Module 9 Human Factors

EASA 66 CAT A/B1
MODULE 09
HUMAN FACTORS
HUMAN FACTORS
ISSUE 1 – May 2010 Page 1

EASA 66 CAT A/B1
MODULE 09
HUMAN FACTORS
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EASA 66 CAT A/B1
MODULE 09
HUMAN FACTORS
CONTENTS
INTRODUCTION
OBJECTIVES
9.1 - The Need to Take Human Factors into Account
9.2 - Human Performance and Limitations
9.3 - Social Phsychology
9.4 - Factors Affecting Performance
9.5 - Physical Enviroment
9.6 - Tasks
9.7 - Communication
9.8 - Human Error
9.9 - Hazards in the Workplace

EASA 66 CAT A/B1
MODULE 09
HUMAN FACTORS

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.1
GENERAL
HUMAN FACTORS
OBJECTIVES
To create an awareness of the "Human" aspect of aircraft maintenance and develop

safeguards to lessen the "Human Cause" factors in maintenance.
To examine the human role of maintenance that can lead to an aviation occurrence and
develop ways to prevent or lessen the seriousness of the occurrence.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.1
GENERAL
Reason's Swiss Cheese Model
Each slice of Swiss cheese represents an organisation or an activity/department within an

organisation. The arrows represent errors and the holes in the cheese inadequate defences
within an organisation allowing errors through. Errors not identified at source are usually
picked up and rectified by the next or subsequent "slices" in the system. However there are
occasions when an error will find its way straight through the system resulting in an accident.
The aim therefore of each department/activity within an organisation is to turn their particular
slice of "Swiss Cheese" into a slice of best "Farmhouse Cheddar".

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.1
GENERAL
¨ The Need to Take Human Factors into Account
Human error is a fixed part of the human condition and therefore cannot be totally
eradicated. We all make hundreds of errors each day. Errors serve a useful service
in the trial and error learning process. Errors with no bad effects can be good. We
must not confuse errors from the bad effects of errors. However, in aviation, we
cannot tolerate the bad effects of error.
When an error occurs in the maintenance system of an airline, the engineer who last
worked on the aircraft is usually considered to be at fault. The engineer may be
reprimanded, sent for further training, or simply told not to make the same mistake
again. However, to blame the engineers for all of the errors that are committed is
perhaps giving them too much credit for their role in the airline's maintenance
system. Many errors are, in fact, committed due to other failures inherent in the
system and the engineer involved is merely the source of one of the failures. In
these cases, it may not matter which engineer is involved at the time of the actual
incident, the system encourages particular errors or violations to be committed.
The failures caused by those in direct contact with the system, ie, the engineers who
are working on the aircraft, are considered to be active failures. These failures are
errors or violations that have a direct and immediate effect on the system. Generally,
the consequences of these active failures are caught by the engineer himself, or by
the defences, barriers and safeguards built into the maintenance system. Thus, the
system must rarely deal with the consequences of active failures. However, when an
active failure occurs in conjunction with a breach in the defences, a more serious
incident occurs.
Latent failures are those failures which derive from decisions made by supervisors
and managers who are separated in both time and space from the physical system.
For example, technical writers may write procedures for a task with which they are
not totally familiar. If the procedure has even one mistake in it, the engineer using
the procedure will be encouraged to commit an error. The latent failures can often
be attributed to the absence or weaknesses of defences, barriers, and safeguards in
the system. Often, latent failures may lie dormant in the system for long periods
before they become apparent.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.1
GENERAL
A CHAIN IS AS STRONG AS ITS "WEAKEST" LINK
How an Aircraft Flies
Any aircraft flies courtesy of the efforts of many people employing their particular skills on a
variety of tasks. Each of these tasks is vital to the safe operation of an aircraft, each task
strengthening the link between its departments activities with others departments and
eventually the aircraft itself. It is a well known fact that the strongest part of any chain is its
weakest link. If a link breaks the aircraft falls out of the sky!! Can you identify any
weaknesses in either yourself or your department that could lead to the chain failing?
For an incident to occur, latent failures must combine with active failures and local triggering
events, such as unusual system states, local environmental conditions, or adverse weather.
There must be a precise 'alignment' of all of the 'holes' in all of the defensive layers in a
system. (See Reason's Swiss Cheese Model). For example, rain may cause a engineers'
foot to be wet, allowing his foot to easily slip off the worn brake pedal in a pushback tug
when the engineer becomes distracted. The tug may then lungs forward contacting a
parked aircraft. The latent failure in the system is that the brake pedal has no anti-slip
surface in place, but the problem does not become an issue until the rainy condition (a local
trigger) cause an incident. It can be seen that if any one of the failures had not occurred
(engineer did not become distracted, the tarmac was not wet, or the brake pedal was in
better condition), the incident would have been avoided.
An incident similar to this at Edinburgh Airport resulted in the loss of life of an engineer
during turnaround when, during the removal of a ground power unit following engine start,
the engineer manoeuvred within the rotating propeller arc.
Thus, it can be seen that a large number of unsafe acts (errors and violations) may occur on
a daily basis, but it is very rare that a situation is elevated into a serious, reportable incident.
Usually, the unsafe acts are either caught immediately, or the defences of the system
prevent the problem from becoming an incident, ie, the error is prevented from propagating
through the system. Engineers are especially conscious of the importance of their work,
and typically expend considerable effort to prevent injuries, prevent damage, and to keep
the aircraft safe.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.1
GENERAL
Murphy's laws
origin
· The following article was
excerpted from The Desert
Wings
March 3, 1978
Murphy's Law ("If anything can

go wrong, it will") was born at
Edwards Air Force Base in 1949
at North Base.
It was named after Capt. Edward

A. Murphy, an engineer working on Air Force Project MX981, (a project) designed
to see how much sudden deceleration a person can stand in a crash.
One day, after finding that a transducer was wired wrong, he cursed the
technician responsible and said, "If there is any way to do it wrong, he'll find it."
The contractor's project manager kept a list of "laws" and added this one, which
he called Murphy's Law.
Actually, what he did was take an old law that had been around for years in a
more basic form and give it a name.
Shortly afterwards, the Air Force doctor (Dr. John Paul Stapp) who rode a sled on
the deceleration track to a stop, pulling 40 Gs, gave a press conference. He said
that their good safety record on the project was due to a firm belief in Murphy's
Law and in the necessity to try and circumvent it.
Aerospace manufacturers picked it up and used it widely in their ads during the
next few months, and soon it was being quoted in many news and magazine
articles. Murphy's Law was born.
The Northrop project manager, George E. Nichols, had a few laws of his own.
Nichols' Fourth Law says, "Avoid any action with an unacceptable outcome."
The doctor, well-known Col. John P. Stapp, had a paradox: Stapp's Ironical
Paradox, which says, "The universal aptitude for ineptitude makes any human
accomplishment an incredible miracle."
Nichols is still around. At NASA's Jet Propulsion Lab in Pasadena, he's the
quality control manager for the Viking project to send an unmanned spacecraft to
Mars.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.1
GENERAL
Murphy's Law or Sod's Law?
While I admit that the name of Murphy's laws is a pleasant one as is the story of
how it came to light, but the original name for 'if anything can go wrong it will' was
sod's law because it would happen to any poor sod who needed such a
catastrophic event the least. It also removes the ability to say "I coined this
phrase!" because sod's law has been around long before any living man and has
existed in many forms for hundreds of years. In the English County of Yorkshire I
know it to have been around for generations because it has been passed through
several Yorkshire families I know. But this original name is dying out because sod
over here is a cursory so is not used much. Murphy's on the other hand is nothing
insulting or lacking in hope I hope this clears any problems up and while this
maybe hard to come to terms with, think about it, would such an obvious piece of
logic have only come about in the second half of the 20th century????

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.2
Human Performance
And Limitations
9.2 HUMANPERFORMANCE & LIMITATIONS
THE POTENTIAL FOR HUMAN ERROR
In our study of human factors we will be mostly concerned with identifying those aspects of
behaviour that can result in people making mistakes or errors which could result in
accidents. Our capacity to perceive what is going on in our working environment by sight,
touch, feel, smell, hearing etc: together with our capacity to remember, process information
and act upon it are all relevant in the context of human error.
Factors which can contribute towards mistakes leading to accidents are incalculable.
However, some of them will fall into one or more of the following:
¨ Inadequate information - be it visual or verbal can, does and will lead to people
making mistakes. If you think the information you have is inadequate or insufficient
do something about it.
¨ Lack of understanding - possibly stemming from inadequate information or maybe

lack of training can lead to people making presumptions as to how a particular
process or procedure is carried out. This can and does lead to accidents. If you're
not sure ask.
¨ Poor design - which can result in the best of intentions turning out wrong.
Remember Murphy? If there's a wrong way to do it that's the way you'll do it! If you
recognise a Murphy do something about it if it's only telling others about it.
¨ Lapses of attention - can and will allow errors to creep in, especially if it’s a simple
straightforward repetitive task. The lesson here is that the more expert you become
at a particular task the more likely you are to make a mistake because, you think you
can afford to allocate less attention to it. Beware the "expert" both in yourself and in
others.
¨ Mistaken actions - brought about by the classic situation of doing the wrong thing
under the impression that it's right. A classic example of this is the 'short cut' wherein
the engineer knows what has to be done but chooses his own method of doing it.
Don't take short cuts.
¨ Misperceptions - meaning the capacity we have to see what we want to see, hear
what we want to hear, feel what we want to feel etc: This factor is particularly
relevant to the work of an aircraft engineer in as much as a great many tasks are of a
repetitive nature. The lesson here is to be vigilant and on guard against it.
¨ Vision
Vision can be adversely affected by certain medications or drugs, alcohol excess,

oxygen shortage (hypoxia), injury (eg a blow to the head), etc. It can also be affected
either temporarily or permanently by medical conditions (eg migrain, cataracts,
inflammation, corneal problems or refractive surgery) or by dirty or dehydrated
contact lenses or even very dirty spectacles.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.2
Human Performance
And Limitations
¨ Noise
Can detrimentally affect human performance in terms of damaging hearing,

interfering with speech communication, and affecting concentration and performance.
It can also be fatiguing. Effects vary between individuals, and noise of a certain type
and level may be good for one individual but bad for another.
Noise can affect motivation, reduce tolerance for frustration and reduce levels of aspiration.
There may be an impact upon the individual's ability to think. It is almost certainly likely to
affect inspection or troubleshooting activities where the strategy used is left to the individual,
being primarily assessment - rather than activity-based, possibly reducing the likelihood of
successfully thinking laterally under such circumstances. How many of us can recall, when
concentrating hard on a task, shouting "Stop that noise; I can't think straight!"?
In order to understand the effect both vision and hearing have in terms of maintenance it is
useful to know a little about the anatomy of them.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.2
Human Performance
And Limitations
9.2.1 Vision
The eye is the organ which receives light information from the external world and
passes it to the brain. The visual cortex area of the brain interprets this information,
presenting it as a rational, realistic image.
The basic structure of the eye is similar to a simple camera with an aperture, a lens,
and a light sensitive screen, the Retina.
The Structure of the Human Eye
The Function and Structure of the Eye
¨ The Cornea. Light enters the eye through the cornea, a clear window at the front of
the eyeball. The cornea acts as a focusing device and is responsible for between 70
and 80% of the total focusing ability of the eye.
¨ The Iris. The amount of light entering the eye is controlled by the iris, the coloured
part of the eye, which acts as a diaphragm.
¨ The Pupil. The amount of light allowed to fall on the retina is governed by the size of
the pupil, the clear centre of the iris. The size of the pupil can change rapidly to cater
for changing light levels.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.2
Human Performance
And Limitations
Note: The amount of light allowed to enter the eye can be adjusted by a factor of
five to one by the pupil.
This 5:1 factor is not sufficient to cope with the different light levels
experienced between full daylight and a dark night and a further mechanism
is required. In reduced light levels a chemical change takes place in the light
sensitive cells on the retina (cones and rods). This dark adaptation does take
time, about 7 minutes for the cones and 30 minutes for the rods. When
complete the chemical change can cope with large changes in luminance
level (of the order of 150,000 : 1 for the cones). After passing through the
pupil the light passes through a clear lens, which can change its shape
(accommodation) to achieve the final focusing onto the retina.
¨ The Retina. The retina is a light sensitive screen lying at the back of the eyeball. On
this screen are light sensitive cells. The cells are of two types; cones and rods. The
cones can only detect colours, the rods can only detect black and white but are much
more sensitive at low light levels. This means that in poor light we see only in black
or white or varying shades of grey. When light falls on these cells a small electrical
charge is generated which is passed onto the brain by the optic nerve.
¨ The Optic Nerve. The optic nerve enters the back of the eyeball along with the
small blood cells needed to carry oxygen to the cells of the eye.
¨ The Fovea. The central part of the retina, the Fovea, is composed only of cone cells
and only at this part of the retina is vision 20/20 or 6/6. The figures are a means of
measuring visual acuity, the ability to discriminate at varying distances. An individual
with 20/20 vision should be able to see at 20 feet that which the so-called normal
person is capable of seeing at this range.
Any resolving power at the fovea drops rapidly as the angular distance from the
fovea increases. At as little as 5° from the fovea the acuity drops to 20/40 that is half
as good as at the fovea. When the angular displacement increases to 20° the visual
acuity will only be one tenth of that at the fovea, that is 20/200.
Anything that needs to be examined in detail is automatically brought to focus on the
fovea. The rest of the retina fulfils the function of attracting our attention to
movement and change.
¨ The Blind Spot. The point on the retina where the optic nerve enters the eyeball
has no covering of light detecting cells. Any image falling at this point will not be
detected. This has great significance when considering the detection of objects
which are on a constant bearing from the observer.
If the eye remains looking straight ahead it is possible for example for a closing
aircraft to remain on the blind spot until a very short time before impact. Safe visual
scanning demands frequent eye movement with minimal time spent looking in any
direction.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.2
Human Performance
And Limitations
Visual Defects. Most visual defects are caused by the natural shape of the eyeball.
¨ Hypermetropia. In long sightedness, (Hypermetropia), a shorter than normal

eyeball along the visual axis results in the image being formed behind the retina and
unless the combined refractive index of the cornea and the lens can combine to
focus the image in the correct plane a blurring of the vision will result when looking at
close objects. A convex lens will overcome this refractive error.
¨ Myopia. In short-sightedness, (Myopia), the problem is that the eyeball is longer

than normal and the image forms in front of the retina. If accommodation cannot
overcome this then distant objects are out of focus whilst close up vision may be
satisfactory. A concave lens will correct the situation.
¨ Astigmatism. This condition is usually caused by a misshapen cornea. Objects will

appear irregularly shaped. Modern surgical techniques can reshape the cornea with
a scalpel or more easily with laser beams.
Colour Defective Vision
Affecting about 8% of men and 0.5% of women "colour blindness" is usually associated with
the inability to differentiate between reds and greens. Other more rare types may involve
blues and yellows. There are degrees of colour defective vision, some suffering more than
others and, ageing of individuals will change their colour perception. Care should be taken
not to discriminate personnel from tasks merely because they are "colour blind". Tasks that
require positive colour perception must however be carried out by personnel who have been
tested to an appropriate standard.
Conclusion
Ultimately, what is important is for the individual to recognise when their vision is adversely
affected, either temporarily or permanently, and to carefully consider the possible
consequences should they continue to work if the task requires good vision. AWN47 states:
"Organisations should identify any specific eyesight requirements and put in place suitable
procedures to address these issues". General human factors advice would be to stress the
joint moral responsibility upon both the individual to admit to poor vision and upon the
Organisation to create an environment whereby engineers will not be penalised if they do so.
9.2.3 Hearing

