Situational Violations
These violations occur due to the particular factors

that exist at the time e.g.
- unrealistic deadlines (time pressure)
- high workload
- unworkable procedures
- inadequate tooling
- poor working conditions
These occur often when in order to get the job
done a procedure cannot be followed
Jan 2005 84
3. Human Error
Violations – Situational Violations
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.
Jan 2005 85
3. Human Error
Violations – Optimizing Violations
These are 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.
An example would be when asked to drive a
company vehicle to stores to collect a part and you
get a thrill from drive fast, spinning the wheels and
doing handbrake turns
Jan 2005 86
3. Human Error
Violations – Exceptional Violations
These are described by Jim Reason as ‘double

binds’
A violation is inevitable regardless of how well
intentioned the person is
These normally occur in emergency situations
when the normal rules no longer apply due to the
local conditions
Jan 2005 87
3. Human Error
Violations - Who are involved
Males (research shows that women tend to be far

more compliant and take less risks)
Young people
‘Experts’ (this includes experienced aviation
maintenance personnel!)
Jan 2005 88
3. Human Error
Consideration when decided to violate rules
If it was 3 ‘o’ clock in the morning, the roads are

deserted and you are very late getting home. What
things would you consider when deciding if you
will break the speed limit?
Jan 2005 89
3. Human Error
Consideration when decided to violate rules
Violation likely
Perceived
benefits
of violation
Violation unlikely
Jan 2005 perceived cost of violation 90

3. Human Error
Violation Balance Sheet
Perceived benefits Perceived costs

Easier way of working Accident to aircraft
Save time Injury to self/others
More exciting Damage to assets
Gets the job done Costly to repair
Shows skill Punishment
Meets a deadline Loss of Job/promotion
Disapproval of peers
Jan 2005 91
3. Human Error
General Factors in Violations
Violations have a tendency to become routine

because they involve less time and effort.
Time pressure and high workload increases 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.
Jan 2005 92
3. Human Error
Organizational culture is an important factor.

Most companies have safety as their stated
overriding goal. In reality, production is often
their first concern.
If workers believe that the company want them to
‘bend the rules’ to get the aircraft away, then
‘messages’ from management saying safety is first
and follow the procedures is seen as just covering
themselves.
Jan 2005 93
3. Human Error
The more rules or procedures we are expected to

abide by, the greater the probability that violations
will occur
If we write a new procedure each time we have a
bad event, there comes a point where it is almost
impossible to get the job done without breaking a
rule
If managers and supervisors turn a ‘blind eye’ to
violations, people will feel that their actions are
condoned.
Violation + error = an accident
Jan 2005 94
3. Human Error
Do We need procedures for everything ?
Not always!
Detailed working instructions are not needed if the
person is trained and competent.
Organizations and managers prefer to issue work
instructions as it is cheaper than training and a
program of competence assessment
Jan 2005 95
3. Human Error
The importance of procedures
There is an assumption that people will follow the

procedures laid down in the safety management
system.
When this assumption is broken the whole basis of
the safety system is put at risk.
Maintenance requirements, safety, is based almost
solely on an assumption that people will follow the
procedures.
Jan 2005 96
3. Human Error
Top Maintenance Problems
CAA Study -1992

1. The fitting of wrong parts
2. Electrical wiring discrepancies (including cross-
connections)
3. Loose objects (tools, etc..) left in aircraft
4. Inadequate lubrication
5. Cowlings, access panels and fairings not secured
6. Fuel/oil caps and refuel panels not secured
7. Landing gear ground lock pins not removed
before departures
Jan 2005 97
3. Human Error
Top Seven causes of in-flight shutdowns
Incomplete installation (33%)

Damage on installation (14.5%)
Improper installation (11%)
Equipment not installed (11%)
Foreign Object Damage (6.5%)
Improper fault isolation,
inspection, test (6%)
Equipment not activated or
deactivated (4%)
Jan 2005 98
3. Human Error
Reasons Bolt and Nuts example
A B C D E F G H
Jan 2005 99
3. Human Error
The “Iceberg Model” of Accidents
Serious Events and Audits
Errors that “Hurt”

e.g. Delays, ATB’s,
Cancellations etc.
ERRORS YOU KNOW

!NOTHING ABOUT
Jan 2005 100

3. Human Error
Learning from Errors
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.
Jan 2005 101

3. Human Error
Avoiding and Managing Errors
Error management seeks to:

• prevent errors from occurring;
• eliminate or mitigate the bad effects of
errors
Jan 2005 102

3. Human Error
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.
Jan 2005 103
3. Human Error
Error Management Measures

Selection
Training and re-training
Work planning
Job cards
Tags and reminders
Shift handover procedures
Licence – to - work systems
Human resource management
Jan 2005 104
3. Human Error
Error Management Measures –contd.

