How To Classify Human Factor in Aviation

HFS303 STUDY NOTES STUDY UNIT 1
E3S3
Effectiveness The product or service meets customer
quality expectations
Efficiency Productivity optimal use of resources
(people, money, materials, equipment, energy etc.)
Ease of Use Human interaction with the product or
service should be convenient, comfortable and error free
Safety The system (product, service) should not fail and
cause harm to the user, associated hardware, the
environment or the organization.
Security The system should be resilient to malicious or
accidental interference by third parties.
Satisfaction All users of the system should be satisfied
with their experience and be motivated to continue to
B P
use the system E 18
SIM UNIVERSITY SU1-1

STUDY UNIT 1 HFS303 STUDY NOTES
SU1-2 SIM UNIVERSITY


17

Dirty
Glasses
A Bar Collect and
Wash
Glasses
Clean Full
Glasses Glasses
Waiter
Queue
Customer
Customer
Arrives
Served
Customer
Queue
Customers
Customer
Drinks
Customer
Leaves
25
25
1)

The HFE Cycle

Evaluation (Processes, Systems and Outcomes)
Outcomes:
Quality - Effectiveness
Productivity - Efficiency In Depth Analysis (Process and System Design)
Safety Acute
Security
Health - Cumulative Screening Analysis (Process and System Design)
Motivation - Satisfaction
Mission Decisions
Job Risks
Benefits
Task Costs
Environment/Context Simulation
Spatial
Mechanical
Physical What Design (Processes and Systems)
Chemical Hardware
cannot be Software
Biological
changed Organization
What can
Psychological be changed
Humanware
Social Interfaces
Organizational
Financial

Ergonomics Process
Feedforward
Context
Environment Mitigation
Time Design for Failure
Analysis Organization
Design
People Simulation
Outcomes
Equipment or
E3S3
Information Process
Organizations
Decisions
Risks
Feedback Analysis
Benefits
$$$$
B P
E 35



Communication Models
Semantic Physical
Concept
Encoding Encoding
Memory Noise and Transmission

Lost Information
Semantic Physical
Feedback
Decoding Decoding
4/1/2010 17


Life Cycle in Product Design

Mission / Purpose
Concept(s) design
Concept evaluation and testing
Concept selection
Design for use (Usability Testing)
Design for manufacturing and assembly
Design for service and maintenance
Design for disposal
Design for SAFETY
Manufacturing and Production Design
Production
Distribution and Sales
Use
Service and Maintenance
Disposal
BP System Safety Lecture 2 66
The Design Process

Mission Design Manned Mars Mission
Navigating, Launching, Eating,

Process Design Exercising, Landing, Modeling
Propulsion, Biomass Production
Equipment, Communications
System Design Equipment, Robots
Time, Resource and Activity

Overlapping Process Integration Planning, Modeling
sequences of Operations Design Analogs, Modeling

requirements,
design activities Operations Implementation
and verifications Monitoring,

Anticipating,
Concurrent Engineering Responding
Feedback / Lessons Learned / Technical Memory

Quality Function Deployment - QFD

Safety
A systematic process to obtain the Voice of the Customer
Cross-functional teams
To design products, processes, services and strategies.
House of Quality - divided into several rooms.
Typically you have customer requirements, design considerations and design
alternatives
Weighted scores prioritization
Matrices connected together using priority ratings from the previous matrix.
Interviews, surveys, focus groups, customer specifications, observation, warranty
data, field reports, etc.
Summarized in a product planning matrix - "house of quality".
These matrices are used to translate higher level "whats" or needs into lower
level "hows"
Product requirements or technical characteristics to satisfy the customer needs.

75
Quality Function Deployment

Nouns System
(Engine, Aerodynamics)
Process
Voice of
2
the
Customer
3
Verbs Adverbs
(Travel) 1 (Quickly)
Adjectives
(V8, Low Profile)
Response of the
The Tasks of the HFE Engineer 76

One Step in the Design Process

People
Guidelines Reviews Reviews

Requirements Activities (Validation)
(Verification)
Specifications
Properties
Information
Feedback
46
The Classroom Analogy
Classes, Labs
Syllabus Exams Department
and
Homework Test the specifications
Reviews
Test the performance requirements
The Course
People Professors, Students, Assistants, Subjects
Properties Notes, Books, Presentations, Discussions, Laboratories, Computers
Feedback?
47







5Ws
What
what happened / will or might happen?
Where
what was / will be the context of the event?
When
when will the event occur, what will be the time scale?
Who
who was / will be directly / indirectly involved?
Why
Why did / will the whats, wheres, whens and whos occur?
And How
What were / will be the details / methods / processes of the
events / activities?

