RM13010 - Human Factors

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RM13010
Human Factors
An AESQ Reference Manual

Supporting SAE AS13100™ Standard
Issued April 21, 2021
RM13010
Human Factors
An AESQ Reference Manual

Supporting SAE AS13100™ Standard
AESQRM010202104
SAE Industry Technologies Consortia provides that: “This AESQ Reference Manual is published by the AESQ Strategy
Group/SAE ITC to advance the state of technical and engineering sciences. The use of this reference manual is entirely
voluntary and its suitability for any particular use is the sole responsibility of the user.”
Copyright © 2021 AESQ Strategy Group, a Program of SAE ITC. All rights reserved.
No part of this publication may be reproduced, stored in a retrieval system, distributed, or transmitted, in any form or by
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Aerospace Engine Supplier Quality (AESQ) Strategy

Group
The origins of the AESQ can be traced back to 2012. The Aerospace Industry was, and still is, facing many
challenges, including:
• Increasing demand for Aero Engines

• Customers expecting Zero Defects
• Increasing supplier / partner engine content
• Increasing global footprint
The Aero Engine manufacturers Rolls-Royce, Pratt & Whitney, GE Aviation and Snecma (now Safran Aircraft
Engines) began a collaboration project with the aim of driving rapid change throughout the aerospace engine
supply chain, improving supply chain performance to meet the challenges faced by the industry and the need
to improve the Quality Performance of the supply chain.
Suppliers to these Engine Manufacturers wanted to see greater harmonisation of requirements between the
companies. Each Engine Manufacturer had Supplier Requirements that were similar in intent but quite different
in terms of language and detail.
This collaboration was formalized as the SAE G-22 Aerospace Engine Supplier Quality (AESQ) Standards
Committee formed under SAE International in 2013 to develop, specify, maintain and promote quality standards
specific to the aerospace engine supply chain. The Engine Manufacturers were joined by six major Aero Engine
suppliers including GKN, Honeywell, Howmet Aerospace, IHI, MTU and PCC Structurals. This collaboration
would harmonise the aerospace engine OEM supplier requirements while also raising the bar for quality
performance.
Subsequently, the Aerospace Engine Supplier Quality (AESQ) Strategy Group, a program of the SAE Industry
Technologies Consortia (ITC), was formed in 2015 to pursue activities beyond standards writing including
training, deployment, supply chain communication and value-add programs, products and services impacting
the aerospace engine supply chain.
AESQ Vision
To establish and maintain a common set of Quality Requirements
that enable the
Global Aero Engine Supply Chain
to be
truly competitive through lean, capable processes
and a
culture of Continuous Improvement.
i
The SAE G-22 AESQ Standards Committee published six standards between 2013 and 2019:
• AS13000 Problem Solving Requirements for Suppliers (8D)

• AS13001 Delegated Product Release Verification Training Requirements (DPRV)
• AS13002 Requirements for Developing and Qualifying Alternate Inspection Frequency Plans
• AS13003 Measurement Systems Analysis Requirements for the Aero Engine Supply Chain
• AS13004 Process Failure Mode & Effects Analysis and Control Plans
• AS13006 Process Control
In 2021 the AESQ replaced these standards, except for AS13001, with a single standard, AS13100.
The AESQ continue to look for further opportunities to improve quality and create standards that will add value
throughout the supply chain.
Suppliers to the Aero Engine Manufacturers can get involved through the regional supplier forums held each
year or via the AESQ website http://aesq.saeitc.org/.
ii
AESQ Reference Manuals

AESQ Reference Manuals can be found on the AESQ website at the following link:
https://aesq.sae-itc.com/content/aesq-documents
AESQ publishes several associated documents through the SAE G-22 AESQ Standards Committee supporting
deployment of AS13100. Their relationship with APQP and PPAP is shown in Figure 1.
Figure 1: AESQ Standards and Guidance Documents and the link to AS9145 APQP / PPAP
iii
RM13010 - Human Factors
Table of Contents
1.0 Scope ...................................................................................................................................................................... 3