Licensing and certification
Checking and sign-offs
Technical and quality audits
Procedures, manuals, rules and regulations
Disciplinary procedures
Total Quality Management (TQM)
Jan 2005 105

3. Human Error
The Principles of Error management
Human Error is both universal and inevitable

Errors are, not intrinsically bad
You cannot change the human condition, but you
can change the condition in which humans work
The best people can make the worst mistakes
People cannot easily avoid those actions they did
not intend to commit
Errors are consequences rather than causes
Many errors fall into recurrent patterns
Jan 2005 106
3. Human Error
The Principles of Error management
Safety –significant systems can occur at all level

of the system
Error management is about managing the
manageable
Error management is about making good people
excellent
There is no one best way
Effective error management aims at continuous
reform rather than local fixes
Managing error management is the most
challenging and difficult part of the EM process
Jan 2005 107
3. Human Error
Human Reliability
usually defined as the probability that a person

will correctly performs some system-required
activity during a given time period (if time is a
limiting factor) without performing any
extraneous activity that can degrade the system.
Jan 2005 108

3. Human Error
Human Reliability – Operator Models
Behavioural or human factors – error models

Information processing – internal mechanisms
Cognitive models – relation between error
models and causes
Jan 2005 109

4. HUMAN PERFORMANCE
AND LIMITATIONS
Jan 2005 110

The aircraft engineer is the central part of the

aircraft maintenance system. It is therefore very
useful to have an understanding of how various
parts of his body and mental processes function
and how performance limitations can influence
his effectiveness at work
Jan 2005 111

Vision
Jan 2005 112

Vision
When a person is tired accommodation is

reduced, resulting in less sharp vision (sharpness
of vision is known as visual acuity)
Visual acuity is the ability of the eye to

discriminate sharp detail at varying distances
Jan 2005 113

Vision – Factors affecting visual acuity
Physical factors – short sightedness, long

sightedness
The influence of ingested foreign substances –
drugs, medication, alcohol, cigarettes
Environmental factors – amount of light, dust ,
mist, rain
Factors associated with object being viewed –
size and contours, contrast, relative motion,
distance, angle
Jan 2005 114
Vision – Colour vision
Good colour vision is important for

Recognizing components
Distinguishing between wires
Using various diagnostic tools
Recognizing various lights
Jan 2005 115

Colour-defective vision (normally referred to

incorrectly as colour blindness) affects about 8%
of men but only 0.5% of women. The most
common type is difficulty in distinguishing
between red and green. More rarely, it is possible
to confuse blues and yellows.
Jan 2005 116

Cones function in good light and are capable of

detecting fine detail and are colour sensitive.
This means the human eye can distinguish about
1000 different shades of colour.
Rods cannot detect colour. They are poor at
distinguishing fine detail, but good at detecting
movement in the edge of the visual field
(peripheral vision). They are much more
sensitive at lower light levels. As light decreases,
the sensing task is passed from the cones to the
rods. This means in poor light levels we see only
in black and white and shades of grey.
Jan 2005 117
Vision – Lighting Conditions
Vision improves with increased lighting levels

(up to a point)
Too much light results in glare
Younger people need less light to see well
Older people need twice as much light to see
things properly
Jan 2005 118

Hearing
Jan 2005 119

Hearing
The amount of vibration detected in the cochlea

depends on the volume and pitch of the original
sound.
The audible frequency range that a young person
can hear is typically between 20 and 20,000
cycles per second (or Hertz), with greatest
sensitivity at about 3000 Hz.
We are more sensitive to higher frequencies than
lower ones (low tones have to have more
intensity to be of equal loudness)
With age we lose sensitivity of higher
Jan 2005 120
Hearing – Typical Noise Levels
 Rustling of leaves 30db

 Office Noise 40db
 Car at 15m 70db
 Petrol mover at 2m 90db
 Night Club 110db
 Jet Engine 140db
 Threshold of pain 140db
Note: Noise is exponential, .e.g. 10 jet engines = 150dbA. 100 jet engines =
160dbA.
Jan 2005 121

Hearing – Recommended Maximum Exposure
Exposure per day Sound Level in db

● 8 hrs 90
● 6 hrs 92
● 4 hrs 95
● 3 hrs 97
● 2 hrs 100
● 1 hrs 105
● 0.5 hrs 110
● >0.25 hrs 115
Jan 2005 122
Hearing – Hearing Protection
Protection against excessive noise is needed to

combat the effects of:
- Fatigue
- Distraction
- Temporary hearing damage
- Permanent hearing damage
- Health and Safety legislation
Jan 2005 123

Hearing – Hearing Protection
Ear muffs reduce noise levels by 40db

Ear plugs reduce noise levels by 20db
Like most human factors intervention strategies
there can be a down-side:
- Oral-aural communication will be affected
by
wearing ear protection
- Removing or reducing the source of the
noise is the preferred strategy
Jan 2005 124
Information Processing
Information processing is the process of

receiving information through the senses,
analyzing it and making it meaningful.
Attention can be thought of as the concentration
of mental effort on sensory or mental events
Jan 2005 125