5S
(Japanese for tidy up your room!)
Seiri - Sort
Seiton - Set in Order (Store)
Seiso - Shine
Seiketsu - Standardize
Shitsuke - Sustain
The 5S Process
http://net1.ist.psu.edu/chu/wcm/5s/5s.htm
Sort
Eliminate unnecessary items from your workplace
What, where, when, why, how many
Use red, yellow and green tagging
Get help from an independent advisor
Order (Store)
Chose the appropriate location for each item
Use visual controls (painted lines, labeled shelves etc.)
Shine
Thoroughly clean your work area
Keep it clean and clear of clutter
Standardize
Standardize the best practices for your work
Check out Blockbuster, McDonalds, UPS
Sustain
Do not revert to the bad old ways
Regularly review your work practices
http://www.isixsigma.com/dictionary/5S-486.htm

5 Whys Example
Why did the car
crash?
Because the driver
Because the was asleep
brakes failed Because the
road was icy Why?
Why?
Because he worked
Why? on the night shift
Because of a lack
of preventive
Why?
maintenance
been sanded Because his employer
Why? required shift rotation
Why?
Because the force Why?
Because the city
was short of
had run out of Because the public
money
budget require 24/7 protection
29

6Ms
(Fishbone Diagrams, Cause and Effect Diagrams)
Ishikawa Diagrams
Materials
http://mot.vuse.vanderbilt.edu/mt322/Ishikawa.htm
Machines
Men (and women)
Methods
Measurement
Management
Plus procedures,and context
http://www.mindtools.com/pages/article/newTMC_03.htm
Management Men Methods

Cause
Cause
Effect
Materials Machines Measurement
32


Elements of FMEA
Activities or Systems
Subsystems or functions
Components or functions
Failure modes
Causes
Predisposing causes
Context, environment
Outcomes, consequences
Frequency, probability
Severity
Risk assessment codes
Solutions
Engineering controls
Administrative controls
System Analyst
FMEA Chart
Subsystem Date
Page
Component Failure Effects on other Effects on Hazard Outcome Risk Comments

Mode Components System Probability Severity Assessment Solutions
(Worst case) Code

System House Lighting Analyst - Me
FMEA Chart
Subsystem - Switch Date 10/25/06
Page - 10
Component Failure Effects on Effects on Hazard Outcome Risk Comments

Mode other System Probability Severity Assessment
Components (Worst Code
case)
Wiring Short Burn House 10-5 Major 2 No fire alarms,

fire sprinklers
Cover Crack Minimal Minimal 10-5 Negligibl 4 Buy a new one

e
Screws Loose Minimal Minimal 10-5 Negligibl 4 Tighten

e
Contacts Broken Open circuit Loss of 10-5 Moderat 3 No flashlight

lights e
Example Functional FMEA

HFACS
Activity travel 5 Whys
Components Driving, walking, flying
Failure modes crash
Causes mechanical failure, human error
Predisposing causes - maintenance, schedule
Context weather, light, traffic
Outcomes
Probability 10-4 - 10-6
Severity Single or multiple fatalities
Risk assessment codes

Example Hardware FMEA

System Car
Subsystem Wheel
Component Lug nut
Failure modes Loose
Cause Not tightened
Context Bumpy road, lateral gs
Outcome Crash
Probability 10-6
Severity Severe
Risk Assessment Codes

Catastrophic Critical Marginal Negligible
Frequent
1 1 1 3
Probable
1 1 2 3
Occasional
1 2 3 4
Remote
2 2 3 4
Improbable
3 3 3 4
How are FREQUENCY and OUTCOMES quantified?

