TRAINING MANUAL

uk HUMAN FACTORS
MODULE 9
CONTENTS

engineering

HUMAN FACTORS

HF Front & Contents.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CONTENTS

engineering

INTENTIONALLY BLANK

HF Front & Contents.doc/Issue

 MODULE 9 : HUMAN FACTOR

INDEX

CONTENTS PAGE

9.0 INTRODUCTION I - VI

9.1 GENERAL
The need to take human factors into account;
Incidents attributable to human factors/human error; 1.1 - 2.4
‘Murphy’s’ law.

9.2 HUMAN PERFORMANCE and LIMITATIONS

Vision;
Hearing;
Attention and perception; 2.5 - 2.29
Memory;
Claustrophobia and physical access.

9.3 SOCIAL PSYCHOLOGY

Responsibility : individual and group;

Motivation and de-motivation;
Peer pressure; 2.30 - 2.48
‘Culture’ issues;
Team working;
Management,supervision and leadership.

9.4 FACTORS AFFECTING PERFORMANCE

Fitness/health;
Stress : domestic and work related; 3.3 - 3.34
Time pressure and deadlines;
Sleep and fatigue,shiftwork;

9.5 PHYSICAL ENVIRONMENT

Noise and fumes; 3.51 - 3.54

Illumination;
9.6 TASKS

Physical work;
Repetitive tasks; 3.55 - 3.58
Visual environment;
Complex systems.

9.7 COMMUNICATION

Within and between teams;

Work logging and recording; 3.35 - 3.50
Keeping up to date,currency;
Dissenmination of information

9.8 HUMAN ERROR

Error models and theories;

Types of error in maintenance tasks; 5.1 - 5.9
Implications of errors (i.e accidents)

9.9 HAZARDS IN THE WORKPLACE

Avoiding and managing errors.

Recognising and avoiding hazards; 4.1 - 4.5
Dealing with emergencies.
 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
INTRODUCTION

engineering
INTRODUCTION

Nobody comes into work to do a 'bad job', indeed we strive to do our very best.
Despite our best endeavours however, mistakes happen and accidents occur as
a result of those mistakes. It was Cicero, a renowned Roman politician who first
coined the phrase 'to err is human', and I believe we can all agree that this is so.
What we must also believe in however is that we can learn from mistakes, both the
ones we ourselves make and also from the mistakes made by others. If we can
grasp this basic concept, of learning from our own and other’s mistakes then we will
reduce the possibility of accidents occurring.

This course is designed to study the underlying causes which may result in a well
intentioned Aircraft Maintenance Engineer (AME) making a maintenance error. We
will also look at what we can do to prevent ourselves from contributing to events
which lead to an accident.

You will get out of this course only what you are prepared to put into it. Be open-
minded, but if you disagree with anything that is being said, then feel free to speak
up. Because we are dealing with the human in the equation, you will find that there
are often no "right" or "wrong" answers but "what works for you" and it could work for
someone else if you share it.

We will start with a look at some of the factors which can influence how we see and
interpret our (working) environment. We will then progress to the means whereby
we can, by understanding their impact ,utilise our knowledge in order to reduce the
possibility of maintenance error occurrences. First though some facts:

JAR-M.80 Maintenance Human Factors States:

i. No person may be required to complete a maintenance work task within an

unrealistic timeframe. This includes any personnel engaged in management,
supervision, planning, maintenance, inspection, maintenance release, record
keeping and quality audit.
ii. No person may be required to perform planning, maintenance, inspection,
maintenance release or record keeping without the appropriate tooling,
equipment and working instructions.
iii. No person may be required to perform planning, maintenance, inspection,
maintenance release or record keeping unless their competence in the task
has been proven.
iv. No person should be pressurised to release an aircraft or aircraft component
when that person has reason to question the safety standard.
v. No person may be required to release or authorise the release of an aircraft
unless that person is able to inspect the aircraft.

1st DRAFT 2 September 1996

HF Introduction.doc/Issue 3 Page i
 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
INTRODUCTION

engineering
Aviation Accidents

Page ii HF Introduction.doc/Issue 3
 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
INTRODUCTION

engineering
CAUSES AND COSTS OF AIR ACCIDENTS

(1982-91) Causal Factors No. Accidents O/B fatalities

Controlled flight into terrain (CFTT) 36 2169

Maintenance and inspection 47 1481
Loss of control/uncontrollable 9 1387
ATC and communication 39 1000
Approach & landing without CFIT 133 910
Postcrash smoke & fire 41 729
Inflight smoke & fire 6 610
Ground de-icing/anti-icing 9 384
Windshear 10 381
Uncontained engine failure 11 199
Out-of-configuration takeoff 11 188
Airport ground operations control 23 138
Rejected takeoff 19 53

FROM: J REASON, Omissions and their Management.

Colloquium held at the University of Amsterdam.
March 4, 1996.

MAINTENANCE ERRORS (122 occurrences 1989-91)

Major category Per cent of total

Omissions 56%
Incorrect installations 30%
Wrong parts 8%
Other 6%

FROM: J REASON, Omissions and their Management.

Colloquium held at the University of Amsterdam.
March 4, 1996.

HF Introduction.doc/Issue 3 Page iii

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
INTRODUCTION

engineering
Incidents/ Accidents Where Maintenance Error was a Factor

There have been several high profile accidents and incidents which have involved
maintenance human factors problems. The ‘hfskyway’ website lists 24 National
Transportation Safety Board (NTSB) accident reports of accidents where
maintenance Human Factors problems have been the cause or a major contributory
factor. In the UK, there have been three major incidents, details of which can be
found on the Air Accident Investigation Branch (AAIB) web site (www.aaib.gov.uk).
Several of the major incidents and accidents where maintenance Human Factors
have been a significant factor are summarised below:

NTSB/AAR-84/04. Eastern Airlines, L-1011, N334EA, Miami, May 1983

During maintenance, technicians failed to fit O-ring seals on the master chip
detector assemblies. This led to loss of oil and engine failure. The aircraft landed
safely with one engine. Technicians had been used to receiving the master chip
detectors with O-ring seals already fitted and informal procedures were in use
regarding fitment of the chip detectors. This problem has occurred before, but no
appropriate action had been carried out to prevent a re-occurrence.

NTSB/AAR-89/03. Aloha Airlines, B737-200, N73711, Hawaii, April 1988

The Aloha accident 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.

AAIB/ AAR 2/95, Excalibur Airways, A320-212, G-KMAM, Gatwick, August 1993

Another incident 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 technicians. This
misunderstanding was due, in part, to familiarity of the technicians 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.

Page iv HF Introduction.doc/Issue 3
 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
INTRODUCTION

engineering

AAIB/AAR 1/92, British Airways BAC1-11, G-BJRT, Didcot, June 1990

In 1990, in the UK, a BAC1-11 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. 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 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 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 organisational and design factors.

AAIB/ AAR 3/96, British Midland, B737-400, G-OBMM, Daventry, February 1995

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 subject to borescope inspections on both
engines during the preceding night and the high pressure (HP) rotor drive covers had
not been refitted, resulting in the 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.

HF Introduction.doc/Issue 3 Page v
 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
INTRODUCTION

engineering

AAIB Bulletin 5/97, British Airways, B747, GBDXK, Gatwick, November 1996

The 4L door handle moved to the ‘open’ position during the climb. The Captain
elected to jettison fuel and return to Gatwick. An investigation revealed that the door
torque tube had been incorrectly drilled/fitted. The Maintenance Manual required a
drill jig to be used when fitting the new undrilled torque tube, but no jig was available.
The LAE and Flight Technical Liaison Engineer (FTLE) elected to drill the tube in the
workshop without a jig, due to time constraints and the operational requirement
for the aircraft. The problem with the door arose as a result of incorrectly positioned
drill holes.

Lufthansa A320 incident, 20 March 2001

During maintenance, two pairs of pins inside one of the elevator/aileron computers
were cross connected. This changed the polarity of the Captain’s side stick and the
respective control channels, bypassing the control unit which might have sensed the
error and would have triggered a warning. Functional checks post maintenance
failed to detect the crossed connection because the technician used the first officer’s
side stick, not the pilot’s. The pilots’ pre-flight checks also failed to detect the fault.
The problem became evident after take-off when the aircraft ended up in a 21° left
bank and came very close to the ground, until the co-pilot switched his sidestick to
priority and recovered the aircraft.

Page vi HF Introduction.doc/Issue 3
 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE NEED TO TAKE
HUMAN FACTORS
INTO ACCOUNT
engineering SECTION 1

HUMAN FACTORS

OBJECTIVES

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

develop safeguards to lessen the "Human Cause" factors in maintenance.

To examine the human role of maintenance that can lead to an aviation occurrence
and develop ways to prevent or lessen the seriousness of the occurrence.

HF Section 1.doc/ Issue 3 Page 1-1

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE NEED TO TAKE
HUMAN FACTORS
INTO ACCOUNT
engineering SECTION 1

What Is Human Factors?

“Human Factors is about people: it is about people in their working and living
environments, and it is about their relationship with equipment, procedures and
the environment. Just as importantly, it is about their relationships with other
people. Human Factors involves the overall performance of human beings within the
aviation system; it seeks to optimise people's performance through the systematic
application of the human sciences, often integrated within the framework of system
engineering. Its twin objectives can be seen as safety and efficiency.”

The Need to Take Human Factors into Account

Human error is a fixed part of the human condition and therefore cannot be
totally eradicated. We all make errors/mistakes every day. Errors serve a useful
service in the trial and error learning process. Errors with no bad effects can
sometimes be good, but we must not confuse these types of errors with the bad
effects of errors. In aviation, we cannot tolerate the bad effects of error.

When an error occurs in the maintenance system of an airline, the engineer who last
worked on the aircraft is usually considered to be at fault. The engineer may be
reprimanded, sent for further training, or simply told not to make the same mistake
again. However, to blame the engineers for all of the errors that are committed is
perhaps giving them too much credit for their role in the airline's maintenance
system. Many errors are, in fact, committed due to other failures inherent in the
system and the engineer involved is merely the source of one of the failures. In
these cases, it may not matter which engineer is involved at the time of the actual
incident, the system encourages particular errors or violations to be committed.

The failures caused by those in direct contact with the system, ie, the engineers who
are working on the aircraft, are considered to be active failures. These failures are
errors or violations that have a direct and immediate effect on the system.
Generally, the consequences of these active failures are caught by the engineer
himself, or by the defences, barriers and safeguards built into the maintenance
system. Thus, the system must rarely deal with the consequences of active failures.
However, when an active failure occurs in conjunction with a breach in the defences,
a more serious incident occurs.

Latent failures are those failures which derive from decisions made by supervisors
and managers who are separated in both time and space from the physical system.
For example, technical writers may write procedures for a task with which they are
not totally familiar. If the procedure has even one mistake in it, the engineer using
the procedure will be encouraged to commit an error. The latent failures can often
be attributed to the absence or weaknesses of defences, barriers, and safeguards in
the system. Often, latent failures may lie dormant in the system for long periods
before they become apparent.
Page 1-2 HF Section 1.doc/Issue 3
 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE NEED TO TAKE
HUMAN FACTORS
INTO ACCOUNT
engineering SECTION 1

Models Describing Human Factors

In order to simplify the relationship between engineers and the factors which impact
upon their every day working lives several models have been produced, examples of
which are:

1. The ‘SHEL’ Model

This model shows the interfaces between the human, being the ‘L’ in the centre
box and the other elements of the SHEL model, e.g: ’S’ for software being the
interpretation of procedures, illegible manuals, poorly designed checklists, ineffective
regulation, untested computersoftware etc. ‘H’ for hardware meaning not enough
tools, inappropriate equipment, poor aircraft design for maintainability etc. ‘E’ for
environment meaning your working environment which may involve an
uncomfortable workplace, inadequate hangar space, variable temperature, noise etc.
and last but by no means least ‘L’ for liveware meaning poor morale, relationships
with other people, shortage of manpower, lack of supervision, lack of support from
managers. However, the model also accepts that sometimes the ‘L’ in the centre box
can stand alone, and there can be problems associated with a single individual
which are not necessarily related to any of the L-S, L-H, L-E, L-L interfaces.

The ‘SHEL’ Model

HF Section 1.doc/ Issue 3 Page 1-3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE NEED TO TAKE
HUMAN FACTORS
INTO ACCOUNT
engineering SECTION 1

2. The British Airways ‘PEEP’ Model

Here the emphasisis is placed upon the interfaces and integration between the
engineer and the aspects which affect his/her performance.

BA’s ‘PEEP’ Model: An Intergrated Approach

Page 1-4 HF Section 1.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE NEED TO TAKE
HUMAN FACTORS
INTO ACCOUNT
engineering SECTION 1

3. Reason's ‘Swiss Cheese’ Model

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

within an organisation. The arrows represent errors and the holes in the cheese
inadequate defences within an organisation allowing errors through. Errors not
identified at source are usually picked up and rectified by the next or subsequent
"slices" in the system. However there are occasions when an error will find its way
straight through the system resulting in an accident.

The aim therefore of each department/activity within an organisation is to turn their

particular slice of "Swiss Cheese" into a slice of best "Farmhouse Cheddar"!!

HF Section 1.doc/ Issue 3 Page 1-5

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE NEED TO TAKE
HUMAN FACTORS
INTO ACCOUNT
engineering SECTION 1

A CHAIN IS AS STRONG AS ITS "WEAKEST" LINK

Page 1-6 HF Section 1.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE NEED TO TAKE
HUMAN FACTORS
INTO ACCOUNT
engineering SECTION 1

4. The Weakest Link

An aircraft flies courtesy of the efforts of many people employing their particular
skills on a variety of tasks. Each of these tasks is vital to the safe operation of an
aircraft, each task strengthening the link between its departments activities with
others departments and eventually the aircraft itself. It is a well known fact that
the strongest part of any chain is its weakest link. If a link breaks the aircraft
falls out of the sky!! Can you identify any weaknesses in either yourself or your
department that could lead to the chain failing?

For an incident to occur, latent failures must combine with active failures and local
triggering events, such as unusual system states, local environmental conditions, or
adverse weather. There must be a precise 'alignment' of all of the 'holes' in all of the
defensive layers in a system. (See Reason's Swiss Cheese Model). For example,
rain may cause a engineers' foot to be wet, allowing his foot to easily slip off the
worn brake pedal in a pushback tug when the engineer becomes distracted. The tug
may then lungs forward contacting a parked aircraft. The latent failure in the system
is that the brake pedal has no anti-slip surface in place, but the problem does not
become an issue until the rainy conditions (a local trigger) cause an incident. It can
be seen that if any one of the failures had not occurred (engineer did not become
distracted, the tarmac was not wet, or the brake pedal was in better condition), the
incident would have been avoided.

An incident similar to this at Edinburgh Airport resulted in the loss of life of an

engineer during turnaround when, during the removal of a ground power unit
following engine start, the engineer manoeuvred within the rotating propeller arc.

Thus, it can be seen that a large number of unsafe acts (errors and violations) may
occur on a daily basis, but it is very rare that a situation is elevated into a serious,
reportable incident. Usually, the unsafe acts are either caught immediately, or the
defences of the system prevent the problem from becoming an incident, ie, the error
is prevented from propagating through the system. Engineers are especially
conscious of the importance of their work, and typically expend considerable effort to
prevent injuries, prevent damage, and to keep the aircraft safe.

HF Section 1.doc/ Issue 3 Page 1-7

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE NEED TO TAKE
HUMAN FACTORS
INTO ACCOUNT
engineering SECTION 1

Page 1-8 HF Section 1.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

THE POTENTIAL FOR HUMAN ERROR

In our study of human factors we will be mostly concerned with identifying those
aspects of our behaviour that can result in the making of mistakes or errors which
could result in accidents. We all have the potential to err. Our capacity to perceive
what is going on in our working environment by sight, touch, feel, smell, hearing
etc: together with our capacity to remember, process information and act upon it are
all relevant in the context of human error.

Types of Error

Basically the types of errors encountered fall into four categories:

1) Slips

2) Lapses

3) Mistakes

4) Violations

Slips

Slips can be thought of as actions not carried out as intended or planned, e.g.
transposing digits when copying out numbers, or carrying out steps in a procedure in
the wrong order. Slips typically appear at the execution stage of a process.

Lapses

Lapses are identified as missed actions or omissions, ie. The occasion when
somebody has failed to do something due to a lapse of memory and/or attention or
because they have forgotten something, e.g. forgotten to close and secure the oil
cap. Lapses typically occur as a result of failures in our capacity to store and
retrieve information from our memory bank.

Mistakes

Mistakes are a specific type of error brought about by a faulty plan or intention,
i.e. somebody doing something believing it to be correct when it is, in fact, wrong,
e.g. an error of judgement such as selecting the wrong bolts when refitting an
aircraft’s windscreen. Mistakes typically occur during the planning stages of a
process.

HF Section 2.doc/ Issue 3 Page 2-1

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

INTENTIONALLY BLANK

Page 2-2 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Violations

Violations sometimes appear to be human errors, but they differ from slips, lapses
and mistakes because they are deliberate ‘illegal’ actions, i.e. somebody doing
something knowing it is against the rules, e.g. deliberately failing to follow the proper
procedures. AMEs may consider a violation is well intentioned, i.e. taking a ‘short
cut’ in order to get the job done on time. Always remember however that procedures
must be followed in the interests of not only safety but also of cost.

Errors which can contribute towards mistakes leading to accidents are incalculable.
However, some of them will fall into one or more of the following:

Inadequate information - be it visual or verbal can, does and will lead to people
making mistakes. If you think the information you have is inadequate or insufficient
do something about it.

Lack of understanding - possibly stemming from inadequate information or maybe

lack of training can lead to people making presumptions as to how a particular
process or procedure is carried out. This can and does lead to accidents. If you're
not sure ask.

Poor design - which can result in the best of intentions turning out wrong.
Remember Murphy? If there's a wrong way to do it that's the way you'll do it! If you
recognise a Murphy do something about it if it's only telling others about it.

Lapses of attention - can and will allow errors to creep in, especially if it’s a simple
straightforward repetitive task. The lesson here is that the more expert you become
at a particular task, the more likely you are to make a mistake, because you think
you can afford to allocate less attention to it. Beware the expert both in yourself
and in others.