Information Processing – Functional Model
Jan 2005 126

Attention and Perception
The vast majority of what arrives at our senses is

never perceived
The brain has only a limited capacity to process
and interpret sensory information
Imagine how chaotic things would be if we were
always aware of all the things reaching our
senses
Jan 2005 127

Perception can be defined as the process of

assembling sensations into a useable mental
representation of the world. Perception
creates faces, melodies, works of art,
illusions, etc. out of the raw material of
sensation.
Jan 2005 128

“Perception is not determined simply by stimulus

patterns; rather it is dynamic searching for the
best interpretation of the available
data….perception involves going beyond the
immediately available evidence of the senses”
“What we perceive is not the data, but the
interpretation of it”.
Jan 2005 129

Attention and Perception - Forms of Attention
Selective attention – greater attention to

more important
Divided attention – doing more than one
thing at the same time
Focused attention – focusing upon a single
source
Sustained attention – ability to maintain
attention over long periods
Jan 2005 130
Attention and Perception - Illusion
Muller-Lyer Illusion
Jan 2005 131

Horizontal Vertical Illusion
Jan 2005 132

Keep staring at the black dot. After a while the gray haze
around it will appear to shrink
Jan 2005 133

Count the black dots
Jan 2005 134

The invisible triangle
Jan 2005 135

Attention and Perception – The importance of context
Jan 2005 136

Attention and Perception – The effects of expectation
Jan 2005 137

Decision Making
Decision making is the generation of alternative

courses of action based on available information,
knowledge, prior experience, expectation,
context, goals, etc. and selecting one preferred
option. It is also described as thinking, problem
solving and judgment.
Jan 2005 138

Situation Awareness
Situation awareness is the synthesis of an

accurate and up-to-date 'mental model' of one's
environment and state, and the ability to use this
to make predictions of possible future states.
An example is an engineer seeing (or perceiving)
blue streaks on the fuselage. His comprehension
may be that the lavatory fill cap could be missing
or the drain line leaking. If his situation
awareness is good, he may appreciate that such a
leak could allow blue water to freeze, leading to
airframe or engine damage.
Jan 2005 139
Situation Awareness
Perception
- Seeing blue streaks on fuselage
Comprehension
- Lavatory fill cap could be missing or drain-line
leaking
Projection
- Leak can allow water to freeze, leading to engine
or airframe damage
Jan 2005 140

Situation Awareness
Once we have formed a mental model of a

situation, we often seek information which will
confirm this model and, not consciously, reject
information which suggests that this model is
incorrect.
Jan 2005 141

Memory
Memory can be considered to be the storage and

retention of information, experiences and
knowledge, as well as the ability to retrieve this
information.
Memory depends on three processes:
• registration - the input of information into
memory;
• storage - the retention of information;
• retrieval - the recovery of stored
information
Jan 2005 142
Memory
Three forms of Memory

Ultra short-term – sensory storage – duration up to
two seconds – used as a buffer
Short term – working memory - 7±2 items – 10-20
seconds
Long term – appears to be unlimited – semantic and
episodic
Jan 2005 143

Claustrophobia and Physical Access
Claustrophobia can be defined as abnormal fear

of being in an enclosed space
Jan 2005 144

Motivation
Motivation can be thought of as a basic human

drive that arouses, directs and sustains all human
behaviour. Generally we say a person is
motivated if he is taking action to achieve
something
“motivation reflects the difference between what

a person can do and what he will do
Jan 2005 145

Maslow’s Hierarchy of Needs
Jan 2005 146

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.
Jan 2005 147

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.
Jan 2005 148

Fitness / Health
“certifying staff must not exercise the privileges

of their certification authorization if they know or
suspect that their physical or mental condition
renders them unfit.”
Jan 2005 149

Fitness / Health
“certifying staff must not exercise the privileges

of their certification authorization if they know or
suspect that their physical or mental condition
renders them unfit.”
Jan 2005 150

Stress
Stress can be defined as any force, that when

applied to a system, causes some significant
modification of its form, where forces can be
physical, psychological or due to social
pressures.
It should be noted that individuals respond to
stressful situations in very different ways.
Jan 2005 151

Stress
Stressors may be:

Physical – heat, cold, noise, vibration
Psychological – emotional upset, worries
Reactive - events
Jan 2005 152

Stress
Stressors may be:

Physical – heat, cold, noise, vibration
Psychological – emotional upset, worries
Reactive - events
Jan 2005 153

Stress
Possible signs of Stress may be:

Psychological symptoms – sweating, dryness, of the
mouth
Health effects – nausea, headaches, sleep problems,
diarrhoea, ulcers
Behavioral symptoms – restlessness, shaking,
nervous laughter, taking longer over talks, change to
appetite, excessive drinking
Jan 2005 154

Stress – Stress management
Defense strategies involve alleviation of the

symptoms (taking medication, alcohol, etc.) or
reducing the anxiety (e.g. denying to yourself
that there is a problem (denial), or blaming
someone else).
Coping is the process whereby the individual

either adjusts to the perceived demands of the
situation or changes the situation itself.
Jan 2005 155
Stress management Techniques include:

