Human Factors for Aircraft

Maintenance
Introduction

Aviation: Safest forms of travelling.

 Chain of Events/human errors

Solution / Safety Net:

 If we break the chain at our level,
the accidents will not happen.
The need to consider the human
factor

Most important human factor:

 Ability to learn from experience & mistakes committed by others.

Basic Rules:
If it has gone wrong once, it will probably gowrong again.

Safety Net:
At Design stage – By manufacturer. ( e.g. Cross wires)
At user level – By following written procedures.
What is important to know about
human error?
 Human error is in our nature
– It might happen everyone, at any time, in any context

 Some errors are preventable through procedures, system design and automation.
– But careful, they may introduce new opportunities of erring.
– Emphasis should be put on error tolerant systems: error recovery instead of
erroneous action prevention.

 Human error might not be an accident cause in

itself…it might be caused by multiple factors
– Do not only blame last human operator alone.
Definition of Human Error

Error will be taken as a generic term to encompass all those

occasions in which a planned sequence of mental or physical
activities fails to achieve its intended outcome, and when these
failures cannot be attributed to the intervention of some change
agency. (Reason, 1990)
Human error performance

 SITUATION ASSESSMENT

SENSE/INTERPR
MISTAKES
ET
INTENT OF ACTION
SLIPS
PLAN/COGNITION OMMSSION/COMMISION

EXECUTION
 Human error taxonomies

 Errors of omission (not doing the required thing)

– Forgetting to do it
– Ignoring to do it deliberately
 Errors of commission (doing the wrong thing)
slips in which the operator has the correct motivation or intention, but carries out the
wrong execution
1. Sequence or wrong order of execution
2. Timing: too fast/slow
errors based in erroneous expectations and schema. (schema are sensory-motor
knowledge structures stored in memory used to guide behavior: efficient and low energy
Building solutions

 Each system will require particular instantiation of the approach, but

some general recommendations might include:
1. Prevent errors: procedures, training, safety
2. awareness, UI design (allow only valid choices)
3. Tolerate error: UI design (constraints on inputs), decision support tools
4. – Recover error: undo capability, confirmation
Learning from past accident/incident

 Great source of lessons to be learnt…not of facts to blame

 Careful considerations to keep in mind:
1. – Most people involved in accidents are not stupid nor reckless. They may be only
blindness to their actions.
2. Be aware of possible influencing situational factors.
3. Be aware of the hindsight bias of the retrospective analyst.

Hindsight bias: Possession of output knowledge profoundly influence the way we

analyze and judge past events. It might impose a deterministic logic on the observer
about the unfolding events that the individual at the incident time would have not
had.
Nine steps to move forward from
error

 • Pursue second stories beneath the surface to discovermultiple

contributors.
 • Escape the hindsight bias
 • Understand work as performed at the sharp end of thesystem
 • Search for systemic vulnerabilities
 • Study how practice creates safety
 • Search for underlying patterns
 • Examine how changes create new vulnerabilities
 • Used new technology to support and enhanced humanexpertise
 • Tame complexity through new forms of feedback