Mistaken actions - brought about by the classic situation of doing the wrong thing
under the impression that it's right. A classic example of this is the 'short cut'
wherein the engineer knows what has to be done but chooses his own method of
doing it. Don't take short cuts.

Misperceptions - meaning the capacity we have to see what we want to see, hear
what we want to hear, feel what we want to feel etc. This factor is particularly
relevant to the work of an aircraft engineer in as much as a great many tasks are of a
repetitive nature. The lesson here is to be vigilant and on guard against it.

HF Section 2.doc/ Issue 3 Page 2-3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Page 2-4 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Vision

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

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

Noise

Can detrimentally affect human performance in terms of damaging hearing,

interfering with speech communication, and affecting concentration and
performance. It can also be fatiguing. Effects vary between individuals, and noise of
a certain type and level may be good for one individual but bad for another.

Noise can affect motivation, reduce tolerance of frustration and reduce levels of
aspiration.

There may be an impact upon the individual's ability to think. It is almost certainly
likely to affect inspection or troubleshooting activities where the strategy used is left
to the individual, being primarily assessment - rather than activity-based, possibly
reducing the likelihood of successfully thinking laterally under such circumstances.
How many of us can recall, when concentrating hard on a task, shouting "Stop that
noise; I can't think straight!"

In order to understand the effect both vision and hearing have in terms of
maintenance it is useful to know a little about the anatomy of both the eye and the
ear. Likewise, in order to understand the potential each one of us possesses to
make mistakes, it will help to know a little about our ability to receive, store and use
information.

HF Section 2.doc/ Issue 3 Page 2-5

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Page 2-6 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

The Eye

The eye is the organ which receives light information from the external world and
passes it to the brain. The visual cortex area of the brain interprets this information,
presenting it as a rational, realistic image. The basic structure of the eye is similar to
a simple camera, with an aperture, a lens, and a light sensitive screen, the Retina.

The Function and Structure of the Eye

The Cornea. Light enters the eye through the cornea, a clear window at the front of
the eyeball. The cornea acts as a focusing device and is responsible for between
70 and 80% of the total focusing ability of the eye.
The Iris. The amount of light entering the eye is controlled by the iris, the
coloured part of the eye, which acts as a diaphragm.
The Pupil. The amount of light allowed to fall on the retina is governed by the
size of the pupil, the clear centre of the iris. The size of the pupil can change rapidly
to cater for changing light levels.

Note: The amount of light allowed to enter the eye can be adjusted by a
factor of five to one by the pupil.

This 5:1 factor is not sufficient to cope with the different light levels
experienced between full daylight and a dark night. A further
mechanism is required. In reduced light levels a chemical change
takes place in the light sensitive cells on the retina (cones and rods).
This dark adaptation does take time, about 7 minutes for the cones and
30 minutes for the rods. When complete the chemical change can
cope with large changes in luminance level (of the order of 150,000 : 1
for the cones). After passing through the pupil the light passes through
a clear lens, which can change its shape (accommodation) to achieve
the final focusing onto the retina.

The Retina. The retina is a light sensitive screen lying at the back of the eyeball.
On this screen are light sensitive cells. The cells are of two types; cones and rods.
The cones can only detect colours, the rods can only detect black and white
but are much more sensitive at low light levels. This means that in poor light we see
only in black or white or varying shades of grey. When light falls on these cells a
small electrical charge is generated which is passed onto the brain by the optic
nerve.
The Optic Nerve. The optic nerve enters the back of the eyeball along with the
small blood cells needed to carry oxygen to the cells of the eye.

HF Section 2.doc/ Issue 3 Page 2-7

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

The Fovea. The central part of the retina, the Fovea, is composed only of cone
cells and only at this part of the retina is vision 20/20 or 6/6. The figures are a
means of measuring visual acuity, the ability to discriminate at varying distances. An
individual with 20/20 vision should be able to see at 20 feet that which the so-called
normal person is capable of seeing at this range.

Any resolving power at the fovea drops rapidly as the angular distance from the
fovea increases. At as little as 5° from the fovea the acuity drops to 20/40 that is half
as good as at the fovea. When the angular displacement increases to 20° the visual
acuity will only be one tenth of that at the fovea, that is 20/200.

Anything that needs to be examined in detail is automatically brought to focus on the

fovea. The rest of the retina fulfils the function of attracting our attention to
movement and change,i.e. our peripheral vision, provided by rods.

The Blind Spot. The point on the retina where the optic nerve enters the eyeball
has no covering of light detecting cells. Any image falling at this point will not be
detected. This has great significance when considering the detection of objects
which are on a constant bearing from the observer. If the eye remains looking
straight ahead it is possible for example for a closing aircraft to remain on the blind
spot until a very short time before impact. Safe visual scanning demands frequent
eye movement with minimal time spent looking in any direction.

Page 2-8 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Visual Defects. Most visual defects are caused by the natural shape of the
eyeball.
Hypermetropia. Is long sightedness, (Hypermetropia). A shorter than normal
eyeball along the visual axis results in the image being formed behind the retina and
unless the combined refractive index of the cornea and the lens can combine to
focus the image in the correct plane a blurring of the vision will result when looking at
close objects. A convex lens will overcome this refractive error.
Myopia. Is short-sightedness, (Myopia). The problem is that the eyeball is longer
than normal and the image forms in front of the retina. If accommodation cannot
overcome this then distant objects are out of focus whilst close up vision may be
satisfactory. A concave lens will correct the situation.
Astigmatism. This condition is usually caused by a misshapen cornea. Objects
will appear irregularly shaped. Modern surgical techniques can reshape the cornea
with a scalpel or more easily with laser beams.

Colour Defective Vision

Affecting about 8% of men and 0.5% of women "colour blindness" is usually

associated with the inability to differentiate between reds and greens. Other more
rare types may involve blues and yellows. There are degrees of colour defective
vision, some suffering more than others and ageing of individuals will change their
colour perception. Care should be taken not to discriminate personnel from tasks
merely because they are "colour blind". Tasks that require positive colour perception
must however be carried out by personnel who have been tested to an appropriate
standard.

Conclusion

Ultimately, what is important is for the individual to recognise when their vision is
adversely affected, either temporarily or permanently, and to carefully consider the
possible consequences should they continue to work if the task requires good vision.
AWN47 states: "Organisations should identify any specific eyesight requirements
and put in place suitable procedures to address these issues". General human
factors advice would be to stress the joint moral responsibility upon both the
individual to admit to poor vision and upon the Organisation to create an
environment whereby engineers will not be penalised if they do so.

HF Section 2.doc/ Issue 3 Page 2-9

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Structure Of The Human Ear

Page 2-10 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

The Ear

The ear performs two quite separate functions: firstly it is used to receive vibrations
in the air (sounds), and secondly it acts as a balance organ and acceleration
detector.

Function and Structure of the Ear

The ear is divided into three sections, the outer, middle, and inner ear:

The Outer Ear. The outer ear consists of the Pinna, which collects the vibrations of
the air which form sounds and a tube, the Meatus, which leads to the eardrum. The
sound waves will cause the ear drum to vibrate.
The Middle Ear. The ear drum or Tympanum separates the outer and middle ear.
Connected to the ear drum is a linkage of three small bones the Ossicles, which
transmit the vibrations across the middle ear, which is filled with air, to the
inner ear which is filled with liquid. The last of the bones connects to another
membrane in the inner ear.

Hearing

The Inner Ear. The vibrating membrane causes the fluid in the Cochlea to vibrate.
Inside the cochlea there is a fine membrane covered with tiny hair like cells. The
movement of these small cells will be dependent on the volume and pitch of the
original sound. The amount and frequency of displacement is detected by the
auditory nerve which leads directly to the brain where the tiny electrical currents are
decoded into sound patterns. Note the Eustachian tube which allows the pressure
in the middle ear to equalise with the atmospheric pressure.

HF Section 2.doc/ Issue 3 Page 2-11

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Hearing Impairments. Hearing difficulties are broadly classified into three

categories:
Conductive deafness. Any damage to the conducting system, the Ossicles or the
ear drum, will result in a degradation of hearing. It is possible that perforations of the
ear drum will result in scarring of the tissue thus reducing its ability to vibrate freely.
A blow to the ear may cause damage to the small bones in the middle ear again
limiting the transfer of vibrations. Modern surgery may help in some circumstances.
Noise Induced Hearing Loss (NIHL). Loud noises can damage the very sensitive
membrane in the Cochlea and the fine structures on this membrane. The loss of
hearing may at first be temporary but continued exposure to loud noise will result in
permanent loss of hearing. The early symptoms are an inability to hear high pitched
notes as these notes are normally detected by the finer cells which suffer the
greatest damage.

The loudness of a noise is measured in Decibels (db). For example a sound

proofed room will have a rating of 9 db, an average office 50 db and a busy street
corner 70 db. An observer standing by a runway whilst a large jet takes off will
experience 100 - 120 db. To cause permanent damage to hearing a noise level of
90 db or more is required. The amount of damage is related to the total noise
energy so time of exposure is important. A noise level of 85 db for 8 hours will
cause the same damage as exposure to 103 db for 30 minutes or 116 db for 1
minute.

The noise level on and around a busy airport can be very high and it is essential
that ear defenders are worn by all personnel working in the area of high noise
levels.

Notes:
1. For the younger element the noise level in discos can be excessive
and personal stereos can reach above the safety level.

2. Noise Induced Hearing Loss (NIHL) is not treatable at the moment.

Recent experiments hold out some hope of a cure as researchers
have been able to regrow the fine hair like cells in the cochlea of
young rats. The treament involves the use of retinoic acid, made
from vitamin A. The treatment in humans is still however a long
way off and the only sure way to avoid NIHL is to protect the
ears from loud noises.
Presbycusis. (Loss through ageing). Hearing deteriorates with advancing age.
Young children can hear high pitched noises outside the range of adults. The loss of
some hearing is natural as one grows older but if combined with some NIHL there
may be a chance of increased impairment.

Page 2-12 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

The Ear and Balance. As well as acting as the organ to detect sounds, the ear is
used to detect angular and linear accelerations. Our primary source of spatial
orientation is sight but the ear provides a secondary system, particularly if vision is
restricted.

Within the inner ear are three Semi-circular canals, tubes filled with liquid and
arranged in three planes at 90 degrees to each other. Within these tubes are fine
hairs which are bent as the liquid in the tubes moves in relation to the walls of the
tubes. The movements of these hairs generates a small electric current which is
passed to the brain to be detected as a movement of the head.

The semi-circular canals detect angular movement; linear acceleration is

detected by the Otoliths at the base of each of the canals. The Otoliths, literally
'stones in the ears', are fleshy stalks surmounted by a small stone or crystal.
Acceleration in any plane causes the stalks to bend and this bending is interpreted
by the brain to decide the new position of the head.
The Semi-circular canals and the Otoliths together make up the Vestibular apparatus
which helps to maintain spatial orientation and control other functions. For example
it controls eye movement to maintain a stable picture of the world on the retina even
when the head is moved.
The Effects of Alcohol. Alcohol has a lower specific gravity than water. Alcohol in
the middle ear may dilute the liquids and cause unfamiliar results for certain
movements, leading to disorientation. Alcohol in the fleshy stalk of the Otolith may
persist for days after all traces of alcohol have vanished from the blood. It is not
unusual for even small movement of the head to cause disorientation or motion
sickness up to three days after alcohol was last consumed.
Conclusion

The effects of noise on performance are extremely complex, with no clear guidance
emerging as to what noise levels are likely to adversely affect performance in
relation to aviation safety. As a rule of thumb and in the absence of more detailed
guidelines, if noise levels are kept within the bounds to protect against hearing
damage (see Table 1) this should also avoid situations where noise is likely to have
a significantly detrimental affect on performance in general terms. This may not,
however, be sufficient to avoid breaking someone's concentration.

HF Section 2.doc/ Issue 3 Page 2-13

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

INTENTIONALLY BLANK

Page 2-14 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

TABLE 1
Duration per day (hr) Sound Level in dB(A)
8 85
6 92
4 95
3 97
2 100
1.5 102
1 105
0.5 110
<0.25 115
Source: OSHA

Maximum Recommended Noise Exposure for Occupational Noise

HF Section 2.doc/ Issue 3 Page 2-15

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Information Processing

Information processing can be represented as a model. This captures the main

elements of the process, from receipt of information via the senses, to outputs such
as decision making and actions. One such model is shown. Information processing is
the process of receiving information through the senses, analysing it and making it
meaningful.

A Functional Model Of Human Information Processing

Page 2-16 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Sensory Receptors and Sensory Stores

Physical stimuli are received via the sensory receptors (eyes, ears, etc.) and
stored for a very brief period of time in sensory stores (sensory memory).

Visual information is stored for up to half a second in iconic memory and sounds
are stored for slightly longer (up to 2 seconds) in echoic memory. This enables us
to remember a sentence as a sentence, rather than merely as an unconnected string
of isolated words, or a film as a film, rather than as a series of disjointed images.

Attention and Perception

Having detected information, our mental resources are concentrated on specific
elements - this is attention.

Attention - This can be thought of as the concentration of mental effort on

sensory or mental events.

Although attention can move very quickly from one item to another, it can only deal
with one item at a time. Attention can take the form of:
• Selective attention,
• Divided attention,
• Focused attention
• Sustained attention.

Selective attention occurs when a person is monitoring several sources of input,

with greater attention being given to one or more sources which appear more
important. A person can be consciously attending to one source whilst still sampling
other sources in the background. Psychologists refer to this as the ‘cocktail party
effect’ whereby you can be engrossed in a conversation with one person but your
attention is temporarily diverted if you overhear your name being mentioned at the
other side of the room, even though you were not aware of listening in to other
people’s conversations. Distraction is the negative side of selective attention.

Divided attention is common in most work situations, where people are required to
do more than one thing at the same time. Usually, one task suffers at the expense of
the other, more so if they are similar in nature. This type of situation is also
sometimes referred to as time sharing.

Focused attention is merely the skill of focussing one’s attention upon a single
source and avoiding distraction.

Sustained attention as its name implies, refers to the ability to maintain attention
and remain alert over long periods of time, often on one task. Most of the
research has been carried out in connection with monitoring radar displays, but there
is also associated research which has concentrated upon inspection tasks.

HF Section 2.doc/ Issue 3 Page 2-17

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

INTENTIONALLY BLANK

Page 2-18 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Perception
This involves the organisation and interpretation of sensory data in order to make it
meaningful, discarding non-relevant data, i.e. transforming data into information.
Perception is a highly sophisticated mechanism and requires existing
knowledge and experience to know what data to keep and what to discard, and how
to associate the data in a meaningful manner.

Perception can be defined as the process of assembling sensations into a useable

mental representation of the world. Perception creates faces, melodies, works of art,
illusions, etc. out of the raw material of sensation.

Examples of the perceptual process:

• the image formed on the retina is inverted and two dimensional, yet we see the
world the right way up and in three dimensions;

• if the head is turned, the eyes detect a constantly changing pattern of images, yet
we perceive things around us to have a set location, rather than move chaotically.

Decision Making
Having recognised coherent information from the stimuli reaching our senses,
a course of action has to be decided upon. In other words decision making
occurs.This may range from deciding to do nothing, to deciding to act immediately in
a very specific manner. A fire alarm bell, for instance, may trigger a well-trained
sequence of actions without further thought (i.e. evacuate); alternatively, an
unfamiliar siren may require further information to be gathered before an appropriate
course of action can be initiated.

We are not usually fully aware of the processes and information which we use to
make a decision. Tools can be used to assist the process of making a decision.
For instance, in aircraft maintenance engineering, many documents (e.g.
maintenance manuals, fault diagnosis manuals), and procedures are available
to supplement the basic decision making skills of the individual. Thus, good
decisions are based on knowledge supplemented by written information and
procedures, analysis of observed symptoms, performance indications, etc. It
can be dangerous to believe that existing knowledge and prior experience will
always be sufficient in every situation.
Finally, once a decision has been made, an appropriate action can be carried out.
Our senses receive feedback of this and its result. This helps to improve knowledge
and refine future judgement by learning from experience.

Decision making is the generation of alternative courses of action based on

available information, knowledge, prior experience, expectation, context,
goals, etc. and selecting one preferred option. It is also described as thinking,
problem solving and judgement.

HF Section 2.doc/ Issue 3 Page 2-19

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Page 2-20 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Memory
Memory is critical to our ability to act consistently and to learn new things. Without
memory, we could not capture a ‘stream’ of information reaching our senses, or draw
on past experience and apply this knowledge when making decisions. Memory
depends on three processes:

• registration - the input of information into memory;

• storage - the retention of information;
• retrieval - the recovery of stored information.

It is possible to distinguish between three forms of memory:

a) ultra short-term memory (or sensory storage);

b) short term memory (often referred to as working memory)
c) long term memory.

Ultra short-term memory has already been described when examining the role of
sensory stores. It has a duration of up to 2 seconds (depending on the sense) and
is used as a buffer, giving us time to attend to sensory input.

Short term memory receives a proportion of the information received into sensory
stores, and allows us to store information long enough to use it (hence the idea of
‘working memory’). It can store only a relatively small amount of information at one
time, i.e. 5 to 9 (often referred to as 7 r 2) items of information, for a short duration,
typically 10 to 20 seconds. As the following example shows, capacity of short term
memory can be enhanced by splitting information in to ‘chunks’ (a group of related
items).

Example
Memory can be considered to be the storage and retention of information,
experiences and knowledge, as well as the ability to retrieve this information.
A telephone number, e.g. 01222555234, can be stored as 11 discrete digits, in which
case it is unlikely to be remembered. Alternatively, it can be stored in chunks of
related information, e.g. in the UK, 01222 may be stored as one chunk, 555 as
another, and 234 as another, using only 3 chunks and therefore, more likely to be
remembered. In mainland Europe, the same telephone number would probably be
stored as 01 22 25 55 23 4, using 6 chunks. The size of the chunk will be determined
by the individual’s familiarity with the information (based on prior experience and
context), thus in this example, a person from the UK might recognise 0208 as the
code for London, but a person from mainland Europe might not.

HF Section 2.doc/ Issue 3 Page 2-21

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Memory Capacity

Short Term Memory

The duration of short term memory can be extended through rehearsal (mental
repetition of the information) or encoding the information in some meaningful
manner (e.g. associating it with something as in the previous example).