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.2
Human Performance
And Limitations
The ear performs two quite separate functions: firstly it is used to receive vibrations in the
air (sounds), and secondly it acts as a balance organ and acceleration detector.
Structure of the Human Ear
Function and Structure of the Ear
The ear is divided into three sections, the outer, middle, and inner ear:
¨ The Outer Ear. The outer ear consists of the Pinna, which collects the vibrations of
the air which form sounds and a tube, the Meatus, which leads to the eardrum. The
sound waves will cause the ear drum to vibrate.
¨ The Middle Ear. The ear drum or Tympanum separates the outer and middle ear.
Connected to the ear drum is a linkage of three small bones the Ossicles, which
transmit the vibrations across the middle ear, which is filled with air, to the inner ear
which is filled with liquid. The last of the bones connects to another membrane in the
inner ear.
¨ The Inner Ear. The vibrating membrane causes the fluid in the Cochlea to vibrate.
Inside the cochlea there is a fine membrane covered with tiny hair like cells. The
movement of these small cells will be dependent on the volume and pitch of the
original sound. The amount and frequency of displacement is detected by the
auditory nerve which leads directly to the brain where the tiny electrical currents are
decoded into sound patterns.
Note the eustachian tube which allows the pressure in the middle ear to equalise with
the atmospheric pressure.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.2
Human Performance
And Limitations
Hearing Impairment. Hearing difficulties are broadly classified into three categories:
v Conductive deafness. Any damage to the conducting system, the ossicles
or the ear drum, will result in a degradation of hearing. It is possible that
perforations of the ear drum will result in scarring of the tissue thus reducing
its ability to vibrate freely. A blow to the ear may cause damage to the small
bones in the middle ear again limiting the transfer of vibrations. Modern
surgery may help in some circumstances.
v Noise Induced Hearing Loss (NIHL). Loud noises can damage the very
sensitive membrane in the cochlea and the fine structures on this membrane.
The loss of hearing may at first be temporary but continued exposure to loud
noise will result in permanent loss of hearing. The early symptoms are an
inability to hear high pitched notes as these notes are normally detected by
the finer cells which suffer the greatest damage.
The loudness of a noise is measured in Decibels (db). For example a sound
proofed room will have a rating of 9 db, an average office 50 db and a busy
street corner 70 db. An observer standing by a runway whilst a large jet takes
off will experience 100 - 120 db.
To cause permanent damage to hearing a noise level of 90 db or more is
required. The amount of damage is related to the total noise energy so time
of exposure is important. A noise level of 90 db for 8 hours will cause the
same damage as exposure to 103 db for 30 minutes or 116 db for 1 minute.
The noise level on and around a busy airport can be very high and it is
essential that ear defenders are worn by all personnel working in the area of
high noise levels.
For the younger element the noise level in discos can be excessive and
personal stereos can reach above the safety level.
Noise Induced Hearing Loss (NIHL) is not treatable at the moment. Recent
experiments hold out some hope of a cure as researchers have been able to
regrow the fine hair like cells in the cochlea of young rats. The treatment
involves the use of retinoic acid, made from vitamin A. The treatment in
humans is still however a long way off and the only sure way to avoid NIHL is
to protect the ears from loud noises.
v Presbycusis. (Loss through ageing). Hearing deteriorates with advancing
age. Young children can hear high pitched noises outside the range of
adults. The loss of some hearing is natural as one grows older but if
combined with some NIHL there may be a chance of increased impairment.
The Ear and Balance. As well as acting as the organ to detect sounds, the ear is used to
detect angular and linear accelerations. Our primary source of spatial orientation is sight but
the ear provides a secondary system, particularly if vision is restricted.
Within the inner ear are three Semi-circular canals, tubes filled with liquid and arranged in
three planes at 90 degrees to each other. Within these tubes are fine hairs which are bent
as the liquid in the tubes moves in relation to the walls of the tubes. The movements of
these hairs generates a small electric current which is passed to the brain to be detected as
a movement of the head.
The semi-circular canals detect angular movement; linear acceleration is detected by the
Otoliths at the base of each of the canals.
The otoliths, literally 'stones in the ears', are fleshy stalks surmounted by a small stone or
crystal. Acceleration in any plane causes the stalks to bend and this bending is interpreted
by the brain to decide the new position of the head.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.2
Human Performance
And Limitations
The semi-circular canals and the otoliths together make up the Vestibular apparatus which
helps to maintain spatial orientation and control other functions. For example it controls eye
movement to maintain a stable picture of the world on the retina even when the head is
moved.
The Effects of Alcohol. Alcohol has a lower specific gravity than water. Alcohol in the
middle ear may dilute the liquids and cause unfamiliar results for certain movements, leading
to disorientation. Alcohol in the fleshy stalk of the otolith may persist for days after all traces
of alcohol have vanished from the blood. It is not unusual for even small movement of the
head to cause disorientation or motion sickness up to three days after alcohol was last
consumed.
Conclusion
The effects of noise on performance are extremely complex, with no clear guidance
emerging as to what noise levels are likely to adversely affect performance in relation to
aviation safety. As a rule of thumb and in the absence of more detailed guidelines, if noise
levels are kept within the bounds to protect against hearing damage (see Table 1) this
should also avoid situations where noise is likely to have a significantly detrimental affect on
performance in general terms. This may not, however, be sufficient to avoid breaking
someone's concentration.
TABLE 1
Duration per day (hr) Sound Level in dB(A)

8 90
6 92
4 95
3 97
2 100
1.5 102
1 105
0.5 110
<0.25 115
Source: OSHA
Maximum Recommended Noise Exposure for Occupational Noi

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.2
Human Performance
And Limitations
9.2.3 Memory
Memory is the process of retaining, recognising and recalling experience (remembering) and
is particularly associated with how people learn things. It is, essentially, the storage facility
of the human system. We have both short-term and long-term memory.
¨ Short-term memory Short-term or immediate memory refers to the temporary

storage of information for a few seconds, as in the case of a telephone number. It is
also associated with the amount of information one can take in and retain and is, in
many cases, a limiting factor on individual ability and safety.
Short-term memory and its limitations can be a significant factor in the causes of
accidents at work, and one that is frequently associated with human error or poor
memory skills. Important on-the-spot instructions should, therefore, be repeated
several times to ensure that the recipient fully understands and can recall them.
¨ Long-term memory Long-term memory is concerned with the ability to store and
subsequently recall information. It is a vast store of information that is organised in
some form of classification. On this basis, any new information is perceived in terms
of these categories and forces into the classification system even when it does not fit
exactly. In this process there is a chance that it may become distorted.
Long-term memory is developed from an early age through the repetition of items
and codifying them to produce a meaning. There is a characteristic drop in memory
over a period of time associated with the ageing process.
Interference with long-term memory can be caused by:
v events of close similarity that tend to confuse.
v the effect of recall on the subsequent memory that can, again, cause
confusion.
RESULTING IN THE INDIVIDUAL FORGETTING.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.2
Human Performance
And Limitations
9.2.4 Information Processing
Generally, people cannot do more than one thing at a time, the speed and sequence of
response varying from person to person. This factor can be significant in accident
causation.
With well-known and practised tasks, such as operating a machine or driving a vehicle, the
monitoring action of the brain can be reduced, depending on the speed with which a person
can respond to stimuli and not monitor specific movements or actions. Results are achieved
through continuous practice or the speed-accuracy trade-off, whereby the monitoring is
voluntarily removed.
The feedback that people receive is an important feature of monitoring a task. Where an
individual may be highly skilled, it can be a hindrance and actually destroy performance. In
the teaching, for instance, of learner drivers or certain activities, such as golf, the instructor
has to put the monitoring aspect back into the task. This can adversely affect the individual's
level of performance.
In the information processing operation, people ascribe different values to various outcomes
of their decisions. These values may be influenced by extraneous factors, such as any
financial benefits to be derived or the possibility of saving time and effort, which are
subjective and influenced by the personality of the person making the decision and previous
experience of similar situations.
The level of brain arousal can also effect the efficiency and rate of mental processing.
Arousal is defined as an increase in alertness and muscular tension. Levels of arousal vary
significantly. Generally, at low arousal levels, performance is poor. As arousal increases to
an optimum, performance rises accordingly, but then drops as further arousal takes place.
Changes in arousal levels take place during the average working cycle.
General principles
The first is the assumption of a limited capacity of the mental system. This means that the
amount of information that can be processed by the system is constrained in some very
important ways. Bottlenecks, or restrictions in the flow and processing of information, occur
at very specific points.
A second principle is that a control mechanism is required to oversee the encoding,
transformation, processing, storage, retrieval and utilization of information. That is, not all of
the processing capacity of the system is available; an executive function that oversees this
process will use up some of this capability. When one is learning a new task or is confronted
with a new environment, the executive function requires more processing power than when
one is doing a routine task or is in a familiar environment.
A third principle is that there is a two-way flow of information as we try to make sense of
the world around us. We constantly use information that we gather through the senses (often
referred to as bottom-up processing) and information we have stored in memory (often
called top-down processing) in a dynamic process as we construct meaning about our
environment and our relations to it. This is somewhat analogous to the difference between
inductive reasoning (going from specific instances to a general conclusion) and deductive
reasoning (going from a general principle to specific examples.) A similar distinction can be
made between using information we derive from the senses and that generated by our
imaginations.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.2
Human Performance
And Limitations
A fourth principle generally accepted by cognitive psychologists is that the human organism
has been genetically prepared to process and organize information in specific ways.
For example, a human infant is more likely to look at a human face than any other stimulus.
Given that the field of focus of a human infant is 12 to 18 inches, one can surmise that this is
an important aspect of the infant's survival. Other research has discovered additional
biological predispositions to process information. For example, language development is
similar in all human infants regardless of language spoken by adults or the area in which
they live (e.g., rural versus urban, Africa versus Europe.) All human infants with normal
hearing babble and coo, generate first words, begin the use of telegraphic speech (e.g., ball
gone), and overgeneralize (e.g., using "goed to the store" when they had previously used
"went to the store") at approximately the same ages. The issue of language development is
an area where cognitive and behavioral psychologists as well as cognitive psychologists with
different viewpoints have fought many battles regarding the processes underlying human
behavior. Needless to say the disussion continues.
Stage Model of Information Processing

One of the major issues in cognitive psychology is the study of memory. The dominant view
is labeled the "stage theory" and is based on the work of Atkinson and Shiffrin (1968).
This model proposes that information is processed and stored in 3 stages.
Sensory memory (STSS). Sensory memory is affiliated with the transduction of energy
(change from one energy from to another). The environment makes available a variety of
sources of information (light, sound, smell, heat, cold, etc.), but the brain only understands
electrical energy. The body has special sensory receptor cells that transduce (change from
one form of energy to another) this external energy to something the brain can understand.
In the process of transduction, a memory is created. This memory is very short (less than 1/2
second for vision; about 3 seconds for hearing).
It is absolutely critical that the learner attend to the information at this initial stage in order to
transfer it to the next one. There are two major concepts for getting information into STM:

