CHAPTER 1

HUMAN FACTORS IN
AVIATION

BY P MAHERE
A good day, or a bad day at the office …
Depending on your perspective
A good day at the office!
 Glossary of Terms

• AME Aircraft Maintenance Engineer

• AMT Aircraft Maintenance Technician
• ATA Air Transport Association of America
• ATC Air Traffic Control
• CAA (UK) Civil Aviation Authority
• CAA Civil Aviation Authority
• CAAZCivil Aviation Authority of Zimbabwe
• CRM Crew Resource Management
 Glossary of Terms
• FAA Federal Aviation Authority
• FAA (US) Federal Aviation Authority
• HF Human Factors
• HFAMI Human Factors in Aviation Maintenance
and Inspection
• IATA International Air Transport Association
• ICAO International Civil Aviation Organization
• LAE Licensed Aircraft Engineer
• LAME Licensed Aircraft Maintenance Engineer
 Glossary of Terms
• MEDA Maintenance Engineering Decision Aid
• MEMS Maintenance Error Management System
• MESH Maintenance Engineering Safety Health
• MRM Maintenance Resource Management
• NAA National Aviation Authority
• NTSB National Transportation Safety Board
• SHEL Model Software, Hardware, Environment,
Liveware
• TWA Time Weighted Average sound level
• TWA Time Weighted Average
 Objectives of this chapter
• To achieve a basic understanding of the meaning of the
term “Human Factors”.
• To understand the history of Human Factors.
• To recognize the contribution of Human Factors to
aviation accidents.
• To understand the goal of Human Factors training.
• To appreciate the need to understand and address
Human Factors.
• To become reasonably familiar with some of the well-
known incidents and studies of incident data, where
Human Factors have contributed.
• Understand why these incidents occurred.
 INTRODUCTION
• Long ago our ancestors lived in an essentially natural environment in
which their existence virtually dependent on what they could do
directly with their hands (as in obtaining food) and with their feet (as
in chasing pray, getting to food sources and escaping from predators)
which has however changed over the years as tools were
manufactured.
• However the current interest in human factors arises from the fact
that technological developments have focused attention on the need
to consider human beings in such developments.
• Have you ever used a tool device, appliance or machine and said to
yourself,
• ‘What a dumb way to design this, it is so hard to use, If only they had
done this or that using it would be so much easier’
• If you have had such experiences you have already began to think in
terms of human factors considerations in the design of things people
use
 Human Factors:
What’s it mean?

Human Factors in action: On the way to Auckland this morning.

Human Factors:
What’s it mean?

What is Human Factors

and what is it not?