Are ratings Ordinal (ranking) , Equal Interval or Ratio?
Are the scales LINEAR or NON LINEAR? Draw them! MIL Std 882B

Hazard Control Rating Matrix

Design Passive Active Safety Warning
Safety Device Device
device
Eliminate
Energy 1 1 2 3
Source
Limit Energy
Accumulated 1 1 2 3
Prevent
Release 1 2 2 3
Provide
Barriers 2 2 3 4
Change
Release 2 3 3 4
Patterns
Minimize /
Treat harm 3 3 4 4
These Interventions are NOMINAL with the implication of being ORDINAL
The interventions may vary in their effectiveness
FMEA Pros and Cons

Systematic Frequency /
Detailed probability estimates
Widely used and Outcome
accepted classification
Flexible Subsystem
interactions
Minimal Human
Factors
Discuss

The SHEL Model

Humans vary on many dimensions
Performance shaping factors
Hardware provides the mechanisms and the interfaces
Environments / contexts make unpredictable demands
on human (and system) performance
The need for robustness
Physical, social, economic
Temporal
Resilience - Processes, systems and interfaces must
accommodate human and environmental variation
The organizational, management and regulatory context
often determines process / system performance
objectives and contexts
Software has evolved as a major component of system
design
Communication, computation and control

The Physical
and People
Operational Training
Context L
Liveware
E INTERACTIONS S
Environment INTERFACES Organizationware
(Software)
H
Hardware
Management
Regulation
Now we
must add
Software
4/12/2010 Accident Investigation - Brian 2
Peacock

Swiss Cheese Model

Organization
Accidents are
Supervision caused by a
sequence /
hierarchy of failure
Preconditions
pathways
Unsafe Acts
Reason

Unsafe Acts
Errors Violations
Skill based Decision Perceptual

Routine Exceptional
Errors Errors Errors
Hands
and Eyes One off
Speeding
Drinking acts- low
Bending flying
Problem Solving
Degraded the rules
Procedures Inputs
Poor Choices
Social
Preconditions
Environmental Personnel
Crew Resource
Physical Technological Personal
Management
Condition of Communications
Interfaces Operators
Facilitators Teamwork
Weather
Noise Rest
Medication
Adverse
Adverse
Physiological Physical / Mental
Mental
States Limitations
States
Fatigue
Hypoxia Senses
Stress Intoxication Aptitude
Vigilance Experience
Distraction

Unsafe
Supervision
Planned Failure to
Inadequate Supervisory
Inappropriate Correct
Supervision Violations
Operations Problem
Training
Assignments Unauthorized
Assignments Uncorrected
Monitoring assignments
Workload hazard
Untrained Procedure
Uncorrected
Supervisor violation
behavior
Fraud

Organizational
Influences
Resource Organizational Organizational

Management Climate Process
Priorities Unofficial rules

Productivity Ill defined policies
Cost cutting Cronyism Assignments
Training Communications Schedules
Procedures



The Transaction Cycle

Evaluation
Outcomes:
Quality - Effectiveness
Productivity - Efficiency In Depth Analysis
Safety Acute
Security
Health - Cumulative Monitoring
Motivation - Satisfaction
Decisions
The Risks
Benefits
Transaction Costs
Environment/Context
Spatial
Mechanical
Physical What INPUT
Chemical
cannot be
Biological
Psychological
changed
Hardware
Social Software
Organizational TIME Organization What can
Financial Humanware
Interfaces be changed


People vary
Physical Characteristics, Capabilities

and Limitations
Size Strength
Stamina Skill

Mental Characteristics,
Capabilities and Limitations
Attending
Perceiving Understanding
Calculating
Sensing
Deciding
Forgetting
Planning
Remembering
Controlling
Consolidating
Communicating
Learning

Environmental Factors
Thermal
Heat Acoustic
Humidity Communication
Cold Hearing loss
Air movement
Light and
Dark
Vibration Vision
Hand / Arm Contrast
Whole body Color

Social Factors Roles

Jobs
Language
and
Jargon Communication
Groups
and
Teams
Cooperation
Customers
Competition
Hierarchies
Businesses and
Companies

Temporal Factors

Senses
Vision, hearing
Musculoskeletal
These all
Strength
Physiological interact with
Stamina
Motor control
or may be
Dexterity compounded
Decision making by DISEASE
Conservatism
Attention and or
Divided, switching
Memory
Drugs
Forgetting Link to Aging and Performance
BR Human Reliability 4/3/2010

21
Percent Decline in Physical Ability

Marathon Records Based on Age 40
120
100
80
60 Men
40
Women
20
0
40 50 60 70 80 90 100
Age