Long Term Memory

The capacity of long-term memory appears to be unlimited. It is used to store

information that is not currently being used, including:

Knowledge of the physical world and objects within it and how these behave;
personal experiences; beliefs about people, social norms, values, etc.;
motor programmes, problem solving skills and plans for achieving various activities;
abilities, such as language comprehension.

Information in long-term memory can be divided into two types: (i) semantic and (ii)
episodic.

Semantic memory refers to our store of general, factual knowledge about the world,
such as concepts, rules, one’s own language, etc. It is information that is not tied to
where and when the knowledge was originally acquired.

Episodic memory refers to memory of specific events, such as our past

experiences (including people, events and objects). We can usually place these
things within a certain context. It is believed that episodic memory is heavily
influenced by a person’s expectations of what should have happened, thus two
people’s recollection of the same event can differ.

Motor Programmes

If a task is performed often enough, it may eventually become automatic and the
required skills and actions are stored in long term memory. These are known as
motor programmes and are ingrained routines that have been established
through practice. The use of a motor programme reduces the load on the central
decision maker. An often quoted example is that of driving a car: at first, each
individual action such as gear changing is demanding, but eventually the separate
actions are combined into a motor programme and can be performed with little or no
awareness. These motor programmes allow us to carry out simultaneous activities,
such as having a conversation whilst driving.

Page 2-22 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Situation Awareness

Although not shown explicitly in the model, the process of attention, perception and
judgement should result in awareness of the current situation. Situation awareness
has traditionally been used in the context of the flight deck to describe the pilot’s
awareness of what is going on around him, e.g. where he is geographically, his
orientation in space, what mode the aircraft is in, etc. In the maintenance
engineering context, it refers to:

The perception of important elements, e.g. seeing loose bolts or missing parts,
hearing information passed verbally;

The comprehension of their meaning, e.g. why is it like this? Is this how it should
be?

The projection of their status into the future, e.g. future effects on safety, schedule,
airworthiness.

An example is an engineer seeing (or perceiving) blue streaks on the fuselage. His
comprehension may be that the lavatory fill cap could be missing or the drainline
leaking. If his situation awareness is good, he may appreciate that such a leak could
allow blue water to freeze, leading to airframe or engine damage.

As with decision making, feedback improves situation awareness by informing us of

the accuracy of our mental models and their predictive power. The ability to project
system status backward, to determine what events may have led to an observed
system state, is also very important in aircraft maintenance engineering, as it allows
effective fault finding and diagnostic behaviour.

Situation awareness for the aircraft maintenance engineer can be summarised as:

The status of the system the engineer is working on;

The relationship between the reported defect and the intended rectification;

The possible effect on this work on other systems;

The effect of this work on that being done by others and the effect of their work on
this work.

This suggests that in aircraft maintenance engineering, the entire team needs to
have situation awareness - not just of what they are doing individually, but of their
colleagues’ activities as well.

HF Section 2.doc/ Issue 3 Page 2-23

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Attention and Perception

A proportion of ‘sensed’ data may be lost without being ‘perceived’. An example with
which most people are familiar is that of failing to perceive something which
someone has said to you, when you are concentrating on something else, even
though the words would have been received at the ear without any problem. The
other side of the coin is the ability of the information processing system to perceive
something (such as a picture, sentence, concept, etc.) even though some of the data
may be missing. The danger, however, is that people can fill in the gaps with
information from their own store of knowledge or experience, and this may lead to
the wrong conclusion being drawn.

Once we have formed a mental model of a situation, we often seek information

which will confirm this model and, not consciously, reject information which suggests
that this model is incorrect.

There are many well-known visual ‘illusions’ which illustrate the limits of human
perception. The following figures show how the perceptual system can be misled.

The Muller-Lyer Illusion

This shows that the perceptual system can be misled into believing that one line is
longer than the other, even though a ruler will confirm that they are exactly the same
length.

Page 2-24 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

The Importance Of Context

This illustrates that we can perceive the same thing quite differently (i.e. the letter “B”
or the number “13”).

The Effects Of Expectation

This demonstrates that most people tend to notice nothing wrong with the sentence.
Our perceptual system sub-consciously rejects the additional “THE”.

HF Section 2.doc/ Issue 3 Page 2-25

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Expectation

As an illustration of how expectation, can affect our judgement, the same video of a
car accident was shown to two groups of subjects. One group were told in advance
that they were to be shown a video of a car crash; the other were told that the car
had been involved in a ‘bump’. Both groups were asked to judge the speed at which
the vehicles had collided. The first group assessed the speed as significantly higher
than the second group.

Expectation can also affect our memory of events. The study outlined above was
extended such that subjects were asked, a week later, whether they recalled seeing
glass on the road after the collision. (There was no glass). The group who had been
told that they would see a crash, recalled seeing glass; the other group recalled
seeing no glass.

Decision Making, Memory, and Motor Programmes

Attention and perception shortcomings can clearly impinge on decision making.

Perceiving something incorrectly may mean that an incorrect decision is made,
resulting in an inappropriate action. Our model also shows the dependence on
memory to make decisions. It was explained earlier that sensory and short-term
memory have limited capacity, both in terms of capacity and duration. It is also
important to bear in mind that human memory is fallible, so that information:

May not be stored;

May be stored incorrectly;
May be difficult to retrieve.

All these may be referred to as forgetting, which occurs when information is

unavailable (not stored in the first place) or inaccessible (cannot be retrieved).

It is generally better to use the manuals and temporary aides-memoires rather

than to rely upon memory, even in circumstances where the information to be
remembered or recalled is relatively simple. For instance, an aircraft maintenance
engineer may think that he will remember a torque setting without writing it down, but
between consulting the manual and walking to the aircraft (possibly stopping to talk
to someone on the way), he may forget the setting or confuse it (possibly with a
different torque setting appropriate to a similar task with which he is more familiar).
Additionally, if unsure of the accuracy of memorised information, an aircraft
maintenance engineer should seek to check it, even if this means going elsewhere to
do so. Noting something down temporarily can avoid the risk of forgetting or
confusing information. However, the use of a personal note book to capture such
information on a permanent basis can be dangerous, as the information in it may
become out-of-date.

Page 2-26 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

The Aloha Incident

Remember this? The Aloha accident, involved 18 feet of the upper cabin structure
of a Boeing 737 suddenly being ripped away, in flight, due to structural failure.
The aircraft involved in this accident had been examined, as required by two
engineering inspectors. One inspector had 22 years experience and the other, the
chief inspector, had 33 years experience. Neither found any cracks in their
inspection. Post-accident analysis determined there were over 240 cracks in the
skin of this aircraft at the time of the inspection.

The Aloha accident investigation report stated also that:

"Inspection of the rivets required inspectors to climb on scaffolding and move along
the upper fuselage carrying a bright light with them; in the case of an eddy current
inspection, the inspectors needed a probe, a meter, and a light. At times, the
inspector needed ropes attached to the rafters of the hangar to prevent falling from
the airplane when it was necessary to inspect rivet lines on top of the fuselage.
Even if the temperatures were comfortable and the lighting was good, the task of
examining the area around one rivet after another for signs of minute cracks while
standing on a scaffolding or on top of the fuselage is very tedious. After examining
more and more rivets and finding no cracks, it is natural to begin to expect that
cracks will not be found. Further, when the skin is covered with several layers of
paint the task is even more difficult. Indeed, the physical, physiological, and
psychological limitations of this task are clearly apparent."

HF Section 2.doc/ Issue 3 Page 2-27

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Claustrophobia, Physical Access and Fear of Heights

Claustrophobia. Claustrophobia is defined as "an abnormal fear of being in an

enclosed space". This is the extreme case. However, there are many
circumstances where people may experience various levels of physical or
psychological discomfort when in an enclosed or small space, which is generally
considered to be quite normal. Most people have no difficulty in entering a lift, for
instance, but would not consider going pot-holing under any circumstances! In this
text, claustrophobia is reserved for the extreme case where a person is extremely
uncomfortable, often to the extent of experiencing panic, in circumstances which
most people would not consider a problem.

It is unlikely that someone suffering from claustrophobia would take up aircraft

maintenance engineering as a career, but it may be the case, however, that
susceptibility to claustrophobia is not apparent at the start of employment but comes
about because of an incident when working within a confined space, e.g. panic if
unable to extricate oneself from a fuel tank. If an engineer feels that they suffer from
this problem, they should make their colleagues and supervisors aware, so that if
tasks likely to generate claustrophobia cannot be avoided, at least colleagues may
be able to assist in extricating an engineer from the confined space quickly and
sympathetically.

Physical Access. Problems associated with physical access are not uncommon in
aircraft maintenance engineering. Maintenance engineers and technicians often
have to access, and work in, very small spaces (eg in fuel tanks), cramped
conditions (such as beneath flight instrument panels, around rudder pedals),
elevated locations (on cherry-pickers or staging), sometimes in uncomfortable
climatic or environmental conditions (heat, cold, wind, rain, noise). This can be
aggravated by aspects such as poor lighting or having to wear breathing apparatus.

Fear of Heights. Work at high levels can also be a problem, especially when doing
'crown' inspections (top of fuselage or top wing engine). Some engineers may be
quite at ease in situations like these whereas others may be so uncomfortable that
they are far more concerned about the height, and holding on to the access
equipment, than they are about the job in hand.

Conclusion

If a person is working in uncomfortable conditions, he may be inclined to get out of

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

Page 2-28 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

The Social Environment

Aircraft maintenance engineers work within a “system”. As indicated in the figure

below, there are various factors within this system that impinge on the aircraft
maintenance engineer, ranging from his knowledge, skills and abilities, the
environment in which he works to the culture of the organisation for which he works.
Even beyond the actual company he works for, the regulatory requirements laid
down for his trade clearly impact on his behaviour. All aspects of this system may
contribute towards errors that the engineer might make.

The Maintenance System

HF Section 2.doc/ Issue 3 Page 2-29

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Organisational Culture

The vast majority of aircraft maintenance engineers work for a company, either
directly, or as contract staff. It is important to understand how the organisation in
which the engineer works might influence him. Every organisation or company
employing aircraft maintenance engineers will have different “ways of doing things”.
This is called the organisational culture. They will have their own company
philosophy, policies, procedures, selection and training criteria, and quality
assurance methods. The impact of the organisation may be positive or negative.
Organisations may encourage their employees (both financially and with career
incentives), and take notice of problems that their engineers encounter, attempting to
learn from these and make changes where necessary or possible. On the negative
side, the organisation may exert pressure on its engineers to get work done within
certain timescales and within certain budgets. At times, individuals may feel that
these conflict with their ability to sustain the quality of their work. These
organisational stresses may lead to problems of poor industrial relations, high
turnover of staff, increased absenteeism, and most importantly for the aviation
industry, more incidents and accidents due to human error
.
Responsibility: Individual and Group

Being an aircraft maintenance engineer is a responsible job. Clearly, the engineer

plays a part in the safe and efficient passage of the travelling public when they use
aircraft.

If someone is considered responsible, they are liable to be called to account

as being in charge or control of, or answerable for something.

Within aircraft maintenance, responsibility should be spread across all those who
play a part in the activity. This ranges from the accountable manager who formulates
policy, through management that set procedures, to supervisors, teams of engineers
and individuals within those teams. Flight crew also play a part as they are
responsible for carrying out preflight checks and walkarounds and highlighting
aircraft faults to maintenance personnel.

Page 2-30 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Working as an Individual or as a Group

Traditionally, in the maintenance engineering environment, responsibility has been

considered in terms of the individual rather than the group or team. This is historical,
and has much to do with the manner in which engineers are licensed and the way in
which work is certified. This has both advantages and disadvantages. The main
advantage to individual responsibility is that an engineer understands clearly that
one or more tasks have been assigned to him and it is his job to do them (it can also
be a strong incentive to an engineer to do the work correctly knowing that he will be
the one held responsible if something goes wrong). The main disadvantage of any
emphasis upon personal responsibility, is that this may overlook the importance of
working together as a cohesive team or group to achieve goals.

In practice, aircraft maintenance engineers are often assigned to groups or teams in

the workplace. These may be shift teams, or smaller groups within a shift. A team
may be made up of various engineering trades, or be structured around aircraft types
or place of work (e.g. a particular hangar). Although distinct tasks may be assigned
to individuals within a team, the responsibility for fulfilling overall goals would fall on
the entire team..

Individual Responsibility

All aircraft maintenance engineers are skilled individuals having undertaken

considerable training. They work in a highly professional environment in the UK and
generally have considerable pride in their work and its contribution to air safety.

All individuals, regardless of their role, grade or qualifications should work in a

responsible manner. This includes not only Licensed Aircraft Engineers (LAEs), but
non-licensed staff. Airworthiness Notice No. 3 details the certification
responsibilities of LAEs. This document states that “The certifying engineer shall be
responsible for ensuring that work is performed and recorded in a satisfactory
manner.

Likewise, non-certifying technicians also have a responsibility in the maintenance

process. An organisation approved in accordance with JAR145 must establish the
competence of every person, whether directly involved in hands-on maintenance or
not. The CAA has previously ruled that an organisation can make provision on
maintenance records or work sheets for the mechanic(s) involved to sign for the
work. Whilst this is not the legally required certification under the requirements of
ANO Article 12 or JAR 145.50, it provides the traceability to those who were
involved in the job. The LAE is then responsible for any adjustment or functional test
and the required maintenance records are satisfied before making the legal
certification.

HF Section 2.doc/ Issue 3 Page 2-31

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

BAe 146 HYDRAULIC BAY ACCESS DOOR OCC NR:

99/02670
NOT PROPERLY CLOSED
STATUS: CLOSED

FLT PHASE: CLIMB DATE: -- MAY

99

A crew change had been carried out at an European airport, the aircraft having
arrived late, and with only 20 minutes before the departure slot. The aircraft was
handed over with an automatic pressurisation defect which required use of manual
pressurisation control. Problems with catering loading caused the slot to be missed,
with a 40 minutes a delay. During starting checks a 'lower door not closed' caption
remained illuminated. The ground-crew were asked to check all lower doors were
closed, and the dispatcher on the headset assured the flight crew that this was so.
However, the caption remained on. A request was made for a second check with the
same result. The ground-crew were then asked to open and close all lower doors as
failed micro-switches on these doors are a known problem. The avionics bay and
forward cargo bay doors were heard to open and close again, but operations of the
hydraulic bay and rear cargo doors cannot be heard from the flight deck. Once
again an assurance was received that all doors were closed, and accepting that the
caption was due to a faulty micro-switch, a normal departure was carried out.
However the cabin failed to pressurise, so the aircraft returned. An external check
found that the hydraulic bay door was latched but not closed. A ground
pressurisation test was carried out satisfactorily. An interview with the dispatcher on
the head-set revealed that he had delegated the check of the doors to another
person and had not checked himself.

Page 2-32 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Group or Team Responsibility

Group responsibility has its advantages and disadvantages. The advantages are that
each member of the group ought to feel responsible for the output of that group, not
just their own output as an individual, and ought to work towards ensuring that the
whole ‘product’ is safe. This may involve cross-checking others’ work (even when not
strictly required), politely challenging others if you think that something is not quite
right, etc.

The disadvantage of group responsibility is that it can potentially act against safety,
with responsibility being devolved to such an extent that no one feels personally
responsible for safety (referred to as diffusion of responsibility). Here, an
individual, on his own, may take action but, once placed within a group situation, he
may not act if none of the other group members do so, each member of the group or
team assuming that ‘someone else will do it’.

Social psychologists have carried out experiments whereby a situation was contrived
in which someone was apparently in distress, and noted who came to help. If a
person was on their own, they were far more likely to help than if they were in a pair
or group. In the group situation, each person felt that it was not solely his
responsibility to act and assumed that ‘someone else would do so’.

Other recognised phenomena associated with group or team working and

responsibility for decisions and actions which aircraft maintenance engineers should
be aware of are:

Intergroup conflict in which situations evolve where a small group may act
cohesively as a team, but rivalries may arise between this team and others (e.g.
between engineers and planners, between shifts, between teams at different sites,
etc.). This may have implications in terms of responsibility, with teams failing to
share responsibility between them. This is particularly pertinent to change of
responsibility at shift handovers, where members of the outgoing shift may feel no
‘moral’ responsibility for waiting for the incoming shift members to arrive and giving a
verbal handover in support of the written information on the workcards or task
sheets, whereas they might feel such responsibility when handing over tasks to
others within their own shift.

HF Section 2.doc/ Issue 3 Page 2-33

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Group polarisation

This is the tendency for groups to make decisions that are more extreme than the
individual members’ initial positions. At times, group polarisation results in more
cautious decisions. Alternatively, in other situations, a group may arrive at a course
of action that is riskier than that which any individual member might pursue. This is
known as risky shift.

Another example of group polarisation is groupthink in which the desire of the group
to reach unanimous agreement overrides any individual impulse to adopt proper,
rational (and responsible) decision making procedures.

Social loafing

This is a term that has been coined to reflect the tendency for some individuals to
work less hard on a task when they believe others are working on it. In other words,
they consider that their own efforts will be pooled with that of other group members
and not seen in isolation.

Responsibility is an important issue in aircraft maintenance engineering, and ought

to be addressed not only by licensing, regulations and procedures, but also by
education and training, attempting to engender a culture of shared, but not diffused,
responsibility.

Page 2-34 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Management, Supervision and Leadership

Management, supervision and leadership are all skills that a team leader requires. Of
course, management is also a function within an organisation (i.e. those managers
responsible for policy, business decisions, etc.), as is the supervisor (i.e. in an official
role overseeing a team).

Managers and supervisors have a key role to play in ensuring that work is carried out
safely. It is no good instilling the engineers and technicians with ‘good safety
practice’ concepts, if these are not supported by their supervisors and managers.

The Management Role

Line Managers, particularly those working as an integral part of the ‘front line’
operation, may be placed in a situation where they may have to compromise
between commercial drivers and ‘ideal’ safety practices (both of which are passed
down from ‘top management’ in the organisation). For example, if there is a
temporary staff shortage, he must decide whether maintenance tasks can be safely
carried out with reduced manpower, or he must decide whether an engineer
volunteering to work a “ghoster” to make up the numbers will be able to perform
adequately. The adoption of Safety Management Principles may help by providing
Managers with techniques whereby they can carry out a more objective assessment
of risk.