Human Factors = Ergonomics

 Human Factors:
What’s it mean?
• Human factors is the term used in the United
States and a few other countries.
• The term Ergonomics is more prevalent in
Europe and the rest of the world.
• Some people have tried to distinguish
between the two but we believe is arbitrary
and that for all practical purpose the terms are
synonymous.
• We approach the definition of human factors
in terms of its focus, objectives and approach.
 Focus of Human
Factors
• Human factors focuses on human
beings and their interaction with
products, equipment, facilities,
procedures and environments
used in work and every day living.
Objectives of Human Factors
• Human factors has two objectives:
1. To enhance the effectiveness and efficiency with
which work and other activities are carried out.
Included are such things as increased
convenience of use, reduced errors and
increased productivity.
2. To enhance certain desirable human values,
including improved safety, reduced fatigue and
stress, increased comfort, greater user
acceptance, increased job satisfaction and
improved quality of life.
 Approach of Human
Factors
• The approach of human factors is the
systematic application of relevant
information about human capabilities,
limitations, characteristics, behaviour
and motivation to the design of things
and procedures people use and the
environments in which they use them.
General Concise Definition
of Human Factors
• It combines the essential elements of focus,
objectives and approach:
Human Factors discovers and applies
information about human behaviour,
abilities, limitations and other
characteristics to the design of tools,
machines, systems, tasks, jobs and
environments for productive, safe,
comfortable and effective human use.
 Three Things Human Factors are not
1. Human factors is not just applying checklists and
guideline: however such aids are only part of the work
of human factors. There is not a checklist or guideline in
existence today that if it were blindly applied would
ensure a good human factors product.
2. Human factors is not using oneself as a model for
designing things. Just because a set of instructions
makes sense to an engineer, there is no guarantee
others will understand them. Just because a designer
can reach all the controls on a machine that is no
guarantee that everyone else will be able to do so.
 Three Things Human Factors are not
• 3. Human factors is not just common sense.
To some extent use of common sense would
improve a design but human factors is more
than just that. Knowing how large to make
letters on a sign to be read at a specific
distance or selecting an audible warning that
can be heard and distinguished from other
alarms is not determined by simple common
sense. Knowing how long it will take pilots to
respond to a warning light or buzzer is also not
just common sense.
 History of Human Factors and Ergonomics in
General
• Early developments concentrated on developments
in the USA but can be traced in other countries.
• Early history – started when early humans first
fashioned simple tools and utensils.
• Intertwined with developments in technology thus
its beginning is in the industrial revolution- late
1800 and early 1900s.
• eg Motion Study and Shop Management by Frank
and Lillian Gilbreth was a front runner to what's
now called Human Factors
1945 to 1960: The Birth of a Profession
• Born the period after the war
• First book –Applied Experimental Psychology:
Human Factors in Engineering
Design(Chapains, Garner and Morgan,1949
• Conferences held on Human Factors
• 1959 International Ergonomics Association
was formed to link several human factors and
ergonomics societies in various countries in
the world
1960 to 1980 A Period of Rapid Growth for
Human Factors
• Became part of military, space program
and beyond e.g. pharmaceuticals,
computers, automobiles etc.
• Up to 1980 relatively unknown to the
man in the street.
• Membership shot from 500 to over 3000
 1980 to 1990: Computers, Disasters and
Litigation
• Membership almost 5000 in 1990.
• Computer technology revolution propelled (user friendly
software) Human Factors into the public limelight.
• Technological Disasters-1979 three mile island nuclear
power station, Union Carbide pesticide plant plant Bhopal
India, 1984 (4000 dead +200 000 injured, Chernobyl USSR
(300 dead +exposure to radiation,1984 –HF played a part
• Dramatic increase in human factors involvement in
forensic and particularly product liability and personal
injury litigation- Human Factors expert witnesses in court
recognised.
 1990 and Beyond
• Safe to predict continued growth in Human
Factors areas.
• Computers and the application of computer
technology will keep Human Factor people
busy for a long time.
• Design of medical devices and in the design of
products and facilities for the elderly will play
a big part in Human Factors area
development.
HUMAN FACTORS IN AVIATION INDUSTRY

The Need To Take Human Factors Into Account

• In the early days of powered flight, the design,
construction and control of aircraft
predominated. The main attributes of the first
pilots were courage and the mastery of a
whole new set of skills in the struggle to
control the new flying machines
• As the technical aspects of flight were
overcome bit by bit, the role of the people
associated with aircraft began to come to the
fore. Pilots were supported initially with
mechanisms to help them stabilize the aircraft,
and later with automated systems to assist the
crew with tasks such as navigation and
communication. With such interventions to
complement the abilities of pilots, aviation
human factors was born.
 Definitions
• Airplane Accident; an occurrence associated
with the operation of an airplane that takes
place between the times when any person
boards the airplane with the intention of flight
and such time all such persons have
disembarked in which:
 Airplane sustains damage
 Death or serious injury resulting from:
 Being in or upon an airplane
 Direct contact with the airplane or anything attached thereto.
 Direct exposure to jet blast.
 HULL LOSS
• Airplane damage that is substantial and is
beyond economic repair.
• Hull loss also includes events in which,
1. Airplane is missing
2. Search for the wreckage has been terminated
without it being located
3. Airplane is substantially damaged and
inaccessible
 Substantial damage
• Damage or structural failure that adversely
affects the structural strength, performance or
flight characteristics of the aircraft and would
normally require major repair or replacement
of the affected component
 Substantial damage is not
• Engine failure or damage limited to an engine
if only one engine fails or is damaged.
• Bent aerodynamic fairings
• Dents in the skin
• Damage to landing gear
• Damage to wheels
• Damage to tyres
• Damage to flaps
 Fatal accident
• An accident that results in fatal injury

