KEMENTERIAN PERHUBUNGAN

REPUBLIK INDONESIA

HUMAN FACTORS
HANDBOOK

CENTRE OF HUMAN RESOURCE DEVELOPMENT ON CIVIL AVIATION

2020

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HUMAN FACTORS HANDBOOK

FIRST EDITION, 2020

CENTRE OF HUMAN RESOURCE DEVELOPMENT ON CIVIL AVIATION

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BIBLIOGRAPHY
 ICAO, Human Factors Training Manual, Doc 9683, 1998.
 ICAO, Safety Management Manual (Vol. 4th Edition), Doc 9859, 2018.
 ICAO, Human Factors Guidelines for Air Traffic Management Systems, Doc 9758,
2000.
 ICAO, Human Factors Guidelines for Safety Audits Manual, Doc 9806, 2002
 ICAO, Human Factors Guidelines for Aircraft Maintenance Manual, Doc 9824,
2003
 ICAO, Training Manual, Doc 7192, 2004
 Human Factors Digest 8,10,11
 James Reason, Human Error, Cambridge University Press, 2009
 AMT Handbook Addendum Human Factors
 Australian Government, CASA, Safety Behaviours : Human Factors for Pilots 2 nd
Edition, 2019
 Australian Government, CASA, Safety Behaviours, 2009
 CAE Oxford Aviation Academy, Human Performance and Limitations, 2014
 Jeppesen, Atlantic Flight Training Ltd, Human Performance and Limitations

 V. David Hopkins, Human Factors in Air Traffic Control, Taylor & Francis, 1995.

 Anne R. Isaac and Bert Ruitenberg, Air Traffic Control: Human Performance
Factors, Ashgate, 1999.

 Christopher D. Wickens et al, The Future of Air Traffic Control: Human Operators
and Automation, National Academy Press, 1998.

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AMANDMENT RECORD LIST

Amandement No Issue Date Inserted By Insertion Date

Original CHRDCA

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FOREWORD

This Human Factors Handbook is designed to be a reference in developing teaching materials

for Human Factors training that conducted by all CHRDCA Training Centre. This handbook
referred to the most updated Human Factors Training Manual document, Doc. 9693 and also
various rules and regulation both national and international.

There are 2 types of Human Factors training organized by CHRDCA Training Centre, as
follows:

1. Initial Human Factors Training

2. Recurrent Human Factors Training.

In developing training materials, it must be adjusted to each training. Initial Human Factors
training should consider, as a minimum, the following:

1. Human Factors Conceptual Model

2. Human Element (Physiology and Psychology)
3. Human – Equipment Relationship
4. Human – Software Relationship
5. Interpersonal Relations
6. The Operating Environment

And for recurrent Human Factors training should focus on changes to the Human Factors
policies, processes and procedures, and should highlight any specific issues relevant to the
organization or lessons learned.

We would like to express our gratitude for the work of the Human Factors Handbook
Development Team. Members of this group recognized the need for these training materials,
identified the goals and objectives of Human Factors training, and provided valuable input that
guided and shaped the development of all of the content of these training modules.

Members of the Advisory Group:

1. Komite Nasional 5. Indonesia Curug 9. Palembang

Keselamatan Transportasi Aviation Polytechnic Aviation
2. Directorate Of Airworthiness 6. Surabaya Aviation Polytechnic
& Aircraft Operation Polytechnic 10. Jayapura Aviation
3. Directorate Of Air Navigation 7. Medan Aviation Polytechnic
4. Centre Of Human Resource Polytechnic 11. Indonesia Civil
Development On Civil 8. Makasar Aviation Pilot Academy-
Aviation Polytechnic Banyuwangi
12. Curug Civil
Aviation College
Hope this handbook can be used as it should be in accordance with our common expectations.
Excerpts from this module may be freely reproduced or adapted with acknowledgement of the
source, provided the material reproduced by and for non-profit distribution.

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Table of Content
HUMAN FACTORS HANDBOOK ............................................................................................................... ii
BIBLIOGRAPHY .................................................................................................................................…….iii

AMANDMENT RECORD LIST................................................................................................................... iv

FOREWORD ............................................................................................................................................. v
List of Figures ......................................................................................................................................... ix
List of Table ............................................................................................................................................ xi

Chapter 1. Fundamental Human Factors............................................................................ 1-1

1.1 Introduction ................................................................................................... 1-1

1.2 The Meaning of Human Factors .................................................................... 1-2
1.3 The Industry Needs for Human Factors......................................................... 1-8
1.4 Human Factors Application in Aviation Operations ...................................... 1-19

Chapter 2. The Human Element (Aviation Physiology)....................................................... 2-1

2.1 Limitation of Sense ........................................................................................ 2-1

2.1.1 Vision......................................................................................................... 2-1
2.1.2 Hearing...................................................................................................... 2-5
2.1.3 Vestibular System ..................................................................................... 2-10
2.1.4 Proprioceptive........................................................................................... 2-13
2.1.5 Tactile........................................................................................................ 2-14
2.2 Fatigue ........................................................................................................... 2-16
2.3 Sleep Disturbance and Deficits...................................................................... 2-20
2.3.1 Insomnia.................................................................................................... 2-22
2.3.2 Sleep Apnea .............................................................................................. 2-22
2.3.3 Restless Legs Syndrome ............................................................................ 2-23
2.3.4 Narcolepsy................................................................................................. 2-24
2.3.5 Other Situation.......................................................................................... 2-24
2.4 Diet, Health and Wellbeing............................................................................ 2-26
2.5 Fasting............................................................................................................ 2-27
2.6 Alcohol and Other Drugs ............................................................................... 2-28
2.7 Blood Donation.............................................................................................. 2-29
2.8 Ageing ............................................................................................................ 2-30
2.9 Mental Health................................................................................................ 2-31
2.10 Pregnancy ...................................................................................................... 2-32

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Chapter 3. The Human Element (Aviation Psychology)...................................................... 3-1

3.1 Human Error .................................................................................................. 3-1

3.2 Workload ....................................................................................................... 3-9
3.3 Human Information Processing ..................................................................... 3-13
3.4 Attitudinal Factors ......................................................................................... 3-19
3.5 Situational Awareness ................................................................................... 3-21
3.6 Decision-making ............................................................................................ 3-25
3.7 Stress.............................................................................................................. 3-28
3.8 Currency and Proficiency............................................................................... 3-32

Chapter 4. Human – Equipment Relationship .................................................................... 4-1

4.1 Ergonomic...................................................................................................... 4-1

4.2 Human Dimensions........................................................................................ 4-5
4.3 Displays and Controls .................................................................................... 4-7
4.4 Alerting and Warning Systems ...................................................................... 4-12
4.5 Personal Comfort........................................................................................... 4-13
4.6 Cockpit Visibility and Eye-reference Position................................................ 4-20
4.7 Motor Workload ............................................................................................ 4-21

Chapter 5. Human – Software Relationship ....................................................................... 5-1

5.1 Standard Operating Procedures .................................................................... 5-1

5.2 Written Materials .......................................................................................... 5-2
5.3 Operational Aspects of Automation.............................................................. 5-6

Chapter 6. Interpersonal Relations..................................................................................... 6-1

6.1 Communication ............................................................................................. 6-1

6.2 Communication Errors................................................................................... 6-7
6.3 Teamwork ...................................................................................................... 6-13
6.4 Team Management ....................................................................................... 6-16

Chapter 7. The Operating Environment.............................................................................. 7-1

7.1 View of Safety Culture ................................................................................... 7-1

7.2 The Aviation System ...................................................................................... 7-6
7.3 General Model of Organizational Safety ....................................................... 7-7
7.4 Organizations Structure and Safety............................................................... 7-12
7.5 Culture and Safety ......................................................................................... 7-13
7.6 Procedures and Safety................................................................................... 7-14
7.7 Safe and Unsafe Organizations...................................................................... 7-16

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Appendix 1. The Dirty Dozen .....................................................................................……APP1-1

Appendix 2. Human Factors for Pilot.........................................................................……APP2-1

Appendix 3. Human Factors for Aircraft Maintenance..............................................……APP3-1

Appendix 4. Human Factors for Air Traffic Services ..................................................……APP4-1

Appendix 5. Human Factors in Air Navigation System Provider (ANSP) ...................……APP5-1

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List of Figures
Figure 1. SHELL Model................................................................................................... 1-7
Figure 2. L1011 crashed in the Florida Everglades ......................................................... 1-10
Figure 3. B-737 crashed at Midway Airport in Chicago................................................... 1-10
Figure 4. B-707 crashed during approach at Pago-Pago in Samoa................................. 1-11
Figure 5. DC-10 crashed after take-off because a cargo door failed................................ 1-11
Figure 6. B-727 approaching Dulles Airport in Washington crashed into Mount Weather 1-12
Figure 7. Two B-747s collided while on the runway at Tenerife....................................... 1-12
Figure 8. DC-I0 crashed into Mount Erebus in Antarctica................................................ 1-13
Figure 9. B-737 crashed after take-off in icing conditions in Washington......................... 1-13
Figure 10. A300 accident in Kuala Lumpur...................................................................... 1-14
Figure 11. DC-10 overran the runway at John F. Kennedy Airport in New York .............. 1-14
Figure 12. MD-80 crashed on take-off in Detroit.............................................................. 1-15
Figure 13. Basic Structure of The Eye............................................................................. 2-1
Figure 14. Hypermotropia ............................................................................................... 2-3
Figure 15. Myopia ........................................................................................................... 2-4
Figure 16. Ear Structure.................................................................................................. 2-5
Figure 17. Semi-circular Canals ...................................................................................... 2-10
Figure 18 Otoliths............................................................................................................ 2-12
Figure 19. Proprioceptive ................................................................................................ 2-14
Figure 20. Example of Tactile.......................................................................................... 2-15
Figure 21. Typical Cycle of Stage 1-4 (NREM) sleep and REM Sleep over a Night......... 2-21
Figure 22. The Circadian Rhythm for Internal Body Temperature ................................... 2-22
Figure 23. Type of Error .................................................................................................. 3-2
Figure 24. Error type base on intention. Source : Reason, 1990 ..................................... 3-4
Figure 25. SHEL Model................................................................................................... 3-5
Figure 26. Crew Error Management Model ..................................................................... 3-8
Figure 27. Momentary Workload vs Cumulative Workload .............................................. 3-10
Figure 28. Working Memory and Workload ..................................................................... 3-11
Figure 29. Human Information Processing Model............................................................ 3-13
Figure 30. Visual Illusion ................................................................................................. 3-16
Figure 31. Triangle of Human Needs .............................................................................. 3-20
Figure 32. Model of Situational Awareness ..................................................................... 3-23
Figure 33. The Yerkes-Dodson law relating performance and arousal ............................ 3-28
Figure 34. Effect of Stress on Human Performance ........................................................ 3-29
Figure 35. Representation of A Person – System Machine ............................................. 4-3

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Figure 36. Human Dimensions........................................................................................ 4-6

Figure 37. Example of Display ....................................................................................... 4-8
Figure 38. Example displays used in presenting quantitative information (adapted from
McCormich et al., 1983)................................................................................ 4-10
Figure 39. Example of Control System ............................................................................ 4-11
Figure 40. Alerting and Warning System ......................................................................... 4-13
Figure 41. The relationship between climate, termperature and performance ................. 4-15
Figure 42. Reference Eye Position.................................................................................. 4-21
Figure 43. Typical Viewing Distance from Pilot’s Eye Design Eye Position to Various
Panels on the Flight Deck of a Large Jet ........................................................ 4-21
Figure 44. The Four Ps ................................................................................................... 5-3
Figure 45. Examples of Pilot-related Insights from Automation Data ............................... 5-7
Figure 46. Garuda 152 .................................................................................................... 6-2
Figure 47. Simplified Model of Communication ............................................................... 6-4
Figure 48. Elements of Safety Culture............................................................................. 7-5
Figure 49. Build Safety Culture ....................................................................................... 7-8
Figure 50. Swiss Cheese Model...................................................................................... 7-11
Figure 51. Concept of Practical Drift................................................................................ 7-15
Figure 52. KLM 747 and Pan Am 747 accident ...................................................... APP1-2

Figure 53. Visual Illusions ...................................................................................... APP2-12

Figure 54. Illusion of Movement ............................................................................. APP2-13

Figure 55. Visual Angle .......................................................................................... APP2-17

Figure 56. The Auditing Process ............................................................................APP3-9

Figure 57. The Physical Audit Process...................................................................APP3-10

Figure 58. Feedback (Audit Follow-up) Process..................................................... APP3-14

Figure 59. Audit/ Surveillance/Inspection Follow-Up Process Flow Diagram ..........APP3-15

Figure 60. Vertical Communication within a Department ........................................APP3-17

Figure 61. Interlan Communications – Horizontal................................................... APP3-18

Figure 62. Type of Communication ........................................................................APP3-26

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List of Table

Table 1. Typical Sounds Level For Various Activities ...................................................... 2-8

Table 2. Limit of Noise Intensity ...................................................................................... 2-9

Table 3. Side Effect of Alcohol and Other Drugs ............................................................. 2-29

Table 4. An example checklist on how to select controls based on their functions .......... 4-12

Table 5. Type of Communication Errors.......................................................................... 6-7

Table 6. Characteristic of Safety Culture ......................................................................... 7-9

Table 7. Times of Useful Consciousness at Various Altitudes ..................... …APP2-8

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 CHAPTER 1

FUNDAMENTAL HUMAN FACTORS CONCEPTS

1.1 INTRODUCTION

Human performance is cited as a casual factor in the majority of aircraft accidents.

If the accident rate is to be decreased, Human Factors issues in aviation must be better
understood and Human Factors knowledge more broadly and proactively applied. By
proaction it is meant that Human Factors knowledge should be applied and integrated
during the systems design and certification stages, as well as during the operational
personnel certification process, before the systems and the people become operational.
The expansion of Human Factors awareness presents the international aviation
community with the single most significant opportunity to make aviation both safer and
more efficient. The purpose of this chapter is to present an overview of the various
components which constitute Human Factors and to clarify its meaning.

Ever since humans began to make took, thousands of years ago. The application of
elementary ergonomics has improved work efficiency. But it is only during the last
hundred years that the modem evolution of ergonomics towards Human Factors has
begun.

The need during the First World War to optimize factory production and to assign
thousands of recruits more effectively to military duties, and the fact that during the
Second World War sophisticated equipment was surpassing human capability to operate
it with maximum effectiveness provided further stimulus to Human Factors progress.
Selection and training of staff, too, began to be approached more scientifically. However,
it might be argued that the renewed interest in Human Factors contribution to aviation
safety was a reactive response to technological limitations prevailing at the time.
Therefore, human capabilities were extended to their maximum through the application
of Human Factors knowledge, sometimes at the cost of overlooking human limitations.

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 The institutionalization of Human Factors occurred with the founding of several
organizations such as the Ergonomics Research Society in 1949. The Human Factors
Society (now Human Factors and Ergonomics Society) in 1957 and the International
Ergonomics Association (IEA) in 1959.

The recognition that basic Human Factors education was needed throughout the
industry led to various approaches to formal training in different countries. This
recognition, tragically emphasized by the investigation of a number of accidents resulting
almost entirely from deficiencies in the application of Human Factors, led ICAO to
implement Human Factors training requirements into the training and licensing
requirements included in Annex 1 (1989) and Annex 6 (1995), as well as into the process
of accident investigations included in Annex 13 (1994).

The 1976 agreement between the United States Federal Aviation Administration
(FAA) and the National Aeronautics and Space Administration (NASA) to establish a
voluntary, non-punitive, confidential Aviation Safety Reporting System (ASRS)
constituted official recognition that adequate information for analysis of human behaviour
and errors in human performance is best obtained by eliminating the threat of punitive
action against the person making the report. Similar schemes were later set up in the
United Kingdom (CHIRP), Canada (CASRP) and Australia (CAIR).

1.2 THE MEANING OF HUMAN FACTORS

Human Factors as a term has to be clearly defined because when these words are
used in the vernacular they are often applied to any factor related to humans. The human
element is the most flexible. Adaptable and valuable part of the aviation system. But it is
also the most vulnerable to influences which can adversely affect its performance.
Throughout the years, some three out of four accidents have resulted from less than
optimum human performance. This has commonly been classified as human error.

The term "human error" is of no help in accident prevention because although it may
indicate WHERE in the system a breakdown occurs, it provides no guidance as to WHY
it occurs. An error attributed to humans in the system may have been design-induced or

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stimulated by inadequate training, badly designed procedures or the poor concept or
layout of checklists or manuals. Further, the term "human error" allows concealment of
the underlying factors which must be brought to the fore if accidents are to be prevented.
In fact, contemporary safety-thinking argues that human error should be the starting point
rather than the stop-rule in accident investigation and prevention.

An understanding of the predictable human capabilities and limitations and the

application of this understanding are the primary concerns of Human Factors. Human
Factors has been progressively developed, refined and institutionalized since the end of
the last century, and is now backed by a vast store of knowledge which can be used by
those concerned with enhancing the safety of the complex system which is today's civil
aviation. Throughout this manual capital initial letters are used for the term "Human
Factors". The terms "human aspects" and "human elements" in common usage are
helpful alternatives to avoid ambiguity and aid comprehension.

The disciplines of Human Factors

Many of the early concerns in aviation were related to the effects on people of noise,
vibration, heat, cold and acceleration forces. Usually, the person nearest at hand with a
knowledge of physiology was a physician; this may have generated one of the more
persistent misconceptions about Human Factors, the belief that it is somehow a branch
of medicine. Yet half a century ago work was expanding on the more cognitive aspects
of aviation tasks and this trend has continued and is outside the scope of medicine.
Optimizing the role of people in this complex working environment involves all aspects of
human performance: decision-making and other cognitive processes; the design of
displays and controls and flight deck and cabin layout: communication and computer
software; maps and charts: and the field of documentation such as aircraft operating
manuals, checklists, etc. Human Factors knowledge is also increasingly used in staff
selection, training and checking and in accident prevention and investigation.

Human Factors is multidisciplinary in nature. For example, information is drawn from

psychology to understand how people process information and make decisions. From

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psychology and physiology comes an understanding of sensory processes as the means
of detecting and transmitting information on the world about us. The measures and
movements of the body - essential in optimizing the design and layout of controls, and
other workplace characteristics of the flight deck and cabin - call upon anthropometry and
biomechanics. Biology and its increasingly important sub-discipline, chronobiology, are
needed to understand the nature of the body's rhythms and sleep, and their effects in
night flying and time-zone changes. No proper analysis or presentation of data from
surveys or studies is possible without some basic understanding of statistics. While
utilizing these academic sources of knowledge, Human Factors is essentially concerned
with solving practical problems in the real world. Human Factors is practical in nature; it
is problem oriented rather than discipline-centred.

Human Factors is about people in their living and working situations; about their
relationship with machines, with procedures and with the environment about them; and
also about their relationships with other people. One definition of Human Factors, as
proposed by Professor Edwards, declares that "Human Factors is concerned to optimize
the relationship between people and their activities, by the systematic application of
human sciences, integrated within the framework of systems engineering". Its objectives
can be seen as effectiveness of the system, which includes safety and efficiency, and the
well-being of the individual.

Professor Edwards further elaborates that "activities" indicates an interest in

communication between individuals and in the behaviour of individuals and groups.
Lately, this has been expanded upon to include the interactions among individuals and
groups and the organizations to which they belong, and to the interactions among the
organizations that constitute the aviation system. The human sciences study the structure
and nature of human beings, their capabilities and limitations, and their behaviours both
singly and in groups. The notion of integration within systems engineering refers to the
Human Factors practitioner's attempts to understand the goals and methods as well as
the difficulties and constraints under which people working in interrelated areas of
engineering must make decisions. Human Factors uses this information based on its
relevance to practical problems.

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 The term "ergonomics" derives from the Greek words 'ergon" (work) and "nomos"
(natural law). It is defined as "the study of the efficiency of persons in their working
environment". In some States, the term ergonomics is used strictly to refer to the study of
human-machine system design issues.

A Conceptual Model of Human Factors

It is helpful to use a model to aid in the understanding of Human Factors, as this
allows a gradual approach to comprehension. One practical diagram to illustrate this
conceptual model uses blocks to represent the different component of Human Factors.
The model can be built up one block at a time, with a pictorial impression being given of
the need for matching the components. The SHEL (Software, Hardware, Environment
and Liveware) was first developed by Edward in 1972, with a modified diagram to illustrate
the model developed by Hawkins in 1975. The following interpretations are suggested:
liveware (human), hardware (machine), software (procedures, symbology, etc.) and
environment (the situation in which the L-H-S system must function). This building block
diagram does not cover the interfaces which are outside Human Factor (hardware-
hardware; hardware-environment; software-hardware) and is only intended as a basic aid
to understanding Human Factor.
Liveware. In the centre of the model is a person, the most critical as well as the most
flexible component in the system. Yet people are subject to considerable variations in
performance and suffer many limitations, most of which are now predictable in general
terms. The edges of this block are not simple and straight, and so the other components
of the system must be carefully matched to them if stress in the system and eventual
breakdown are to be avoided.
In order to achieve this matching, an understanding of the characteristics of this
central component is essential. Some of the more important characteristics are the
following:
a. Physical and shape. In the design of any workplace and most equipment, a vital
role is play by body measurements and movements, which will vary according
to age and ethnic and gender groups. Decisions must be made at an early
stage in the design process, and the data for these decision are available from
anthropometry and biomechanics.

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 b. Physical needs. People’s requirements for food, water and oxygen are
available from physiology and biology.
c. Input characteristics. Humans have been provided with a sensory system for
collecting information from the world around them, enabling them to respond to
external events and to carry out the required task. But all sense are subject to
degradation for one reason or another, and the sources of knowledge here are
physiology, psychology and biology.
d. Information processing. These human capabilities have severe limitations.
Poor instrument and warning system design has frequently resulted from a
failure to take into account the capabilities and limitations of the human
information processing system. Short and long-term memory are involved, as
well as motivation and stress. Psychology is the source of background
knowledge here.
e. Output characteristic. Once information is sensed and processed, messages
are sent to be muscle to initiate the desired response, whether it be a physical
control movement or the initial of some form communication. Acceptable control
forces and direction of movement have to be known and biomechanics,
physiology and psychology provide such knowledge.
f. Environment tolerances. Temperature, pressure, humidity, noise, time of day,
light and darkness can all be reflected in performance and also in well-being.
Height, enclosed spaces and a boring or stressful working environment can
also be expected to influence performance. Information is provided here by
physiology, biology and psychology.

The Liveware is the hub of the SHEL model of Human Factors. The remaining
components must be adapted- and matched to this central component.
Liveware-hardware. This interface is the one most commonly considered when
speaking of human machine systems; design of seats to fit the sitting characteristic of the
human body, of displays to match the sensory and information processing characteristics
of the user, of controls with proper movement, coding and location. The user may never
be aware of an L-H deficiency, even where it finally leads to disaster, because the natural

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human characteristic of adapting to L-H mismatches will mask such a deficiency, but will
not remove its existence. This constitutes a potential hazard to which designer should be
alert. With the introduction of computers and advanced automated systems, this interface
has repositioned itself at the forefront of Human Factors endeavors.
The image part with relationship ID rId8 was not found in the file.

Figure 1. SHELL Model

Liveware-Software. This encompasses humans and the non-physical aspects of the

system such as procedures, manual and checklist layout, symbology and computer
programs. Liveware-software problems are conspicuous in accident reports, but they are
often difficult to observe and are consequently more difficult to resolve (for example,
misinterpretation of checklist or symbology, non-compliance with procedures, etc.)

Liveware-Environment. The human environment interface was one of the earliest

recognized in flying. Initially, the measures taken all aimed at adapting the human to the
environment (helmets, flying suits, oxygen masks, anti-G suits). Later, the trend was to

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reverse this process by adapting the environment to match human requirements
(pressurization and air-conditioning systems, soundproofing). Today, new challenges
have arisen, notably ozone concentrations and radiation hazards at high flight levels and
the problems associated with disturbed biological rhythms and related sleep disturbance
and deprivation as a consequence of the increased speed of transmeridian travel. Since
illusions and disorientation are at the root of many aviation accidents the L-E interface
must consider perceptual errors induced by environmental conditions, for example,
illusions during approach and landing phases. The aviation system also operates within
the context of broad political and economic constraints, and those aspects of the
environment will interact in this interface. Although the possibility of modifying these
influences is sometimes beyond Human Factors practitioners, their incidence is central
and should be properly considered and addressed by those in management with the
possibility to do so.

Liveware-Liveware. This is the interface between people. Training and proficiency

testing have traditionally been done on an individual basis. If each individual team
member was proficient, then it was assumed that the team consisting of these individuals
would also be proficient and effective. This is not always the case, however and for many
years attention has increasingly turned to the breakdown of teamwork. Flight crews, air
traffic controllers, maintenance technicians and other operational personnel function as
groups and group influences play a role in determining behavior and performance. In this
interface, we are concerned with leadership, crew co-operation, teamwork and
personality interactions. Staff/management relationships are also within the scope of this
interface, as corporate culture, corporate climate and company operating pressures can
significantly affect human performance.

1.3 THE INDUSTRY NEED FOR HUMAN FACTORS

Admiral Donald Engen, the former Administrator of the United States Federal
Aviation Administration, has been quoted as saying (1986): "We spent over fifty years on
the hardware, which is now pretty reliable. Now it's time to work with people." This
declaration somehow sets the foundation upon which the industry need for Human

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Factors can be assessed. Curiously enough, we retain a lawyer for advice about a Iegal
problem, or hire an architect to build a house, or consult a physician when trying to
establish the diagnosis of a medical problem, but when it comes to solving Human Factors
problems. we have adopted an intuitive and in many cases perfunctory approach, even
though many lives may depend on the outcome. A background of many years of industry
experience or thousands of flying hours may have little or no significance when looking
for the resolution of problems which only a thorough understanding of Human Factors
can provide.

This is of special significance because, as already mentioned, it has long been

known that some three out of four accidents result from performance errors made by
apparently healthy and properly certificated individuals. The sources of some of these
error may be traced to poor equipment or procedure design or to inadequate training or
operating instructions.

But whatever the origin, the question of human performance capabilities and
limitations and human behaviour is central to the technology of Human Factors. The cost,
both in human and financial terms, of less than optimum human performance has become
so great that a makeshift or intuitive approach to Human Factors is no longer appropriate.
Safety being the ultimate objective of all those involved in aviation, its logical follow-up is
to ensure a proper level of Human Factors knowledge throughout the industry.

The industry need for Human Factors is based on its impact on two broad areas,
which interrelate so closely that in many cases their influences overlap and factors
affecting one may also affect the other. These areas are:

Effectiveness of the system

- safety

- efficiency

Well-being of operational personnel.

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Effectiveness of the system

Safety

The best way to illustrate the effect of Human Factors issues on aviation safety is
through the example of accidents. A few accidents in which aspects of Human Factors
triggered the attention of the aviation community and paved the way to the proliferation
of Human Factors endeavours in aviation are described here as examples.

1) In the same month - December 1972 - an L1011 crashed in the Florida Everglades
(NTSB/AAR 73-14) and a B-737 crashed at Midway Airport in Chicago (NTSB/AAR
73-16). In the first case, duties were not properly allocated and the whole flight crew
became preoccupied with a landing gear indicator light bulb. In the second case, the
captain - as a leader - did not properly manage the resources which were available
to him.

The image part with relationship ID rId8 was not found in the file. The image part with relationship ID rId8 was not found in the file.

Figure 2. L1011 crashed in the Florida Figure 3. B-737 crashed at Midway Airport
Everglades in Chicago

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2) In 1974, a B-707 crashed during approach at Pago-Pago in Samoa, with a loss of 96
lives. A visual illusion related to the black-hole phenomenon was a cause factor
(NTSB/AAR 74-15).
The image part with relationship ID rId8 was not found in the file.

Figure 4. B-707 crashed during approach at Pago-Pago in Samoa

3) In 1974, a DC-10 crashed after take-off because a cargo door failed (it opened and
blew out). The force applied by a cargo handler to close the cargo door, the door
design and an incomplete application of a service bulletin were cited as factors (ICAO
Circular 132-AN/93).
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The image part with relationship ID rId8 was not found in the file.

Figure 5. DC-10 crashed after take-off because a cargo door failed

4) In 1974, a B-727 approaching Dulles Airport in Washington crashed into Mount

Weather, with a loss of 92 lives. Lack of clarity and inadequacies in air traffic control
procedures and regulations led to the accident. The absence of timely action of the

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 regulatory body to resolve a known problem in air traffic terminology was also listed
as a factor (NTSB/AAR 75-16).

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Figure 6. B-727 approaching Dulles Airport in Washington crashed into Mount Weather

5) In 1977, two B-747s collided while on the runway at Tenerife, with a loss of 583 lives.
A breakdown in normal communication procedures and misinterpretation of verbal
messages were considered factors (ICAO Circular 153-AN/98).
The image part with relationship ID rId8 was not found in the file.

Figure 7. Two B-747s collided while on the runway at Tenerife

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6) In 1979, a DC-I0 crashed into Mount Erebus in Antarctica. Information transfer and
data entry errors played a role in the accident (Accident Report No. 79/139, New
Zealand).
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Figure 8. DC-I0 crashed into Mount Erebus in Antarctica

7) In 1982, a B-737 crashed after take-off in icing conditions in Washington. Erroneous

engine thrust readings (higher than actual), and the copilot's lack of assertiveness in
communicating his concern and comments about aircraft performance during the
take-off run were among the factors cited (NTSB/AAR 82-08).

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Figure 9. B-737 crashed after take-off in icing conditions in Washington

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8) The report of a 1983 A300 accident in Kuala Lumpur suggests that variations in panel
layout amongst the aircraft in the fleet had adversely affected crew performance. (The
aircraft was on a dry lease.) (Accident Report No. 2/83, Malaysia).
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Figure 10. A300 accident in Kuala Lumpur

9) In 1984, a DC-10 overran the runway at John F. Kennedy Airport in New York.
Excessive reliance on automation was noted in the accident report (NTSB/AAR 84-
15). Excessive reliance on automation was also listed as a factor in a loss of control
incident in 1985, in which a B-747 lost 20.000 feet in less than two minutes and
sustained structural damage (NTSB/AAR 86-03).
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Figure 11. DC-10 overran the runway at John F. Kennedy Airport in New York

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10) In 1987 an MD-80 crashed on take-off in Detroit. The pilots had not set the flaps, thus
violating standard operating procedures. Also, the take-off configuration warning did
not sound, for undetermined reasons (NTSB/AAR 88-05).
The image part with relationship ID rId8 was not found in the file.

Figure 12. MD-80 crashed on take-off in Detroit

Efficiency

The- need for application of Human Factors is not limited to flight safety. Efficiency
is also radically influenced by the application of, or the lack of Human Factors knowledge.
For instance, neglect of Human Factors in flight operations can be expected to cause less
than optimum performance of tasks. The following paragraphs are intended as an
overview of particular applications of Human Factors knowledge which relate to efficiency,

Motivation can be explained as reflecting the difference between what a person can
and actually will do; motivated individuals perform with greater effectiveness than
unmotivated individuals. Human error and its consequences in aviation can be controlled
by Human Factors technology, thus improving effectiveness.

The proper layout of displays and controls in the flight deck promotes and enhances
effectiveness. Properly trained and supervised crew members are likely to perform more
efficiently. From the perspective of efficiency, standard operating procedures (SOPS),

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which are developed to provide the most effective methods of operations, should be
regarded as a means of measuring the performance of crew members.

Application of group interaction principles enhances the managerial position of the

captain, whose leadership role is essential to the integration of a team and thus to more
effective performance. The relationship between cabin attendants and passengers is also
important. Cabin crew members should have an understanding of passenger behaviour
and the emotions they can expect to encounter on board, as well as how to manage
emotional situations. Well-being of operational personnel.

Three of the many factors which may influence the well-being of operational
personnel are fatigue, body rhythm disturbance, and sleep deprivation or disturbance.
These are briefly explained below. Other factors affecting physiological or psychological
well-being include temperature, noise, humidity, light, vibration, workstation design and
seat comfort.

Fatigue

Fatigue may be considered to be a condition reflecting inadequate rest, as well as

a collection of symptoms associated with displaced or disturbed biological rhythms. Acute
fatigue is induced by long duty periods or by a string of particularly demanding tasks
performed in a short term. Chronic fatigue is induced by the cumulative effects of fatigue
over the longer term. Mental fatigue may result from emotional stress, even with normal
physical rest. Like the disturbance of body rhythms, fatigue may lead to potentially unsafe
situations and a deterioration in efficiency and well-being. Hypoxia and noise are
contributing factors.

Body rhythm disturbance

The most commonly recognized of the body's rhythms is the circadian, or 24-hour
rhythm, which is related to the earth's rotation time. This cycle is maintained by several
agents: the most powerful are light and darkness, but meals and physical and social
activities also have an influence on the body's systems. Safety, efficiency and well-being

1 - 16
are affected by the disturbed pattern of biological rhythms typical of today's long-range
flights. The impact of circadian dysrhythmia is relevant not only to long-distance
transmeridian flying - shorthaul operators (couriers and freight carriers, for instance) flying
on irregular or night schedules can suffer from reduced performance produced by
circadian dysrhythmia. Air traffic controllers and maintenance technicians with frequently
changing shift schedules can suffer a similar deterioration in their performance.

Jet lag is the common term for disturbance or desynchronization of body rhythms,
and refers to the lack of well-being experienced after long-distance transmeridian air
travel. Symptoms include sleep disturbance and disruption of eating and elimination
habits, as well as lassitude, anxiety, irritability and depression. Objective evidence shows
slowed reaction and decision-making times, loss of or inaccurate memory of recent
events, errors in computation and a tendency to accept lower standards of operational
performance.

Sleep

The most common physical symptoms associated with long-range flying result from
disturbance of the normal sleep pattern, which may in some cases involve an over-all
sleep deprivation. Adults usually take sleep in one long period each day; where this
pattern has been established it becomes a natural rhythm of the brain, even when
prolonged waking is imposed. Wide differences are found amongst individuals in their
ability to sleep out of phase with their biological rhythms. Tolerance to sleep disturbance
varies between crew members and is mainly related to body chemistry and, in some
cases, to emotional stress factors.

Insomnia defines a condition where a person has difficulty sleeping or when the
quality of sleep is poor. When occurring under normal conditions and in phase with the
body rhythms, it is called primary insomnia. Circadian rhythm sleep disorder refers to
difficulty in sleeping in particular situations where biological rhythms are disturbed, and is
the one we are concerned about in long-range transmeridian flying.

The use of drugs such as hypnotics, sedatives (including antihistamines with a

sedative effect) and tranquilizers to induce sleep is usually inappropriate, as they have

1 - 17
an adverse effect on performance when taken in therapeutic doses for up to 36 hours
after administration. Alcohol is a depressant of the nervous system. It has a soporific
effect, but it disturbs normal sleep patterns and entails poor quality of sleep. The effects
persist after it has disappeared from the blood ("hangover"). Ingestion of hypnotics in
combination with alcohol can have bizarre consequences. Caffeine in coffee, tea and
various soft drinks increases alertness and normally reduces reaction times, but it is also
likely to disturb sleep. Amphetamines, when used to maintain the level of performance
during sleep deprivation, only postpone the effects of sleep loss.

Sleep has a restorative function, and is essential for mental performance. Sleep
deprivation and disturbance can reduce alertness and attention. When this phenomenon
is recognized, alertness and attention can at least be partly restored by the application of
extra effort. The relevance of this phenomenon to safety is obvious.

The resolution of the problem of sleep disturbance or deprivation includes:

- scheduling crews with due consideration to circadian rhythms and fatigue resulting
from sleep deprivation and disturbance;
- adapting the diet, understanding the importance of meal times, and adopting other
measures in relation to light/darkness, rest/activity schedules and social interaction;
- recognizing the adverse long-term effect of drugs (including caffeine and alcohol);
- optimizing the sleeping environment; and
- learning relaxation techniques.

Health and performance

Certain pathological conditions - gastrointestinal disorders, heart attacks, etc. - have

caused sudden pilot incapacitation and in rare cases have contributed to accidents. While
total incapacitation is usually quickly detected by other crew members, a reduction in
capacity or partial incapacitation - produced by fatigue, stress, sleep, rhythm
disturbances, medication, certain mild pathological conditions may go undetected, even
by the person affected.

Although no conclusive evidence is available, physical fitness may have a direct

relationship to mental performance and health. Improved fitness reduces tension and

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anxiety and increases self-esteem. It has favourable effects on emotions, which affect
motivation, and is believed to increase resistance to fatigue. Factors having a known
influence on fitness include diet, exercise, stress levels and the use of tobacco, alcohol
or drugs.

Stress

Stress can be found in many jobs, and the aviation environment is particularly rich
in potential stressors. Of main interest is the effect of stress on performance. In the early
days of aviation, stressor were created by the environment: noise, vibration, temperature,
humidity, acceleration forces. etc., and were mainly physiological in nature. Today, some
of these have been replaced by new sources of stress: irregular working and resting
patterns and disturbed circadian rhythms associated with long-range, irregular or night-
time flying.

Stress is also associated with life events, such as family separation, and with
situations such as periodic medical and proficiency checks. Even positive life events, such
as a wedding or the birth of a child, can induce stress in normal life. Likewise, in situations
where mental workload becomes very high, such as during take-off, landing or an in-flight
emergency, mental stress may appear.

Individuals differ in their responses to stress. For example, flight in a thunderstorm

area may be challenging for one individual but stressful for another. The same stressor
(the thunderstorm) produces different responses in different individuals, and any resulting
damage should be attributed to the response rather than to the stressor itself.

1.4 HUMAN FACTORS APPLIC.4TIONS IN AVIATION OPERATIONS

Control of human error

To contain and control human error, one must first understand its nature. There are
basic concepts associated with the nature of human error: the origins of errors can be
fundamentally different; and the consequences of similar errors can also be significantly

1 - 19
different. While some errors are due lo carelessness, negligence or poor judgment, others
may be induced by poorly designed equipment or may result from a normal reaction of a
person to a particular situation. The latter kind of error is likely to be repeated and its
occurrence can be anticipated.

Errors at the model interfaces

Each of the interfaces in the SHEL model has a potential of error where there is a
mismatch between its components. For example:

- The interface between Liveware and Hardware (human and machine) is a frequent
source of error: knobs and levers which are poorly located or lack of proper coding
create mismatches at this interface.
- In the Liveware-Software interface, delays and errors may occur while seeking vital
information from confusing, misleading or excessively cluttered documentation and
charts.
- Errors associated with the Liveware-Environment interface are caused by
environmental factors (noise, heat. lighting and vibration) and by the disturbance of
biological rhythms in long-range flying resulting from irregular working/sleeping
patterns.
- In the Liveware-Liveware interface, the focus is on the interaction between people
because this process affects crew effectiveness. This interaction also includes
leadership and command, and shortcomings at this interface reduce operational
efficiency and cause misunderstandings and errors.

Information processing

Before a person can react to information, it must first be sensed; there is a potential
for error here, because the sensory systems function only within narrow ranges. Once
information is sensed, it makes its way to the brain, where it is processed, and a
conclusion is drawn about the nature and meaning of the message received. This
interpretative activity is called perception and is a breeding ground for errors. Expectation,

1 - 20
experience, attitude, motivation and arousal all have a definite influence on perception
and are possible sources of errors.

After conclusions have been formed about the meaning of a message, decision-
making begins. Many factors may lead to erroneous decisions: training or past
experience; emotional or commercial considerations; fatigue, medication, motivation and
physical or psychological disorders. Action (or inaction) follows decision. This is another
stage with potential for error, because if equipment is designed in such a way that it can
&e operated wrongly, sooner or later it will be. Once action has been taken, a feedback
mechanism starts to work. Deficiencies in this mechanism may also generate errors.

Controlling human error

The control of human error requires two different approaches. First, it is necessary
to minimize the occurrence of errors by: ensuring high levels of staff competence;
designing controls so that they match human characteristics; providing proper checklists,
procedures, manuals, maps, charts, SOPS, etc.; and reducing noise, vibration,
temperature extremes and other stressful conditions. Training programs aimed at
increasing the co-operation and communication between crew members will reduce the
number of errors (the total elimination of human error is a difficult goal, since errors are a
normal part of human behaviour). The second avenue to the control of human error is to
reduce the consequences of the remaining errors by cross-monitoring and crew
cooperation. Equipment design which makes errors reversible and equipment which can
monitor or complement and support human performance also contribute to the limitation
of errors or their consequences.

Training and evaluation

The purpose of this section is to illustrate how Human Factors applies to the design
of methods of operational training.

Education and training are seen here as two different aspects of the teaching
process. Education encompasses a broad-based set of knowledge, values, attitudes and
skills required as a background upon which more specific job abilities can be acquired
later. Training is a process aimed at developing specific skills, knowledge or attitudes for

1 - 21
a job or a task. Proper and effective training cannot take place unless the foundations for
the development of those skills, knowledge or attitudes have been laid by previous
education.

A skill is an organized and coordinated pattern of psychomotor, social, linguistic and

intellectual activity. Teaching is a skill in its own right, and the possession of a skill in a
particular activity does not necessarily indicate skill in teaching that activity to others. This
is an important consideration in the selection of flight instructors, check pilots, or anyone
connected with a teaching activity.

Skills, knowledge or attitudes gained in one situation can often be used in another.
This is called positive transfer. Negative transfer occurs when previous learning interferes
with new learning. It is important to identify the elements of training which can induce
negative transfer since a return to earlier learned practices may occur in conditions of
stress.

