CHAPTER 1

INTRODUCTION

Md Jalal Uddin Rumi

Assistant Professor
Department of Aeronautical Engineering, MIST
 CHAPTER 1
INTRODUCTION

This chapter introduces human factors and explains its

importance to the aviation industry. It examines the
relationship between human factors and incidents largely
in terms of human error and "Murphy's Law" (i.e., if
something can go wrong, it will).
 What is "Human Factors"?
A Definition of Human Factors
• The human factor is the performance and behavior
of the individual, and the group.
• It involves internal psychological and physical aspects
of the individual, as well as interaction with other
people, with the machine and the equipment in use,
and with the operating environment.
The Need To Take Human Factors Into Account

• The human factor is the most important factors in

aviation.
• Human factors play a major role in safe operation of
aircraft during flight.
• The importance of human factors to the pilot, aircraft
maintenance technician, supervisors and managers is
essential.
• This is because human factors will affect everything they
do in the course of their job in one way or another.
• Human factors not only play a major role in the safe
operation of aircraft – they also play a major role in
unsafe operation, leading to incidents and accidents.
The meaning of Human Factors in Aviation

• The term "human factors" is used in many different

ways in the aviation industry.
• Most people known it in the context of aircraft cockpit
design and Crew Resource Management (CRM).
• However, those activities are only a small part of
aviation related human factors, as broadly speaking it
covers all aspects of human involvement in aviation.
 What is CRM?
• Crew Resource Management is the sharing of
knowledge and best practices to reduce errors and
incidents.
• Used by high reliability organizations (HROs):
– Aviation, military, fire services, oil production,
nuclear operations, commercial shipping, medical
field
• CRM has been used by commercial airlines since
1981.
 Evolution of CRM
• 1990s grows to include pilots, flight attendants,
dispatch, maintenance.
• Currently Federal Aviation Administration (FAA)
Advanced Qualification program (AQP) requires CRM
to be incorporated into all aspects of training.
• Required by FAA and International Civil Aviation
Organization (ICAO) for airlines in 185 countries.
 Aspect in Human Factors

Human factors includes:

• Human physiology
• Psychology (including perception, cognition, memory,
social interaction, error, etc.)
• Work place design
• Environmental conditions
• Human-machine interface
•Anthropometrics (the scientific study of measurements
of the human body)
 The Pear Model
• There are many concepts related to the science and
practice of human factors. Pear model is one of
them.
• PEAR prompts recall of the four important
considerations for human factors programs, which
are listed below:
1. People who do the job.
2. Environment in which they work.
3. Actions they perform.
4. Resources necessary to complete the job.
P:PEOPLE
E: ENVIRONMENT
A: ACTION
R: RESOURCES
 Optimizing Human Performance
• The Human Factor SHELL approach involves
viewing Human being as the central
‘components’ in the complex operation of a flight
and considering their strength/weakness both in
isolation and in relation to other ‘components’.
 ICAO “SHEL” MODEL

A conceptual model using 4

blocks to represent
interaction between the
different components of
“Human Factors”.
S – Software
H – Hardware
E – Environment
L - Liveware

Source: Edwards, 1972 (as referenced in ICAO Human Factors Digest No 1,

Circular 216 (1989))
 The SHELL Model Components
A model which is often used is the SHELL model, a name
derived from the initial letters of its components:
• S = Software
Rules/procedure and their design - Manuals, Charts,
Checklist layout, etc.
• H = Hardware
The design of the aircraft itself and includes control,
displays and system - tools, test equipment, the physical
structure of aircraft, design of flight decks, positioning
and operating sense of controls and instruments, etc.
 The SHELL Model Components
• E = Environment
Physical environment such as conditions in the hangar,
conditions on the line, etc. and work environment such as
work patterns, management structures, public perception
of the industry, etc.
• Liveware
The Human component, the ‘hub’ of the model. The
person or people at the center of the model, including
pilot, ATC, engineers, maintenance technicians,
supervisors, planners, managers, etc.
 Deficiencies in Safety
Software: misinterpretation of procedures, badly written manuals,
poorly designed checklists, untested or difficult to use computer
software.

Hardware: not enough tools, inappropriate equipment, poor

aircraft design for maintainability.

Environment: uncomfortable workplace, inadequate hangar

space, extreme temperatures, excessive noise, poor lighting.