Relaxation techniques
Careful regulation of sleep and diet
Regular physical exercise
counseling
Jan 2005 156

Stress management Techniques include:

Relaxation techniques
Careful regulation of sleep and diet
Regular physical exercise
counseling
Jan 2005 157

Workload Management
Workload management should include:

Ensuring staff have he necessary skills
Availability of required tools
Allocation of tasks which are accomplishable
HF training to supervisors and planners
Encouraging to recognize build up of over load
situation
Jan 2005 158

Workload Management
Methods to help relieve over load:

Seeking alternate method
Delegating activities
Securing further time
Postponing, delaying tasks / deadlines and refusing
additional work
Jan 2005 159

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.”
Jan 2005 160

Fatigue
Symptoms of Fatigue:
Diminished perception
Diminished motor skills
Problems with short-term memory
Channelled concentration
Being easily distracted
Poor judgment
Abnormal moods
Diminished standards of own work
Jan 2005 161
Alcohol, Medication and Drugs
It should come as no surprise to the aircraft

maintenance engineer that his performance will
be affected by alcohol, medication or illicit drugs
Under JAA legislation it is an offence for safety
critical personnel to carry out their duties whilst
under the influence of alcohol or drugs
Jan 2005 162

“The holder of an aircraft maintenance

engineer’s licence shall not, when exercising the
privileges of such a licence, be under the
influence of drink or a drug to such an extent as
to impair his capacity to exercise such
privileges.”
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.
Jan 2005 163
Medication can be regarded as any over-the-

counter or prescribed drug used for therapeutic
purposes
Medication is usually taken to relieve symptoms
of an illness. Even if the drugs taken do not affect
the engineer’s performance, he should still ask
himself whether the illness has made him
temporarily unfit for work.
Jan 2005 164

If the aircraft maintenance engineer has any

doubts about the suitability of working whilst
taking medication, he must seek appropriate
professional advice
Jan 2005 165

5. ENVIRONMENT
Jan 2005 166

5. Environment
Peer Pressure
If 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
Jan 2005 167

5. Environment
Conformity
B is the same length as X

Jan 2005 168
5. Environment
Conformity
Factors affecting individual’s view :

Culture
Gender
Self-esteem
Familiarity
Expertise of the group members
Jan 2005 169

5. Environment
Stressors
Type of Stressors:
Physical – heat, humidity, confined spaces, noise,
vibration
Social – anxiety, group pressures, incentive schemes,
disciplinary actions
Drugs – alcohol, nicotine, medication
Pace of work – boredom, fatigue, interruptions, time
pressure
Personal factors – domestic worries, aches and pains,
cold and generally feeling below par
Jan 2005 170
5. Environment
Time Pressure and Deadlines
Aircraft Engineers have two driving forces:

Deadlines handed down to them
Responsibility to carry our a safe job
The potential conflict of the two driving forces

can cause problems
Jan 2005 171

5. Environment
Factors to be considered :
Prioritizing work needed to be done
Actual time available
Manpower available
Appropriate utilization of tasks
Availability of parts, spares, tools and equipment
Jan 2005 172

5. Environment
It is important that engineering staff at all levels

are not afraid to voice concerns over
inappropriate deadlines, and if necessary, cite the
need to do a safe job to support this
As highlighted earlier, within aircraft
maintenance, responsibility should be spread
across all those who play a part
Thus, the aircraft maintenance engineer should
not feel that the ‘buck stops here’.
Jan 2005 173
5. Environment
Workload
The degree of stimulation exerted on an

individual caused by a task is generally referred
to as workload, and can be separated into
physical workload and mental workload
Jan 2005 174

5. Environment
Workload
Optimum arousal leads to best task performance
Jan 2005 175

5. Environment
Workload
Factors determining workload

The nature of the task – physical demands, mental
demands
Circumstances under which task is performed –
degree of accuracy, time, simultaneous tasks,
perceived control of the task, environmental factors
The person and his state – skills, experience, health
and fitness level,
Emotional state
Jan 2005 176

5. Environment
Overload
EASA part 145.A.30 (d) states that:

“The organization shall have a maintenance
man-hour plan showing that the organization has
sufficient staff to plan, perform, supervise,
inspect and quality monitor the organization in
accordance with the approval.
In addition the organization shall have a
procedure to reassess work intended to be
carried out when actual staff availability is less
than the planned staffing level for any particular
Jan 2005 177
5. Environment
Shift Work
Advantages and Disadvantages

More off days
Avoiding peak traffic when traveling to work
Working ‘unsociable hours’
Working when human performance known to be poor
Problems associated with disturbed body rhythms
Jan 2005 178

5. Environment
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
Jan 2005 179

5. Environment
Circadian Rhythms
Circadian rhythms are physiological and

behavioural functions and processes in the body
that have a regular cycle of approximately a day
(actually about 25 hours in man)
Although, circadian rhythms are controlled by
the brain, they are influenced and synchronized
by external (environmental) factors such as light
Jan 2005 180