2.0 Purpose ................................................................................................................................................................... 3
3.0 Applicable Documents ............................................................................................................................................ 4
SAE Publications: .................................................................................................................................................... 4
Other Documents: .................................................................................................................................................. 4
4.0 Definitions............................................................................................................................................................... 5
5.0 Introduction to Human Factors .............................................................................................................................. 6
5.1 What are Human Factors? ...................................................................................................................................... 6
5.2 Why is Human Factors important? ......................................................................................................................... 9
6.0 Leadership Commitment ...................................................................................................................................... 11
6.1 What is a Just Culture? ......................................................................................................................................... 11
6.2 Defining and deploying a Human Factors Policy .................................................................................................. 12
6.3 Employee engagement & monitoring .................................................................................................................. 13
7.0 Management System Requirements .................................................................................................................... 15
7.1 Where to embed Human Factors within the Quality Management System ........................................................ 15
7.2 Open reporting ..................................................................................................................................................... 16
7.3 Human Factors in investigations .......................................................................................................................... 17
7.4 Reducing the risk of Human Error ........................................................................................................................ 19
7.5 Monitoring and continually improving the learning from Human Factors .......................................................... 21
8.0 Human Factors training ........................................................................................................................................ 21
8.1 Scope and considerations for the training ........................................................................................................... 21
8.2 Typical training programme ................................................................................................................................. 22
Appendix 1 – Example checklist when considering deploying a Human Factors programme ............................................ 26
Appendix 2 – Example checklist when reviewing investigations involving Human Factors ................................................ 27
Appendix 3 –Example MEDA form ...................................................................................................................................... 28
Appendix 4 - Acknowledgements ........................................................................................................................................ 29
1
Figures
Figure 1 AESQ Standards and Guidance Documents and the link to AS9145 APQP / PPAP ............................................... iii
Figure 2 The interaction of Human Factors .......................................................................................................................... 6
Figure 3 Example of difference between error and violation ............................................................................................... 7
Figure 4 Example of types of errors ...................................................................................................................................... 8
Figure 5 Example of basic exercise to demonstrate difference ............................................................................................ 8
Figure 6 The Dirty Dozen developed by Gordon Dupont (Transport Canada) ...................................................................... 9
Figure 7 James Reason’s Swiss Cheese Model .................................................................................................................... 11
Figure 8 EASA Management System Assessment tool for SMS .......................................................................................... 14
Figure 9 Problem solving process – Human Factors considerations................................................................................... 18
Figure 10 Performance modes graph ................................................................................................................................. 20
Figure 11 Example of training matrix for Human Factors ................................................................................................... 22
Figure 12 SHELL concept ..................................................................................................................................................... 23
Figure 13 PEAR concept ...................................................................................................................................................... 23
Figure 14 Training syllabus ................................................................................................................................................. 25
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1.0 Scope
This is a guidance document to provide context and learning to deliver the Human Factors
mandatory requirements embedded within AS13100 chapters listed below:
• 5.1.1.1 Top Management shall reflect a commitment to Human Factors
• 5.2.1.1 The organization shall have a policy that includes Human Factors that
promotes:
o Open Reporting.
o Continually improving the maturity of Human Factor deployment within the
organization.
• 4.4.3 The organization’s Quality Management System shall include processes for
Management of Human Factors including:
o Training of employees.
o An open reporting culture, encouraging the sharing of mistakes without fear of
inappropriate retribution.
o Considering Human Factors in investigations.
o Considering Human Factors in the reporting of performance and identifying
improvement plans.
Human Factors should be an integrated part of product and service design, manufacturing /
assembly, and product servicing.
• 7.3.1 Human Factors Awareness. The organization shall provide an appropriate
program of training and awareness of Human Factors based on role, for reference, see
RM13010.
• 10.2.1 The organization shall have a criteria and approach defined for recognizing and
addressing Human Error causes in investigations.
As the document gives guidance, the word “Should” has been used.
2.0 Purpose
This Guidance Document aims to provide supplemental information on Human Factors to
accompany requirements specified in AS13100. It includes detailed explanations of the
requirements and what may be expected as means of compliance. In many cases, shared of
examples from AESQ company members are given to provide guidance.
AS13100 includes requirements for embedding Human Factors within the Aero-Engine
Supply Chain. Human Factors is a well-known and understood discipline in areas of the
Aerospace industry, particularly Maintenance Repair & Overhaul (MRO) and Flight Safety,
but it has not previously been widely considered further down the supply chain into Production
and Design areas. As part of the effort to make Aerospace even safer, it is now considered
an essential element, especially as part complexity increases and part design gets nearer to
operating capability limits.
At the time of writing this document, the Civil Aerospace industry regulators are reviewing the
current Safety Management System requirements where Human Factors requirements
reside with a view to broaden the application deeper into the Operational supply chain. This
material is written in line with knowledge of existing requirements within the EASA Part 145
regulations and may be subject to change or review at any time.
3
3.0 Applicable Documents
The latest issue of SAE publications should apply. Nothing in this document should
supersede applicable laws and regulations unless a specific exemption has been obtained.
The documents listed below are intended to support the requirements of this document and
provide guidance on Human Factors and related topics.
SAE Publications:
• IAQG SCMH Section 3.6.2: Human Factors in New Manufacturing
Other Documents:
• Regulation (EU) No 376/2014 of the European Parliament and of the Council on the
reporting, analysis and follow-up of occurrences in civil aviation https://eur-
lex.europa.eu/legalcontent/EN/TXT/?qid=1576245532595&uri=CELEX%3A32014R037
6
• Section 5.1 - Human error / violations - https://www.nopsema.gov.au/resources/human-