Learning is an internal process and training is the control of this process. The
success or failure of training must be determined by the changes in performance or
behaviour which the learning produces. Since learning is accomplished by the student
and not by the teacher, the student must be an active rather than a passive participant.
Memory is relevant to learning - short-term memory (STM) refers to the storage of
information which will be stored and quickly forgotten, while long-term memory (LTM)
allows the storage of information for extended periods of time. STM is limited to a few
items of information during a few seconds. Through repetition, information is transferred
into LTM. While there is a very large capacity in LTM and fewer storage problems, there
are certainly retrieval problems, as exemplified by the problems of witness recollections
of past events.

A number of factors can interfere with the success of a training programme - obvious
ones like sickness, fatigue or discomfort as well as others like anxiety, low motivation,
poor quality instruction, an unsuitable instructor, inadequate learning techniques or
inadequate communication.

1 - 22
 It is cost-effective to observe a systems approach to training. Its first step is to
determine the training needs, possibly through job task analyses. The second step
provides a clear job description and analysis. The objective of the training can then be
formulated, and criteria can be established for the selection of the trainees. Next, the
course content is determined, and the course implemented. Different methods include:
lectures, lessons, discussions, tutorials, audio-visuals, programmed instruction, and
computer-based training.

There are two major types of training devices: training aids (such as slides,
videographs, blackboards. wall charts), which help the teacher present a subject and
training equipment (such as the flight simulator), which provides for active participation
and practice by the trainee. The development of simulators is based on the need to
provide practical training in as realistic an environment as possible, at low cost and risk,
and with a high degree of efficiency. To obtain approval from certifying authorities, the
simulator's fidelity must be high enough to develop the proficiency and performance which
are expected in real life situations.

It is often assumed that to achieve the best training results it is necessary to

incorporate the highest degree of fidelity in the training situation. Fidelity is expensive,
however, and it should be cost-effective. Motion, control loading, sound and visual
systems, and specific equipment simulation (radar - built-in test equipment - flight
management computers, etc.) involve considerable expenditure. At the upper limits of
simulation, a very small increase in fidelity becomes very expensive - this .is especially
relevant since available evidence supports the fact that a good return of training transfer
is often obtained from moderate levels of fidelity. It is the specialist's task to determine
the degree of fidelity needed to meet specific training requirements for a particular
situation. High fidelity is required in a training device when the student must learn to make
discriminations when selecting switches or controls and where the responses required
are difficult to make or critical to the operation. Low fidelity in the equipment is acceptable
when procedures are first being learned, in order to avoid confusion and not overload the
beginner. As the training progresses, increased fidelity is generally required for user
acceptance.

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Leadership

A leader is a person whose ideas and actions influence the thought and the
behaviour of others. Through the use of example and persuasion, and an understanding
of the goals and desires of the group, the leader becomes a means of change and
influence.

It is important to establish the difference between leadership, which is acquired, and

authority, which is assigned. An optimal situation exists when the two arc combined.
Leadership involves teamwork, and the quality of a leader depends on the success of the
leader's relationship with the team. Leadership skills should be developed for all through
proper training; such training is essential in aircraft operations where junior crew members
are sometimes called upon to adopt a leadership role throughout the normal performance
of their duties. This may occur when the co-pilot must take over from an absent or
incapacitated captain, or when a junior flight attendant must control the passengers in a
particular cabin section.

Skilled leadership may be needed to understand and handle various situations. For
instance, personality and attitude clashes within a crew complicate the task of a leader
and can influence both safety and efficiency. Aircraft accident and incident investigations
have demonstrated that personality differences influence the behaviour and performance
of crew members. Other situations requiring skilled leadership may be rooted in the
frustrations of first officers over slow promotions, or of pilots who are employed as flight
engineers.

Personality and attitudes

Personality traits and attitudes influence the way we conduct our lives at home and
at work. Personality traits are innate or acquired at early stages of life. They are deep-
rooted characteristics which define a person, and they are very stable and resistant to
change. Traits such as aggression, ambition and dominance may be seen as reflections
of personality.

Attitudes are learned and enduring tendencies or predispositions, more or less

predictable, to respond favourably or unfavourably to people, organizations, decisions,

1 - 24
etc. An attitude is a predisposition to respond in a certain way; the response is the
behaviour itself. It is believed that our attitudes provide some sort of cognitive organization
of the world in which we live, allowing us to make rapid decisions on what to do when
facing certain situations.

Accidents have been caused by inadequate performance by people who had the
capacity to perform effectively and yet failed to do so. Reports from the Confidential
Human Factors Reporting Programme (CHIRP) and the Aviation Safety Reporting
System (ASRS) support the view that attitudes and behaviour play a significant role in
flight safety: This indicates the need for more research into desirable and undesirable
personality characteristics in crew members, and the importance of an effective
assessment of personality during crew selection. If personality or attitude differences on
the fight deck have indeed been cited as the cause of accidents and incidents, then we
should also look at the extent to which it may be possible to influence attitudes through
training.

The difference between personality and attitudes is relevant, because it is unrealistic

to expect a change in personality through routine training, or captaincy or management
training. The initial screening and selection process are the place and time to take
appropriate action. On the other hand, attitudes are more susceptible to change through
training. The effectiveness of the training depends on the strength of the attitude(s) which
are to be modified. To this end, some States have demonstrated the safety benefits -
particularly for single-pilot operations - of programmes for improving the pilot decision-
making process by identifying hazardous thought patterns. Modifying attitudes or
behaviour patterns through persuasion is also of direct relevance to safety and efficiency.
Crew bulletins, staff notices and advertising are examples of persuasion.

Communication

Effective communication, which includes all transfer of information, is essential for

the safe operation of flight. The message might be transferred by speech, by the written
word, by a variety of symbols and displays (e.g. instruments, CRT, maps) or by non-verbal
means such as gestures and body language. The quality and effectiveness of

1 - 25
communication is determined by its intelligibility: the degree to which the intended
message is understood by the receiver.

There are several hazards which reduce the quality of communications:

- failures during the transmitting process (e.g. the sending of unclear or ambiguous
messages, language problems);
- difficulties caused by the medium of transmission (e-g. background noises or distortion
of the information);
- failures during receiving (e-g. the expectation of another message, wrong interpretation
of the arriving message or even its disregard);
- failures due to interference between the rational and emotional levels of
communication (e.g. arguments);
- physical problems in listening or speaking (e.g. impaired hearing or wearing of the
oxygen mask);
- use of English among native and non-native speakers; and
- encoding/decoding/noise.

It is the task of Human Factors training to prevent communication errors. This task
includes the explanation of common communication problems as well as the
reinforcement of a standard of language to ensure the error-free transmission of a
message and its correct interpretation. Ambiguous, misleading, inappropriate or poorly
constructed communication, combined with expectancy, have been listed as elements of
many accidents, the most notorious one being the double B747 disaster in Tenerife
(March 1977).

Crew coordination

Crew co-ordination is the advantage of teamwork over a collection of highly skilled

individuals. Its prominent benefits are:

- an increase in safety by redundancy to detect and remedy individual errors; and

- an increase in efficiency by the organized use of all existing resources, which improves
the inflight management.

1 - 26
 The basic variables determining the extent of crew co-ordination are the altitudes,
motivation and training of the team members. Especially under stress (physical. emotional
or managerial), there is a high risk that crew co-ordination will break down. The results
are a decrease in communication (marginal or no exchange of information), an increase
in error (e.g. wrong decisions) and a lower probability of correcting deviations either from
standard operating procedures or the desired flight path. Additionally, emotional conflicts
in the cockpit may result.

The high risks associated with a breakdown of crew co-ordination show the urgent
need for Crew Resource Management training. This kind of training ensures that:

- the pilot has the maximum capacity for the primary task of flying the aircraft and making
decisions;
- the workload is equally distributed among the crew members, so that excessive
workload for any individual is avoided: and
- a coordinated cooperation - including the exchange of information, the support of fellow
crew members and the monitoring of each other's performance - will be maintained
under both normal and abnormal conditions.

Motivation

Motivation reflects the difference between what a person can do and actually will
do, and is what drives or induces a person to behave in a particular fashion. Clearly,
people are different and driven by different motivational forces. Even when selection,
training and checking ensure capability to perform, it is motivation that determines
whether a person will do so in a given situation.

There is a relationship between expectancy and reward as motivators, since the

utility of a reward and the subjective probability of its achievement determine the level of
effort which will be applied to obtain the reward. This effort must be accompanied by the
proper skills. It is important for high performers to see that they are in a better position
than poor performers to achieve a reward, otherwise motivation may decline. Job
satisfaction motivates people to higher performance.

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 Modifying behaviour and performance through rewards is called positive
reinforcement; discouraging undesirable behaviour by use of penalties or punishment is
called negative reinforcement. Even though positive reinforcement can be more effective
in improving performance, both must be available to management. Different responses
are to be expected from different individuals in relation to positive and negative
reinforcers. Care should be taken not to generate an effect which is opposite from that
which is intended.

Documentation

Inadequacies in aviation documentation have a twofold impact: there is a monetary

aspect associated with increased time or the impossibility of performing a particular task
and there is also a safety aspect. With reference to documentation - including electronic
flight documentation displayed on screen - some basic aspects require Human Factors
optimization:

a) written language, which involves not only vocabulary and grammar, but also the
manner in I which they are used;
b) typography, including the form of letters and printing and the layout, has a significant
impact on the comprehension of the written material:
c) the use of photograph diagrams, charts or tables replacing long descriptive text is
advantageous to help comprehension and maintain interest The use of colour in
illustrations reduces 'the discrimination workload and has a motivational effect;
d) the working environment in which the document is going to be used has to be
considered when print and page size are determined (for example, an airport chart
which is too small may induce error during taxiing).

Workstation design

For design purposes, the flight deck should be considered as a system, as opposed
to a collection of particular aspects or systems such as hydraulic, electrical or
pressurization. Expertise should be applied towards matching the characteristics of these
systems to those of humans, with due consideration to the job to be performed. Proper

1 - 28
matching of working areas to human dimensions and characteristics is important - for
instance, size, shape and movements of the body provide data used to ensure adequate
visibility in the flight deck, location and design of controls and displays, and seat design.

The importance of the standardization of panel layout relates to safety, since there
are numerous reports of errors arising from inconsistent panel layouts, involving
inadvertent reversion to an operating practice appropriate to an aircraft flown previously.
Seat design considerations include seat controls, headrests, seat cushion and fabric,
lumbar support, thigh support, etc.

A display is any means of presenting information directly to the operator. Displays

use the visual, aural or tactile senses. The transfer of information from a display to the
brain requires that information is filtered, stored and processed, a requirement which can
cause problems. This is a major consideration in the design of flight deck displays. The
information should be presented in such a way as to assist the processing task, not only
under normal circumstances, but also when performance is impaired by stress or fatigue.

A fundamental consideration in display design is to determine how, in what

circumstances, and by whom the display is going to be used. Other considerations include
the characteristics of visual displays and aural signals; light requirements; the selection
of analogue or digital alternatives: the applicability of LEDs (light-emitting diodes), LCDs
(liquid-crystal displays) and CRTs (cathode-ray tubes): the angle at which the display is
to be viewed and its related parallax: viewing distance, and possible ambiguity of the
information.

Three fundamental operational objectives apply to the design of warning, alerting

and advisory systems: they should alert the crew and draw their attention, report the
nature of the condition, and when possible, guide them to the appropriate corrective
action. System reliability is vital, since credibility will be lost if false warnings proliferate,
as was the case with earlier generations of ground proximity warning systems. In the
event of a technical failure of the display system, the user should not be presented with
unreliable information. Such information must be removed from sight or clearly flagged.
For example, unreliable Bight director command bars should disappear. Invalid guidance
information which remained on display has been a factor in accidents.
1 - 29
 A control is a means of transmitting discrete or continuous information or energy
from the operator to some device or system. Control devices include push buttons, toggle
or rotary switches, detented levers, rotary knobs, thumbs wheels, small levers or cranks
and keypads. The type of device to be used depends on functional requirements and the
manipulation force required. Several design features apply to controls:

a) location;
b) control-display ratio (control movement related to that of the moving element of the
associated display);
c) direction of movement of the control relative to the display:
d) control resistance;
e) control coding, by means of shape, size, colour, labelling and location: and
f) protection against inadvertent actuation.

The application of automation to flight deck displays and controls may breed
complacency and overreliance on the automated system, which have been suggested as
factors in accidents and incidents. If the Human Factors-related issues (e.g. the limited
performance of the human as monitor and effects on motivation) are properly addressed,
there may be a justification for automation. It may contribute to improved aircraft and
system performance and over-all efficiency of the operation. It may relieve the crew of
certain tasks so as to reduce workload in phases of flight where it reaches the limit of
operational acceptability.

Cabin design

Human Factors considerations for the cabin include aspects of workspace and
layout as well as information on human behaviour and performance

Human size and shape are relevant in the design of cabin equipment (toilets,
galleys, meal carts and overhead bins); emergency equipment design (lifejackets, life-
rafts, emergency exits, oxygen masks); seats and furnishings (including in-flight
entertainment); jump seats and rear-facing seats. Knowledge of the user's height and
reach determines location of equipment and controls. Proper access and room to work
must be provided in cargo compartments. The estimation of human forces required to

1 - 30
operate doors, hatches and cargo equipment have to be realistic. Anthropometry (the
study of human dimensions) and biomechanics (study of the movement of parts of the
body and the forces which they can apply) are the sources of the required information for
those purposes.

Due consideration has to be given to handling special passengers: the physically

handicapped, the intoxicated, and the fearful. Passenger behaviour, including group
influences, and expected human behaviour when facing a crisis are of relevance here.

Recent accidents and incidents have documented the need for Human Factors
information for those involved in ground operations, such as maintenance and inspection
managers, flight line supervisors and others. Similarly, persons involved in the design of
aircraft systems should recognize human limits in maintaining, inspecting and servicing
aircraft. Such factors as training, work environment, communication methods,
physiological limitations and human engineering of equipment should be considered

Visual performance and collision avoidance

A proper understanding of how the visual system works helps in the determination
of optimum working conditions. The characteristics and measurement of light, the
perception of colour, the physiology of the eyes and the way the visual system works are
relevant in this area. Also important are factors involved in the ability to detect other
aircraft at a distance, either in daytime or at night, or to identify outside objects in the
presence of rain or other contamination on the windscreen.

Visual illusions and disorientation in flight operations may be directly related to

safety. During all phases of flight, but in particular during approach and landing, visual
illusions are believed to have played a significant role in accidents for which it is difficult
to find any other explanation. Factors of specific consideration here include sloping
terrain, runway width, lighting intensity, the "black hole” phenomenon and lack of runway
texture.

An effective step in reducing the risks associated with visual illusions in flight
operations is the recognition through training that visual illusions are a natural
phenomenon. Training should also help in understanding that the circumstances in which

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they occur are often predictable. The use of additional information sources to supplement
visual cues (radar, attitude displays, radio altimeters, VASIs, DMEs, etc.) is the most
effective protective measure against disorientation and illusions. To some extent the risk
from visual illusions may be alleviated by design features such as high optical quality
windshield glass, adequate visibility, eye position guidance, effective windshield rain and
ice protection, etc.

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 CHAPTER 2
THE HUMAN ELEMENT (AVIATION PHYSIOLOGY)

2.1 LIMITATION OF THE SENSES

2.1.1 VISION
The basic structure of the eye is similar to a simple camera with an aperture (the
iris), a lens and a light sensitive surface (the retina). Light enters the eye through the
cornea, then passes through the iris and the lens and falls on the retina. Light stimulates
the light-sensitive cells on the retina (rods and cones) and these pass small electrical
impulses by way of the optic nerve to the visual cortex in the brain. Electrical impulses
are interpreted and an image is perceived.

Figure 13. Basic structure of the eye

Basic Function of the eye as follow :

Cornea
The cornea is a clear ‘window’ at the very front of the eye. The cornea acts as a fixed
focusing device. The focusing is achieved by the shape of the cornea bending the
incoming light rays. The cornea is responsible for between 70% and 80% of the total
focusing ability (refraction) of the eye.

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The Iris and Pupil
The iris (the coloured part of the eye) controls the amount of light that is allowed to
enter the eye. It does this by varying the size of the pupil (the dark area in the centre of
the iris). The size of the pupil can be changed very rapidly to cater for changing light
levels. The amount of light can be adjusted by a factor of 5:1.
The Lens
After passing through the pupil, the light passes through the lens. Its shape changed
by the muscles (cillary muscles) surrounding it which results in the final focusing
adjustment to place a sharp image onto the retina. The change of shape of the lens is
called accommodation. In order to focus clearly on a near object, the lens is thickened.
To focus on a distant point, the lens is flattened. The degree of accommodation can be
affected by factors such as fatigue or the ageing process. When a person is tired
accommodation is reduced, resulting in less sharp vision (sharpness of vision is known
as visual acuity).
The Retina
The retina is located on the rear wall of the eyeball. It is made up of a complex layer of
nerve cells connected to the optic nerve. Two types of light sensitive cells are found in
the retina - rods and cones.
The central area of the retina is known as the fovea and the receptors in this area are
all cones. It is here that the visual image is typically focused. The cones become less
dense and are progressively replaced by rods, so that in the periphery of the retina, there
are only rods. Cones function in good light and are capable of detecting fine detail and
are colour sensitive. This means the human eye can distinguish about 1000 different
shades of colour.
Rods cannot detect colour. They are poor at distinguishing fine detail, but good at
detecting movement in the edge of the visual field (peripheral vision). They are much
more sensitive at lower light levels. As light decreases, the sensing task is passed from
the cones to the rods. This means in poor light levels we see only in black and white and
shades of grey.

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 At the point at which the optic nerve joins the back of the eye, a ‘blind spot’ occurs.
This is not evident when viewing things with both eyes (binocular vision), since it is not
possible for the image of an object to fall on the blind spots of both eyes at the same time.
Even when viewing with one eye (monocular vision), the constant rapid movement of the
eye (saccades) means that the image will not fall on the blind spot all the time.
The eye is very sensitive in the right conditions (e.g. clear air, good light, etc.). In fact,
the eye has approximately 1.2 million nerve cells leading from the retinas to the area of
the brain responsible for vision. While there are only about 50,000 from the inner ears,
making the eye about 24 times more sensitive than the ear.
An individual with an acuity of 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. It may be expressed in
metres as 6/6 vision. The figures 20/40 mean that the observer can read at 20 feet what
a ‘normal’ person can read at 40 feet.

Factors can affect and limit the visual acuity of the eye
a. Physical factors
• Physical imperfections in one or both eyes (short sightedness, long sightedness),
Long sight known as Hypermetropia is caused by a shorter than normal eyeball
which means that the image is formed behind the retina. If the cornea and the lens
cannot use their combined focusing ability to compensate for this, blurred vision
will result when looking at close objects.

Figure 14. Hypermotropia

A convex lens will overcome long sightedness by bending light inwards before it
reaches the cornea.

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 Short sight - known as Myopia is where the eyeball is longer than normal, causing
the image to be formed in front of the retina. If the accommodation of the lens
cannot counteract this then distant objects are blurred.

Figure 15. Myopia

A concave lens will overcome short sightedness by bending light outwards before
it reaches the cornea.
• Age.
Person grows older, the lens becomes less flexible meaning that it is unable to
accommodate sufficiently. This is known as presbyopia and is a form of long
sightedness. After the age of 40, spectacles may be required for near vision,
especially in poor light conditions.
b. The influence of ingested foreign substances
Vision can be adversely affected by the use of certain drugs and medications, alcohol,
and smoking cigarettes. With smoking, carbon monoxide which builds up in the
bloodstream allows less oxygen to be carried in the blood to the eyes. This is known
as hypoxia and can impair rapidly the sensitivity of the rods. Alcohol can have similar
effects, even hours after the last drink.
c. Environmental factors
• Amount of light available
Vision can be improved by increasing the lighting level, but only up to a point, as
the law of diminishing returns operates. Also, increased illumination could result in
increased glare. Moving from an extremely bright environment to a dimmer one
has the effect of vision being severely reduced until the eyes get used to less light
being available. This is because the eyes have become light adapted. Works in a

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 very dark environment for a long time, the eyes gradually become dark adapted
allowing better visual acuity. This can take about 7 minutes for the cones and 30
minutes for the rods.
• Clarity of the air (e.g. dust, mist, rain, etc.)
d. Factors associated with object being viewed
• Size and contours of the object
• Contrast of the object with its surroundings
• Relative motion of the object
• Distance of the object from the viewer
• The angle of the object from the viewer

2.1.2 HEARING
The ear performs two quite different functions. It is used to detect sounds by
receiving vibrations in the air, and secondly, it is responsible for balance and sensing
acceleration. Of these two, the hearing aspect is more pertinent to the maintenance
engineer and thus it is necessary to have a basic appreciation of how the ear works

Figure 16. Ear Structure

Outer Ear
The outer part of the ear directs sounds down the auditory canal and on to the
eardrum. The sound waves will cause the eardrum to vibrate.
Middle Ear

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 Beyond the eardrum is the middle ear which transmits vibrations from the eardrum
by way of three small bones known as the ossicles, to the fluid of the inner ear. The middle
ear also contains two muscles which help to protect the ear from sounds above 80 dB by
means of the acoustic or aural reflex, reducing the noise level by up to 20 dB.
However, this protection can only be provided for a maximum of about 15 minutes,
and does not provide protection against sudden impulse noise such as gunfire. It does
explain why a person is temporarily ‘deafened’ for a few seconds after a sudden loud
noise.
The middle ear is usually filled with air which is refreshed by way of the Eustachian
tube which connects this part of the ear with the back of the nose and mouth. However,
this tube can allow mucus to travel to the middle ear which can build up, interfering with
normal hearing.
Inner Ear
Unlike the middle ear, the inner ear is filled with fluid. The last of the ossicles in the
middle ear is connected to the cochlea. This contains a fine membrane (the basilar
membrane) covered in hair-like cells which are sensitive to movement in the fluid. Any
vibrations they detect cause neural impulses to be transmitted to the brain via the auditory
nerve. The amount of vibration detected in the cochlea depends on the volume and pitch
of the original sound.

Performance and Limitations of the Ear

The performance of the ear is associated with the range of sounds that can be
heard both in terms of the pitch (frequency) and the volume of the sound. The audible
frequency range that a young person can hear is typically between 20 and 20,000 cycles
per second (or Hertz), with greatest sensitivity at about 3000 Hz. Volume (or intensity) of
sound is measured in decibels (dB).

Noise
Noise is unwanted sound. Noise is not only distracting and stressful, it can cause
permanent hearing loss. In the design of aviation maintenance facilities, the goals are to
make certain sounds easy to hear and to isolate and protect workers from noise.

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Noise can have various negative effects in the work place. It can:
• Be annoying (e.g. sudden sounds, constant loud sound, etc.)
• Interfere with verbal communication between individuals in the workplace
• Cause accidents by masking warning signals or messages
• Be fatiguing and affect concentration, decision making, etc.
• Damage workers hearing (either temporarily or permanently)
Intermittent and sudden noise are generally considered to be more disruptive than
continuous noise at the same level. High frequency noise generally has a more adverse
effect on performance than lower frequency. Noise tends to increase errors and variability
rather than directly affect work rate.
Hearing loss can result from exposure to even relatively short duration noise. The
degree of impairment is influenced mainly by the intensity of the noise. Such damage is
known as Noise Induced Hearing Loss (NIHL). The hearing loss can be temporary lasting
from a few seconds to a few days or permanent.
Temporary hearing loss may be caused by relatively short exposure to very loud
sound, as the hair-like cells on the basilar membrane take time to ‘recover’. With
additional exposure, the amount or recovery gradually decreases and hearing loss
becomes permanent. Regular exposure to high levels of noise over a long period may
permanently damage the hair like cells in the cochlea, leading to irreversible hearing
impairment.
The UK ‘Noise at Work’ regulations (1989) impose requirements upon employers.
They stipulate three levels of noise at which an employer must act:
a) 85 decibels (if normal speech cannot be heard clearly at 2 metres), employer must
• Assess the risk to employees’ hearing
• Tell the employees about the risks and what precautions are proposed provide
their employees with personal ear protectors and explain their use.
b) 90 decibels (if normal speech cannot be heard clearly at 1 metre) employer must
• do all that is possible to reduce exposure to the noise by means other than by
providing hearing protection,
• mark zones where noise reaches the second level and provide recognised
• signs to restrict entry

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c) 140 decibels (noise causes pain)

The combination of duration and intensity of noise can be described as noise dose.
Exposure to any sound over 80 dB constitutes a noise dose, and can be measured over
the day as an 8 hour Time Weighted Average sound level (TWA).
Permanent hearing loss may occur if the TWA is above the recommended maximum.
It is normally accepted that a TWA noise level exceeding 85 dB for 8 hours is hazardous
and potentially damaging to the inner ear. Exposure to noise in excess of 115 decibels
without ear protection, even for a short duration, is not recommended.
Hearing protection is available, to a certain extent, by using ear plugs or ear
defenders. Noise levels can be reduced (attenuated) by up to 20 decibels using ear plugs
and 40 decibels using ear muffs. However, using ear protection will tend to adversely
interfere with verbal communication.
Hearing deteriorates naturally as one grows older (presbycusis). This affects ability
to hear high pitch sounds first, and may occur gradually from the 30’s onwards. When this
natural decline is exacerbated by Noise Induced Hearing Loss, it can obviously occur
rather sooner

Table 1. Typical sound levels for various activities

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 Indonesian national regulations are also regulated related to noise contained in the
Ministry of Manpower decree number PER.13/MEN/X/2011. They stipulate limit of noise
intensity as follows:

Exposure time per day Noise Intensity Limit in dBA

8 Hours 85
4 88
2 91
1 94

30 Minutes 97
15 100
7,5 103
3,75 106
1,88 109
0,94 112

28,12 Seconds 115

14,06 118
7,03 121
3,52 124
1,76 127
0,88 130
0,44 133
0,22 136
0,11 139
Table 2. Limit of Noise Intensity
Someone may not be exposed to noise more than 140 dBA, even for a moment.

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2.1.3 VESTIBULAR SYSTEM
The vestibular system of the ear consists of the semi-circular canals which detect
angular accelerations of the body, and the otolith organs, the utricle and saccule, which
detect linear acceleration or deceleration.

Semi-Circular Canals
There are three fluid-filled, semi-circular canals in each ear. The canals are oriented
in three planes, each at right angles to the other two. Their names are the Lateral Canal,
the Anterior Canal and the Posterior Canal.

Figure 17. Semi-circular canals

At the base of each canal is a sensory organ, the cupula. The cupula is a gelatinous
bulb anchored at one end to the semi-circular canal, detecting movements of the fluid that
surrounds it. These movement become electrical signals. Since there are three canals at
right angles, the brain can use these signals to give three dimensional information to help
control balance and tell us which direction is up.

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 During any lateral motion, the fluid in the canal lags behind the movement. The
cupula then deflects in response to the pressure of the fluid.

As the motion of the fluid catches up to the motion of the head, a state of equilibrium
is reached, and the cupula returns to a state of rest

When the movement stops, the fluid within the canals keeps moving due to the
inertia. This causes a deflection of the cupula in the opposite direction.

Since the semi-circular canal are at right angles to one other, combining the signals
from all six canals detects acceleration forces in any direction. In the absence of visual
cues, the brain interprets these stimuli as :
 Acceleration as movement
 Simple acceleration
 Change of acceleration
 Constant velocity
In general terms, the semi-circular canals sense any angular movement of the head.

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Otoliths
The otolith organs are small sacs located in the vestibule. Sensory hairs project from
each macula into the otolith membrane, an overlying gelatinous membrane that contains
chalk-like crystals called otoliths. The otoliths are sensitive to linear movement and the
force of gravitiy.

Figure 18. Otoliths

Change in the position of the head relative to the gravitational force cause the
otolithic membrane to shift position on the macula. The sensory hairs bend, signaling a
change in head position. When the head is upright, the hair cells generate a “resting”
frequency of nerve impulses. When the head tilts, the “resting” frequency alters. The brain
is informed of the new position of the head relative to the vertical.
Linear acceleration also stimulates the otolith organs. The body cannot physically
distinguish between the inertial forces resulting from linear accelerations and those
resulting from the force of gravity. For example, a forward acceleration result in backward
displacement of the otolithic membranes. When an adequate visual reference is not
available this can create an illusion of backward tilt. Hence, movement in a linear sense
can give a false impression of climbing or descending.

Common Vestibular Disorders

Benign paroxysmal positional vertigo (BPPV)
This is the most common cause of positional vertigo, a sudden feeling that you’re spinning
or swaying. It happens when tiny calcium crystals in one part of your ear move into an area
where they shouldn’t be. This causes your inner ear to tell your brain you’re moving when
you’re really not.

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Labyrinthitis
This might know this as an inner ear infection. It happens when a fragile structure deep inside
the ear known as a labyrinth gets inflamed. This affects not just the balance and hearing, but
you also may have ear pain, pressure, pus or fluid coming from the ear, nausea, and a high
fever.
Vestibular neuritis
A viral infection somewhere else in your body, such as chickenpox or measles, can bring on
this disorder that affects the nerve that sends sound and balance information from your inner
ear to your brain. The most common symptoms are sudden dizziness with nausea, vomiting,
and trouble walking.
Meniere's disease
People with this disorder have sudden attacks of vertigo, tinnitus (a ringing, buzzing, or
roaring sound in their ears), hearing loss, and a feeling of fullness in the affected ear. This
may be caused by too much fluid in the inner ear, thanks to a virus, allergy, or autoimmune
reaction. The hearing loss gets worse over time and can be permanent in some cases.
Perilymphatic fistula (PLF)
This is a tear or defect between your middle ear and fluid-filled inner ear that can make you
feel dizzy and may cause some hearing loss. You can be born with PLF, or it can be caused
by barotrauma (increased pressure in your ear), a head injury, or heavy lifting.

2.1.4 PROPRIOCEPTIVE
Proprioception also referred to as kinaesthesia (or kinesthesia), is the sense of self-
movement and body position. Proprioception is the ability of our muscles and joints to
determine where they are in space. The proprioceptive nerve endings in the body provide
us with the information of where our hands, arms, and legs are in space without having
to look at them.

The specialized proprioception receptors in the body tell the brain about the
movement and position of the body. For example, being able to touch our nose with our
finger when our eyes are closed uses proprioception.

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 Proprioception allows the body to plan and react so that we position our movements
correctly and smoothly without needing to rely on our vision sense. People use their sense
of proprioception for most motor actions.

Figure 19. Proprioceptive

We need our sense of proprioception to look where we are going when we walk, to
pick up a glass of water, to walk in the sand, to wave hello, to avoid knocking into other
people and the list goes on and on.
A diminished sense of proprioception can result in clumsiness, poor coordination,
improper posture, using too much or too little force, decreased body awareness, motor
planning deficits and more.

2.1.5 TACTILE
The Tactile System, includes multiple types of sensation from the body - light touch,
pain, pressure, temperature, and joint and muscle position sense (also called
proprioception). However, these modalities are lumped into three different pathways in
the spinal cord and have different targets in the brain. The first modality is
called discriminative touch, which includes touch, pressure, and vibration perception, and

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enables us to “read” raised letters with our fingertips, or describe the shape and texture
of an object without seeing it. The second grouping is pain and temperature, which is just
what it sounds like, and also includes the sensations of itch and tickle. The third modality
is called proprioception, and includes receptors for what happens below the body surface:
muscle stretch, joint position, tendon tension, etc. This modality primarily targets the
cerebellum which needs minute-by-minute feedback on what the muscles are doing.
The central nervous systems ability to process tactile sensory input is distorted in
the child with SPD and causes the child great discomfort. Their brain may register even
the most subtle sensations as extreme irritation or even painful and he may respond in
an abnormally reactive way such as grimacing or pulling away from the stimulus.

Figure 20. Example of Tactile

The central nervous system must rely on five sensory nerve receptors in the skin to
keep it informed about its environment. These receptors are; light touch (surface),
pressure (deep), temperature (hot & cold) and pain. It is quite possible for one type of
receptor to be sensitive and the other normalized.
The tactile defensive individual who experiences this extreme sensory registration
can have great distress in daily living. This discomfort may be compared to the experience
of trimming your fingernails too close.The raw sensation experienced by nerves that are
no longer protected by the fingernail can be very irritating. This is similar to the way that

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a person with extreme touch sensitivity may experience sensations, except for two
important differences.
First, in the case of the person who just clipped their nails, the discomfort comes
because the nerves that have been sheltered are now exposed making the person acutely
aware of sensations he does not ordinarily feel. The nerve function is normal, but the
experience is abnormal. For a person who is overly sensitive to touch the experiences
are normal and the nerve function is abnormal. Second, the person who has clipped his
nails will soon become accustomed to the sensation, while the person with the over
sensitive system does not accommodate to the sensations no matter how much exposure
he has. Because of this he may feel bombarded by dozens of unpleasant sensory
experiences on a daily basis.

2.2 FATIGUE
Fatigue is the state of feeling very tired, weary or sleepy resulting from insufficient
sleep, prolonged mental or physical work, or extended periods of stress or anxiety. Boring
or repetitive tasks can intensify feelings of fatigue. Fatigue can be described as either
acute or chronic.
Acute fatigue results from short-term sleep loss or from short periods of heavy
physical or mental work. The effects of acute fatigue are of short duration and usually can
be reversed by sleep and relaxation.
Chronic fatigue syndrome is the constant, severe state of tiredness that is not
relieved by rest. The symptoms of chronic fatigue syndrome are similar to the flu, last
longer than six months and interfere with certain activities. The exact cause of this
syndrome is still unknown.
It is a human problem that we tend to underestimate our level of fatigue and
overestimate our ability to cope with it. Therefore, it is important that workers are aware
of the signs and symptoms of fatigue – in themselves and others. Fatigue self-
management involves a three-sided programme of regular sleep, healthy diet (including
reduced use of alcohol and other drugs), and exercise. Work of a critical and complex
nature should not be programmed during the low point on the body’s circadian

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rhythm (usually 03:00 – 05:00am); and, when fatigued always get someone else to check
your work.
Employers and supervisors should be concerned about the impact of fatigue in the
workplace as it can be considered a form of impairment, making fatigue a workplace
hazard. However, fatigue levels are not easily measured or quantified; therefore, it is
difficult to isolate the effect of fatigue on accident and injury rates. Awareness and
observation of changes in behaviour is one method to identify fatigue. Factors that may
influence fatigue are shift rotation patterns, balanced workloads, timing of tasks and
activities, availability of resources, and the workplace environment (e.g., lighting,
ventilation, temperature, etc).
Some research studies have shown that when workers have slept for less than 5
hours before work or when workers have been awake for more than 16 hours, their
chance of making mistakes at work due to fatigue are significantly increased.
Research has shown that the number of hours awake can be similar to blood alcohol
levels. One study reports the following:

 17 hours awake is equivalent to a blood alcohol content of 0.05

 21 hours awake is equivalent to a blood alcohol content of 0.08 (legal limit in
Canada)
 24-25 hours awake is equivalent to a blood alcohol content of 0.10
Symptoms of fatigue (in no order) may include:

 diminished perception (vision, hearing, etc.) and a general lack of awareness.

 diminished motor skills and slow reactions.
 problems with short-term memory.
 channelled concentration - fixation on a single possibly unimportant issue, to the
neglect of others and failing to maintain an overview.
 being easily distracted by unimportant matters.
 poor judgement and decision making leading to increased mistakes.
 abnormal moods - erratic changes in mood, depressed, periodically euphoric, and
energetic.
 reduced standards.

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 Fatigue is regarded as having an impact on work performance. Government of
Alberta, Labour* reports that most incidents occur when people are more likely to want
sleep - between midnight and 6 am, and between 1 to 3 pm. Government of Alberta,
Labour also reports that fatigue affects people differently but it can increase a worker’s
hazard exposure by:

 reducing mental and physical functioning,

 impairing judgement and concentration,
 lowering motivation,
 slowing reaction time, and
 increasing risk-taking behaviour.
Because fatigue cannot be "measured", it is difficult to separate the effects of long
working hours or lack of sleep to any changes in incident or injury rates. However, studies
report the effects of fatigue as:

 reduced decision making ability,

 reduced ability to do complex planning,
 reduced communication skills,
 reduced productivity or performance,
 reduced attention and vigilance,
 reduced ability to handle stress on the job,
 reduced reaction time - both in speed and thought,
 loss of memory or the ability to recall details,
 failure to respond to changes in surroundings or information provided,
 unable to stay awake (e.g., falling asleep while operating machinery or driving a
vehicle),
 increased tendency for risk-taking,
 increased forgetfulness,
 increased errors in judgment,
 increased sick time, absenteeism, rate of turnover,
 increased medical costs, and
 increased incident rates.

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Workload
Workload has to do with the amount of work expected from an individual. In
aviation, workload generally implies mental effort as opposed to physical effort. If the
workload generated by a task or set of tasks exceeds a person’s mental capacity,
performance will suffer. Understandably, there are considerable differences in capacities
for given workloads. Generally speaking, training and experience equip us to effectively
deal with increasing workloads. However, if affected by any of the stressors previously
discussed our capacity can vary markedly over time. When overloaded, people may try
to cope by skipping steps in their safe work routines, perhaps even ignoring obvious cues
of unsafe conditions.

Shift Work
The ADAMS (Aircraft Dispatch and Maintenance Safety) project accepts that
aviation is a 24-hour operation with significant pressure to meet deadlines. It suggests
that shift-work systems should be designed with the following principles in mind in order
to minimize the effects of mental and physical fatigue:
a. Provide regular opportunities for sufficient night sleep to prevent the accumulation of
“sleep debt”;
b. Provide a predictable shift system which allows workers to plan their schedule of rest
and sleep to minimize sleep loss. Rotating shift patterns prevent this and should be
avoided;
c. Allow at least two successive nights’ sleep in order to allow for recovery from
accumulated fatigue and sleep debt;
d. Take account of reduced physical and mental capacity at night by avoiding the
scheduling of such work under strong time pressures;
e. Be flexible so as to take account of an individual’s ability to cope with the disruptions
of shift work (e.g. age and domestic circumstances);
f. Have the same support services available at night as during the day (e.g.
administration, planning, quality, canteen/cafeteria and welfare);

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g. Allow opportunities for individuals to recover from conditions which give rise to fatigue
and sleep loss; and
h. Although overtime work is one option for completing tasks not completed during a
shift, repeated overtime should be discouraged as it may possibly lead to reduced
staff motivation and performance. The alternative is to pass the work to the next shift.

2.3 SLEEP
Man, like all living creatures must have sleep. Despite a great deal of research, the
purpose of sleep is not fully understood. Sleep is a natural state of reduced consciousness
involving changes in body and brain physiology which is necessary to man to restore and
replenish the body and brain.

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 four 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 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 like 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.

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

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show rebound effects. This means that in subsequent sleep, he will make up the deficit
in that sleep. This shows the importance of both types of sleep.

As can be seen from Figure 11, sleep occurs in cycles. Typically, the first REM sleep
will 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.

Figure 21. Typical Cycle of Stage 1-4 (NREM) sleep and REM Sleep over a Night

Circadian Rhythms

Apart from the alternation between wakefulness and sleep, man has other internal
cycles, such as body temperature and hunger/eating. These are known as circadian
rhythms as they run on an approximately daily basis. Circadian rhythms are physiological
and behavioural functions and processes in the body that have a regular cycle of
approximately a day (about 25 hours in man).

Although, circadian rhythms are controlled by the brain, they are influenced and
synchronised by external (environmental) factors such as light. An example of disrupting
circadian rhythms is by taking a flight that crosses time zones. This will interfere with the
normal synchronisation with the light and dark (day/night). This throws out the natural link
between daylight and the body’s internal clock, causing jet lag, resulting in sleepiness

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during the day, etc. Eventually however, the circadian rhythm readjusts to the revised
environmental cues.

Figure 12 shows the circadian rhythm for body temperature. This pattern is very
robust, meaning that even if the normal pattern of wakefulness and sleep is disrupted (by
shift work for example), the temperature cycle remains unchanged. Hence, if you are
awake at 4-6 o’clock in the morning, your body temperature is in a trough and it is at this
time that it is hardest to stay awake. Research has shown that this drop in body
temperature appears to be linked to a drop in alertness and performance in man.

Figure 22. The Circadian Rhythm for Internal Body Temperature

Sleep Disturbances and Deficits

How much sleep do people need? It varies, but on average studies say we need at
least 7 to 9 hours every day. Studies have reported that most night workers get about 5
to 7 hours less sleep per week than the day shift. (You can accumulate a sleep "debt",
but not a surplus.)
Humans follow an "internal" or "biological clock" cycle of sleep, wakefulness, and
alertness. Although these circadian rhythms are influenced by external clues such as the
sun setting and rising, it is the brain that sets your pattern. Most cycles are 23-25 hours
long and there are natural dips or periods when you feel tired or less alert - even for those
who are well-rested. Sometimes, a sleep disorder may cause fatigue. These conditions
include:

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2.3.1 INSOMNIA
People who suffer from insomnia often complain that they cannot fall asleep, or
cannot stay asleep for a full night. They may frequently wake up during the night, wake
up too early, not able to fall asleep at night, or have difficulty getting back to sleep if
woken. Either way, they do not feel rested. Insomnia can be both short term (in response
to a stressful event or change in environment) and long term.

2.3.2 SLEEP APNEA

Most cases of sleep apnea are caused by a condition called "Obstructive Sleep
Apnea". Sleep apnea is a breathing disorder in which there are brief interruptions (lasting
a minimum of 10 seconds) in breathing during sleep. This condition is caused by a
narrowing (or collapse) of the throat or upper airway during sleep.
This narrowing restricts or prevents breathing while you are sleeping (air cannot flow
into or out of your nose and mouth even though your body continues to try to breathe).
With sleep apnea, there are frequent interruptions to sleep making your sleep unrestful.
People often complain of early morning headaches and excessive daytime sleepiness.