HF Section 2.doc/ Issue 3 Page 2-35

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

The Supervisory Role

Supervision may be a formal role or post (i.e. a Supervisor), or an informal

arrangement in which a more experienced engineer ‘keeps an eye on’ less
experienced staff. The Supervisor is in a position not only to watch out for errors
which might be made by engineers and technicians, but will also have a good
appreciation of individual engineer’s strengths and weaknesses, together with an
appreciation of the norms and safety culture of the group which he supervises. It is
mainly his job to prevent unsafe norms from developing, and to ensure that good
safety practices are maintained. There can be a risk however, that the Supervisor
becomes drawn down the same cultural path as his team without realising. It is good
practice for a Supervisor to step back from the day-to-day work on occasion and to
try to look at his charges’ performance objectively.

It can be difficult for supervisory and management staff to strike the right balance
between carrying out their supervisory duties and maintaining their engineering skills
and knowledge (and appropriate authorisations), and they may get out of practice. In
the UK Air Accidents Investigation Branch (AAIB) investigation reports of the
BAC 1-11, A320 and B737 incidents, a common factor was:

‘Supervisors tackling long duration, hands-on involved tasks’. In the B737 incident,
the borescope inspection was carried out by the Base Controller, who needed to do
the task in order to retain his borescope authorisation. Also, there is unlikely to be
anyone monitoring or checking the Supervisor, because of his seniority, and
because of his seniority:

He is generally authorised to sign for his own work (except, of course, in the case
where a duplicate inspection is required);

He may often have to step in when there are staff shortages and, therefore, no
spare staff to monitor or check the tasks;

He may be ‘closer’ (i.e. more sensitive to) to any commercial pressures which may
exist, or may perceive that pressure to a greater extent than other engineers.

It is not the intention to suggest that supervisors are more vulnerable to error; rather
that the circumstances which require supervisors to step in and assist tend to be
those where several of the ‘defences’ have already failed and which may result in a
situation which is more vulnerable to error.

Page 2-36 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Characteristics Of A Leader

There are potentially two types of leader in aircraft maintenance: the person officially
assigned the team leader role (possibly called the Supervisor), an individual within a
group that the rest of the group tend to follow or defer to (possibly due to a dominant
personality, etc.). Ideally of course, the official team leader should also be the person
the rest of the group defer to.

A leader in a given situation is a person whose ideas and actions influence the
thought and the behaviour of others.

A good leader in the maintenance engineering environment needs to possess a

number of qualities:

Motivating his team;

Reinforcing good attitudes and behaviour;
Demonstrating by example;
Maintaining the group;
Fulfilling a management role.

These will now be examined in a little more detail:

Motivating the Team

Just as the captain of a football team motivates his fellow players, the leader of a
maintenance team must do likewise. This can be done by ensuring that the goals or
targets of the work which need to be achieved are clearly communicated and
manageable. For instance, the team leader would describe the work required on an
aircraft within a shift. He must be honest and open, highlighting any potential
problems and where appropriate encouraging team solutions.

Reinforcing Good Attitudes and Behaviour

When team members work well (i.e. safely and efficiently), this must be recognised
by the team leader and reinforced. This might be by offering a word of thanks for
hardwork, or making a favourable report to senior management on an individual. A
good leader will also make sure that bad habits are eliminated and inappropriate
actions are constructively criticised.

Demonstrating by Example
A key skill for a team leader is to lead by example. This does not necessarily mean
that a leader must demonstrate that he is as adept at a task as his team. (It has
already been noted that a Supervisor may not have as much opportunity to practise
using their skills). Rather, he must demonstrate a personal understanding of the
activities and goals of the team so that the team members respect his authority. It is
particularly important that the team leader establishes a good safety culture within a
team

HF Section 2.doc/ Issue 3 Page 2-37

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Maintaining the Group

Individuals do not always work together as good teams. It is part of the leader’s role
to be sensitive to the structure of the team and the relationships within it. He must
engender a ‘team spirit’ where the team members support each other and feel
responsible for the work of the team. He must also recognise and resolve disputes
within the team and encourage co-operation amongst its members.

Fulfilling a Management Role

The team leader must not be afraid to lead (and diplomatically making it clear when
necessary that there cannot be more than one leader in a team). The team leader is
the link between higher levels of management within the organisation and the team
members who actually work on the aircraft. He is responsible for co-ordinating the
activities of the team on a day-to-day basis, which includes allocation of tasks and
delegation of duties. There can be a tendency for team members to transfer some of
their own responsibilities to the team leader, and he must be careful to resist this.

Skilled management, supervision and leadership play a significant part in the

attainment of safety and high quality human performance in aircraft
maintenance engineering.

In terms of the relationship between managers, supervisors and engineers,

a ‘them and us’ attitude is not particularly conducive to improving the safety
culture of an organisation. It is important that managers, supervisors, engineers and
technicians all work together, rather than against one another, to ensure that aircraft
maintenance improves airworthiness.

Page 2-38 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Culture

The culture of an organisation can be described as 'the way we do things here'. It

can refer to safety culture, professional culture, political culture, business culture,
etc, although the safety culture is obviously the area with which this text is primarily
concerned. It is difficult to pinpoint where the culture of an organisation is driven
from. It is not necessarily always generated or driven from the top, as one might
think, but this is the best point from which to influence the safety culture. Whilst it is
possible for cultural differences to exist between sites or even between shifts, a
certain cultural climate tends normally to be associated with a particular branch of
the industry e.g. helicopter maintenance, light aircraft maintenance, line
maintenance, etc.

Safety Culture

The culture of an organisation can best be judged by what is done rather than by
what is said. Organisations may have grand 'mission statements' concerning safety
but this does not indicate that they have a good safety culture unless the policies
preached at the top are actually put into practice at the lower levels. It may be
difficult to determine the safety culture of an organisation by auditing the procedures
and paperwork; a better method is to find out what the majority of the staff actually
believe and do in practice.

A method for measuring attitudes to safety has been developed by the Human
Factors in Reliability Group (HFRG) violations sub-group, utilising a questionnaire
approach. The questionnaire takes the form of statements to which respondents are
asked the extent to which they agree. Examples include:

i. It is necessary to bend some rules to achieve a target

ii. Short cuts are acceptable when they involve little or no risk
iii. I often come across situations with which I am unfamiliar
iv. I sometimes fail to understand which rules apply
v. I am not given regular break periods when I do repetitive and boring jobs
vi. There are financial rewards to be gained from breaking the rules

The results are scored as outlined in the methodology and results are given which
give an indication of the safety culture of the organisation, broken down according to
safety commitment, supervision, work conditions, logistic support, etc. In theory, this
enables one organisation to be objectively compared with another.

Whilst safety culture has been discussed from the organisational perspective, the
responsibility of the individual should not be overlooked. Ultimately, safety culture is
an amalgamation of the attitude, beliefs and actions of all the individuals working for
the organisation and each person should take responsibility for their own
contribution towards this culture, ensuring that it is a positive contribution rather
than a negative one.

HF Section 2.doc/ Issue 3 Page 2-39

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Social Culture

The influence of social culture (an individual’s background or heritage) can be

important in determining how an individual integrates into an organisational culture.
The way an individual behaves outside an organisation is likely to have a bearing on
how they behave within it. Internal pressures and conflicts within groups at work can
be driven by underlying social cultural differences (e.g. different nationalities,
different political views, different religious beliefs, etc.). This is an extremely
complex subject, however, and in-depth discussion is beyond the scope of this text.

Page 2-40 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Motivation and De-motivation

Motivation, is a force coming from within your brain that drives you to act in certain
ways. It is usually considered to be a positive rather than a negative force in that it
causes you to move forward as opposed to remaining stagnant. It manifests itself
both in intensity and in direction. Generally we say a person is motivated if he/she is
taking action on some subject. The action, however, can be either good or bad, and
just because someone is positively motivated, this does not mean to say that they
are doing the right thing. Many criminals are highly motivated, for instance.
Motivation to do the right things, in terms of safety, is vital. In Aviation, you can be
motivated to take risks (eg for the satisfaction of getting an aircraft turned around
more quickly) or to make safe decisions (eg to satisfy your own personal integrity). It
is important to associate motivation with the right type of actions, ie point it in the
right direction.

The psychological concept of motivation and what we understand as being

motivated, are subtly different.

Motivation

Highly motivated people tend to show the following characteristics:

i. high performance and results being consistently achieved

ii. the energy, enthusiasm and determination to succeed
iii. unstinting co-operation in overcoming problems
iv. willingness to accept responsibility
v. willingness to accommodate change

De-motivation

People who lack motivation, either intrinsically or through a failure of their

management to motivate the staff who work for them, tend to demonstrate the
following characteristics:

i. apathy and indifference to the job

ii. a poor record of time keeping and high absenteeism
iii. an exaggeration of the effects/difficulties encountered in problems, disputes and
grievances
iv .a lack of co-operation in dealing with problems or difficulties
v. unjustified resistance to change

However, care should be taken when associating these characteristics with lack of
motivation, since some could also be signs of stress.

HF Section 2.doc/ Issue 3 Page 2-41

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Maslow’s Hierarchy Of Needs

Page 2-42 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Maslow’s Hierarchy of Needs

Possibly one of the most well known theories which attempts to describe human
motivation is Maslow’s hierarchy of needs. Maslow considered that humans are
driven by two different sets of motivational forces:

i. those that ensure survival by satisfying basic physical and

psychological needs;

ii. those that help us to realise our full potential in life known as
self-actualisation needs (fulfilling ambitions, etc.).

Maslow’s model shows the hypothetical hierarchical nature of the needs we are
motivated to satisfy. The theory is that the needs lower down the hierarchy are more
primitive or basic and must be satisfied before we can be motivated by the higher
needs. For instance, you will probably find it harder to concentrate on the information
in this document if you are very hungry (as the lower level physiological need to eat
predominates over the higher level cognitive need to gain knowledge). There are
always exceptions to this, such as the mountain climber who risks his life in the
name of adventure. The higher up the hierarchy one goes, the more difficult it
becomes to achieve the need. High level needs are often long-term goals that have
to be accomplished in a series of steps.

HF Section 2.doc/ Issue 3 Page 2-43

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

(B is the same length as X)

Page 2-44 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Peer Pressure

In the working environment of aircraft maintenance, there are many pressures

brought to bear on the individual engineer. We have already discussed the influence
of the organisation, of responsibility and motivational drives. In addition to these,
there is the possibility that the aircraft maintenance engineer will receive pressure at
work from those that work with him. This is known as peer pressure.

Peer pressure is the actual or perceived pressure which an individual may feel,
to conform to what he believes that his peers or colleagues expect.

For example, an individual engineer may feel that there is pressure to cut corners in
order to get an aircraft out by a certain time, in the belief that this is what his
colleagues would do under similar circumstances. There may be no actual pressure
from management to cut corners, but subtle pressure from peers, e.g. taking the
form of comments such as “You don’t want to bother checking the manual for that.
You do it like this…” would constitute peer pressure.Peer pressure thus falls within
the area of conformity. Conformity is the tendency to allow one’s opinions,
attitudes, actions and even perceptions to be affected by prevailing opinions,
attitudes, actions and perceptions.

Experiments in Conformity

Several experiments investigating the nature of conformity, in which people were

asked to judge which of lines A, B & C was the same length as line X.
Questions were asked under a set of different conditions:

I. where the individuals were asked to make judgements on their own;

ii. where individuals carried out the task after a group of 7-9 ‘primed individuals’
(stooges)had all judged that line A was the correct choice. Of course, the real
participant did not know the others were “stooges”

In the first condition, very few mistakes were made (as would be expected of such a
simple task with an obvious answer). In the latter condition, on average, participants
gave wrong answers on one third of the trials by agreeing with the ‘stooge’ majority.
Clearly, participants yielded to group pressure and agreed with the incorrect ‘group’
finding (however, it is worth mentioning that there were considerable individual
differences: some participants never conformed, and some conformed all the time).

HF Section 2.doc/ Issue 3 Page 2-45

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Team Working

The responsibility of aircraft maintenance engineers within teams has been

discussed, and the influence of peers on the behaviour of the individual highlighted.
We will now look in more detail at team working in aircraft maintenance.

The Concept of A Team

.
Whereas individualism encourages independence, teams are associated with
interdependence and working together in some way to achieve one or more goals.

Teams may comprise a number of individuals working together towards one shared
goal. Alternatively, they may consist of a number of individuals working in parallel
to achieve one common goal. Teams generally have a recognised leader and one or
more follower(s). Teams need to be built up and their identity as a team needs to be
maintained in some way. A team could be a group of engineers working on a specific
task or the same aircraft, a group working together on the same shift, or a group
working in the same location or site. There are natural teams within the aircraft
maintenance environment. The most obvious is the supervisor and the engineers
working under his supervision. A team could also be a Licensed Aircraft Engineer
(LAE) and unlicensed engineers working subject to his scrutiny. A team may well
comprise engineers of different technical specialities (e.g. sheet/metal structures,
electrical/electronics/avionics, hydraulics, etc.).

There has been a great deal of work carried out on teamwork, in particular “Crew
Resource Management (CRM)” in the cockpit context and, more recently,
“Maintenance Resource Management (MRM)” in the maintenance context. The
ICAO Human Factors Digest No. 12 “Human Factors in Aircraft Maintenance and
Inspection” (ICAO Circular 253), includes a Chapter on team working.

Some Advantages and Disadvantages of Team Working

The discussion on motivation suggests that individuals need to feel part of a social
group. In this respect, team working is advantageous. However, the work on
conformity suggests that they feel some pressure to adhere to a group’s views,
which may be seen as a potential disadvantage.

Working as part of a team has a number of potential benefits which include:

i. individuals can share resources (knowledge, tools, etc.);

ii. they can discuss problems and arrive at shared solutions;

iii. they can check each others’ work (either “officially” or “unofficially”).

Page 2-46 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Team Identity

Teams can be encouraged to take ownership of tasks at the working level. This
gives a team greater responsibility over a package of work, rather than having to
keep referring to other management for authorisation, support or direction. However,
groups left to their own devices need proper leadership. Healthy competition and
rivalry between teams can create a strong team identity and encourage pride in the
product of a team. Team identity also has the advantage that a group of engineers
know one another’s capabilities (and weaknesses). If however work has to be
handed over to another group or team (e.g. shift handover), this can cause problems
if it is not handled correctly. If one team of engineers consider that their diligence (i.e.
taking the trouble to do something properly and carefully) is a waste of time because
an incoming team’s poor performance will detract from it, then it is likely that
diligence will become more and more rare over time.

Important Elements of Team Working

For teams to function cohesively and productively, team members need to have or
build up certain interpersonal and social skills. These include communication,
co-operation, co-ordination and mutual support

Communication

Communication is essential for exchanging work-related information within the team.

For example, a team leader must ensure that a team member has not just heard an
instruction, but understood what is meant by it. A team member must highlight
problems to his colleagues and/or team leader. Furthermore, it is important to
listen to what others say.

Co-operation

‘Pulling together’ is inherent in the smooth running of a team. Fairness and

openness within the team encourage cohesiveness and mutual respect.
Disagreements must be handled sensitively by the team leader.

Co-ordination

Co-ordination is required within the team to ensure that the team leader knows what
his group members are doing. This includes delegation of tasks so that all the
resources within the team are utilised. Delegated tasks should be supervised and
monitored as required. The team leader must ensure that no individual is assigned a
task beyond his capabilities. Further important aspects of co-ordination are
agreement of responsibilities (i.e. who should accomplish which tasks and within
what timescale), and prioritisation of tasks.

HF Section 2.doc/ Issue 3 Page 2-47

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE POTENTIAL FOR
HUMAN ERROR

engineering SECTION 2

Mutual Support

Mutual support is at the heart of the team’s identity. The team leader must engender
this in his team. For instance, if mistakes are made, these should be discussed and
corrected constructively.

It is worth noting that in many companies, line engineers tend to work as individuals
whereas base engineers tend to work in teams. This may be of significance when an
engineer who normally works in a hangar, finds himself working on the line, or vice
versa. This was the case in the Boeing 737 incident involving double engine oil
pressure loss, where the Base Controller took over a job from the Line Maintenance
engineer, along with the line maintenance paperwork. The line maintenance
paperwork is not designed for recording work with a view to a handover, and this
was a factor when the job was handed over from the Line engineer to the Base
Controller.

Page 2-48 HF Section 2.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
CAUSES OF ERRORS

Having looked at the potential each of us possesses to make mistakes, we will now
address some of the factors which present themselves each and every day, being
factors that will, unless we are vigilant realise the potential, resulting in an incident or
an accident. There are a multitude of factors which can and will contribute to errors
being committed: Here are some of them:

Stress
Fatigue
Complacency
Communication
Ignorance

We shall address the more common, easily recognisable ones but, be aware that
around every corner a new one is waiting to trap the unwary.

HF Section 3.doc/Issue 3 Page 3-1

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

INTENTIONALLY BLANK

Page 3-2 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
STRESS

i Sickness absence costs to UK economy on average £11,000,000,000

i 30 - 40% of this is stress related

(C.B.I. 1994)

i ALCOHOLISM costs over £2.2 billion per year in terms of premature

death, sickness absence, unemployment and N.H.S. treatment

HF Section 3.doc/Issue 3 Page 3-3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

INTENTIONALLY BLANK

Page 3-4 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
STRESS

What is Stress?

Stress is usually something experienced due to the presence of some form of

stressor, which might be a one-off stimulus (such as a challenging problem or a
punch on the nose), or an on-going factor (such as an extremely hot hangar or an
acrimonious divorce). From these, we get acute stress (typically intense but of short
duration) and chronic stress (frequent recurrence or of long duration) respectively.