• Fatal injury-- An injury that results in death

within 30 days as a result of an accident
 SERIOUS INJURY
• An injury sustained in an accident that;
– Requires hospitalization for more than 48 hours that
begins within 7 days of the date of injury.
– Results in a fracture of any bone (except simple fractures
of fingers, toes or nose.
– Produces lacerations that result in severe haemorrhage or
nerve, muscle or tendon damage.
– Involves injury to any internal organ.
– Involves second or third degree burns over 5% or more of
the body.
– Involves verified exposure to infectious substance or
injurious radiation.
 Excluded events
• Fatal and non fatal injuries from natural causes
• Fatal and non fatal self inflicted injuries.
• Fatal and non fatal injuries of stowaways.
• Experimental test flight accidents
• Nonfatal injuries resulting from atmospheric
turbulence, manoeuvring, loose objects, boarding,
dis-embarking, evacuation and maintenance and
servicing
• Nonfatal injuries to persons not on-board the aircraft
 Regional identification
• Events are identified by the operators national
domicile and by event location
 Airplane collisions
• Events involving two or more airplanes are
counted as separate events, one for each
airplane.
• For example , destruction of two airplanes in a
collision is considered two separate hull loss
accidents.
 Accidents rates
• It is a measure of accidents per million
departures.
• Departures (or flight cycles) are used as the
basis for computing rates, since there is a
stronger statistical correlation between
accidents and departures than there is between
accidents and flight hours, or between accidents
and the number of airplanes in service, or
between accidents and passenger miles.
 INTRODUCTION TO HF (Aviation).
DEFINITION:
Human Factors refers to the study of human capabilities and
limitations in the workplace. It is the study of maintenance
personnel, the equipment they use the procedures and rules
they follow (written and verbal) and the environmental
conditions of the system.

The aim of HF training is to optimize the relationship

between maintenance personnel and systems with a view to
improving safety, efficiency and well-being.

(FITTING THE MAN TO THE JOB AND THE JOB TO THE MAN)
INTRODUCTION TO HF.
 Human factors
• This chapter examines the relationship
between human factors and incidents largely
in terms of human error and “ Murphy’s Law”
(i.e. if it can happen, one day it will).
• It is best known in the context of aircraft
cockpit design and Crew Resource
Management (CRM)
• Or ergonomics
• It can be described as fitting the man to the
job and the job to the man.
 Its attributes
• 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)
 Who does Human Factors?
• Multi-Disciplinary HF Specialists
• Some:
1. Psychologists
2. Engineers
3. Doctors
4. Kinesiologists
5. Retrained Subject Matter Experts … Yes, it is
possible to retrain engineers (pilots and doctors)
6. Scientists
HF’s contribution to Aviation
accidents (IATA 1975)

70%
Flight crew, ATC,
Aircraft design,
Maintenance human failure, etc
 1986 study of accident causes.
Cause/major contributory factor % of accidents
1. Pilot deviated from basic operational procedures 33
2. Inadequate cross-check by second crew member 26
3. Design faults 13
4. Maintenance & inspection deficiencies 12
5. Absence of approach guidance 10
6. Captain ignored crew inputs 10
7. Air traffic control failures or errors 9
8. Improper crew response during abnormal conditions 9
9. Insufficient or incorrect weather information 8
10. Runaways hazards 7
11. ATC/crew communication deficiencies 6
12. Improper decision to land 6