Symptoms of sleep apnea include:

 chronic, loud snoring,
 gasping or choking while sleeping,
 excessive daytime sleepiness, and
 personality changes or difficulties thinking.

2.3.3 RESTLESS LEGS SYNDROME

With restless legs syndrome, people report sensations of creeping, crawling, pulling,
or tingling which cause an irresistible urge to move their legs. This phenomenon usually
happens as a person is trying to fall asleep, making sleep difficult. Movements may also
occur during sleep, partially waking the person (even though they might not "notice") and
disrupting sleep patterns.

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2.3.4 NARCOLEPSY
Narcolepsy is a rare condition associated with sudden sleep "attacks" where a
person will have an uncontrollable urge to sleep many times in one day.

2.3.5 OTHER SITUATIONS

Substances such as nicotine, caffeine, and alcohol can affect the quality of sleep.
Caffeine can remain in the body for about 3 to 7 hours and may affect sleep. Alcohol may
shorten the time to fall asleep, but it disrupts later in the night. Nicotine also can disrupt
sleep and reduce total sleep time.
Other substances such as over-the-counter medications or prescriptions may also
affect sleep. For example, long-acting benzodiazepines (drugs used to relieve anxiety or
insomnia) may contribute to daytime sleepiness.

Jet lag

Jet lag is a condition that affects your energy and state of alertness. It’s caused
when your body’s natural clock, or circadian rhythm, is disrupted by traveling to different
time zones.

Your body is aligned on a 24-hour cycle or body clock. Your body uses this clock to
perform specific biological functions, like releasing hormones that promote sleep, or
increasing your body temperature to help you wake up at the start of your day.

Jet lag, also called desynchronosis or circadian dysrhythmia, is temporary, but it can
interfere with your day in many ways. It can cause tiredness, drowsiness, lethargy, or
even upset stomach.

Causes of jet lag

Your body is naturally set to a 24-hour cycle. This cycle is known as your circadian rhythm.
Your body’s temperature, hormones, and other biological functions rise and fall according to this
internal time gauge.

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 When you travel, this clock may no longer align with the time in your new location.
For example, you may fly out of Atlanta at 6 p.m. local time and arrive in London at 7 a.m.
local time. Your body, however, thinks it’s 1 a.m. Now, just as you’re possibly reaching
peak fatigue, you need to stay awake another 12 to 14 hours to help your body adjust to
the new time zone.

You could help prepare your body to the new time zone by sleeping on the plane,
but several factors make that task difficult. These include temperature, noise, and comfort
level.

One factor works in your favor, however. The barometric pressure on planes tends
to be lower than air on the ground. This is similar to being on a mountain that’s 8,000 feet
above sea level. While there’s just as much oxygen in the air, the lower pressure may
result in less oxygen reaching the bloodstream. Lower oxygen levels may make you
lethargic, and this can encourage sleep.

Symptoms of jet lag

Jet lag occurs when your body’s natural rhythms are significantly upset by travel.
When you fight your body’s natural rhythm to match the new time zone, you may begin
experiencing symptoms of jet lag. These symptoms usually show up within 12 hours of
arriving at your new location, and they may last several days. The most common
symptoms of jet lag include:

 tiredness and fatigue

 drowsiness
 irritability
 feeling slightly disoriented and confused
 lethargy
 minor gastrointestinal issues, including upset stomach and diarrhea
 excessive sleepiness
 insomnia
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2.4 DIET, HEALTH AND WELLBEING
Your gut is home to the micro biome, trillions of bacteria, viruses, fungi and other
microbes which live mainly in your large intestine or colon. They influence mood, weight
and the immune system. The micro biome weighs between one and two kilos and until
relatively recently was largely ignored.
You should care about your microbiome because recent research has shown that
having the right mix of ‘good’ bacteria in your gut is vitally important for your long-term
health and wellbeing. And this affects your performance.
As you get older, having lots of ‘good’ bacteria in your gut is increasingly important,
as they will help you fight infection and prevent the onset of type 2 diabetes, depression
and common gut disorders.
Over the past few decades, there has been a huge rise in common gut disorders
such as irritable bowel syndrome, food allergies and gluten or lactose intolerance. The
reasons include poor diet and overuse of antibiotics, which have killed off lots of the ‘good’
gut microbes which keep the immune system in check. Without them your immune system
is liable to over-react, leading to all sorts of gut related problems.

Basics of Healthy Eating

Eating healthily and in moderation is important for weight control and proper
functioning of bodily processes. We need to eat to be active and maintain our bodies, and
a balanced diet with adequate levels of essential nutrients to maintain good health. These
include proteins, fats, carbohydrates, vitamins, minerals and trace elements. The typical
Western diet is high in fats, sugars and salt, and low in fibre. This can lead to ill health
and obesity.
Make an effort to choose healthier foods more often to get the balance right. Drinks
count: choose those which can add nutrients (such as calcium from milk) and avoid those
which just add kilojoules we don’t need (such as sugar-sweetened drinks). Water is best.
Make sure you drink more when it is hot and dry; the colour and smell of your urine are
good indicators. You can sum up the basics of healthy eating in three words: balance,
variety and moderation.

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 Balance is key when it comes to food and health. Eating well and staying healthy is
a balancing act that takes effort and practice. Balance your weight by matching the food
you eat with the physical activity you do. Energy from what we eat and drink is measured
in kilojoules (kj) and the amount of energy we need is different for everyone.
A balanced diet involves mostly fresh whole foods and plenty of vegetables, and
fewer convenience and processed foods, most of which have too much added sugar and
salt.
Variety is the spice of life, and it’s certainly an important goal when it comes to eating
well. Try to eat from all five food groups every day to give your body the nutrients it needs.
It’s also good to enjoy a variety of different foods from within the food groups to keep
meals interesting and to give you a broad range of nutritional benefits. Avoid fried food—
which can contain harmful trans-fat from the cooking oil.
Moderation means not going overboard with treats, restaurant or take-away meals,
alcohol, or the amount of food you eat. Enjoy the treats you love in moderation, because
they tend to be high in kilojoules and low in nutrients. This can be a challenge because
less-healthy foods are a quick and easy option when you are on the road or on an
overnight trip away from home.
Our bodies convert saturated fats into cholesterol which is important for our
metabolism, but too much cholesterol can lead to fatty deposits blocking blood vessels
and can lead to strokes and heart attacks. Excess salt in our diet is linked to high blood
pressure. We need fibre to provide bulk to assist excretion of waste products.
It is important to drink plenty of fluid to maintain healthy body function. Dehydration
degrades our cells’ metabolic processes and can lead to heat exhaustion. Clean, fresh
water is ideal for keeping us well hydrated. We should limit the amount of sugary,
caffeinated and carbonated drinks in general and especially when we fly.

2.5 FASTING
Total population in Indonesia is about 240 million people, and around 85% of the
total population were a Moslem. Ramadhan is a holy lunar month for Moslems. During
Ramadhan, all Moslem are required to fast. Refraining from eating and drinking from
sunrise to sunset.

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 While fasting, HDL cholesterol increases and LDL decreases, this is beneficial for
cardiovascular disease risk. Some truly believe that their performance is better while
fasting since their faith is sustaining them.

Effect of Fasting
Ramadan fasting, involving 1 month of abstention from food and fluid intake during
daylight hours, is practised by a large part of the world population. This period involves a
shift in the pattern of intake from daytime to the hours of darkness. There seems to be
little effect on overall daily dietary intake and only small metabolic effects, but there may
be implications for both physical and cognitive function. The effect of fasting include :
 Decreased alertness
 Increased fatigue
 Irritability and impaired mood
 Impaired memory
 Decreased work performance

2.6 ALCOHOL AND OTHER DRUGS

Alcohol, medication and drugs can be adversely affected human body. For
operational personnel, the use of drugs such as hypnotics, sedatives (including
antihistamines with a sedative effect) and tranquillizers to induce sleep is usually
inappropriate, as they have an adverse effect on performance when taken in therapeutic
doses for up to 36 hours after administration.
Alcohol acts as a depressant on the nervous system. It has a soporific effect, but it
disturbs normal sleep patterns and causes poor quality of sleep. The effects persist after
it has disappeared from the bloodstream (i.e. “hangover”). Ingestion of hypnotics in
combination with alcohol can have bizarre consequences.
Caffeine in coffee, tea and various soft drinks increases alertness and normally
reduces reaction times, but it is also likely to disturb sleep. Amphetamines, when used to
maintain performance during sleep deprivation, only postpone the effects of sleep loss.

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 Drug Common Side Effects
Alcohol A depressant that affects
concentration and coordination.
Antihistamines Drowsiness, slower reaction time, disturbed
(allergies) balance.
Amphetamines (with Stimulants such as amphetamines can make
appetite suppressant you anxious and uncoordinated. They can
side-effects) effect judgment and increase risk taking
Barbiturates Noticeably reduce alertness.
Motion sickness drugs Drowsiness, depressed brain function, impact
judgment and decision making
Sulfa drugs Allergic reactions are common and include
(antimicrobial) visual disturbances, dizziness, slowed reaction
time, depression.
Tranquilizers Slow reaction time,
drowsiness, reduced concentration and
attention.
Tabel 3. Side Effects of Alcohol and other drugs

2.7 BLOOD DONATION

An adult body contains about six litres of blood. Just over half of this is plasma which
is the liquid medium in which the blood cells are carried. There are three kinds of blood
cell, each with different function.
The white blood cells consist of a number of types which have a range of functions.
They engulf invading bacteria, they produce antibodies to resist attack by foreign
invaders, they identify antigens and other foreign substances, they release anticoagulants
and help combat inflammation and they devour bacteria.
Red blood cells (erythrocytes) contain hemoglobin which contains iron and is the
major component of the red cells. This has a strong affinity for oxygen (and incidentally
also for carbon monoxide, the affinity being 210 to 250 times greater than for oxygen).

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Anemia is a condition in which the number of red blood cells is below normal and thus
less oxygen can be carried from the lungs to the tissues. For this reason, it is
recommended that flight crew engaged in regular flying do not donate blood. Red blood
cells with their hemoglobin are manufactured in the bone marrow, and live for
approximately 108 days. If an individual should decide to donate blood, a period of 24
hours should elapse before flying to ensure replenishment of the depleted red blood cells
by the bone marrow. If bone marrow itself donate, the minimum recommended time
interval before flying is 48 hours to ensure recovery from the associated general
anesthetic.
The remaining cells are platelets which are involved in blood coagulation.

2.8 AGEING
At the biological level, ageing results from the impact of the accumulation of a wide
variety of molecular and cellular damage over time. This leads to a gradual decrease in
physical and mental capacity, a growing risk of disease, and ultimately, death. But these
changes are neither linear nor consistent, and they are only loosely associated with a
person’s age in years. While some 70 year-olds enjoy extremely good health and
functioning, other 70 year-olds are frail and require significant help from others.
Common conditions in older age include hearing loss, cataracts and refractive
errors, back and neck pain and osteoarthritis, chronic obstructive pulmonary disease,
diabetes, depression, and dementia. Furthermore, as people age, they are more likely to
experience several conditions at the same time.
Older age is also characterized by the emergence of several complex health states
that tend to occur only later in life and that do not fall into discrete disease categories.
These are commonly called geriatric syndromes. They are often the consequence of
multiple underlying factors and include frailty, urinary incontinence, falls, delirium and
pressure ulcers.
Geriatric syndromes appear to be better predictors of death than the presence or
number of specific diseases. Yet outside of countries that have developed geriatric
medicine as a specialty, they are often overlooked in traditionally structured health
services and in epidemiological research.

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 Ageing also affecting visual search, memory deficit, decrease the ability to manage
and coordinate dual-task.

2.9 MENTAL HEALTH

We can all feel sad, moody or low from time to time. However, some people
experience these feelings intensely, for long periods (weeks, months or even years) for
no apparent reason.
Depression is more than just a low mood—it’s a serious mental illness affecting our
physical health, concentration levels, alertness, reaction time and decision-making ability.
It affects how we feel about ourselves and makes life more difficult to manage from day
to day. We may lose interest in work, hobbies and doing things we normally enjoy. We
may lack energy, have difficulty sleeping or sleep more than usual. We may feel irritable
and find it hard to concentrate.
The statistics show that one in six of us will experience depression at some stage of
our lives, from minor (but still disabling) through to very severe.
The issue of pilots’ mental health has been highlighted in pilot-suicide tragedies such
as that in March 2015, when Germanwings fight 4U 9525 crashed into the French Alps
killing 150 people. Investigators reported the 27-year-old co-pilot deliberately crashed the
plane and found evidence suggesting he suffered from clinical depression.
Such occurrences are very rare, and mental health advocacy group SANE Australia
says, ‘no mental health myth causes more harm than the nonsense that people living with
mental illness are violent.
Nevertheless, depressive episodes can be incapacitating. Overt incapacitation
includes suicidal thoughts or attempts, psychosis of major depression and development
of other chronic diseases or conditions such as anxiety and substance abuse. Subtle
incapacitation includes impaired perception, reduced concentration and memory
problems.
Some medications used to treat depression and anxiety can impair performance by
impairing perception and causing sedation, nausea, lack of balance, impaired sleep and
fatigue.

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2.10 PREGNANCY

Pregnancy under normal circumstances can be compatible with flying and

controlling duties. However, the certificate holder’s obstetrician should be made aware
of the relevant considerations of the aviation environment in order to properly advise of
the safety (or otherwise) of flying or controlling when pregnant. The following effects
should be considered.

Effect of aviation on condition

 Cosmic radiation, especially for long-haul high latitude flights

 Prolonged sitting in restricted posture
 Limited access to toilet facilities
 Risk of trauma from turbulence or accident
 Possible exposure to physical hazards, including radiation, noise, fuels, and cabin
air contamination.
 Adverse effect of vibration on fetus
 Adverse effect of aerobatics

Effect of condition on aviation

 Fatigue and daytime sleepiness

 Neurocognitive impairment, including concentration, memory and speed of
processing
 Mood lability
 Decrease in visual acuity
 Back and pelvis pain, especially with prolonged sitting.
 Pregnancy-related nausea (‘morning sickness’)
 Anaemia
 Postural hypotension and syncope
 Increasing abdominal size may interfere with flight controls
 Risk from miscarriage or premature labour.
 Pre-eclampsia and eclampsia

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 Flying and controlling are physically and physiologically demanding tasks, and
changes due to pregnancy which normally cause only inconvenience can have significant
safety implications in the aviation environment. Someone who pregnant should ground
herself as soon as she becomes aware she is pregnant.
Restricting flying/controlling duties during the first trimester should be considered,
given the high prevalence of morning sickness, and the higher risk of miscarriage.

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 CHAPTER 3
THE HUMAN ELEMENT (AVIATION PSYCHOLOGY)

3.1 HUMAN ERROR

It has long been acknowledged that human performance is at times imperfect.
Nearly two thousand years ago, the Roman philosopher Cicero cautioned “It is the nature
of man to error”. It is a clear fact that whenever men and women are involved in an activity,
human error will occur at some point.

In his book “Human Error”, Professor James Reason defines error as follows:

“Error will be taken as a generic term to encompass all those occasions in which a
planned sequence of mental or physical activities fails to achieve its intended outcome,
and when these failures cannot be attributed to the intervention of some chance agency”.
Human error is cited as being a causal or a contributing factor in the majority of
aviation occurrences. All too often, these errors are committed by normal, healthy,
qualified, experienced, and well-equipped personnel. Indeed, when we examine human
error, it is clear that we all commit errors. Errors are not the results of a type of aberrant
behaviour but are a natural by-product of virtually all human endeavours. Understanding
how “normal” people commit errors is an important element of Human Factors in aviation.
In other words, to advance aviation safety, we must develop an understanding of the
operational contexts that facilitate errors.
Errors may be the consequence of intentional or unintentional behaviour and may
be further subdivided into slips, lapses and mistakes, depending on the degree of
intentionality preceding them.:
a. Slips are unintentional actions resulting from a lack of appropriate attention
caused by distractions, misordered sequences or mistimed actions. (e.g. the
pilot knew the correct frequency but erroneously entered another.)

3-1
 b. Lapses are unintentional actions caused by a memory failure arising from
forgetting one’s intention, losing one’s place or omitting planned items. (e.g. the
pilot knew that an altitude call-out was required, but simply forgot to make it.)
c. Mistakes are intentional actions resulting from errors in planning without any
deliberate decision to contravene established rules or procedures. (e.g. the
pilot-in-command decides to proceed to an alternate that has an acceptable
weather forecast but which has inadequate ground support equipment available
for that aircraft type.) Mistakes are based on the application of “rules” that we
draw from our experiences. They may result from the application of a rule that
is bad for a given situation or from the misapplication of an otherwise good rule.

Slips and lapses are essentially conditioned or automatic responses, with little, if
any, conscious decision making. On the other hand, mistakes involve deliberate decision-
making and evaluation, based on knowledge, experience and mental models that have
worked well in the past

Basic error
types
Attention failures / Ommissions
Slips
Misordering, etc
Unintended
actions Memory failure / Losing place
Lapses
Omitting items, etc
Unsafe
Acts
Mistakes Rule-based / Knowledge-based
Intended
actions
Routine / Exceptional
Violation
Acts of sabotage

Figure 23. Type of Error

Violations are related to mistakes. Although slips, lapses and mistakes may all lead
to technical breaches of aviation regulations or company operating procedures, they are
considered to be errors because they are not based on a deliberate decision to

3-2
contravene the established rules. Violations, however, are not errors. Like mistakes,
violations involve intentional planning failures, often based on knowledge and the mental
models acquired through daily experience, but also involve a deliberate decision to
contravene established rules or procedures. (e.g. the pilot decides to descend below
prescribed approach minima, or the controller reduces aircraft separation below the
standard).
A Violation is an intentional action (or inaction) that results in noncompliance with
known rules, policies, procedures or acceptable norms. There are three types of
violations:
 Routine violations.
 Situational violations.
 Optimising violations.

Routine violations

Routine violations are things which have become ‘the normal way of doing
something’ within the person’s work group (e.g. flight crew from one company base). They
can become routine for several reasons: flight crew may believe that procedures may be
over prescriptive and violate them to simplify a task (cutting corners), to save time and
effort. This rarely happens in flight operations, since flying tasks are so procedurals, but
it is not unusual to see this type of violations in maintenance engineering.

Situational violations

Situational violations occur due to the factors that exist at the time, such as time
pressure, high workload, unworkable procedures, poorly designed man-machine
interface in the cockpit. These occur often when, to get the job done, pilots consider that
a procedure cannot be followed.

Optimising violations

Optimising violations involve breaking the rules for ‘kicks’. These are often quite
unrelated to the actual task. The person just uses the opportunity to satisfy a personal
need. Flying an illegal circuit over a friend's house might be an example. Time pressure

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and high workload increase the likelihood of all types of violations occurring. People weigh
up the perceived risks against the perceived benefits, unfortunately the actual risks can
be much higher.
Involuntary or non-
NO intentional action
Was there a prior NO Was there intention in
Intention to act? the action? Spontaneous or
YES subsidiary action
YES

Did the actions NO Unintentional action –

Proceed as planned? slip or lapse
YES

Did the actions

NO Intentional but
Achieve the desired
mistaken action
end?

YES

SUCCESSFUL ACTION
Figure 24. Error type base on intention. Source : Reason, 1990

The following is a refined discussion of human errors which is more operationally

oriented:
a. Procedural error. An unintentional error that includes slips, lapses or mistakes
in the execution of aviation regulations and/or company procedures. The
intention is correct but the execution is flawed. These also include errors where
the flight crew (or aircraft maintenance technician or air traffic controller) forgot
to do something. Both written procedures and crew intention are required for
procedural errors.
b. Communication error. An unintentional error that is a miscommunication,
misinterpretation, or failure to communicate pertinent information within the
flight crew or between the flight crew and an external agent (e.g. ATC or ground
operations).
c. Proficiency error. An unintentional error that indicates a lack of knowledge or
physical skill.

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 d. Operational decision error. An unintentional, decision-making error, which is
not specifically directed by aviation regulation or company operating
procedures, that unnecessarily compromises safety (e.g. a crew’s decision to
fly through known wind shear on an approach).
e. Intentional non-compliance. A wilful deviation from aviation regulations and/or
company procedures. If the crew is under heavy workload or commits the error
only once, it would likely be a procedural error. However, if the crew makes the
same error over and over again, or it is an error of complacency, then it is
intentional non-compliance (i.e. a violation).

Error-producing condition
In the SHEL model, the irregular surfaces on the various blocks of the model depict
the imperfect matches between humans and other elements of the model. Thus, at each
interface in the SHEL model the potential exits for initiating or exacerbating errors. For
example:

Figure 25. SHEL Model

a. At the Liveware-Hardware interface, knobs and levers that are poorly located or
lack the proper coding may create confusion, leading to slips.

3-5
 b. At the Liveware-Software interface, delays and errors may occur while seeking
vital information from confusing, misleading or excessively cluttered
documentation and charts, leading to slips and mistakes.
c. At the Liveware-Environment interface, environmental factors or disturbance of
biological rhythms may affect concentration, the ability to reason or
communicate, and perhaps attitude towards other crew members and the flight
itself — any of which could facilitate slips, lapses or mistakes.
d. A poor Liveware-Liveware interface may reduce operational efficiency and
cause misunderstandings and leading to slips, lapses and mistakes (e.g.
inadequate information transfer which is frequently cited as causal in accident
reports).

Violation producing condition

Violation producing conditions are not as well understood as error-producing
factors. Examples of violation-producing conditions are listed below in no particular
sequence:
a. conflicting goals (e.g. on-time service or fuel conservation versus safety);
b. company operating pressure (e.g. “If you can’t do the job, I’ll hire some who
can.”);
c. self-induced and peer pressure (e.g. “The previous captain got in okay, so can
I.”);
d. worker/management conflict;
e. poor supervision and checking;
f. inappropriate norms (e.g. acceptance of unsafe practices by fellow workers);
g. misperception of risks;
h. perceived managerial indifference (e.g. tacit understanding that bending the
rules is acceptable);
i. belief that “accidents can’t happen to me”;
j. unclear or meaningless rules;
k. “Can do” culture requiring bending of rules.

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Control of Human Error
As already stated, errors are normal; they are found in nearly all human endeavour.
Fortunately, few errors lead to adverse consequences. Typically, errors are identified and
corrected before undesirable outcomes result. To the extent that errors are normal in
human behaviour, the total elimination of human error would be an unrealistic goal. The
challenge then is not merely to prevent errors but to learn to safely manage errors that do
occur.
The control of human error requires two different approaches. The first approach
is to minimize the probability of errors by ensuring high levels of competence, designing
controls so that they match human characteristics, providing proper checklists,
procedures, manuals, maps, charts, and SOPs, and reducing noise, vibration,
temperature extremes and other stressful conditions, etc. Training programmes aimed at
increasing the cooperation and communication between crew members will also reduce
the probability of errors. The second approach is to reduce the consequences of any
errors through cross monitoring and crew cooperation. Equipment design to make errors
reversible, and equipment that monitors or complements and supports human
performance, also contribute to limiting errors and their consequences.
Three strategies for error prevention, which is actually form of risk mitigation, are
briefly discussed below. These strategies are relevant to flight operations, air traffic
control or aircraft maintenance.
a. Error reduction strategies are intended to intervene directly at the source of the
error itself, by reducing or eliminating the contributing factors to the error. They
seek improved task reliability by eliminating any adverse conditions that
increase the risk of error, and they are the most often-used strategies. Examples
of error reduction strategies include improving the access to a part for
maintenance, improving the lighting in which the task is to be performed, and
providing better training.
b. Error capturing assumes the error has already been made. The intent is to
“capture” the error before the adverse consequences of the error are felt. Error
capturing is different than error reduction in that it does not directly serve to
reduce or eliminate the error. Error-capturing strategies include post-task

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 inspection, verification, or testing; for example, cross-checking a checklist. It
should be noted that people may be less vigilant when they know there is an
extra defence in place to capture their errors.
c. Error tolerance refers to the ability of a system to accept an error without serious
consequence. For example, as a strategy to prevent the loss of both engines on
an aircraft involved in extended twinengine operations, the regulatory authority
might prohibit the same maintenance task being performed on both engines
prior to a flight. Examples of measures to increase error tolerance are the
incorporation of multiple hydraulic or electrical systems on the aircraft and a
structural inspection programme that allows multiple opportunities to detect a
fatigue crack before it reaches critical length.
In aviation, the accident record has frequently lead to an examination of crew
performance. If the interface among the crew members is weak, for whatever reasons,
errors in communication and decision making will result. Crew Resource Management
(CRM) and Line Oriented Flight Training (LOFT), two processes for improving crew
performance. Of note, the lessons of CRM are being widely adapted for broader
applications. In the course of their duties, safety auditors will undoubtedly encounter many
unsafe conditions. The challenge in this regard will be to convince the Contracting State
how these unsafe conditions could facilitate human errors (and violations) and help the
Contracting State to find ways to better control human errors by reducing or eliminating
the error-producing (and violation-producing) conditions.

Figure 26. Crew Error Management Model

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Managing Violation
An effective strategy for managing violations will include the establishment and
maintenance of effective management systems that ensures, at a minimum, the following:
 Good leadership, planning, training, and resourcing.
 Both management and employees are aware of their responsibilities and key
risks related to their work and understand how violations reduce vital safety
margins. *Channels are established to communicate difficulties and to discuss
solutions. This facilitates learning about problems and adjusting planning
accordingly to avoid strains, which could lead to violations.
 Existing violations are analysed to fully understand their causes and any
contributing human and organisational factors. Use of a standard taxonomy
and descriptors for the different types of violation can help with understanding
as well as directing mitigating measures.
 A change management process is established such that pre-determined and
unexpected changes are safety assessed to consider impact on human
performance.
 Employees are invited and encouraged to participate in setting boundaries and
limits, as appropriate, of what is acceptable and unacceptable.
 A defined and measurable programme for workplace culture improvement is
undertaken, such that violations are not an acceptable option for employees.
 Appropriate communication and feedback systems are used to ensure all the
above happens, and employees really “feel it”.

3.2 WORKLOAD
Workload has to do with the amount of work expected from an individual. In
aviation, workload generally implies mental effort as opposed to physical effort. If the
workload generated by a task or set of tasks exceeds a person’s mental capacity,
performance will suffer.
There are two types of mental workload :

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 – Momentary workload. The workload existing at a single point in time, may exceed
an individual’s capacity to cope. Momentary workload can exceed information
processing capabilities. Example : an in-flight emergency
– Cumulative workload. Less complex tasks in some period of time, may exceed an
individual’s capacity to cope. Cumulative workload can lead to stress and fatigue,
and then performance problems. Example: Series of flight in a day

Figure 27. Momentary workload vs Cumulative workload

Measuring Mental Workload

There are several ways to measure mental workload including :
• Physiological measures
– Blood pressure
– Heart rate
– Pupil dilation
• Dual/secondary task (laboratory testing)
– Measure performance on an easy task
– Measure performance on a difficult task
– Perform two tasks simultaneously and observe impairment in easy task
performance

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  Self Report Measures
– Cooper-Harper rating scale
– Subjective Workload Assessment Technique (SWAT)
– NASA Task Loading Index (TLX) rating scale
– The Crew Status Survey
– The AFFTC Revised Workload Estimate Scale

Working Memory and Workload

Moderate task demand with sufficient resources will causing low of anxiety it
become low of stress. But in the other hand if moderate task demand come with lack
of resources it will causing high stress.

Figure 28. Working memory and workload

Factors Affecting Perceptions of Workload

• Individual well-being (includes fatigue)
• Level of stress
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 • Mental overload or underload. Especially underload with modern automated
flight decks
• Degree of task difficulty
• Familiarity with the task
• Skill of the individual
• Training
• Communication
• Profesionalism
• Motivation
• Tiredness
• Foresight
• Patience
• Confidence
Workload Management Strategies:
– Chunking, reduces the number of items to be remembered
– Segmentation
– Prioritisation
– Training & practice
– Use of checklists & standard operating procedures
– Good communications
– Delegate when due

Understandably, there are considerable differences in capacities for given

workloads. Generally speaking, training and experience equip us to effectively deal
with increasing workloads. However, if affected by any of the stressors previously
discussed our capacity can vary markedly over time. When overloaded, people may
try to cope by skipping steps in their safe work routines, perhaps even ignoring obvious
cues of unsafe conditions.

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3.3 HUMAN INFORMATION PROCESSING
To make decisions and take action, we gather, assess and prioritize information
from our five senses—vision, hearing, touch, taste and smell. The vestibular system,
largely responsible for our sense of balance and spatial orientation, is also very important.
But we can also be tricked by our senses. In aviation, it is vital that we recognize
illusions and deal with them before they get us into trouble. We need to practice and be
prepared for these situations.
Figure below shows the four main stages in human information processing: sensing,
perceiving, deciding, and acting. Supporting these stages are various elements of
memory, and our ‘attention directing’ mechanism.
We continuously sense and assess changes resulting from our actions and make
any necessary adjustments, such as to attitude on take-off and climb out, or to maintain
a constant aim point on approach. However, sometimes things aren’t what they seem!
We will look at specific information processing misperceptions later in this section.

Figure 29. Human information processing model

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 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.

Attention
Having detected information, our mental resources are concentrated on specific
elements this is attention. Attention 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
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 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
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
Focused attention is merely the skill of focusing one’s attention upon a single source
and avoiding distraction.
• Sustained attention
Sustained attention 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

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with monitoring radar displays, but there is also associated research which has
concentrated upon inspection tasks.
Attention is influenced by arousal level and stress. This can improve attention or
damage it depending on the circumstances

Decision Making
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 judgment.

Perception
Involves the organization 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.

Perceiving and Countering Illusions

Perception is the way in which the brain understands information acquired through
the senses. It makes the connection between external events (such as objects, people,
movement, sounds and smells) and our thoughts about them. Misperception is when we
get this wrong.
We generally perceive things we fnd interesting (that we are looking for, or are
sensitive to), that strongly impact on our senses (bright lights, loud noises, irregular
movement), or that signal potential danger and trigger fear. We take less notice of things
that don’t interest us, are not making a large impact, and that don’t scare us.
The performance limitations of our sensory organs mean that we also don’t always
perceive things accurately. This is mainly because of the way the brain reconstructs data.
We can be fooled into believing, or literally feeling, a false interpretation of the outside
world.

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 We are all susceptible to misperceptions caused by sensory limitations, and we
generally experience these misperceptions in the same way. However, as individuals with
different experiences and personalities, these experiences can affect us in markedly
different ways.
Other factors such as concentration, motivation, fatigue, stress, alcohol and other
drugs, illness, and medication can also affect our perception.

Perceptual illusions
Several perceptual illusions may affect fight safety. These relate mainly to
misperceptions about the position of the aircraft, projected fight path in space and in the
horizontal plane, and in relation to other objects, such as the runway. They invariably
include perception of power (engines/thrust) and aircraft configuration (landing gear,
flaps, slats, air-brakes, trim etc.) This is linked to situational awareness and spatial
disorientation.

Visual illusions
Visual illusions are familiar to most of us. You have probably seen pictures like the
ones in figure below before.

Figure 30. Visual Illusion

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 The first is the Müller-Lyer illusion: lines (a) and (b) are the same length, but the
outward fins in (a) make us perceive (a) to be longer. The second is the Rubin’s vase
illusion. The third is the scintillating grid illusion. Dark dots seems to appear and disappear
at random intersections. If you stare directly at a single intersection, you do not see the
dark dot.
These illusions are interesting to look at in the comfort of your home or classroom.
But when our eyes play tricks on us while we’re flying, there’s potential for disaster
Some visual misperceptions are due to physiological limitations of the eye, such as
blind spots and colour blindness, as well as an inability of our eyes to detect objects in
very low light conditions (night) or at the other extreme in very bright conditions (looking
directly at the sun).

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)
Ultra short-term memory or sensory storage 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.

b) Short Term Memory (often referred to as working memory)

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

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 time, i.e. 5 to 9 (often referred to as 7 ±2) items of information, for a short duration,
typically 10 to 20 seconds.
There are methods of increasing short-term memory:

- Chunking.

As the following example shows, capacity of short-term memory can be enhanced by

splitting information in to ‘chunks’ (a group of related items).

A telephone number, e.g., 021 4786 9945 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 Indonesia, 021 may be stored as one chunk, 478 as
another, and 699 as another, using only three chunks and therefore, more likely to be
remembered. In Indonesia, the same telephone number would probably be stored as
021 47 86 86 99 45, using six 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 Jakarta might recognise 021 as the
code for Jakarta, but a person from Papua might not.

This duration 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 example above).
- Association

This technique is used by many when remembering spoken lists of items. A wild
and bizarre association is imagined and attached to each item on the list. Many
politicians make use of this method when putting faces to names.

- Mnemonics

The use of mnemonics, the art of making up a word, phrase, or sentence in order to
remember many points, is useful.
c) 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:

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 • knowledge of the physical world and objects within it and how these behave;
• personal experiences;
• beliefs about people, social norms, values, etc
• motor programs, 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:

 semantic and
 episodic.

- Semantic

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

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.

3.4 ATTITUDINAL FACTORS

Personality
Personality can be described as the inner person. It is personality that makes each
person an individual. Personality is :
 What person is born with
 What a person acquires in the formative years from family, friends and education
Once the formative years have passed, personality is fixed. However, personality
can be changed by a traumatic influence such as brain damage after a car crash.

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Motivation
Our most basic motivation comes from physiological needs such as the need to eat
and drink. However, we are also driven by a complex combination of psychological and
social needs.
Achievement motivation is the aspiration to achieve a specific goal. There are many
additional forms of personal motivation. One such motivational factor is job satisfaction.
This is a complex mix of factors such as financial reward, the relationship with
management and colleagues, the working environment, the nature and variety of the
tasks involved in the job, and the opportunities for progression to a higher level.
Enhancing job satisfaction is not easy. An increase in financial reward only has
temporary effect on increasing job satisfaction. The longer lasting factors usually relate
to relationship, working environment, and the nature and variety of tasks.
It is important to remember that motivation can also be defined in terms of those
ingredients of a job that are not present and, as a result, lead to job dissatisfaction. Salary,
holiday entitlement, status recognition, and job security are all examples of this.

Theory of Motivation

Figure 31. Triangle of human needs

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 To satisfy the human needs there is an order of priority. Maslow introduced a triangle
of human needs. The lower order motives are aroused first and must be satisfied first.
Once a need is satisfied then the next level in the hierarchy can be satisfied. The triangle
of needs starts with basic physiological needs, and progresses up to those related to ego.
Eventually the person reaches self-fulfillment. The hierarchy of needs is shown in the
diagram above.

Culture
Culture is the characteristics and knowledge of a particular group of people,
encompassing language, religion, cuisine, social habits, music and arts.
The Center for Advance Research on Language Acquisition goes a step further,
defining culture as shared patterns of behaviors and interactions, cognitive constructs and
understanding that are learned by socialization. Thus, it can be seen as the growth of a
group identity fostered by social patterns unique to the group.
"Culture encompasses religion, food, what we wear, how we wear it, our language,
marriage, music, what we believe is right or wrong, how we sit at the table, how we greet
visitors, how we behave with loved ones, and a million other things," Cristina De Rossi,
an anthropologist at Barnet and Southgate College in London, told Live Science.
The word "culture" derives from a French term, which in turn derives from the Latin
"colere," which means to tend to the earth and grow, or cultivation and nurture. "It shares
its etymology with a number of other words related to actively fostering growth," De Rossi
said.

3.5 SITUATIONAL AWARENESS

Situation awareness is the synthesis of an accurate and up-to-date 'mental model'
of one's environment and state and the ability to use this to make predictions of possible
future states.
Maintaining awareness of an evolving situation is a complex process that includes
recognizing that perception of reality may differ from reality itself. Situation awareness
requires continual questioning, cross-checking, refinement and updating of perception.
Constant, conscious monitoring of the total operational and human situation is required.

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Factors that reduce SA include:
■ Insufficient communication
■ Fatigue and/or stress
■ Task overload
■ Task underload
■ ‘Press-on-regardless’ philosophy
■ Degraded operating conditions.

10 Clues to loss of situational awareness

These clues can warn of an ‘error chain’ in progress - a series of events that may
lead to an accident. Most accidents involving human error include at least four of these
clues.
a. Ambiguity: information from two or more sources that doesn’t agree.
b. Fixation: focusing on any one thing to the exclusion of everything else.
c. Confusion: uncertainty about a situation (often accompanied by anxiety or
psychological discomfort).
d. Failure to fly the plane: everyone is focused on non-flying activities.
e. Failure to look outside: everyone is looking down.
f. Failure to meet an expected checkpoint on flight plan or profile.
g. Failure to adhere to standard operating procedures.
h. Failure to comply with limitations, minimums, regulations etc.
i. Failure to resolve discrepancies: contradictory data or personal conflicts.
j. Failure to communicate fully and effectively: vague or incomplete statements.

A Model of Situational Awareness

Probably the most widely cited definition of SA is from Dr Mica Endsley, one of the
leading authorities on the subject:
‘… situational awareness is the [accurate] perception of the elements in the environment
within a volume of time and space, the comprehension of their meaning, and the
projection of their status in the near future’. (Endsley, 1988: p. 7).
She describes SA as comprising three levels:

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Level 1: perception of elements,
Level 2: comprehending what those elements mean, and
Level 3: using that understanding to project future states.
Endsley (1995) has developed a model to help illustrate the factors that influence
SA in complex and dynamic settings such as flying operations. This model is shown
below.

Figure 32. Model of Situational Awareness. (Endsley, 1995)

Level 1 SA – Perception
Perception of cues (Level 1 SA) is fundamental. Without basic accurate perception
of important information, the odds of forming an incorrect picture of the situation increase
dramatically. For example, a pilot needs to perceive important elements such as other
aircraft, terrain, system status and warning lights, along with their relevant characteristics.
Level 2 SA – Comprehension
Situational awareness goes beyond mere perception. It also encompasses how
people combine, interpret, store, and retain information. Thus, it includes more than
perceiving or attending to information, but also the integration of multiple pieces of
information and a determination of their relevance to the person’s goals (Level 2 SA). This
is analogous to having a high level of reading comprehension, as compared to just
reading words without really understanding them.
For example, upon seeing warning lights indicating a problem during take-off, the
pilot must quickly determine the seriousness of the problem in terms of the immediate

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airworthiness of the aircraft, and combine this with knowledge on the amount of runway
remaining, in order to know whether or not to abort. A novice pilot may be capable of
achieving the same Level 1 SA as more experienced pilots, but may fall far short of being
able to integrate various data elements to comprehend the situation effectively.

Level 3 SA – Projection
At the highest level of SA, the ability to forecast future situation events and dynamics
(Level 3 SA) represents operators who have the highest level of understanding of the
situation. This ability to project from current events and dynamics to anticipate future
events (and their implications) allows for timely decision making. This is the domain of
skilled experts.

Situational Awareness and Safety

The link between poor situational awareness and accidents has been well
documented in aviation. According to FAA statistics, spatial disorientation and loss of
situational awareness cause up to 15–17 per cent of fatal general aviation crashes
annually (about 2.5 per cent of the total). More significantly, nine out of 10 cases of spatial
disorientation result in a fatality. Most of these mishaps occur when pilots are flying at
night and/or intentionally, or inadvertently flying in instrument meteorological conditions
(IMC).
Problems with SA were found to be the leading causal factors in a review of military
aviation accidents/incidents (Hartel, Smith & Prince, 1991). Furthermore, according to
Endsley (1995) in a study of accidents among major air transport operators, 88 per cent
of those involving human error could be attributed to problems with situational awareness.
Gibson, Orasanu, Villeda and Nygren (1997) also performed a study of SA errors
based on the US Aviation Safety Reporting System (ASRS) reports. They found multiple
factors were commonly involved with each report. These included workload/distraction
(86 per cent), communications/coordination (74 per cent), improper procedures (54 per
cent), time pressure (45 per cent), equipment problems (43 per cent), weather (32 per
cent), unfamiliarity (31 per cent), fatigue (18 per cent), night conditions (12 per cent),
emotion (7 per cent) and other factors (37 per cent).

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 Consequences of loss of SA were: altitude deviations (26 per cent), violations of
Federal Aviation Regulations (25 per cent), heading deviations (23 per cent), traffic
conflicts (21 per cent), and non-adherence to published procedures (19 per cent).
Dangerous situations were found to result from 61 per cent of the cases.

3.5 DECISION MAKING

Decision-making is a process for reaching a judgement or selecting an option to
address or resolve a situation. Some decisions, such as when to turn onto final
approach at a familiar airstrip, are so well practiced that they are highly resistant to
mistakes, although decision-making can be affected by fatigue or high stress levels.
However, many decisions are non-routine.

Decision-Making Process
Decision-making generally has four components:
■ Defining the problem
■ Considering the options
■ Selecting and implementing the options
■ Reviewing the outcome.

Defining the problem

Weigh up the information gained from a number of sources and make an
assessment of the available alternatives. For example, the process to handle an
aggressive passenger in commercial aviation might begin by evaluating comments
from passengers and crew, as well as your own impressions of the passenger’s
behaviour.

Considering the options

Consider the various options. From the above example, consider the choices
available when a passenger is aggressive – e.g. request flight crew intervention,
attempt to calm the passenger, threaten the passenger with restraint, apply physical
restraint.

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Selecting and implementing the options
Choose an appropriate action based upon the pros and cons of the probable
outcome. A decision-maker never has complete information, so the most probable
outcome is only an estimate. For example, the passenger’s aggressive behaviour
based upon the information available may be a symptom of a fear of flying and
excessive alcohol consumption. A possible action is to request a travelling companion
and a crew member to sit with the passenger to reassure them, while drinks service is
suspended.