Liveware: relationships with other people, shortage of manpower,

lack of supervision, lack of support from managers.
 Minimizing Human Error
Human error can be minimized by:
 Good selection of people (in a professional
environment)
 Good training
 Good design – matching the machine, controls,
displays and operating procedures to human
characteristics (physical and psychological)
 Providing a good working environment (low noise
level, comfortable temperature, no vibration)
 Good operating procedures – such as good cockpit
checklists, and cross-checking and crew cooperation
in two-pilot cockpits.
 Human Factor Influence in Maintenance
Engineering
• The use of the term "human factors" in aviation
maintenance engineering is new.
• Aircraft accidents such as that of the Aloha aircraft in
the USA in 1988 and the BAC 1-11 windscreen
accident in the UK in June 1990 focused attention on
human factors.
 Incidents and Accidents Attributable to Human
Factors / Human Error
Aircraft Accidents Causes
In 1940, it was
calculated that
approximately 70% of
OTHER
CAUSES
all aircraft accidents
Other
Causes were attributable to
HUMAN FAILURE
Human man’s performance,
Flight Crew, ATC, Failure
Maintenance, etc that is to say human
error.

The dominant role played by human performance

Source: IATA, 1975
Causes/major contributory factor % accidents in which
this was a factor
Pilot deviated from basic operational procedure 33
Inadequate cross-check by second crew member 26
Design faults 13
Maintenance and inspection deficiencies 12
Absence of approach guidance 10
Captain ignored crew inputs 10
Air Traffic control failures or errors 9
Improper crew response during abnormal conditions 9
Insufficient or incorrect weather information 8
Runway hazards 7
Air traffic control/crew communication deficiencies 6
Improper decision to land 6

• A study was carried out in the USA in 1986 looking at significant accident causes in
the 93 aircraft accidents. The results of this study are highlighted in Table 1 above.
 Examples of Incidents and Accidents

• Some of the major incidents and accidents that will

be used as case studies in this subject are
summarized below;
Accident to Boeing 737, (Aloha flight 243), Maui,
Hawaii, April 28 1988
Accident to BAC 1-11, G-BJRT (British Airways
flight 5390), over Didcot, Oxfordshire on 10 June
1990
 Aloha Airlines Flight 243
• Aloha Airlines Flight 243 (AQ 243, AAH
243) was scheduled Aloha Airlines flight
between Hilo and Honolulu in Hawaii. On
April 28, 1988, a Boeing 737-297 serving
the flight suffered extensive damage after an
explosive decompression in flight, but was
able to land safely at Kahului Airport on
Maui. The only fatality was flight attendant
Clarabelle “C.B” Lansing, who was blown
out of the airplane. Another 65 passengers
and crew were injured.
• The safe landing of the aircraft despite the
substantial damage inflicted by the
decompression established Aloha Airlines
Flight 243 as a significant event in the
history of aviation, with far-reaching effects
on aviation safety policies and procedures.
 Aloha Flight 243 Investigation
The accident involving Aloha flight 243 in April 1988 involved
18 feet of the upper cabin structure suddenly being ripped
away in flight due to structural failure.
The Boeing 737 involved in this accident had been examined,
as required by US regulations, by two of the 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.
 Aloha Flight 243 Investigation Result
• Investigation by the United States National Transportation Safety
Board (NTSB) concluded that the accident was caused by metal
fatigue exacerbated by crevice corrosion.
• The aircraft was 19 years old and operated in a coastal
environment, with exposure to salt and humidity.
• Post accident analysis determined there were over 240 cracks in the
skin of this aircraft at the time of the inspection.
• The ensuing investigation identified many human factors-related
problems leading to the failed inspections.
• As a result of the Aloha accident, the US instigated a program of
research looking into the problems associated with human factors
and aircraft maintenance, with particular emphasis upon inspection.
 Final Report of the Incident
• The NTSB concluded in its final report on the accident:
 The National Transportation Safety Board determines that the probable
cause of this accident was the failure of the Aloha Airlines maintenance
program to detect the presence of significant disbonding and fatigue
damage which ultimately led to failure of the lap joint a S-10L and the
separation of the fuselage upper lobe.
 Contributing to the accident were the failure of Aloha Airlines
management to supervise properly its maintenance force;
 the failure of the FAA to require Airworthiness Directive 87-21-08
inspection of all the lap joints proposed by Boeing Alert Service Bulletin
SB 737-53A1039;
 and the lack of a complete terminating action (neither generated by
Boeing nor required by the FAA) after the discovery of early production
difficulties in the B-737 cold bond lap joint which resulted in low bond
durability, corrosion, and premature fatigue cracking.
 British Airways Flight 5390
• On June 10th 1990 in the UK, a BAC 1-11 (British
Airways flight 5390) was climbing through 17,300
feet on departure from Birmingham International
Airport when the left windscreen, which had been
replaced prior to flight, was blown out under the
effects of cabin pressure when it overcame the
retention of the securing bolts, 84 of which, out of a
total of 90, were smaller than the specified diameter.
 British Airways Flight 5390