5. Environment
Circadian Rhythms – Internal Body Temperature
Jan 2005 181

5. Environment
Noise and Fumes
Noise can be thought of as any unwanted sound,

especially if it is loud, unpleasant and annoying
It is very important that aircraft maintenance
engineers remain aware of the extent of the noise
around them
It is likely that some form of hearing protection
should be carried with them at all times and, as a
rule of thumb, used when remaining in an area
where normal speech cannot be heard clearly at 2
meters.
Jan 2005 182
5. Environment
Noise and Fumes
Apart from noxious fumes that have serious

health implications and must be avoided,
working in the presence of fumes can affect an
engineer’s performance, as he may rush a job in
order to escape them.
If the fumes are likely to have this effect, the
engineer should increase the ventilation locally
or use breathing apparatus to dissipate the fumes
Jan 2005 183

5. Environment
Illumination
Illumination refers to the lighting both within the

general working environment and also in the
locality of the engineer and the task he is
carrying out. It can be defined as the amount of
light striking a surface.
Jan 2005 184

5. Environment
Climate and Temperature
EASA part 145.A.25 (c) 1 states that
“temperatures must be maintained such that

personnel can carry out required tasks without
undue discomfort.”
Jan 2005 185

5. Environment
Climate and Temperature
Jan 2005 186

5. Environment
Complex Systems
Any complex system can be thought of as having

a wide variety of inputs. The system typically
performs complex modifications on these inputs
or the inputs trigger complex responses. There
may be a single output, or many distributed
outputs from the system.
When working with complex systems, it is
important that the aircraft maintenance engineer
makes reference to appropriate guidance
material. This typically breaks down the system
conceptually or physically, making it easier to
understand and work on.
Jan 2005 187
5. Environment
Hazards in Workplace
In brief, a maintenance organization has a duty

under health and safety legislation to:
identify hazards in the workplace
remove them where possible
mitigate the risks to employees
Every aircraft maintenance engineer should be
aware that he can influence the safety of those
with whom he works
Jan 2005 188

5. Environment
Potential hazards in aircraft maintenance

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
Jan 2005 189

5. Environment
Hazards in Workplace – Health and Safety policy
Carry out assessments of work to determine Health and

Safety risks
Provide safe working practices and procedures
Inform employees and other persons of any risk
Provide suitable training and/or instruction to meet any
Health and Safety risks
Develop and introduce practices and procedures to
reduce risks to Health and Safety
Provide for the welfare of employees
Discuss with and consult employee representatives on
Health and Safety matters
Jan 2005 190
5. Environment
Warning Signs must:

Clearly identify the hazard
Describe the danger
Inform employees what to do or what not to do
Jan 2005 191

5. Environment
Hazards in Workplace – Dealing with Emergencies
The basic actions in an emergency are to:

Stay calm and assess the situation
Observe what has happened;
Look for dangers to oneself and others;
Never put oneself at risk.
Make the area safe
Protect any casualties from further danger;
Remove the danger if it is safe to do so (i.e. switching
off an electrical current if an electrocution has
occurred);
Jan 2005 192
5. Environment
Hazards in Workplace – Dealing with Emergencies
The basic actions in an emergency are to: (contd.)

Be aware of ones own limitations (e.g. do not fight a fire
unless it is practical to do so).
Assess all casualties to the best of ones abilities (especially if
one is a qualified first aider)
Call for help
Summon help from those nearby if it is safe for them to
become involved;
Call for local emergency equipment (e.g. fire extinguisher);
Call for emergency services (ambulance or fire brigade, etc.).
Provide assistance as far as one feels competent to
Jan 2005 193

5. Environment
Lack of Manpower
EASA part 145.A.30 (d) state that

The organization shall have a maintenance man-
hour plan showing that the organization has
procedure to reassess work intended to be carried
out when actual staff availability is less than the
planned staffing level for any particular work
shift or period.
Jan 2005 194
5. Environment
Lack of Manpower
EASA part 145.A.30 (d) state that

The organization shall have a maintenance man-
hour plan showing that the organization has
procedure to reassess work intended to be carried
out when actual staff availability is less than the
planned staffing level for any particular work
shift or period.
Jan 2005 195
5. Environment
Distractions and Interruptions
Steps to minimize the effects of distraction

Always finish the job or unfasten the connection
Mark the uncompleted work
Lockwire where possible or torque seal
Double inspect by another or self
When return to the job always go back few steps
Use a detailed check sheet
Jan 2005 196

6. PROCEDURES,
INFORMATION, TOOLS AND
PRACTICES
Jan 2005 197

6. Procedures, Information, Tools and Practices
Visual Inspection
Visual inspection can be described as the process

of using the eye, alone or in conjunction with
various aids to examine and evaluate the
condition of systems or components of an
aircraft.
Jan 2005 198