Reviewing the outcome

Monitor the situation to ensure the decision is successful. This last step is a
closed-loop process to ensure the decision made and action taken are effective in
resolving the issue of the passenger’s aggression.

Characteristics of Decision-Making
Decisions made in stressful or high arousal situations have a number of characteristics
in common:
 Any decision made has a ‘deadline’. It is only valid for a short time in changing
conditions
 A decision is only effective if it can be implemented within the time available
 The value of the decision depends upon understanding the situation
 Usually a decision is irreversible and cannot be undone.

Factors Influencing Decision-Making

Two sources of bias generally affect our ability to make good decisions:
■ Social influences
■ Situational limitations.

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Social influences
Research and accidents demonstrate that people tend to comply with social
pressure to avoid rejection or to gain social approval. Over the years, many university
experiments have examined this concept, and demonstrate that such group pressure
can be strong enough to make people conform to falsehoods.
Individuals are frequently influenced by the dominant opinions of a group or team
and sometimes accept illogical decisions to avoid conflict. Studies on group conformity
suggest that the second-highest member of a group is usually the most conforming
member.

Situational limitations
Situational limitations can affect our ability to make a sound decision.
Stress
Stress in a given situation is primarily caused by a feeling of inadequacy. Stress
interferes with our ability to make sound decisions and encourages us not to make fully
committed decisions. As a result, major problems may occur in highly dangerous or
quickly-changing situations.

Time pressure
All the facts in a given situation may not always be taken into account when time
is at a premium. Frequently, one poor decision is followed by another. Unfortunately,
time pressure is greatest in emergencies where the consequences of error are least
forgiving.

Fatigue
The cumulative effects of fatigue, particularly at the end of a day or after a long
shift, often encourage people to persevere with a chosen course of action, despite the
strategy not working. Fatigued workers frequently fail to review a plan and increasingly
neglect information which contradicts decisions previously made.

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3.7 STRESS
Stress has traditionally been linked to arousal, which refers to nonspecific changes
(e.g. hormonal and brain activities) in the body to external stimulation. In general, stress
and arousal levels are positively related - that is to say, high stress is associated with high
arousal level.

The Yerkes-Dodson law depicted in Figure below relates performance and arousal.
It shows that people's performance levels increase according to the degree of arousal to
a point beyond which any additional boost in arousal will generally be detrimental to task
performance. The over-all shape of the relationship curve remains the same across
different tasks, but the exact shape and location of each curve vary according to task
complexity.

Stress is related to a person's ability to pay attention to cues in the environment. In

a simple situation with few cues, stress will improve performance by causing attention to
be focused. In a complex situation with many cues, stress will decrease performance
because many cues will go unheeded. This explains many accidents in which crew under
stress "locked on" to some particular instrument which was defective (even if the
instrument was of minor importance), failing to attend to other pieces of crucial
information.

Figure 33. The Yerkes-Dodson law relating performance and arousal

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 There are many types of stress. Typically in the aviation environment there are two
distinct types - acute and chronic. Acute stress arises from real-time demands placed on
our senses, mental processing and physical body; such as dealing with an emergency,
or working under time pressure with inadequate resources. Chronic stress is
accumulated and results from long-term demands placed on the physiology by life’s
demands, such as family relations, finances, illness, bereavement, divorce, or even
winning the lottery. When we suffer stress from these persistent and long-term life events,
it can mean our threshold of reaction to demands and pressure at work can be lowered.
Thus at work, we may overreact inappropriately, too often and too easily.
Some early visible signs of stress include changes in personality and moods, errors
of judgement, lack of concentration and poor memory. Individuals may notice difficulty
in sleeping and an increase in fatigue, as well as digestive problems. Longer-term signs
of stress include susceptibility to infections, increased use of stimulants and self-
medication, absence from work, illness and depression.
It is important to recognise the early signs of stress and to determine whether it is
acute or chronic. Coping with daily demands at work can be achieved with simple
breathing and relaxation techniques. However, perhaps more effective is having channels
of communication readily available through which to discuss the issue and help to
rationalise perceptions. It is entirely appropriate that some of these channels involve
social interaction with peers.

Figure 34. Effect of stress on Human Performance

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 As with fatigue, sleep, diet and exercise are all important factors in helping to reduce
stress and build resilience to stressors. If the stress is chronic, then definite lifestyle
changes will be required; this must be achieved with support from the Company.
Companies ought therefore, to have employee assistance (or wellbeing) policies that
include stress reduction programmes.

Stressor
Stress affects human performance, sometimes positively and sometimes
negatively. Although ubiquitous, stress is difficult to quantify. The concern here is with
decreases in human performance caused by anything that affects the way we live and
work. These things are called “stressors”. They include such things as fatigue, time
pressures, workload, personality conflicts, family problems and substance abuse.
The aviation environment is particularly rich in potential stressors. In the early
days of aviation, the stressors of concern to flight crews were created by the environment
(noise, vibration, temperature, humidity and acceleration forces) and were mainly
physiological in nature. Today, they include such things as irregular working and resting
patterns and disturbed circadian rhythms associated with long-range, irregular or night-
time flying.
Individuals differ widely in their responses to stress. For example, flight in a
thunderstorm area may be challenging for one individual but quite stressful for another.
In some ways, the effect of a particular stressor can be predicted. Training and experience
may help individuals in overcoming a particular work-related stress or such as performing
a complex task under adverse conditions. Other stressors may be reduced or eliminated
through life style modification.

Pressure
Any pressure we feel can lead to stress and stress can lead to human
error. Current minimum turn-around times place additional pressure on maintenance staff
and create a challenge for any defects which are found and the steps which need to be
taken.

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 The first of course is real pressure, applied directly or indirectly, for the task to be
completed in a given time. On the other hand, individuals or teams may feel self-imposed
pressure to complete a task within a given time, even when the time available may be
unrealistic or the task may not be achievable with the allocated resources and time frame.
The definition of self-imposed is something that you require or expect of yourself,
rather than something required by another so our way of dealing with self-imposed time
pressure is somewhat different to how we can deal with external time pressure for
example for commercial reasons.
For an individual, the self-imposed pressure is real. For them, it is no different from
any actual pressure being applied to the completion of the task. All pressure (self-imposed
or otherwise) will affect the performance of those subjected to it.

Stress Management
Learning to recognize the factors that lead to stress, and using coping strategies to deal
with stressful situations, can greatly improve performance. Practical actions for coping
with stress include:
• managing your time effectively
• avoiding over commitment—working within your limitations
• discussing your problems with others so they can offer support
• eating healthily
• ensuring you are well rested and getting plenty of sleep to avoid fatigue
• maintaining your sense of humor—being able to laugh about things helps maintain a
positive mental state
• practicing mindfulness meditation—there are many helpful apps online
• recognizing the physical signs of tightening up in response to stress and learning how
to relax mentally and physically when feeling tense
• recognizing and responding to factors which are combining to cause stress
• staying hydrated
• exercise and staying physically fit.
Where stress is caused by mental overload, it helps to focus on high-priority tasks:
• follow standard operating procedures

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• use checklists
• share tasks in multi-crew operations
• seek assistance from your company

3.8 CURRENCY VS. PROFICIENCY

Currency and proficiency have similar definitions and they do complement each
other, but neither one is a replacement for the other. Being current means that you have
met the requirements to act as a pilot in command of an aircraft within a certain time
period. Being proficient means, according to Webster's College Dictionary, "fully
competent in any art, science, or subject." You can be current without being a proficient
pilot, but if you are proficient, most likely you have also met the currency requirements to
get to that point.
Learning how to become current is as easy as reading the SARPs for the type of
flying that you are going to do. To act as pilot in command of an aircraft, you need to have
accomplished a flight review or one of the exceptions within the preceding 24 calendar
months. To be able to carry passengers, you need at least three takeoffs and three
landings within the preceding 90 days. For night flights with passengers, the landings
need to be full stop at night, not touch and go. When the IFR environment is considered,
then at least six approaches need to have been performed and logged within the
preceding six calendar months. There might be further requirements and exceptions to
each of these situations, and we strongly recommend a thorough reading of the
regulations to verify your requirements.
Many of the articles and studies that have been collected on this subject stress that
one can meet the above currency requirements without becoming proficient in the
operation of an aircraft. Proficiency in an aircraft includes normal operations as well as
knowledge of the emergency procedures for the aircraft that you fly, as well as type of
flying. Maintaining proficiency in aircraft of different categories and classes can be more
of a challenge due to the different skill sets that are required.
The main similarity is practice. To become proficient, you should practice your skills.
It is best to do this with an instructor to make sure that you are practicing correctly, but
you can also achieve this on your own. There are many ways to become a proficient pilot.

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One way is to become current and then practice more on your own until you feel you are
fully competent in the aircraft. You can solicit assistance from many sources, including a
safety pilot, an instructor, and a computer software program.
Practicing performance maneuvers by yourself is not as rewarding as challenging
another pilot to a skills contest, with each pilot judging the other on how close to the
minimums described in the Practical Test Standards the other can perform. You do not
have to test yourself under the watchful eyes of an instructor, but a fellow pilot can still
suggest ways to perform a smooth short-field landing that may have been taught to him
or her differently. If you want to practice a maneuver that you do not normally perform,
such as soft-field landings, or landing on snow, then an hour or two of instruction from a
CFI may accomplish much more than a few hours of practicing on your own.
One of the newest areas of training that you can use to your advantage is the use
of computer simulator programs. From an inexpensive VFR or IFR sim to the expensive
training systems in use by many FBOs and training centers, the programs can provide
valuable insight into procedures and checklists. The feel of the "aircraft" may not be what
you are used to, but the programs are getting better as the technology improves. Training
companies and aircraft manufacturers alike endorse the latest version of Microsoft's Flight
Simulator. Offering simulated flight in a variety of aircraft, Microsoft can accommodate a
wide range of users with one package.

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 CHAPTER 4

HUMAN – HARDWARE RELATIONSHIP

4.1 ERGONOMIC

Ergonomics has been applied in the design of tools, even in an elementary way,
since the beginning of civilization. In aviation, the focus in the early pioneering days - and
for many years afterwards - was on advancing some general principles to guide the
design of flight deck displays and controls. This later broadened into the experimental
analysis of the design and layout of equipment, in close association with the analysis of
the demands and workload that the equipment and tasks imposed upon the human
operator. Today's approach to design takes the user's characteristics (capabilities,
limitations, and needs) into consideration early on in the system development process,
and subordinates engineering convenience to them. The terms "user-friendly" and "error
tolerant', referring to modem equipment, reflect this intent.

It cannot be denied that technological progress has occurred, nor that such progress
has enhanced flight safety, but operational experience indicates that human error is still
induced to a significant extent by shortcomings in equipment design or in the procedures
used to operate the equipment. Only by taking into account appropriate Human Factors
considerations in system design can safety be further enhanced. It would be misleading,
however, to propose that safety in the system can be achieved through design
improvement alone.

This chapter addresses Human Factors issues relative to the interface between
humans and machines in aviation. This interface has traditionally been viewed as
presenting simple "knobs and dials" solutions to Human Factors problems. In some
cases, these solutions could be found by looking at the appropriate table, but an
understanding of how to solve Human Factors problems with respect to the human-
machine interface within the aviation system is more than learning how to look at tables,
especially since such simple solutions may not be valid for all situations.

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Definition

The term "ergonomics" derives from the Greek words 'ergon" (work) and "nomos"
(natural law). It is defined as "the study of the efficiency of persons in their working
environment". In some States, the term ergonomics is used strictly to refer to the study of
human-machine system design issues.

Basic Facts about Ergonomics

While in many countries the terms ergonomics and Human Factors are used
interchangeably, there is a small difference in emphasis. Human Factors has acquired a
wider meaning, including aspects of human performance and system interfaces which
are not generally considered in the mainstream of ergonomics. Chapter 1 proposes that
the two terms be considered synonymous, to preclude dwelling on academic or semantic
considerations and to avoid confusion: however, it indicates that the term ergonomics is
used in many States to refer strictly to the study of human-machine system design issues.
From this perspective, ergonomics is the study of the principles of interaction between
human and equipment, for the purpose of applying them in design and operations.
Ergonomics studies human attributes, determining what requirements in hardware and
software result from the characteristics of the activities involved. It attempts to solve the
problem of adapting technology and working conditions to humans. Throughout this
chapter, this latter concept of ergonomics has been adopted, and as such, it is clearly
differentiated from Human Factors.

A systems approach to safety

Safety in aviation through design can best be achieved following a system approach
strategy. A system approach-is a way of breaking down the "real world" into identifiable
component, and looking at how these components interact and integrate. The Liveware-
Hardware interface in the SHEL model, introduced in Chapter 1, can be seen as a human-
machine system, comprising people and machines interacting in an environment in order
to achieve a set of system goals. Ergonomics will try to optimize the interaction between
people and machines in the system (the LH interface), while taking into consideration the
characteristics of all system components (e.g. the environment as well as the software).

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 Person – machine interface
Perceived Displays
information

Information Internal
Processing and equipment
decision making status

Motor response
for control Controls
activation

Figure 35. Representation of a person-system machine (adapted from Meister,1979)

The machine component is displayed on the right. Displays (e.g. visual and auditory)
inform the human about the status of the internal system or about conditions external to
the system, while controls allow the human to effect changes in the system status.
Information displayed must be perceived and processed by the human, and then
conscious decisions may be made. Motor responses may be sent to effect changes in
control settings. The line depicted, separating the machine and human represents the
human-machine interface. Information travels through this interface in both directions;
ergonomics is very much concerned with getting the information across this interface, and
the ergonomist must ensure that displays and controls are compatible with human
capabilities and task needs.

System goals must be defined before a person-machine system can be specified

and designed. These goals, together with the identified operational constraints, spell out
the conditions within which the person-machine system will function. Operation of the
system outside this set of conditions may lead to unsafe conditions.

Another important task of the ergonomist is the allocation of functions and tasks to
the human and machine components. The system design team (including the ergonomist)
decides what functions should be given to the hardware and software and to the human,
based on considerations such as human characteristics, task needs, workload, costs,

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training requirements, and technologies available. Functions allocated inappropriately
may jeopardize system effectiveness and safety. The tendency to compare human and
machine, in terms of the functions for which humans are superior to machines vis-a-vis
those for which machines are superior to humans, should not be allowed to lead to a
simplistic allocation of functions entirely to the human or the machine. Humans and
machines should be complementary in the accomplishment of tasks. Furthermore, this
complementarity should be designed with adequate flexibility so that function allocation
can be adapted to various operational situations (from routine flight to emergencies).

The ergonomist must proceed systematically in order to achieve the desired system
goals. The following set of example questions illustrates how an ergonomist may proceed
when designing systems:

 What inputs and outputs must be provided to satisfy systems goals?

 What operations are required to produce system outputs?
 What functions should the person perform in the system?
 What are the training and skills requirements for he human operators?
 Are the tasks demanded by the system compatible with human capabilities?
 What equipment interfaces does the human need to perform the job?

To minimize human error, one must first understand its nature. There are basic
concepts associated with the nature of human error the origins and frequencies of errors
can be fundamentally different, and the consequences of errors can also be significantly
different. While some errors may be due to carelessness, negligence or poor judgment,
many are induced by poorly designed equipment or may result from the normal reaction
of a person to a stressful situation. Errors due to poor equipment design or stressful
situations are likely to be repeated and can be remedied through the practice of
ergonomics.

Each of the interfaces in the SHEL model has a potential for error where there is a
mismatch between its components. For example:

 The Liveware-Hardware interface is a frequent source of error: knobs and levers which
are poorly located or improperly coded create mismatches at this interface.

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 In the Liveware-Software interface, delays and errors may occur while seeking vital
information from confusing, misleading or excessively cluttered documentation and
chart. Problems can also be related to information presentation and computer software
design.
 Errors associated with the liveware-Environment interface are caused by
environmental factors such as noise, heat, lighting, air quality and vibration and by the
disturbance of biological rhythms.
 In the Liveware-liveware interface, the focus is on the interaction between people
because this process may affect crew and system effectiveness. This interaction also
includes leadership and command, shortcomings in which may reduce operational
efficiency and cause misunderstanding and error.

Considerations which prevent errors such as these are in the mainstream of ergonomics.

The control of human error requires two different approaches. First, it is desirable to
minimize the occurrence of errors (total elimination of human error is not a realistic goal,
since errors are a normal part of human behaviour). For example, errors may be reduced
by ensuring a high level of staff competence; by designing controls and displays so that
they match human characteristics; by providing proper checklists, procedures, manuals,
maps and chart; by controlling noise, vibration, temperature extremes and other stressful
conditions; and by providing mining and awareness programmes aimed at increasing co-
operation and communication among crew members. The second approach in the control
of human error involves minimizing the impact or consequences of errors by providing
safety buffers such as cross monitoring, crew co-operation and fail-safe equipment
design.

4.2 HUMAN DIMENSIONS

One of the primary objectives of ergonomics is to match working (and living) areas
and stations with human characteristics. Some of the basic characteristics of humans are
those associated with the size and shape of the various pans of the body and with their

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movements. Figure below illustrates the importance of considering human dimensions in
equipment design.

The controls of some lathes in current use are so placed that the ideal operator
should be four-and-a-half feet tall, be two feet across the shoulders, and have a four-foot
arm span -it is probably easier to change the machine than the people who must operate
it. Anthropometry is concerned with human dimensions such as weight, Statute, limb size
and other specific measures such as seated eye height and reach when seated with and
without restraining devices (such as a shoulder harness).

With this information it is possible to estimate the optimum height for work surface
and location of controls, the height and depth of stowage areas, minimum knee room
between seat rows, width of seats, length of armrests, height of headrest, life-raft and
scat cushion design, and reach requirements.

Biomechanics specializes in the application of the science of mechanics in the study

of living organisms (the human being in this case). The discipline studies areas such as
the movements of body pans and the forces they can apply. For example, it is necessary
not only to know that a certain force will move a control, but also where the control is
located relative to the body and the direction of control movement.

Figure 36. Human Dimension

Data collection is an important step. Data must be collected from a representative

and sufficiently large sample of the people who will use the equipment. When using these
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data, one must take into account the date of data collection, since human physical
dimensions may change from generation to generation. For example, it is known that
people in some developed countries have generally become taller during the past 50
years. An ergonomist must determine when and how such changes will become a factor
in design considerations.

The ergonomist should take into account the concept of designing for human
differences. Not only are there differences in physical dimensions among ethnic groups,
but there are also differences between men and women within one ethnic group (for
instance, control force requirement which can be met by males may be too high for
females). Many aviation hardware pieces have for some time been manufactured
according to Caucasian male dimensions, even though in many cases they are equally
used by Asians, Africans, and others. The ergonomist will identify the target user group
and design equipment accordingly. If a single design solution to accommodate all user
differences is not possible, a range of adjustments is provided, so that most users are
accommodated - rudder pedal and seat adjustment on the Right deck are among the
examples.

4.3 DISPLAYS AND CONTROLS

Displays and controls are at the heart of ergonomics. If we refer to the SHEL model,
they are mostly pan of the Liveware-Hardware and Liveware-Software interfaces. In the
case of displays, the transfer of information goes from the Equipment to the Liveware.
Controls are used to transfer information and commands in the other direction, from the
Liveware to the Equipment.

There is usually an information loop involved in this process, and ergonomists have
the mission of optimizing the flow within this loop. The following paragraphs present some
of the considerations in the design of displays and controls and their integration into the
workplace of the flight deck.

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Displays

The function of a display is to convey information (about the status of the flight for
example) accurately and rapidly from its source to the operator. Human capabilities and
limitations in information processing discussed before should be considered in the design
of displays. Timely, appropriate, accurate, and adequate amount of information must be
presented to the operator according to task requirements. It would be detrimental to task
performance to present more information than required, especially when the operator is
overloaded, fatigued or under stress.

Figure 37. Example of Display

Visual displays may be dynamic (e.g. altimeters and attitude indicators) or static
(e.g. placards, signs, and charts). They present quantitative (e.g. altitude and heading) or
qualitative (e.g. landing gear status) information. They may warn (e.g. ENGINE FIRE) or
caution (e.g. oil pressure indicator or light).

Displays may also be tactile/kinaesthetic (tactile means related to the sense of

touch, kinaesthetic related to the sense of motion) or auditory. Especially when the visual
system is (or is expected to be) heavily loaded, these displays may be used to
communicate information to the human operator. Tactile/kinaesthetic information transfer
may also be applied under degraded visual condition. (A stall warning using the stick-
shaker method is a good example). The auditory canal is particularly suited for alerts such
as warnings. For this reason, there is a tendency to apply such aural displays heavily.
Sometimes indiscriminately, on the flight deck. Indiscriminate use of aural alerts on the
flight deck has been known to cause annoyance and confusion or to affect task
performance negatively. In such cases, one cannot overemphasize the importance of
taking proper Human Factors considerations into account in the design of these displays.

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 There are basic issues which must be resolved before a display can be properly
designed and located. Both design and location of displays can greatly influence the
effectiveness of the dialogue between human and machine.

 How, by whom, and in what circumstances will the display be used?

 Auditory displays are generally omnidirectional, while visual displays are not. Will
more than one person be required to see the display?
 How will ambient illumination influence the effectiveness of the visual display?
 Should the information be presented in the analogue or digital format? Digital
displays provide greater accuracy for recording or systems monitoring (e.g. for
engine instruments), while analogue instruments are preferable when the numeric
values are changing frequently or rapidly (e.g. with altimeter and rate of climb
indicators).
 What is the angle at which the display will be viewed?
 Will there be parallax problems?
 What will be the viewing distance?
 Will character and symbol sizes need to be increased to afford readability at a
distance?
 Displays which are in a standby or inactive mode should clearly enunciate that fact.
Ambiguity will likely increase mental workload and induce errors.
 Information which is suspect should not continue to be displayed to the operator.
 Consider display factors such as brightness, colour, contrast and flicker.

The display of letters and numbers (known as alphanumeric) has been the subject
of much research. Mechanical, electro-mechanical and electronic displays present
various ergonomic problems which deserve attention. Information presented must be
legible, so that characters can be easily differentiated or identifiable. In addition, the
information must be readable, which means that total words or groups of letters and
numerals are comprehensible. Readability is generally a function of factors such as
character style, type form (e.g. uppercase or italics), size, contrast and spacing.

Dial markings and shapes are two additional aspects considered by the ergonomist.
Scale progressions should have fixed and regular graduation markings, and should be
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presented in single units. Care should be taken in the design of pointers when the
instrument also contains a digital read-out which can be obscured by the pointer.

The tip of the pointer should touch the end of the graduation scale but should not
overlap it. The distance between the pointer and the surface of the scale may result in
parallax which should be eliminated or minimized. There will be no such problem if the
scale is displayed on an electronic display. In general, the size of the displayed
information (e.g. scales and icons) must be positively related to the viewing distance (i.e.
the longer the viewing distance, the larger the scale or icon size). This design
consideration must allow for environmental correction factors like lighting, vibration and
non-optimum viewing angles.

Figure 38. Example displays used in presenting quantitative information (adapted from
McCormich et al., 1983)

The introduction of electronic (e.g. cathode-ray tube) displays provided the

opportunity to overcome many of the earlier constraints of electro-mechanical displays,
permitted integration of displays, and afforded greater flexibility and a more effective use
of panel space. Electronic displays generally have three applications on the flight deck:
for flight instruments, systems information (e.g. engine data as well as data on other
systems, including warning systems), and flight management systems (FMS).

Electronic displays present a variety of ergonomics concerns, including: brightness

and brightness contrast; the use of colours for different pieces of information: the fatiguing

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effect of extended periods of screen monitoring; the symbology utilized; what information
should appear, and where, on the screen: and the fact - for reasons not yet very clear -
that reading text from a screen is slower than from printed paper. On the other hand,
electronic displays are generally cost-effective and versatile, and offer the user a
reasonable amount of control over certain important display properties such as brightness
and brightness contrast.

Many operators have introduced heads-up displays (HUDs) as an additional tool to

allow for operations in lower weather minima. The symbology utilized by these devices
must be common to the symbology utilized in screens.

Control

Controls are means for the human operator to transmit messages or command
inputs to the machine. The message should be transmitted within a specified accuracy
and time period. Different types of controls perform different functions: they may be used
to transmit discrete information (e.g. selecting a transponder code) or continuous
information (e.g. cabin temperature selector).

They may send a control signal to a system (e.g. the flap lever) or control a display
directly (e.g. an altimeter setting knob). As is the case with displays, the characteristics
of the user population must be taken into account by the designer.

Figure 39. Example of Control System

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 The functional requirements, as well as the manipulation force required, will
determine the type and design of control to be adopted. An example checklist on how to
select controls based on their functions is provided below.

Function/force Type of control

Discrete functions and/or low Push buttons, toggle switches, and rotary
switched
Continuous function and/or Rotary knobs, thumb wheels, small levers
forces low or cranks
High control forces Handwheels and large levers, large cranks
and foot pedals
Table 4. An example checklist on how to select controls based on their functions

Another basic requirement for controls, from the ergonomics point of view, is their
location within the work area. However, it must be remembered that the optimal location
for a display may not be optimal for reach.

Other design considerations include: control display ratio, which is the ratio between
the amount of change in a display in response to a control input and the amount of change
in the control effected by the operator; and the direction of movement of display element
(e.g. a pointer) relative to the direction of control movement. A rotary knob located on the
right side of a longitudinal display should go clockwise to move the arrow indicator up.
Control resistance affects the speed and precision of control operation, control "feel",
smoothness of control movement and susceptibility of control to inadvertent operation.
Control coding (i.e. shape. size. colour, labelling and location) aims to improve
identification, and reduce error and time taken in selection.

The last of the example principles in control design involves protection against
inadvertent actuation. This can be achieved by methods such as gating, locking and
interlocking (e.g. by interconnecting controls to guarantee that reverse thrust levers
cannot be operated until thrust levers are in idle). In some cases, an action which is
incompatible with existing conditions may trigger a visual or aural warning (e.g. closing
the thrust levers when the landing gear is retracted will turn on an aural warning).

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4.4 ALERTING AND WARNING SYSTEMS

Warnings signify a condition requiring an immediate crew action for maintaining the
safety of the system, and their colour coding is normally RED. Cautions imply a condition
which may become an emergency if allowed to progress or deteriorate. These usually
require the appropriate, but not immediate, attention, and their coding is AMBER.
Advisories are generally for information only, and may or may not require crew action.
Their coding may be BLUE. WHITE, or GREEN. Three basic principles apply to the design
of flight deck warning systems:

 they should alert the crew and draw their attention;

 they should report the nature of the condition: and
 preferably they should provide guidance regarding the appropriate action required.

Figure 40. Alerting and Warning System

Several considerations can be given to the last item. A good indication is provided
by the number of aircraft which were involved in an accident because the crew shut down
the wrong engine after an engine failure. Considerations in the design of the ACW
systems include, first, system reliability, since confidence in a system will be lost if it is
plagued by spurious warnings.

Secondly, excessive appearance of an ACW signal will reduce response to it and

become a nuisance. Lastly, auditory multi-warnings (i.e. the same sound being used to
ales to more than one condition) require special considerations. They are effective in

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attracting attention, but may breed error or delay in corrective response. Voice messages
may be added to enhance identification and interpretation.

Advisories, cautions, and warnings on the flight deck can be grouped into four broad
categories:

 those which inform about performance, or departures from operational envelopes

or safe flight profiles (e.g. for stall, overspeed and ground proximity): they are
usually of high urgency;
 those which inform about aircraft configuration (e.g. landing gear and flap
positions);
 those which inform about the status of aircraft systems; these include limiting
bands and flags on instruments; and
 those related to communications (e.g. SELCAL and interphone).

The following important principle must be reiterated: in the case of a failure, the user
of a display should not be presented with unreliable information. The failure should be
annunciated on the display itself, rather than on an indicator. It is very likely that, as long
as the unreliable information is shown, sooner or later it will be used.

4.5 PERSONAL COMFORT

Temperature

Temperature extremes are one of the most common environmental stressors. Since
humans are comfortable only over a narrow band of temperatures, it is necessary to know
how well they function at different temperature levels before remedial measures can be
derived. Questions about air-conditioning requirements and human performance under
heat or cold stress should be answered and taken into account during system design.
Cabin environmental control systems are the principal means for controlling the internal
aircraft environment.

Humans generate heat while performing mechanical work, and to a lesser extent,
when resting. The excess heat is transferred to the environment, primarily by perspiration

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and sweating, in order to maintain a relatively constant body temperature of 37 degrees
Celsius (C). The success of body temperature regulation depends on various factors:
ambient temperature, humidity, and air velocity. If body temperature increases by more
than 2 degrees C, physiological efficiency will be impaired

The physiological effects of ambient temperature extremes are well known, but the
effects of heat stress on human performance are more complex. It is generally accepted
that excessive heat will cause performance decrement, but there is little agreement
regarding how much decrement will take place, or how long it will take to occur. People
can withstand exposure to excessive temperatures for only a short period of time before
measurable degradation sets in. Acclimatization prolongs this period. In non-acclimatized
persons, degradation appears when the ambient temperature exceeds 30 degrees C, the
relative humidity is high, and exposure exceeds three hours. Obviously, clothing and
physical activity level play important roles, too.

Performance

Good
Performance

Poor Poor
Performance Performance

Temperature/
Climate

Cold/wet Warm/dry Hot/humid

Figure 41. The relationship between climate, termperature and performance

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 When exposed to cold, the body attempts to maintain its core temperature by
shivering and restricting blood flow to the body surface. Body temperatures below 35
degrees C are dangerous. Consciousness becomes clouded at 34 degrees C,
unconsciousness follows around 30 degrees C, cardiac irregularities are usual between
30 and 28 degrees C, and death is imminent. Although humidity is not a factor, air velocity
is important; as a result, wind chill indices are increasingly being provided in weather
reports. (Wind chill is not a psychological effect - it effectively lowers body temperature.)
Cold increases both reaction and movement time, and manual dexterity begins to
deteriorate when hand-skin temperature falls below 18 degrees C.

Illumination

The nature and quantity of cockpit illumination required for a certain task may vary
considerably. Factors of importance are the speed and accuracy with which the displays
must be read, the ambient illumination, other light sources (in particular, sunshine), and
the presence of glare. Glare is defined as a condition of vision where there is discomfort
or a reduction in the ability to see significant objects, or bob, due to an unsuitable
distribution or range of luminance (i.e. density of light, or light intensity per unit projected
area) or to extreme contrasts in space or time.

Glare is an important aspect of the quality of the illuminated environment. It can be

caused by bright light sources or light reflection off environmental surfaces. Glare may
produce discomfort or annoyance, and may interfere with visual performance. The type
of reflection off surfaces depends on the properties of the surface (e.g. whether it is
polished. rough or matted). Some evidence suggests that there is an element of
subjectivity in tolerance to glare. The most effective techniques for reducing glare include
blocking the glare surface or placing supplementary lighting to offset the effects of glare.

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Humidity

Humidity may become an issue with high-altitude jet transport aircraft because of
the low relative humidity at their operational altitudes. The discomfort arising from low
relative humidity may not imply physical indisposition. Over-all dehydration can be
prevented with adequate fluid intake. Diuretics like coffee or tea should be avoided. The
installation of humidifiers on aircraft could raise cabin cockpit humidity, but there are
potential problems such as weight penalty, condensation and mineral contaminations that
the designer must consider.

Pressure

Cabin pressurization eliminates many problems associated with high altitude flying,
but it introduces other potential problems, the most important being the risk of a rapid
decompression. The time of useful consciousness (TUC) following a rapid decompression
depends on aircraft altitude, the rate at which pressure falls, and the level of physical
activity of the individual at the time of the event. At typical jet transport aircraft altitudes
(35 000 feet) TUC will vary between 33 and 54 seconds. Those average values can be
expected to drop by a half at 40 000 feet. This emphasizes the importance of immediate
availability of supplemental oxygen to crew members.

The technical reliability of automatic delivery systems, as well as the design of

certain types of flight crew quick-donning masks have sometimes been sub-optimal. It
should be borne in mind that oxygen systems will be used in conditions accompanied by
anxiety and other stressors, and simplicity of use and reliability are of utmost importance.

Vibration

Vibration is any form of oscillating motion that changes its magnitude of

displacement periodically with reference to a point, and it is a widespread physical
phenomenon. The movement of pistons within the cylinders of engines or the
disturbances generated in aircraft flying through turbulent air are forms of vibration which
can be transmitted to humans. Vibration is generally transmitted through direct contact
between the body and the vibrating structure, and it can have potentially harmful effects.

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 Vibration is of operational significance in aviation because it may impair visual
acuity, interfere with neuromuscular control and lead to fatigue. Although better than
before, high levels of vibration can still be encountered in helicopters as well as in fixed-
wing aircraft during low-level flight.

Protection against vibration can be provided by attention to its source, by

modification of the transmission pathway or by the alteration of the dynamic properties of
the aircraft body. Reduction of vibration emanating from aircraft engines is a primary task
for design and maintenance engineers. The installation of devices called dynamic
vibration absorbers ha reduced vibration levels on helicopters. Another ergonomic
approach is by means of vibration isolation of the flight crew seats.

Noise

Noise is defined as any unwanted sound. There are two important aspects of noise
which must be considered: the sources of noise, and the physiological and psychological
effects on the person exposed to it. Noise affects a person in many ways depending on
whether it is expected, whether it makes a task more difficult, and whether the person is
relaxed or alert.

Major sources of noise in fixed-wing aircraft include the engines, the air conditioning,
pressurization and hydraulic systems, and boundary layer turbulence. Inside the aircraft
noise is louder near the sides of the fuselage than at the centre. Noise level in the cockpit
is easily changed by the interaction of the airflow with the fuselage surface.
Soundproofing will reduce noise, but it will increase aircraft weight as well. This has many
undesirable effects such as increases in fuel cost. Design improvement lo reduce noise
at its so- would be a better alternative. For example, removing the windshield wipers in
one particular large jet transport reduced the flight deck noise level by 2 dB.

The most important pathogenic effect of noise, impaired hearing, has already been
discussed in Chapter 2. Other physiological effects include changes in blood pressure
and heart rate, headaches, tiredness and gastrointestinal problems such as ulcers. In the
past, prolonged monitoring of high-frequency (HF) radio represented a significant
exposure to noise. This has been alleviated by the introduction of selective calling

4 - 18
(SELCAL). Technological progress in communications - as well as in other areas - will
certainly provide new improvements in hearing protection. The fact remains, however,
that crew members who are exposed to intense aircraft noise over a long period of time
can be expected to suffer hearing loss in addition to the natural loss through ageing.

Noise affects performance by interfering with the detection and understanding of

task-related signals or speech. It interferes with verbal communication by affecting the
signal-to-noise ratio and by decreasing speech intelligibility. It further affects verbal
communication by impairing hearing.

Because it is annoying for most people, noise can have an impact on psychological
conditions. On the flight deck, this annoyance is compounded by the problems noise
genera- in communication. This may result in frustration and anxiety over the need to
repeat messages or to understand them. This in turn may increase workload and fatigue.
While it is the ergonomist's task to try to minimize noise through design and by providing
hearing protection, crew members should be aware of the insidious effects of noise and
the damage it can provoke, and of methods to reduce noise levels or to protect oneself
from its detrimental effects.

Position

General principles in seat design are equally applicable to flight deck and passenger
seats. Some of those principles include distributing the body weight throughout the
buttock region around the sitting bones and providing a proper seat height to avoid
excessive pressure on the back of the thighs.

The spinal column should be kept in balance and maintain its relatively natural
curvature by proper lumbosacral support and seat design. Armrests should provide the
proper am support while allowing free mobility of shoulders, arms and torso. In addition,
consideration must be given to factors such as durability and weight of the material,
flammability, structural integrity, reliability, space available, certification requirements and
cost. Proper attention must also be directed to seat controls, restraint systems and
footrests.

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 Pilots are required to remain strapped to their seats for many hours, and the effects
of seat characteristics go beyond the medical problems (e.g. back ailments) which may
appear. Back pain or discomfort is distressing and can affect motivation, behaviour and
performance.

4.6 COCKPIT VISIBILITY AND EYE-REFERENCE POSITION

The ergonomics approach starts with an appraisal of task requirements and user
characteristics which will affect design decisions such as those specifying the layout and
makeup of the flight deck. In addition, the designer must take into account constraints
which can limit design options. Such constraints include the aerodynamic characteristics
of the aircraft, which are related to the cross-section of the fuselage and the shape of the
nose. For example, the Concorde flight deck width of 148 cm, which is dictated by
aerodynamic requirements, represents a relatively cramped environment when compared
with a Boeing 747 which has a deck width of 191 cm.

Downward visibility during approach is a requirement which influences the design of

the windshield and the location of the design eye position (see Figure below). The design
eye position is an important reference point which helps to determine placement of
equipment such as displays.

The distance between pilot’s seats is a factor when cross-monitoring is required or

when the same displays or controls are used by both pilots. Difficulties in access to pilot’s
seats may result in the decision to move the seats slightly outwards; however, proper
consideration must be given to chis misalignment of pilot and control so that it does not
lead to hazardous conditions during operations.

Viewing distances for displays is another important aspect dictated by flight deck
geometry. For large aircraft, typical viewing distances from the pilot's eyes are 71-78 cm
for the main panel, 20 cm for the overhead panel, and 2 m for the lateral systems panel.
Size of display details (e.g. alphanumeric) are determined by display location and
distance from the eyes of the prospective user. Viewing distance issues are particularly

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applicable to persons wearing glasses. Viewing distances are also particularly relevant to
"glass cockpits".

Figure 42. Reference eye position (adapted from Human Factors in Flight, F.H.
Hawkins, 1987)

Figure 43. Typical viewing distances from the pilot’s eye design eye position to various
panels on the flight deck of a large jet (adapted from Human Factors in Flight, F.H.
Hawkins, 1987)

4.5 MOTOR WORKLOAD

Motor workload characterized the flight which was largerly performed using
automatic flight systems. Scan pattern activities mainly contributed to the visual workload.
Motor workload was expecienced by the modeled pilot, not due to manual flight control

4 - 21
tasks, but rather to the autopilot commands such as pull-down gears and extension of
flaps, which were specified in the approach, landing, and go-around procedure.

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 CHAPTER 5

HUMAN – SOFTWARE RELATIONSHIP

5.1 STANDARD OPERATING PROCEDURES

Standard Operating Procedures (SOPs) in an ATC Unit are a specific set of

procedures that specify how the unit’s controllers ATC responsibilities are to be
coordinated. (EUROCONTROL EATM Glossary of Terms)

Within ATM, many types of procedure are rigidly applied, especially in regard to
communication. However, with other types of procedure modification may be permitted
to suit individual situations and personalities. Nevertheless, it should be remembered that
standard procedures are based on long years of experience; if there is intent to modify
an existing procedure, careful consideration must be given to ensure that unforeseen
consequences do not result.

In Flight Operations, strict procedures are defined covering every aspect of flight
deck activity and embracing normal, abnormal and emergency situations. This wide range
of procedures and checklists is essential because of the large number of situations which
can arise and the critical nature of some of these situations. Although these procedures
are written down in checklists and quick reference handbooks, pilots must be able to
perform certain vital actions from memory, referring to the written procedure later to
confirm that correct action has been taken.

Flight Operations procedures have been defined after much research in order to
ensure the most successful outcome from all reasonably likely circumstances. They are
not discretionary and must be followed precisely. Failure to follow established procedures
has been found to be a causal factor in many aircraft accidents and serious incidents.

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Effects

Deviations from SOPs occur for a variety of reasons; intentional deviations and
inadvertent deviations from SOPs have been identified as causal factors in many aircraft
accidents and incidents.

Crew Resource Management (CRM) and Team Resource Management (TRM) are
not effective without adherence to SOPs, because SOPs provide a standard reference
for the ATC team and for the crew’s tasks on the flight deck. SOPs are effective only if
they are clear and concise.

SOPs are the result of a careful process, often conducted over a period of many
years, which considers all likely outcomes; deviation from a standard procedure may lead
to an unexpected and unsafe outcome.

5.2 WRITTEN MATERIALS

There is an even more subtle activity that management can undertake to contribute
to safety. The development of, implementation of and adherence to standardized
operating procedures (SOPs) have recently been recognized as a major contribution by
management to safety. Failure to conform to sound SOPs has indeed been linked to
numerous accidents and incidents.

There are Human Factors considerations related to SOPs which concern both the
underlying philosophy and the design of such procedures. Procedures are specifications
for conducting predetermined actions: they specify a progression of actions to assist
operational personnel in achieving their tasks in a manner which is logical, efficient and,
most importantly, error-resistant. Procedures are not produced in a vacuum nor are they
inherent in the equipment; they are based on a broad concept of operation. There is a

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link between procedures and philosophy, which Wiener and Degani have called The four
Ps of operations": Philosophy, Policies, Procedures and Practices.

Management

Phylosophy

Policies

Procedures
Standardization
Training and
Quality Control Individualism
Demands/Tasks

Experience
Crew Beliefs
Values
Attitudes
Environment

Policies Techniques

System Outcome

Figure 44. The Four Ps

These researches contend that by establishing a philosophy of operations,

management states how it wants the organization to function. Such philosophy can only

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be established by the highest corporate level. From philosophy, policies can be
developed. Policies are broad specifications of the manner in which management expects
tasks to be accomplished –training, flying, maintenance, exercise of authority, personal
conduct, etc. Policies are usually dictated by line management.

The procedures, normally developed by supervisors, determine how tasks will be

accomplished. The procedures must be designed to be consistent with the policies, which
must be consistent with the over-all guiding philosophy. Lastly, management must effect
the quality control to make sure that practices in the operational environment do not
deviate from written procedures. Any attempt to shortcut this process may well produce
inconsistent procedures, which will breed doubts among the operational personnel about
the preferred behaviour management expects from them to accomplish their task.