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.2
Human Performance
And Limitations
First, individuals are more likely to pay attention to a stimulus if it has an interesting
feature. We are more likely to get an orienting response if this is present.
Second, individuals are more likely to pay attention if the stimulus activates a known
pattern. To the extent we have students call to mind relevant prior learning before we begin
our presentations, we can take advantage of this principle.
Short-term memory (STM). Short-term memory is also called working memory and relates
to what we are thinking about at any given moment in time. In Freudian terms, this is
conscious memory. It is created by our paying attention to an external stimulus, an internal
thought, or both. It will initially last somewhere around 15 to 20 seconds unless it is repeated
(called maintenance rehearsal) at which point it may be available for up to 20 minutes. The
hypothalamus is a brain structure thought to be involved in this shallow processing of
information. The frontal lobes of the cerebral cortex is the structure associated with working
memory. For example, you are processing the words you read on the screen in your frontal
lobes. However, if I ask, "What is your telephone number?" your brain immediately calls that
from long-term memory and replaces what was previously there.
Another major limit on information processing in STM is in terms of the number of units that
can be processed an any one time. Miller (1956) gave the number as 7 + 2, but more recent
research suggests the number may be more like 5 + 2 for most things we are trying to
remember. Because of the variability in how much individuals can work with (for some it may
be three, for others seven) it is necessary to point out important information. If some
students can only process three units of information at a time, let us make certain it is the
most important three.
There are two major concepts for retaining information in STM: organization and repetition.
There are four major types of organization that are most often used in instructional design:
· Component (part/whole)--classification by category or concept (e.g., the
components of the teaching/learning model);
· Sequential -- chronological; cause/effect; building to climax (e.g., baking a

cake, reporting on a research study);
· Relevance -- central unifying idea or criteria (e.g., most important principles of

learning for boys and girls, appropriate management strategies for middle
school and high school students);
· Transitional (connective) -- relational words or phrases used to indicate

qualitative change over time (e.g., stages in Piaget's theory of cognitive
development or Erikson's stages of socioemotional development)
A related issue to organization is the concept of chunking or grouping pieces of data into
units. For example, the letters "b d e" constitute three units of information while the word
"bed" represents one unit even though it is composed of the same number of letters.
Chunking is a major technique for getting and keeping information in short-term memory; it is
also a type of elaboration that will help get information into long-term memory.
Repetition or rote rehearsal is a technique we all use to try to "learn" something. However, in
order to be effective this must be done after forgetting begins. Researchers advise that the
learner should not repeat immediately the content (or skill), but wait a few minutes and then
repeat. For the most part, simply memorizing something does not lead to learning (i.e.,
relatively permanent change). We all have anecdotal evidence that we can remember
something we memorized (a poem for example), but just think about all the material we tried
to learn this way and the little we are able to remember after six months or a year.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.2
Human Performance
And Limitations
Long-term memory (LTM). Long-term memory is also called preconscious and unconscious
memory in Freudian terms. Preconscious means that the information is relatively easily
recalled (although it may take several minutes or even hours) while unconscious refers to
data that is not available during normal consciousness. It is preconscious memory that is the
focus of cognitive psychology as it relates to long-term memory. The levels-of-processing
theory, however, has provided some research that attests to the fact that we "know" more
than we can easily recall. The two processes most likely to move information into long-term
memory are elaboration and distributed practice (referred to as periodic review in the direct
instruction model).
There are several examples of elaboration that are commonly used in the teaching/learning
process:
· imaging -- creating a mental picture;
· method of loci (locations)--ideas or things to be remembered are connected to

objects located in a familiar location;
· pegword method (number, rhyming schemes)--ideas or things to be

remembered are connected to specific words (e.g., one-bun, two-shoe, three-
tree, etc.)
· Rhyming (songs, phrases)--information to be remembered is arranged in a

rhyme (e.g., 30 days hath September, April, June, and November, etc.)
· Initial letter--the first letter of each word in a list is used to make a sentence
(the sillier, the better).
Organization (types) of knowledge

As information is stored in long-term memory, it is organized using one or more structures:
declarative, procedural, and/or imagery.
Declarative Memory (generally refers to information we can talk about)
· Semantic Memory-- facts and generalized information (concepts, principles,

rules; problem-solving strategies; learning strategies)
o Schema / Schemata -- networks of connected ideas or relationships;

data structures or procedures for organizing the parts of a specific
experience into a meaningful system (like a standard or stereotype)
o Proposition -- interconnected set of concepts and relationships; if/then

statements (smallest unit of information that can be judged true or
false)
o Script -- "declarative knowledge structure that captures general

information about a routine series of events or a recurrent type of
social event, such as eating in a restaurant or visiting the doctor"
(Stillings et al., 1987)
o Frame -- complex organization including concepts and visualizations

that provide a reference within which stimuli and actions are judged
(also called "Frame of Reference")

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.2
Human Performance
And Limitations
o Scheme -- an organization of concepts, principles, rules, etc. that

define a perspective and presents specific action patterns to follow
o Program -- set of rules that define what to do in a particular situation
o Paradigm -- the basic way of perceiving, thinking, valuing, and doing

associated with a particular vision of reality (Harman, 1970)
o Model -- a set of propositions or equations describing in simplified

form some aspects of our experience. Every model is based upon a
theory or paradigm, but the theory or paradigm may not be stated in
concise form. (Umpleby in Principia Cybernetica Web, no date)
· Episodic Memory-- personal experience (information in stories and analogies)
Procedural Memory-- how to (driving a car, riding a bike)
Imagery -- pictures
Conclusion
Memory is an important feature of human behaviour, particularly where people may be

exposed to hazards. It is directly affected by learning, past experience, feedback from
events of particular significance and an individual's capacity for storing information.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.2
Human Performance
And Limitations
The Aloha Incident
The Aloha accident, involved 18 feet of the upper cabin structure of a Boeing 737 suddenly
being ripped away, in flight, due to structural failure. The aircraft involved in this accident
had been examined, as required by two engineering inspectors. One inspector had 22 years
experience and the other, the chief inspector, had 33 years experience. Neither found any
cracks in their inspection. Post-accident analysis determined there were over 240 cracks in
the skin of this aircraft at the time of the inspection.
The Aloha accident investigation report stated also that:
"Inspection of the rivets required inspectors to climb on scaffolding and move along the
upper fuselage carrying a bright light with them; in the case of an eddy current inspection,
the inspectors needed a probe, a meter, and a light. At times, the inspector needed ropes
attached to the rafters of the hangar to prevent falling from the airplane when it was
necessary to inspect rivet lines on top of the fuselage. Even if the temperatures were
comfortable and the lighting was good, the task of examining the area around one rivet after
another for signs of minute cracks while standing on a scaffolding or on top of the fuselage is
very tedious. After examining more and more rivets and finding no cracks, it is natural to
begin to expect that cracks will not be found. Further, when the skin is covered with several
layers of paint the task is even more difficult. Indeed, the physical, physiological, and
psychological limitations of this task are clearly apparent."

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.2
Human Performance
And Limitations
9.2.6 Claustrophobia, Physical Access and Fear of Heights
¨ Claustrophobia. Claustrophobia is defined as "abnormal fear of being in an

enclosed space". This is the extreme case. However, there are many circumstances
where people may experience various levels of physical or psychological discomfort
when in an enclosed or small space, which is generally considered to be quite
normal. Most people have no difficulty in entering a lift, for instance, but would not
consider going pot-holing under any circumstances! In this text, claustrophobia is
reserved for the extreme case where a person is extremely uncomfortable, often to
the extent of experiencing panic, in circumstances which most people would not
consider a problem.
It is unlikely that someone suffering from claustrophobia would take up aircraft
maintenance engineering as a career, but it may be the case, however, that
susceptibility to claustrophobia is not apparent at the start of employment but comes
about because of an incident when working within a confined space, eg panic if
unable to extricate oneself from a fuel tank. If an engineer feels that they suffer from
this problem, they should make their colleagues and supervisors aware so that if
tasks likely to generate claustrophobia cannot be avoided, at least colleagues may
be able to assist in extricating an engineer from the confined space quickly and
sympathetically.
¨ Physical Access. Problems associated with physical access are not uncommon in
aircraft maintenance engineering. Maintenance engineers and technicians often
have to access, and work in, very small spaces (eg in fuel tanks), cramped conditions
(such as beneath flight instrument panels, around rudder pedals), elevated locations
(on cherry-pickers or staging), sometimes in uncomfortable climatic or environmental
conditions (heat, cold, wind, rain, noise). This can be aggravated by aspects such as
poor lighting or having to wear breathing apparatus.
¨ Fear of Heights. Work at high levels can also be a problem, especially when doing
'crown' inspections (top of fuselage or top wing engine). Some engineers may be
quite at ease in situations like these whereas others may be so uncomfortable that
they are far more concerned about the height, and holding on to the access
equipment, than they are about the job in hand.
Conclusion
If a person is working in uncomfortable conditions, he may be inclined to get out of that

situation as soon as possible, possibly resulting in checks not being carried out quite as
diligently as they might be. Although there is no formal evidence of this, there is anecdotal
evidence of situations where this has occurred. Engineers should be aware of this and
guard against it. Managers and supervisors should attempt to make the job as comfortable
and secure as reasonably possible (eg providing knee pad rests, ensuring that staging does
not wobble, providing ventilation in enclosed spaces, etc) and allow for frequent breaks if
practicable.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.3
Social
Psychology
9.3 SOCIAL PSYCHOLOGY

9.3.1 Responsibility: Individual and Group
¨ Individual. Traditionally, in the maintenance engineering environment, responsibility

has been considered in terms of the individual rather than the team (whether the
team working on a specific job, the shift, the site or the Company). This is historical,
and has much to do with the manner in which engineers are licensed and the way in
which work is certified. This has both advantages and disadvantages. The
advantages are that it can be a strong incentive to an engineer to do the work
correctly or to check what others have done, if he knows that he will invariably be the
one held responsible if something goes wrong, probably resulting in punitive measure
or loss of job. However, this applies mainly to Licensed Aircraft Engineers (LAEs),
and may not provide quite the same incentive to those who are not licensed. This
does not mean to say that engineers would not have personal responsibility if they
were not licensed; indeed, it is hoped that all staff working in aircraft maintenance
are well aware of their personal, moral responsibilities to ensure that the work that
they do does not compromise the safety of an aircraft. The disadvantages of the
emphasis upon personal responsibility, especially that of LAEs, is that this may
lessen the concept of team or group responsibility.
AWN No 3 details the certification responsibilities of LAEs, adding that "It should be
noted that where the holder of a license is performing maintenance activies on
aircraft which he or she is not appropriately licensed, ie acting as a non-certifying
engineer, they are still expected to act responsibly and carry out such work in
accordance with the procedures and standards identified in [the paragraphs of
AWN3]".
BAe 146 HYDRAULIC BAY ACCESS DOOR OCC NR: 99/02670

NOT PROPERLY CLOSED
STATUS: CLOSED
FLT PHASE: CLIMB DATE: -- MAY 99
A crew change had been carried out at an European airport, the aircraft having
arrived late, and with only 20 minutes before the departure slot. The aircraft was
handed over with an automatic pressurisation defect which required use of manual
pressurisation control. Problems with catering loading caused the slot to be missed,
with a 40 minutes a delay. During starting checks a 'lower door not closed' caption
remained illuminated. The ground crew were asked to check all lower doors were
closed, and the despatcher on the headset assured the flight crew that this was so.
However, the caption remained on. A request was made for a second check with the
same result. The ground crew were then asked to open and close all lower doors as
failed microswitches on these doors are a known problem.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.3
Social
Psychology
The avionics bay and forward cargo bay doors were heard to be opened and closed
again, but operations of the hydraulic bay and rear cargo doors cannot be heard from
the flight deck. Once again an assurance was received that all doors were closed,
and accepting that the caption was due to a faulty microswitch, a normal departure
was carried out. However the cabin failed to pressurise, so the aircraft returned. An
external check found that the hydraulic bay door was latched but not closed. A
ground pressurisation test was carried out satisfactorily. An interview with the
despatcher on the head set revealed that he had delegated the check of the doors to
another person and had not checked himself.
¨ Group. Group responsibility, also, has its advantages and disadvantages. 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. This may take the form of cross-
checking others' work when not strictly required, politely challenging others if you
think that something is not quite right, etc. The disadvantage of group responsibility
is that it can act against safety, with responsibility being devolved to such an extent
that no-one feels personally responsible for safety, each member of the group
assuming that 'someone else will do it'. There has been a great deal of research
carried out on the phenomenon whereby an individual, on his own, may take action
but, once placed within a group situation, he may not act if none of the other group
members do so. This is referred to as diffusion of responsibility. Two researchers
named Latané and Rodin conducted several experiments whereby they set up a
situation where someone was apparently in distress, and noted who came to help. If
a person was on their own, they were far more likely to help than if they were in a
pair or group. In the group situation, each person felt that it was not solely his
responsibility to act, and assumed that someone else would do so. Whilst these
situations were rather contrived, and dissimilar to the maintenance engineering
context, nevertheless they serve as a good illustration of the dangers of devolved
responsibility among a group, against which engineers should guard.
Responsibility is an important issue, and ought to be addressed not only by licensing,
regulations and procedures, but also by education and training, attempting to
engender a culture of shared, but not diffused, responsibility.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.3
Social
Psychology
9.3.2 Management, Supervision and Leadership
Managers and supervisors have a key role to play in ensuring that work is carried out safely.
It is no good instilling the engineers and technicians with 'good safety practice' concepts, if
these are not supported by their supervisors and managers. It is appreciated that line
managers, particularly 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, eg if there is a temporary staff shortage, deciding whether that
maintenance tasks can be safely carried out with reduced manpower, or whether an
engineer volunteering to work a "ghoster" to make up the numbers will be able to perform
adequately. The adoption of Safety Management Principles may help by providing
Managers with techniques whereby they can carry out a more objective assessment of risk
(eg of operating a shift with one man short) and make decisions based on this knowledge.
Similarly, engineers must realise that compromises will have to be made from time to time.
In terms of the relationship between managers and engineers, a 'them and us' attitude is not
particularly conducive to improving the safety culture of an organisation. It is important that
managers, supervisors, engineers and technicians all work together, rather than against one
another, to ensure that aircraft maintenance improves airworthiness, as opposed to
converting what was previously a perfectly serviceable aircraft into a potential incident or
accident by injecting a latent failure.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.3
Social
Psychology
9.3.3 Culture
The culture of an organisation can be described as 'the way we do things here'. It can refer
to safety culture, professional culture, political culture, business culture, etc, although the
safety culture is obviously the area with which this text is primarily concerned. It is difficult to
pinpoint where the culture of an organisation is driven from. It is not necessarily always
generated or driven from the top, as one might think, but this is the best point from which to
influence the safety culture, Whilst it is possible for cultural differences to exist between
sites or even between shifts, a certain cultural climate tends normally to be associated with
an or with a particular branch of the industry (eg helicopter maintenance, light aircraft
maintenance, line maintenance, etc).
The culture of an organisation can best be judged by what is done rather than by what is
said. Organisations may have grand 'mission statements' concerning safety but this does
not indicate that they have a good safety culture unless the policies preached at the top are
actually put into practice at the lower levels. It may be difficult to determine the safety
culture of an organisation by auditing the procedures and paperwork; a better method is to
find out what the majority of the staff actually believe and do in practice.
A method for measuring attitudes to safety has been developed by the Human Factors in
Reliability Group (HFRG) violations sub-group, utilising a questionnaire approach. The
questionnaire takes the form of statements to which respondents are asked the extent to
which they agree. Examples include:
¨ It is necessary to bend some rules to achieve a target