The commander was sucked halfway out of the

windscreen aperture and was restrained by cabin crew
whilst the co-pilot flew the aircraft to a safe landing at
Southampton Airport.
Then the unexpected
happened -captain
Lancaster came to!
He was hospitalized with
a broken right arm and wrist
and a broken left thumb as
well as frostbite and shock.
Minor injuries, considering
he had ridden on the
outside of an airliner at high
altitudes for 18 minutes.
Lancaster was the only
person injured in the
incident. He recovered and
returned to flying a few
months later.
 British Airways Flight 5390 Investigation
• The Shift Maintenance Manager (SMM), short-handed on a night shift, had decided
to carry out the windscreen replacement himself.
• He consulted the Maintenance Manual (MM) and concluded that it was a
straightforward job.
• He decided to replace the old bolts and, taking one of the bolts with him (a 7D), he
looked for replacements.
• The store man advised him that the job required 8Ds, but since there were not
enough 8Ds, the SMM decided that 7Ds would do (since these had been in place
previously).
• However, he used sight and touch to match the bolts and, erroneously, selected 8Cs
instead, which were longer but thinner.
• He failed to notice that the countersink was lower than it should be, once the bolts
were in position.
• He completed the job himself and signed it off, the procedures not requiring a
pressure check or duplicated check.
 British Airways Flight 5390 Investigation
• There were several human factors issues contributing
to this incident, including;
perceptual errors made by the SMM when
identifying the replacement bolts,
Poor lighting in the stores area,
failure to wear corrective lenses,
circadian effects,
Working practices,
possible organizational and design factors.
 Human Factors Contributing to Incidents and
Accidents
In all of these incidents, the technicians involved
Accident
were considered by their companies to be well
qualified, competent, and reliable employees.
All of the incidents were characterized by the
following:
• There were staff shortages
• Time pressures existed Management Crew
• All the errors occurred at night
• Shift or task hand overs were involved
• There was an element of a "can-do“ attitude Maintenance
• Interruptions occurred If we can break just one link of the chain,
• Manuals were confusing the accident does not happen.
• There was inadequate pre-planning,
The Error Chain. - Source: Boeing2
equipment, or spares
• They all involved supervisors doing long hands-
on tasks
• There was some failure to use approved data or
company procedures
 Incidents and Accidents - A Breakdown in Human
Factors
• In all of the previous examples, the accident or incident
was preventable and could have been avoided if any
one of a number of things had been done differently.
• As with many incidents and accidents, all the examples
above involved a series of human factors problems
which formed an error chain.
• If any one of the links in this error chain had been
broken by built-in measures to intercept a problem at
one or more of these stages, these incidents may have
been prevented.
 Murphy's Law
• There is a tendency among human beings towards
complacency, the belief that an accident will never
happen to "me" or to "my company".
• This can be a major problem when attempting to
convince individuals or organizations of the need to
look at human factors issues, recognize their risks
and implement improvements, rather than merely
paying "lip-service."
 Murphy’s Law
• If everyone could be persuaded to acknowledge
Murphy's Law, "If something can go wrong, it will,"
this might help overcome the "It will never happen to
me" belief that many people hold.
• It is not true that accidents only happen to people
who are irresponsible or "sloppy."
• The incidents and accidents described previously
show that errors can be made by experienced, well-
respected individuals and can occur in organizations
previously thought to be "safe."
 Summary
• While keeping in mind Murphy's Law may increase
our awareness of potential incidents and accidents,
there are other human factors to consider that are
based on the limitations of the human body and
mind.
End of Chapter 1