factors/human-error/
• Section 5.0 - CAP 716 - Aviation Maintenance Human Factors (EASA / JAR145
Approved Organisations). Guidance Material on the UK CAA Interpretation of Part-145
Human Factors and Error Management Requirements -
http://publicapps.caa.co.uk/docs/33/CAP716.PDF
• Section 6.1 Global Aviation Safety Network (GAIN) have created a handbook “A roadmap
to just culture: enhancing the safety environment” https://flightsafety.org/wp-
content/uploads/2016/09/just_culture.pdf
• Section 6. 3 -European Aviation Safety Agency: Management System Assessment Tool
introduced to support the implementation of Regulation (EU) No 965/2012 laying down
technical requirements and administrative procedures related to air operations pursuant
to Regulation (EC) No 216/2088 of the European Parliament and of the Council.
https://www.easa.europa.eu/document-library/general-publications/management-
system-assessment-tool
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4.0 Definitions
HUMAN ERROR - An action or inaction that unintentionally results in an undesirable or
unwanted condition, deviates from a set of rules or expectations, or leads a task or system
outside acceptable limits.
HUMAN FACTORS - Human Factors is the way the People, Programs and Processes, the
Work Environment, Organization and Equipment all work together as a system. The individual
is at the middle of that system. Any flaws in the system impact the performance of the
individual and any flaws in the individual impact the system.
JUST CULTURE – An atmosphere of trust where people are encouraged to provide essential
information, but in which they are also clear where the line must be drawn between
acceptable and unacceptable behavior.
MEDA - Maintenance Error Decision Aid – originally a tool to investigate contributing factors
to maintenance errors, but has more recently been expanded to violations in company
policies, processes, and procedures that lead to an unwanted outcome.
MAGNIFICENT SEVEN – A list of issues focused on positive aspects of Human Factors that
every employee can take.
OPEN REPORTING – A reporting system that allows people to raise concerns in a
confidential and anonymous manner without fear retaliation and with the confidence that they
will be addressed in a consistent and fair manner.
PFMEA – Process Failure Mode and Effects Analysis – tool to assess and rank risks to a
process and can also be used to reduce risks for human errors
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5.0 Introduction to Human Factors

In order to deploy Human Factors into a company there are many parts to consider and this
document includes guidance on the core elements. Appendix 1 has been included as an
example (not exclusively) of a Human Factors deployment checklist to help with
implementation.
5.1 What are Human Factors?

Human Factors is about studying human behavior and understanding what affects
performance and limitations of all operators working on products, services and processes so
that they can be:
 Safe & Efficient
 Easy to use, to learn, & to support
 Pleasant to use
 Easy to design & to manufacture
"Human Factors is the scientific discipline concerned with the understanding of interactions
among humans and other elements of a system, and the profession that applies theory,
principles, data, and other methods to design in order to optimize human well-being and
overall system performance." (Definition adopted by the International Ergonomics
Association in August 2000).
Figure 1 The interaction of Human Factors
Indeed, the primary focus of any Human Factors initiative is to improve safety and efficiency
by reducing and managing human error made by individuals and organisations.
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Then, from an operational perspective, it aims to optimise the fit between people and the
systems in which they work, to improve safety and performance.
Error / Violation
One of the key aspects of Human Factors is the understanding of Errors and violations and
how these lead to non-compliance or un-safe acts:
Error
 Unintended action with unintended consequence

Errors occur irrespective of one’s will to avoid them
Violation
 Intended action with unintended consequence -

Rule breaking without expecting the outcome
There are 3 such types of violations:
o Routine Violations: They are habitual actions, performed repetitively.

o Exceptional Violations: Violation performed only once, depending on
circumstances.
o Optimization Violations: Violation in order to optimize tasks.
 Intended action with intended consequence -

Sabotage
ERROR
VIOLATION
Figure 2 Example of difference between error and violation
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Figure 3 Example of types of errors
To help with determining between an error or violation, here is a useful exercise that can
be used to test people’s understanding and create discussion on the differences between
error & violation, and the types of violations.
Figure 4 Example of basic exercise to demonstrate difference

between error & violation and types of violations
Human Factors studies have led to divide primary causes for human errors into 12 main
clusters, the “dirty dozen”:
This dirty dozen is an easy way to talk about HF but there is still only a categorizing of
Human Error.
“The Dirty Dozen refers to twelve of the most common human error preconditions, or
conditions that can act as precursors, to accidents or incidents. These twelve elements
influence people to make mistakes. The Dirty Dozen is a concept developed by Gordon
Dupont, in 1993, whilst he was working for Transport Canada, and formed part of an
elementary training program for Human Performance in Maintenance.
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since 1993 all areas of the aviation industry, not just aircraft maintenance, have found the
Dirty Dozen a useful introduction to open discussions into human error in their businesses,
organizations and workplaces.” - From Skybrary
So, it may be possible to find Dirty Dozen lists similar in design and manufacturing
Figure 5 The Dirty Dozen developed by Gordon Dupont (Transport Canada)
However, Human Factors can also include all the positive aspects of human performance
known as the Magnificent Seven: the unique things human beings do well.
1. Safety is not a game because the price of losing is too high.
2. We all do our part to prevent Murphy from hitting the jackpot.

3. We always work with a safety net.
4. Our signature is our word and more precious than gold.
5. We work to accentuate the positive and eliminate the negative.
6. We are all part of the team.
7. Just for today—zero error.
The dirty dozen is a simple model to help increase the awareness to employees of a common
set of 12 elements that influence people to make mistakes. It can then be used to help assess
the risks of each element & identify mitigating actions that would prevent or reduce the effect
of such factors.
The magnificent seven is a more positive perspective and can be used to promote desired
behaviours and practises that reduce the risk of human error.
5.2 Why is Human Factors important?