13. It is apparent that maintenance & inspection deficiencies are a major contributory factor
to accidents , hence the need for human factors training for maintenance personnel.
 Goal of human factors training
• To provide practical Human factors guidance
based on issues concerned with aircraft
maintenance and inspection.
• To show how human capabilities and
limitations can influence task performance
and safety within the maintenance and
inspection environments
 What is not Human Factors?
• “Just applied common sense”
• Training people to accommodate poor design
• Blaming the user - “Pilot error”
• Designers projecting their skills onto users - If
it’s easy for the designer it must be easy for
the end user
• Human Resources
 THE ICAO SHELL MODEL
Origins
It can be helpful to use a model to aid in the understanding of human factors, or as
a framework around which human factors issues can be structured.
SHEL model
The SHEL model is a theoretical framework developed by Edwards
in 1972. The model places the person as the focus of interest of
the discipline "Human Factors". However, humans are not
independent and unrelated elements in the system but interact
with other elements. Therefore, the main interest of "Human
Factors" also expands to the interrelations between that person
and other elements in the system: software, hardware, and the
environment.
The SHEL model thus takes its name as an acronym of its
constituent elements (Software, Hardware, Environment,
Liveware). Nowadays, the model is practically "lost" in time and
buried in academic history.
It, however, survives in its offspring, the SHELL model.
 THE ICAO SHELL MODEL
SHELL model
The SHELL model was proposed by Hawkins in 1975 (see Hawkins &
Orlady, 19931) as a modified version of the SHEL model. Hawkins
introduced a further "liveware" element to the original model in order to
represent group processes (or the interface liveware-liveware). The model
acronym thus reflect the extra element (Software, Hardware, Environment,
Liveware, Liveware). Hawkins also presented the model in graphical form,
with the main operator (one of the "liveware" elements) in the center of the
model, interacting with the remaining four elements, which are placed as
outer elements. This graphical representation enhanced the central concept
of the model: the human (operator) in interaction with those other elements
in the system. Notice that the focus of the model is on this central human
operator and his interactions (referred to as interfaces), not on the outer
elements per se.
 THE ICAO SHELL MODEL

Hardware

Environment

Software
Liveware
 Liveware
The critical focus of the model is the human participant, or liveware, the most
critical as well as the most flexible component in the system. The edges of this
block are not simple and straight, and so the other components of the system
must be carefully matched to them if stress in the system and eventual
breakdown are to be avoided.
However, of all the dimensions in the model, this is the one which is least
predictable and most susceptible to the effects of internal (hunger, fatigue,
motivation, etc.) and external (temperature, light, noise, workload, etc.) changes.
Human Error is often seen as the negative consequence of the liveware
dimension in this interactive system. Sometimes, two simplistic alternatives are
proposed in addressing error: there is no point in trying to remove errors from
human performance, they are independent of training; or, humans are error prone
systems, therefore they should be removed from decision making in risky
situations and replaced by computer controlled devices. Neither of these
alternatives are particularly helpful in managing errors.
 Liveware-Liveware
(the intertface between people and other people)

• interface between people.

• concerned with
• leadership,
• co-operation,
• teamwork and
• personality interactions.

Includes programmes like Crew Resource Management

(CRM), the ATC equivalent - Team Resource Management
(TRM), Line Oriented Flight Training (LOFT) etc.
 Liveware-Software
(The interface between people and software)

Software is the collective term which refers to all the laws, rules,
regulations, orders, standard operating procedures, customs and
conventions and the normal way in which things are done. Increasingly,
software also refers to the computer-based programmes developed to
operate the automated systems.
In order to achieve a safe, effective operation between the liveware and
software it is important to ensure that the software, particularly if it
concerns rules and procedures, is capable of being implemented. Also
attention needs to be shown with phraseologies which are error prone,
confusing or too complex. More intangible are difficulties in symbology
and the conceptual design of systems
 Liveware-hardware
The interface between people and hardware

Another interactive component of the SHELL model is the interface between

liveware and hardware. This interface is the one most commonly considered
when speaking of human-machine systems: design of seats to fit the sitting
characteristics of the human body, of displays to match the sensory and
information processing characteristics of the user, of controls with proper
movement, coding and location.
Hardware, for example in Air Traffic Control, refers to the physical features
within the controlling environment, especially those relating to the work
stations. As an example the press to talk switch is a hardware component
which interfaces with liveware. The switch will have been designed to meet a
number of expectations, including the probability that when it is pressed the
controller has a live line to talk. Similarly, switches should have been
positioned in locations that can be easily accessed by controllers in various
situations and the manipulation of equipment should not impede the reading
of displayed information or other devices which might need to be used at the
same time.
 Liveware - Environment
The interface between people and the environment

The liveware - environment interface refers to those interactions which

may be out of the direct control of humans, namely the physical
environment - temperature, weather, etc., but within which aircraft
operate. Much of the human factor development in this area has been
concerned with designing ways in which people or equipment can be
protected, developing protective systems for lights, noise, and radiation.
The appropriate matching of the liveware - environmental interactions
involve a wide array of disparate disciplines, from environmental studies,
physiology, psychology through to physics and engineering.
 SHEL
• Thanks to modern design aircraft are
becoming more and more reliable.
• However it is not possible to redesign the
human being, we have to accept the fact that
humans are intrinsically unreliable.
• We can work around that unreliability by
providing good training, procedures, tools,
duplicate inspections etc.
 THE DIRTY DOZEN.