¨ Short cuts are acceptable when they involve little or no risk
¨ I often come across situations with which I am unfamiliar
¨ I sometimes fail to understand which rules apply
¨ I am not given regular break periods when I do repetitive and boring jobs
¨ There are financial rewards to be gained from breaking the rules
The results are scored as outlined in the methodology and results are given which give an
indication of the safety culture of the organisation, broken down according to safety
commitment, supervision, work conditions, logistic support, etc. In theory, this enables one
organisation to be objectively compared with another.
Whilst safety culture has been discussed from the organisational perspective, the
responsibility of the individual should not be overlooked. Ultimately, safety culture is an
amalgamation of the attitude, beliefs and actions of all the individuals working for the
organisation and each person should take responsibility for their own contribution towards
this culture, ensuring that it is a positive contribution rather than a negative one.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.3
Social
Psychology
9.3.4 Motivation and De-motivation
Motivation, is a force coming from within your brain that drives you to act in certain ways. It
is usually considered to be a positive rather than a negative force in that it causes you to
move forward as opposed to remaining stagnant. It manifests itself both in intensity and in
direction. Generally we say a person is motivated if he/she is taking action on some subject.
The action, however, can be either good or bad, and just because someone is positively
motivated, this does not mean to say that they are doing the right thing. Many criminals are
highly motivated, for instance. Motivation to do the right things, in terms of safety, is vital. In
Aviation, you can be motivated to take risks (eg for the satisfaction of getting an aircraft
turned around more quickly) or to make safe decisions (eg to satisfy your own personal
integrity). It is important to associate motivation with the right type of actions, ie point it in
the right direction.
The psychological concept of motivation and what we understand as being motivated, are
subtly different.
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
People who lack motivation, either intrinsically or through a failure of their management to
motivate the staff who work for them, tend to demonstrate the following characteristics:
¨ apathy and indifference to the job

¨ a poor record of time keeping and high absenteeism
¨ an exaggeration of the effects/difficulties encountered in problems, disputes and
grievances
¨ a lack of co-operation in dealing with problems or difficulties
¨ unjustified resistance to change
However, care should be taken when associating these characteristics with lack of
motivation, since some could also be signs of stress.
It is important that maintenance engineers are motivated by a desire to ensure safety rather
than necessarily a fear of being punished and losing one's job. The fears associated with
job security in aircraft maintenance engineering are very real in the modern, commercially
competitive world. It is possible that the "can do" culture, which is evident in some areas of
the industry, may be generated by the expectancy that if individuals do not 'deliver', they will
be dismissed or punished and, conversely, those who do 'deliver' (whether strictly by the
book or not, finding ways around lack of time, spares or equipment) are rewarded and
promoted. This is not motivation in the true sense but it has its roots in a complex series of
pressures and drives and is one of the major influences upon human performance and
human error in maintenance engineering.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.3
Social
Psychology

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.3
Social
Psychology
9.3.5 Peer Pressure and Conformity
Conformity is "the tendency to allow one's opinions, attitudes, actions and even perceptions
to be affected by prevailing opinions, attitudes, actions and perceptions". In the work
context, in particular, this is sometimes referred to as 'peer pressure', which is the actual or
perceived pressure which an individual may feel, to conform to what he believes that his
peers or colleagues expect.
A researcher named Solomon Asch carried out several experiments investigating the nature
of conformity, one of the better known experiments being where he asked people to judge
which of lines A, B & C was the same length as line X.
An experiment to illustrate conformity
X A B C
(B is the same length as X)
He asked this question under different conditions, one where the individual was asked to
make the judgement on his own, without being influenced, and the other where the individual
was asked to judge last, after a series of 'stooges' had all judged that line A was the correct
choice. In the latter condition, about 25% of people yielded to group pressure and agreed
with the incorrect 'group' finding.
Peer pressure may be actual or perceived. It is often not overt, and it can be difficult to find
actual evidence that it exists. An individual engineer may feel that there is pressure to cut
corners in order to get an aircraft out by a certain time, in the belief that this is what his
colleagues would do under similar circumstances. There may be no actual pressure from
management to cut corners, but subtle pressure from peers, eg taking the form of comments
such as "You don't want to bother checking the manual for that. You do it like this …" would
constitute peer pressure.
As already mentioned, peer pressure can be good or bad, depending on the context and on
whether the group view is the correct one. As far as safety is concerned, if the group (or
shift) view is one which believes that safety is very important, then peer pressure will have a
positive effect in influencing others to conform to this attitude. Too often, however, it works
in reverse, with safety standards gradually deteriorating as shift members develop practices
which might appear to them to be more efficient but which erode safety, placing pressure,
albeit possibly unwittingly, upon new engineers joining the organisation, to do likewise.
9.3.6 Team Working

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.3
Social
Psychology
The importance of teamwork in aircraft maintenance cannot be over-stressed. As aircraft

and their systems become more complex, a greater emphasis on technical specialities(eg
sheet/metal structures, electrical/electronics/avionics, hydraulics, etc) is emerging. An
unfortunate parallel trend is to organise the technical specialists into distinct departments or
'functional silos', which tends to inhibit teamwork. This is true particularly of support services
where technical specialists are often separated out from the aircraft fleets. The larger the
organisation, the more this tends to be the case, and the greater the need for more
formalised team skills to overcome the barriers (eg in communication, or even availability of
staff when needed) between the various specialists and technicians.
Establishments of maintenance teams should be carefully planned; it is not enough simply

to separate people into groups and label them team A or team B. Principles of job design
should be employed when creating work teams. Well-structured teams can result in
improvements in work performance and employee satisfaction; poor team design can lead
to effects in the opposite direction. Without adequate management direction and regular
evaluation of team performance, negative results are likely. Groups left to their own devices
can lack direction, making poor decisions as a consequence. Inter-and intra-group conflicts
can emerge with devastating effects. To maintain team cohesiveness, there may be a need
to redefine goals and objectives as well as a need to periodically exchange or replace team
members for a variety of reasons as suggested above.
Team members should be trained in their roles. This training is important especially for
newly formed groups of people who are accustomed to working as individual engineers and
technicians. The training should include methods of group decision making, development of
interpersonal skills and working with other teams.
It may be worth noting that, in many companies, line engineers tend to work as individuals
whereas base engineers tend to work in teams. This may be of significance when an
engineer who normally works in a hangar, finds himself working on the line, or vice versa.
This was the case in the A320 incident involving double engine oil pressure loss, where the
Base Controller took over a job from the Line Maintenance engineer, along with the line
maintenance paperwork. The line maintenance paperwork is not designed for recording
work with a view to a handover, and this was a factor when the job was handed over from
the Line engineer to the Base Controller. Although there was no suggestion that this
incident was due to differences between team working vs working as an individual,
nevertheless it illustrates some of the differences between the Line and Base maintenance
working practices.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.4
Factors Affecting
performance
9.4 FACTORS AFFECTING PERFORMANCE
CAUSES OF ERRORS
As stated previously there are a multitude of factors which can and will contribute to errors
being committed: Here are some of them:
¨ Stress
¨ Fatigue
¨ Complacency
¨ Communication
¨ Ignorance
We shall address the more common, easily recognisable ones but, be aware that around
every corner a new one is waiting to trap the unwary.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.4
Factors Affecting
performance
9.4.1 STRESS
¨ Sickness absence costs to UK economy on average £11,000,000,000
¨ 30 - 40% of this is stress related

(C.B.I. 1994)
¨ ALCOHOLISM costs over £2.2 billion per year in terms of premature death,
sickness absence, unemployment and N.H.S. treatment
STRESS
What is Stress?
It has been said that stress is 'a reality like love and electricity - unmistakable in experience
but hard to define!' Research has shown what stress is not
¨ Stress is not nervous tension
¨ Stress is not the discharge of hormones from the adrenal glands (the common
association with adrenaline and stress is not totally false but the two are only
indirectly associated)
¨ Stress is not simply the influence of some negative occurrence - stress can be
caused by quite ordinary, even positive events, such as a passionate kiss
¨ Stress is not entirely a bad event; we all need a certain amount of stimulation in life
and most people thrive on a certain amount of stress
¨ Stress does not cause the body's alarm reaction which is the most common use of
the expression - what causes stress is a Stressor

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.4
Factors Affecting
performance
OCCUPATIONAL STRESSORS
Most if not all of us will recognise and readily relate to the following list of stress factors:
NEW WORK PATTERNS

NEW TECHNOLOGY
PROMOTION
RELOCATION
DEREGULATION
DOWN SIZING
JOB DESIGN
BOREDOM
NOISE
TEMPERATURE
INCREASED COMPETITION
LONGER HOURS
REDUNDANCY
EARLY RETIREMENT
ACQUISITION
MERGER
MANNING LEVELS
INSECURITY
LIGHTING
ATMOSPHERE/VENTILATION

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.4
Factors Affecting
performance
PRESSURE
Pressure at work to complete the job is part of stress which motivates us to do the job. We
all know that if we have two weeks to do a 2 hour job, it is likely that we will do the job on the
last available day. WHY? There was no pressure (Stress) to complete the job until the last
day when you will see most of the pressure to do a job comes from within ourselves. The
boss may say "I need the aircraft by 5 pm", but if the timescale is unreasonable and you
don't say anything, then YOU, not the boss, are responsible for the pressure. The monkey
on your back is yours because you have accepted it.
How to deal with pressure
Since pressing is a form of stress, the same advice applies.
¨ Stop and assess the situation
¨ Look at the situation rationally
¨ What is the reality of the situation? Can I safely complete my work on time?
¨ Have I communicated my concern in a concise and rational way?
¨ What is the worst thing that can happen to me?
Listen to your rational mind
¨ Has this happened before and what can I do better?
¨ What is the best rational plan
Act
¨ Speak up and ask for help or extra time as required
Often the error of pressure is due to an error of not communicating properly and trying to
make do.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.4
Factors Affecting
performance
LACK OF AWARENESS
Lack of awareness, differs from lack of knowledge in that it occurs to engineers who often
are very knowledgeable but fail to reason the possible consequences to what is normal good
maintenance practice.
For example: An engineer mounts a fire extinguisher on a bulkhead as per normal

maintenance practices, but fails to realise that in a crash, the person sitting in front of the
bulkhead will remove the extinguisher with his head!!
It is not easy to be aware of all the consequences of a maintenance action, yet, particularly
when one modifies anything on an aircraft, one must work to examine all possible outcomes.
A court of law is no place to explain why it is that you did not realise.
COMPLACENCY
Self-satisfaction accompanied by a loss of awareness of the dangers
Because of the repetitive nature of a lot of aviation maintenance work, complacency is an

ever-present danger. As a person becomes complacent his stress level, for that task,
decreases and with it his performance. A greater stimulus will be required in order to obtain
a response.
With complacency can come Expectancy, where the AME will often see what he expects to
see and not what is actually there. If other factors are also present such as fatigue,
resources and stress (from a different source) then the chance of an error becomes very
real.
The error of complacency can be lessened by:
i) Always following the checklist or work sheet: ie don't attempt to do work from
memory.
ii) Be aware of the danger of complacency and tell yourself: "Today I am going
to find a crack" or whatever.
Awareness is your strongest advocate in preventing complacency.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.4
Factors Affecting
performance
DISTRACTION
Meaning:
Draw one's attention away, Confuse
Distractions are a common occurrence anyway yet, if they occur in a critical phase of our
work, they can have disastrous consequences. Distraction is one of the main reasons that
an engineer fails to secure NUT "B" or a control cable or other critical part. Psychologists
say it is the number one cause of forgetting. Often after an error has occurred, the engineer
will be at a loss to explain how it happened. If other factors are present such as fatigue and
stress, then the likelihood of an error occurring increases.
Prevention consists of awareness of the problem and the use of safety nets such as:
¨ proper use of detailed check lists
¨ flagging incomplete work
¨ witness marks
¨ dual or independent inspection
¨ going back three steps, ie return to a "known" point in the procedure.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.4
Factors Affecting
performance
FATIGUE
Fatigue is the body's normal reaction to a physical or mental stress of prolonged duration.
Its onset is insidious and the symptoms are not always recognised until the person has
reached a high degree of fatigue. There are two types of fatigue:
Acute Fatigue:
is the result of intense physical or mental activity at a single task. It is of short duration,
measured in hours, and is cured with a good night's sleep.
Chronic Fatigue:
is caused over a period of time and takes much longer to recover from. Each person has a
personal level of ability to withstand fatigue which slowly diminishes as the person ages.
Causes of Fatigue:
Some of the things that can induce fatigue are:
i) Long hours of labour of any type, physical or mental, but the harder the
labour, the sooner the fatigue.
ii) Lack of sleep due to time to or inability to, sleep. If one can not sleep, it
likely is due to stress, but physiological factors can play a role. Pain due to
sickness or injury or simply a disruption of one's circadium rhythm ie jet lag.
iii) Stress of high intensity and/or long duration will induce fatigue.
iv) Large temperature variations, hot or cold, will induce fatigue.