Visual Inspection
Steps that are helpful to carry out visual inspection

ensure that he understands the area, component or
system he has been asked to inspect
locate the corresponding area, component or system on
the aircraft itself
make sure the environment is conducive to the visual
inspection task
conduct a systematic visual search, moving his eyes
carefully in a set pattern so that all parts are inspected
examine thoroughly any potential degradation or defect
that is seen
Jan 2005 199
Work logging and recording
The key aspects of work logging and recording are captured in the
CAA’s Airworthiness Notice No. 3 (AWN3). This states:
“In relation to work carried out on an aircraft, it is the duty
of all persons to ensure that an adequate record of the work
carried out is maintained.
This is particularly important where such work carries on beyond
a working period or shift, or is handed over from one person to
another. The work accomplished, particularly if only disassembly
or disturbance of components or aircraft systems, should be
recorded as the work progresses or prior to undertaking a
disassociated task. In any event, records should be completed no
later than the end of the work period or shift of the individual
undertaking the work. Such records should include ‘open’ entries
to reflect the remaining actions necessary to restore the aircraft to
a serviceable condition prior to release.
Jan 2005 200
Work logging and recording
The Reasons why people choose not comply with

procedures
If followed to the letter, the job would not get done.
People are not aware that a procedure exits.
People prefer to rely on their own skills and
experience.
People assume that they know what is in the
procedure.
Jan 2005 201

7. COMMUNICATION
Jan 2005 202

7. Communication
Communication is defined in the Penguin

Dictionary of Psychology as:
“The transmission of something from one
location to another.
The ‘thing’ that is transmitted may be a message,
a signal, a meaning, etc.
In order to have communication both the
transmitter and the receiver must share a
common code, so that the meaning or
information contained in the message may be
interpreted without error”.
Jan 2005 203
7. Communication
Methods of Communication
Communication is defined as the dynamic and

irreversible process by which we exchange and
interpret messages within a given situation or
context
___________________
Verbal
Tone of voice
Body Language (Non-verbal Communication)
Written (includes text, symbols and pictures)
Jan 2005 204
7. Communication
Which form of communication do you think is

the most important?
 Verbal
 Tone of voice
 Body language
Jan 2005 205

7. Communication
 Verbal = 7%
 Tone of voice = 38%
 Body language = 55%
Jan 2005 206

7. Communication
Of the three types of communication, spoken words are
the least important
People attach more important to tone of voice and most
importance of all to facial expressions, gestures, etc
When two messages conflict with each other, more
importance is placed on the non verbal communication
(NVC) cues
NVC may give information about people’s attitudes
(Posture, pupil size, and eye contact etc)
NVC may give information about emotional states-fear,
anger, anxiety etc as signals ‘leak’
Jan 2005 207
7. Communication
Redundancy in Communication
Communication is extremely important in the

context of aviation maintenance
Because communication is very difficult to be

100% more than one method of communication
should be used whenever possible
The more redundancy we have, the greater the

likelihood that effective communication will
occur
Jan 2005 208
7. Communication
Redundancy in Communication
Basic rules of thumb to help aircraft maintenance

engineers minimize poor communication are:
think about what you want to say before
speaking or writing;
speak or write clearly;
listen or read carefully;
seek clarification wherever necessary.
Jan 2005 209

7. Communication
Shift / Task handover
EASA part 145.A.47 (c) states that:
When it is required to hand over the continuation

or completion of maintenance tasks for reasons
of a shift or personnel changeover, relevant
information shall be adequately communicated
between outgoing and incoming personnel.
Jan 2005 210

7. Communication
Shift / Task handover
AMC 145.A.47 (c) state that:
The primary objective of the changeover / handover
information is to ensure effective communication at the point
of handing over the continuation or completion of maintenance
actions. 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 formalized process for exchanging information between
outgoing and incoming persons and a planned shift overlap and
a place for such exchanges to take place.
Jan 2005 211
8. TEAMWORK
Jan 2005 212

8. Teamwork
Teams may comprise a number of individuals

working together towards one shared goal
Alternatively, they may consist of a number of
individuals working in parallel to achieve one
common goal
Teams generally have a recognized leader and
one or more follower(s)
Jan 2005 213

8. Teamwork
Discussion on motivation suggests that

individuals need to feel part of a social group. In
this respect, team working is advantageous.
The work on conformity suggests that they feel
some pressure to adhere to a group’s views,
which may be seen as a potential disadvantage.
Jan 2005 214

8. Teamwork
Potential benefits of working as a team :
Individuals can share resources (knowledge,

tools, etc.)
They can discuss problems and arrive at shared
solutions
They can check each others’ work (either
“officially” or “unofficially”)
Jan 2005 215