One of the early MRM training programmes

was developed by Gordon Duport for
Transport Canada & is called the Dirty Dozen.
These are the 12 areas of potential problems
in HUMAN FACTORS, and giving potential
solutions.
Posters produced one of each giving few
examples of good practices or safety nets
which ought to be adopted.
 Possible Problem Potential Solution

1 Lack of Use logbooks, worksheets etc ,to communicate and

Communication remove doubt .discuss work to be done or what has
been completed. NEVER ASSUME ANYTHING.
2 Complacency Train yourself to expect to find a fault.

3 Lack of knowledge Get training on type. 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
tourque seal Double inspect by another or self.When
you return to the job always go back 3 steps.Use a
detailed check sheet..
5 Lack of teamwork Discuss what, who and how a job is to be done .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
(Resources) 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 is not self-induced .Communicate
your concerns. Ask for extra help. Just say NO.
9 Lack of If its not critical record it in the log book and only sign for
assertiveness what is serviceable .refuse to compromise standards.
10 Stress Be aware of how stress can affect your work. Stop and
look at the problem rationally. 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 awareness Think of what may occur in the event of an accident.
Check to see if your work will conflict with an existing
modification or repair. Ask others if they can see any
problems with the work done.
12 NORMs Always work as per instructions or have the instruction
changed. Be aware the NORMS do not make it right.
 Need to address Human Factors.
• Human error is a factor in most if not all lapses,
incidents and accidents.
• Humans will make mistakes.
• How to identify and analyze human errors and the
conditions and situations that cause them.
• How to improve and optimize HUMAN performance,
procedures
 Accidents & Incidents where
maintenance human factors have
been the cause.
• Accident to Boeing 737 (Aloha flight 243), Maui,
Hawaii, April 28 1988
• BAC One-Eleven, G-BJRT (British Airways flight
5390), over Didcot, Oxford shire, 10 June 1990
• Airbus A32o, G-KMAM at London Gatwick
Airport, 26 August 1993
• Boeing 737, G-OBMM near Daventry, 23
February 1995
• 1. Accident to Boeing 737, (Aloha flight 243), Maui, Hawaii,
April 28 1988;
• 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. 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 programme
of research looking into the problems associated with human
factors and aircraft maintenance, with particular emphasis upon
inspection.
Accident to BAC One-Eleven, G-BJRT (British Airways flight 5390), over Didcot, Oxford
shire on 10 June 1990.
• On June 10th 1990 in the UK, a BAC1-11 (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 total of 90, were smaller than the specified diameter. 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. The Shift Maintenance
Manager (SMM), short-handed on a night shift, had decided to carryout 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 storeman 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. 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
spectacles, circadian effects, working practices, and possible organizational and design
factors.
Incident involving Airbus A320, G-KMAM at London Gatwick
Airport, on 26 August 1993.
• An incident in the UK in August 1993 involved an Airbus 320
which, during its first flight after a flap change, exhibited an
undemanded roll to the right after takeoff. The aircraft
returned to Gatwick and landed safely. The investigation
discovered that during maintenance, in order to replace the
right outboard flap, the spoilers had been placed in
maintenance mode and moved using an incomplete procedure;
specifically the collars and flags were not fitted. The purpose of
the collars and the way in which the spoilers functioned was
not fully understood by the engineers. This misunderstanding
was due, in part, to familiarity of the engineers with other
aircraft (mainly 757) and contributed to a lack of adequate
briefing on the status of the spoilers during the shift handover.
The locked spoiler was not detected during standard pilot
functional checks.
Incident involving Boeing 737, G-OBMM near Daventry, on 23
February 1995.
• In the UK in February 1995, a Boeing 737-400 suffered a loss of
oil pressure on both engines. The aircraft diverted and landed
safely at Luton Airport. The investigation discovered that the
aircraft had been subjected to borescope inspections on both
engines during the preceding night and the high pressure (HP)
rotor drive covers had not been refitted, resulting in loss of
almost all the oil from both engines during flight. The line
engineer was originally going to carry out the task, but for
various reasons he swapped jobs with the base maintenance
controller. The base maintenance controller did not have the
appropriate paperwork with him. The base maintenance
controller and a fitter carried out the task, despite many
interruptions, but failed to refit the rotor drive covers. No
ground idle engine runs (which would have revealed the oil
leak) were carried out. The job was signed off as complete.
 Human error
• Estimates of human error contribution to
accidents has increased over the years, from a
low of 20% in the 1960s to values in excess of
80% in the 1990s
 STATISTICS
TYPES OF ERROR IN MAINTANENCE
(top maintenance problems CAA 1992 )
1. Incorrect installation of components.
2. Fitting of wrong parts.
3. Electrical wiring discrepancies (e.g cross-connections)
4. Loose objects left in A/C (tools, etc--)
5. Inadequate lubrication.
6. Cowlings, access panels and fairings not secured.
7. Fuel/oil caps and refuel panels not secured.
8. Landing gear ground lock pins not removed before departure.
 Stastics. (cont’d)
Maintenance Lapses
omissions 56%
incorrect installations 30%
wrong parts 8%
other 6%
 In Flight Shut Down.
• Incomplete installation 33%
• Damage on installation 14.5%
• Improper installation 11%
• Equipment not installed 11%
• Foreign Object Damage 6,5%
• Improper fault isolation ,inspection & test 6%
• Equipment not activated or deactivated 4%
• In all three of these UK incidents, the engineers involved 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;
• All the errors occurred at night;
• Shift or task handovers were involved;
• They all involved supervisors doing long hands-on-tasks;
• There was an element of a “can-do” attitude;
• Interruptions occurred;
• There was some failure to use approved data or company
procedures;
• Manuals were confusing;
• There was inadequate pre-planning, equipment or spares.
 The Error Chain.
As with many incidents and accidents, all the
examples discussed involved a series of
human factors problems which formed an
error chain (see Figure 1-5). If any one of the
links in this ‘chain’ had been broken by
building in measures which may have
prevented a problem at one or more of these
stages, these incidents may have been
prevented.
 Murphy’ Law.