Temperatures in excess of 90 deg F (32C) can lead to heat exhaustion while
temperatures below 50 deg F (10C) without proper clothing, can lead to
hypothermia.
v) Noise if above the 80 dB mark for long duration will cause fatigue. Exposure
to loud noises without proper hearing protection is a self correcting problem
because, in time, you will no longer hear the noise (or any other noise) and
the damage cannot be reversed.
vi) Vibration can also cause fatigue. If for prolonged periods and of sufficient
intensity, it will cause headaches and muscle discomfort. However unlike
noise, vibration is not known to cause any permanent damage although
"white hand" from chain saw vibration and rivet guns can become permanent
if ignored long enough.
vii) Strong Lighting and to a lesser degree, poor lighting will contribute to
fatigue. The normal symptom is a headache, and if bad or long enough,
eyestrain.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.4
Factors Affecting
performance
Symptoms of Fatigue
Because the symptoms come on slowly it is important that we come to recognise the
symptoms and be aware of its effects. Often the fatigued person is unaware that he is
fatigued until the symptoms and effects have become quite extreme, therefore:
¨ An Enhanced Stimulus is required in order to respond.
The person would require a larger crack in order to see it. The greater the fatigue,
the greater the stimulus required.
¨ Attention is reduced
The person begins to overlook basic task elements.

The person becomes preoccupied with a single task to the exclusion of others.
The person begins to lessen his visual scan.
The person becomes less aware of poor performance.
¨ Memory is diminished
The person begins to have inaccurate recall.

The person forgets peripheral tasks.
The person begins to revert to "old" habits.
¨ Mood becomes withdrawn
The person becomes less likely to converse.

The person becomes less likely to perform low demand tasks.
The person becomes more distracted by discomfort.
The person becomes more irritable.
The person begins to develop a "don't care" attitude.
Persons who work a midnight shift should be particularly aware of the symptoms as most
persons have a normal low (circadian rhythm-time of day effect) between 0300 and 0500.
Fatigue, as seen by its detrimental effects, can easily lead to a maintenance error, especially
if the person isn't aware he is suffering from it.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.4
Factors Affecting
performance
Circadian Rhythms
As you well know, the human body has its ups and downs. One reason for this is shown in
the diagram below.
Body Control Diagram 1
Most body functions are controlled between an upper and a lower limit. Every day of your
life you ride this roller coaster. On good days, you go up and down without getting too close
to your limits. On bad days, you push the limits.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.4
Factors Affecting
performance
Many body functions which affect how you feel are like this, including such things as blood
pressure, heart rate, body temperature, and alertness, to name a few.
The body functions that follow this type of up-and-down rhythm are connected. For
example, most people will feel alert and do their best work when their body temperature is
on the up cycle. This is probably because "up" body temperature reflects heat being
produced by the energy furnaces of the body. The more energy to go around, the more
energetic you feel.
Shift work can throw you off your rhythm in several ways. It can initially increase the ups
and downs of your cycle and then, as you adapt to the new schedule, your rhythm will settle
down again.
One of the keys to coping with shift work is to decrease the time it takes to resettle your body
rhythms.
Shift work can throw your rhythms off cycle by changing the timing of your ups and downs.
This can affect how you feel at different times of the day. It can also affect how you feel
compared to someone else.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.4
Factors Affecting
performance
SHIFT WORK
Have you ever noticed how some people seem to breeze through shiftwork with little
difficulty while others have a hard time? There are certain individual differences that have
been shown to cause these different reactions to shiftwork. Even if you don't work on shifts,
you might find that the information is useful anyway since we all occasionally experience the
sleepless night or stressful day not unlike that experienced by shiftworkers.
Approximately 23% of all workers in the service sector work on shifts. Not all shiftwork
creates difficulties, but some, especially 24-hour-a-day, 7-day-a-week operation, can create
problems such as poor quality of sleep and disruption of daily biological rhythms.
Accordingly, the two major complaints from most shiftworkers are: lack of sleep and
fatigue. But some individuals adapt readily to shiftwork while others manage to get by and
still others can never adjust. A look at some of the reasons behind these individual
differences in adaption will highlight steps that may be taken to improve our ability to
manage the difficulties caused by shiftwork.
Individual Differences
Younger people apparently handle the physical demands of shiftwork better, but older
workers handle the social and interpersonal problems more effectively, and extroverted,
outgoing people seem to adapt more easily to shiftwork than introverted types. The
remainder of this section will look at techniques that can be used by anyone, regardless of
age or personality type, to help improve the quality of sleep and reduce fatigue.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.4
Factors Affecting
performance
The Role of Sleep
Although the role of sleep is not fully known, it is generally agreed that sleep is not
necessarily a passive state. there are a number of things that happen during sleep that do
not seem to happen when we are awake. For example, body temperature, breath rate, heart
rate, and blood pressure all drop during sleep, while the secretion of human growth hormone
and other anabolic hormones (hormones that are involved in the cell building process) seem
to increase.
Thus the role of sleep may be to serve a rebuilding function by restoring certain enzymes
and chemicals needed in our bodies. However, it is possible that not all of sleep is
necessary for restoration. Sleep researcher James Horne suggests that there are two sleep
drives, the first being "obligatory" sleep comprising the first five hours or so. The second
sleep drive is "facultative" and probably serves to pass time during the early morning hours
when there is nothing to do anyway.
In other words, Horne suggests that if we normally sleep eight hours then the last three
hours of sleep really only pass time. The main work of sleep is done after approximately five
hours. so even if we don't get a full night's sleep, chances are we are getting enough to
recharge our systems.
Many of us who experience sleep deprivation on a continuous basis, however, might not
agree. Five hours sleep per night does not seem to be enough, especially if we usually
sleep longer. We could, as Horne suggests, practice getting by with only five or six hours of
sleep per night, but once we establish a pattern of sleep, it is often hard to break.
The quality of sleep is important, especially REM (Rapid Eye Movement) sleep Non-REM
sleep has fairly low-frequency electrical waves in the brain and is sometimes referred to as
'slow-wave sleep'; REM sleep is characterised by high frequency electrical waves, the brain
activity actually being similar to when we are awake. It is thought that non-REM sleep
revitalises the body (specially after strenuous physical activity) whereas REM sleep restores
the brain (especially after strenuous mental activity). It is important to get adequate amounts
of both types of sleep. REM sleep can suffer as a result of stress, being forcefully wakened,
alcohol or drugs. A rule of thumb is that one hour of high-quality sleep is good for two hours
of activity.
Physical Fitness
Physically fit individuals adapt to shiftwork better for a number of reasons: they can handle
the physical demands of shiftwork better, and regular physical exercise promotes better
sleep and helps to manage stress. Remember that fitness activities can be anything from
running marathons to gardening, depending upon your interests and experience. Even low
levels of physical fitness seem to promote better health, which in turn can combat some of
the negative effects of shiftwork.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.4
Factors Affecting
performance
RESOURCES
Resources, or more appropriately the 'lack of' resources have been the cause of many an
accident. Engineers are notorious for making do with less than adequate resources. The
lack of up to date manuals can cause an error especially in these rapidly changing times and
how often does an engineer have to make difficult decisions due to the lack of materials. In
difficult times, lack of material may lead to an engineer to letting something go a little longer,
against his better judgement.
Sometimes the resource needed is an expensive special tool that is seldom used. Work is
carried out without the proper tool and can cause a maintenance error if it is not done
properly. There have been cases where the person who can procure the tool is unaware
that it is even required. An engineer was heard to say "I asked for the tool two years ago
and I still haven't got it", while the Production Director wasn't aware that the request was
ever made.
One of the most common lack of resources is adequate lighting for the task in hand.
Engineers often depend heavily on flashlights perched on some part of the aircraft to carry
out a task when only a few metres away is a proper portable light.
Some facilities, especially as we move north, have woefully inadequate heat in winter. It is
easy to make a mistake when you are cold and miserable and all your subconscious is
thinking about is getting warm.
Do not be afraid to ask for help when needed and ensure that you have done everything you
can to obtain the necessary resources.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.4
Factors Affecting
performance
LACK OF KNOWLEDGE
In these times of ever changing technology, it is not difficult to come upon a task which you
lack the knowledge. To counteract this, aircraft companies attempt to provide the correct
amount of detail to their manuals or workcards without boring you with complacency.
The key to the "lack of knowledge" error is to understand each step of what you are doing, or
talk to someone who does. Technical reps are paid good money to keep you out of trouble.
If it's new, don't be afraid to ask. Don't learn by mistakes and remember Murphy's Law if you
have any doubts.
ALCOHOL, MEDICATION AND DRUG ABUSE
Despite an individual's belief that he can still work effectively after drinking alcohol, such
behaviour will not be tolerated within aviation maintenance activities. Consumption of even
relatively small amounts of alcohol is unacceptable since, in combination with a number of
other factors such as fatigue, illness or medication, there may still be a distinguishable
impairment of judgement and decision making. Organisations may have an alcohol and
drug policy, including random testing for such substances. Even where such policy is not
defined by the organisation, it does not absolve the individual from complying with the
relevant legislation. (ANO Article 13, JAR 66.50 refers).
Whilst it is acceptable to take prescribed drugs, such as generic or trade-marked medicines,

to address medical conditions or short-term illness, it should be noted that many of these
may have side effects. These may affect individuals in different ways and even differently on
separate occasions. Maintenance personnel should therefore be aware of potential side
effects, as advised by the manufacturer of the medicine.
Alcohol
Alcohol has similar effects to tranquillisers and sleeping tablets and may remain circulating in
the blood for a considerable time, especially if taken with food. It may be borne in mind that
a person may not be fit to go on duty even 8 hours after drinking large amounts of alcohol.
Individuals should therefore anticipate such effects upon their next duty period. Special note
should be taken of the fact that combinations of alcohol and sleeping tablets, or anti-
histamines, can form a highly dangerous and even lethal combination.
Anaesthetics
It should be remembered that following local, general, dental and other anaesthetics, a
period of time should elapse before returning to duty. This period will vary depending on
individual circumstances, but may even extend up to 24 or 48 hours. Any doubts should be
resolved by seeking appropriate medical advice.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.4
Factors Affecting
performance
Medication and Drugs
The following are some of the types of medicine in common use which may impair work
performance. The list is not exhaustive and care should be taken in ensuring the likely
effects of any prescribed drug are adequately known before taking it.
¨ Sleeping tablets - these dull the senses, cause mental confusion and slow reaction
times. The duration of effect is variable from person to person and may be unduly
prolonged. Individuals should have expert medical advice before taking them.
¨ Tranquillisers - anti-depressants and sedatives depress the alerting system and have
been a contributory cause of mistakes leading to fatal accidents. Therefore a person
should not work when taking them.
¨ Antibiotics - antibiotics (Penicillin and the various mycins and cyclines) and sulpha
drug may have short term or delayed effects which affect work performance. Their
use indicates that a fairly severe infection may well be present and apart from the
effects of these substances themselves, the side-effects of the infection will almost
always render an individual unfit for work.
¨ Anti-histamine - such drugs are widely used in 'cold cures' and in the treatment of
hayfever, asthma and allergic skin conditions. Many easily obtainable nasal sprays
and drop preparations contain anti-histamines. Most of this group of medicines tend
to make the taker feel drowsy. Admittedly, very mild states of hayfever, etc, may be
adequately controlled by small doses of anti-allergic drugs, but a trial period to
establish the absence of side effects is essential before going on duty. When
individuals are affected by allergic conditions which require more than the absolute
minimum of treatment, and in all cases of asthma, advice should be consulted.
¨ 'Pep' pills (eg containing Caffeine, Dexedrine, Benzedrine) used to maintain
wakefulness are often habit forming. Susceptibility to each drug varies from one
individual to another, but all of them can create dangerous overconfidence. Over-
dosage may cause headaches, dizziness and mental disturbances. The use of 'pep'
pills whilst working cannot be permitted. If coffee is insufficient, you are not fit for
work.
¨ Drugs for the relief of high blood pressure are proving to be very effective in
controlling this condition. However, antihypertensive agents all have some side
effects and should not be administered before adequate assessment of the need for
treatment. The prescribing practitioner should be able to advise on any side effects
to be considered.
¨ Drugs when prescribed for anti-malaria in normally recommended doses do not
usually have any adverse effects. However, the drug should be taken in good time.
¨ Oral contraceptive tablets in standard dose do not usually have any adverse effects,
although regular supervision is required.
¨ 'Sudafed' is the trade name of a preparation containing pseudo-ephedrine
hydrochloride. This may be prescribed for relief of nasal congestion. Side-effects
reported, however, are anxiety, tremor, rapid pulse and headache. The preparation
does not contain anti-histamines which could sedate and cause drowsiness but the
effects can nevertheless affect skilled performance. Sudafed, therefore, is not a
preparation to be taken when making engineering decisions or performing licenced
duties.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.4
Factors Affecting
performance
Medication and Drugs - contd
Although these are common groups of drugs, which may have adverse effects on
performance, it should be pointed out that many forms of medication, which although not
usually expected to affect efficiency, may do so if the person concerned is unduly sensitive
to a particular drug. Therefore no drugs or medicines, or combinations, should be taken
before or during duty unless the taker is completely familiar with the personal effects of the
medication and the drugs or medicines have been medically prescribed for the individual
alone.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.5
Physical Enviroment
9.5 PHYSICAL ENVIRONMENT
Aviation maintenance has many features in common with other industries. The physical
facilities in which aviation technicians work, however, are unique. No other industry uses
quite the combination of facilities, including exposed aprons, aircraft hangars, workshops,
offices, inspection rooms, etc. The primary reason for using hangars is obvious, of course.
Aviation maintenance technicians work on aircraft, and hangars are often needed to shelter
aircraft and workers from the elements for certain maintenance activities.
Aircraft hangars present a range of human factors issues. They are generally quite large
and are built so that most of the floor area is unobstructed by structural support members.
This design allows large aircraft to be moved and parked in the building. Their vast areas
and high ceilings make hangars difficult to light properly. Their large, unobstructed volume
makes public address systems difficult to hear. Large, open doors make controlling
temperature and humidity problematic. The use of extensive and elevated, multi-level
access platforms is common due to the sizes of today's aircraft and the varying heights of
component locations. Access requirements vary according to the nature of the work being
carried out. In some cases, the close proximity of different pieces of equipment to each
other bring its own problems. Individual workspaces tend to be clustered around certain
areas of the aircraft, eg undercarriage bays and engines.
Lighting
One of the most important work parameters in aircraft maintenance is lighting. It is very
difficult to provide adequate lighting for all aspects of maintenance work including inspection
and repair. Poor ambient illumination of work areas has been identified as a significant
deficiency during the investigation of certain accidents. In the BAC 1-11 accident, an
adequately lit working area may have made it possible for the shift maintenance manager to
see the successive annulus of unfilled countersink which was easily discernible when viewed
under good lighting conditions.
The type of lighting used can also affect colour perception, various type of lighting
strengthening some colours but subduing others. This may not be overly important for
aircraft exterior maintenance tasks, but may be relevant for visual discrimination between
different coloured wiring, or other work where colour differences are important.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.5
Physical Enviroment
Fumes and Confined Spaces
Maintenance of aircraft involves working on a variety of systems. Many of these use, as a