8. Teamwork
Elements of Team Working
Communication
Cooperation
Coordination
Mutual support
Jan 2005 216

8. Teamwork
Responsibility
Responsibility should be spread across all those

who play a part in the activity. This ranges from
the accountable manager who formulates policy
through management that set procedures
to supervisors, teams of engineers and
individuals within those teams
Flight crew are responsible for carrying out pre-
flight checks, walk-around and highlighting
aircraft faults to maintenance personnel
Jan 2005 217
8. Teamwork
Responsibility
In the maintenance engineering environment,
responsibility has been considered in terms of the
individual
This has much to do with the manner in which
engineers are licensed and the way in which work is
certified.
The main advantage to individual responsibility is that
an engineer understands clearly that one or more tasks
have been assigned to him and it is his job to do them (it
can also be a strong incentive to do the work correctly)
This may overlook the importance of working together
as a cohesive team or group to achieve goals.
Jan 2005 218
8. Teamwork
Group Responsibility
The advantages are that each member of the

group ought to feel responsible for the output of
that group, not just their own output as an
individual, and ought to work towards ensuring
that the whole ‘product’ is safe.
The disadvantage of group responsibility is that it
can potentially act against safety – diffusion of
responsibility
Jan 2005 219

8. Teamwork
Group Responsibility
Problems associated with team working
Inter-group conflict –small group may act

cohesively but may have friction with others
Group polarization – tendency for groups to
make decisions that are more extreme
Social loafing - tendency for some
individuals to work less hard
Jan 2005 220

8. Teamwork
Management Supervision and Leadership
Line Managers, those working as an integral part

of the ‘front line’ operation, may be placed in a
situation where they may have to compromise
between commercial drivers and ‘ideal’ safety
practices
Jan 2005 221

8. Teamwork
Leader
Qualities of a good leader
Motivating his team

Reinforcing good attitudes and behaviour
Demonstrating by example
Maintaining the group
Fulfilling a management role
Jan 2005 222

8. Teamwork
Decision Making
Ideally, we would make all our work-related

decisions by following a careful rational process
in which we consider all options, evaluate each in
turn and then select the best course of action.
In reality things are somewhat different.
Workplace decisions can be biased and distorted
by a range of factors. Sometimes we do not
consider all the alternatives, or we take labour-
saving mental short cuts. Or under emotional or
time pressures, our thinking is 'short circuited'
Jan 2005 223
8. Teamwork
Decision Making
Ideally, we would make all our work-related

decisions by following a careful rational process
in which we consider all options, evaluate each in
turn and then select the best course of action.
In reality things are somewhat different.
Workplace decisions can be biased and distorted
by a range of factors. Sometimes we do not
consider all the alternatives, or we take labour-
saving mental short cuts. Or under emotional or
time pressures, our thinking is 'short circuited'
Jan 2005 224
8. Teamwork
Decision Making
Two common decision making problems
Confirmation Bias
Emotion and Decision Making
Jan 2005 225

9. PROFESSIONALISM AND
INTEGRITY
Jan 2005 226

Concepts of Professionalism
Professionals are characterized as persons with a

high degree of
competence in their field
control (both in authority and ability) to make
decisions based on their competence
commitment to the greater public
being central to the operation of the larger
enterprise
Jan 2005 227

Does an organization shape an individual or

does an individual shape an organization?
Jan 2005 228

If the organization's expectations are higher than

the individual's threshold,
the individual should improve his/her practices to
meet the organization's expectations.
The organization, on the other hand, should have
structured on-the-job training to help the individuals
improve themselves
periodic evaluation system to assess the individual's
performance.
Jan 2005 229

If the organization's expectations are lower than

the individual's threshold,
the individual has three choices:
acquiesce to the organization's expectations
seek proper channels to improve the
organization
leave the organization
Jan 2005 230

Six elements of professionalism that are

specifically applicable to the aviation
maintenance environment (CAPWIT):
Communication
Assertiveness
Preparation
Work Management
Integrity
Teamwork.
Jan 2005 231
keeping up-to-date
To maintain currency, must keep abreast of

pertinent information relating to:
new aircraft types or variants
new technologies and new aircraft systems
new tools and maintenance practices
modifications to current aircraft and systems
revised maintenance procedures and
practices
Jan 2005 232

keeping up-to-date
Engineers are likely to keep up-to-date by:
undertaking update courses

reading briefing material, memos and
bulletins (QN, TN etc.)
studying maintenance manual
amendments
Jan 2005 233

Error Provoking Behaviour
An unchanged part of human condition

is fallibility
Most workers have little control over

system issues – hours of work,
equipment and work schedules
Jan 2005 234

Person Measures
Understanding error provoking factors
Excessive reliance on memory
Interruptions
Pressure
Tiredness
Inadequate coordination between
maintenance staff
Jan 2005 235
Person Measures (contd.)