Philosophies, policies and procedures must be developed with due consideration

for the operational environment in which they will be used. Incompatibility of the
procedures with the operational environment can lead to the informal adoption of unsafe
operating practices. External activities, type of operation and the layout of the cockpit or
workstation are factors to be considered when evaluating the operational environment in
which SOPs will be used. Feedback from operational situations, through the observed
practices of or reports from operational personnel, is essential to guarantee that the
bridge between the Ps and the operational environment remains intact.

The example of the Ground Proximity Warning System (GPWS) Policy, as instituted
by one operator, illustrated this point:

 Philosophy: it is a corporate goal to be a safe and secure airline, as stated in the

corporate mission and goals.
 Policy: in the event of a full, or partial, “Pull-up” or other hard warning, the following
action must be taken promptly:
a) Below MSA (Minimum Safe Altitude)
Announce "PULLUP Go-Amund" Immediately complete the pull-up manoeuvre
in all circumstances.
b) b) At and Above MSA

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 Immediately assess aircraft position, altitude and vertical speed. If proximity to
MSA is in doubt, take action as in a above.
 Procedure: GPWS pull-up maneuver is described in fleet-specific manuals.
Describe the call-outs by the handling pilot and the non-handling pilot - procedures
at and below MSA and procedures above MSA: define MSA during climb and
descent in case of ambiguities and include additional operational information
deemed appropriate for the crews to observe the GPWS Policy.
 Practices: do flight crews observe the policy and follow the procedure in
operational conditions?

In the GPWS example discussed above, the operator's original policy mandated an
immediate pull-up upon receipt of any GPWS warning, regardless of altitude and position
of the aircraft Operational feedback obtained through the operator's internal safety
information system, however, indicated that during the first calendar year after this policy
was implemented, GPWS alerts had not been followed by a pull-up in 60% of occasions.
This was due to a variety of reasons, including false and nuisance warnings of particular
concern was the fact that pull-ups had not been initiated on 20% of occasions when the
warning had been genuine. An obvious discrepancy between the three first Ps and the
last one - Practices - was evident.

The safety services of the operator determined that the reason for this discrepancy
between philosophy, policy, procedures and practice centred around the unreliability of
the technology which resulted in false and nuisance warnings. In some cases, warnings
had been triggered at 37 000 ft flying in cruise, immediately after takeoff, when there were
no obstacles in the flight path or in holding patterns with other aircraft 1000ft below the
host GPWS policy, with immediate intent of ensuring compliance with the policy on all
occasions.

Internal feedback and trend-monitoring systems. The previous paragraph illustrates

the importance of the feedback from the "front end", that is, from day-to- day operations.
So that management can effect the control of the operations that policies and procedures
support.

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5.3 OPERATIONAL ASPECTS OF AUTOMATION

The dictionary clearly defines automation as "the use of computers to control a

particular process in order to increase reliability and efficiency, often through the
replacement of employees. Both definitions basically focus on two aspects - the
introduction of "computers" and the implications on "humans" in the performance of a
task.

With the advent of modern technology, the use of computers becomes inevitable in
the completion and performance of a particular task. While automation proves to improve
the completion of a job, it drastically affects the "operator" whose task shifts from being
the "performer" to being the "onlooker". This is where the issue of "complacency" sets in.
With this major revolution, one may ask if the introduction of automation is indeed an
advantage or disadvantage.

Since the evolution of this major global trend, automation has widely enveloped the
aviation field. Industry-wide, it has become a by-name and is considered an indispensable
or integral addition to this highly complex, dynamic, and competitive business with the
objective of improving and controlling flight management efficiency. Nowadays, we can
see a widespread use and increasing level of automation in aviation particularly in flight
and air traffic control operations. However, it has also given rise to issues and concerns
pertaining to human intervention, accidents and incidents; and issues on human factors,
specifically complacency.

Design Philosophies

Two distinct approaches to the design of automation began to emerge; these are
referred to as the technology-centred and human-centred approaches.

Technology-centred automation seeks to overcome the limitations of human

performance by replacing human functioning with machine functioning. The overriding
design philosophy is to use automation wherever possible to reduce workload and
eliminate errors. Designers seek to exploit the accuracy and effciency of automation to
achieve economies such as fuel effciency, passenger comfort and reduced training costs.

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 By contrast, human-centred automation seeks to enhance the capabilities of, and
compensate for, the limitations of human performance. The philosophy is not to replace
human functioning, but rather to enhance human effectiveness by optimising workload
and supporting the pilot in managing complex systems and making effective and timely
decisions.

Staying in the loop

There are concerns that technology-centred automation has taken human ‘out of
the loop’, to the extent that they may not be able to adequately perform their monitoring
and supervisory roles. Many of the human performance issues that have been identifed
for many decades, such as error introduction and error recognition, remain unresolved.
Designers have now realised that the goal of eliminating human error from the cockpit is
unrealistic and unachievable.

Figure 45. Examples of pilot-related insights from automation data

The maxim ‘as long as we are human we will continue to make mistakes’ has held
true through the history of flight. That is, while the environment in which pilots operate

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has changed considerably in recent decades, the human condition has not, and we will
continue to make mistakes, no matter how well intended our efforts.

Systems design over the past 10-15 years has been more human-centred than in
the past, with an emphasis on training pilots to recognise and manage errors, rather than
making futile attempts to eliminate them.

Automation-induced complacency

As autopilots and automated systems become more reliable, we tend to place

greater trust in them and become less vigilant when monitoring their functionality and
performance. This has led to what researchers refer to as automation-induced
complacency, and it has been identified as a factor in many aircraft accidents, particularly
in those involving aircraft with sophisticated glass cockpits.

It is important to note that complacency is different from boredom, low workload or

simply lack of attention. Complacency relates to trust, confidence and reliance on
automation to ‘do the right thing’, whereas automation-induced complacency often leads
to delays in detecting changes in autopilot performance and system failures. We are
hesitant to intervene at the first signs of trouble as we have a high level of trust in the
system to correct itself, and often leave it until it is too late to intervene.

Workload reduction and crew complement

A central theme and motivation for increasing cockpit automation has been to
reduce pilot workload. Wiener suggests the three key objectives of cockpit automation
are to:

 reduce pilots’ physical and cognitive workload so that they have more time and mental
capacity to manage the fight more effectively, and to perform optimally in emergency
situations

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 allow pilots to spend less time ‘head down’ in the cockpit, and more time maintaining
an effective lookout for traffic and other threats, such as hazardous weather and
terrain, particularly in the terminal area
 lessen the workload to allow a reduction in minimum crew complement.

Training

Operators must develop expected standards and guidance material for maintaining
knowledge of automation and manual flying skills, including cognitive and manipulative
skills

 pilots must be provided with opportunities to refine the knowledge and practice the
skills required to recover from automation malfunctions
 training and checking should address this topic directly during initial and recurrent
training. Opportunities should include cognitive and manipulative skills practice and
opportunities to train to proficiency.
 operators’ training and checking standards for flight path management must support,
and be consistent with, automation policy and in accordance with SOPs for each type.

5-9
 CHAPTER 6

INTERPERSONAL RELATION

6.1 COMMUNICATION

Communication is a major part of good teamwork and is critical to both safety and
operational efficiency. Communication relates to many different activities and takes so
many different forms, that in itself it is not an easy concept to define. However, most
researchers and human factors practitioners agree that communication is characterized
by two issues

■ The transfer of information from one party to another

■ The transfer of meaning.

The distinction between ‘information’ and ‘meaning’ is significant. The transfer of

information alone does not ensure effective communication. For communication to be
effective and useful, there should be shared meaning: parties should share the same
significance and purpose. Accordingly, communication is the process of sharing
information within a shared interpretative framework which allows that information to be
meaningful and useful.

Relevance to safety

Effective communication has a critical role in ensuring safe and efficient aviation
operations. When pilots, air traffic controllers, dispatchers and other frontline staff talk to
each other using the right protocols, the risk of accidents and incidents reduces
significantly. However, there are many examples where confusion between the sender
and receiver of information has resulted in tragic aircraft accidents, as illustrated by the
case study below.

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 On 26 September 1996, GIA 152 flew into a mountain just prior to landing at Medan,
Indonesia. An error from ATC resulted in the aircraft being routed directly into
mountainous terrain, which due to forest fires at the time, was obscured by some and
haze. None of the 234 passengers and crew survived the impact.

This extract of conversation illustrated the confusion between the ATC tower and
flight crew :

 ATC : GIA 152, turn right heading 046 report established localizer
 GIA 152 : Turn right heading 040 GIA 152 check established
 ATC : Turning right sir
 GIA 152 : Roger 152
 ATC : Confirm you’re making turning left now?
 GIA 152 : We are turning right now
 ATC : OK you continue turning left now
 GIA 152 : A (pause) confirm turning left? We are starting turning right now
 ATC : OK (pause) OK
 ATC : GIA 152 continue turn right heading 015

Ten seconds after this transmission, the accident occurred.

Figure 46. Garuda 152

6-2
Communication Models

Communication can be described as one-way or two-way. One-way communication

involves information or a message being sent via a medium to one or more receivers who
then interpret the information. Examples of one-way communication could include:

■ Emails

■ Letters

■ Instructions

■ Voicemail, etc.

Two-way communication involves information or a message being sent via a

medium to one or more receivers who have the opportunity to respond, thereby becoming
the sender. This forms a closed feedback loop. Examples of two-way communication
include exchanges in which information flows back and forward between the sender and
receiver, such as:

■ Conversations

■ Telephone calls

■ Radio transmissions, etc.

The communication process

The communication process involves a message or communication being sent by the

sender through a communication channel to a receiver. The sender must encode the
message (the information being conveyed) into a form appropriate to the communication
channel, and the receiver then decodes the message to understand its meaning and
significance. The following diagram illustrates this process.

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 Figure 47. Simplified model of communication

Types of communication

Information may be transferred by speech, written word, symbols, displays or

gestures.

Both formal and informal communication methods are adopted for different types of
information. There are several different processes for communicating different sorts of
information. Formal methods and documents such as user manuals, safety cases, hazard
logs etc. are used routinely. However, other types of communication of a less formal
nature may include:

■ Face-to-face briefings

■ Informal documents (such as newsletters, bulletins, electronic mail)

■ Audio-visual packages

■ Training.

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Written communication

Written communication can be in hard copy (paper) or soft copy (electronic) format
and includes, but is not limited to:

■ Flight manuals

■ Forms

■ Radio-transmitted text messages.

Verbal communication

Verbal (oral) communication consists of direct or transmitted speech between two

or more individuals and is more likely to be misinterpreted than written information. Verbal
communication can include, but is not limited to, communication via:

■ Landline

■ Mobile phone

■ Radio

■ Face-to-face communication.

While passing on information verbally is sometimes required to convey information

quickly and resolve misunderstandings rapidly, it is always good practice to follow up
safety-critical communication in writing.

Non-verbal communication

Non-verbal communication consists of wordless messages, where meaning may be

conveyed by gestures, posture, appearance, voice tone, eye-contact. Eye contact for
example, indicates attention, interest, involvement; gestures such as winking, or rolling
one’s eyes communicate powerful messages.

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 ■ Body language – important for teamwork communication

■ Appearance.

Phraseology
Verbal communication has significant safety implications. In order to minimise
potential ambiguities and other variances in aviation, there are established rules or
protocols regarding which words, phrases or other elements will be used for
communicating.

For example, International Civil Aviation Organization (ICAO) phraseology now

requires that the word ‘departure’ is used instead of ‘take-off’ (except for the single case
of the take-off itself) and that clearances, heading, runway etc. are read-back. This was
introduced to enhance safety following many cases where messages were
misinterpreted.

However, read-back alone does not guarantee that the message has been
accurately received or processed. The four most common errors associated with
miscommunication in the air are:

■ Similar aircraft call signs resulting in confusion in transmission or reception

■ Only one pilot on board working and monitoring the ATC frequency

■ Numerical errors, such as confusing ‘one zero thousand’ with ‘one one thousand’

■ Expectancy (hearing what one expects to hear).

Barriers to Effective Communication

Barriers in communication can occur at any point in the communication process:

 In the sender’s message: e.g. using jargon or non-standard phraseology which some
individuals may not be familiar with
 In the outside environment: e.g. when background noise interferes with the
transmission of the message;

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 In receivers themselves: e.g. the receiver does not want to hear a message, or has
such a high workload that a message is not completely received.

6.2 COMMUNICATION ERRORS

Communication errors which have an adverse effect on safety include:
Types of errors Examples
Senders’ errors
Omitting communication Clipping call signs
Passing on incomplete/ambiguous Not adequately defining an abnormal
information situation to ATC
Passing on incorrect information Call-sign confusion
Senders’/receivers’ errors
Failing to reach a clear and mutual Confusion about assigned runway
understanding
Failing to follow recognised sequence for Using non-standard phraseology or
communication jargon
Failure to use correct units of speech Excessive use of
abbreviations/acronymns
Poor elocution/failing to speak clearly Rushing or mumbled speech
Failing to read back messages Failure to read back mandatory pieces of
information to ATC requiring further
communication to resolve
Receivers’ errors
Not responding correctly to An aggressive response to ATC
communication
Mis-recording information communication Writing down an incorrect QNH
Not listening (partial or total message) Tuning out due to high workload
Table 5. Type of Communication Errors

Many other factors influence effective communication in safety critical industries

such as aviation, including:

• attitudes
• conflicts and pressures
• culture
• fatigue
• gender

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 • high workload
• inadequate language proficiency
• interruptions
• personality
• physical conditions
• stress

ATC/pilot miscommunication arises because of a combination of human and

technical communication factors, including:

• blocked transmission
• callsign confusion (the message was wrongly addressed or was taken by another
aircraft)
• communication equipment problems caused by malfunction or complete failure of
aircraft or ground equipment
• fight crew unintended mismanagement of radio frequency (one of the main
causes of prolonged loss of communication)
• frequency congestion
• radio interference making messages difficult or impossible to read.

Errors by sender and receiver can be seen in:

• failure of the read-back/hear-back process

• failure to use standard phraseology
• poor language skills

Workload and distraction can have a major effect on communication and indeed,
communication can lead to distraction. The extract below from an accident report
demonstrates how ATC communication disrupted a charter pilot during approach to
land.

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Verbal Communication Errors
Effective communication involves organisations and individuals minimising potential
misunderstanding to overcome any barriers to communication at each stage in the
communication process

There are numerous verbal communication errors and contributing factors,

including:

• environmental aspects (noise, distractions, stress)

• failure to demonstrate understanding (receiver)
• failure to listen
• failure to plan clear communication of message
• failure to test meaning (receiver) or understanding (transmitter)
• incongruence between verbal and nonverbal communication.
• lack of emphasis of importance and/or urgency
• physiological reasons (speech and/or hearing)
• poor use of pace and tone
• poor use of volume to suit the environment
• technical factors (equipment and transmission medium)
• use of uncommon accent
• use of uncommon language and/or phraseology.

Safety-critical communication
Effective communication is essential for safe operations. Information may be
transferred by speech, written word, symbols, displays or gestures. The quality and
effectiveness of communication is determined by the degree to which the intended
message is understood by the receiver.

In most industries, safety-critical communication can occur in the following

situations:

• Shift/crew handovers
• Communications during emergencies

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 • Any form of remote communication
• Communication of hazards and risks to contractors
• Use of radios
• Plant/equipment labelling and identification
• Communication of changes to procedures.

Organizations should make arrangements to pass on the following sorts of safety-

related information to people who need it to reduce risk:

• Hazards, risks and arrangements to control them

• Limitations on the products and systems and any implications for users and
maintainers
• Lessons learned relating to safety, and
• Safety-related information about products.

Any changes to this type of information should be passed on promptly to those who
may be affected by it. Organizations should have arrangements in place to capture and
record safety-related information; to decide who should receive it; and to make sure that
they do receive it.

Unreliable communication
Unreliable communication can result from a variety of problems including:

• Missing information
• Unnecessary information
• Inaccurate information
• Poor or variable quality of information
• Misunderstandings
• Failing to carry forward information over successive shifts/crew changes.

Managing Communication
There are certain communication principles common across all industries, and
which should be adopted by the entire workforce:

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 • Communicating effectively with all members of the workforce, both up and down
the chain of responsibility, to help ensure that risk management activities are
sufficiently comprehensive and understood.
• Endeavouring to raise awareness of potential hazards and risk issues amongst the
workforce.
• Ensuring that all those involved with a project are aware of any risks to which they
may be exposed, of any relevant limitations inherent in the design or operating
procedures, and of any implications for their conduct.
• Discussing the reasons for incidents and near misses with the workforce, so that
lessons can be learned.

A number of simple steps can assist in improving safety-critical communication:

• Carefully specify what key information needs to be communicated

• Eliminate unnecessary information
• Use aids (such as logs, computer displays) to help accurate communication
• Repeat the key information using different mediums, e.g. use both written and
verbal communication
• Allow sufficient time for communication, particularly at shift/crew handovers
• Encourage two-way communication with both the giver and recipient of the
information taking responsibility for accurate communication
• Encourage the asking of confirmation, clarification and repetition
• Encourage face-to-face communication wherever feasible
• Try to develop all employees’ communication skills
• Set standards for effective and safe communication.

ICAO’s document on aeronautical telecommunications (Annex 10, Volume II)

provides rules and procedures for pilot-controller communications. These guidelines and
techniques for radio transmission highlight the following objectives:

• carry out transmissions concisely in a normal conversational tone

• make full use of standard phraseologies whenever prescribed in ICAO documents
and procedures

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 • speech-transmitting techniques shall be such that the highest possible intelligibility
is incorporated in each transmission.

To reach these objectives, pilots and controllers should:

• enunciate each word clearly and distinctly

• maintain an even rate of speech (not exceeding, typically, 100 words per minute)
• make a slight pause preceding and following numerals; this makes them easier to
understand
• maintain speaking volume at a constant level
• be familiar with microphone-operating techniques (particularly in maintaining a
constant distance from the microphone if the aircraft does not have a constant-
level modulator)
• suspend speech temporarily if it becomes necessary to turn your head away from
the microphone.

Best-practice communication protocols

The following communication protocols are good practice for all pilots to help
maintain clear communication and avoid confusion or potential errors:

Use correct radio procedures

• Ensure your radio procedures comply with regulatory and company requirements.
Write longer messages (e.g. a clearance) down and read back what you have
recorded.

Read back clearances

• Read back any clearances containing altitude, heading or speed assignments

completely. Always read back any hold-short or position-and-hold instructions.
• For longer clearances (e.g. entry into controlled airspace for an instrument
approach) you can reduce errors and improve recall by writing down the
information before read back. This can provide an extra check to confrm the
information written down is the same as that ATC provided.

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When in doubt, verify

• Always seek verifcation of any clearances you do not understand; or if two crew
members do not agree on the clearance, verify the information rather than guess.

Use full call signs

• Misunderstandings can occur when full call signs are not used. Acknowledge all
communication with a call sign (not a double click of the mike button or stating
‘Roger’).

Be alert for similar call signs

• Ensure the controller and other aircraft involved are aware of similar call signs in
use.

Use thoughtful radio technique

• Listening for a full two seconds before keying a microphone will reduce
simultaneous transmissions on the same frequency.

Hear back

• Pilots should never assume that ATC is listening to their read backs or that errors
will be corrected.

Keep communication simple

• Clearances, instructions or requests should never contain more than two or three
critical items unless preceded by words such as ‘ready to copy?’

6.3 TEAMWORK
Team is a small number of people with complementary skills who are equally
committed to a common purpose, goal and working approach for which they hold
themselves mutually accountable. Teamwork means a dynamic process involving two or
more professionals with complementary background and skills contributing in the most
effective way to the overall tasks and goals of the team.

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 Successful teamwork occurs when the output of the team is greater than the sum of
the efforts of the individual crew members acting in isolation. In a successful team, each
individual is empowered and encouraged to contribute in the most effective way to the
overall task of the team. This process of interaction is known as ‘synergism’.

Synergism is unlikely to occur however, unless all individual members of the team
fully understand their role within the group and how this role may vary with the decisions
being made and the actions being taken. Pre-requisites for the creation of synergy and
high team performance depend on effective communications within the group, a high
degree of situational awareness and a comprehensive understanding of the decision-
making process of the group.

Elements of Teamwork

Teamwork consists of a number of elements as discussed below.

Supporting others

Effective teamwork includes providing support to other team members by:

• Sharing work load when appropriate

• Accepting responsibility for your role
• Maintaining good working relationships
• Establishing openness.

Solving conflicts

Conflict between team members may arise when roles and responsibilities are not
clarified. It is good practice to discuss and define the task clearly and who will assume
particular duties. For example, the roles and expectations of the pilot flying (PF) vs pilot
not flying (PNF) should be fully discussed.

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 Another potential area of conflict is interpersonal conflict, which is usually managed
by remaining objective and un-emotional, with an assertive manner. At times, this can be
challenging.

Exchanging information

Exchanging information enables a shared understanding (or mental model) of a

situation to be established. The concept of shared mental models has been proposed as
a means to explain coordinated performance in teams. Through teamwork, crews develop
shared understanding of the nature of problems, solution strategies, cue significance (e.g.
the implications of emergency language such as ‘pan, pan, pan’ and ‘mayday’) and
participants’ roles and responsibilities. Having a shared understanding means all
participants are solving the same problem and creates a context where everybody can
contribute.

While one person may have ultimate responsibility for decision-making and the
overall safety of the flight, team members provide critical redundancy. In addition to
performing their own tasks, team members support each other by monitoring the situation
and the performance of others. This ‘cross-monitoring’ allows ‘primary errors’ (procedural,
technical or decision errors) to be detected and rectified before they cause problems.

According to research, reduced errors occur when flight crew members verbalise
pertinent information and challenge the actions and decisions of others. Reviews of
accidents and incidents indicate that it is the captain who usually commits the primary
error, and the first officer who then fails to catch or correct it. These errors are significant,
as they often represent the last opportunity to break the chain of events leading to an
accident. Failure to challenge another crew member’s questionable decision or action
may occur by choice, or because of pressure not to say anything.

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Coordinating activities

Rather than working as highly-skilled individuals, working as a team reduces

possible errors, breakdowns in communication and conflicts. With coordinated activities,
workload can be shared or delegated to ensure any one team member is not overloaded.
In addition, team members can monitor the performance of other team members and
provide support as required.

6.4 TEAM MANAGEMENT

Teamwork Skills

Teamwork and coordination are important in most aviation operations, and there
may be considerable risks to safety if they break down. Characteristics of good teamwork
include leadership, followership, effective communication, trust building, motivation and
praise giving.

The following issues should be discussed, clarified, agreed and understood by all
team members:

• a clearly defined and maintained aim or goal(s)

• each team member’s roles and responsibilities
• communication messages and methods
• limitations and boundaries
• emergency procedures
• individual expectations and concerns
• what defines a successful outcome?
• debriefing arrangements
• team dismissal arrangements
• opportunities for questions and clarification.

A team’s effectiveness can also be improved by selecting members with a broad

range of experience and skill sets, and through practice and rehearsal.

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 Research has identified a set of eight major teamwork skills that are beneficial for
all team members:

• adaptability
• communication
• coordination
• decision making
• interpersonal relations
• leadership/team management
• performance monitoring/feedback
• shared situational awareness.

Acknowledging the whole team

Apart from teamwork skills, training and competencies, one of the biggest
determinants of successful and sustained teamwork is the motivation of the crew or team.
This can be targeted by ensuring the efforts of all are acknowledged and they feel valued.

It is important that when the ‘face’ of a team has a success, there is also
acknowledgement of those who supported the team behind the scenes, not just those
who are highly visible.

A great example of this was observed with Apollo 11—the first manned mission to
land on the Moon. That major event back on 20 June 1969 is generally associated with
the names Neil Armstrong and Buzz Aldrin, even though the crew actually had three crew
members.

While Armstrong, the mission commander, and Aldrin, the lunar module pilot,
descended to the surface of the Moon, Michael Collins, the command module pilot stayed
in orbit.

Armstrong and Aldrin would forever be known as the frst men to walk on the Moon,
but at every opportunity the astronauts called the world’s attention to the efforts of Collins,
as well as their many teammates back on Earth. The Apollo 11 team included hundreds

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of thousands of people led by program and project managers at the National Aeronautics
and Space Administration (NASA).

On 26 July 1969, their last night in space, Armstrong made a special television
broadcast acknowledging the efforts of the entire team:

“We would like to give special thanks to all those Americans who built the spacecraft;
who did the construction, design, the tests, and put their hearts and all their abilities
into those craft. To those people tonight, we give a special thank you.”

Don’t ever underestimate the value of acknowledging successful teamwork and ensuring
all people feel part of the team.

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 CHAPTER 7

THE OPERATING ENVIRONMENT

7.1 VIEW OF SAFETY CULTURE

Definitions of safety culture

The Chernobyl and Piper Alpha accidents stimulated a vast amount of work on
safety culture. Because safety culture is a subset of overall company culture, it is not
surprising that definitions of the term vary from organization to organization. The following
are some examples:

• Worksafe, QLD. ‘A safety culture is an organizational culture that places a high level
of importance on safety beliefs, values and attitudes—and these are shared by the
majority of people within the company or workplace. It can be characterized as “the
way we do things around here”.’
• The National Offshore Petroleum Safety and Environmental Management Authority
(NOPSEMA). ‘The shared basic assumptions, held by most members of an
organization, which create and reinforce group norms of thoughts, language and
behaviour in relation to major accident event prevention.’
• NSW Roads and Maritime Services (RMS). ‘Safety culture reflects the values, beliefs
and attitudes in the organization that influence what people do and why they do it. A
mature safety culture contributes to strong safety performance.’
• Australian Radiation Protection and Nuclear Safety Agency (ARPANSA). ‘The core
values, beliefs and behaviours resulting from a collective commitment by leaders and
individuals throughout an organization that appropriately priorities safety against other
organizational goals to allow business objectives to be undertaken without undue risk

The International Civil Aviation Organization (ICAO) states:

• Culture itself is characterized by the beliefs, values, biases and their resultant
behaviour that are shared by members of a society, group or organization.

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• a safety culture encompasses the commonly held perceptions and beliefs of an
organization’s members pertaining to the public’s safety and can be a determinant of
the behaviour of the members

While there are many definitions of safety culture, they have two things in common.

• Safety culture is about people’s values, attitudes, beliefs and behaviours. In an

organization with a good safety culture, these focus on safety, which is considered a
priority.
• Safety culture is about the extent to which these values, attitudes, beliefs and
behaviours pervade the organization. In organizations with a good safety culture these
values extend throughout—from the CEO/head of operations to line pilots and the
hangar—and in everything everyone does in the organization

Characteristics of safety culture

Every organization has common internal characteristics that we call its culture.
These characteristics are often invisible to insiders because they are ingrained, but to an
outsider may appear quite shocking.

Imagine coming from a highly regimented organization where all incidents are
reported, and which communicates safety lessons, to one where a heavy blame culture
and a mantra from fellow workers that ‘we don’t report incidents or talk to management’
prevent incident reporting.

Conversely, imagine coming from an organization where safety comes a poor

second to production, and where the process is never questioned if the outcome for the
business is positive. It would be challenging to adapt to a more mature organization where
the emphasis on safety practices and processes takes priority over operational outcomes,
such as meeting deadlines, whatever the cost. Pressures on operators to keep to
schedules can be difficult.

For many public transport operators, keeping to published or arranged schedules is

an important indicator of success and effectiveness. In busy airports, missing your slot

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can result in big delays. In some industries, they publish on-time performance figures and
sometimes issue fines for schedule-non-adherence. Passenger expectations and
demands can create insidious pressures on charter operators, also affecting industry
reputation.

Characteristics of good and poor safety cultures

By default, every organization has a safety culture. What distinguishes the good
from the bad?

A good safety culture ensures that operations are as safe as possible because:

• everyone, from staff on the ground to managers, is involved

• everyone takes safety seriously, remains watchful and avoids compromises.

By contrast, in an organization with a poor safety culture:

• not everyone takes safety seriously

• people are not watchful and compromise too readily
• some workers or operations may be at greater risk of incidents or accidents
• incidents, especially near misses, are not reported, communicated, or acted upon
adequately
• instructions are not followed properly.

What are the characteristics of a good safety culture? ICAO advocates that in an
organization with a strong safety culture:

• senior management places a strong emphasis on safety as part of the strategy of

controlling risk
• decision makers and operational personnel hold a realistic view of the short- and long-
term hazards involved in the organization’s activities
• those in senior positions do not use their influence to force their views on others, or to
avoid criticism
• those in senior positions create an organizational climate which is open to criticism,
and fosters comments and feedback from all employees
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• there is an awareness of the importance of communicating relevant safety information
at all levels of the organization (both internally and with outside entities)
• there is promotion of appropriate, realistic and workable rules relating to hazards, to
safety and to potential sources of damage, with such rules being supported and
endorsed throughout the organization
• personnel are well trained and well educated and fully understand the consequences
of unsafe acts.

Conversely, there are distinct symptoms of a poor safety culture. These are:

• the number of hazard reports is lower than expected

• the appointed safety executive does not take responsibility for the safety program
• there is active resistance to the safety program
• the number of high-risk safety incidents is not decreasing over time (or, is increasing)
• the number of workplace accidents is not decreasing over time (or, is increasing)
• there are management silos
• upper management does not actively support the safety program
• there is retaliation from managers or other employees against people who report safety
issues
• there is a strong tendency for employees or management to focus on individual
blame— to focus on the ‘who’ rather than the ‘why’ of an incident
• there is resistance to change
• safety information is not readily accessible
• safety managers do not communicate important safety concerns (effectively)
• there is a lack of safety budget
• there is a high number of repeat safety incidents

Elements of Safety Culture

Professors James Reason and Patrick Hudson are recognized as experts who have
done much to advance safety in many industries, including aviation. They describe how
organizational cultures making safety a priority share common characteristics—five
elements which can be defined and measured.

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• An informed culture—those who manage and operate the system have current
knowledge about the human, technical, organizational and environmental factors
underpinning the safety of the system.
• A reporting culture—people are willing to report errors and near misses.
• A just culture—there is an atmosphere of trust, and people are encouraged or even
rewarded for providing essential safety related information, but there is also a clear line
between acceptable and unacceptable behaviour (i.e. fair and just culture).
• A flexible culture—this can take different forms but is characterized as shifting from the
conventional hierarchical mode to a fatter professional structure.
• A learning culture—has the willingness and the competence to draw the right
conclusions from its safety information system, and the will to implement major reforms
when necessary.

On the following page are some examples of positive safety performance indicators
against each of the safety culture elements. While it is not an exhaustive list, it does
provide organizations with some practical goals for measuring their safety culture
maturity.

Figure 48. Elements of Safety Culture

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7.2. THE AVIATION SYSTEM
The aviation system as a whole comprises many and different functional systems
such as finance, environment, safety and security. The latter two are the primary
operational domains of the greater aviation system.

Aviation is a system of systems. Maier (1998) characterised a ‘system of systems’

as possessing five basic traits: operational independence of elements; managerial
independence of elements; evolutionary development; possessing emergent behaviour;
having a geographical distribution of elements. In the context of aviation, these systems
have distinct operational independence (aircraft operations; maintenance; air traffic
management/control) and each of these aspects has managerial independence (they are
offered by independent companies or national providers); however, they are bound by a
set of common operating principles and international regulations for design and operation.
All aspects of aviation encompass technical, human and organisational aspects. It is a
sociotechnical ‘system of systems’ encompassing critical human factors considerations
such as usability, training, design, maintenance, safety, procedures, communications,
workload and automation.

It is fair to say, though, that the aviation ‘system of systems’ was never designed, it
is a legacy system that has evolved over the past century. All the components in aviation
are themselves open systems (i.e. they must interact with their environment). Open
Systems Theory is derived from General Systems Theory (von Berthalanfry 1956);
however, these organisations are only selectively open, in that they interact with their
environment but also need boundaries in order to exist. In the operation of civil aircraft,
there are a great number of inter- and intraorganisational boundaries that information and
resources must cross in this system of systems.

Within the aviation system, organizations include airlines and other operators,
manufacturers, airports, air traffic control, weather services, civil aviation authorities,
safety investigation agencies, international organizations (ICAO, JAA. EUROCONTROL,
etc.) and professional associations (IATA. IFALPA, IFATCA, ISASI. etc.).

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7.3 GENERAL MODELS OF ORGANISATIONAL SAFETY
Whether an organization realizes it or not, it will have a number of different “safety
cultures” that reflect group-level attitudes and behaviours. No two organizations are
identical, and even within the same organization, different groups may have various ways
of thinking about safety, talking about safety and acting on safety issues. This variation
may be appropriate for different activities.

How safety values are incorporated into practices by management and personnel
directly affects how key elements of Safety Management System (SMS) are established
and maintained. As a consequence, safety culture has a direct impact on safety
performance. If someone believes that safety is not that important then workarounds,
cutting corners, or making unsafe decisions or judgements may be the result, especially
when the risk is perceived as low and there is no apparent consequence or danger. The
safety culture of an organization therefore significantly influences how their SMS develops
and how effective it becomes. Safety culture is arguably the single most important
influence on the management of safety. If an organization has instituted all the safety
management requirements but does not have a positive safety culture, it is likely to
underperform.

When the organization has a positive safety culture, and this is visibly supported by
upper- and middle-management, front-line personnel tend to feel a sense of shared
responsibilities towards achieving the organization’s safety objectives. Effective safety
management also supports efforts to drive towards an increasingly positive safety culture
by increasing the visibility of management’s support and improving active involvement of
personnel in managing safety risk.

A positive safety culture relies on a high degree of trust and respect between
personnel and management. Time and effort are needed to build a positive safety culture,
which can be easily damaged by management decisions and actions, or inactions.
Continuous effort and reinforcement are needed. When leadership actively endorses safe
practices, it becomes the normal way of doing things. The ideal situation is a fully
implemented and effective SSP/SMS and a positive safety culture. Hence, an
organization’s safety culture is often seen as a reflection of the maturity of its SSP/SMS.

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Effective safety management empowers a positive safety culture and a positive safety
culture empowers effective safety management.

How to build Safety Culture

Figure 49. Build Safety Culture

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Characteristics of safety Sample goals and targets
culture from Reason
(1997)
Reporting culture • Corrective actions completed within agreed timeframes.
• Percentage of planned corrective actions which have been
finalized.
• Number and quality of safety hazards reported.
• Percentage of near misses to incidents reported over a 12-
month period.
• Percentage of quality near misses assessed based on
minimum standard reported over a 12-month period.
• Actual number of safety observations/interactions
completed compared with number planned.
• Percentage of quality safety observations/interactions
assessed based on minimum standard over a 12-month
period.
• Percentage of feedback provided to reports on action taken
within agreed maximum timeframes.
Learning culture • Percentage of issues addressed from strategic reviews
compared with total number.
• Percentage of compliance with CASA or WHS audit
actions/notices.
• Quality assurance process in place to improve quality of
incident investigations.
• Evidence of process in place to identify repeat systemic
factors from significant incidents.
Informed culture • Safety briefings/toolbox talks completed to quality
agreement based on 95 per cent target.
• Number of risk assessments conducted against those
planned.
• Evidence that risk issues have been considered and
mitigated as part of a major change project.
• Number of new worker inductions conducted on site against
number planned.
Flexible culture • Percentage of operators trained against skills matrix.
• Percentage of staff trained against skills matrix.
• Evidence of emergency scenario training held.
• Examples of succession plans for key roles.
• Evidence of competency certificates in place.
Just culture • Number of staff identified needing investigation training
compared with actual number trained.
• Evidence of a formal fair and just culture management
review process applied consistently.
• Evidence of a formal reward and recognition process
applied consistently.
• Evidence of formal communication of the outcomes from
performance management decisions, particularly for
breaches of safety critical rules
Tabel 6. Characteristics of safety culture

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Accident Causation

The “Swiss-Cheese” (or Reason) Model, developed by Professor James Reason

and well known to the aviation industry, illustrates that accidents involve successive
breaches of multiple defences. These breaches can be triggered by a number of enabling
factors such as equipment failures or operational errors. The Swiss-Cheese Model
contends that complex systems such as aviation are extremely well defended by layers
of defences (otherwise known as “barriers”).

A single-point failure is rarely consequential. Breaches in safety defences can be a

delayed consequence of decisions made at the higher levels of the organization, which
may remain dormant until their effects or damaging potential are activated by certain
operating conditions (known as latent conditions). Under such specific circumstances,
human failures (or “active failures”) at the operational level act to breach the final layers
of safety defence. The Reason Model proposes that all accidents include a combination
of both active failures and latent conditions.

Active failures are actions or inactions, including errors and rule-breaking, that have
an immediate adverse effect. They are viewed, with the benefit of hindsight, as unsafe
acts. Active failures are associated with front-line personnel (pilots, air traffic controllers,
aircraft maintenance engineers, etc.) and may result in a harmful outcome.

Latent conditions can exist in the system well before a damaging outcome. The
consequences of latent conditions may remain dormant for a long time. Initially, these
latent conditions are not perceived as harmful, but under certain conditions may become
clear when the operational level defences are breached. People far removed in time and
space from the event can create these conditions. Latent conditions in the system may
include those created by the safety culture; equipment choices or procedural design;
conflicting organizational goals; defective organizational systems; or management
decisions.

The “organizational accident” paradigm assists by identifying these latent conditions

on a system-wide basis, rather than through localized efforts, to minimize active failures
by individuals. Importantly, latent conditions, when created, had good intentions.

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Organizational decision makers are often balancing finite resources, and potentially
conflicting priorities and costs. The decisions taken by decision makers, made on a daily
basis in large organizations, might, in particular circumstances, unintentionally lead to a
damaging outcome.

Figure below illustrates how the Swiss-Cheese Model assists in understanding the
interplay of organizational and managerial factors in accident causation. Multiple
defensive layers are built into the aviation system to protect against variations in human
performance or decisions at all levels of the organization. But each layer typically has
weaknesses, depicted by the holes in the slices of “Swiss cheese”.

Sometimes all of the weaknesses align (represented by the aligned holes) leading
to a breach that penetrates all defensive barriers and may result in a catastrophic
outcome. The Swiss-Cheese Model represents how latent conditions are ever present
within the system and can manifest through local trigger factors.

It is important to recognize that some of the defences, or breaches, can be

influenced by an interfacing organization. It is therefore vitally important that service
providers assess and manage these interfaces.

Figure 50. Swiss Cheese Model

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7.4 ORGANISATIONS STRUCTURES AND SAFETY
The design of the organization, that is its permanent structure and hierarchy, can
facilitate or hinder departmental interfaces. Once again, the accident record is rife with
examples where deficiencies in organizational design compromised operational
effectiveness, efficiency and safety. Structural problems can lead to blurred
responsibilities and overlapping jurisdictions and confusion regarding which
organizational element is accountable for particular tasks or services. Organizational
elements may be slow in responding to the needs of other organizational elements
dependent on them for goods, professional services or for information.
Investigations of major accidents in sociotechnical systems have clearly
demonstrated that it is possible to design individual components of the organizational
structure (departments, sections, etc.) to achieve their assigned objectives safely and
efficiently and yet fail to secure overall organizational safety and effectiveness because
of inattention to the way those individual components interact. If the organizational
structure is poorly conceived, it may contribute to safety breakdowns when operating
under pressure. The following are several factors that can influence the effectiveness of
organizational structures.
a. Complexity. This includes the number of managerial levels, the division of labour
and job specializations, the degree to which operational personnel and facilities
must be geographically dispersed or centralized and the extent to which
mechanisms to facilitate communication between levels have been integrated
into the organization.
b. Standardization. This is related to the complexity of the job and the level and type
of expertise of employees. In general terms, the simpler the job (e.g. assembly-
line manufacturing), the greater the benefits of standardization while for more
complex jobs (e.g. management tasks requiring high levels of professionalism),
a lower the level of standardization is desirable. In aviation, operational activities
are highly proceduralized, even when the highest levels of professionalism are
involved. Complex tasks, such as flight deck management, require both high
levels of professionalism and standardization.

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 c. Centralization. Centralization of the formal decision-making process depends on
the stability and predictability of the surrounding environment. Unpredictable
environments require decentralization to rapidly cope with unexpected changes.
d. Adaptability to the environment. Environmental uncertainty is the most powerful
of all the system factors affecting organizational design. In highly uncertain
environments (unstable economic or political climates, corporate mergers or rapid
expansions, major equipment acquisitions and labour contract negotiation)
organizations should be flexible and capable of rapid response to change. In
highly stable environments, it is desirable to incorporate stability and control for
maximum effectiveness.

All these organizational factors can influence human performance, which in turn
affects the way organizations achieve their objectives, including safety. Organizations
with unnecessarily complex structures (too many managerial levels or excessive
departmentalization) foster dilution of responsibilities and lack of accountability. Complex
structures tend to make interdepartmental communications more difficult. Sluggish
interdepartmental communications, especially regarding safety-relevant information,
reduce safety margins and invite safety breakdowns.

7.5 CULTURE AND SAFETY

National culture differentiates the characteristics of particular nations, including the
role of the individual within society, the manner in which authority is distributed, and
national priorities with respect to resources, accountabilities, morality, objectives and
legal systems.

From a safety management perspective, national culture influences organizational

culture and plays a large part in determining the nature and scope of regulatory
enforcement policies, including the relationship between regulatory authority personnel
and industry personnel, and the extent to which safety information is protected. These, in
turn, impact on peoples’ willingness to report safety issues.

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 The majority of organizations today employ people from multiple cultural
backgrounds, which may be defined by their nationality, ethnicity, religion, and/or gender.
Aviation operations and safety rely on effective interaction between different professional
groups, each with its own professional culture. Hence, the organization’s safety culture
may also be significantly affected by the variety of cultural backgrounds of the members
of its workforce.