Human Factor is not a root cause!
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When a quality escape involving a human occurs, it’s most likely to be something is not right
around the employee. The aim of Human Factor approach is to understand and identify the
true root causes of human errors in order to define appropriate barriers and prevent re-
occurrence.
The consequences of one’s mistakes are not always known.
The tendency is to judge the consequence and not to seek the cause or causes of error.
The right to make mistakes needs to be recognized, but that does not mean 'lax'.
Murphy’s law:
It is important to understand that if an error can

happen, It will!
Why?
• Because Errors are not made deliberately

• Several contributory factors lead to an error
(accident / anomaly)
• Once identified, most of these contributory
factors can be corrected.
It is important to be able to analyse each situation / event in order to contain it.
James Reason’s Swiss Cheese Model

The Swiss Cheese model of accident causation, originally proposed by James Reason,
likens human system defenses to a series of slices of randomly holed Swiss Cheese
arranged vertically and parallel to each other with gaps in-between each slice.
Reason hypothesizes that most accidents can be traced to one or more of four levels of
failure:
• Organizational influences,
• Unsafe supervision,
• Preconditions for unsafe acts, and
• The unsafe acts themselves.
In the Swiss Cheese model, an organization’s defenses against failure are modelled as a
series of barriers, represented as slices of the cheese. The holes in the cheese slices
represent individual weaknesses in individual parts of the system and are continually
varying in size and position in all slices.
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The system as a whole produces failure when holes in all of the slices momentarily align,
permitting "a trajectory of accident opportunity", so that a hazard passes through holes in all
of the defenses, leading to an accident.
This text comes from Skybrary
https://www.skybrary.aero/index.php/James_Reason_HF_Model
Organizational factors involved in large-scale accidents:

James Reason’s model highlighted that an event is the result of the sequence of failures:
- Active failures; It is the error committed by the actor in the first line;
- Latent failures: characteristics present in the system and that contributed to the
occurrence of event.
Accidents occur when faults in protective barriers combine into a rare sequence.
When performing investigations of Human Errors like in 7.1.c we check the different layers
to see if we can find holes to understand the active decision the employee made when
performing the task.
Figure 6 James Reason’s Swiss Cheese Model

This model highlights that an event is the result of a series of failures. Each slice represents
operations/ services/ functions/design/ … any element of an organization.
6.0 Leadership Commitment

6.1 What is a Just Culture?
Focusing on Human Factors is important when considering the impact on product safety and
production. It also encompasses how a business should promote a culture striving to
encourage open and honest reporting from everyone to ensure potential & known unsafe
acts and risks are reported and appropriate actions taken.
A Just Culture is one where organisations hold themselves to account for ensuring that they
suitably develop, support and resource their staff to be able 'to do things right' and where
individuals at all levels of the organisation are held to account for 'doing the right thing.' It is
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a culture that ensures all staff feel that risks, occurrences and errors can be reported openly
without fear of inappropriate action. However, this does not advocate the need for a 'blame
free' approach, this culture recognises that some blatant negligent actions may require
disciplinary action.
Striving to embed a Just Culture will enable the organisation to embrace such values, embed
learning back into the system, processes and organisation, and will always require continual
effort to endorse through casting the appropriate behaviours at all levels across the
organisation.
Embedding a just culture starts with demonstrating commitments to:
• Inform employees about how they will be treated fairly, and define how differences
between unacceptable, acceptable and blameless behaviour will be treated (see section
5.1 explanation of error and violations);
• Provide means for employees to speak up and report openly without fear of retaliation;
• Respond appropriately to situations in the context of what and how things occurred that
may have led to an incident or issue;
• Take appropriate action
• Engage employees to learn from incidents and issues to find ways in which the
management system, environment and organisation can be improved to reduce
occurrence & impact of human errors.
These commitments should be captured within a company policy.
For more information on just culture and how to embed, there are references to further
literature and information in section 3.
6.2 Defining and deploying a Human Factors Policy

AS13100 requires that there must be a clear policy explaining what and how the company
will embed a Human Factors framework within their operating system. This can be within an
existing company policy and it is recommended that this be either the company’s Quality or
Safety policy.
The purpose of having a policy including Human Factors is one which:
• Is accessible by everyone in the organization
• Supports anonymous reporting
• Enables analysis, drives action, embeds learning
• Provides feedback to the business & employees
The company should outline their commitments and how they intend to meet the AS13100
human factor requirements, which can be summarized into 5 elements:
1) Live a just culture by ensuring the company defines what behaviour is tolerated by the
organisation and what is not.
2) Provide awareness of Human Factors & engage the workforce in open discussions to
keep the topic alive (e.g. talks on dirty dozen using examples)
3) Embed open reporting to capture hazards, mistakes and risks
4) Consider Human Factors within investigations to get to the root causes that led to a
human error and ensure appropriate action.
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5) Continually improve through reducing the risk of Human Factors influencing outcomes.
Considerations for the leadership when embedding the policy in the company should include:
• Providing regular awareness training sessions of what is Human Factors and linkage to
the company’s policy (see section 8.0 Human Factors training)
• Ensuring that the influence & risk of Human Factors is assessed regularly, and that plans
are put in place for continuous improvement (see section 7.4)
• Identify how the company’s risk management process considers Human Factors.
• Considering the benefit of having a designated Human Factors management
representative with the responsibility and authority for establishment, implementation and
maintenance of the Program. AS13100 requires this person to have completed
appropriate training.
• Setting up a defined network across the business of people to support the implementation
and sustainment of the Human Factors policy. It might be part of a quality or Health and
Safety Policy.
• Ensuring processes within the management system support the principles outlined in the
policy and provide employees with the means of compliance.
6.3 Employee engagement & monitoring