Perceiving
Thinking
Deciding
Remembering Controlling
Sensing etc
Emotional Cognitive
Interface Interface
Displays System Controls
Product Energy,
Materials
And
Environment Information


A B
.9 .8
Or = 1 .9 * .8 = .28
.9
.8


Icebergs
Collision
p= .0076359 = 8/1000 = 8 x 10 -3
OR
p= .0031949 = 3/1000 = 3 x 10 -3
First mate does not Captain does not

respond respond
p=.00315 p=.0045
AND p=.000045
AND
First mate does not

Radar not Intercom
Working recognize problem not Working
p=.315
p=.1 p=.1
Radar not Captain Iceberg Captain
AND Working Degraded Present On Duty
p=.1 p=.1 p=.9 p=.5
First mate First mate Iceberg p=.001

Untrained on Duty Present
p=.7 p=.5 p=.9


Reliability Block Diagrams

If both
subsystems are
on, current will
Series flow
System If A OR B fails
A B
system will fail
Parallel If one subsystem is

System
A
If A AND B fail
system will fail
B

Independent Failures?
Accident Only one must
FAIL for the
accident to
occur
OR
Driver Vehicle Road Environment Regulations
Redundancy
All must
Accident fail for
the
accident
AND to occur
Driver Vehicle Road Environment Regulations

Venn Diagrams / Set Theory
B
W
A
C
Symbols
And AND x Intersection
OR U OR + Union

Intersection
A and B and C
B
What does this area
represent?
Union
A or B or C
Draw and describe:
AUC
AUBUC
Why?
Prob (AUBUC) = Prob (A) + Prob (B) + Prob C
Other Concepts
Sample space u Universal set
Independent events
Empty set
where A and B represent the sample space
Mutually exclusive events
Laws
Identity
Idempotent A U A = A
Complement
Commutative
Associative A U (B U C) = (A U B) U C
Distributive
Conditional Probability
Bayes Theorem

A Bicycle Trip
Trip Success
AND
Tire remain Brakes work Legs remain

inflated energized
Trip Failure
OR
Flat Tire Brakes fail Legs get tired
Bicycle Trip Planning Exercise

Plan a Draw
Concept maps
bicycle trip
FMEA, 5 Whys
with parallel Reliability diagrams
redundancy Fault trees
among Activity Cycle Diagrams
Brakes
What if the trip were 5 miles or 500 miles?
Tires What if the trip required the carrying of mail
to distant villages?
Legs How many spares and how much food can
be carried?
What about a trip to Mars?

Probability Processes also have variable

durations
System (and process) failure is

probabilistic
The bicycle trip
Tires may fail every 100 miles (on average)
Brakes may last 1000 miles (on average)
Legs need replenishing every 10 miles (on
average)
The Rescue Mission
All the subsystems and sub processes (mission
phases) have different, probabilistic failure rates
Back to Venn Diagrams

IF:
Prob (A) = 0.5
Prob (B) = 0.2
Prob (C) = 0.1
B
What is the probability of A

and B and C occurring?
A What about A OR C?

Fault Tree Conventions

AND AND Gate A * B) Basic Event
OR OR Gate (A + B A * B)
Conditioning
Event (e.g.
restrictions)
Mutually Exclusive OR
M Transfer in
Gate (A + B) (Only one
fails) (tree to be
developed)
Undeveloped
Event Continued from
Sheet 1
Developed
On Sheet 2
Intermediate
Event OR
Cut Sets
A set of events that must all occur for the
top event to occur
A B
Cut Sets
}
C1= A, B if A and C fail system fails
Minimal Cut Sets
C2 = B, C if B and C fail system fails
C3 = A, B, C if all fail the system fails (C3 is redundant it
contains the other cut sets)
Fault Tree Analysis

More elaborate technique for evaluating
complex systems and system / process
failures
Can be used qualitatively
Can use quantitative (probabilistic)
methods to predict system failure
likelihoods

General Event / Activity
Event
Basic Event bottom tier Tree
Diagrams
Constraint
OR gate One or more inputs must occur
AND gate all inputs must occur
Undeveloped terminal event
Event Tree
Stamping
AND Order
Operator Power Press Material
OR OR
Nuclear Oil Steel Copper
Fault Rear End

Collision
Tree OR
Car not fitted
with ABS
Car 1 Car 2
Icy road brakes hard brakes late
AND AND
Brake lights Driver 2 Driver 2