Managing safety within the aviation system therefore requires interaction with, and
management of, culturally diverse personnel. However, when implementing safety
management, managers should be capable of moulding their culturally-diverse workforce
into effective teams. Eliminating differences in safety risk perceptions that may derive
from different cultural interpretations and enhancing other safety-related aspects, such as
communication, leadership styles and interaction between supervisors and subordinates
is key. The degree of success will depend on management’s ability to promote a common
understanding of safety and each individual’s role in its effectiveness.

Regardless of an individual’s cultural background, effective safety management

relies on a shared safety culture, with everyone in the organization understanding how
they are expected to behave in relation to safety and risk “even when no one is watching”.

7.6 PROCEDURES AND SAFETY

Deviation of procedure can affect safety, introduce in Chapter 5, intentional
deviations and inadvertent deviation from SOPs have been identified as causal factors in
many aircraft accidents and incident.

Scott A. Snook's theory of practical drift is used to understand how performance of

any system “drifts away” from its original design. Tasks, procedures, and equipment are
often initially designed and planned in a theoretical environment, under ideal conditions,
with an implicit assumption that nearly everything can be predicted and controlled, and
where everything functions as expected. This is usually based on three fundamental
assumptions that the:

a) technology needed to achieve the system production goals is available;

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 b) personnel are trained, competent and motivated to properly operate the
technology as intended; and
c) policy and procedures will dictate system and human behaviour.

These assumptions underlie the baseline (or ideal) system performance, which can
be graphically presented as a straight line from the start of operational deployment as
shown in Figure below.

Figure 51. Concept of practical drift

Once operationally deployed, the system should ideally perform as designed,

following baseline performance (orange line) most of the time. In reality, the operational
performance often differs from the assumed baseline performance as a consequence of
real-life operations in a complex, ever-changing and usually demanding environment (red
line). Since the drift is a consequence of daily practice, it is referred to as a “practical drift”.
The term “drift” is used in this context as the gradual departure from an intended course
due to external influences.

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 Snook contests that practical drift is inevitable in any system, no matter how careful
and well thought out its design. Some of the reasons for the practical drift include:

a) technology that does not operate as predicted;

b) procedures that cannot be executed as planned under certain operational
conditions;
c) changes to the system, including the additional components;
d) interactions with other systems;
e) safety culture;
f) adequacy (or inadequacy) of resources (e.g. support equipment);
g) learning from successes and failures to improve operations, and so forth.

In reality people will generally make the system work on a daily basis despite the
system’s shortcomings, applying local adaptations (or workarounds) and personal
strategies. These workarounds may bypass the protection of existing safety risk controls
and defences.

7.7 SAFE AND UNSAFE ORGANISATIONS

Over time, researchers and academics studying organizations have resorted to a
metaphor to assist their endeavours: they have compared organizations to living
organisms, notably the human being. Organizations are viewed like complex living
structures, with brain, body, personality and objectives. Like human beings, organizations
struggle for survival within a constantly changing environment. Within organizational
literature, it is a basic premise that "... organizations think. Like individuals, they exhibit a
consciousness, a memory, an ability to create and solve problems. Their thinking strongly
affects the generation and elimination of hazards." In this comparison, the managers and
decision-makers become the brain; the hierarchies, departments and other permanent
structures (including the workforce) become the body; and corporate culture becomes the
personality.

Traditional Human Factors endeavours have focused on the brain, body and
personality of human kings and their interactions with the surrounding environment. The

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purpose is to either foster safe behaviour or discourage unsafe behaviour and thus
improve safety and efficiency as well as the well-being of those in the aviation system.
Human Factors ideas and techniques can also be applied to organizations. This chapter
borrows from the organism metaphor and discusses the equivalent components of brain,
body, personality and objectives as they apply to organizations. Thus the characteristics
of safe and unsafe organizations and organizational behaviour can be considered as yet
another contribution to the pursuit of safety, efficiency and individual well-being within the
aviation system.

Organizations have objectives which are usually related to production: building

aircraft or other equipment, transporting passengers, transporting goods, etc. Producing
profit for stockholders is one of the goals of many organizations. Most organizations within
the aviation industry are formed to achieve some practical objective or goal, and safety is
not the primary goal. Safety fits into the objectives of organizations, but in a supporting
role, to achieve the production objectives safely, i.e. without harm to human life or damage
to property.

Therefore, before discussing safe and unsafe organizations, it is essential to put

safety into perspective and decide where it fits within the objectives of aviation
organizations. From an organizational perspective, safety should be seen as a method of
conserving all forms of resources, including controlling costs.

Safety allows organizations to pursue their production objectives with minimum

damage to equipment or injury to personnel. It assists management in achieving this
objective with the least risk. There is an element of risk in aviation that cannot be
eliminated, but it can be successfully controlled through risk management programmes
directed at correcting safety deficiencies before an accident occurs. These programmes
are an essential tool for decision-makers to formulate decisions on risk and to contribute
to safety while pursuing the production goals of their organizations.

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Safe organisations

The concept and practices of safety have evolved over the years from being simply a
collection of processes and standards, to a systematic approach specifc to safety.
Unfortunately, this has occurred because of lessons from some catastrophic accidents
and losses along the way. Safe organisations are said to have the following traits:

• they pursue safety as one of the objectives of the organisation and regard safety
as a major contributor in achieving production goals
• they have developed appropriate risk management structures, which allow for an
appropriate balance between managing productivity and risk
• they enjoy an open, good and healthy safety organisational culture
• they possess a structure which has been designed with a suitable degree of
complexity
• they have standardised procedures and centralised decision making which is
consistent with the objectives of the organisation and the characteristics of the
surrounding environment
• they rely on internal responsibility rather than regulatory compliance to achieve
safety objectives
• they respond to observed safety deficiencies with long-term measures in response
to latent conditions as well as short-term, localized actions in response to active
failures.

Bearing these traits in mind, the following case study is an example of an unsafe
organisation, where safety and risk management was compromised in the extreme.
Sadly, it took the deaths of nine people to learn the lessons and overhaul aviation
oversight, safety and standards.

Corporate Culture

The inevitable questions then arise: What is culture? Can decision-makers influence
corporate culture? If so, what can decision-makers do to influence it?

7 - 18
 Culture refers to beliefs and values which are shared by all or almost all members
of a group. Culture shapes behaviour and structures a person's perception of the world.
In that sense, culture is a collective mental programming which distinguishes one human
group from another. Culture defines the values and predisposes attitudes, exerting a final
influence on the behaviour of a particular group.

Norms are the most common arid acceptable patterns of values, attitudes and
behaviour for a group. Norms are enforced by expressing disapproval of wrongdoers; how
strongly a culture sanctions those who violate norms is an indication of the importance
attached to those norms. For years people have thought that organizations were beyond
the influence of culture and were only influenced by the technologies they utilize or the
tasks they pursue.

Research has demonstrated, however, that culture deeply influences organizational

behaviour. If an organization attempts to impart values or behaviours which are in contrast
with existing organizational/corporate culture or which are perceived to be in contrast with
corporate goals, achieving these values or behaviours will either take considerable time
and effort or be impossible altogether.

A corporate culture may also allow or prevent violations, since they take place in
situations where the shared values of individuals and the group favour certain behaviours
or attitudes. In the simplest term, a group will meet whatever norms are established for
an organization and will do whatever it thinks or perceives management really wants.

Safe and unsafe corporate cultures

Culture, like personality, involves deep-seated traits and it is extremely resistant to

change. As with personality traits, change can be accomplished, but slowly and over
prolonged periods of time. By identifying what constitutes a good safety-oriented
corporate culture and its characteristics, managers can change and improve existing
corporate culture by setting examples which are consistent across the whole value
system.

7 - 19
 A safety culture within an organization can be regarded as a set of beliefs, norms,
attitudes, roles and social and technical practices concerned with minimizing exposure of
employees, managers, customers and members of the general public to conditions
considered dangerous or hazardous. It is one which promotes among participants a
shared attitude of concern for the consequences of their actions, an attitude which would
cover material consequences as well as the possible effects on people.

In general terms, the characteristics which define a safe culture and which decision-
makers should observe when modelling corporate safety culture include the following:

 senior management places strong emphasis on safety as part of the strategy of

controlling risks;
 decision-makers and operational personnel hold a realistic view of the short- and
long-term hazards involved in the organization's activities;
 those in top positions do not use their influence to force their views or to avoid criticism
about safety issues;
 those in top positions implement measures to contain the consequences of identified
safety deficiencies;
 those in top positions foster a climate in which there is a positive attitude towards
criticisms, comments and feedback from lower levels of the organization;
 there is an awareness of the - importance of communicating relevant safety
information at all levels of the organization (both within it and with outside entities)
 there is promotion of appropriate, realistic and workable rules relating to hazards, to
safely and to potential sources of damage. with such rules being supported and
endorsed throughout the organization: and
 personnel are well trained and well educated and fully understand the consequences
of unsafe acts.

7 - 20
 APPENDIX 1
DIRTY DOZEN

As an individual working in the aviation industry, regardless of occupation (ATC, pilot,

manager, engineer) we must be aware that we not only are part of a process chain, but also
one of the fail-safes in the accident prevention system. Although a self – check before a task
is important (eg. IMSAFE), a constant awareness of the factors which cause us to fail is also
crucial to accident prevention.

Factors which are known to affect the individual working in an organization are shown on
the “Dirty Dozen” series of posters issued by Transport Canada as Follows:

Lack of Communication
Poor communication often appears at the top of contributing and causal factors in
accident reports, and is therefore one of the most critical human factor elements.
Communication refers to the transmitter and the receiver, as well as the method of
transmission. Transmitted instructions may be unclear or inaccessible. The receiver may make
assumptions about the meaning of these instructions, and the transmitter may assume that the
message has been received and understood. With verbal communication it is common that
only 30% of a message is received and understood.

Detailed information must be passed before, during and after any task, and especially
across the handover of shifts. Therefore, when messages are complex they should be written
down, and organisations should encourage full use of logbooks, worksheets, and checklists
etc. Verbal messages can be kept short, with the most critical elements emphasised at the
beginning and repeated at the end. Assumptions should be avoided and opportunities for
asking questions both given and taken.

Eg. The squelch distorted communications between the KLM 747, PanAm 747 and the
ATC. The result was the assumption of take off clearance, when in-fact it was a take off NON-
clearance.

APP1 - 1
 Figure 52. KLM 747 and Pan Am 747 accident

Improve your communication with :

• Say the most important things in the beginning and repeat them at the end.
• Use checklists.

Complacency
Complacency can be described as a feeling of self-satisfaction accompanied by a loss of
awareness of potential dangers. Such a feeling often arises when conducting routine activities
that have become habitual and which may be “considered”, by an individual (sometimes by the
whole organisation), as easy and safe. A general relaxation of vigilance results and important
signals will be missed, with the individual only seeing what he, or she, expects to see.
Complacency can also occur following a highly intense activity such as recovering from a
possible disaster; the relief felt at the time can result in physical relaxation and reduced mental
vigilance and awareness. This particular psychological experience is referred to as a Lacuna.

Whilst too much pressure and demand causes over-stress and reduced human
performance, too little results in under-stress, boredom, complacency and reduced human
performance. It is therefore important, when conducting simple, routine and habitual tasks, and
when fatigued, to maintain an adequate, or optimum, level of stress through different

APP1 - 2
stimulation. Always expect to find a fault! Following written instructions, and adhering to
procedures that increase vigilance, such as inspection routines, can provide suitable stimulus.
It is important to avoid: working from memory; assuming that something is ok when you haven’t
checked it; and, signing off work that you are unsure has been completed. Teamwork and
mutual cross-checking will provide adequate stimulus when fatigued.

Eg. Assuming that the aircraft’s oil level is sufficient and skipping the check

Avoid the tendency to see what you expect to see with :

• Expect to find errors.

• Don’t sign it if you didn’t do it.

• Use checklists.

• Learn from the mistakes of others

Lack of Knowledge
The regulatory requirements for training and qualification can be comprehensive, and
organisations are forced to strictly enforce these requirements. However, lack of on-the-job
experience and specific knowledge can lead workers into misjudging situations and making
unsafe decisions. Aircraft systems are so complex and integrated that it is nearly impossible
to perform many tasks without substantial technical training, current relevant experience and
adequate reference documents. Furthermore, systems and procedures can change
substantially and employees’ knowledge can quickly become out-of-date.

It is important for employees to undertake continuing professional development and for

the most experienced workers to share their knowledge with colleagues. Part of this learning
process should include the latest knowledge on human error and performance. It should not
be a taken as a sign of weakness to ask someone for help or for information; in fact this should
be encouraged. Checklists and publications should always be referred to and followed, and
never make assumptions or work from memory

APP1 - 3
 Eg. Fixing a component without having proper training

Don’t guess, know it by:

• Use current manuals.

• Ask when you don’t know.

• Participate in training.

Distraction or Interruption
Distractions can be mental or physical in nature. They can occur when the work is located
on the aircraft or in the hangar. They can also occur in the psyche of the technician independent
of the work environment. Something as simple as a cell phone call or a new aircraft being
pushed into the hangar can disrupt the technician’s concentration on a job. Less visible is a
difficult family or financial matter or other personal issues that may occupy the technicians
thought process as work is performed. This can make performance of the required
maintenance less effective.

Regardless of their nature, numerous distractions may occur during the course of
maintaining an aircraft. The technician must recognize when attention to the job at hand is
being diverted and assure that work continues correctly. A good practice is to go back three
steps in the work procedure when one is distracted and resume the job from that point. Use of a
detailed step-by-step written procedure and signing off each step only after it is completed also
helps. Incomplete work can be marked or tagged, especially when the technician is pulled from
the work by a distraction, and it is unknown when work will be resumed and by whom.
Disconnect any connector and leave it plainly visible if an installation is not complete. There is
a tendency to think a job is finished when a component is “hooked up.” Similarly, when a step
in the maintenance procedure is complete, be sure to immediately lock wire or torque the
fasteners if required. This can be used as an indication that all is well up to that point in the
procedure.

APP1 - 4
 Eg. An ATC controller answering a call from his cell phone while talking down multiple
aircraft.

Get back in the groove after a distraction by:

• Use checklists.

• Go back 3 steps when restarting the work

Lack of Teamwork
In aviation many tasks and operations are team affairs; no single person (or organisation)
can be responsible for the safe outcomes of all tasks. However, if someone is not contributing
to the team effort, this can lead to unsafe outcomes. This means that workers must rely on
colleagues and other outside agencies, as well as give others their
support. Teamwork consists of many skills that each team member will need to prove their
competence.

Some of the key teamwork skills include: leadership, followership,

effective communication, trust building, motivation of self and others, and praise giving.

To create an effective team it is necessary that the following issues, as appropriate, are
discussed, clarified, agreed, and understood by all team members:

 A clearly defined and maintained aim, or goal(s)

 Each team member’s roles and responsibilities
 Communication messages and methods
 Limitations and boundaries
 Emergency procedures
 Individual expectations and concerns
 What defines a successful outcome
 Debriefing arrangements
 Team dismissal arrangements

APP1 - 5
  Opportunities for questions and clarification

A team’s effectiveness can also be improved through the selection of team members to
reflect a broad range of experience and skill sets, and also through practice and rehearsal.

Eg. An employee receiving word that a particular task is urgently required to be

performed, however, timely execution is intentionally delayed.

Build solid teamwork by :

• Discuss how a task should be done.

• Make sure everyone understands and agrees.

• Trust your teammates.

Fatigue
Fatigue may be considered to be a condition reflecting inadequate rest, as well as a
collection of symptoms associated with displaced or disturbed biological rhythms. Acute fatigue
is induced by long duty periods or by a string of particularly demanding tasks performed in a
short term. Chronic fatigue is induced by the cumulative effects of fatigue over the longer term.
Mental fatigue may result from emotional stress, even with normal physical rest. Like the
disturbance of body rhythms, fatigue may lead to potentially unsafe situations and a
deterioration in efficiency and well-being. Hypoxia and noise are contributing factor.

Eg. Long flights on auto pilot results in fatigue toward the end of the flight (ie. Landing)

Eliminate fatigue-related performance issues by:

• Watch for symptoms of fatigue in yourself and others.

• Have others check your work.

APP1 - 6
Lack of Resources
If all the parts are not available to complete a maintenance task, then there may
be pressure on a technician to complete the task using old, or inappropriate parts. Regardless
of the task, resources also include personnel, time, data, tools, skill, experience and knowledge
etc. A lack of any of these resources can interfere with one’s ability to complete a task. It may
also be the case that the resources available, including support, are of a low quality or
inadequate for the task.

When the proper resources are available, and to hand, there is a greater chance that we
will complete a task more effectively, correctly and efficiently. Therefore, forward planning to
acquire, store and locate resources is essential. It will also be necessary to properly maintain
the resources that are available; this includes the humans in the organisation as well

Eg. Employees were not equipped with a torque wrench; hence, all bolts were hand
tightened.

Improve supply and support by:

• Order parts before they are required.

• Have a plan for pooling or loaning parts.

Pressure
Pressure is to be expected when working in a dynamic environment. However, when the
pressure to meet a deadline interferes with our ability to complete tasks correctly, then it has
become too much. It is the old argument of Quantity versus Quality; and in aviation we should
never knowingly reduce the quality of our work. Pressure can be created by lack of resources,
especially time; and also from our own inability to cope with a situation. We may come under
direct, or indirect, pressure from the Company, from clients and even our colleagues. However,
one of the most common sources of pressure is ourselves. We put pressure on ourselves by
taking on more work than we can handle, especially other people’s problems, by trying to save

APP1 - 7
face, and by positively promoting super powers that we do not possess. These poor
judgements are often the result of making assumptions about what is expected of us.

Learning assertiveness skills will allow a worker to say ‘No’, ‘Stop!’, and communicate
concerns with colleagues, customers and the Company. These skills are essential, and when
deadlines are critical, then extra resources and help should always be obtained to ensure the
task is completed to the required level of quality.

Eg. Backlogged flight schools tend to overwork trainee pilots, forcing them to fly even
when they try to exercise their discretion to say no.

Reduce the burden of physical or mental distress by:

• Communicate concerns.
• Ask for extra help.
• Put safety first.

Lack of Assertiveness
Being both unable to express our concerns and not allowing other to express their
concerns creates ineffective communications and damages teamwork. Unassertive team
members can be forced to go with a majority decision, even when they believe it is wrong and
dangerous to do so.

Assertiveness is a communication and behavioural style that allows us to express

feelings, opinions, concerns, beliefs and needs in a positive and productive manner. When we
are assertive we also invite and allow others to assert themselves without feeling threatened,
undermined or that we’ve lost face. Speaking one’s mind assertively is not to be confused with
aggression. It is about communicating directly, but honestly and appropriately; giving respect
to the opinions and needs of others, but not compromising our own standards.

APP1 - 8
 Assertiveness techniques can be learnt and they focus on keeping calm, being rational,
using specific examples rather than generalisations, and inviting feedback. Most importantly,
any criticisms should be directed at actions and their consequences rather than people and
their personalities; this allows others to maintain their dignity, and a productive conclusion to
be reached.

Eg. Seeing and knowing the captain continue approach in extremely bad weather and
not preventing it.

Express your feelings, opinions, beliefs, and needs in a positive, productive manner by:

• Express concerns but offer positive solutions.

• Resolve one issue before addressing another

Stress
There are many types of stress. Typically in the aviation environment there are two
distinct types - acute and chronic. Acute stress arises from real-time demands placed on our
senses, mental processing and physical body; such as dealing with an emergency, or working
under time pressure with inadequate resources. Chronic stress is accumulated and results
from long-term demands placed on the physiology by life’s demands, such as family relations,
finances, illness, bereavement, divorce, or even winning the lottery. When we suffer stress
from these persistent and long-term life events, it can mean our threshold of reaction to
demands and pressure at work can be lowered. Thus at work, we may overreact
inappropriately, too often and too easily.

The situation of stress arising from lack of stimulation at work has been covered above
under Complacency above.

Some early visible signs of stress include changes in personality and moods, errors
of judgement, lack of concentration and poor memory. Individuals may notice difficulty
in sleeping and an increase in fatigue, as well as digestive problems. Longer-term signs of

APP1 - 9
stress include susceptibility to infections, increased use of stimulants and self-medication,
absence from work, illness and depression.

It is important to recognise the early signs of stress and to determine whether it is acute
or chronic. Coping with daily demands at work can be achieved with simple breathing and
relaxation techniques. However, perhaps more effective is having channels of communication
readily available through which to discuss the issue and help to rationalise perceptions. It is
entirely appropriate that some of these channels involve social interaction with peers. As
with fatigue, sleep, diet and exercise are all important factors in helping to reduce stress and
build resilience to stressors. If the stress is chronic, then definite lifestyle changes will be
required; this must be achieved with support from the Company. Companies ought therefore,
to have employee assistance (or wellbeing) policies that include stress reduction programmes.

Eg. An engineer at work, who has to deal with a demanding boss, a divorce and an ailing
father.

Manage stress before it affects your work by:

• Take a rational approach to problem solving.

• Take a short break when needed.

• Discuss the problem with someone who can help.

Lack of Awareness
Working in isolation and only considering one’s own responsibilities can lead to tunnel
vision; a partial view, and a lack of awareness of the affect our actions can have on others and
the wider task. Such lack of awareness may also result from other human factors, such
as stress, fatigue, pressure and distraction.

It is important to build experience throughout our careers, especially concerning the roles
and responsibilities of those we work with, and our own place in the wider Team. Developing
our foresight is essential in pre-empting the affects our actions may have on others. This is an

APP1 - 10
attitude of professionalism and involves constant questioning “what if …?” Asking others to
check our work and challenge our decisions is useful in gaining the relevant experience and
expanding our awareness. Vigilance is closely related to situational awareness, and workplace
procedures, such as scanning, two-way communication and use of checklists will help to
maintain vigilance.

Eg. The pilot commenced take-off, not realising that he had turned onto a runway under
construction (SQ006, Taipei).

See the whole picture by :

• Make sure there are no conflicts with an existing repair or modifications.

• Fully understand the procedures needed to complete a task.

Norms
Workplace practices develop over time, through experience, and often under the
influence of a specific workplace culture. These practices can be both, good and bad, safe and
unsafe; they are referred to as “the way we do things round here” and become Norms.
Unfortunately such practices follow unwritten rules or behaviours, which deviate from the
required rules, procedures and instructions. These Norms can then be enforced through peer
pressure and force of habit. It is important to understand that most Norms have not been
designed to meet all circumstances, and therefore are not adequately tested against potential
threats.

Rules and procedures should have been designed and tested, and therefore ought to be
enforced and followed rigorously. Where workers feel pressure to deviate from a procedure,
or work around it, then this information should be fed back so that the procedure can be
reviewed and amended, if necessary. Developing assertiveness can allow workers to express
their concerns about unsafe Norms, despite peer pressure.

APP1 - 11
 Eg. It is okay to chip off rust spots from the engine using a screwdriver. Using the de-
ruster costs money. Everyone does it, why not?

Help maintain a positive environment with your good attitude and work habits by:

• Existing norms don’t make procedures right.

• Follow good safety procedures.
• Identify and eliminate negative norms.

APP1 - 12
 Appendix 2

HUMAN FACTOR FOR PILOT

Introduction

We have seen from the previous chapter that oxygen is required by all the cells
and tissues of the body. Certain cells are much more sensitive to a lack of oxygen than
others. Brain cells for example will die if they are deprived of oxygen for as little as two
minutes. The oxygen required by the body is obtained from the air we breathe.
Whereas the brain only constitutes approximately 2% of body weight, it consumes
20% of the total required oxygen for the normal functioning of the body. Nitrogen is
also dissolved into the blood to a small extent but plays no part in the bodily processes.
However the importance of this nitrogen content and its role in decompression
sickness (DCS) is discussed in this chapter.

The level of carbon dioxide in the bloodstream has been referred to in the previous
chapter. It is this that triggers the brain to increase or decrease breathing. The higher
the carbon dioxide level the more the brain is stimulated to increase breathing and
thus increase the oxygen content. This, in turn, reduces the carbon dioxide content.
Once the brain senses that the level is normal, the breathing rate is reduced. Certain
cells in the brain also detect shortage of oxygen in the blood and will again trigger an
increase in respiration. Air is drawn into the lungs during inspiration, when the
intercostal muscles between the ribs acting in unison with the diaphragm increase
the volume of the chest cavity thereby reducing the internal pressure. Expiration is the
reverse process, achieved in normal breathing by relaxation of the above muscles.
This mechanism is sometimes referred to as external respiration. Under normal
conditions, external respiration is a subconscious process that occurs at a rate of 12
to 20 breaths/minute, averaging 16 breaths/minute.

Normal breathing is a purely automatic process. In some diseases such as

poliomyelitis the automatic system fails and an artificial respirator is required to
maintain respiration. Air entering the nose (where it is warmed, moistened and filtered)
and mouth passes into the trachea, which is a tube reinforced with cartilage rings. The

APP2 - 1
trachea divides into the left and right bronchi which take the air to the two lungs.
Within the lungs the airways become progressively smaller until they end in tiny sacs,
the alveoli. These sacs are very small but the normal lung contains thousands of them
giving a total area of some hundreds of square metres.

Hypoxic Hypoxia

The term for the effects of a shortage of oxygen is hypoxic hypoxia. This can
result from a number of reasons such as extreme anaemia, asthma and meningitis.
But the most important reason, as far as pilots are concerned, is altitude. Haemoglobin
at sea level is approximately 97.5% saturated with oxygen. At 10 000 ft this falls to
87% and thereafter falls off rapidly so that, at 20 000 ft, the haemoglobin is only 65%
saturated with oxygen. The symptoms of hypoxia may develop slowly at lower levels
or very rapidly at high altitudes.

Hypoxic Hypoxia Symptoms

Hypoxic hypoxia is a shortage of oxygen to the body which can be caused by, for
example, altitude, pneumonia or strangulation.

The symptoms of hypoxic hypoxia are:

Apparent personality change. A change in outlook and behaviour with euphoria or

aggression and lack of inhibitions. The very real danger of this was graphically
described in 1875 by G. Tissandier after his balloon flight to 25 000 ft, which proved
fatal to both his companions. The words still ring true today:

“But soon I was keeping absolutely motionless, without suspecting that

perhaps I had lost use of my movements. Towards 7500 m (24 606 ft) the
numbness one experiences is extraordinary. The body and the mind weaken
little by little, gradually, unconsciously, without one’s knowledge. One does
not suffer at all; on the contrary. One experiences an inner joy, as if it were
an effect of the inundating flood of light. One becomes indifferent; one no
longer thinks of the perilous situation; one rises and is happy to rise”.

APP2 - 2
Impaired judgement. Loss of self-criticism and individuals are unaware of their
reduced performance. Short-term memory loss exacerbates this condition and can
occur at approximately 12 000 ft.

 Headache (particularly if mildly hypoxic for a long period).

 Tingling in hands and feet.

 Increased rate of breathing - hyperventilation.

Muscular impairment. Finely co-ordinated movements become difficult through slow

decision making and poor fine muscular control. Handwriting becomes more and more
illegible. In the late stages of hypoxia, muscular spasms and convulsions may occur.

Memory impairment. Short-term memory is lost making drills difficult to

complete. This starts at approximately 12 000 ft.

Visual sensory loss. Vision is affected early. Colour perception is reduced and
peripheral vision is gradually lost. The light-sensitive cells of the eye are particularly
oxygen “hungry” and a deterioration of night vision can occur at altitudes as low as
5000 ft.

Tunnel vision develops making it necessary to make larger head movements to scan
the instruments and the external environment.

Impairment of consciousness. As hypoxia progresses the individual’s level of

consciousness drops until he/she becomes confused, then semi-conscious, and
unconscious.

Cyanosis. An individual who has become hypoxic at altitude is likely to be Cyanosed,

that is the lips and fingertips under the nails will develop a blue tinge, due to much of
the blood haemoglobin being in the deoxygenated state.

APP2 - 3
Formication. The hypoxic individual may experience formication, a creeping
sensation on the skin, as of ants crawling over the body.

Unconsciousness. The part of the mind which is inaccessible to the conscious mind but
which affects behavior and emotions

Death. The permanent ending of vital processes in a cell or tissue.

UNLESS HE OR SHE RECEIVES OXYGEN THE INDIVIDUAL WILL DIE

AND AT HIGH ALTITUDES DEATH CAN OCCUR WITHIN A FEW
MINUTES.

Stages/Zones of Hypoxia

Hypoxia can be classified by stages/zones of performance decrement. The 4 stages

are:

1. The Indifferent Stage/Zone GL - 10 000 ft (3048 m)

Dark adaption is adversely affected (can be as low as 5000 ft).
Performance of new tasks may be impaired.
Slight increase in heart and breathing rates occurs.

2. The Compensatory Stage/Zone 10 000 ft - 15 000 ft (3048 - 4572 m)

In this stage the physiological automatic responses provide some protection against
hypoxia trying to maintain homeostasis. These include:
 An increase in the respiratory volume.
 An increase in cardiac output and blood pressure.

However after a short time the effects of hypoxia on the CNS are perceptible causing:
 drowsiness.
 decreased judgement and memory.
 difficulty in performing tasks requiring mental alertness or very small
movements.

APP2 - 4
The Disturbance Stage/Zone 15 000 ft - 20 000 ft (4572 - 6092 m)

In the Disturbance Stage/Zone, the physiological compensatory mechanisms are no

longer capable of providing for adequate oxygenation of the tissues.

The symptoms include:

 Euphoria
 Dizziness
 Sleepiness
 Headache
 Fatigue
 Intellectual impairment and slow thought processes
 Memory impairment
 Motor performance is severely impaired
 Loss of judgement
 ‘Grey-out’ and tunnelled vision

The Critical Stage/Zone 20 000 ft - 23 000 ft (6092 - 7010 m)

 Mental performance deteriorates rapidly.
 Confusion and dizziness occurs within a few minutes.
 Total incapacitation with loss of consciousness follows with little or no warning.
Note: A healthy person is normally able to compensate for altitudes up to
approximately 10 000 - 12 000 ft.

Factors Determining the Severity of and the Susceptibility to Hypoxic Hypoxia

The most important factors in determining an individual’s likelihood of becoming
hypoxic are:

Altitude. The greater the altitude the greater the degree of hypoxia and the more rapid
the onset and progression.

Time. The longer the time exposed to high altitude the greater will be the effect.

APP2 - 5
Exercise (workload). Exercise increases the demand for oxygen and hence
increases the degree of hypoxia. Even the smallest of physical exertion will
significantly reduce the time of useful consciousness.

Extremes of temperature. Extremes of heat or cold place a heavy demand upon the
circulatory adjustments which the body has to make, and thus lower the tolerance to
hypoxia. At low temperatures we shiver in order to maintain body temperature, thus
increasing the demand for oxygen and so increasing the state of hypoxia.

Illness and fatigue. Both increase the energy demands of the body and lower the
threshold for hypoxia symptoms.

Alcohol/drugs. Alcohol affects metabolization and causes histotoxic hypoxia, thus

reducing the tolerance to hypoxic hypoxia. Many other drugs have adverse effects on
the brain function which may lead to hypoxia as altitude tolerance decreases.

Anaemic Hypoxia

Anaemic Hypoxia is caused by the inability of the blood to carry oxygen and may be
due to a medical condition (anaemia) or to carbon monoxide poisoning both of which
have been discussed in Chapter 2.

Smoking and Anaemic Hypoxia

Smoking produces carbon monoxide which is inhaled. As the haemoglobin in the red
blood cells has a much greater affinity to this carbon monoxide than to oxygen it
reduces the availability of haemoglobin to transport oxygen. Heavy smoking produces
8% - 10% carboxyhaemoglobin in the blood. A regular smoker will start to suffer from
hypoxia approximately 4000 ft - 5000 ft below that of a non-smoker.

The importance of aircrew being able to recognize hypoxia cannot be

overstated. It is of particular danger to inexperienced aircrew who may not
recognize the onset of the initial symptoms.

APP2 - 6
Treatment of Hypoxia
Knowledge of the signs and symptoms and early identification of the problem will allow
the correct drills to be carried out before anyone is placed in jeopardy but it is important
that these drills are well learnt and easily accomplished.

Principally:

Provide oxygen.

Descend to a level where atmospheric oxygen is present in sufficient quantities to

meet the body’s needs or to Minimum Safe Altitude (MSA), whichever is the higher.

Aircrew must familiarize themselves with the appropriate oxygen drills for the aircraft
they are flying before venturing above an altitude at which hypoxia can occur (above
10 000 ft).

Prevention of Hypoxia
Some of the factors predisposing to hypoxia are unavoidable risks of flying; others can
be reduced by good personal habits and forethought. Some pointers are:

When anticipating flying above 10 000 ft ensure that a serviceable supplementary

supply of oxygen is available and that the correct method of use is known.

Ensure that passengers are correctly briefed.

If you smoke - stop.

Fly only if you are 100% fit and you are not taking any medication or drugs.

Ensure that cabin heaters are thoroughly checked and serviceable. If used, ensure
that fresh air is also brought into the cabin.

Time of Useful Consciousness (TUC)

APP2 - 7
This is the time available for the development of hypoxia and the pilot to do something
about it, i.e. it is the time of useful consciousness. It is not the time to unconsciousness
but the shorter time from a reduction in adequate oxygen until a specific degree of
impairment, generally taken to be the point when the individual can no longer take
steps to help him/herself.

The time will depend on the individual, and will be affected by any or all of the following:

 Individual fitness
 Workload
 Smoking
 Overweight or obesity
 Decompression is progressive or explosive

The average times of useful consciousness at various altitudes are set out in the
following table.

Altitude Person seated or at Moderate activity

rest
20 000 ft 30 minutes 5 minutes
30 000 ft 1 – 2 minutes
35 000 ft 30 – 90 seconds
40 000 ft 15 – 20 seconds
Table 7. Times of Useful Consciousness at Various Altitudes

Hyperventilation

Hyperventilation can be defined as lung ventilation in excess of the body’s

needs and denotes an overriding of the normal automatic control of breathing by the
brain. Simply, hyperventilation is overbreathing. That is breathing in excess of the
ventilation required to remove carbon dioxide. Overbreathing induces a reduction in
the carbon dioxide and thus decreases the carbonic acid balance of the blood. This
disturbance of the acid balance has a number of effects, the major one being that
haemoglobin gives up its oxygen readily only in an acid medium.

APP2 - 8
 Hypoxia does cause hyperventilation but it is far from the only cause. Anxiety,
motion sickness, shock, vibration, heat, high g-forces, pressure breathing can
all bring on the symptoms of hyperventilation. A high standard of training breeds
confidence and decreases the chances of confronting unusual and stressful situations
and is, without doubt, the best means of preventing hyperventilation in aircrew. An
anxious passenger boarding an aircraft must be closely watched since
hyperventilation may take place even whilst still on the ground.

Symptoms of Hyperventilation

 Dizziness and a feeling of unreality.

 Tingling. Especially in the extremities and lips.

 Visual disturbances. Blurred, tunnelling and clouding vision.

 Hot or cold sensations. These may alternate in time and vary as to parts of
the body affected.

 Anxiety. Thus establishing a vicious circle.

 Loss of muscular coordination and impaired performance.

 Increased heart rate.

 Spasms. Just prior to unconsciousness, the muscles of the hands, fingers and
feet may go into spasm.

 Loss of consciousness. Hyperventilation can lead to collapse but thereafter

the body’s automatic system will restore the normal respiration rate and the
individual will recover.

APP2 - 9
Treatment of Hyperventilation
The classic way to treat a patient suffering from hyperventilation is to make him/her
breathe into a paper bag. The sufferer is then forced to inhale the carbon dioxide that
has been exhaled. The immediate effect of this is to increase the carbonic acid level
to its norm and the brain consequently reduces the breathing rate.

The symptoms can, in themselves, be alarming. In all cases try to calm the patient and
encourage her/him to slow down the rate of breathing.

Hypoxia or Hyperventilation?

The natural reaction to a shortage of oxygen is for the body to try to obtain more
air by breathing faster and deeper. The hypoxic individual may hyperventilate in an
effort to get more oxygen, but this is of little value when in an environment of low
ambient pressure.In flight it can be difficult to distinguish the symptoms of hypoxia and
hyperventilation. The appropriate response of pilots must be to assume the worst
and if they are at an altitude where hypoxia is a possibility they must take that to be
the cause and carry out their hypoxia drills. If symptoms occur at an altitude at which
hypoxia is not a consideration (below 10 000 ft) they should regulate the rate and
depth of breathing to restore the normal acid/base balance of the blood and alleviate
the symptoms. When flying below 10 000 ft significant symptoms of hypoxia are
unlikely and hyperventilation may be assumed.

DO NOT ASSUME HYPERVENTILATION IF IT COULD BE HYPOXIA

HYPERVENTILATION - AFTER UNCONSCIOUSNESS - RECOVERY
HYPOXIA - AFTER UNCONSCIOUSNESS – DEATH

Problems of Balance and Disorientation

Statistics have shown that spatial disorientation has been a contributory factor in 37%
of accidents in general aviation and 12% in commercial transport operations. It is the

APP2 - 10
most dangerous of conditions and over 80% of accidents resulting directly from
disorientation are fatal. The most well known example of disorientation among pilots
is “The Leans”.

Leans or Somatogyral Illusion.

The vestibular apparatus is not always sufficiently reliable to maintain an accurate
model of orientation. This condition is known as the leans or somatogyral illusion.
It can occur in all conditions of flight, and can persist for up to an hour after the event
causing it.

The two most common circumstances under which the ‘leans’ may be experienced
are: “The pilot commences a very gentle slow turn, so gentle that the movement of the
liquid is not enough to cause a detectable bending of the hair cells. Therefore, although
in a turn, the balance mechanism senses no change has been made. A subsequent
normal return to straight and level flight, will be detected as a turn from the straight
and level by the balance mechanism. The aircraft is now, in reality straight and level,
but the pilot feels that he is still turning.”

The pilot executes a prolonged turn to such an extent as to allow the hairs to erect in
the canals while still in the turn. This gives the pilot the erroneous feeling that he/she
is straight and level. As the pilot rolls out, the ends of the hairs move again to give a
false impression of a turn when - in fact - the aircraft is level.

In both the above, the pilot will be subjected to two conflicting signals. The visual sense
will tell him that he/she is level whereas the vestibular apparatus will tell him he/she is
turning.

If in IMC
BELIEVE YOUR INSTRUMENTS
If in VMC
LOOK OUT AT THE HORIZON

Illusions – General

We use mental models as frameworks to make sense of the world and guide
our actions. Mental models can be incomplete and thus faulty. In aviation the mismatch
between what we sense and what we expect is an illusion. In other words the

APP2 - 11
difference between perception and reality. Objects seen from the air look quite
different than when viewed on the ground. Because of the lack of stable visual
references and the erroneous mental models that may be produced, the pilot is at a
disadvantage. In addition, in flight, the pilot’s cognitive and sensory orientation
mechanisms have to try and cope with a third dimension to which they have not been
designed. This will lead to both mental and physical illusions.

Illusions may occur during all stages of the flight and to pilots of every
experience and skill level. The pilot, therefore, should be aware of the possibility of
misinterpreting the information received. Illusions can affect all of our senses but those
of particular concern in aviation are those which affect our visual sense and those
affecting the balance organs in the middle ear. We also possess a position sensing
system derived from nerve endings in the skin, muscles and joints which can be a
source of incorrect information passed to the brain.

Visual illusions are particularly dangerous in aviation as we normally consider

our visual input to be the most reliable of our senses.

Visual Illusions

Figure 53. Visual Illusions

Most people are familiar with the two dimensional figures in Figure 53.

APP2 - 12
In A the figure with the out-going fins appears to contain a longer line than the other,
although both are exactly the same length. We are not often going to see large finned
lines on our airfields but the natural scenery, the junction of two roads or railways, the
alignment of valleys, even a small runway running into the corner of a field where
hedges meet can give a false impression of runway length.

In B the upper of the two horizontal lines appears the longer, but they are the same
size.

In C the vertical straight lines appear curved, but they are straight.

In D which line passes through the two vertical parallel lines? Try it with a straight
edge.

Other visual illusions involve a perceived depth appreciation.

An Illusion of Movement

Move the page slowly away then towards the face while concentrating on the central
dot

Figure 54. Illusion of Movement

Atmospheric Perspective
Visual illusions in flying are often associated with inappropriate experiences. For
example the pilot who has done most of his flying in relatively polluted air may have

APP2 - 13
learned to use ‘atmospheric perspective’ as a good cue to range. If the pilot then
operates in a very clear atmosphere he/she may believe distant objects, because of
their clarity, to be much closer than they actually are, or mistake the distant object for
a similar, smaller, object he/she was expecting to see close by - both the expected
and actual object will give the same angular size on the retina.

A number of accidents have occurred in the polar regions in VMC when the pilots have
miscalculated the distance to a landing spot situated close to a landmark with the result
that the aircraft has run out of fuel.

Other Sources of Illusions

The Gestalt Theory

Our senses - sight, hearing, touch etc. - do not account for all the sensory
illusions. Sometimes the perception is correct, but comprehension and identification
may be in question. The human brain is continually working on the construction of
mental models. The Gestalt Theory (from the German word gestalt = shape) of
learning proposes that any individual’s understanding of the world results from sorting
out and combining multiple cues perceived in the environment until a ‘coherent whole’
appears that is acceptable according to the individual’s standards as regards the
world. Gestalt psychologists propose that perception, rather than being a simple
repeated association between a stimulus and a response, is an active construction of
an object by the brain.