A core part of leadership commitment to Human Factors is to ensure the “leadership shadow”
is visible and the intent of the Human Factors policy is delivered through both the actions and
behaviours of people within the company.
Employees need to have confidence in the just culture and the supporting processes (e.g.
reporting system) so they know that confidentiality will be maintained and that information
they submit will be acted upon, otherwise they could decide there is no benefit in their
reporting
Part of knowing if employees are engaged is to measure the effectiveness of a Human
Factors programme and whether the company is truly living a Just Culture. This is not simple.
However, there are some tools available that can help companies to assess their current
maturity and enable the development of improvement programmes in order to increase
maturity over time.
An example is the EASA Management system assessment tool, which primarily is aimed at
reviewing and assessing a company’s Safety Management System (SMS). However, just
culture and Human Factors are fundamental parts of such a SMS and so this assessment
can help provide an overall way of determining strengths and weaknesses in the current
system in place. It can also be useful guide in setting up a system since it helps provide
information on what the different maturity levels “look like”. Further information can be
reviewed by following the link in the reference index in section 3.0.
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Figure 7 EASA Management System Assessment tool for SMS
When considering how to engage the workforce on Human Factors and just culture, there
are simple effective ideas that should be considered and selected based on the type of
message or reinforcement you are looking for. The Human Factors training (see section 7.0)
is a good start to engaging the employees but it is important to consider how to keep the topic
alive and being discussed. A few ideas for helping to promote this are listed below:
 To visualise / create impact of key principles of Human Factors – use of posters placed
strategically at points in the facility where risks of human error may be prevalent.
 Using visual aids to make employees think before acting, which may be specific to a
task or activity that has a high human error occurrence.
 Use of go look see practises or listening sessions with leadership to engage in
conversation with employees – could be discussing recent issues, could be to ask about
how it feels to work in the team / environment. It is best to be seen engaging proactively
not just when there has been a problem!
 Consider if a survey would help to engage and measure what the culture “feels like” in
the organisation. Does it mirror the policy and expected outcomes?
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7.0 Management System Requirements

7.1 Where to embed Human Factors within the Quality Management System
An organization should consider how all elements of a robust Human Factors framework
(see example in diagram 2) links within their existing processes and identify any gaps which
may require a separate process to be defined. It is acceptable for the Human Factors
considerations to be added to existing processes and procedures.
Human Factors initiatives will be more effective if they are integrated within our existing
processes. Much of Human Factors are common sense, professionalism, quality
management, and safety management. Ideally Human Factors best practice should be
seamlessly and invisibly integrated within existing processes, such as training, open
reporting, problem investigations and risk reduction practises.
It should be clearly defined how Human Factors is considered and managed in all aspects
of the organizations’ processes, cross functionally and throughout the product or service
lifecycle.
AS13100 requires the organization’s Quality Management System to include processes for
Management of Human Factors and cover the following as a minimum:
a) Training of employees (See section 8.0 for more details)
• Provide recurring Human Factors general knowledge material (leverage local
regulatory guidance when appropriate) and utilize a test of knowledge retention (i.e.
a quiz) to improve retention and have some data on employee understanding.
• Keep training records for auditing purposes.
b) An open reporting culture encouraging the sharing of mistakes without fear of

inappropriate retribution. (see section 7.3 for more details)
• Provide a reporting structure make sure it’s known, easy and accessible, with clear
usage and closed feedback loops in place
c) Consideration of Human Factors when performing investigations (see section 7.4

for more details)
• AS9100D (10.2.1.b) requires organizations to address Human Factors related root
causes.
• There should also be consideration of requirement to perform specific human factor
focused investigations where there is a real connection of the human behaviors and
actions in influencing the event that occurred.
d) Considering Human Factors in the reporting of performance and identifying

improvement plans
• Identify what impact Human Factors have had on occurrence of product escapes
• Analyse themes related to human errors and the causation of errors so systemic
actions can be taken to not just fix the specific issue but embed learning across the
business to avoid future recurrence
• Avoid just taking the action to re-train employees since this will very often not fix the
underlying causes of why human errors have occurred. It can be appropriate
though for knowledge gaps.
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• It is important to recognize the linkage with having a just culture, so the reaction
and treatment of individuals aligns to having a framework where people are treated
fairly based on the findings of such HF investigations. Typically, such
investigations are followed by holding an independent event review panel to review
the outcomes and findings so a course of action can be decided.
e) Human Factors should be an integrated part of product and service design,