medium for transmitting power (eg hydraulic systems), oil or fluids. Other chemical
compound and gases are to be found in greases, protective coatings, lubricants or aircraft
components themselves. Where any chemical compound is involved it is likely that, at some
time, fumes will be produced. For some substances, fumes will always be detectable, eg
fuel, hydraulic oil. For others it may require a particular set of circumstances to produce
fumes, eg overheated grease or oils, smouldering insulation. Chemicals in isolation may be
relatively harmless but in combination with others may give rise to fumes, which may even
be toxic by nature.
The entry of personnel into any space, with limited means of entry or exit, which is not
intended for normal use or designed for continuous occupancy, needs to be managed, eg
fuel tank access. Such activities will benefit from the availability of written control
procedures, prior safety training and the possession of adequate and appropriate safety
equipment. These should address the likely risks to be encountered. For example,
attaching only a safety rope to someone is no good if there is a likelihood that they will be
overcome with fumes in any case. Using breathing apparatus could well prevent the need
for the rope to be used. Some confined spaces have other hazards present, such as toxic
gases or fumes, electricity, machinery, etc. A recent report delineated the risks associated
with fuel cell repair as an example. Confined spaces are considered inherently hazardous
even without being associated with other hazards.
Anyone entering a confined space should:
¨ Receive appropriate training in entering such spaces and in using any safety
equipment.
¨ Secure a written entry permit before entering the space if it contains any hazards that
could cause death or serious physical harm.
¨ Test the space for sufficient oxygen and for dangerous gases or vapours.
¨ Ventilate the space before and during entry.
¨ Lock out any connecting lines.
¨ Have the appropriate safety equipment and trained assistance present during entry.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.5
Physical Enviroment
Climate and Temperature
Humans can operate within quite a wide range of temperatures and climatic conditions, but
performance is adversely affected at extremes, and is best within a fairly narrow range of
conditions. Although this text refers mainly to maintenance carried out in hangars, it is
realised that some work must take place outside hangars, often in extreme heat, cold, wind,
snow, rain or humidity. This may be unavoidable, but engineers and managers should be
aware of the effects of extremes in temperature and climatic conditions upon their
performance, both within and outside the hangar.
Human Performance at various temperatures

Temperature (°F) / (°C): Performance Effect:
90 32 Upper limit for performance

80 28 Maximum acceptable upper limit
75 25 Optimum with minimal clothing
70 21 Optimum for typical clothing and tasks
65 18 Optimum for winter clothing
60 15 Hand and finger dexterity begins to deteriorate
55 12 Hand dexterity reduced by 50%
It is difficult to strictly control temperatures in hangars due to the large expanses of space to
heat or cool, and the fact that the hangar doors need to be opened and closed from time to
time, to let aircraft and large equipment in and out of the hangar. It may be expensive to
continually reheat the air in a hangar each time the heat is lost, but it is important that
engineers are able to work in a reasonable temperature environment. Indeed, many
Countries have legislation which requires that the working environment is within a certain
temperature range, to protect the workers.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.5
Physical Enviroment

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.6
Tasks
9.6 Tasks
Physical Work
People vary in the strength they can bring to bear on a task; they also differ in their
capacities to perform different types of work over time. Many studies have attempted to
describe the acceptable range of energy usage over different periods of time and in different
environments. As with other basic physical variables, one's ability to perform work is
affected by a number of different factors.
Excessive physical work over a period can result in fatigue. This has been mentioned briefly
in Section 3 - Fatigue. Fatigue generated as a result of physical effort is normally not a
problem if there is adequate rest and recovery time between work periods. It can, however,
become a problem if the body is not allowed to recover, possibly leading to illness or injuries.
As an engineer progresses through his shift, he will tend to become more tired and his ability
to cope with physical work will tend to decrease. Circadian rhythm effects may also reduce
ability to cope with physical work. This is not considered a major safety hazard, however,
since people tend to be more aware of their reduced physical performance and associated
errors are likely to be fairly obvious (eg dropping an item of equipment because it is too
heavy). It is reductions in cognitive performance which are less evident and which constitute
a more serious risk, since errors are likely to be made and to go unnoticed.
Repetitive Tasks
There will be some 'repetitive' tasks in aircraft maintenance engineering, eg in brake or

engine shops, in the sense of the same task possibly being carried out several times a day.
The main danger is that engineers may become so practiced at such tasks that they may
cease to consult the manual or to use work cards and, if something about the tasks is
changed, the engineer may not be aware of the change. There is also a danger that an
engineer may become complacent regarding tasks which are relatively simple and carried
out often, and may skip steps or fail to give due attention to steps in the procedure,
especially if it is to check something which is rarely found to be wrong, damaged or out of
tolerance. This applies particularly to visual inspection.
Repetitive tasks, such as the detailed inspections of rivets along a lap joint, are tedious,
boring and lead to errors being made (missed defects). The effects are made worse when
the inspector has a very low expectation of finding a discrepancy, eg on a new aircraft.
Motivation and arousal are low without the reward of a defect.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.6
Tasks
Visual Inspection
Visual inspection is the process of examination and evaluation of systems and components
by us of human sensory systems, aided only by mechanical enhancements to sensory input,
such as magnifiers, dental picks, stethoscopes, and the like. The visual input to the
inspection process may be accompanied by such behaviours as listening, feeling, smelling,
shaking, twisting, etc.
It is however one of the primary methods employed during maintenance to ensure the
aircraft remains in an airworthy condition. The majority of inspection is visual (80% to 99%,
depending on circumstances); 1% to 20% is Non-Destructive Testing (NDT).
Good eyesight is obviously of prime importance in visual inspection and there is a standard
for those engineers involved in NDT. (Airworthiness Notice 47 refers).
COMPLEX SYSTEMS
The main difference between simple systems and complex systems, from a maintenance
point of view, is that the degree of complexity of the latter, and the interface between
systems, is such that it is not (usually) possible for one person to have the knowledge and
skills to maintain the system without support. This support may be achieved by distributing
the workload among individuals or specialists who have an expertise in a particular trade
discipline. Alternatively it may be provided by the manufacturer in the form of well defined,
comprehensive and prescriptive maintenance manuals and documentation.
With complex systems and aircraft, written procedures become more important as a source
of reference rather than just as a reminder. The reference material may describe
comprehensively the method of performing maintenance tasks, the related tasks,
inspections, adjustments and tests, the relationship to other systems and often, most
importantly, provide cautions or bring attention to specific areas of design or criticality. As a
result of the complexity, the system has to be broken down, conceptually or even physically,
into smaller parts which one person, or a small group of people, can work upon. It is vital to
ensure that all the separated activities occur in concert and that dependencies are
addressed.
A single modern aircraft is complex enough, but many engineers are qualified on several
types and variants of aircraft. If an engineer works on several different types of aircraft, this
will usually mean that he has less time to become familiar with one type, making it even
more important that he sticks to the prescribed procedures and refers to the manual
wherever necessary. There is a particular vulnerability where tasks are very similar between
two different aircraft (eg: spoiler systems on the A320, B757 and B767), and may be more
easily confused if no reference is made to the manual. Continuation or refresher training is
important to keep this knowledge topped up.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.6
Tasks
Conclusion
One of the early MRM training programmes, developed by Gordon Dupont for Transport
Canada, introduced "The Dirty Dozen", which are 12 potential problem human factors areas.
A series of posters have been produced, one for each of these headings, giving a few
examples of good practices which ought to be adopted, or "safety nets". These are
summarised as follows:
1. Lack of Use logbooks, worksheets, etc to communicate and remove doubt.

communication Discuss work to be done or what has been completed.
Never assume anything.
2. Complacency Train yourself to expect to find a fault.
Never sign for anything you didn't do [or see done].
3. Lack of Get training on type.
knowledge Use up-to-date manuals.
Ask a technical representative or someone who knows.
4. Distraction Always finish the job or unfasten the connection.
Mark the uncompleted work.
Lockwire where possible or use torqueseal.
Double inspect by another or self.
When you return to the job, always go back three steps.
Use a detailed check sheet.
5. Lack of Discuss what, who and how a job is to be done.
teamwork Be sure that everyone understands and agrees.
6. Fatigue Be aware of the symptoms and look for them in yourself and others.
Plan to avoid complex tasks at the bottom of your circadian rhythm.
Sleep and exercise regularly.
Ask others to check your work.
7. Lack of parts Check suspect areas at the beginning of the inspection and AOG the
required parts.
Order and stock anticipated parts before they are required.
Know all available parts sources and arrange for pooling or loaning.
Maintain a standard and if in doubt ground the aircraft.
8. Pressure Be sure the pressure isn't self-induced.
Communicate your concerns.
Ask for extra help.
Just say No.
9. Lack of If its not critical record it in the journey log book and only sign for what
Assertiveness is serviceable.
Refuse to compromise your standards.
contd….

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.6
Tasks
Conclusion - contd
10. Stress Be aware of how stress can affect your work.

Stop and look rationally at the problem.
Determine a rational course of action and follow it.
Take time off or at least have a short break.
Discuss it with someone.
Ask fellow workers to monitor your work.
Exercise your body.
11. Lack of Think of what may occur in the event of an accident.
awareness Check to see if your work will conflict with an existing modification or
repair.
Ask others if they can see any problem with the work done.
12. Norms Always work as per the instructions or have the instruction changed.
Be aware the "norms" don't make it right.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.7
Communication
9.7 Communication
HUMAN INTERACTION
One way of understanding how we interact with other people is to imagine that people are
television sets. The various broadcasting channels then represent the different
communication channels, or personal styles, that people have. Each person seems to select
the channels that suit them best. So, one person may choose a comedy, another a serious
drama, another a musical channel, and so on.
When we meet someone, we respond to these personal styles in the same way we might to
the TV programme. If we like their particular communication channel, we will expect to get
on with them. For example, if both of us prefer a channel that plays old movies, then we will
feel we have a lot in common. However, if we adopt different styles, we may not want to
interact much.
Someone who likes documentaries may not feel comfortable with a colleague who adopts a
less serious approach. Someone who selects a comedy channel may think anyone who
prefers the news channel is boring.
Skilful communicators are the people who have the greatest range of channels available to
them. They are quick to identify the channel that someone else is tuned to, and flexible
enough to switch quickly to a corresponding channel themselves. In this way, other people
find them easier to interact with.
Unskilled communicators tend to stay within a restricted range of channels. They may even
be stuck in just one style. They make little attempt to match other people. Instead, they
expect other people to change to suit them. This inflexibility limits their effectiveness when
dealing with others.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.7
Communication
Occasionally we meet someone who does not seem to tune in to a channel properly. We
pick up conflicting signals, just as when a TV is not properly adjusted. We then find it difficult
to know which programme to pay attention to. Or it feels as if there is a lot of interference
within the communication.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.7
Communication
THE PROCESS OF COMMUNICATION

Communication starts with an idea, a thought or an emotion. The process that takes place
when somebody wants to communicate an idea is as follows: the sender translates an idea
into symbols and sends a message to the receiver, who decodes the message into
information. A very simple process, but in interpersonal communication many things can go
wrong. For example: there is little chance that the decoded information corresponds to the
original idea if the sender decides to use the Chinese language as symbol for his idea and
the receiver does not understand Chinese. Communication can lead to transfer of
information when the symbols can be translated, and even then it is still uncertain whether
the information corresponds to the original idea. Feedback is necessary to check whether
the information is right.
An enormous number of factors influence interpersonal communication. All players in the

process have their own particular characteristics like expectations, attitudes, prejudices,
history, values and beliefs, moods, likes and dislikes, abilities, etc. This module deals with
these factors in more detail in the different chapters to follow. In our normal daily
conversations we tend to forget about all these influences. The feedback principle, for
example, is seldomly used, which all too often leads to misunderstandings or conflicts. The
readback/hearback loop is a compulsory feedback mechanism in Air Traffic Control and in
interpersonal communication often simply forgotten! Do I make myself clear? (Baker, 1996).