Car 1
not working Light turns distracted approaches
approaches
to orange light by cell phone lights too
quickly
Car 2
Poorly
maintained

Icebergs
Collision
p= .0076359 = 8/1000 = 8 x 10-3

OR
p= .0031949 = 3/1000 = 3 x 10 -3
First mate does not Captain does not

respond respond
p=.00315 p=.0045
AND p=.000045
AND
Radar not
First mate does not Intercom
Working recognize problem not Working
p=.315
p=.1 p=.1
Radar not Captain Iceberg Captain
AND Working Degraded Present On Duty
p=.1 p=.1 p=.9 p=.5
First mate First mate Iceberg p=.001

Untrained on Duty Present
p=.7 p=.5 p=.9
Calculate the
probability of the Rear End
Collision
Fault Tree
top event
Analysis
Repeat with Car not fitted
different OR with ABS P = .1
probabilities and
base events
Car 1 Car 2
Icy road brakes hard brakes late
P = .01
AND AND
Brake lights Driver 2 Driver 2

not working Light turns Car 1 distracted approaches
to orange approaches by cell phone lights too
light too quickly quickly
Car 2
Poorly
maintained
P = .5 P = .9 P = .3 P = .5
P = .1

Fault Tree Base Events

Traditional fault tree methods address the particular
incident or unsafe act that resulted in the accident.
The root causes may involve many other
predisposing conditions including:
System / process design
Selection and training
Supervision
Exceptional contexts / environments
Habitual unsafe behaviors and violations
Production priorities
And so on
Other models / analysis techniques
delve into these indirect and
contributory causes


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HFS303 STUDY NOTES STUDY UNIT 1

SIM UNIVERSITY SU1-1

SU1-2 SIM UNIVERSITY

SIM UNIVERSITY SU1-3

SU1-4 SIM UNIVERSITY

SIM UNIVERSITY SU1-5

The HFE Cycle

SU1-6 SIM UNIVERSITY

SIM UNIVERSITY SU1-7

SU1-8 SIM UNIVERSITY

SIM UNIVERSITY SU1-9

Memory Noise and Transmission

SU1-10 SIM UNIVERSITY

SIM UNIVERSITY SU1-11

Life Cycle in Product Design

BP System Safety Lecture 2 66

The Design Process

Navigating, Launching, Eating,

Time, Resource and Activity

sequences of Operations Design Analogs, Modeling

and verifications Monitoring,

Feedback / Lessons Learned / Technical Memory

SU1-12 SIM UNIVERSITY

Quality Function Deployment - QFD

SIM UNIVERSITY SU1-13

Quality Function Deployment

SU1-14 SIM UNIVERSITY

One Step in the Design Process

Guidelines Reviews Reviews

The Classroom Analogy

SIM UNIVERSITY SU1-15

SU1-16 SIM UNIVERSITY

SIM UNIVERSITY SU1-17

SU1-18 SIM UNIVERSITY

SIM UNIVERSITY SU1-19

SU1-20 SIM UNIVERSITY

SIM UNIVERSITY SU1-21

SIM UNIVERSITY SU2-1

SU2-2 SIM UNIVERSITY

SIM UNIVERSITY SU2-3

Management Men Methods

Materials Machines Measurement

SU2-4 SIM UNIVERSITY

SIM UNIVERSITY SU2-5

Component Failure Effects on other Effects on Hazard Outcome Risk Comments

SU2-6 SIM UNIVERSITY

System House Lighting Analyst - Me

Component Failure Effects on Effects on Hazard Outcome Risk Comments

Wiring Short Burn House 10-5 Major 2 No fire alarms,

Cover Crack Minimal Minimal 10-5 Negligibl 4 Buy a new one

Screws Loose Minimal Minimal 10-5 Negligibl 4 Tighten

Contacts Broken Open circuit Loss of 10-5 Moderat 3 No flashlight

Example Functional FMEA

SIM UNIVERSITY SU2-7

Example Hardware FMEA

Risk Assessment Codes

How are FREQUENCY and OUTCOMES quantified?

SU2-8 SIM UNIVERSITY

Hazard Control Rating Matrix

FMEA Pros and Cons

SIM UNIVERSITY SU2-9

The SHEL Model

SU2-10 SIM UNIVERSITY