manufacturing / assembly and product servicing.
Both manufacturing & assembly tasks can be early indicators of Human Factors
concerns/challenges in product servicing; given the similarity of tasks in both assembly
and servicing/maintaining.
Utilizing a Failure Mode Effects Analysis (FMEA), for example, during or after assembly
issues arise will provide structure to prioritizing the most impactful response. Combined
with maintainability considerations, product service design should focus on, for
example, accessibility, visibility, feedback, and design features that eliminate the
opportunity for error (e.g. parts able to be installed incorrectly). Human Factors in
product servicing or product maintenance should include some form or risk analysis
relative to the impact and likelihood of error for various servicing tasks – such that the
tasks, team and other factors (i.e. duty time and shift length) can be coordinated and
scheduled accordingly.
Regarding service design and the 95th, 5th percentiles, fatigue impacts, etc.
Service design and assembly tasks can benefit from considering the anthropometrics of the
user/ working population. Software tools such as Siemen’s Classic Jack enable digital
modeling of assembly and servicing tasks for all ranges of the population (i.e. tallest and
shortest individuals). In addition to the general ergonomic considerations this modeling can
provide insight into the potential for perceptual errors (related to visibility, touch, tactile
feedback). Also, repetitive and/or unusual postures can lead to fatigue more quickly than a
non-repetitive, stationary task (for example) and this fatigue, both physical and mental can
create opportunities for errors (increased mental workload, physical exhaustion). If the
people performing the task find an easier and/or faster way to perform the task as well
intended as it might be, the shortcut could lead to other unforeseen consequences either in
personal safety or part/product integrity.
7.2 Open reporting

Research shows that organizations with strong ethical & safety cultures have lower rates of
witness misconduct. By implementing an open reporting system, organizations are
encouraging employees to ensure potential risks, events, hazards or improvements are
easily reported, investigated and actioned. This system should be used for Human Factor
events, hazards and improvements in the business to ensure the business learns from
these and reduces the error opportunity.
Such a program creates a culture of trust and respect. As employees see their issues
addressed in a confidential and anonymous fashion, they build confidence that they will be
addressed in a consistent and fair manner.
A comprehensive open reporting system has three essential elements.
1) It must have simple and clearly understood ways for an employee to raise an issue,
anonymously if preferred.
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2) Secondly, a management process is required to make sure reports are collected

centrally, resolved in a timely manner, accurately reported by an independent body and
a process to feedback to the individual and the organization.
3) The analysis of trends should be undertaken to identify gaps in policy and the
compliance program in order to help determine where training may be needed or the
identification of any areas in the business where action may be needed.
The additional benefits of an open reporting system include;
• A confidential place for employees to clarify policy and discuss or report concerns.
• A way to direct employee questions to the appropriate resource.
• An opportunity to provide guidance before a poor decision is made.
• An early warning of issues within the organization.
• An opportunity before someone takes their grievance outside the company.
Examples of the critical components of a reporting system include:

• The credibility of any program requires top down support to create an atmosphere of
trust both in the anonymity of reporting and the absence of any retaliatory action.
• The process should define stakeholder involvement, including representation across
the company.
• Those involved in investigating events should know the regulatory requirements,
including any local or national rules, and should be trained to promote a consistent
approach using a formal investigation protocol.
• Any investigation should capture the most complete, accurate and verifiable
information: don’t just rely on anonymous e-mail or voicemail. Interactive
communication with an independent party is essential.
• Responses should be made confidentially and in a timely manner to promote credibility
of the program.
• Consider publicizing information on the types of cases investigated to build trust in the
process, but without disclosing sensitive or private data.
• The program objectives and performance should be reviewed regularly to identify
changes to the operating environment and effectiveness of the process.
Employees are often reluctant to share their concerns from fear of retaliation and cynicism
that they will not be taken seriously. Furthermore, when an issue is raised, it may never
reach a place in the organization where proper policies and processes can be enacted to
resolve. Most ethics and compliance issues go directly to managers and, if organizations do
not have systems in place to deal with these consistently, visibility into such cases can be
significantly limited.
7.3 Human Factors in investigations
The investigation of events is a fundamental element of a Quality System. The process used
must recognise the analysis must focus on determining the true root cause of the incident.
In human error cases this can be a complex task with possible multiple causes and requires
timely action to ensure that facts and circumstances are not lost or forgotten.
A robust approach to investigating human errors is based on two distinct stages. The
investigation of the event based mainly on interviews with people involved, and the review
17
afterwards to identify the recommendations from the investigation and agree appropriate
actions.
Human error investigations are primarily concerned with finding out what happened and why,
with the purpose of proposing recommendations that reduce the likelihood of reoccurrence.
Due to the sensitive nature of these investigations, it is critical that an investigator is fully
trained in carrying out human error investigations.
There should be a clear, and timely, process to distinguish between violations and errors.
Evidence of training and application of the process. There must be evidence of the approach
used to include identification of human error root cause in investigations, inclusion of Human
Factors in root cause training, and examples of human error corrective actions.
Root Cause & Corrective &