“If something can go wrong, it will.”

There is a tendency among human beings towards
complacency. The belief that an accident will
never happen to “me” or to “my Company” can
be a major problem when attempting to
convince individuals or organizations of the need
to look at human factors issues, recognize risks
and to implement improvements, rather than
merely to pay ‘lip-service’ to human factors.
 Murphy’ Law.
• If everyone could be persuaded to acknowledge
Murphy’s Law, 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 in this section
show that errors can be made by experienced,
well-respected individuals and accidents can
occur in organizations previously thought to be
“safe”
 CONCLUSION
• In conclusion the term human factors has
been defined and its goals have been clearly
expressed. The contribution of human factors
to aviation accidents haven been highlighted
with emphasis being placed for the need to
understand and address human factors in the
aviation industry
 CHAPTER 2
SAFETY CULTURE &
ORGANISATIONAL FACTORS
• Objectives of this chapter
• To achieve a good understanding of the concept
of “safety culture”
• To understand what is meant by the
“organizational aspects” of human factors
• To appreciate the vital importance of a good
safety culture
• To identify the elements of a good safety culture
 INTRODUCTION
• An organization with a good safety culture is
one which has managed to successfully
institutionalize safety as a fundamental value
of the organization, with personnel at every
level in the organization sharing a common
commitment to safety.
Effective support from the top levels of the
organization, for safety.
• Senior management to demonstrate their
commitment to safety in practical terms, not
just verbally or only as long as safety is a no-
cost item.
• Organization to commit to putting in place, for
example, a safety reporting and investigation
scheme but if such a scheme is not resourced
properly, or if safety recommendations are not
acted upon, it will be ineffective.
• Commitment to safety is long-term, and that
safety initiatives are not the first items to be cut
in terms of financial support.
• A good safety culture needs to be nurtured, and
is not something which can be put in place
overnight, or with a training course alone (short
term).
------ improvement will only be sustained if the
types of behaviors conducive to safety are
rewarded and poor safety behaviour is not
condoned, or even punished (in the extreme
cases).
 Safety culture and Org factors
• A good safety culture is based on what
actually goes on within an organization on a
day-to-day basis, and not on rhetoric or
superficial, short term safety initiatives.
• Measure the safety culture by using a safety
culture questionnaire survey. Care should be
taken with the timing of such a survey, in that
it may be affected by specific recent events
such as industrial action, training courses, etc.
 KEY ELEMENTS CONTRIBUTING TOWARDS A
GOOD SAFETY CULTURE
 Support from the top
 A formal safety policy statement
 Awareness of the safety policy statement and
participation from everyone (buy-in fm all levels) in
the organization
 Practical support to enable the workforce to do their
jobs safely e.g. in terms of training, planning
resources, procedures etc.
 A just culture and open reporting
 A learning culture and willingness to change when
necessary
 Corporate and personal integrity in supporting the
safety policy principles in the face or potentially
conflicting commercial demands.
 Organisational Culture
This is a group or company norm.
“the way we do things here.”
 SAFETY CULTURE.
“A set of beliefs, norms attitudes, roles, social and
technical practices concerned with minimising
exposure of employees, managers, customers and
members of the general public to conditions
considered dangerous or hazardous.”