Laws of Perceptual Organization

To reach this ‘coherent whole’ the brain has developed a set of rules about the
combination of all the cues available. These rules are the laws of perceptual
organization of the Gestalt Theory and deal with factors such as proximity, continuity,
similarity, symmetry, simplicity and closure. In many cases an individual will add cues
which are not in the environment, and which the brain thinks are hidden or not visible
in what has been perceived. Basically, Gestalt laws formulate basic principles
governing how objects are organized and perceived.

As an example of the application of the Gestalt laws it is possible to make sense

out of a number of words where half of the letters have been removed. The brain of

APP2 - 14
the observer will ‘fill in’ the missing portions of the text to match what he believes is
correct. The danger in this is that what the individual fills in will depend greatly on that
individual’s previous experience and expectation. Consider the following ...... P y ol g
st. A psychology student would probably read it as - Psychologist whereas a biology
student could read Physiologist.

One must use extreme caution to ensure that we do not construct our mental model
according to our wishes or desires.

Illusions When Taxiing

Relative Movement
Even on the ground we are not free of illusions. A loading bridge moving away
from the aircraft may give an illusion that it is the aircraft that is moving. When arriving
at a gate which itself may be moving the pilot may believe that the aircraft is stationary
and apply the parking brake, perhaps causing cabin staff to be thrown forward with the
danger of injury.

Blowing snow may give a false impression of relative speed. When an aircraft is taxiing
with a tailwind, the snow may appear to be falling vertically, giving the impression that
the aircraft has stopped, when in fact it may still have a relatively fast taxiing speed.
Application of the parking brake in these circumstances again could have serious
consequences. Alternatively the aircraft could creep forward, colliding with an
obstacle, when it was thought to be stationary. When taxiing into a headwind the
blowing snow will give the illusion that the aircraft is taxiing faster than is the fact. In
either case the pilot must look out of the side cockpit windows to gain an accurate
assessment of taxi speed.

Cockpit Height above the Ground

Pilot eye height from the ground may be the source of misjudged speed. Pilots
converting to an aircraft with an eye position that is higher than on their previous type
(8.66 m above the ground on a 747 compared with 3.48 m on a DC9) will have their

APP2 - 15
normal visual references at a greater distance, which will give the illusion of slower
relative motion, and in the initial stages of training they may well taxi at excessive
speeds as a result.

Illusions in the Cruise

Autokinesis
Staring at an isolated and stationary light when other visual references are inadequate
or absent, may cause autokinetic movements of the eyes. This gives the illusion that
the light is moving and can lead the pilot to believe that a single star is another aircraft.
Numerous cases have been reported of mistaken identity of lights. These illusions can
be avoided by shifting the gaze to eliminate staring. The illusion is created by small
movements of the eye ignored by the brain and interpreted as motion of the object.

Vertical Separation
A common problem in flight is the evaluation of the relative altitude of approaching
aircraft and the assessment of a potential collision risk. At a distance an aircraft may
appear to be at a higher level but may eventually pass below the observer. Mountains
or clouds at a distance tend to appear to be above the aircraft but often pass below.

Holding
In civilian transport flying the normal manoeuvres are unlikely to create significant
vestibular illusions. However, prolonged turning as in a holding pattern can create an
illusion if the head is moved while still turning (vertigo - sometimes referred to as the
somatogyral illusion - or coriolis effect).

Approach and Landing

50% of all airline accidents occur on the approach and landing and, of all the phases
of flight, this is the one most prone to human error (73%). In the final stages of a flight
the pilot has to cope with the most critical visual tasks, and these may be divided into
3 stages:
 Initial judgement of glideslope.
 Maintenance of the glideslope.
 Ground proximity judgements.

APP2 - 16
Initial Judgement of Appropriate Glideslope

Visual Angle
The judgement of the glideslope can be made easier by the use of VASIs or PAPIs at
the airfield, or by positioning the aircraft at a predetermined height above known
ground features. However, the judgement must frequently be made without such aids.
To judge the approach path, normally 3°, the pilot is attempting to establish an angle.
This angle is the visual angle, (see Figure below) and is measured at the pilot’s eye
down from the horizon to the visual aiming point on the runway. This, of course, is
equal to the approach angle.

Figure 55. Visual Angle

Coping with Stress

Stress Awareness
In order to cope with stress it is fundamental that there is an awareness
that the problem exists. An individual who recognizes the fact that he/she is suffering
from stress is a long way along the road to identifying the source(s) and overcoming
the problem. Once recognized, the object is to change our attitudes or our environment
in order to re-establish harmony between the two.

Among any population there is a wide variation in how stress is perceived. At

one extreme, individuals suppress knowledge of problems and thereby appear not to
perceive them or require stress coping strategies. At the other extreme are those who
are highly sensitive to problems and will anticipate difficulties not perceived by others
and employ coping strategies to avoid the stress experience.

Coping strategies may be classified into three categories:

APP2 - 17
 Action Coping.
 Cognitive Coping.
 Symptom Directed Coping.

Action Coping
In action coping the individual attempts to reduce stress by taking some
action. He reduces the level of demand by either removing the problem or changes
the situation so that it becomes less demanding. For example a pilot asked to fly in
marginal conditions could refuse, thus removing the immediate stressor. However, this
action could lead to another stressor - loss of employment. The demand could be
changed, however, by delaying take-off for a few hours when the weather is forecast
to improve. In this case, reducing the perceived demand of the original task, without
substituting another stressor. The individual may also hand over some tasks, either to
other crew members, or to Air Traffic Control by asking for, as an example, assistance
in navigation. The individual may remove himself from the stress situation by changing
his job, or in the case of domestic stress, by divorce. These methods may, however,
only substitute one source of stress for another. Clearly in many cases it is impossible
to undertake this kind of solution.

Cognitive Coping
As action coping cannot change some situations, cognitive coping involves
reducing the impact of stress on the individual. Our brain can employ ‘defence
mechanisms’ which operate outside our conscious awareness; a system of repression
or denial to prevent the conscious brain from even becoming aware of the stressor.
Other strategies involve rationalization or detachment which may change the
perceived magnitude of the problem. “Pretend it’s a simulator detail the same as the
one you did last week” will enable the conscious mind to perceive the problem as
having a solution.

Symptom Directed Coping

APP2 - 18
 Some of the symptoms of stress may be relieved by the use of drugs. In this
context the drugs may be relatively simple such as coffee or tea. Other cases may be
eased by the use of alcohol or tobacco. It must be emphasized that only the symptoms
are treated by this form of coping and that the stressor(s) will remain until addressed
separately.

Coping with Stress on the Flight Deck

Coping is the process whereby the individual either adjusts to the

perceived demand of the situation or changes the situation itself. Some coping
changes appear to be carried out unconsciously; it is only if they are unsuccessful that
we consciously take note of the stressor. To reduce the effect of stress in flight involves
mainly psychological mechanisms and includes behavioural patterns which can be
learned.

Individually one must learn and acquire experience to develop automatic responses
which cost little in energy and strongly resist stress:

A thoroughly professional approach to training will increase the range of responses

available to the individual and will reduce the chances of meeting unknown situations.
Hence the emphasis on regular simulator flights when any emergency can be
practised in a safe environment.

One should learn from the past, including the experience of others.

Thorough preflight briefing and preparation will allow the individual to anticipate
events. The pilot must be prepared for all incidents which could, plausibly, arise during
the flight.

Crew Resource Management (CRM) will teach techniques for sharing and allocating
tasks to prevent any one individual becoming overloaded and will highlight the
effective use of all members’ knowledge to increase the range of possible responses.
It should improve everyone’s awareness of the situation, and, by combined efforts,
allow for the creation of new ideas.

APP2 - 19
A good atmosphere on the flight deck is a great help in a stressful situation and humour
can be an effective antidote to stress.

There are five major guidelines to prevent stress affecting safety:

 Keep it simple and basic - fly the aircraft.

 Accept the situation - do not attempt to conceal the facts or danger.
 Use all crew resources (group support).
 The captain (unless incapacitated) must make the decisions and control the
situation.
 Never give up: there is always a suitable response.

Acceleration
Acceleration is the rate of change in velocity, either as regards to speed or direction
or both. Man is exposed to the forces of acceleration in one form or the other almost
constantly throughout flight. Acceleration is referred to in aviation medicine as:
 Linear.
 Radial (centripetal).
 Angular.

Difference between Radial and Angular Acceleration

Angular acceleration involves rotation about an axis which passes through the
pilot’s body whereas radial (centripetal) is where the axis is external to the pilot. Thus,
when a very gentle turn is initiated, the body will initially experience angular
acceleration but, as the turn develops, both angular and radial accelerations are
experienced. The effects of acceleration on the human body may be classified into
long or short duration accelerations. In long duration acceleration the force will act for
longer than one second. In the case of short acceleration, which lasts for one second
or less, we are mainly concerned with impact forces.

G-forces
The human body has adapted to live under the force of gravity on the earth (the
pull of the earth’s gravity giving the body weight). Acceleration in an aircraft can subject
the body to forces much greater than this. For convenience, the forces are measured

APP2 - 20
as multiples of our 1g terrestrial environment. Acceleration in the fore and aft (the
horizontal) plane is referred to as Gx, whereas acceleration in the lateral plane (side
to side) is known as Gy. However the usual g-force encountered in aviation is that in
the vertical plane which is termed as Gz.

Effects of Positive G-force on the Human Body

In long-term positive acceleration, the changes in g-force are perceived as:

An increase in body weight so that limbs become harder to move, the head
becomes heavy (2g and above). Mobility is impaired, for example, if the head is
lowered it may be impossible to raise it again. At 2.5g it is impossible to rise from the
sitting position.
Internal organs are displaced downwards from their normal positions and the lower
facial area feels “pulled down” (3-4g and above).

An increase in hydrostatic variation of the blood pressure. Normally the blood

pressure in the legs and lower body is greater than that at the heart. As the positive g-
forces increase so the hydrostatic variation increases. The result is a pooling of blood
in the lower body with a reduced venous return to the heart. There is a consequent
reduction of blood pressure in the head and blood supply to the brain, heart and eyes
with an increased blood pressure at the feet.

The photosensitive cells of the eyes (rods and cones) need a disproportionate amount
of oxygen from the blood. Positive g-forces reduces the amount of oxygen available,
thus causing a ‘greying out’ (3-4g) as vision is affected. It also induces a tunnelling
of vision as the eye cells at the edge of the retina, being furthest from the blood supply,
suffer first. Eventually (above 5g) the individual will lose consciousness “blackout” -
now more commonly referred to as G-LOC. The effects of blacking out disappear
almost as soon as the g level is reduced, although the individual will be confused for
a few seconds and may have difficulty in focusing his/her eyes.

 Inspiration difficulties due to the lowering of the diaphragm (4-5g).

 Loss of sensory functions (above about 8g).

APP2 - 21
  Cramping of the calf muscles. At very high g-forces haemorrhages can occur
about the legs and feet.
 At extreme g-forces, fracture of the vertebrae and death will occur due to lack
of venous return to the heart.

Long Duration Negative G

In negative g situations, such as inverted flight, outside loops, and some forms
of spinning, the symptoms can be more uncomfortable than those caused by positive
g. Organs are forced upwards and blood is forced into the region of the head thus
affecting the hydrostatic variation. The individual will experience respiration difficulties,
facial pain and lower eyelid will be pushed up giving rise to ‘redout’ vision. Additionally
the upward flow of blood causes a slowing of the heart. With high negative g, the small
blood vessels in the face and eye may burst.

Short Duration G-forces

Short duration g-forces are concerned with impact forces. The maximum tolerable
levels are determined by the strength of various parts of the body. The human body
can stand short-term g-forces of surprising magnitudes.

Susceptibility and Tolerance to G-forces

Susceptibility
The ability to withstand even moderate g-forces is reduced by the following factors:

 Hypoxia.
 Hyperventilation.
 Hypotension.
 Stress.
 Fatigue.
 Heat.
 Low blood sugar.
 Smoking.
 Obesity.
 Alcohol.

APP2 - 22
Factors That Increase Tolerance to Long Duration G-forces
The normal relaxed individual will usually be able to withstand or tolerate about
+3.5g without serious effects such as greying out, other visual disturbances, or
unconsciousness. The factors that can increase tolerance are:

Body Position
It has been found that, while in the sitting position, by raising the knees and feet
and bending the trunk forward from the hips has a small benefit in delaying the effect
of blackout. Firstly it decreases the vertical distance between the lower limbs and the
heart, and secondly, it causes the acceleration force to drive the blood in the thighs
towards the heart instead of away from it. Certainly lying in the prone or supine
positions go a long way to eliminate the hydrostatic variation and it has been known
for the human being to tolerate up to 12G in this position before blacking out.

Voluntary Manoeuvres
It is possible to raise the g tolerance by about 1-1.5g by taking a number of
physical actions. The principle underlying the first three of the following manoeuvres
is to raise the pressure in the abdominal cavity, so as to maintain the level of the
diaphragm and facilitate the return of the venous blood. This can be done by:

 Straining.
 Shouting.
 Tensing leg muscles

It is essential that these measures are kept short and intermittent since they cause
fatigue and will have a negative effect if prolonged.

Anti-g Straining Manoeuvre

This is now widely accepted as a means of combining the beneficial effects of
the manoeuvres listed above. It is a combination of muscle tensing and the valsalva
manoeuvre performed rhythmically every 3 to 4 seconds.

Anti-g Suits

APP2 - 23
 The object of the suit is to provide more counter-pressure to the lower limbs
and help to maintain the level of the diaphragm. The operation is automatic and
varying pressures are delivered to the suit according to the g level experienced.
Combined with the anti-g straining technique, the tolerance level can be increased
by 1.5 to 2g, however these techniques are normally confined to military flying. The
tolerance for negative g-forces is much lower being only -3g. This level can only be
tolerated for a few seconds.

Short Duration Positive (Impact) g-Forces

The body can tolerate at most 25g in the vertical axis and 45g in the fore and
aft axis. Forces above these levels will cause serious injury and death.The lap strap,
as worn by airline passengers, is the simplest form of restraint. Although tolerance is
increased when correctly fitted, the body may jackknife over the belt causing injury
as the head strikes a forward structure. Knees can be severely damaged and
compression of internal organs may also result The five point harness with the anti-
g or crutch strap, offers the best protection as the lap and diagonal and four point
harnesses found in most general aviation and some commercial aircraft do not give
complete protection against submarining (sliding under the harness that can occur
in some impact situations).

Summary of G Tolerances

Long duration (More than 1 second)

+ 3.5g in relaxed subject.

+ 7 to +8g using anti-g straining techniques.
- 3g but only for short periods.

Short duration (Impact forces)

25g in vertical axis.

45g in fore/aft axis.

APP2 - 24
 Remember: The effects of acceleration are mainly cardiovascular and
pulmonary but it can also produce perceptual disorders and
neurosensory illusions.

AGGRAVATING CONDITIONS

Barotrauma

Barotrauma is pain caused by the expansion and contraction, due to outside

pressure changes, of air trapped in the cavities of the body, notably within the
intestines, middle ear, sinuses or teeth. Barotrauma can cause discomfort or extreme
pain sufficient to interfere with the pilot’s ability to operate the aircraft.

Otic (Middle Ear) Barotrauma

Pressure is normally equalized across the eardrum by the eustachian tube
leading from the middle ear to the back of the mouth/nose. There is seldom any
problem in the climb when air passes from the middle ear to atmosphere. Most
problems occur in the descent when air is attempting to return to the middle ear. The
end of the eustachian tube acts as a flap valve which allows air to escape with relative
ease (required in the ascent) but can restrict air entering the middle ear (required in
the descent). With a reduced pressure in the middle ear the increasing pressure
outside will cause a distortion of the ear drum and sometimes extreme pain. The
severity of otic barotrauma depends upon the rate of climb or descent. It occurs mainly
at lower levels where pressure changes are the greatest.

The problem is increased if the person has a cold or any other condition which has
caused the mucous membrane lining the eustachian tube to become inflamed and
swell. One or both ears can be affected and will cause:

 Pain (gradual or sudden), which can radiate to the temples.

 Temporary deafness.
 Pressure Vertigo.
 Tinnitus (a ringing in the ears).
 Rupture and bleeding of the ear drum in extreme cases. This may cause
deafness.

APP2 - 25
  It is most important that pilots ensure that, having suffered from otic
barotrauma, they are in a perfect state of health before returning to flying. If the
resumption of flying takes place prior to a complete recovery, this can lead to
further damage to the system which may result in a chronic state and the risk
of infection.

“Clearing the Ears”

Care also must be used when “clearing the ears” by blowing down a held nose with
the mouth closed (Valsalva Manoeuvre). A violent usage of this method may cause
pressure vertigo. Less severe methods include:

 The Frenzel Manoeuvre (similar to stifling a sneeze).

 Swallowing with the nose held.
 Yawning.
 Moving the lower jaw from side to side.

These methods should only be used for equalizing pressure in the middle ear during
the descent. Should all these methods fail, a landing should be made as soon as
practicable and medical assistance sought from an aviation medical specialist.

Sinus Barotrauma
Sinuses are cavities within the skull which are air-filled and their function is to
make the skull lighter and the voice resonant. They are situated above the eyes, in the
cheeks and at the back of the nose and are connected to the nasal cavity by narrow
ducts. These tiny ducts can become swollen or obstructed allowing air to become
trapped within the sinuses. As with the ears, the sinuses can vent air more easily in
the ascent than they allow gas to re-enter in the descent. Thus the painful results
normally occur in the descent if the sinuses are infected by a cold or influenza.

The pain, which normally starts around the eyes spreading to the temples, can
be so severe as to render the pilot quite incapable of maintaining control of the aircraft.
Fainting due to such pain is not unknown. Associated with the pain is a watering of the
eyes making vision difficult and, in addition, bleeding from the nose may occur.The

APP2 - 26
immediate treatment is to return to the altitude where the pain first became apparent.
The flight should then be terminated with a return to ground level at as slow a rate as
possible.

Note: Unlike otic barotrauma, the pain suffered due to sinus barotrauma may be
equally as acute in the climb or the descent.

Barotrauma of the Teeth (Aerodontalgia)

Healthy teeth do not contain air but gas pockets can form in old or poor
fillings or abscesses. Aerodontalgia is most common in the ascent as the gas expands,
perhaps pressing on a nerve, and can cause severe tooth pain. Good dental care and
hygiene can prevent any problem.

Gastrointestinal Barotrauma
The Gastro-intestinal tract is, in effect a tube from the mouth to the anus.
Air can be swallowed along with food and the digestive processes produce gas. Gas
collecting in the stomach can easily escape through the mouth whereas at the other
end of the system, gas in the large intestine, mostly caused by the action of bacteria,
can readily be vented to the outside (known as “passing flattus”).

The main problem is gas in the small intestine. It has no easy exit from the
system at either end and will expand causing discomfort and sometimes pain
sufficiently severe to cause fainting. Very occasionally the wall of the intestine may
tear. There is no easy way to relieve the symptoms during flight except by descending
but the effects may be greatly reduced by:

 Avoiding foods which are high gas producers (raw apples, cabbage, cauliflower,
celery, cucumber, beer, beans, any highly spiced foods such as curries) before
flight.
 Eating slowly and not rushing meals, especially just before flight.
 Eating smaller portions (less swallowed air).
 Not using chewing gum (less swallowed air).

Lungs

APP2 - 27
 The lungs contain a large volume of gas but there is easy communication to the
outside air so that pressure changes are rapidly dealt with. The only potential risk is
from a very rapid decompression but, provided the individual breathes out during this
stage, lung damage is extremely rare.

Plaster Casts
It is worth noting that air trapped within plaster casts will expand and can cause
acute distress to the wearer. If in doubt, passengers’ casts should be split prior to take-
off especially if the flight is to be lengthy.

Toxic Hazards
Aviation involves the use of many substances that are themselves toxic or have
the potential to become so in a fire, releasing dangerous fumes which may be inhaled.
In some cases, raised temperature and lowered atmospheric pressure are significant
factors in producing or aggravating toxic effects.
Even mild toxic effects can lower an individual’s performance which can result
in an aircraft accident.

Fuels, lubricants and propellants can release vapours which may cause
drowsiness or irritation to the respiratory system, together with skin damage.
Hydrocarbon and lead tetra ethyl can effect the nervous system causing a loss of
sensation. If the sense of smell is affected, an individual’s awareness of continued
exposure may be reduced.

Anti-icing fluid gives off fumes which, if allowed to enter the fuselage, can be
harmful. Ethylene glycol, which is often used, can cause kidney damage.

Fire Extinguishing agents, (particularly Halon 1211 or BCF) may cause

suffocation, lung irritation, dizziness, confusion and coma.

Agricultural chemicals, although not normally carried by commercial aircraft,

can cause health problems. Some insecticides can be as poisonous to people as they
are to pests and even at low trace levels can result in vomiting, diarrhoea, tremors and
coma.
APP2 - 28
 Mercury is exceedingly corrosive and poisonous and, in addition, its vapour is
highly toxic. Mercury is still used in instruments and gyroerection systems of a number
of old aircraft. It may be found in the thermometer carried as part of the first aid kit in
modern aircraft. In the event of contact with mercury, you should at once wash in
quantities of hot water followed by soap and hot water. Should the vapour be inhaled
immediate and urgent medical treatment must be sought.

Mercury spillage in an aircraft can lead to catastrophic results. It attacks

aluminium by a chemical reaction known as amalgamation. In this process, the
mercury attacks the grain of the alloy and, in an exceedingly short time, will completely
destroy it. Mercury will flow through minute cracks to get to the lowest part of the
structure where it will cause extensive damage. Extreme care must be exercised when
removing spillages and on no account should an attempt be made to blow it with
compressed air as this will only scatter it and increase the risk of further damage.
Vacuuming is the best method.
Batteries, if fitted incorrectly, can leak corrosive liquid and dangerous vapours.

Ozone, a variant of oxygen, is highly toxic when inhaled, even in small

quantities. It is an irritant to the lungs and can cause severe headaches. It also impairs
night vision. The amount of ozone in the air increases above 40 000 ft but during the
winter months the low tropopause may mean that there are significant amounts at
much lower levels. Fortunately most aircraft effectively break down excess ozone at
the compressor stage of cabin air supply through catalytic converters before it enters
the cabin. Although present mainly in the stratosphere, ozone is not considered a
component in the composition of the atmosphere. Ozone is a very corrosive gas which
is toxic to living organisms.

Furnishings and baggage. In case of fire on board an aircraft, some cabin furnishings
and plastic or foam upholstery give off poisonous fumes as they are heated. There is
also the risk that luggage may contain lethal items which may not have been detected
during routine screening. The tragic Saudia Tristar aircraft accident, which killed over
300 people as a result of toxic fumes, is a prime example of this very real danger.

APP2 - 29
Plastic coated electric wires can be a source of highly toxic fumes when burnt. If the
concentration is high enough damage to the central nervous system can occur.

Exhaust gases must be avoided at all times as they contain carbon monoxide. Be
especially aware of this when on the apron and while carrying out preflight inspections.
The effects and dangers of carbon monoxide have already been discussed.

Acetone and Turpentine, which are both used in aviation, can damage mucous
membranes and eyes.

Individuals who have been exposed to any toxic hazard should seek medical
assistance as soon as possible from an aviation specialist.

Body Mass Index (BMI)

Body Mass Index is the measure of a person’s weight in relation to a normal standard.
The following formula is used to calculate the BMI of an individual.

BMI = ( )²

A BMI of:

Up to 20 for males or up to 19 for females = Underweight.

Between 20 and 25 for males or between 19 and 24 for females = Normal.

Over 25 - 30 inclusive for males and over 24 - 29 for females = Overweight.

Over 30 for males or 29 for females = OBESE.

Thus a male with a height of 1.80 metres and weighing 85 kilograms has a BMI of
26.23 indicating that he is overweight. BMI is also known as The Quetelet Index.

Backache

APP2 - 30
There are a number of back complaints from which flight crew can suffer. These can
range from unspecific back pains to a slipped disk.

Aircrew should be aware of the importance of a good sitting position in flight and the
correct setting of the seat lumber support provided. In-flight exercise can help if and
most problems can be cured by physiotherapy treatment.

Obesity

Obesity, which tends to be genetic, is the term for an excess of fatty tissue in the body.
An individual who is obese is susceptible to:

 Heart attack.
 Hypertension (high blood pressure) with the higher risk of a stroke.
 Hypoxia at lower altitudes than normal.
 General circulation problems.
 Gout (painful inflammation of the joints due to an excess of uric acid).
 Osteoarthritis (wear and tear on the joints).
 Diabetes.
 G-forces.
 Problems with joints and limbs due to weight.
 Decompression sickness (DCS).
 Heavy sweating.
 Chest infections.
 Varicose veins.
 A reduced life expectancy.

Losing Weight

If an individual is overweight or obese there are obvious advantages in losing

weight. There is no magic formula or secret dietary method to reduce weight. Any food
taken in has to be balanced by the energy output. Any excess is stored in the body as
fat. The only practical way to lose weight is to eat less from a balanced diet containing
the right mix of carbohydrates, protein and fat. The use of “crash diets” must be
avoided. They are normally ineffective in the long term and may cause dangerous

APP2 - 31
physical and emotional symptoms. The overall objective must be to introduce new
habits of eating, with a change in frequency, size and content of meals. On no account
should appetite suppressants be taken unless under the direct supervision of an
aviation medical specialist.

Exercise
Exercise promotes both mental and physical fitness and a sense of well-being
but the amount of exercise required to burn off excess weight is so high that it is not a
practical solution to obesity. Those who do take regular exercise can cope with fatigue
much better and their resistance to stress is improved. As pilots are required to sit for
long periods of time, regular exercise is of particular importance.
To be effective in reducing coronary artery disease, exercise must be regular and
sufficient to raise the resting pulse rate by 100% for at least 20 minutes, three times a
week.

Playing squash or tennis, swimming, jogging and cycling provide good exercise.
Playing a round of golf or walking the dog may be pleasant but provide insufficient
exercise to benefit the individual physically.

Composition of the Standard Atmosphere - Humidity, Gas Laws and Partial

Pressure

The Standard Atmosphere

The ICAO Standard atmosphere is defined as follows:

 MSL temperature of +15°C.

 MSL pressure of 1013.25 hPa (760 mm Hg).
3
 MSL density of 1225 g/m

A lapse rate of 1.98°C/1000 ft (6.5°/km) up to 36 090 ft (11 km) thereafter the

temperature remains constant at -56.5°C up to 65 617 ft (20 km).
The altitudes in the standard atmosphere that pressure will be ¼, ½ and ¾ of MSL
pressure is approximately:

 ¼ MSL - 36 000 ft
 ½ MSL - 18 000 ft

APP2 - 32
  ¾ MSL - 8000 ft

Note : Atmospheric pressure decreases at a faster rate at low altitudes than at

higher altitudes

Composition of the Atmosphere

The atmosphere is made up of:
 21.0% oxygen
 78.0% nitrogen
 0.93% argon
 0.03% carbon dioxide
 0.04% rare gases
These volume percentages for each of the gasses remain constant to about 70 000
ft - well within the altitudes at which conventional aircraft operate. For the pilot oxygen
is the most important of these gases.

Humidity and Relative Humidity - Definitions

Absolute Humidity. The weight of water vapour in unit volume of air which is
usually expressed in g/m³.

Relative Humidity. The amount of water vapour present in a volume of air

divided by the maximum amount of water vapour which that volume could hold at that
temperature expressed as a percentage.

BOYLE’S LAW states that:

“Providing the temperature is constant the volume of gas is inversely
proportional to its pressure”. (Otic and gastrointestinal tract barotrauma,
aerodontalgia).

CHARLES’ LAW states that:

APP2 - 33
 “The volume of a fixed mass of gas held at a constant pressure varies directly
with the absolute temperature”.

THE COMBINED GAS LAW states that:

“The product of the pressure and the volume of a quantity of gas divided by its
absolute temperature is a constant”.

Partial Pressure. Looking closer at Dalton’s Law with regards to the

atmosphere, it is well-known that the total pressure decreases as altitude increases.
As the proportion of oxygen remains constant it follows that the partial pressure of
oxygen must also reduce. In dealing with the pressures at various altitudes instead of
hectopascals/millibars used in other subjects such as Meteorology or Instruments, the
unit of measurement is the millimetre of mercury (mm Hg). At sea level the standard
pressure is 760 mm Hg. As oxygen is 21% of the total then the partial pressure of
oxygen is twenty one hundredths of 760 - 160 mm Hg.

Humans operate best at sea level but they are perfectly capable of operating at
higher altitudes where the partial pressure of oxygen is lower. People who live
permanently at high altitudes can adapt to the reduced amount of oxygen by producing
extra red blood cells to enable more oxygen to be carried. Healthy people without
these extra cells can function normally up to about 10 000 -12 000 ft provided no
strenuous exercise is undertaken.

As altitude increases the overall pressure decreases as does the partial

pressures of the various gases in the atmosphere. The partial pressure of oxygen in
the air is not, however, the governing factor. The reason being that the body takes its
oxygen from the alveoli of the lungs where the partial pressure is less. The body
produces carbon dioxide and water vapour which is passed into the alveoli.

As the total pressure both inside and outside the lungs remains the same then
the partial pressure of oxygen must reduce. The table following shows the partial
pressures of the various gases in the atmosphere and in the alveoli at various altitudes.

Cabin Decompression

APP2 - 34
 Loss of cabin pressurization can occur in flight. The rate of loss may be slow,
with the crew recognizing the problem and making appropriate height reductions
before the passengers are aware of anything amiss. Very occasionally there is rapid
decompression perhaps due to the loss of a window or door, or a failure in the
fuselage. Occupants, crew and passengers, will rapidly be exposed to the full rigours
of high altitude: hypoxia, cold, decompression sickness. Oxygen can be supplied to all
occupants but for only a limited period.

THE AIRCRAFT MUST RAPIDLY DESCEND

TO 10 000 ft OR MSA WHICHEVER IS THE HIGHER
In cases of rapid decompression the altitude of the cabin may actually rise to
above the pressure altitude. The Venturi effect of air passing over the fuselage can
suck air out of the cabin; this can make up to 5000 ft difference in pressure terms.

Another effect of decompression at height is that, due to the sudden drop in

temperature within the aircraft, windows and cockpit windshields will be prone to
misting or fogging.

It is most important to emphasize that crew protection must be the highest

of priorities. Should decompression take place it is critical for the crew to
individually don oxygen masks and check flow as quickly as possible. Any delay
caused by helping other members of the crew or passengers could have
catastrophic results for all the occupants of the aircraft.

Decompression Sickness (DCS)

As we have seen, the gas making up the major part of the air - nitrogen - is
dissolved in the blood to a small extent but plays no part in the normal bodily
processes. It may however cause severe problems if the nitrogen should come out of
solution as small bubbles. It can be likened to the bubble formation in fizzy drinks when
the top of the bottle is opened and the pressure allowed to drop. If this occurs in the
human body and nitrogen bubbles are formed in the blood, the process leads directly
to DCS.

APP2 - 35
 Body exposure to reduced pressure can lead to DCS since the body is normally
saturated with nitrogen. When ambient pressure is abruptly reduced some of this
nitrogen comes out of solution as bubbles. Any ascent to altitudes over 25 000 ft is
normally associated with DCS however it is more likely the higher and longer the
exposure to altitudes above 18 000 ft. It is unlikely to occur below 14 000 ft. Ultimately
the individual may collapse and in rare cases DCS may occur or persist after descent
and go on to cause DEATH. Hypoxia and cold increase the risk as does age and
excess body mass/obesity.

The primary symptoms are:

Joints. Bubbles in the joints (shoulders, elbows, wrists, knees and ankles) cause
rheumatic-like pains called the bends. In aviation the shoulder, wrist, knee and ankles
are most commonly affected. Movement or rubbing the affected parts only aggravates
the pain but descent usually resolves the problem.

Skin. Nitrogen bubbles released under the skin causes the creeps when the sufferer
feels that a small compact colony of ants are crawling over, or just under, the skin.

Respiratory system. This is known as the chokes. Nitrogen bubbles may get caught
in the capillaries of the lungs blocking the pulmonary blood flow. This leads to serious
shortness of breath accompanied by a burning, gnawing and sometimes piercing pain.

Brain. The bubbles affect the blood supply to the brain and the nervous system. This
effect is known as the staggers. The sufferer will lose some mental functions and
control of movement. In extreme cases chronic paralysis or even permanent mental
disturbances may result.

The secondary symptom is:

Post descent collapse. This may occur up to four hours after the primary symptoms
when nitrogen bubbles have combined and therefore not gone back into solution and
have reached the heart.

DCS can be avoided by preoxygenation before exposure to high altitudes, thus

reducing the body store of nitrogen as much as possible.

APP2 - 36
DCS in Flight and Treatment

If the symptoms of DCS appear in any passenger or crew member, the pilot should
commence an immediate descent to a level at which the symptoms are relieved. The
aircraft should land as soon as possible. Meanwhile the sufferer should be kept warm
and rested and put onto a 100% oxygen supply. Urgent medical assistance must be
sought on landing even if the patient appears to have recovered.

Flying and Diving

DCS is rare but the incidence is greatly increased for individuals who have been diving,
using compressed air, shortly before a flight. The pressure that a 30 ft column of sea
water exerts is the same as that exerted by the atmosphere at sea level (i.e. 760 mm
Hg). Therefore a person at a depth of 30 ft is exposed to a pressure of 2 atmospheres
(1 atmosphere caused by the air above the water and the other by the water itself).

In scuba diving, air under pressure is used and this increases the amount of nitrogen
in the body. On subsequent ascent this may come out of solution giving rise to DCS.
The following rules must be strictly results in incidents each year in which individuals
develop DCS in flight at altitudes as low as 6000 ft.

DO NOT FLY WITHIN 12 HOURS OF SWIMMING USING COMPRESSED AIR

AND AVOID FLYING FOR 24 HOURS IF A DEPTH OF 30 FEET HAS BEEN
EXCEEDED.

APP2 - 37
 APPENDIX 3

HUMAN FACTOR FOR AIRCRAFT MAINTENANCE

A. REPORTING AND INVESTIGATING ERRORS

A.1. Company And State Regulatory Requirements

For many years, Annex 6 has specified requirements for ensuring that flight crew
operate aircraft in accordance with Human Factors principles, taking into account
normal human performance. In 1998, Amendment 23 to Annex 6, Part I, included
similar Human Factors requirements for the following aspects of aircraft maintenance
activities:

• The design and application of the maintenance programme and

• The training of maintenance personnel in an AMO

The primary objective of introducing State regulations relating to Human Factors

is to reduce aircraft accidents and incidents due to errors during maintenance. There
is also the obligation on the State, as a signatory to the Chicago Convention, to
implement and enforce regulations in conformity with Annex 6.

The State aviation regulatory body should develop a policy for the issue of
regulatory material intended to ensure that appropriate maintenance Human Factors
interventions are introduced by all its operators and associated aircraft maintenance
organizations.

a. The first, and perhaps most important, policy consideration is how detailed and
prescriptive the regulations need to be in order to achieve a satisfactory level of
Human Factors interventions. Policy makers should bear in mind that in recent
years, non-prescriptive programmes have been initiated in several States and
have successfully achieved implementation in a significant number of their
operators and maintenance organizations. However, Annex 6 requires 100 per
cent implementation, and it is too early to tell if persuasion alone is sufficient to
achieve this requirement. The State should consider this aspect carefully and

APP3 - 1
 strike the balance between the detailed regulation and persuasion best suited to
its national legal and cultural circumstances.
b. A second important policy consideration is to determine which entity is the most
appropriate to “target” for Human Factors regulations. In a State where all
operators perform their own maintenance, the answer is simple as only one party
exists. However, in many States, operators contract maintenance to other
organizations, and one possible solution would be to address all the regulations
to the operator which would then require compliance by the maintenance
organization. The operator would then need to perform a Human Factors audit of
this maintenance organization and require compliance before work was started. A
more practical and balanced solution would be to address the regulations
regarding practical Human Factors application to the maintenance organization.
Human Factors regulations associated with the design of the maintenance
programme itself would then be addressed to the operator.
c. A third policy consideration is to establish the level of Human Factors interventions
necessary to produce a satisfactory result.

A.2. Immunity Statements And Disciplinary Issues

In some cases a maintenance error may cause an occurrence, incident or

accident which falls within the category of being legally reportable. If the subsequent
investigation reveals a breach or violation of regulations, then the State aviation
regulatory body should have a policy in relation to prosecution or sanctions against
those persons or bodies having committed the breach. In some States, for example,
there is a statutory obligation to prosecute violators. In other States that have
discretion over prosecution of violators, a range of sanctions is available which can be
graded to suit the circumstances of the particular case. In some States, the tradition
is for the aviation regulatory body to encourage AMO and operator compliance by
influence or attempts to influence. This influence can include a graded set of sanctions,
which can be threatened and/or imposed, such as the suspension or restriction of
licences or certificates. In order to ensure that the reporting responsibilities of
organizations and individuals are not inhibited by the possibility of punitive action,
some States have promulgated their policies in respect of immunity and
confidentiality.

APP3 - 2
Example : U.S. FAA Aviation Safety Reporting Program (ASRP)

The FAA Aviation Safety Reporting Program is described in FAA Advisory Circular
(AC) No. 00-46D dated 26 February 1997 and utilizes the National Aeronautics and
Space Administration (NASA) as a third party to receive reports. The AC includes the
following section on “Enforcement” which describes how the immunity concept
applies to pilots, controllers, flight attendants and maintenance personnel making
incident reports…

AMO managers sometimes believe that the State aviation regulatory body
expects them to take a clear disciplinary position with their staff who commit violations.
However, in many cases this belief is implicit and may not be well founded. The
ADAMS project report suggests that disciplinary systems can be more effective in
influencing the general climate of acceptable behaviour than in changing the
individual. To achieve this influence, an AMO or operator disciplinary system needs
to be seen as follows:

• To be independent, transparent and fair;

• To be routinely and universally enforced; and
• To have proper process and proportionality in the sanctions, taking into account
mitigating circumstances.

The ultimate sanction for any employer is to dismiss someone who is perceived
to be an “unsuitable” employee. However, this action raises the question as to why the
person was appointed to that particular position, which questions earlier AMO/operator
management decisions to employ the person in the first place or to continue to employ
the person.

A.3. Confidental Reporting Systems

Confidential, independent, non-punitive human error reporting systems have

been established over the past two decades by some States for both flight and ground
crew. Experience with these systems has generally been favourable, but they are a
supplement, not a substitute, for good reporting systems managed by the AMO,
operator and the State aviation regulatory body. However, these confidential systems
can provide much valuable information for use in training and awareness programmes,
as well as the early identification and correction of risks.

APP3 - 3
 As examples of current practice by State aviation regulatory bodies where
confidential Human Factors reporting systems have been established.

Example : U.K. Confidential Human Factors Incident Reporting Programme (CHIRP)

In the United Kingdom, an independent charitable trust is responsible for the

Confidential Human Factors Incident Reporting Programme. The following statement
is published by the CAA in Aeronautical Information Circular No. 47/2001 dated 31
May 2001…

A.4. Investigation Responsibilities And Procedures

The investigation of maintenance errors by AMOs and operators must look for
the contributing factors that they can manage within their organization. Measures that
involve telling people to “be more careful” have only limited effectiveness. Human error
can only be reduced to a point, not eliminated altogether. Professor Reason states
that “the difficulty has been to discriminate between the truly bad behaviors and the
vast majority of unsafe acts to which the attribution of blame is neither appropriate nor
useful. Nevertheless there is an interface between discipline and Human Factors and
this interface must be well understood by all concerned if the event investigations are
to be effective.”

The primary goal of any maintenance error investigation by an AMO or operator

is to extract from the incident the lessons that can be learned to help prevent similar
incidents in the future. Investigations that merely satisfy a regulatory requirement or
apportion blame are inappropriate and will not lead to learning by the organization.

There are normally five phases that an AMO or operator follow in the conduct of
an investigation of what appears to be a maintenance error incident:

1. What happened? — establishing basic information about the incident and its
consequences;
2. What happened? — constructing the event sequence;
3. Why did it happen? — identifying the errors and failures;
4. Why did it happen? — identifying the contributory factors; and
5. How can it be prevented in the future? — making recommendations.

APP3 - 4
 The five phases above describe a logical progression through the investigation
process by first establishing the facts of the incident and the sequence of events before
attempting explanations and making recommendations. The basis of the “what
happened?” phase of the investigation should be the task documentation and
interviews with the personnel concerned and the witnesses. The “why did it happen?”
phase should first comprise the error(s) and/or failure(s) and then the contributory
factors. The “how can it be prevented in the future?” phase should focus on the
recommendations. The final report should consist of various sections with narrative
and associated factual data.

A.5. Maintenance Error Data Analysis And Reporting Of Issues

The Boeing Maintenance Error Decision Aid (MEDA) is one of several useful
Human Factors “tools” for AMOs and operators to use in the investigation of errors.
The major objective of MEDA is to provide a standardized process for analysing
maintenance errors and the contributing factors to those errors, and developing
possible corrective actions. MEDA identifies the following four broad error prevention
strategies:

• error reduction/elimination;
• error capture;
• error tolerance; and
• audit programmes.

The overall MEDA process is as follows:

• Event: an event occurs, such as a return to the gate or an air turn back.
• Decision: after correcting the problem and returning the aircraft to service, the
operator decides if the problem was maintenance related — if yes, the operator
performs a MEDA investigation.
• Investigation: the operator uses the MEDA results form to perform the
investigation. This identifies the type of error that caused the event, the
contributing factors to the error, and a list of possible corrective actions.
• Corrective actions: the operator reviews, prioritizes and then implements
actions to avoid or reduce the likelihood of similar errors in the future.

APP3 - 5
 • Feedback: the operator provides feedback to the maintenance workforce. This
informs them that changes have been made to the maintenance system based
on the MEDA process.