It has been said that stress is 'a reality like love and electricity - unmistakable in
experience but hard to define!' Research has shown what stress is not

i. Stress is not nervous tension

ii. Stress is not the discharge of hormones from the adrenal glands (the common
association with adrenaline and stress is not totally false but the two are only
indirectly associated)

iii. Stress is not simply the influence of some negative occurrence - stress can be
caused by quite ordinary, even positive events, such as a passionate kiss

iv. Stress is not entirely a bad event; we all need a certain amount of stimulation in
life and most people thrive on a certain amount of stress

v. Stress does not cause the body's alarm reaction which is the most common use
of the expression - what causes stress is a Stressor

Domestic Stress

When aircraft maintenance engineers go to work, they cannot leave stresses

associated with home behind. Pre-occupation with a source of domestic stress can
play on one’s mind during the working day, distracting from the working task. Inability
to concentrate fully may impact on the engineer’s task performance and ability to pay
due attention to safety.

Domestic stress typically results from major life changes at home, such as marriage,
birth of a child, a son or daughter leaving home, bereavement of a close family
member or friend, marital problems, or divorce.

HF Section 3.doc/Issue 3 Page 3-5

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
Work Related Stress

Aircraft maintenance engineers can experience stress for two reasons at work:
because of the task or job they are undertaking at that moment, or because of the
general organisational environment. Stress can be felt when carrying out certain
tasks that are particularly challenging or difficult. This stress can be increased
by lack of guidance in this situation, or time pressures to complete the task or job
(covered later in this chapter). This type of stress can be reduced by careful
management, good training, etc.

Within the organisation, the social and managerial aspects of work can be stressful.
The impact on the individual of peer pressure, organisational culture and
management can all be stressors. In the commercial world that aircraft maintenance
engineers work in, shift patterns, lack of control over own workload, company
reorganisation and job uncertainty can also be sources of stress.

Stress Management

Once we become aware of stress, we generally respond to it by using one of two

strategies: defence or coping.

Coping strategies involve dealing with the source of the stress rather than just the
symptoms (e.g. delegating workload, prioritising tasks, sorting out the problem, etc.).

Defence strategies involve alleviation of the symptoms (taking medication, alcohol,

etc.) or reducing the anxiety (e.g. denying to yourself that there is a problem (denial),
or blaming someone else).

Unfortunately, it is not always possible to deal with the problem if this is outside the
control of the individual (such as during an emergency), but there are well-published
techniques for helping individuals to cope with stress. Good stress management
techniques include:

i. Relaxation techniques;

ii. Careful regulation of sleep and diet;

iii. A regime of regular physical exercise;

iv. Counselling - ranging from talking to a supportive friend or colleague to

seeking professional advice.

There is no magic formula to cure stress and anxiety, merely common sense
and practical advice. Coping is the process whereby the individual either
adjusts to the perceived demands of the situation or changes the situation
itself.

Page 3-6 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
OCCUPATIONAL STRESSORS

Most if not all of us will recognise and readily relate to the following list of stress
factors:

NEW WORK PATTERNS

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

HF Section 3.doc/Issue 3 Page 3-7

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

Page 3-8 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
Time Pressure and Deadlines

There is probably no industry in the commercial environment that does not impose
some form of deadline, and consequently time pressure, on its employees. Aircraft
maintenance is no exception. It was highlighted in the previous section that one of
the potential stressors in maintenance is time pressure. This might be actual
pressure where clearly specified deadlines are imposed by an external source (e.g.
management or supervisors) and passed on to engineers, or perceived where
engineers feel that there are time pressures when carrying out tasks, even when no
definitive deadlines have been set in stone. In addition, time pressure may be self
imposed, in which case engineers set themselves deadlines to complete work (e.g.
completing a task before a break or before the end of a shift).

Management have contractual pressures associated with ensuring an aircraft is

released to service within the time frame specified by their customers. Striving for
higher aircraft utilisation means that more maintenance must be accomplished in
fewer hours, with these hours frequently being at night. Failure to do so can impact
on flight punctuality and passenger satisfaction. Thus, aircraft maintenance
engineers have two driving forces: the deadlines handed down to them and their
responsibilities to carry out a safe job. The potential conflict between these two
driving pressures can cause problems.

The Effects of Time Pressure and Deadlines

As with stress, it is generally thought that some time pressure is stimulating and
may actually improve task performance. However, it is almost certainly true that
excessive time pressure (either actual or perceived, external or self-imposed), is
likely to mean that due care and attention when carrying out tasks diminishes and
more errors will be made. Ultimately, these errors can lead to aircraft incidents and
accidents.

It is possible that perceived time pressure would appear to have been a contributory
factor in the BAC 1-11 accident described in the introduction. Although the aircraft
was not required the following morning for operational use, it was booked for a wash.
The wash team had been booked the previous week and an aircraft had not been
ready. This would have happened again, due to short-staffing, so the Shift Manager
decided to carry out the windscreen replacement task himself so that the aircraft
would be ready in time.

HF Section 3.doc/Issue 3 Page 3-9

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

INTENTIONALLY BLANK

Page 3-10 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
Example

An extract from the NTSB report on the Aloha accident refers to time pressure as a
possible contributory factor in the accident: “The majority of Aloha's maintenance
was normally conducted only during the night. It was considered important that the
airplanes be available again for the next day's flying schedule. Such aircraft
utilization tends to drive the scheduling, and indeed, the completion of required
maintenance work. Mechanics and inspectors are forced to perform under time
pressure. Further, the intense effort to keep the airplanes flying may have been so
strong that the maintenance personnel were reluctant to keep airplanes in the
hangar any longer than absolutely necessary.”

Managing Time Pressure and Deadlines

One potential method of managing time pressures exerted on engineers is through

regulation. For example, FAA research has highlighted the need to insulate aircraft
maintenance engineers from commercial pressures. They consider this would help
to ensure that airworthiness issues will always take precedence over commercial
and time pressures. Time pressures can make ‘corner-cutting’ a cultural norm in an
organisation. Sometimes, only an incident or accident reveals such norms (the
extract from the Aloha accident above exemplifies this).

Those responsible for setting deadlines and allocating tasks should consider:

i. Prioritising various pieces of work that need to be done;

ii. The actual time available to carry out work (considering breaks, shift
handovers, etc.);

iii. The personnel available throughout the whole job (allowing a contingency
for illness);

iv. The most appropriate utilisation of staff (considering an engineer’s

specialisation, and strengths and limitations);

v. Availability of parts and spares.

It is important that engineering staff at all levels are not afraid to voice concerns
over inappropriate deadlines, and if necessary, cite the need to do a safe job to
support this. Within aircraft maintenance, responsibility should be spread across all
those who play a part. Thus, the aircraft maintenance engineer should not feel that
the ‘buck stops here’.

HF Section 3.doc/Issue 3 Page 3-11

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

Page 3-12 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
LACK OF AWARENESS

Lack of awareness, differs from lack of knowledge in that it occurs to engineers who
often are very knowledgeable but fail to reason the possible consequences to what is
normal good maintenance practice.

For example: An engineer mounts a fire extinguisher on a bulkhead as per normal

maintenance practices, but fails to realise that in a crash, the person sitting in front of
the bulkhead will remove the extinguisher with his head!!

It is not easy to be aware of all the consequences of a maintenance action, yet,

particularly when one modifies anything on an aircraft, one must work to examine all
possible outcomes.

A court of law is no place to explain why it is that you did not realise.

HF Section 3.doc/Issue 3 Page 3-13

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

Page 3-14 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
COMPLACENCY

Meaning

Self-satisfaction accompanied by a loss of awareness of the dangers

Because of the repetitive nature of a lot of aviation maintenance work, complacency

is an ever-present danger. As a person becomes complacent his stress level, for
that task, decreases and with it his performance. A greater stimulus will be required
in order to obtain a response.

With complacency can come Expectancy, where the AME will often see what he
expects to see and not what is actually there. If other factors are also present such
as fatigue, resources and stress (from a different source) then the chance of an error
becomes very real.

The error of complacency can be lessened by:

i) Always following the checklist or work sheet: ie don't attempt to do

work from memory.

ii) Be aware of the danger of complacency and tell yourself: "Today I am

going to find a crack" or whatever.

Awareness is your strongest advocate in preventing complacency.

HF Section 3.doc/Issue 3 Page 3-15

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

Page 3-16 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
DISTRACTION

Meaning:

Draw one's attention away, Confuse

Distractions are a common occurrence anyway yet, if they occur in a critical phase of
our work, they can have disastrous consequences. Distraction is one of the main
reasons that an engineer fails to secure NUT "B" or a control cable or other critical
part. Psychologists say it is the number one cause of forgetting. Often after an
error has occurred, the engineer will be at a loss to explain how it happened. If other
factors are present such as fatigue and stress, then the likelihood of an error
occurring increases.

Prevention consists of awareness of the problem and the use of safety nets such
as:

i. proper use of detailed check lists

ii. flagging incomplete work

iii. witness marks

iv. dual or independent inspection

v. going back three steps, ie return to a "known" point in the procedure.

HF Section 3.doc/Issue 3 Page 3-17

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

INTENTIONALLY BLANK

Page 3-18 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
FATIGUE

Fatigue is the body's normal reaction to a physical or mental stress of prolonged

duration. Its onset is insidious and the symptoms are not always recognised until the
person has reached a high degree of fatigue. There are two types of fatigue,
Physiological fatigue and Subjective fatigue.

Physiological Fatigue

Physiological fatigue reflects the body’s need for replenishment and restoration. It is
tied in with factors such as recent physical activity, current health, consumption of
alcohol and with circadian rhythms. It can only be satisfied by rest and eventually, a
period of sleep. There are two types of Physiological fatigue, Acute and Chronic.

Acute Fatigue:

This can be brought about by a period of intense physical or mental activity at a

single task. It is of short duration, measured in hours, and can be cured with a
good night's sleep.

Chronic Fatigue:

This would reveal itself over an extended period of time and takes much longer to
recover from. Each person has a personal level of ability to withstand fatigue, the
ability to combat it slowly diminishing as the person ages.

Subjective Fatigue

Subjective fatigue is an individual’s perception of how sleepy or tired they feel.

This is not only affected when they lest slept and how good that sleep was but other
factors as well, such as the level or degree of motivation presented by the particular
task involved.

HF Section 3.doc/Issue 3 Page 3-19

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

INTENTIONALLY BLANK

Page 3-20 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
Causes of Fatigue:

Some of the things that can induce fatigue are:

i) Long hours of labour of any type, physical or mental, but the harder
the labour, the sooner and greater the fatigue.

ii) Lack of sleep due to time to or inability to, sleep. If one can not sleep,
it likely is due to stress, but physiological factors can play a role. Pain
due to sickness or injury or simply a disruption of one's circadium
rhythm, i.e. jet lag.

iii) Stress of high intensity and/or long duration will induce fatigue.

iv) Large temperature variations, hot or cold, will induce fatigue.

Temperatures in excess of 90 deg F (32C) can lead to heat exhaustion
while temperatures below 50 deg F (10C) without proper clothing, can
lead to hypothermia.

v) Noise if above the 80 dB mark for long duration will cause fatigue.
Exposure to loud noises without proper hearing protection is a self
correcting problem because, in time, you will no longer hear the noise
(or any other noise) and the damage cannot be reversed.

vi) Vibration can also cause fatigue. If for prolonged periods and of
sufficient intensity, it will cause headaches and muscle discomfort.
However unlike noise, vibration is not known to cause any permanent
damage although "white hand" from chain saw vibration and rivet guns
can become permanent if ignored long enough.

vii) Strong Lighting and to a lesser degree, poor lighting will contribute to
fatigue. The normal symptom is a headache, and if bad or long
enough, eyestrain.

HF Section 3.doc/Issue 3 Page 3-21

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

INTENTIONALLY BLANK

Page 3-22 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
Symptoms of Fatigue

Because the symptoms come on slowly it is important that we come to recognise the
symptoms and be aware of its effects. Often the fatigued person is unaware that
he is fatigued until the symptoms and effects have become quite extreme, therefore:

An Enhanced Stimulus is required in order to respond.

The person would require a larger crack in order to see it. The greater the
fatigue, the greater the stimulus required.

Attention is reduced

The person begins to overlook basic task elements.

The person becomes preoccupied with a single task to the exclusion of
others.
The person begins to lessen his visual scan.
The person becomes less aware of poor performance.

Memory is diminished

The person begins to have inaccurate recall.

The person forgets peripheral tasks.
The person begins to revert to "old" habits.

Mood becomes withdrawn

The person becomes less likely to converse.

The person becomes less likely to perform low demand tasks.
The person becomes more distracted by discomfort.
The person becomes more irritable.
The person begins to develop a "don't care" attitude.

Persons who work a midnight shift should be particularly aware of the symptoms as
most persons have a normal low (circadian rhythm-time of day effect) between
0300 and 0500.

Fatigue, as seen by its detrimental effects, can easily lead to a maintenance error,
especially if the person isn't aware he is suffering from it.

HF Section 3.doc/Issue 3 Page 3-23

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
Circadian Rhythms

As you well know, the human body has its ups and downs. One reason for this is
shown in the diagram below.

Body Control Diagram

Most body functions are controlled between an upper and a lower limit. Every day of
your life you ride this roller coaster. On good days, you go up and down without
getting too close to your limits. On bad days, you push the limits. These limits form
what is known as circadian rhythms and influence our physiological and behavioral
functions and processes. They have a regular cycle of approximately 25 hours.

The body functions that follow this type of up-and-down rhythm are connected. For
example, most people will feel alert and do their best work when their body
temperature is on the up cycle. This is probably because "up" body temperature
reflects heat being produced by the energy furnaces of the body. The more energy
to go around, the more energetic you feel.

Shift work can throw you off your rhythm in several ways. It can initially increase
the ups and downs of your cycle and then, as you adapt to the new schedule, your
rhythm will settle down again.

One of the keys to coping with shift work is to decrease the time it takes to resettle
your body rhythms.

Shift work can throw your rhythms off cycle by changing the timing of your ups and
downs. This can affect how you feel at different times of the day. It can also affect
how you feel compared to someone else.

Page 3-24 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
SHIFT WORK

Have you ever noticed how some people seem to breeze through shiftwork with little
difficulty while others have a hard time? There are certain individual differences that
have been shown to cause these different reactions to shiftwork. Even if you don't
work on shifts, you might find that the information is useful anyway since we all
occasionally experience the sleepless night or stressful day not unlike that
experienced by shiftworkers.

Approximately 23% of all workers in the service sector work on shifts. Not all
shiftwork creates difficulties, but some, especially 24-hour-a-day, 7-day-a-week
operation, can create problems such as poor quality of sleep and disruption of daily
biological rhythms.

Accordingly, the two major complaints from most shiftworkers are: lack of sleep
and fatigue. But some individuals adapt readily to shiftwork while others manage to
get by and still others can never adjust. A look at some of the reasons behind these
individual differences in adaption will highlight steps that may be taken to improve
our ability to manage the difficulties caused by shiftwork.

AWN47 highlights the potential for fatigue in aircraft maintenance engineering:

“Tiredness and fatigue can adversely affect performance. Excessive
hours of duty and shift working, particularly with multiple shift periods or
additional overtime, can lead to problems. Individuals should be fully
aware of the dangers of impaired performance due to these factors and
of their personal responsibilities.”

Advantages and Disadvantages of Shift Work

There are pros and cons to working shifts. Some people welcome the variety of
working different times associated with regular shift work patterns. Advantages may
include more days off and avoiding peak traffic times when travelling to work. The
disadvantages of shift working are mainly associated with:

i. working ‘unsociable hours’, meaning that time available with friends,

family, etc. will be disrupted;

ii. working when human performance is known to be poorer (i.e. between 4

a.m and 6 a.m.);

iii. problems associated with general desynchronisation and

disturbance of the body’s various rhythms (principally
sleeping patterns).

HF Section 3.doc/Issue 3 Page 3-25

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

INTENTIONALLY BLANK

Page 3-26 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
Working At Night

Shift work means that engineers will usually have to work at night, either
permanently or as part of a rolling shift pattern. As discussed earlier in this chapter,
this introduces the inherent possibility of increased human errors. Working nights
can also lead to problems sleeping during the day, due to the interference of daylight
and environmental noise. Blackout curtains and use of ear plugs can help, as well as
avoidance of caffeine before sleep.

Rolling Shift Patterns

When an engineer works rolling shifts and changes from one shift to another (e.g.
‘day shift’ to ‘night shift’), the body's internal clock is not immediately reset. It
continues on its old wake-sleep cycle for several days, even though it is no longer
possible for the person to sleep when the body thinks it is appropriate, and is only
gradually resynchronised. However, by this time, the engineer may have moved onto
the next shift. Generally, it is now accepted that shift rotation should be to later
shifts (i.e. early shift Ÿ late shift Ÿnight shift or day shift Ÿnight shift) instead of
rotation towards earlier shifts (night shift Ÿ late shift Ÿearly shift).

Continuity of Tasks and Shift Handovers

Many maintenance tasks often span more than one shift, requiring tasks to be
passed from one shift to the next. The outgoing personnel are at the end of anything
up to a twelve hour shift and are consequently tired and eager to go home.
Therefore, shift handover is potentially an area where human errors can occur.
Whilst longer shifts may result in greater fatigue, the disadvantages may be offset by
the fact that fewer shift changeovers are required (i.e. only 2 handovers with 2 twelve
hour shifts, as opposed to 3 handovers with 3 eight hour shifts

Sleep, Fatigue, Shift Work and the Aircraft Maintenance Engineer

Most individuals need approximately 8 hours sleep in a 24 hour period, although this
varies between individuals, some needing more and some happy with less than this
to be fully refreshed. They can usually perform adequately with less that this for a
few days, building up a temporary sleep ‘deficit’. However, any sleep deficit will
need to be made up, otherwise performance will start to suffer.

A good rule of thumb is that one hour of high-quality sleep is good for
two hours of activity.

HF Section 3.doc/Issue 3 Page 3-27

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

Typical Cycle Of Stage 1 to 4 REM (NREM) Sleep and REM Sleep

Page 3-28 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

THE ROLE OF SLEEP

What Is Sleep?

Man, like all living creatures has to have sleep. Despite a great deal of research, the
purpose of sleep is still not fully understood. Sleep can be resisted for a short time,
but various parts of the brain ensure that sooner or later, sleep occurs. When it does,
it is characterised by five stages of sleep:

Stage 1: This is a transitional phase between waking and sleeping. The heart rate
slows and muscles relax. It is easy to wake someone up.

Stage 2: This is a deeper level of sleep, but it is still fairly easy to wake someone.