-Active role in error prevention by everybody.

-Judged by what is done rather than what is said
 Key components of a safety culture
• The ‘engine’ that continues to propel the system towards
the goal of maximum safety health, regardless of the
leadership’s personality or current commercial concerns;
• Not forgetting to be afraid;
• Creating a safety information system that collects,
analyses and disseminate information from incidents and
near-misses as well as from regular proactive checks on
the system’s vital signs.
• A just culture – an atmosphere of trust, where people are
encouraged, even rewarded, for providing essential safety
related information – but in which they are clear about
where the line must be drawn between acceptable and
unacceptable behaviour;
 Key components of a safety culture cont

• A good reporting culture, where staff are willing

to report near-misses;
• A flexible culture;
• Respect for the skills, experience and abilities of
the workforce and first line supervisors;
• Training investment;
• A learning culture – the willingness and the
competence to draw the right conclusions from its
safety information system, and the will to
implement major reforms when their need is
 Social culture
• It considers at an individuals background or
heritage.
• Internal pressures and conflicts can be driven
by underlying social cultural differences (e.g.
different nationalities, different political views,
different religious beliefs, etc.)
• Influence of social culture is important in
determining how an individual integrates into
an organizational culture as the responsibility of
the individual is also an important factor as
regards Safety Culture.
 Social culture
• Safety culture is an amalgamation of the
attitude, beliefs and actions of all the
individuals working for the org and each
person should take responsibility for their own
contribution towards this culture, ensuring
that it is positive contribution rather than
negative.
 Maintenance Error Management System

 Maintenance error is said to have occurred when the

maintenance system, including the human element, fails to
perform in the manner expected in order to achieve its
safety objectives.

 . The human element includes technicians, engineers,

planners, managers, store-keepers – in fact any person
contributing to the maintenance process.
 Definition differs from that of a human error as it demands
consideration of the system failings (e.g. inadequate staffing,
organizational factors, tooling availability, ambiguous
manuals etc.) as well as the error committed by a person.
 MAINTENANCE ERROR
MANAGEMENT SYSTEM (MEMS)

• The CAA is declaring its policy on

Maintenance Error Management Systems
such that maintenance organizations, in
particular those maintaining large
commercial aircraft, are encouraged to
adopt the concept.
 AIM OF MEMS
• The aim of the system is to identify the
factors contributing to incidents, and to
make the system resistant to similar errors.
• Whilst not essential to the success of a MEMS, it
is recommended that for large organizations a
computerized database be used for storage and
analysis of MEMS data. This would enable the full
potential of such a system to be utilized in managing
errors
 MEMS ELEMENTS
MEMS should contain the following elements:
• Clearly identified aims and objectives
• Demonstrate corporate commitment with
responsibilities for the MEMS clearly identified
• Corporate encouragement of uninhibited
reporting and participation by individuals.
• Disciplinary policies and boundaries identified
and published
 MEMS ELEMENTS cont
• An event investigation process
• The events that will trigger error investigations
identified and published
• Investigators selected and trained
• MEMS education for staff, and training where
necessary
• Appropriate action based on investigation
findings
• Feedback of results to workforce
• Analysis of the collective data showing
contributing factor trends and frequencies.