Unfamiliar jobs
Ambiguity
Highly routine procedures
Understanding why people violate good
procedures
Jan 2005 236

Intentions to violate are shaped by three

interrelated factors:-
Attitudes to behaviour ('I can do it.')
Subjective norms (they would/would not like
me doing this.')
Perceived behavioural control ('I can't help it.')
Jan 2005 237

Measures designed to reduce violations
The most commonly used technique for reducing
violations is aimed at the first of the three elements
above, attitudes to behaviour
Efforts are made to scare people into compliance by
graphic posters and videos that highlight the grisly
consequences of unsafe behaviour
These fear appeals can serve three useful functions.
First, they inform people about the links between
unsafe acts and safety
Second, they have the power to shock
Third, they should indicate the correct way of doing
things.
Jan 2005 238

Social controls address the second factor listed

above: subjective norms.
That is, the extent to which other people - whose
opinions matter to the individual - would approve
or disapprove of the violating behaviour
Jan 2005 239

Social controls represent one of the most

effective ways of modifying individual
behaviour.
We are social animals.
We need the approval, liking and respect of those
we care about.
Many of the manageable ways of influencing
social controls involve group discussions and
group activities
Jan 2005 240
Social controls represent one of the most

effective ways of modifying individual
behaviour.
We are social animals.
We need the approval, liking and respect of those
we care about.
Many of the manageable ways of influencing
social controls involve group discussions and
group activities
Jan 2005 241
Assertiveness
Assertiveness involves verbal alerting of a

discrepancy as well as constructive analysis of
one's own judgment
Jan 2005 242

10. ORGANIZATION’S HUMAN
FACTOR PROGRAM
Jan 2005 243

10. organization’s Human Factor Program
EASA part 145.A.30 (e) state that:

The organization shall establish and control the competence of
personnel involved in any maintenance, management and/or
quality audits in accordance with a procedure and to a standard
agreed by the competent authority.
In addition to the necessary expertise related to the job function,
competence must include an understanding of the application of
human factors and human performance issues appropriate to that
person's function in the organization.
‘Human factors’ means principles which apply to aeronautical
design, certification, training, operations 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.
Jan 2005 244
QUALITY POLICY
We at SriLankan Airlines - Engineering & Maintenance division are committed
to provide a service par excellence that would continually delight our customers
where safety of the aircraft, reliability of our service and punctuality will be our
key goals
To achieve this objective we shall:
Recognize safety as a prime consideration in all our activities
Ensure human factor requirements are identified and applied
to eliminate errors and that all employees fully comply to procedures, safety
standards and regulations. Ensure
an effective system of communication is established to report and review
maintenance related errors and incidents.
Ensure all internal operations are
carried out under controlled conditions and in
an audited environment
Ensure that all customer/ regulator requirements are continually
determined with the view of meeting with those requirement
Ensure all
aircrafts are routinely monitored and maintained and thereby made
commercially available to maximize revenue generation.
To this end, we are committed to establish and maintain a Quality Management
System and set quality objectives at all relevant levels of the division and review
Jan 2005 these objectives at planned intervals for continual improvement. 245
EASA part 145.A.30 (e) state that:

The organization shall establish and control the competence of
personnel involved in any maintenance, management and/or
quality audits in accordance with a procedure and to a standard
agreed by the competent authority.
In addition to the necessary expertise related to the job function,
competence must include an understanding of the application of
human factors and human performance issues appropriate to that
person's function in the organization.
‘Human factors’ means principles which apply to aeronautical
design, certification, training, operations 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.
Jan 2005 246

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HUMAN FACTORS

The aim of human factors in aviation

The technology concerned to optimize the

In aviation, Human Factors involves a set of

Human Factors is the study of the human as a central part

Ergonomics derives from the Greek words

The study of the efficiency of persons in their

Original concentration on biomechanical and

Anthropometry is the science of measurement

The name derives from anthropos meaning

The science of Biomechanics addressees

Muscles and tendons provide the motive force

Parallel to aviation development

Anthropometrics – Eye datum in cockpit

Human Factors - US led development

Terms now synonymous in aviation context

MRM is defined as:

Humans are better than Machines in :

Machines are better than Humans in :

Safety is the major reason

United Airlines Flight 173 –DC8 aircraft

United Airlines commenced CRM workshops

British Midland B737-400 [almost brand new]

The combination of heavy engine vibration,

As the #2 engine was throttled back the noise

Examination of the aircraft revealed dis-

Maintenance, Inspection – Improper

THE HUMAN FACTORS ELEMENTS

 Lack of communication  Lack of resources

If anything can go wrong, it will.

If an individual perceives that there are four

Beliefs, Attitudes and Values – of an

Structures, Practices, Controls, and Policies

Most organizations would seek to change

Changing collective values of adult people in

Values, beliefs and attitudes can be changed,

Is the first critical step in socially engineering

Zero tolerance for reckless conduct

Psychological and Organizational Barriers

Characteristics of successful reporting programs

Value of a safety information system lies in its

Reporting culture is a prerequisite for a

Actions Single – loop

Four stage model of organizational learning

Three kinds of Safety Culture – the way that

“It is the nature of man to err”

“Because civil aircraft are designed to fly safely

“Error will be taken as a generic term to

Design versus operator – induced errors

Slips and Lapses

Slips can be thought of as actions not carried out as

“Skill-based behaviors are those that rely on stored

Example of an action slip

Some holes due

Some holes due

Any maintenance task performed on an aircraft is

Error of Commission (Type 1 Error)

 Misapply a good rule or principle

Misapplying Good Rules