Stage 3: Sleep is even deeper and the sleeper is now quite unresponsive to
external stimuli and so is difficult to wake. Heart rate, blood pressure and body
temperature continue to drop.

Stage 4: This is the deepest stage of sleep and it is very difficult to wake
someone up.

Rapid Eye Movement or REM Sleep: Even though this stage is characterised by
brain activity similar to a person who is awake, the person is even more difficult to
awaken than stage 4. It is therefore also known as paradoxical sleep. Muscles
become totally relaxed and the eyes rapidly dart back and forth under the eyelids.
It is thought that dreaming occurs during REM sleep.

Stages 1 to 4 are collectively known as non-REM (NREM) sleep. Stages 2-4 are
categorised as slow-wave sleep and appear to relate to body restoration, whereas
REM sleep seems to aid the strengthening and organisation of memories. Sleep
deprivation experiments suggest that if a person is deprived of stage 1-4 sleep or
REM sleep he will show rebound effects. This means that in subsequent sleep, he
will make up the deficit in that particular type of sleep. This shows the importance of
both types of sleep.

As can be seen from the accompanying diagram, sleep occurs in cycles.

Typically, the first REM slee pwill occur about 90 minutes after the onset of sleep.
The cycle of stage 1 to 4 sleep and REM sleep repeats during the night
about every 90 minutes. Most deep sleep occurs earlier in the night and REM sleep
becomes greater as the night goes on. Sleep is a natural state of reduced
consciousness involving changes in body and brain physiology which is necessary to
restore and replenish the body and brain.

HF Section 3.doc/Issue 3 Page 3-29

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

INTENTIONALLY BLANK

Page 3-30 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
FITNESS AND HEALTH

The job of an aircraft maintenance engineer can be physically demanding. In

addition,his work may have to be carried out in widely varying physical
environments, including cramped spaces, extremes of temperature, etc. There are at
present no defined requirements for physical or mental fitness for engineers or
maintenance staff however, Article 13 (paragraph 7) of the Air Navigation Order
(ANO). states:

“The holder of an aircraft maintenance engineer’s licence shall not exercise

the privileges of such a licence if he knows or suspects that his physical or
mental condition renders him unfit to exercise such privileges.”

IJAR 66.50 also imposes a requirement that “certifying staff must not exercise
the priveges of their certification authorisation if they know or suspect that
their physical or mental condition renders them unfit.”

In addition the CAA’s Airworthiness Notice No. 47 (AWN47) points out, it is a

legal requirement for aircraft maintenance engineers to make sure they are fit for
work:

“Fitness:

In most professions there is a duty of care by the individual to assess his or her own
fitness to carry out professional duties. This has been a legal requirement for some
time for doctors, flight crew members and air traffic controllers. Licensed aircraft
maintenance engineers are also now required by law to take a similar professional
attitude. Cases of subtle physical or mental illness may not always be apparent to
the individual but as engineers often work as a member of a team any substandard
performance or unusual behaviour should be quickly noticed by colleagues or
supervisors who should notify management so that appropriate support and
counselling action can be taken.”
Many conditions can impact on the health and fitness of an engineer and there is
not space here to offer a complete list. However, such a list would include:

• Minor physical illness (such as colds, ‘flu, etc.);

• More major physical illness (such as HIV, malaria, etc.);
• Mental illness (such as depression, etc.);
• Minor injury (such as a sprained wrist, etc.);
• Major injury (such as a broken arm, etc.);
• Ongoing deterioration in physical condition, possibly associated with the ageing
process (such as hearing loss, visual defects, obesity, heart problems, etc.);
• Affects of toxins and other foreign substances (such as carbon monoxide
poisoning, alcohol, illicit drugs, etc.).

HF Section 3.doc/Issue 3 Page 3-31

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

It is important that the engineer is aware that his performance, and consequently the
safety of aircraft he works on, might be affected adversely by illness or lack of
fitness. An engineer may consider that he is letting down his colleagues by not going
to work through illness, especially if there are ongoing manpower shortages.
However, he should remind himself that, in theory, management should generally
allow for contingency for illness. Hence the burden should not be placed upon an
individual to turn up to work when unfit if no such contingency is available. Also, if
the individual has a contagious illness (e.g. ‘flu), he may pass this on to his
colleagues if he does not absent himself from work and worsen the manpower
problem in the long run. There can be a particular problem with some contract staff
due to loss of earnings or even loss of contract if absent from work due to illness.
They may be tempted to disguise their illness, or may not wish to admit to
themselves or others that they are ill. This is of course irresponsible, as the illness
may well adversely affect the contractor’s standard of work.

Positive Measures

Aircraft maintenance engineers can take common sense steps to maintain their
fitness and health. These include:

• Eating regular meals and a well-balanced diet;

• Taking regular exercise (exercise sufficient to double the resting pulse rate for 20
minutes, three times a week is often recommended);

• Stopping smoking;

• Sensible alcohol intake (for men, this is no more than 3 - 4 units a day or 28 per
week, where a unit is equivalent to half a pint of beer or a glass of wine or spirit);

Page 3-32 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
RESOURCES

Resources, or more appropriately the 'lack of' resources have been the cause of
many an accident. Engineers are notorious for making do with less than adequate
resources. The lack of up to date manuals can cause an error especially in these
rapidly changing times and how often does an engineer have to make difficult
decisions due to the lack of materials. In difficult times, lack of material may lead to
an engineer to letting something go a little longer, against his better judgement.

Sometimes the resource needed is an expensive special tool that is seldom used.
Work is carried out without the proper tool and can cause a maintenance error if it
is not done properly. There have been cases where the person who can procure the
tool is unaware that it is even required. An engineer was heard to say "I asked for
the tool two years ago and I still haven't got it", while the Production Director wasn't
aware that the request was ever made.

One of the most common lack of resources is adequate lighting for the task in
hand. Engineers often depend heavily on flashlights perched on some part of the
aircraft to carry out a task when only a few metres away is a proper portable light.

Some facilities, especially as we move north, have woefully inadequate heat in

winter. It is easy to make a mistake when you are cold and miserable and all your
subconscious is thinking about is getting warm.

Do not be afraid to ask for help when needed and ensure that you have done
everything you can to obtain the necessary resources.

HF Section 3.doc/Issue 3 Page 3-33

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

Page 3-34 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
COMMUNICATION

Most people associate communication with verbal communication. For maintenance

personnel, communication encompasses much more than inter-team verbal
interaction. Communication not only includes face-to-face interaction, but also
paperwork such as maintenance cards, procedures, work orders, and logs.
Such paperwork may provide a reasonable record of work completed and work yet to
be completed but unless a strict protocol for raising, completing and controlling it is
adopted, the record may not capture all the activities to be undertaken or the status
at any point in time. In addition, because maintenance is an ongoing process
independent of specific teams, inter-team communication, especially between
shifts, is extremely important. In this way, asynchronous communication
(communication in which there exists a time delay between responses) is used to a
greater extent than real time, synchronous communication. Asynchronous
communication is typified by a unique set of characteristics, such as the lack of non-
verbal communication cues (eg body language, verbal inflection, etc). An
example of asynchronous communication at work in the hangar would be an e-mail
message sent from the day supervisor to the night supervisor. Other examples
include memos left between shifts or passed between the shop and the hangar.

Mechanics, crew leaders, supervisors, and inspectors all must have the knowledge
and skills to communicate effectively. Because aviation maintenance may involve
persons of different nationalities, because of flight crew engineering interfaces or the
use of foreign contract staff, it is essential that as part of a good communication
strategy a common language is established. All parties involved must have a good
understanding of the language used to ensure that communication is effected. A
lack of proper communication can have any or all of the following undesired
consequences:

i The quality of work and performance may be reduced.

i Time and money may be lost as errors occur because important information is
not communicated or messages are misinterpreted.

i Improper communication may cause frustration and high levels of stress.

HF Section 3.doc/Issue 3 Page 3-35

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

Page 3-36 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
COMMUNICATION

MEANING:

The exchange of information

To Improve Communication

"Learn to Listen"

Don't:

i Debate what is being said in your mind.

i Detour ie, look for a key word to change the subject.

i Pre-plan: Now is not the time to be planning what you are going to say.

i Tune out: Whatever is being said should be important enough to listen.

Do:

i Ask questions

i Paraphrase

i Make eye contact

i Use positive body language

HF Section 3.doc/Issue 3 Page 3-37

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

INTENTIONALLY BLANK

Page 3-38 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
Written Communication
This is one of the more critical aspects of aviation maintenance, in terms of
human factors, since inadequate logging or recording of work has been cited as
contributor to several incidents. In the B737 double engine oil loss incident1 in
February 1995, for instance, one of the AAIB conclusions was:

“…the Line Engineer…had not made a written statement or annotation

on a work stage sheet to show where he had got to in the inspections”.

Granted, the reason for this was because he had intended completing the job himself
and, therefore, did not consider that detailed work logging was necessary. However,
this contributed towards the incident in that:

“the Night Base Maintenance Controller accepted the tasks on a verbal

handover [and] he did not fully appreciate what had been done and what
remained to be done”.

It is not unusual for shift handovers to take place after the technicians concerned
have left, in which case it is vital that unfinished work is recorded in detail for the
benefit of the incoming shift. Even if technicians think that they are going to complete
the job, it is always necessary to keep the record of work up-to-date just in case
the job has to be handed over.

AWN3 states:

“In relation to work carried out on an aircraft, it is the duty of all persons to whom
this Notice applies to ensure that an adequate record of the work carried out is
maintained. This is particularly important where such work carries on beyond a
working period or shift, or is handed over from one person to another. The work
accomplished, particularly if only disassembly or disturbance of components or
aircraft systems, should be recorded as the work progresses or prior to
undertaking a disassociated task. In any event, records should be completed no later
than the end of the work period or shift of the individual undertaking the work. Such
records should include ‘open’ entries to reflect the remaining actions necessary
to restore the aircraft to a serviceable condition prior to release. In the case of
complex tasks which are undertaken frequently, consideration should be given to
the use of pre-planned stage sheets to assist in the control, management and
recording of these tasks. Where such sheets are used, care must be taken to ensure
that they accurately reflect the current requirements and recommendations of the
manufacturer and that all key stages, inspections, or replacements are recorded.”

HF Section 3.doc/Issue 3 Page 3-39

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
THIS IS COMMUNICATION?

I have to tell you that

what you heard and
what I said are
two different things and
that what you think
I said is definitively
not what I meant.

THE SECRET TO GOOD COMMUNICATION

You have

2 Ears

+ 2 Eyes

+ 1 Mouth

Use them in that order and proportion.

Page 3-40 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
Task and Shift Handovers

The primary objective of handovers is to ensure that all necessary information is

communicated between the out-going and in-coming personnel. Effective task and
shift handover depends on three basic elements:

i. The outgoing person’s ability to understand and communicate the

important elements of the job or task being passed over to the incoming
person.

ii. The incoming person’s ability to understand and assimilate

the information being provided by the outgoing person.

iii. A formalised process for exchanging information between outgoing and

incoming persons and a place and time for such exchanges to take place.

Organisations should have a recognised procedure for task and shift handovers
which all staff understand and adhere to. This procedure should be listed in the
MOE.
.
Whilst there is no specific requirement in JAR145 for time to be specifically
rostered in to allow for an overlap of 20 or 30 minutes whilst a shift handover takes
place, this would be considered good human factors practice.

Whilst all essential information (especially the detailed status of tasks) should be
recorded in written form, it is also important to pass this information verbally in
order to reinforce it. This is known as redundancy, or the ‘belt and braces’ approach.

The Department Of Energy ( DOE) shift handover standards stress two

characteristics that must be present for effective shift handover to take place:
ownership and formality. Individuals must assume personal ownership and
responsibility for the tasks they perform. They must want to ensure that their tasks
are completed correctly, even when those tasks extend across shifts and are
completed by somebody else. The opposite of this mental attitude is “It didn’t happen
on my shift”, which essentially absolves the outgoing person from all responsibility
for what happens on the next shift.

Formality relates to the level of recognition given to the shift handover procedures.
Formalism exists when the shift handover process is defined in the
Maintenance Organisation Exposition (MOE) and managers and supervisors are
committed to ensuring that cross-shift information is effectively delivered.
Demonstrable commitment is important as workers quickly perceive a lack of
management commitment when they fail to provide ample shift overlap time,
adequate job aids and dedicated facilities for the handovers to take place. In such
cases the procedures are just seen as the company covering their backsides and
paying lip service as they don’t consider the matter important enough to spend effort
and money on.

HF Section 3.doc/Issue 3 Page 3-41

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
Aids to Effective Communication at Shift Handover

Research has shown that certain processes, practices and skills aid effective
communication at shift handover.

I. People have to physically transmit information in written, spoken or gestured

(nonverbal or body language) form. If only one medium is used there is a risk of
erroneous transmission The introduction of redundancy, by using more than one
way of communicating i.e. written, verbal or non verbal, greatly reduces this risk.
For this reason information should be repeated via more than one medium.
For example verbal and one other method such as written or diagrams etc.

II. The availability of feedback, to allow testing of comprehension etc. during

communication increases the accuracy. The ability for two-way communication to
take place is therefore important at shift handover.

III. A part of the shift handover process is to facilitate the formulation of a shared
mental model of the maintenance system, aircraft configuration, tasks in work
etc.Misunderstandings are most likely to occur when people do not have this
same mental ’picture’ of the state of things. This is particularly true when
deviations from normal working has occurred such as having the aircraft in the
flight mode at a point in a maintenance check when this is not normally done.
Other considerations are when people have returned following a lengthy
absence (the state of things could have changed considerably during this time)
and when handovers are carried out between experienced and inexperienced
personnel (experienced people may make assumptions about their knowledge
that may not be true of inexperienced people). In all these cases handovers can
be expected to take longer and should be allowed for.

iv. Written communication is helped by the design of the documents, such as the
handover log, which consider the information needs of those people who are
expected to use it. By involving the people who conduct shift handovers and
asking them what key information should be included and in what format it should
be helps accurate communication and their ‘buy-in’ contributes to its use and
acceptance of the process.

Page 3-42 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
Barriers to Effective Communication at Shift Handover

Research has also shown that certain practices, attitudes and human limitations
act as barriers to effective communication at shift handover.

I. Key information can be lost if the message also contains irrelevant, unwanted
information. We also only have a limited capability to absorb and process what
is being communicated to us. In these circumstances it requires time and effort
to interpret what is being said and extract the important information. It is
important that only key information is presented, and irrelevant information
excluded.

II. The language we use in everyday life is inherently ambiguous. Effort therefore
needs to be expended to reduce ambiguity by:

• carefully specifying the information to be communicated e.g. by specifying the

actual component, tooling or document.

• facilitating two-way communication which permits clarification of any ambiguity

(e.g. do you mean the inboard or out board wing flap?)

III. Misunderstandings are a natural and inevitable feature of human

communication and effort has to be expended to identify, minimise and repair
misunderstandings as they occur. Communication therefore has to be two-
way, with both participants taking responsibility for achieving full and
accurate
communication.

iv. People and organisations frequently refer to communication as unproblematic,

implying that successful communication is easy and requires little effort. This
leads to over-confidence and complacency becoming common place.
Organisations need to expend effort to address complacency by:

• emphasising the potential for miscommunication and its possible

consequences

• developing the communication skills of people who are involved in shift

handovers

HF Section 3.doc/Issue 3 Page 3-43

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

Page 3-44 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
LACK OF KNOWLEDGE

In these times of ever changing technology, it is not difficult to come upon a task
which you lack the knowledge. To counteract this, aircraft companies attempt to
provide the correct amount of detail to their manuals or workcards without boring you
with complacency.

The key to the "lack of knowledge" error is to understand each step of what you are
doing, or talk to someone who does. Technical reps are paid good money to keep
you out of trouble.

If it's new, don't be afraid to ask. Don't learn by mistakes and remember Murphy's
Law if you have any doubts.

MURPHY’S LAW

If there is a wrong way to do it, that's the way you'll do it.

HF Section 3.doc/Issue 3 Page 3-45

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

INTENTIONALLY BLANK

Page 3-46 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
ALCOHOL, MEDICATION AND DRUG ABUSE

Despite an individual's belief that he can still work effectively after drinking alcohol,
such behaviour will not be tolerated within aviation maintenance activities.
Consumption of even relatively small amounts of alcohol is unacceptable since, in
combination with a number of other factors such as fatigue, illness or medication,
there may still be a distinguishable impairment of judgement and decision making.
Organisations may have an alcohol and drug policy, including random testing for
such substances. Even where such policy is not defined by the organisation, it does
not absolve the individual from complying with the relevant legislation. (ANO Article
13 and JAR 66.50 refers).

Whilst it is acceptable to take prescribed drugs, such as generic or trade-marked

medicines, to address medical conditions or short-term illness, it should be noted
that many of these may have side effects. These may affect individuals in different
ways and even differently on separate occasions. Maintenance personnel should
therefore be aware of potential side effects, as advised by the manufacturer of the
medicine.

Alcohol

Alcohol has similar effects to tranquillisers and sleeping tablets and may remain
circulating in the blood for a considerable time, especially if taken with food. It may
be borne in mind that a person may not be fit to go on duty even 8 hours after
drinking large amounts of alcohol. Individuals should therefore anticipate such
effects upon their next duty period. Special note should be taken of the fact that
combinations of alcohol and sleeping tablets, or anti-histamines, can form a highly
dangerous and even lethal combination.

The current law which does not prescribe a blood/alcohol limit, is soon to
change. There will be new legislation permitting police to test for drink or
drugs where there is reasonable cause, and the introduction of a blood/alcohol
limit of 20 milligrams of alcohol per 100 millilitres of blood for anyone
performing a safety critical role in UK civil aviation (which includes aircraft
maintenance engineers).

Anaesthetics

It should be remembered that following local, general, dental and other anaesthetics,
a period of time should elapse before returning to duty. Persons involved in the
maintenance of aircraft should be aware that this period will vary depending on
individual circumstances, but may extend up to 24 or even 48 hours. Any doubts
should be resolved by seeking appropriate medical advice.

HF Section 3.doc/Issue 3 Page 3-47

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

Page 3-48 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
Medication and Drugs

The following are some of the types of medicine in common use which may impair
work performance. The list is not exhaustive and care should be taken in ensuring
the likely effects of any prescribed drug are adequately known before taking it.