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.7
Communication
BRAIN FRIENDLY COMMUNICATION
Brains are like walnuts...

If we could look into our skull we would see our brain as a giant wrinkled walnut, which is
split lengthwise down the middle by a deep rift. This valley divides the brain into two almost
identical parts, united only deep down, near the centre of the brain. In other words we can
clearly identify a left and a right side. The left side helps us to pay attention to things which
can be translated into words, while the right side helps us to concentrate on visual images.
It is important to know that digital information only can be understood when it is “under-
stood”; in other words, it is information that we have learned (Birkenbihl,1991). An example
explains how this influences our communication: if I ask you not to think of a white
kangaroo, the left side of your brain scans colours and animals, and translates the colour
white and the animal kangaroo into a picture in the right side of your brain. It is in fact
impossible not to think of a white kangaroo because the information is processed left and
right, digital and analog, in words and in pictures. It is far easier when I ask you not to think
of a thalamus, because most of you probably don’t know the word, and the right side of your
brain doesn’t create a picture. The left side keeps on scanning and is unable to inform the
right side. This scanning only stops when you learn what a thalamus is. To help you: a
thalamus is the butterfly-shaped part in the centre of the brain (see Figure 2) - the left side
helps us to concentrate on words and the right side helps us to concentrate on visual
images. (You knew it, but you didn’t have the full picture yet!)
Left: digital, detail and analysis
Information in the left side of the brain is what we think (in words), say, write, read, calculate
and analyse. Left brain is analytical, logic, rational, linear, detailed, sequential (step by step)
and time oriented. We easily recognise that we learned to develop left brain processes at
school. This side concentrates on what we hear.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.7
Communication
Right: analog, overview and synthesis
The right side of the brain provides us with overview, it recognises shapes and structures.
Right is synthesis, creativity, perception of melody, intuition, etc. Synthetic thinking puts the
details from the left side together into the entire picture. Right is visually oriented and in
terms of understanding and memory much more effective than the left side. This side
concentrates on what we see.
Left and right: teamwork
Characteristics of the left side are often attributed as typical male and right side
characteristics as typical female. Our orientation shows in our communication, typical macho
or macha behaviour proves limited use of the full potential of the brain, good teamwork
between left and right is needed for good communication. The good communicator can
convince and listen, sees the detail and the big picture, is analytical and synthetic at the
same time. We normally have little difficulties in finding the right words when we have a
clear picture of what we want, digital (left) and analog (right) information are in balance. On
the other hand is it difficult to believe the salesman who rubs his nose while informing you
about the quality of his product. What we see – we often rub our nose when we tell a lie - is
not in balance with what we hear - “believe me, the quality is excellent!” Most people have
better developed their left brain processes, because most school and training methods are
based on development of logical and rational abilities. But remember, left recognises the
trees and right sees the forest, only together they create the whole picture. A way to improve
right brain communication is based on a very simple pattern: as children we learned by
listening to fairy tales, as adults we adopt by listening to analogies. Improving interpersonal
communication is done by improving the abilitiy to communicate in analogies and pictures.
Reptile Communication
In the ‘Stress’ Module (EATCHIP, 1996) the principle of the fight-flight response - or the
functioning of our stress hormones - was explained. For those who have forgotten about the
detail, a quick review: When we find ourselves in a threatening situation our so-called reptile
brain quickly decides whether we should fight or flee. The amount of stress hormones in our
bloodcirculation increases and prepares the body for muscular action, necessary to win or to
run. These stress hormones also influence our communication. An example to illustrate this:
Fred is late - again. His colleague asks: ‘Fred, what time is it?’, and Fred punches his
colleague on the nose!
You don’t need much psychological background to recognise Fred’s reptile reaction as the
fight-response. Very straight forward communication, Fred wasn’t in the mood and didn’t like
the question! It is more difficult to recognize the so-called flight-responses, because almost
everybody spends a lifetime developing very intelligent flight-communication. Let us take a
closer look at late-comer Fred to illustrate the influence of this flight principle on his
communication.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.7
Communication
Fred is a notorious late-comer, and every time that a supervisor or a colleague points him on
the effects of this behaviour he seems to have a ‘good reason’ for being late this time: the
wife was sick, he helped the victims of a car accident, traffic jams and traffic lights, wild
animals bumping into his car, the security officer didn’t let him pass......., an endless list of
events, all against Fred. Under four eyes and under serious threat of disciplinary action Fred
admits and promises improvement. He seems to keep up for a while but falls back to his old
behaviour after two or three weeks.
What exactly happens in this example? Fred is addressed at the moments of being late,
Fred knows he is late and on the way to work he already ‘prepared’ himself by an adequate
increase of stress hormones. His reactions to the threatening remarks of colleagues or
supervisor are very much influenced by his reptile brain: fight or flight. Fighting is socially
unacceptable, flight is the only way out, and we often ‘flee’ by making up excuses. It would
be better to raise the issue with Fred when he is in time, his reactions are at that moment
not influenced by fight or flight signals and his communication will be rational. We all have
developed very intelligent flight-communication, this reptile communication has however little
impact on our rational and should therefor be recognised and avoided at important moments.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.7
Communication
THE TWO LEVELS IN COMMUNICATION
Bosses should learn about listening
Few people these days would deny that communication has a vital role to play in all aspects
of leadership, motivation, commitment, willingness, ability to change, etcetera. Yet it appears
that many bosses still have an over-reliance on outmoded “top-down employee
communication”- techniques. Too often communication is seen as a way of transmitting
information rather than a means of getting people’s commitment. Small fortunes are spent
on employee newsletters, which push positive messages about how well the organisation is
doing in its struggle to survive. This is of course important and necessary, but it only covers
a small part of what human communication is about. Human communication takes place at
two levels (Watzlawick, 1967). At level one we exchange information, the content of our
words. ‘Exchange’ means that we give and receive information, only giving or only receiving
is incomplete communication and sorts limited effect. On level two we give meaning to the
information that we give and receive, our perception of the whole situation takes place on
level two - and information is only a small part of the whole picture. This level is called the
emotional level and it has an enormous influence on what we hear and say. People
communicate in fact like ice-bergs. When icebergs meet they first bump into each other
under water, because 7/8 of their volume is under the water surface.
The same is true for human beings, when people meet they first ‘bump’ into each other at
emotional level. The emotional level informs in a constant dialogue the rational level about
its findings such as likes or dislikes, danger or safety, high or low expectations, etc. The
influence of the emotional level on the willingness to listen or to talk is enormous and
determines far more the outcome of communication than the actual exchange of words.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.7
Communication
Commitment is not only a function of information, it is also and even mainly a function of
attitudes and people usually communicate their attitudes nonverbal. Bosses should therefor
learn to listen at both levels, and good listeners have excellent eyes. The chapters about
body language tell - or should I say ‘show’ - more about recognising non-verbal
communication.
Rational and emotional level were defined in more detail for Crew Resource Management
(Kanki & Palmer, 1993), this definition is also used in the concepts for Team Resource
Management in the world of Air Traffic Control:
1. Communication provides information.
2. Communication establishes interpersonal relationships.
3. Communication establishes predictable behaviour patterns.
4. Communication maintains attention to task and monitoring.
5. Communication is a management tool.
Although each of these communication functions can be looked at as a topic in its own right,
in reality, most communications fulfill several functions at the same time. For example, if a
supervisor makes it a point to bring the new shift together for a briefing, his/her
communications serve several functions simultaneously. First, they provide important
operational information for all team members. Second, they provide a means for the
supervisor to establish an interpersonal tone with the rest of the team. Third, they help to
establish predictability, because the team members now know something about the
supervisor’s style and expectations of them and are provided a preview of how they will work
together.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.7
Communication
Employees should learn about followership

Communication is often referred to in the context of good leadership. Little is said about what
a good follower is, although good followership is not a given. Good communication is as
much a responsibility for employees as it is for bosses. Employees add value to the team by
using followership skills to ensure that their potential becomes an active contribution.
Assertive communication is such a skill. Assertive communication is essential in good
teamwork, it is a means of getting attention and respect from other people without being
submissive or aggressive. Submissiveness leads to the ‘door-mat effect’ - people walk over
you too easily. Aggressiveness may look successful in the short term, in the longer term,
however, you make enemies - people turn their back on you. Assertive communication is
adult to adult communication as will be explained later in this module, open and fair
communication including honesty about norms, values and emotions. In other words,
assertive communication is communication on both levels: the rational level (the content of
our words) and the emotional level (how we feel about it).
BODY LANGUAGE
We listen through our eyes
We have already seen that human communication is not simply talking and listening. Other
messages, many of which we are unaware of, are passing to and from us at the same time.
The two major elements in human communication are verbal communication or speech, and
non-verbal communication or body language. In fact, although we often believe it is the
persuasive, verbal power of what we are saying to someone that wins them over to us, it is
more likely to be the body language that has had more influence.
Research shows that our verbal communication is responsible for only 10 to 20 per cent of
our message getting through to the other person, whereas 70 to 80 per cent of the impact is
produced by our body language (Morris, 1938). In other words: we best listen through our
eyes! So body language is very important because of this strong impact, whether we
recognise it or not. If we were more aware of the meaning of body language, we could better
understand or influence the situations we encounter. But body language is also a difficult
medium since it is more open to abuse and misinterpretation than verbal communication.
We send and receive body signals all the time, whether we are aware of it or not. A typical
example of a body language signal is the smile. When you smile at someone, you are
usually telling that you want to be friendly and that you would like the other person to be
friendly in return.
Body language can have more than one meaning and not all body language is positive. In
fact the negative gestures are usually the easier ones to identify. If I walk up to Fred, and,
without saying a word, punch him hard on the nose, he gets the message. He may not know
why I did it, but he is certainly aware that I am angry with him.
It is important to know that body signals rarely stand alone. Body language has - like spoken
language - words, sentences, punctuations, etc., and we must link words and signals to
make a complete message. When we try to read body language, there are two important
things to look for: clusters and incongruence (Pease, 1984).

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.7
Communication
Clusters
Much can be made of people’s attitude and feelings by observing their body language. But
don’t be too quick to judge. Body language is open to misinterpretation, particularly if you try
to pin a meaning on to a single gesture or signal.
Look for groups of gestures. These groups or clusters will give clear indication of the way
people feel. For example, suppose you are talking to some people when they suddenly fold
their arms. The folding of arms is one of the negative or defensive gestures. You might
conclude from this that they are not being receptive to what you have to say, or that they
may disagree with you. On the other hand, they may simply be assuming that position
because they feel more comfortable. Then you notice them pulling at their ear-lobe; another
negative gesture meaning I’ve had enough. Now things aren’t looking too hopeful, and your
worst fears are confirmed when you notice them doing up their jacket - another form of
negative or defensive gesture. Three gestures - which on their own could have had different
meanings - have been clustered together to leave you in no doubt that the persons did not
agree with, or where not interested in what you had to say.
You could have acted on the first gesture, the arm fold, and you would have been right; this
time! You won’t always be, so wait for confirmation. Watch for those clusters!
Incongruence
Many of our gestures and signals are ingrained. Nodding and shaking of the head are two of
the gestures we learn very early in life and because of this we would find it almost
impossible to unlearn them. Here then lies the secret of body language. If we say yes and
mean it, our head will nod back and forth. On the other hand, if we say yes but we really
mean no our head movement will contradict our words by shaking from side to side. It’s
almost as if the body is saying: You can lie if you want to, but I can’t. Perceptive people can
pick up this difference and immediately recognise that something is not quite right.
Furthermore, when they encounter incongruence perceptive people will ignore what is being
said and act on what they see. Some people instinctively read body language, others ignore
even the plaintest of transmitted messages. Either way, understanding and awareness can
be increased and from that you can begin to make body language work for you. Whatever
the situation, be it an on the job training or a discussion with colleagues or friends,
recognising and interpreting body language will give you a greater insight into what people
really think and feel.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.7
Communication
COMMUNICATION
Most people associate communication with verbal communication. For maintenance

personnel, communication encompasses much more than inter-team verbal interaction.
Communication not only includes face-to-face interaction, but also paperwork such as
maintenance cards, procedures, work orders, and logs. Such paperwork may provide a
reasonable record of work completed and work yet to be completed but unless a strict
protocol for raising, completing and controlling it is adopted, the record may not capture all
the activities to be undertaken or the status at any point in time. In addition, because
maintenance is an ongoing process independent of specific teams, inter-team
communication, especially between shifts, is extremely important. In this way, asynchronous
communication (communication in which there exists a time delay between responses) is
used to a greater extent than real time, synchronous communication.
Asynchronous communication is typified by a unique set of characteristics, such as the lack