Event
Investigation Containment Corrective Preventative
Occurrence
Action Actions
Problem definition and Identify and verify root Verify corrective actions
investigation (AS13000 D0 – cause and identify and implement
D2) corrective action preventative action
(AS13000 D4 & D5) (AS13000 D6 & D7)
• Integrate identification
of Human Errors causes • Root cause analysis • Training program and
into general problem includes Human follow-up process
solving process Factor error analysis both recognise the
• Distinguish between tools typically broad
violations and human impact of human
errors factor root causes
• Recognises time critical
nature of Human Factor
caused error
investigation
Figure 8 Problem solving process – Human Factors considerations
For investigations where it is likely there has been an element of human error, the
Maintenance Error Decision Aid (MEDA) and the Human Factors Analysis and Classification
System (HFACS) tools should be considered. Both tools together provide structure and
commonality across business in the investigation and classification of Human Factors work
pertaining to human error. It is important to move beyond general “human error” labels as
that will only go so far in identifying and not resolving the true root causes.
Fishbone diagrams, DMA, RCCA (e.g. 3x5 why) can drive to root causes but in the case that
human error is the “root cause” further investigation is necessary as human error is the result
(e.g. a system weakness or lake or defences, preventative measures) not the root cause.
Example regarding MEDA (see appendix 3), HFACS (and taking a 3x5 why a little further)
A disruption in field operations, due to an assembly error, caused a fuel leak during revenue
service. The disruption report indicates a fuel leak and the hardware is checked and
assumed to be faulty. Because this interrupted revenue service and was deemed
important/impactful the further investigation utilized the MEDA.
Through this process it was revealed that the engine recently came from an overhaul visit
and the hardware in question was disconnect as part of the module service. The leak was
18
not from a faulty hose but a connection point; when the torqued fitting was checked it was
not adequately torqued per the manual. What was originally flagged as a fuel leak/faulty
hardware should be more appropriately categorized as a human error
(assembly/maintenance).
According to HFACS this could be identified as a Skill-based error. Identifying the error type
will enable better corrective actions appropriate to the error type. In this case it is unlikely
that the connection was left loose to do inadequate knowledge of torque wrenches, but rather
it was missed because of distraction and lapse in memory.
Similar to this example, other tools such as the 3x5 why can be helpful in determining
underlying causes, to an extent. A 3x5 why may have also uncovered the loose connection
in the example above and the last why could be that the assembly technician forgot. Utilizing
the Human Factors discipline here will take that analysis farther and identify potential reasons
the task was forgotten, perhaps the distractions were excessive that shift due to any number
of reasons.
7.4 Reducing the risk of Human Error

Opportunities for human error can be seen as risk(s).
The Reason’s model shown in 5.2 can be viewed as layers of swiss cheese and each hole
in the cheese/layer of the organization is an opportunity or risk for error, big and small,
some will be caught by other parts of the organization/process, but a few may not.
Aside from acknowledging that we’re fallible and that everybody makes mistakes we can
take additional measures to mitigate the risk of those mistakes/errors occurring.
Two approaches are described here, one semi-qualitative (Rasmussen’s performance

modes model) and the other quantitative (the Human Error Assessment and Reduction
Technique).
When considering the risk of human error, it can be helpful to account for performance
modes (Rasmussen…). Performance modes include Knowledge, Rule, and Skill, -based
(from most to least likely to commit an error, respectively). Individuals operating in the
knowledge-based performance mode are likely to be unfamiliar with a task and require a
high level of attention. In contrast, individuals operating in the skill-based performance
mode are very familiar with the task and therefore don’t need to give it a lot of attention.
Both extremes have risk of different types of errors and therefore different mitigations
Human Error Types (Skybrary, 2016)
https://www.skybrary.aero/index.php/Human_Error_Types
19
Figure 9 Performance modes graph
To reduce the risk of Human Error, consider the Human Error Assessment and Reduction
Technique (HEART). This Human Reliability Analysis (HRA) begins with choosing from
predefined conditions and the corresponding unreliability value, then determine if there’s any
Error-Producing Conditions (EPCs), weight them based on influence on the scenario and
determine the corresponding Human Error Probability (HEP) value. This method may help
quantify risk and any process changes impact to an original or baseline risk.
Human Reliability Analysis: Comparison of Methods (Sandia National Laboratories, 2018)
https://www.osti.gov/servlets/purl/1515627
20
7.5 Monitoring and continually improving the learning from Human Factors
“The Human Factor training is well received at and it develops continuously. Appropriate
examples from our daily work are an important part of the training.” Feedbacks and lessons
learned are also appropriate to count and share.
Maturity assessment of organization and/or different part of the company might be

interesting to measure.
8.0 Human Factors training

AS13100 requires the organization to provide an appropriate program of training and
awareness of Human Factors based on role
8.1 Scope and considerations for the training
Human Factors Training combines different areas of research and facts with the individuals
understanding of it and how it affects one’s everyday work.
It is recommended to consider use of real facts, involve exercises and discussion to check
understanding. Practical illustrations and examples should be used which can be related to
by the audience, especially accident and incident reports/root cause/corrective actions/action
plans as well as successful proactive work.
Human Factors topics to cover:
• Human Performance and Limitations
• Factors Affecting Performance
• Environment
• Procedures, information, tools and practices
• Communication
• Teamwork
• Safety Culture/Organizational factors
• Professionalism and integrity.
Human Factors training should cover all the topics either as a dedicated course or else
integrated within other training. The content is advised to be standard so common messages
are communicated, but the use of different examples that are relatable to the specific teams,
functions or areas will help to embed knowledge but also engage conversations on the topics.
It is also recommended in the design and development of the training syllabus, whilst being
based on the above topics, it is tailored in depth and technical content of the subject that
aligns to the level of the organization and the role of the employees. This may require there
to be different training syllabus categorized by role.
• Managers & Supervisors
• Operator
• Inspector
• Technicians
• Production support
• Certifying Staff
21
Subject Shop Floor