Analgesics are used for pain relief and to counter the symptoms of colds and ‘flu.
In the UK, paracetamol, aspirin and ibuprofen are the most common, and are
22 January 2002 CAP 715 An Introduction to Aircraft Maintenance Engineering
Human Factors for JAR 66 generally considered safe if used as directed. They
can be taken alone but are often used as an ingredient of a ‘cold relief’ medicine. It is
always worth bearing in mind that the pain or discomfort that you are attempting to
treat with an analgesic (e.g. headache, sore throat, etc.) may be the symptom of
some underlying illness that needs proper medical attention.

Antibiotics (such as Penicillin and the various mycins and cyclines) may have short
term or delayed effects which affect work performance. Their use indicates that a
fairly severe infection may well be present and apart from the effects of these
substances themselves, the side-effects of the infection will almost always render
an individual unfit for work.

Anti-histamines are used widely in ‘cold cures’ and in the treatment of allergies
(e.g. hayfever). Most of this group of medicines tend to make the user feel drowsy,
meaning that the use of medicines containing anti-histamines is likely to be
unacceptable when working as an aircraft maintenance engineer.

Cough suppressants are generally safe in normal use, but if an over-the-counter

product contains anti-histamine, decongestant, etc., the engineer should
exercise caution about its use when working.

Decongestants (i.e. treatments for nasal congestion) may contain chemicals such
as pseudo-ephedrine hydrochloride (e.g. ‘Sudafed’) and phenylphrine. Side-effects
reported, are anxiety, tremor, rapid pulse and headache. AWN47 forbids the use
of medications containing this ingredient to aircraft maintenance engineers when
working, as the effects compromise skilled performance.

‘Pep’ pills are used to maintain wakefulness. They often contain caffeine,
dexedrine or benzedrine. Their use is often habit forming. Over-dosage may cause
headaches, dizziness and mental disturbances. AWN47 states that “the use of
‘pep’ pills whilst working cannot be permitted. If coffee is insufficient, you are not
fit for work.”

Sleeping tablets (often anti-histamine based) tend to slow reaction times and
generally dull the senses. The duration of effect is variable from person to person.
Individuals should obtain expert medical advice before taking them.

HF Section 3.doc/Issue 3 Page 3-49

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
Melatonin (a natural hormone) deserves a special mention. Although not available
without a prescription in the UK, it is classed as a food supplement in the USA (and
is readily available in health food shops). It has been claimed to be effective as a
sleep aid, and to help promote the resynchronisation of disturbed circadian rhythms.
Its effectiveness and safety are still yet to be proven and current best advice is to
avoid this product.

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

Page 3-50 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
PHYSICAL ENVIRONMENT

Aviation maintenance has many features in common with other industries. The
physical facilities in which aviation technicians work, however, are unique. No other
industry uses quite the combination of facilities, including exposed aprons, aircraft
hangars, workshops, offices, inspection rooms, etc. The primary reason for
using hangars is obvious, of course. Aviation maintenance technicians work on
aircraft, and hangars are often needed to shelter aircraft and workers from the
elements for certain maintenance activities.

Aircraft hangars present a range of human factors issues. They are generally quite
large and are built so that most of the floor area is unobstructed by structural support
members. This design allows large aircraft to be moved and parked in the building.
Their vast areas and high ceilings make hangars difficult to light properly. Their
large, unobstructed volume makes public address systems difficult to hear.
Large, open doors make controlling temperature and humidity problematic. The
use of extensive and elevated, multi-level access platforms is common due to the
sizes of today's aircraft and the varying heights of component locations. Access
requirements vary according to the nature of the work being carried out. In some
cases, the close proximity of different pieces of equipment to each other bring
its own problems. Individual workspaces tend to be clustered around certain areas
of the aircraft, eg undercarriage bays and engines.

Lighting

One of the most important work parameters in aircraft maintenance is lighting. It is

very difficult to provide adequate lighting for all aspects of maintenance work
including inspection and repair. Poor ambient illumination of work areas has been
identified as a significant deficiency during the investigation of certain accidents. In
the BAC 1-11 accident, an adequately lit working area may have made it possible for
the shift maintenance manager to see the successive annulus of unfilled countersink
which was easily discernible when viewed under good lighting conditions.

The type of lighting used can also affect colour perception, various type of lighting
strengthening some colours but subduing others. This may not be overly important
for aircraft exterior maintenance tasks, but may be relevant for visual discrimination
between different coloured wiring, or other work where colour differences are
important.

HF Section 3.doc/Issue 3 Page 3-51

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
Fumes and Confined Spaces

Fumes

Maintenance of aircraft involves working on a variety of systems. Many of these use,

as a medium for transmitting power (eg hydraulic systems), oil or fluids. Other
chemical compound and gases are to be found in greases, protective coatings,
lubricants or aircraft components themselves. Where any chemical compound is
involved it is likely that, at some time, fumes will be produced. For some
substances, fumes will always be detectable, eg fuel, hydraulic oil. For others it may
require a particular set of circumstances to produce fumes, eg overheated grease or
oils, smouldering insulation. Chemicals in isolation may be relatively harmless but in
combination with others may give rise to fumes, which may even be toxic by nature.

Confined Spaces

The entry of personnel into any space, with limited means of entry or exit, which is
not intended for normal use or designed for continuous occupancy, needs to be
managed, eg fuel tank access. Such activities will benefit from the availability of
written control procedures, prior safety training and the possession of adequate and
appropriate safety equipment. These should address the likely risks to be
encountered. For example, attaching only a safety rope to someone is no good if
there is a likelihood that they will be overcome with fumes in any case. Using
breathing apparatus could well prevent the need for the rope to be used. Some
confined spaces have other hazards present, such as toxic gases or fumes,
electricity, machinery, etc. A recent report delineated the risks associated with fuel
cell repair as an example. Confined spaces are considered inherently hazardous
even without being associated with other hazards.

Anyone entering a confined space should:

i. Receive appropriate training in entering such spaces and in using any

safety equipment.

ii. Secure a written entry permit before entering the space if it contains any
hazards that could cause death or serious physical harm.

iii. Test the space for sufficient oxygen and for dangerous gases or vapours.

iv. Ventilate the space before and during entry.

v. Lock out any connecting lines.

vi. Have the appropriate safety equipment and trained assistance present
during entry.

Page 3-52 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
Climate and Temperature

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

Human Performance at various temperatures

Temperature (°F) / (°C): Performance Effect:

90 32 Upper limit for performance

80 28 Maximum acceptable upper limit
75 25 Optimum with minimal clothing
70 21 Optimum for typical clothing and tasks
65 18 Optimum for winter clothing
60 15 Hand and finger dexterity begins to deteriorate
55 12 Hand dexterity reduced by 50%

It is difficult to strictly control temperatures in hangars due to the large expanses of

space to heat or cool, and the fact that the hangar doors need to be opened and
closed from time to time, to let aircraft and large equipment in and out of the hangar.
It may be expensive to continually reheat the air in a hangar each time the heat is
lost, but it is important that engineers are able to work in a reasonable temperature
environment. Indeed, many Countries have legislation which requires that the
working environment is within a certain temperature range, to protect the workers.

HF Section 3.doc/Issue 3 Page 3-53

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

INTENTIONALLY BLANK

Page 3-54 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
Physical Work

People vary in the strength they can bring to bear on a task; they also differ in their
capacities to perform different types of work over time. Many studies have
attempted to describe the acceptable range of energy usage over different periods of
time and in different environments. As with other basic physical variables, one's
ability to perform work is affected by a number of different factors.

Excessive physical work over a period can result in fatigue. Fatigue generated as a
result of physical effort is normally not a problem if there is adequate rest and
recovery time between work periods. It can, however, become a problem if the body
is not allowed to recover, possibly leading to illness or injuries.

As an engineer progresses through his shift, he will tend to become more tired and
his ability to cope with physical work will tend to decrease. Circadian rhythm effects
may also reduce ability to cope with physical work. This is not considered a major
safety hazard, however, since people tend to be more aware of their reduced
physical performance and associated errors are likely to be fairly obvious (eg
dropping an item of equipment because it is too heavy). It is reductions in cognitive
performance which are less evident and which constitute a more serious risk,
since errors are likely to be made and to go unnoticed.

Repetitive Tasks

There will be some 'repetitive' tasks in aircraft maintenance engineering, eg in brake

or engine shops, in the sense of the same task possibly being carried out several
times a day. The main danger is that engineers may become so practiced at such
tasks that they may cease to consult the manual or to use work cards and, if
something about the tasks is changed, the engineer may not be aware of the
change. There is also a danger that an engineer may become complacent
regarding tasks which are relatively simple and carried out often, and may skip steps
or fail to give due attention to steps in the procedure, especially if it is to check
something which is rarely found to be wrong, damaged or out of tolerance. This
applies particularly to visual inspection.

Repetitive tasks, such as the detailed inspections of rivets along a lap joint,
are tedious, boring and lead to errors being made (missed defects). The effects
are made worse when the inspector has a very low expectation of finding a
discrepancy, eg on a new aircraft. Motivation and arousal are low without the reward
of a defect.

HF Section 3.doc/Issue 3 Page 3-55

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
Visual Inspection

Visual inspection is the process of examination and evaluation of systems and

components by us of human sensory systems, aided only by mechanical
enhancements to sensory input, such as magnifiers, dental picks, stethoscopes, and
the like. The visual input to the inspection process may be accompanied by such
behaviours as listening, feeling, smelling, shaking, twisting, etc.

It is however one of the primary methods employed during maintenance to ensure

the aircraft remains in an airworthy condition. The majority of inspection is visual
(80% to 99%, depending on circumstances); 1% to 20% is Non-Destructive Testing
(NDT).

Good eyesight is obviously of prime importance in visual inspection and there is a

standard for those engineers involved in NDT. (Airworthiness Notice 47 refers).

Visual inspection requires a considerable amount of concentration. Long spells of

continuous inspection can be tedious and result in low arousal. An engineer’s low
arousal or lack of motivation can contribute to a failure to spot a potential problem or
a failure in recognising a defect during visual inspection. The effects are potentially
worse when an inspector has a very low expectation of finding a defect, e.g. on a
new aircraft.

Engineers may find it beneficial to take short breaks between discrete visual
inspection tasks, such as at a particular system component, frame, lap joint, etc. This
is much better than pausing midway through an inspection.

The Aloha accident highlights what can happen when visual inspection is poor.
The accident report included two findings that suggest visual inspection was one of
the main contributors to the accident:

i. “There are human factors issues associated with visual and non-destructive
inspection which can degrade inspector performance to the extent that
theoretically detectable damage is overlooked.”

ii. “Aloha Airlines management failed to recognise the human performance

factors
of inspection and to fully motivate and focus their inspector force toward the
critical nature of lap joint inspection, corrosion control and crack detection…..”

Finally, non-destructive inspection (NDI) includes an element of visual inspection, but

usually permits detection of defects below visual thresholds. Various specialist tools
are used for this purpose, such as the use of eddy currents and fluorescent
penetrant inspection (FPI).

Page 3-56 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
Complex Systems

All large modern aircraft can be described as complex systems. Within these aircraft,
there are a myriad of separate systems, many of which themselves may be
considered complex, e.g. flying controls, landing gear, air conditioning, flight
management computers. The table below gives an example of the breadth of
complexity in aircraft systems.

Any complex system can be thought of as having a wide variety of inputs. The
system typically performs complex modifications on these inputs or the inputs trigger
complex responses. There may be a single output, or many distributed outputs from
the system.

The purpose, composition and function of a simple system is usually easily

understood by an aircraft maintenance engineer. In other words, the system is
transparent to him. Fault finding and diagnosis should be relatively simple with such
systems (although appropriate manuals etc. should be referred to where necessary).
Any complex system can be thought of as having a wide variety of inputs. The
system typically performs complex modifications on these inputs or the inputs trigger
complex responses. There may be a single output, or many distributed outputs from
the system.

Example of increasing complexity - the aileron system

HF Section 3.doc/Issue 3 Page 3-57

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

With a complex system, it should still be clear to an aircraft maintenance engineer

what the system’s purpose is. However, its composition and function may be harder
to conceptualise - it is opaque to the engineer.

To maintain such complex systems, it is likely that the engineer will need to have
carried out some form of system-specific training which would have furnished
him with an understanding of how it works (and how it can fail) and what it is made
up of (and how components can fail). It is important that the engineer understands
enough about the overall functioning of a large, complex aircraft, but not so much
that he is overwhelmed by its complexity. Thus, system-specific training must
achieve the correct balance between detailed system knowledge and analytical
troubleshooting skills.

With complex systems within aircraft, written procedures and reference material
become an even more important source of guidance than with simple systems.
They may describe comprehensively the method of performing maintenance tasks,
such as inspections, adjustments and tests. They may describe the relationship of
one system to other systems and often, most importantly, provide cautions or bring
attention to specific areas or components. It is important to follow the procedures
to the letter, since deviations from procedures may have implication on other parts
of the system of which the engineer may be unaware.

In modern aircraft, it is likely that the expertise to maintain a complex system may
be
distributed among individual engineers. Thus, B1 engineers and B2 engineers
may need to work in concert to examine completely a system that has an interface to
the pilot in the cockpit (such as the undercarriage controls and indications).

A single modern aircraft is complex enough, but many engineers are qualified on
several types and variants of aircraft. This will usually mean that he has less
opportunity to become familiar with one type, making it even more important that he
sticks to the prescribed procedures and refers to the reference manual wherever
necessary. There is a particular vulnerability where tasks are very similar between a
number of different aircraft (e.g. spoiler systems on the A320, B757 and B7671), and
may be more easily confused if no reference is made to the manual. When working
with complex systems, it is important that the aircraft maintenance engineer
makes reference to appropriate guidance material. This typically breaks down the
system conceptually or physically, making it easier to understand and work on.

Page 3-58 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering
Conclusion

One of the early MRM training programmes, developed by Gordon Dupont for
Transport Canada, introduced "The Dirty Dozen", which are 12 potential problem
human factors areas. A series of posters have been produced, one for each of these
headings, giving a few examples of good practices which ought to be adopted, or
"safety nets". These are summarised as follows:

PROBLEM SAFETY NET

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

HF Section 3.doc/Issue 3 Page 3-59

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CAUSES OF ERRORS

SECTION 3
engineering

Conclusion - contd

10. Stress Be aware of how stress can affect your work.

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

Page 3-60 HF Section 3.doc/Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
AVOIDING AND MANAGING
ERRORS

engineering SECTION 4

AVOIDING AND MANAGING ERRORS

Whilst we should always strive towards ensuring that errors do not occur in the
first place, we will never be able to eradicate them totally, therefore we should aim to
'manage' errors and concentrate upon preventing or mitigating the bad effects of
errors, in addition to trying to prevent them from occurring.

If we wish to prevent errors from occurring, we need to predict where they are
most likely to occur and to put in place preventative measures, ie error tolerant
design. Safety management concepts offer mechanisms for identifying potential
weak spots and error-prone activities or situations, often drawing upon risk
management techniques developed within the nuclear and process control industries
in the '70s and '80s.

No attempt is made here to list the various means by which errors might be
prevented, reduced or managed, since such a list would be very large and
inappropriate out of context. In effect, the whole of this document includes such
mechanisms, from ensuring that individuals are fit and alert, to producing
workcards using good design techniques, to making sure that the hangar
lighting is adequate. However, one of the things likely to be most effective in
preventing error is to make sure that engineers follow procedures. This can be
affected by ensuring that the procedures are correct and usable, that the means of
presentation of the information is user friendly and appropriate to the task and
context, that the engineers are encouraged to follow procedures and not to cut
corners. Obviously there are many other factors associated with why engineers do
or do not follow procedures, but it cannot be stressed too often that this is an
extremely important issue and one which should be high on an organisation's and
individual's list of priorities when it comes to error management.

HF Section 4.doc/Issue 3 Page 4-1

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
AVOIDING AND MANAGING
ERRORS

engineering SECTION 4

Page 4-2 HF Section 4.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
AVOIDING AND MANAGING
ERRORS

engineering SECTION 4

HAZARDS IN THE WORKPLACE

The Civil Aviation Authority, your company and your work-colleagues will expect you
to work on an aircraft/aircraft equipment in complete safety - safety for you - safety
for others - safety for the passengers - safety for the aircraft.

Additionally, employers and employees have a legal obligation under the

Health and Safety at Work, etc Act 1974 (HASAWA).

Two of the main philosophies set out in HASAWA require that:

i. The employer must, so far as it is reasonably practicable:

Ensure the health, safety and welfare of employees and others

Provide and maintain safe systems of work
Provide information, instruction, supervision and training
Provide a safe and healthy work environment and adequate welfare facilities

ii. For their part employees have an absolute duty to:

Take reasonable care of their own health and safety and that of others
Co-operate with their employer in discharging their duties under the Act

To achieve safe working practices, separate publications are available covering the
prevention of hazardous conditions in the work place.

For Health and Safety issues relating to a specific company, then the Health and
Safety Manual for that company should be referred to.

HF Section 4.doc/Issue 3 Page 4-3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
AVOIDING AND MANAGING
ERRORS

engineering SECTION 4

Recognising and Avoiding Hazards

Where hazards exist in the work place, staff should be made aware of them and
how to avoid them. Avoidance cannot be left to 'common sense' alone. Warnings
and signs should be used and training given.

Warnings must contain the following elements:

a) Clear identification of the hazard(s)

b) A description of the possible consequences of ignoring the hazard

c) Information on what to do or what not to do in avoiding a hazard

Signs must be conspicuous and legible in available light. They must be

understandable to the person or persons affected and durable enough to remain
effective, possibly for a number of years.

Positive recommendations are more effective than negative ones. For example, the
statement "Stay behind yellow line on floor" is better than "Do not come near this
equipment". Warning signs should be constructed with two "panels". The
upper panel should contain a signal word indicating the degree of risk associated
with the hazard. DANGER denotes that the hazard is immediate and could cause
grave, irreversible damage or injury. CAUTION in the upper panel indicates a
hazard of lesser magnitude. The sign's lower panel provides the message or
instructions regarding how to avoid or manage the risk. CAUTION signs generally
mix yellow and black in the two primary panels. DANGER signs should use a
mixture of red, black and white to convey the message.