of non-verbal communication cues (eg body language, verbal inflection, etc). An example of
asynchronous communication at work in the hangar would be an e-mail message sent from
the day supervisor to the night supervisor. Other examples include memos left between
shifts or passed between the shop and the hangar.
Mechanics, crew leaders, supervisors, and inspectors all must have the knowledge and skills
to communicate effectively. Because aviation maintenance may involve persons of different
nationalities, because of flight crew engineering interfaces or the use of foreign contract
staff, it is essential that as part of a good communication strategy a common language is
established. All parties involved must have a good understanding of the language used to
ensure that communication is effected. A lack of proper communication can have any or all
of the following undesired consequences:
¨ The quality of work and performance may be reduced.
¨ Time and money may be lost as errors occur because important information is not
communicated or messages are misinterpreted.
¨ Improper communication may cause frustration and high levels of stress.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.7
Communication
COMMUNICATION
MEANING:
The exchange of information
To Improve Communication
"Learn to Listen"
Don't:
¨ Debate what is being said in your mind.
¨ Detour ie, look for a key word to change the subject.
¨ Pre-plan: Now is not the time to be planning what you are going to say.
¨ Tune out: Whatever is being said should be important enough to listen.
Do:
¨ Ask questions
¨ Paraphrase
¨ Make eye contact
¨ Use positive body language
THIS IS COMMUNICATION?
I have to tell you that what you heard and what I said are two different things and
that what you think I said is definitively not what I meant.
THE SECRET TO GOOD COMMUNICATION
You have
2 Ears
+ 2 Eyes
+ 1 Mouth
Use them in that order and proportion.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.8
Human Error
9.8 Human Error
There are many different kinds of errors that organizational systems of humans can make,
but one of the trickiest is directly related to the questions of "integrity", "transparency", and
"prejudice." I want to relate these to the classic "swiss cheese" multi-layered defense system
that James Reason made famous:
[ source of that slide: ..? ]
Instead of looking at the layers the way he does, let's just use one slice of cheese as a
model, and examine what can happen when an organization, initially one person, has a base
fully covered but then the organization starts to grow and add people.
The problem is that, as the organization spreads out one conceptual task over more and
more people, gaps start to occur in the coverage. They occur particularly in the area where
it's a little fuzzy which person or team's job it is to handle that task.
This seems to me to be an intrinsic failure mode for organizations. It turns out, that
regardless how good a job anyone in a company can do, if they don't actually do it, their
skill level doesn't matter. Furthermore, a very common way for people not to do a job is for
them not to realize that it's their job to do. In some organizations this might be
accompanied by a twinge of remorse, but then a resigned "It's not my job!" and forgetting
about the task.
So, when a task that used to be something one person does get's divided up among many
people, there is a risk that none of those people will decide the task is their to do, regardless
how well intentioned or skilled they are. This effect can completely neutralize years of effort
getting skilled at a task. Things, almost literally, "fall through the cracks."
And the cracks almost always appear, if the task and organization keep growing and growing
and adding more and more people to distribute a single conceptual task among. Soon, the
organization looks like the following, with entire "silos" of separate groups, and each silo
broken into a pecking order of elites, middle class, and bottom rung workers of some kind.
Now there are a lot of gaps, but still, the gaps are fairly small.
But, as the organization continues to grow and evolve more specialized skills in each local
area, the people in each box start to spend more time talking to each other than they do
talking to people outside their own little box. It's more convenient, and the language is more
directly relevant. We all speak the same language. It begins to become "us" here in this box,
versus "them" out there in other boxes.
Still, the teams may be cooperating, but that won't last. Sooner or later, messages are

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.8
Human Error
missed, or silence itself becomes interpreted as a hostile message. Something falls through
the cracks, there is a storm of blame and recimination, and a deadly spiral sets in of
becoming more and more convinced that all problems are due to the people in other boxes,
who are surely idiots or else have evil intent. The boxes draw away from each other, in a
mild form of disgust. The "us" becomes fractured into many different kinds of "us".
As the communication between teams becomes more hostile, "management" may decide to
simlify the problems by having all communications go through them. The number of
connections going into one box is now at most two, one from above, and one going to a box
below in the pecking order. This allows the fabric of the cheese to twist around the thin
connecting segments, as if around an axle. Within each section of cheese, this is unnoticed,
because their world is still fine, locally.
Then, the layer of cheese may start to warp and become a curved surface, not a flat surface.
Again, seen from within that section, everything is fine, because the observers in that "flat
land" are measuring a curved surface with curved rulers, and it looks just fine. Even simple
facts and reasoning from other sections, however, don't seem to make sense anymore,
because they don't line up correctly. This is attributed to the other group losing touch with
reality.
Finally, the fabric of the organization is so frayed and fragmented that whole pieces fall off,
unnoticed from within. Now you can "drive a small truck" through the gaps and holes, but
again this is not visible from inside each segment, because it spends zero time pondering
the middle territory or white space. That space is "not our job" but is "someone else's job".
This condition of an organization is now somewhat stable. Life goes on, and a number of
errors come and go, with everyone attributing the errors to everyone else, and shaking their
heads at how those "others" aren't doing their jobs. Other groups are seen as actively hostile
enemies, blaming us for things we didn't do. Relations deteriorate. Errors abound.
Now the amazing thing is that this can occur even though each team is doing an almost
perfect job of managing what they see as their own turf.
The error occurs in a place we are so unfamiliar with we don't even have a name for it. I call
it the M.C. Esher Waterfall Error, after this work of Escher. At first glance and even close
inspection, the image seems a little strange, but harmless.
A closer inspection reveals that the water, however, is following an impossible path.
It flows down a waterfall, then flows down a zigzag of channels, and finds itself back at the
top of the waterfall, so it falls down the waterfall, ...
etc. forever. It's a perpetual motion machine.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.8
Human Error
The vertical columns in the middle tier in front have something terribly wrong with them too.
And yet, if you look at any small part of this lithograph, nothing seems wrong.
This is a problem we are simply not used to encountering - the detail level is correct, but the
larger global level is clearly absurd and wrong.
We have "emergent error", sort of the opposite of synergy.
The swiss cheese and waterfall pictures are meant to illustrate that organizations break
down in a funny way, where all the pieces continue to work, but the overall integrity falls
apart, in a very subtle and unnoticed way. In fact, it is generally hard to get anyone to pay
attention to the fact that something serious is wrong, because anyone can see, from inside,
that everything (that you see from inside) is correct. (We have run into Godel's Theorem as a
problem.)
Conclusions:
1) Just because everything locally measures as fine does not mean things are fine.
2) Even if everyone can do a perfect job, that won't matter if they don't do it.
3) They won't do it if it's not perceived as "their job".
4) This mode of breakdown is very insidious, but I think it is also very common.
This kind of expansion and condensation and specialization needs to be balanced with a
corresponding effort at reintegration, although it may seem a minor and non-urgent task.
Then, something huge comes through the gap, and everyone is astounded that such a thing
could happen.. This post is just to document that there is a type of problem that
organizations can suffer, a malady or disorder or disease, that is very difficult to trace locally.
It always seems to be coming from "over there", but if you go "over there" you see that it isn't
coming from "over there" either. It locks itself down with blame, stereotyping, and sullen
bitterness about having to put up with "those idiots" in the other departments who keep
messing things up. It is hard to decipher because the simplest messages from other
departments don't even make sense and you have to wonder if they've remembered to take
their medications lately. The more errors go through the hole, the more people lock into
blaming each other, and the more the subsections curl up to avoid touching the other
sections and withdraw into their own comfortable world where people talk sense and behave
rationally.
No one is doing anything wrong, and everyone is doing something wrong, but the wrongness
is subtle. It has something to do with whether everyone is OK with not being clear whose job
a task might be, and not being able to find out whose job it is. If people are "responsibility
seeking", this may be less likely than if they are "responsibility avoiding" as an ethic. If
people feel an error is "not my problem" or "someone else's problem" this can worsen.
If the world is divided into "us" and "them", there is always a middle ground that is very
confusing and not clearly us and not clearly them. Errors flow to that ground, like pressurized
gas trying to escape. If there are cracks between teams, errors seem eerily capable of
finding them. The errors are remarkably resilient to efforts to track them down and fix them,
and seem to keep happening, as if those idiots over there have no learning curve at all.
But, it is a very dangerous wrongness, if this problem occurs on a global scale, and teams
don't just get annoyed at each other and fight figurative wars, but actually start dropping

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.8
Human Error
explosive devices on each other in order to stop the continual assault they feel they are
under.
It may also be that the efforts to reduce animosity by controlling all communications between
hostile teams by routing them through management is well intended, but is based on a
model of communication that is single-channel, explicit, context-independent, and rooted
deeply in processing linear strings of symbols - where one mistake can throw off everything.
The communication that takes place before the body is fractured and fragmented howerver
is more like image-processing: it is multi-channel, implicit, context dependent, and not based
on symbol processing, so it is robust and fairly immune to point-noise. In fact, generally,
changing a single pixel in an image has zero effect on the contained communication.
It may be that what is needed is a lot more socializing, and sloppy, many-to-many
uncontrolled interactions, as a kind of glue to keep the pieces from falling apart. As Daniel
Goleman notes in his book Social Intelligence, humans have a great many different ways to
synchronize and synch up and coordinate with each other, most of which are non-verbal,
very fast, and intrinsically sloppy and prone to pointwise error. Those errors are made up by
having massive parallel communications, not by reducing communications to a single
channel that is very tightly regulated. There is not enough bandwidth in a single channel to
synchronize two disparate groups at all points. The groups can "twist" and "rotate" around
that channel, and move out of synch. Best efforts mysteriously fail.
AVOIDING AND MANAGING ERRORS
Whilst we should always strive towards ensuring that errors do not occur in the first place,
we will never be able to eradicate them totally, therefore we should aim to 'manage' errors
and concentrate upon preventing or mitigating the bad effects of errors, in addition to trying
to prevent them from occurring.
If we wish to prevent errors from occurring, we need to predict where they are most likely to
occur and to put in place preventative measures, ie error tolerant design. Safety
management concepts offer mechanisms for identifying potential weak spots and error-
prone activities or situations, often drawing upon risk management techniques developed
within the nuclear and process control industries in the '70s and '80s.
No attempt is made here to list the various means by which errors might be prevented,
reduced or managed, since such a list would be very large and inappropriate out of context.
In effect, the whole of this document includes such mechanisms, from ensuring that
individuals are fit and alert, to producing workcards using good design techniques, to
making sure that the hangar lighting is adequate. However, one of the things likely to be
most effective in preventing error is to make sure that engineers follow procedures. This
can be affected 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
the engineers are encouraged to follow procedures and not to cut corners. Obviously there
are many other factors associated with why engineers do or do not follow procedures, but it
cannot be stressed too often that this is an extremely important issue and one which should

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.8
Human Error
be high on an organisation's and individual's list of priorities when it comes to error

management.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.9
Hazards in
the Workplace
9.9 HAZARDS IN THE WORKPLACE
The Civil Aviation Authority, your company and your work-mates will expect you to work on
an aircraft/aircraft equipment in complete safety - safety for you - safety for others - safety
for the passengers - safety for the aircraft.
Additionally, employers and employees have a legal obligation under the Health and Safety
at Work, etc Act 1974 (HASAWA).
Two of the main philosophies set out in HASAWA require that:
· the employer must, so far as it is reasonably practicable:
Ø ensure the health, safety and welfare of employees and others

Ø provide and maintain safe systems of work
Ø provide information, instruction, supervision and training
Ø provide a safe and healthy work environment and adequate welfare facilities
· for their part employees have an absolute duty to:
Ø take reasonable care of their own health and safety and that of others
Ø co-operate with their employer in discharging their duties under the Act
To achieve safe working practices, separate publications are available covering the
prevention of hazardous conditions in the work place.
For Health and Safety issues relating to a specific company, then the Health and Safety
Manual for that company should be referred to.

EASA 66 CAT A/B1
HUMAN FACTORS
Module 9.9
Hazards in
the Workplace

Module 9 Human Factors

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EASA 66 CAT A/B1

ISSUE 1 – May 2010 Page 1

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ISSUE 1 – May 2010 Page 2

9.1 - The Need to Take Human Factors into Account

9.2 - Human Performance and Limitations

9.3 - Social Phsychology

9.4 - Factors Affecting Performance

9.5 - Physical Enviroment

9.8 - Human Error

9.9 - Hazards in the Workplace

ISSUE 1 – May 2010 Page 3

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ISSUE 1 – May 2010 Page 4

To create an awareness of the "Human" aspect of aircraft maintenance and develop

ISSUE 1 – May 2010 Page 5

Reason's Swiss Cheese Model

Each slice of Swiss cheese represents an organisation or an activity/department within an

ISSUE 1 – May 2010 Page 6

¨ The Need to Take Human Factors into Account

ISSUE 1 – May 2010 Page 7

A CHAIN IS AS STRONG AS ITS "WEAKEST" LINK

How an Aircraft Flies

ISSUE 1 – May 2010 Page 8

Murphy's Law ("If anything can

It was named after Capt. Edward

ISSUE 1 – May 2010 Page 9

Murphy's Law or Sod's Law?

ISSUE 1 – May 2010 Page 10

9.2 HUMANPERFORMANCE & LIMITATIONS

THE POTENTIAL FOR HUMAN ERROR

¨ Lack of understanding - possibly stemming from inadequate information or maybe

Vision can be adversely affected by certain medications or drugs, alcohol excess,

ISSUE 1 – May 2010 Page 11

Can detrimentally affect human performance in terms of damaging hearing,

ISSUE 1 – May 2010 Page 12

The Structure of the Human Eye

The Function and Structure of the Eye

ISSUE 1 – May 2010 Page 13

ISSUE 1 – May 2010 Page 14

¨ Hypermetropia. In long sightedness, (Hypermetropia), a shorter than normal

¨ Myopia. In short-sightedness, (Myopia), the problem is that the eyeball is longer

¨ Astigmatism. This condition is usually caused by a misshapen cornea. Objects will

Colour Defective Vision

ISSUE 1 – May 2010 Page 15

Structure of the Human Ear

Function and Structure of the Ear

ISSUE 1 – May 2010 Page 16

ISSUE 1 – May 2010 Page 17

Duration per day (hr) Sound Level in dB(A)

ISSUE 1 – May 2010 Page 18

¨ Short-term memory Short-term or immediate memory refers to the temporary

Interference with long-term memory can be caused by:

v events of close similarity that tend to confuse.

RESULTING IN THE INDIVIDUAL FORGETTING.

ISSUE 1 – May 2010 Page 19

9.2.4 Information Processing

ISSUE 1 – May 2010 Page 20

Stage Model of Information Processing

This model proposes that information is processed and stored in 3 stages.

ISSUE 1 – May 2010 Page 21

· Sequential -- chronological; cause/effect; building to climax (e.g., baking a

· Relevance -- central unifying idea or criteria (e.g., most important principles of