CEO / Shop MEDA Problem
Course Short Description Matter
Executives
Leaders
Floor
Supporting
Investigators Investigators
Quality
Expert Functions
Provides overview of what promotes a just
Just Culture Essentials for
culture where there is trust through open
Leaders reporting & managing investigations in a fair
manner.
Engagement style session using some
standard material on HF and includes case
studies from local business/area to show
Human Factors Awareness
errors do happen, highlghting the human
error influences that occurred. Encourage
conversations and sharing of exmaples.
Specific training in the MEDA tool to help
with investigaitons where it is clear human
acts have directly influenced the outcome
MEDA
and may recur a focused approach to
exploring and gathering the facts as to what
occurred leadings up to the event.
Root cause analysis training that has been
supplemented with dirty dozen
Human Factors RCA considerations to help identify what human
factor influences have contributed to cuase
of the problem
Figure 10 Example of training matrix for Human Factors
Training refresh every two years might be considered!

Dedicated Human Factor personnel: Focal point or specific resourced need to have a more
complete training and skills.
They have to lead the HF program in the whole organization and promote investigation and
risks assessment.
They should be trained for those specific tools.
8.2 Typical training programme

There are different concepts of forming a Human Factors training program. The concepts are
used as a way to see the person within the interaction of multiple system components
Here are two examples:
22
Figure 11 SHELL concept
The SHELL concept was first developed by Edwards in 1972, with a modified diagram to
illustrate the model developed by Hawkins in 1975.
Figure 12 PEAR concept
Example Human Factors Initial Training syllabus

• In the first column are listed most popular Human Factor topics.
23
• The others column can be used to adapt and personalize the courses contents for all
category of employees.
• For example, you can use the cells to specify, with a "X", the topic to be treated during
the course for each category of personnel, or you can specify the level of detail each
topic will be treated for each category of employees.
• In the cells there is a "R" for recommended topics and an "O" for optional topics
24
production support
Certifying Staff
Managers &
Technicians
Supervisors
HUMAN FACTOR TRAINING
Inspector
Operator
Introduction
Introduction to the course R R R R R
General
The need to take Human Factors into account;
R R R O R
Incidents attributable to Human Factors/human error;
‘Murphy's’ law
Error models and theories

Implications of errors; Avoiding and managing errors; R O R R R
Human reliability
Human Performance and Limitations

Vision; Hearing; Information processing;
O R R R R
Attention and perception; Memory;
Claustrophobia and physical access.
Teamwork/Safety Culture/Organizational factors Social

Psychology; Responsibility: individual and group;
R R R R R
Motivation and de-motivation; Peer pressure; ‘Culture’
issues; Management, supervision and leadership.
Factors Affecting Performance

Fitness/health; Stress: domestic and work related; Time
pressure and deadlines; Workload: overload and R R R O R
underload; Sleep and fatigue, shiftwork; Alcohol,
medication, drug abuse.
Environment
Noise and fumes; Illumination; Climate and temperature; R R R O R
Motion and vibration; Working environment.
Procedures, information, tools and practices

Tasks; Physical work; Repetitive tasks; Visual inspection; R R R R R
Complex systems.
Communication
Within and between teams; Work logging and recording;
R R R R R
Keeping up to date, currency; Dissemination of
information. Shift handover
Hazards in the Workplace

Recognizing and avoiding hazards; Dealing with R O O O R
emergencies.
Professionalism and integrity R R R R R
Figure 13 Training syllabus
25
Appendix 1 – Example checklist when considering deploying a Human Factors programme
 Safety Policy includes Just Culture – underpinned by processes and resources (HF
trained investigators etc.)
 Senior Management support – Reporting, Stop & Fix etc. - Shadow of the Leader
 Domestic agreement on Just Culture with Trade Unions – Stakeholder engagement and
buy-in
 Confidential reporting system – simple and accessible reporting mechanism
 Employee Feedback on all Reports – trust and engagement
 Linked to Safety Process - Occurrence Reporting / Safety concerns
 Human Factors Training – all employees and targeted refresher every 2 years
 Just Culture training – myth busting etc., aligned with People (HR) discipline processes
- again stakeholder engagement is key
 Human Factors investigation – MEDA, non-judgemental investigation process
 Safety Performance Indicators – Reporting & Just Culture – evidence a difference has
been made and improving
 Safety Culture surveys – checks that change is sustained or not etc. over time
26
Appendix 2 – Example checklist when reviewing investigations involving Human Factors
27
Appendix 3 –Example MEDA form
28
Appendix 4 - Acknowledgements
This reference manual represents the consensus of the members of the AESQ. The Team
members who developed this guidance and whose names appear below, wish to acknowledge the
many contributions made by individuals from their respective organizations.
Organization Representative
Safran Catherine Catarina-Graca – Team Leader
Rolls-Royce Christine Brown
Airbus Ludovic Chevet
PCC Richard Bolingbrook
GKN Björkälv Håkan
29
Change History
Revision Date Description of Change
March
Initial Release
2021
For more information or to provide feedback:
AESQ Strategy Group

400 Commonwealth Drive
Warrendale, PA 15096
Email: info@aesq.sae-itc.org
30

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