Page 4-4 HF Section 4.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
AVOIDING AND MANAGING
ERRORS

engineering SECTION 4

Safe Working

The safety of others lies within the control of every engineer.

Before operating aircraft systems, clearance checks around moveable surfaces

should be made, eg flying controls, landing gear, flaps, etc before working on
systems, the deactivation procedures should be followed, eg pull circuit breakers,
isolate valves, disconnect power. Deactivation should, in all circumstances, be
carried out as per the maintenance manual since an 'ad-hoc' deactivation may not
render the system safe for work to be performed on.

System status must always be placarded to inform others of deactivation/activation

as appropriate. Placards should be positioned in key locations.

Control of Substances Hazardous to Health (COSHH)

A great many substances are used within the airline/aircraft industry which present
a danger to health. The COSHH Regulations are the main piece of legislation
covering control of risks from chemicals and toxic substances generally and set
out the steps which employers must take to control exposure of workers to
substances hazardous to health.

Measures taken may include provision of personal protective equipment (PPE),

monitoring of exposure and health surveillance.

HF Section 4.doc/Issue 3 Page 4-5

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
AVOIDING AND MANAGING
ERRORS

engineering SECTION 4

INTENTIONALLY BLANK

Page 4-6 HF Section 4.doc/ Issue 3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CASE STUDY

SECTION 5
engineering
CASE STUDY

Airline: Pennitoff International Airways (PIA) an International carrier

based at Gatwick
Employees: 13,000
Aircraft: Boeing 777, 747, 757 and Airbus A320 average age 12.3 years
Maintenance: Carries out own Base and Line maintenance, contracted out
Heavy checks to Stansted and Singapore based JAR 145
approved companies.
Recent history: Just emerged from near bankruptcy, very strong Union yet
workers elected to accept pay cut as part of bankruptcy
agreement. Facing very strong competition from other profitable
low-cost operators.

Personnel involved in the incident:

Riley: 22 years old 'A' shift B1 licensed engineer, 5 years experience, ex

Ab-initio student joined PIA with licences. Has dreadlocks and a
goatee beard. Loves Soul and Raggae music, always in the crew
room with his walkman on loud.

Tony: 43 years old B1 Licensed 'A' shift Supervisory engineer, 27 years

experience with PIA, served apprenticeship with PIA, never worked
anywhere else. Big burley Scotsman, doesn't have time for young
engineers, believes most of the airline problems are because these
kids don't want to get their hands dirty and have no respect for
authority.

Sarah: 32 years old, 'B' shift B1licensed engineer, 5 years experience

served apprenticeship with Royal Air Force. One of only three female
engineers in PIA engineering. Extremely conscientious engineer
keen to progress to supervisor, seen as one of her shifts best
engineers.

Brendan: 40 Years old, 'B' shift Supervisory engineer, B1 licensed engineer, 18

years experience served with Air Boil Cargo.

HF Section 5.doc/Issue 3 Page 5-1

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CASE STUDY

SECTION 5
engineering
Event summary

Pennitoff International Airways (PIA) flight 1016, 777 service from London (LGW) to
Tokyo experienced a "WAI PRESS SEN L" EICAS (wing anti-ice pressure sensor -
left) message 130 miles east of Paris. Captain Rodney and First Officer Nigel
diverted to Paris (GDG). All 352 passengers and crew including the airline Director
of Engineering and his staff, were delayed overnight waiting for repairs.

The local investigation revealed the technical cause of the diversion. The wing
thermal anti-ice (TAI) valve was not installed per the Boeing Maintenance
Manual (MM) in that the duct clamps downstream were loosened during TAI valve
removal and not tightened on installation.

When the captain selected wing anti-ice over Paris, the valve operated normally and
all system indications were normal. However, due to the leaks at the clamps the
wing TAI Pressure Sensor detected low pressure and generated the 'WAI
PRESS SEN L" EICAS message.

Page 5-2 HF Section 5.doc/Issue3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CASE STUDY

SECTION 5
engineering
Investigation

The aeroplane came into Gatwick from Boston with an "ANTI-ICE WING L" EICAS
message. The wing anti-ice valve cockpit indicator light was amber, showing valve /
indicator light disagreement. The crew raised a Tech' Log defect for the problem.
Because the next leg was likely to encounter icing conditions, this was not MEL
deferrable; it had to be repaired. Tony, day shift supervisor, believed that the
scheduled two hour down time would provide sufficient time to remove and replace
the Wing TAI valve.

This task had become very familiar to Tony and the other engineers on the first
shift. Since introduction of the 777, this valve had been a constant source of
failure. The valve manufacturer had determined that the bearings were of dissimilar
metals and fretting was occurring which caused the bearings to seize and the valve
would not operate properly. This resulted in an inoperative wing TAI and a flight
deck EICAS message. The manufacturer had issued a service bulletin (which
was mandated by Airworthiness Directive) to replace these bearings. However,
PIA management had agreed with the CAA to include an option of repetitive
inspections in lieu of terminating action. Even with these repetitive inspections, PIA
was experiencing frequent in-flight valve failure. Tony assigned the task to Riley.

Riley is a 22 year old engineer with five years at PIA. Riley is a B1 Licensed and
company authorised engineer, and is considered technically very competent by
his peers and superiors; however, it was well known that Riley was also
considered cocky and often deviated from procedures. Past infractions of
company policy were treated as minor by his supervisors because they involved
Riley short-cutting procedures to get aircraft out on time.

Riley got the Tech Log defect report from Tony and went to the aircraft to begin
work. He stated he did not get the Maintenance Manual (MM) procedure because
the MM's were not conveniently located, and he stated: "This was a routine task
and, even though I had never done it before, I believed I should be able to sort out a
straight replacement task".

To ensure Riley knew how to perform the task Tony quickly briefed him on the
procedure used by the others locally to perform the task. Tony was very familiar
with the task and explained it very quickly to Riley. Riley didn't ask any questions
so Tony assumed Riley understood. Riley stated he didn't want to ask questions
because he knew Tony didn't like him. Riley stated Tony thought of him as "a weird
kid who spent too much time listening to crappy music".

Riley stated he was not concerned about this verbal lesson because this was how he
and other engineers had learned most new procedures: OJT from the more
experienced engineers. He stated these experienced engineers always showed you
the best and fastest way to perform the task, including all the shortcuts.

HF Section 5.doc/Issue 3 Page 5-3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CASE STUDY

SECTION 5
engineering
Investigation – cont’d

Formal training had been further reduced during bankruptcy proceedings.

Therefore, this OJT format had rapidly become the engineer's primary source of
training. The classroom training engineers did receive, was driven primarily by
Health & Safety requirements and some airline Quality procedures. Engineers
received the usual classroom system type training, but recurrent training had died
off during the bankruptcy proceedings, so awareness of recurrent defects, such as
this valve, were never communicated to the workforce.Riley went to the stores to get
the new valve. He stated he returned the old valve and picked up the new one. He
did not compare the valves or check part numbers because someone offered him a
lift back to the aircraft if he hurried. When he got to the aircraft he realised he had
the wrong valve and had to return to stores. Riley was a little concerned when he
realised he had lost twenty minutes. However, he believed he could work fast and
make up the lost time

When Riley was replacing the TAI valve he followed the normal practice Tony told
him of and loosened one extra clamp downstream of the valve to allow him better
access to the TAI valve. He didn't have to remove the clamp, just loosen it slightly to
allow rotation for easier TAI valve replacement. This shortcut was not in the MM.
Riley stated even though he wasn't sure if this step was correctly documented in the
MM, he assumed everyone knew about it. Therefore, he believed it wasn't a
concern and it allowed the work to be done faster. Additionally, Riley stated he had
been told by "someone" that a temporary revision (TR) had been issued by a
Maintenance Planner to "cover the engineers" using the modified procedure. Riley
was also aware that, because the new procedure broke into the wing TAI system,
the new test required a full pressure test to check for leaks.

Riley stated he did not know if the airline's publication change request (PCR)
process was used to update this procedure. However, he did say it was common
knowledge that the PCR process was inefficient and not worth the time and
effort. He did not know of any engineers who used the change request process.

In fact, the MM procedure, 30-11-03, had been updated in a TR six months ago and
included loosening the extra clamp and a pressure test of the system. However, the
update was not done through the proper channels using the PCR process. One
of the engineers knew a planner and asked her to issue a TR to cover the engineers
for the way they were doing this procedure. Knowing the work involved to issue a
TR per her department procedures, the planning engineer circumvented the
system and hand wrote the TR for the shop floor to cover the engineers.
Because the TR was not done through the official process, the TR was not included
in the list of TR's to be included in the scheduled quarterly MM updates. Standard
update procedure is, "a TR in the shop floor TR folder is invalid after four months",
because it should have been incorporated in the MM by then. So when the
publications control clerk reviewed the TR file at the MM stations, he noted the six
month old date on this TR and assumed that it had been incorporated into the MM
and discarded the TR without reviewing the MM. Therefore, all records of the
procedure change had been lost.
Page 5-4 HF Section 5.doc/Issue3
 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CASE STUDY

SECTION 5
engineering
Investigation – cont’d

Riley had run out of time to fit the valve, remembering there was a torque loading on
the clamps, he looked in his note book for the figures. He had forgotten to bring
a torque wrench. Riley would have used his calibrated elbow if he had time, as he
had seen the experienced engineers and supervisors do many times.

He had to face Tony and delay the repair longer by walking the ½ mile to the line
office. Riley asked Tony to allow him one hour overtime to complete this task. Tony
said no overtime was available due to budget constraints, Riley should handover his
work and go.

Riley stated he was tired at the end of his shift because he, until recently had
been on the 8 hour C shift, this was his first time on the A shift 12 hour pattern. Riley
stated he changed to A shift to allow him to take a part-time job on his days off, to
help with the new mortgage he had recently taken on, necessary as he and his
girlfriend had just had their first baby.

The shift would be Sarah's first shift in five days. She had been out with the flu.
She still didn't feel well and had wanted to stay out longer, but Brendan, her
supervisor, had called and pushed her to come back sooner because there was a
shortage for this shift. She overslept and arrived ten minutes late for her shift. She
was concerned Brendan would give her an 'ear-bending'. Brendan was too busy to
notice and asked her to take over Riley's work.

Riley and Sarah were friends having been on two type courses together and Riley
felt their friendship gave them good communication and that a verbal handover was
sufficient. Following a recent CAA audit finding, the official handover procedure in
the PIA "Technical Procedures" Manual now required the completion of a
UB40 form for all shift handovers. However, it was well known by all engineers
and supervisors that this procedure was never followed. The UB40 handover
procedure was complicated. cumbersome and not ever taught to them in detail.
Riley had always used verbal handovers, he only used the UB40 when Quality and
the CAA were around.

Riley handed over the work to Sarah, not inside at the work control station as usual,
but outside on the ramp, due to her being late. Neither was happy about this
because it was already dark and rainy and engine noise made communicating
difficult.

During previous handovers, Sarah always asked the departing engineer to go over
the work he had done up to the handover point. However, because Sarah was late,
Riley was unable to be as thorough as Sarah liked.

HF Section 5.doc/Issue 3 Page 5-5

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CASE STUDY

SECTION 5
engineering
Investigation – cont’d

Sarah stated Riley was slightly agitated because she was late and he was in a hurry
to leave. Sarah stated Riley said, "I've done the usual steps up to this point; take it
from here. After you're done, you should do the full-pressure test per the MM".
Sarah didn't question Riley, although she stated she thought that a full-pressure
test was not required, but Riley must know better from his experience. She assumed
Riley was confused because this was the first time he had performed the task. She
assumed Riley meant she should perform the required functional test. However, she
stated she always checked the MM and would confirm the required test.

Especially at times like these when she felt rushed, Sarah was not comfortable with
verbal handovers and a couple of times she tried to communicate her concerns to
Brendan. He always told her that the UB40 form was not always necessary and a
verbal handover was standard practice for simple jobs. He couldn't understand why
she had difficulty with this. Anyhow Brendan was always too busy and would not
listen to Sarah, she was a girl, what did she know about aircraft maintenance.
On more than one occasion he had said; "this is not the RAF, you don't have
procedures for everything. that's why the CAA give you a licence". So Sarah
continued using the verbal handover and compensated by writing her own notes
while Riley spoke.

The TAI valve replacement was a common remove and replace task and Sarah had
performed the task dozens of times on the 757 but never the 777. Regardless,
she prided herself in her following the manual every time. As a result she was given
a hard-time by the other guys on shift but she believed following the MM was the
proper way. She was aware most engineers did not use the procedure and there
were unwritten 'normal' ways of doing each task. However, Sarah felt as long as she
followed the published procedure she was in the right, she did it the correct way -
others should follow her.

Sarah went to the reader / printer area ½ a mile away to obtain the required MM
procedure. The CD-ROM PC was not working, as was frequently the case, so
Sarah made a copy of the MM procedure from the cassette which was mixed up
with the 757 cassettes, this room was always a 'tip' with books, 'print-outs' and
coffee cups all over the place. Due to this lost time and frustration Sarah forgot
about looking in the PIA Temporary Revision (TR) file.

The TR process reduces the number of updates to the MM to save time and money.
Updates from the manufacturer and engineers (although it was well known that
engineering requested updates were infrequently incorporated because of the time
required to research the requests and make the changes) are reviewed by the
Technical Services group. If updates are required, temporary revision (TR) sheets
are published with the changes. The engineer is required to first look at the MM for
the procedures and then the TR file for any changes.

Page 5-6 HF Section 5.doc/Issue3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CASE STUDY

SECTION 5
engineering
Investigation - cont’d

Sarah stated she was starting to understand why the experienced engineers have
unwritten rules not to use the MM procedures. These guys see MM procedures
as a label of an inexperienced new boy (girl is even lower in the pile); experienced
engineers rarely use the MM. And newer engineers like learning how to do the
procedure from the more experienced guys because they learn the
best/easiest way. Besides Sarah can think of three times in the last four months
where she found errors in the MM. How could she trust the MM? In the past, she
had tried to get the MM corrected, however, the process was unresponsive, so she
stopped trying.

This was one of the regular maintenance tasks which used to be covered by
recurrent training, but this training was cut back to a minimum due to budgets and
these common tasks were no longer reviewed. She could not understand how the
CAA could allow that to go on?

When Sarah returned to the aircraft with the MM procedure, her supervisor,
Brendan, gave her a hard time for taking the time to find the MM when the procedure
was "so simple" and nearly complete. Sarah was told the aircraft had to depart on
time in 30 minutes, because Ard Bustard (the Engineering Director) was on the
flight. Nothing could hold up the flight.

Sarah stated she began work feeling the pressure to complete her task even
though she knew completing the job would only take 15 minutes. Using the notes
she made during her verbal shift handover with Riley she completed the task per the
MM. While performing the task, Sarah noticed they still had not replaced the shaky
workstands the others had been complaining about. She never felt safe working on
this stand; however, she said she did not have time to look for a better one.

The MM Operational Check (task 30-11-00/501) called for operating the valve using
the WING ANTI-ICE switch. No requirements were listed to pressurise the system
after opening the valve as she remembered Riley telling her. She intended to follow
Riley's instructions because he was a good engineer and usually right.

She went to the flight deck to complete the functional test. After checking the valve
operation, she asked the flight crew, already on the flight deck, to start the left engine
to allow her to pressurise the system. The Captain said the aircraft was still being
fuelled due to previous fuelling problems and the engine could not be started.
Further, fuelling would not be completed until 10 minutes prior to schedule departure
and there would not be sufficient time to do the test without delaying the flight.

HF Section 5.doc/Issue 3 Page 5-7

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CASE STUDY

SECTION 5
engineering
Investigation – cont’d

Sarah went to Brendan to explain the situation. Brendan knew the functional test
only required the operation of the valve, which Sarah had already completed. There
was no requirement to pressurise the system, no matter what "that dirty haired idiot
on A shift told you". Sarah stated Brendan gave her one of his 'you really are rather
stupid' lectures on the fact that "the system had not been disturbed, only the valve
had been replaced, and it had passed the functional test, so why would you
pressurise the system?" Brendan went on, "This task has been performed hundreds
of times by many different engineers, without any problem, maybe I should have put
someone else on such a 'complex' task?". Finally, Brendan told Sarah to just get on
and sign for the job. Sarah, unable to explain the reason for pressurising the system
and unwilling to go to her Shift Manager, signed the work as complete. She was not
comfortable doing this.

Page 5-8 HF Section 5.doc/Issue3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CASE STUDY

SECTION 5
engineering
Having read and analysed the 'Pennitoff International Airways' incident can you list
the factors which could have contributed to the incident?

Contributing Factors

Discuss

HF Section 5.doc/Issue 3 Page 5-9

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
CASE STUDY

SECTION 5
engineering

INTENTIONALLY BLANK

Page 5-10 HF Section 5.doc/Issue3

 TRAINING MANUAL
uk HUMAN FACTORS
MODULE 9
THE GROUND OCCURRENCE
REPORT (GOR)

engineering SECTION 6

THE GROUND OCCURRENCE REPORT (GOR)

THE CHANGING ENVIRONMENT IN ENGINEERING

Current forecasts envisage a substantial rise in the number of people travelling

by air over the next 10-20 years. This will entail a corresponding growth in the
number of aircraft. There is, therefore, a high probability of accident rates
increasing both in flight and on the ground. A large number of recorded accidents
have been attributed to human error and it is this particular factor which is bringing
about changes in the operation and maintenance of aircraft. Flight deck crews and
air traffic controllers are already addressing ways and means of combating human
error hence the ASR scheme. Engineering is also involved and similar efforts are
being used and developed to reduce accident rates.

Mistakes or accidents are the result of either unforeseeable errors or violation

of procedures laid down in maintenance manuals, repair manuals, company
procedure manuals etc. In the case of unforeseeable errors, little can be done to
prevent the first occurrence of an accident. A reporting system would, however,
significantly reduce its recurrence. The MOR scheme currently in use is well
documented and familiar to maintenance engineers and flight deck crews. KLM UK
Engineering has adopted a similar "in house" scheme termed the
"Ground Occurrence Report" to cover maintenance errors that occur.

HF Section 6.doc/sg Issue 2 Page 6-1