A.5.1. Reporting of issues

Annex 13 requires all States to have legislation requiring accident and incident
reporting. In addition, Annex 6 calls for legislation to require operators to report service
difficulties to the State of Registry. Furthermore, there are some unavoidable events
having operational significance (e.g. technical delays, cancellations and in-flight
engine shutdowns) that are not legally required to be reported externally; however, the
AMO or operator concerned frequently investigates these events, although most often
only to assign responsibility for them. At an even lower level, there are events without
operational significance that only rarely are reported or investigated, for example, the
omission of an oil filler cap which, by chance, is noticed and corrected before flight. In
order to gain a better understanding of the problems and factors that contribute to
errors, these less significant events should be investigated by either the AMO or
operator before a similar occurrence contributes to an accident or incident.

The Confidential Human Factors Incident Reporting Programme (CHIRP)

scheme provides an alternate reporting mechanism for individuals who want to report
safety concerns and incidents confidentially.

A.5.2. Feedback

Selected reports/extracts are published on a quarterly basis in a newsletter titled

FEEDBACK and distributed to the principal user groups.

A.6. Management Decision-Making

Organizational learning from incidents is perhaps the most difficult task of error
management. There are numerous case studies that can help, and an examination of
these reveals the following characteristics:

APP3 - 6
 • Several attempts and time may be necessary to achieve an adequate solution
for change;
• Validating the change is a critical step in the change process and should involve
those who actually perform the task; and
• Monitoring and reviewing the effectiveness of the changes on a continuous
basis is essential.

Completion of the investigation report, with its associated recommendations for

change, is only the starting point of a management process in the organization to
reduce the probability of another similar occurrence in the future. If these changes are
to be effective they must:

• Be implemented;
• Be directed towards eliminating the factors identified as the cause; and
• Be free from adverse side effects, which create additional or compensatory
problems.

B. MONITORING AND AUDITING

B.1. Team Or Individual : Composition

B.1.1. Indivudual

Audit Manager

The CA will appoint an audit manager for each audit. This individual will be an
operations or airworthiness inspector. For a large air operator, the audit manager
should be appointed at least two months prior to the planned audit. This will allow
sufficient time for research, familiarization with the terms of reference, the selection of
the audit team and the development of an audit plan.

The audit manager:

• Will report directly to the CA for all audit matters. Team members will report to
the Audit Manager until released from their audit duties; and
• Will immediately contact the CA with a recommendation for action in the event
of an imminent threat to aviation safety.

APP3 - 7
B.1.2. Team Member

1) Terms of Reference
Audit Manager will appoint team members in consultation with the CA.
2) Qualifications
A team member shall:
a) Have completed the audit procedures course;
b) Have experience related to the type of organization to be audited; and
c) Possess a sound knowledge of aeronautical legislation and regulations.
3) Responsibilities
A team member shall:
a) Become familiar with auditing procedures and associated company
documentation;
b) Become familiar with the auditee’s policies and procedures;
c) Revise the audit checklists applicable to the assigned audit functions;
d) Conduct audit fieldwork and document audit findings
e) Liaise with the Audit Manager to ensure that audit progress is reported and
potential problems are addressed; and
f) Review the validity and applicability of audit findings by ensuring that all are
tied to applicable regulations or standards and supported by specific examples

B.2. Purpose : Quality, Ergonomic Or Others

The audit program (AP) and surveillance program (SP) have been developed to
promote conformance with the aviation regulations and standards that collectively
prescribe an acceptable level of aviation safety. It also ensures that DGCA audit/
surveillance policies and procedures are applied uniformly.

“The Quality System ensures the fulfilment of all applicable airline and authority
requirements. By meeting these requirements, minimising non-conformities and thus
supporting precision in all work performed, airline operations will be safer, more
efficient and profitable. … A Quality System has to be Quality Assured.”

Quality Assurance is provided when an independent body is established,

separate from the entity, for monitoring and reporting according to an established
Quality Assurance Program. In practical terms, Quality In the context of Human

APP3 - 8
Factors, an important function of a quality system could be to ensure the correct
operation of a Human Factors programme already in place in an organization.

The ERgoNomic Audit Program (ERNAP): This is a programme specifically

designed for the analysis of aircraft maintenance activities. It is based on a checklist
concept to collect data before, during and after maintenance, either on paper or
directly into a portable computer. See Appendix F to this chapter for more details;

The terms “workplace” and “equipment” are very general when used in the
context of an ergonomic audit. It is therefore important to understand that the prime
purpose of designing, or redesigning, the workplace and its equipment is as follows:

• To determine what the worker is required to do;

• To identify what information, tools, controls and procedures are needed; and
• To provide those elements in their proper size, form and format.

B.3. Process And Procedure

B.3.1. Audit Activities

The audit process consists of the following four distinct phases of activities:

a. The pre-audit (desk audit);

b. The physical audit;
c. Post-audit; and
d. The audit follow-up.

Figure 56. The Auditing Process

APP3 - 9
a. Pre-Audit
Planning and preparation during the pre-audit phase will ensure that the objectives
of the audit are achieved effectively, efficiently and economically. The scope and
depth of the proposed audit, to be addressed and justified within the audit plan,
will determine the time schedule, personnel and financial resources required.
b. Physical Audit
The physical audit phase will be implemented in accordance with the audit plan. It
includes the entry meeting with the auditee, the determination of audit findings
through interviews, inspections and the evaluation and verification of files and
records, functional area debriefings and the exit meeting.

Figure 57. The Physical Audit Process

c. Post-Audit
Post-audit activities include completion of the audit report and parallel report.
d. Audit Follow-up
Audit follow-up includes the development and approval of the auditee’s Root
caude analysis and Corrective Action Plan (CAP) and ensures full implementation
of the corrective action plan (CAP).

APP3 - 10
B.4. Audit Findings, Reporting, And Data Analysis

B.4.1. Audit Finding

The exit meeting with the company’s senior management should provide an
overview of the audit. The meeting should summaries the audit findings, stating areas
of strength and weakness. A controversial discussion with company representatives
regarding audit report content must be avoided. All audit findings should have been
discussed with company officials as each functional area was completed. New audit
findings should not normally be identified at the exit meeting. The meeting should
provide an overview of the audit and not become a debate between the team and the
organization. The auditee should be advised that the company will have an opportunity
to respond formally to the audit report. The auditee will be advised of those audit
findings that may be subject to enforcement action. The auditee will also be advised
of the company’s responsibility to take appropriate action to correct all non-
conformances and prevent their recurrence. The audit manager shall advise the
auditee that the audit report will be forwarded to the company within ten working days
and that a CAP must be submitted to DGCA within 15 working days after the company
has received the report.

B.4.2. Type of Finding

A finding is generated as the result of a non conformity to a standard: CASR,
internal rules or procedure. A finding can be of 3 different types:
1) Non-Compliance (NCP) (immediate corrective action/Level 1) means a
deficiency in characteristic, documentation, or procedure with respect to
provisions of the Aviation Act No. 01 of 2009 or a CASR.
2) Non-Conformance (NCF) (Short-Term Corrective Action/Level 2) means a
deficiency in a characteristics, documentation, or procedures. which renders the
quality of a product or service unacceptable or indeterminate, or not according to
specified requirements, e.g. Physical defects, test failures inadequate
documentation.
3) Non-adherence (NAD) (Long-Term Corrective Action/Level 3) means a
deficiency in characteristic, documentation, or procedure with respect to a

APP3 - 11
 recommended practice, procedure, guideline or good aviation safety. Non
adherence finding including safety observation is linked to.

B.4.3. Audit Report

1) The audit report should normally be presented to the company within ten working
days. Any delay must be documented since the validity of the audit will be
compromised if the report is not presented in a timely manner. Although draft audit
finding forms may be left with the company as a courtesy, this is not mandatory.
2) The Audit manager is responsible for the preparation of the audit report.
3) A sample covering letter and audit report for combined audits report will include:
a) Part I - Introduction, which summarizes the audit process and the content of the
audit report;
b) Part II - Executive Summary of Findings, which summarizes the most significant
findings for the information of the senior management of the audit and DGCA;
c) Part III - Airworthiness, which contains the functional summaries for airworthiness;
d) Part IV - Operations, which contains the functional summaries for operations;
e) Part V - Safety, which contains the functional summaries for safety; and
f) An Appendix, which contains the audit findings for both airworthiness and
operations.
4) The audit report will be a factual account of the audit and will not include subjective
statements, suggestions or recommendations.
5) The CA will sign the covering letter and forward it, with a copy of the audit report,
to the company. The letter will outline the procedure for responding to audit
findings and specify the required response time of 15 working days from the time
the company receives the report.

B.4.4. Data Analysis (Root Cause Analysis)

The initiating cause in a causal chain that leads to an undesirable situation or

condition; the point in the causal chain where corrective action could reasonably be
implemented and expected to correct and prevent recurrence of the undesirable
situation or condition. Root cause analysis is a method of analysis that focuses on
identifying the root cause(s) of an undesirable situation or condition of finding (non-

APP3 - 12
conformities). It is the responsibility of the auditee (AOC holder) to determine the
cause(s) of any finding (non-conformities) and to implement corrective actions after
findings have been raised. Clearly, the organisation being audited is best placed to
develop a causal analysis as it better understands the environment it operates in, its
own operations, methods and personnel, and the events that may have led to the
problem. In some cases, in particular where risks to safety are highest and causes
and actions require complex analysis and lengthy implementation, a joint DGCA-AOC
holder approach may be required. The DGCA is responsible for ensuring that the
causal factors as determined by the AOC holder are accurate and that the associated
actions implemented by the operator are effective. The root cause analysis is the tool
or method designed to help auditee and auditors describe what happened during a
particular finding (nonconformities), then determine how it happened and understand
why it happened.

B.5. Feedback And Corrective Action

B.5.1. Feedback (Audit Follow-up)

Upon completion of the audit, the CA will delegate follow-up responsibilities to

the Audit Manager who will then ensure that all audit findings have been resolved in
accordance with an approved CAP. b. Immediate Action Immediate action will be
taken by DGCA upon finding of non-compliance against Civil Aviation Safety
Regulations or Aviation Act. After generate the finding, the Audit Manager shall
immediately informed the CA using the parallel report mechanism. Based on that
report, CA will inform Director of DAAO to determine the type of immediate actions
taken. Determination of the type of immediate action is based on management review
of DAAO, which will be convened by the Director. The type could vary, from issuing
warning letter, restriction or limitation of operation, suspension, recommendation of
revocation, or proceeding to enforcement actions. The decision will then be informed
to the auditee, which in turn will need to establish corrective action plan and informed
DGCA / DAAO within the time frame established in accordance with the type of
associated finding. The schematic process is as follow:

APP3 - 13
 Figure 58. Feedback (Audit Follow-up) Process

B.5.2. Corrective actions

After findings have been raised and root causes determined the DGCA will agree
with the auditee (AOC holder) on corrective actions and/or a corrective action plan. It
is the auditee (AOC holder) who has the resources and authority to implement
corrective actions. The fundamental goal of the findings-causes-actions process is to
shift from fixing the effects of non-compliances to eliminating, changing, or controlling
the causes of problems, hence implementing corrective action and in the context of
safety risk management, preventive action.

a. Types of Corrective Action

1) Immediate corrective action/Level 1 for non-compliance finding. This is
action must be taken immediately but not exceed than 15 days upon
identification of the audit finding. Audit findings that have direct impact on
aviation safety may be taken to stop the operation of aircraft, maintenance,
suspend of personnel licensing or termination of AOC activities.
2) Short-Term Corrective Action/Level 2 for Non-Conformance finding. This is
short-term action to correct a non-conformance that does not pose an
immediate threat to aviation safety, which ensures that conformance is
established quickly until long-term action is completed to prevent

APP3 - 14
 recurrence of the problem. Short-term corrective action will maximum take
place within 30 days.
3) Long-Term Corrective Action/Level 3 for Non-adherence finding This is
longer-term action and has two components. The first will involve identifying
the cause of the problem and indicating the measures the company will take
to prevent a recurrence. These measures should focus on a system
change. The second component will include a timetable for company
implementation of the longterm corrective action. Long-term corrective
action will maximum take place within 60 days. Non adherence finding
including safety observation is linked to safety and evaluation of the risks
linked to operational hazards and raised when the risk pertaining to a
specific hazard is evaluated by DGCA as non acceptable for safety

Figure 59. Audit/ Surveillance/Inspection Follow-Up Process Flow Diagram

APP3 - 15
C. COMMUNICATION

Every organisation depends upon a communication network. The bigger the

organisation, the more elaborate the communication system. The precise form of the
network will vary from company to company. However most communication will follow
the lines of Management and Organisation within the companies.

Downward communication from the accountable manager to the engineer on

the shop floor usually has to pass several managerial levels and requires each
superior level to pass down the information fully, accurately, with full understanding of
the next subordinate level. The passing downwards of some directive, communication
or instruction implies temporary ‘storage’ of that information in the mind or in the ‘in
tray’. Careful consideration must be given on how this information is stored and
displayed.

Upward communication is equally important. The shop floor workers are in

direct contact with the actual work carried out and can often see more clearly possible
ways of improving methods of performing a task, of eliminating certain processes or
identifying cost savings. This upward flow of information should include the
supervisors at each level as soon as the information is available, otherwise the
supervisors will develop feelings of loss of status due to a loss of control. A good
communication system both up and down will create an atmosphere of co-operation
and goodwill between employees and management.

Downward communications are usually ‘directives’ to produce actions by

subordinates. Upward communications are usually ‘non-directive’ ie. they report
results or genuine information, but are not necessarily intended to prompt action. The
amount of downward communication generally exceeds that going up. Should a
manager devote time to dealing with upwards communications after dealing with
downward communications, or is it the other way around?

APP3 - 16
 Figure 60. Vertical Communication within a Department

Information is often communicated within departments between colleagues,

whether it be mere transfer of data or giving professional advice. This is a horizontal
flow of information and can be used at inter-departmental level when co-ordinated
effort is required on a particular task or project

The flow of information is subject to variations in speed. It may be due to peaks

in company activity, the time of day, week, month or year. The vital factor of good
communication is FEEDBACK. It should inform the sender of the information that his
message has been understood and acted upon. Hopefully this will be in the required
manner producing the expected result. Information can also be inward into any
organisation; by face to face meetings with visitors, letter, E-mails, and telephone calls.
Companies also give outward information such as advertising and other promotional
devices to perhaps alter how that company is perceived in its behaviour and
performance.

APP3 - 17
 Figure 61. Interlan Communications - Horizontal

Spoken Communications

Between members of a team or organisation, spoken communication can be

applied in different ways;

For Example:

Written Communications

ONE TO ONE DIRECTIVE ‘do it this way’

ONE TO ONE DISCUSSION appraisals and interviews
ONE TO GROUP Lecture
GROUP DISCUSSIONS project teams, task group

Written communications for the aircraft engineer may take many forms ie

 Maintenance Manuals
 Company Engineer Expositions
 Service Bulletins
 Company Memos etc.

APP3 - 18
He, in turn, produces written records of:

 Aircraft Maintenance
 Hand Over Reports at shift change and
 Mandatory Occurrence Reports –
when incidences become known to him, to pass upwards or horizontally within
his

company or outward to other organisations required by the Authorities.

From the list below we can see both written and verbal communications being
used in the directions discussed. The list is not exhaustive and you may be able to
add others you have seen or know about.

DOWNWARDS

COMPANY EXPOSITION :Objectives of the organisation, Conditions of

employment etc.

House Magazine :News of company activities, personal items,

social and sports details, safety articles

Bulletin Boards : Brief notices, properly set out (all ‘dead wood’
should be cleared awayregularly).

Pay-packet Notices : Limited uses and should only be used

infrequently.
Meetings: To explain changes, new methods,
etc. time for questions should be allowed.

Public Address Announcements: Quick, but must be limited to special

announcements.

Manuals & Service Bulletins: Procedures and instructions.

DOWNWARDS AND UPWARDS

Joint Consultation : Meetings between workers and managers

APP3 - 19
Social Gatherings : These allow all levels to meet on common
ground and encourage a group spirit.

Conferences : For foremen, section leaders, supervisors

and managers to interchange ideas and
participate in development of company policy.

The ‘Grapevine’ : An informal and occasionally not very reliable

source of information – sometimes speedier
than other systems.

UPWARDS

Suggestion Schemes : These may increase productivity and

efficiency besides being rewarding to the
employees. In addition they promote contact
between employees and management.

Opinion Polls : A method of determining opinions, eg. best

period for annual holiday shutdown, etc.

Grievance investigations : Hearing of complaints and grievances.

Incidents : The UK Confidential Human Factors Incident

Reporting Programme (CHIRP) Mandatory
report for aircraft incidences (MORs)

HORIZONTAL

Co-ordinating Committees : Meetings of finance, purchasing and stores

management to exchange views and ideas
and to plan co-ordinated action.

APP3 - 20
Head Office Conferences : Circulating Files: Meetings of branch
managers at the same level to discuss their
problems and how they can handle them.

INWARDS

Personal calls : To assess the organisation’s capacity in some

degree.

Telephone calls : To deal with comparatively urgent matters.

Correspondence : To confirm in writing requests or data

provided.

OUTWARDS

Advertising & Promotions : All types, eg. television, press radio, films,
etc., to inform and to foster good relations with
the customer and the general public.

Annual Reports & Shareholders :To keep the shareholders informed of the
progress of the company, turnover, profits, etc.

Communication Problems

The most important distortions and misunderstandings occur in vertical

communications, especially where messages change from oral to written and vice
versa. Departments tend to operate in isolation and in larger organisations this can
lead to strained and difficult communications. There are other barriers which must be
overcome if successful communication is to take place, such as perceptions, jargon,
technical words and process difficulties.

APP3 - 21
Perception

If the transmitter of a message wrongly perceives the receiver he will use the
wrong language and medium for transmission of that message. Similarly if the receiver
has a perceived image of the sender ie. he thinks he is a ‘bit of an old granny’ then the
message received might not be treated with the respect and urgency the transmitter
desired.

Jargon

With modern technology there are a large number of words, phrases and
acronyms being used in communication. When a member of one group communicates
with a member of another group, problems can occur because of the different
language being used within each group.

Technical Words

The transmitter of the message must know his audience. If technical words are
used to communicate to a non-technical person/group, the sense of the message will
become difficult and may be lost.

Process Difficulties

If there is a difficult message to be communicated and there is no ‘feedback’ a

problem may exist as a result of the message not being correctly transmitted or
understood.

Verbal Reports

If a message is straightforward and simple, and the other person is easily

reached, then you might prefer to talk to him personally. The message might be for his
ears alone, or he might need to be shown something. If the information is relatively
simple and easily understood a short ‘briefing’ may be given to a group in order that it
can be passed easily to their subordinates and so on amongst the employees.

APP3 - 22
 The disadvantage is that the message can change as it is conveyed down the
line. The classic example is the army message sent back from the front line to
headquarters:

‘Send reinforcements we’re going to advance.’

Unfortunately, by the time it reached headquarters, the message had become:

‘Send three and fourpence we’re going to a dance.’

This, perhaps, is due to whispered words being perceived by their sounds rather than
their sense and meaning.

Communications can fail when one or the other party is not listening or is being
distracted. The man reading his paper at breakfast, muttering and nodding without
really listening to his wife’s conversation. Where distance or an interval of time is
involved, or the message is complex, a written report should be made. It can be
referred ‘back to’ if it is difficult to remember and understood. In itself it forms a record
and may be a basis for other actions.

Written Reports

All written reports should be written as clearly and concisely as possible for the
intended reader. ‘Purpose’ type reports are used where commercial policy and
company control is used within the organisation.

News Summaries

This is used within organisations to inform employees of changes in company

performance, safety issues, training course information etc. It can be in the form of a
Newsletter, Magazine or a Notice on the bulletin board.

Body Language

Eye contact, facial expression, body orientation, hand and head movement and
physical separation are all ways we communicate without speaking. It can also affect
our relationships with and perception of the personality of the other person. Body

APP3 - 23
language conveys far more than speech alone. Eye contact is usually very brief,
except between the most intimate of friends. Prolonged staring is seen as threatening
and should be avoided.

Facial expressions can convey a whole series of emotions, sadness, delight,

disgust, contempt, boredom and many more. By observing the listener’s facial
expression it soon becomes apparent that you may have lost their interest or perhaps
are antagonising them.

Touch, except for a brief handshake, is not welcome in western society, one
tends to be suspicious of someone who clings to your hand when introduced. Posture
and whole body movement is a guide to the listener’s interest. We tend to lean towards
those with whom we agree and away from those we dislike. When bored we avoid
even the briefest of eye contact or may display our disinterest by drumming fingers or
playing with a pencil.

We guard our personal space jealously, sitting or standing in close proximity to

other than intimate friends unsettles us. If colleagues are sharing a desk, facing each
other, they tend to resent spill-over from their colleague’s side into what they see as
‘their space’ and will move objects, openly or surreptitiously, back to the other side.

Verbal communication can be altered by varying the pattern of speech; by

changing the pitch of our voice, stressing some phrases or inserting pauses. A rising
voice and rapid speech may portray anxiety whilst short clipped speech may express
urgency. Rambling speech indicates uncertainty. The end of a meaningful sentence,
dropping the voice, eye contact and possibly gestures are all clues to the completion
of that speaker’s turn and it is time for an input from another speaker. An interruption
can be taken as a threat. Most people, when interrupted, will give way to avoid
simultaneous speech. An interruption is considered to break the rules and is seen as
rude and domineering.

Non-Verbal Communication (NVC)

While talking, people also communicate on a non-verbal level through posture,

facial expression and gestures. Usually individuals make their speech clear and
unambiguous, but with NVC signals are sometimes less clear.

APP3 - 24
For Example:

A particular facial expression might signal either agony or ecstasy.

The facial expression has to be interpreted in the context of the situation and
the combination of hands and body position. Often whilst communicating verbally, we
give non-verbal signals without realising it. The student who glances at his watch and
yawns might well convey the message to his teacher that he wishes the lesson to end.
Nodding heads show agreement to the person talking, other signals might show they
want to ‘get a word in’. Most of us learn these signals in childhood and we do not notice
that we are using them.

However, certain signals have different meaning in different cultures. For

example, sticking your tongue out in Britain is regarded as rude and is an insult; in
China it is an expression of apology or surprise; in Tibet it is a sign of respect and on
the Marquesan Islands it means NO. Certain signals such as these are also used in
place of speech.

NVC also is used as a signal of our attitude towards others. Young lovers have
close bodily and eye contact whilst strangers on the tube train, while physically close
together, often look up to prevent making eye contact. Guess where the adverts are
placed on the tube!

Non-verbal aspects of speech itself – not what is being said, but the messages
that can be understood from how it is being said, is used in communication. The pitch,
tone and speed of delivery might show anxiety or confidence. Lack of knowledge might
be shown by too many ‘um’s’ in his speech. We have a degree of control over our face
muscles and can use these to disguise our feelings, but we are less successful in
concealing our emotions by the use of our voices and hands.

Dialect and accent in our speech can show what culture and class we come
from, and alter our perception of one another, which can affect the comprehension of
the communication. The distinctions between written, vocal and non-vocal
communications is summarised in the next Table.

APP3 - 25
Communication

Figure 62. Type of Communication

Function of Communications

As a Manager you must be able to:

 Motivate people and get them going

 Instruct people in the task to be done
 Explain any problems that might be met
 Advise on the control and correction of others activities
 KNOW WHAT IS GOING ON
 LISTEN to other’s ideas and opinions

To do all these, a range of vocal skills and techniques will be needed. The
communication can then take the form of:

 Talks and speeches

 Lessons and lectures
 Interviews
 Group discussions and meetings
 Direct instructions

Communication Failures occur:

APP3 - 26
  When the technique of communication and the objectives become confused.
 If there is too much talking and not enough listening by managers.
 When there is lack of definition in the management structure leading to
difficulties in responsibilities
 In the understanding of Human Behaviour. Believing Man to be logical and
independent; not sufficiently appreciating his emotional, social and group
needs.
 When insincerity is shown ie. not believing in what you are saying, and
adopting as fact.
 Too often when we speak and think afterwards, realising from the reactions
given, we have made a mistake.
 If there is ambiguity in the message. When I nod my head, you hit it.
 Inattention – not focusing your mind fully to the person’s message.
 When there is lack of FOLLOW UP ACTIONS to verify the instructions given.
 In our overconfidence that our information if fully understood, 70% of our
communication is misunderstood, rejected, distorted or forgotten.
 When information is left out, to come up with any meaning we have
abstracted.

D. WORKLOGGING & RECORDING

While it is generally regarded that English is the international language of the

aeroplane, it is not the language used nationally. Manuals and documentation are
provided in the country of manufacture in the national language and are adequate for
use there. When such aircraft equipment is used on the British register then the
necessary written information must be in English, Log Books also must be in English,
foreign language log books will be closed and retained with the records. The
information being provided by every organisation and person associated with aircraft
and equipment needs to be clear and concise and free from ERROR. To this end
training and examination techniques produce certifiers who have demonstrated the
ability to communicate effectively in written English!!!

This ability is used when communicating between individuals, teams,

companies and authorities from the ramp to the boardroom. Lines of communications
are created which ensures the transmission of information to all parties, the most

APP3 - 27
important being how we communicate with our colleagues in the work area. It is
necessary to receive work instructions in writing from whoever plans and schedules
the work, this is usually maintenance control in the form of workpacks. These will be
compiled from various sources, monitored by the department and presented to the
workteam as a package. The progress of the work can be accounted for only by strict
adherence to the rules laid down in company manuals with regard to use of the
workpack. Don’t do it your way, do it the Correct way!!

E. DOCUMENTATION

The work layout on Job Cards and Work Sheets should encourage work to be
signed for as it progresses throughout the stages. The design of the forms should be
such that there are full instructions available on how to complete the form with the
required information. Ambiguity should be avoided. The form should be as simple as
possible to achieve the results desired. Any data for onward processing should be in
a form which is easy to use. The layout should leave ample space for recording action.

Printing of forms should have letters and numbers of a size that is easily read,
without the danger of misreading due to poor quality printing.

When recording work on the Job Cards and Work Sheets it shall be in
accordance with the approved maintenance manual text, and all references made in
accordance with the manual numbering system. This also applies to work in
accordance with Service Bulletins, Airworthiness Directives and Airworthiness Notices
etc. There should be NO RELYING ON MEMORY or referring to unauthorised books
ie using training notes. Routine tasks and major components changes usually have
pre-printed work sheets, with the job laid down in stages for certification signatures.
Non-routine tasks, such as repair and rectification has to rely on the licensed engineer
completing the work sheets as the job progresses in a logical, safe manner with
duplicate inspections and tasks correctly called up as required by the task. The
technical information used is only found in approved publications and great care is
needed to ensure these are complete and up to date. It is the responsibility of the

Certificate of Release to Service issuer to ensure this. Should errors be found

or suspected in Manuals, Drawings and CDs your company publications’ section

APP3 - 28
should help you initially. If problems still exist the Aircraft’s Customer Services
Department must be contacted.

The certifying engineer should also be up to date with Company Procedures

and report discrepancies through the usual channels. He should be aware of his
responsibilities and duties in accordance with the ANO, EASA’s and AWN No 3, with
paragraph 1:15 in mind constantly.

DO NOT ASSUME - CHECK!!

Keeping Up To Date, Currency

Updating

All aircraft engineers have to be UP TO DATE with the latest service bulletins,
letters and amendments to Manuals etc. This awareness of changes can be brought
to the attention of engineers by safety notices on the company notice boards and by
passing copies of the amendments around to be read. The company’s Quality
Assurance Department probably will require signatures of proof, that the engineer has
read those important amendments which are applicable to him. Outside the direct
changes to the aircraft the engineer is currently certificating, he should be kept up to
date with changing technology and modern techniques.

Reading commercial aircraft periodicals, watching technical programmes on

television and downloading technical information from the Internet, help in the process
of keeping abreast of new developments in the industry. If the new techniques and
technology is going to be required in the near future by the company, the engineers
will be sent for specialist courses, seminars and briefings etc.

One of the biggest causes of aircraft accidents and incidents which can be
attributed to engineers is the incorrect assembly of components. This can be due to
engineers’ carrying out work without reading the Manuals and other technical
information, perhaps they are reverting to memory, We have also heard the term ‘if all
else fails, read the instructions’, and many people dealing with technology have used
this approach from time to time. This is WRONG, the CORRECT thing to do is to read
the manuals FIRST! Not only the Aircraft Maintenance Manuals, but the Service

APP3 - 29
Bulletins, Illustrated Parts Catalogue, the pre-printed job cards for the task in hand and
any other information required BEFORE you start the job.

The literature supplied to support the operation of the aircraft should contain all
the information you need. If it doesn’t contact the publication section of your company
or contact the Aircraft/Component Manufacturer direct. If the correct information
cannot be found straight away, the work on the aircraft/equipment should STOP until
it is available.

Reading Manuals during ‘slack periods’ will help with your subject knowledge
and ease of referral in the future.

F. Dissemination Of Information

In the maintenance of aircraft, over their life, information has to pass between
the Manufacturers’ Regulatory Bodies, Operators and the Licensed Aircraft Engineers.
Dissemination means spreading information broad and this information can be passed
on by several methods. The information may be of a GENERAL OR TECHNICAL
nature, not requiring any certifying action by an individual engineer. The Civil Aviation
Authority disseminates information of an Airworthiness Technical and General nature
to all pilots, airfield ranges operators and licensed engineers, by their publication CAP
455 Airworthiness Notices.

Where information is required for the certification of aircraft by the individual,

the information will be written in a format he should be capable of understanding. This
information will be Service Bulletins, Letters, Amendments to Manuals etc.
Incoming information will be disseminated, by circulars, notice board bulletins posters,
charts, photographs, videos and films. Short, precise and urgent messages to groups
could be conveyed by telephone and public address systems.

If the information is very important and has a safety aspect, feedback is

required. All those who have a need to know, have received the information and that
they understand it is shown by signing an attached action slip. When completed it will
give evidence that all those who need to know have been made aware of the
new/changes of information.

APP3 - 30
 The Licensed Aircraft Engineer should be made aware of all Service Bulletins,
Letters, Manual Amendments, Airworthiness Directives and Airworthiness Notices for
those aircraft/components that he is certifying serviceable for Release to Service. The
engineer, when he becomes aware of the problem, has a duty to share his knowledge
with others. Directly to his peers verbally, and management within his company,
perhaps following a laid down in-house reporting system.

It is also the duty of the licensed engineer, when he becomes aware of a

problem which could possibly result in an aircraft accident to inform the Airworthiness
Authorities and Manufacturers in accordance with the Mandatory Occurrence
Reporting Scheme. This is required by the Air Navigation Order Article 117 and further
details can be found in Air Navigation (GENERAL) Regulations Article 17, CAAIP
Leaflet BL/1-13 and Civil Aircraft Publication (CAP) 382.

If the engineer comes across a problem where the information he wishes to

pass on is sensitive and he wishes to remain anonymous, it can be passed on through
the CONFIDENTIAL HUMAN FACTORS INCIDENT REPORTING PROGRAMME
(CHIRP). It is a charitable organisation which publishes a periodical called
FEEDBACK. The periodical contains details of accident/incidents that have occurred
in flight or on the ground. The reports are sent in also by flight crew and air traffic
controllers on events they feel might have led to an accident or could lead to one in
the future. All articles are anonymous. All details such as the operator, registration
markings, identity of persons concerned in the incident are omitted.

The idea of the CHIRP Trust is to publicise details of the incidents in the hope
that, if people are made aware of the pre-knowledge might help prevent a further
occurrence.

Absence of Communication in the Hangar Kills 14

The aircraft was an Embraer 120 with 14 persons on board. The date was
September 11, 1991 and the place was over Eagle Lake, TX at 24,000 feet. The
aircraft was cleared to descent to 9,000 and commenced a power descent at 260 knots
– 12 knots below its safe operating speed. The copilot was heard to say ‘pushin this
descent-making like the space shuttle’. Fifty-three seconds later, as the aircraft passed
through 11,500 feet a grunt was recorded followed by warning bells. The aircraft broke

APP3 - 31
up in the air and disappeared from the radar screen. The structural break-up and loss
of 14 lives was attributed to the loss of the left horizontal stabiliser leading edge in
flight which resulted in a violent five-G nose-down pitch. What caused the loss of the
horizontal stabiliser leading edge? There were 47 screws missing that would have
secured it.

The night before the accident the left and right horizontal stabiliser de-ice boots
were scheduled for replacement. The work began with the second shift at 2130. They
removed the stabiliser leading edge in order to change the boot. One inspector walked
over on top of the left stabiliser and also removed the top screws of the left leading
edge. The right leading edge was subsequently removed by the third shift and the de-
ice boot was replaced. The aircraft was pushed outside into the dark during this time
and the right leading edge, with the new de-ice boot, was reinstalled without the aid of
any direct light. Because there wasn’t time to replace the left boot as well, the right
side was signed off and the aircraft was returned to service with 47 screws still missing
on the left horizontal stabiliser leading edge.

Why did it occur? A lack of communication between the two shifts started the
chain of events. There was no verbal changeover and the worksheets did not indicate
that the left, top screws had been removed. Add the fact that the right leading edge
was reinstalled in the dark, the top of the horizontal stabilisers could not be seen from
the ground, and the links are in place for failure. There was no call for an independent
inspection and in the light of darkness there is no guarantee that they would have
inspected anything more than the right stabiliser because the paperwork would have
communicated a requirement for that side only.

So what can be done to prevent a recurrence? A greater awareness of the

importance of communication – both verbal and written – is a must if accidents are to
be avoided. Any work done that isn’t covered on a workcard must be written up.
‘Assuming has no place in our business’ – Gordon Dupont

‘Gordon Dupont is a special programmes co-ordinator, systems safety, for

Transport Canada’.

APP3 - 32
 APPENDIX 4

HUMAN FACTOR IN AIR TRAFFIC CONTROLLER

INTRODUCTION

The provision of Air Traffic Services (ATS) requires large human-machine systems
designed with the principal objective of achieving the safe, orderly and expeditious flow of air
traffic. In addition to their principal aim, ATS systems have several secondary objectives,
including fuel conservation, noise abatement, minimum environmental disturbance, cost
effectiveness, impartiality towards all users within the rules and regulations, and the granting
of users’ requests whenever possible. In such systems, humans (controllers and flight service
specialists) rely on their equipment (hardware) to fulfil the functions of the system. To fully
exploit the capabilities of their equipment, they must be able to effectively interface with the
ATS system through software support, and more importantly, must interact with other persons
within the ATC system and with the users of the system (controllers, flight service specialists
and flight crews). While a safe and efficient ATC system must include appropriate technology,
it must also comprise trained and knowledgeable professional air traffic controllers who can
understand and apply such technology and provide an effective air traffic service — safely.

Most Human Factors issues in ATC derive from fundamental human capabilities and
limitations. For example, the information a controller (liveware) actually sees on a display can
depend on what is displayed (hardware), how appropriate it is for the task (software), whether
it is obscured by glare (environment) and what the controller is expecting to see after
conversing with the pilot (liveware). As air traffic demands increase, so does the dependence
on technological tools to aid the controller in such areas as conflict prediction and resolution,
information transfer and memory. Achieving the expected benefits from any technological
solution requires the successful matching of the technology with natural human capabilities
and limitations for interfacing with the other elements of the system (the hardware, the
software, the environment and the liveware).

APP4 - 1
 Given the continuous growth in air traffic world-wide, there has been a parallel increase
in demand for air traffic services that often stretches the capabilities of ATC systems to the
limits of its capacity. A traditional method for expanding capacity has been the division of the
airspace into smaller, more manageable sectors. However, increased sectorization of airspace
may create so many more coordination and liaison problems as to be counter-productive.
Alternative solutions are required, for example:

 Replacement of manual functions by automated ones;

 Automated data handling and presentation such as data link;
 Automated assistance for cognitive human tasks such as problem-solving
and decision making such as collision avoidance systems;
 Flexible use of airspace based on operational requirements rather than
geographic boundaries, including direct routing;
 A change from short-term, tactical interventions to solve problems that arise
to strategic planning of efficient traffic flows to prevent problems from arising
in the first place, such as air traffic flow management.

APP4 - 2
 Such advances are changing the working environment and the role of controllers, and
thus, ATC procedures and practices. To ensure the continuing integrity of the ATC system and
safe flight operations, diligence in the application of known Human Factors principles during
the design, development and implementation of these changes will be required.

This chapter is provided for ICAO safety oversight auditors responsible for air traffic
services to help them apply the basic concepts and frameworks described in Chapters 2, 3
and 4 in the air traffic services environment. Although many of the examples cited earlier in
this manual are based on the performance of flight crews, they can be applied equally to the
safe and reliable performance of air traffic controllers. A comprehensive safety audit will
address SARPs related to Human Factors in air traffic services (Chapter 10 refers). The safety
oversight auditor responsible for air traffic services can also provide meaningful information to
States on the implementation and operation of effective safety management programmes,
taking account of the impact of Human Factors in ATC, including the effects of organizational
and management factors, as well as cultural factors.

ATC IN AVIATION ACCIDENTS

Several major aviation accidents serve as reminders of the vulnerability of aviation

safety to failures to respect the importance of Human Factors:

 In 1956 a DC7 collided with a Constellation over Grand Canyon, U.S.A., killing all
on board. (This accident precipitated the transformation of the American ATC
system to what we know today).
 In 1976 a Trident 3 en-route from Heathrow to Istanbul collided at FL 330 with a
DC-9 flying from Split to Cologne, killing all 178 people on board. An error committed
by a controller, working under nearly impossible conditions in the Zagreb air traffic
control centre, triggered the accident.
 In 1977, two Boeing 747s collided on the runway in Tenerife killing 583 persons.
Misunderstanding of verbal communications between the aircraft taking-off and
ATC led to the second aircraft continuing to taxi down the active runway in restricted
visibility.

APP4 - 3
  In 1991, a Boeing 737 landing at Los Angeles collided on the runway with a Fairchild
Metroliner that had been cleared to hold 2 200 feet from the threshold on the same
runway for an intersection take-off. (Forgetting about an aircraft which has been
cleared to position to hold for further clearance is a common error — usually
corrected without consequence).

ERRORS AND ATC

Controllers and flight service specialists commit errors for the same reasons as all other
persons these reasons being lack of skill, lack of information, misunderstanding, fatigue, lack
of motivation and so on. Fortunately, most of these errors are identified and corrected before
an unsafe situation develops. Indeed, considering the number of departures annually around
the world, the frequency and severity of serious incidents and accidents involving air traffic
services is remarkably low. The ATC system includes several built-in defences to protect
against human or technical failures such as position reports, single direction routes, standard
aircraft cruising altitudes and readback of instructions. Nonetheless, analyses have shown that
most ATC errors occur in the following situations:

 Under light to moderate traffic conditions and complexity;

 During a controller’s first fifteen minutes on position; and
 When controllers have less than six years’ experience.

Factors under the general headings of inattention, forgetfulness or lack of vigilance

appear to be contributory in as much as 50 per cent of all ATS occurrences. Unfortunately, the
human is inherently ill-suited for the monitoring function; yet the ATC system requires a high
level of reliability in monitoring. To compensate for lapses in vigilance, the ATC system
incorporates various redundancies, such as readback of clearances and effective first-line
supervision.

Distraction appears to be the close companion of lapses in vigilance. Multiple concurrent

tasks such as monitoring, communicating, preparing of flight data and interacting with the
computer are highly vulnerable to distraction. Controllers may focus a disproportionate amount

APP4 - 4
of attention on a relatively minor problem, such as a delayed response from a pilot, to the
detriment of more important tasks.

Because compliance with SOPs is the principal guarantee of a coherent and

coordinated ATC system, failure to apply SOPs, for whatever reason, potentially compromises
the overall integrity of the system. Blatant or wilful non- compliance may be rare, but for a
variety of reasons, SOPs are not always followed. In their desire to accommodate traffic and
provide the users with a high level of service, controllers may compromise SOPs by, for
instance, reducing longitudinal separation or accepting hand-offs outside designated areas of
responsibility. In essence, these are errors in judgement. However, systematic non-compliance
with SOPs calls into question the effectiveness of supervision and managemen.

COMMON ISSUES AFFECTING HUMAN PERFORMANCE IN ATC

The everyday performance of controllers and flight service specialists can be adversely
affected by most of the factors mentioned in earlier chapters of this manual. An elaboration on
some of these in the context of air traffic services is provided in the following paragraphs.

The Nature of ATC Work

Air traffic control requires a lot of cognitive processing in the synthesis and analysis of
significant amounts of information, the mastery of often complex procedures, real-time problem
solving, and the listening and speaking skills necessary for effective information transfer.
Specific cognitive skills required include:

 Perception for sensing and reacting to visual and aural information. An example is
detecting and resolving emerging deviations from planned flight paths.
 Attention (or vigilance) sometimes for prolonged periods of intense activity, and
sometimes for prolonged periods of relative inactivity.
 Learning to master the procedures, practices and peculiarities of the position as well
as from day-to-day operational experience.

APP4 - 5
 Memory to interpret the evolving situation correctly and quickly, both short-term for
dealing with a situation in real-time as well as long-term for integrating knowledge and
procedures.
 Information processing to synthesize many diverse pieces of changing data about
traffic, weather, aerodrome conditions, navigation aids, etc. into a coherent “picture”
and to manage that picture in accordance with existing plans and procedures.
 Situation awareness to successfully integrate all the relevant information into a
coherent and current picture. This includes knowledge of the present, past and
pending situation, system functioning, human roles and tasks, and ATC roles,
procedures and objectives. A controller’s worst nightmare is losing this “picture”, this
understanding.
 Planning to integrate the time element by extrapolating from the controller’s picture to
develop expected aircraft sequencing and spacings in accordance with established
procedures and objectives.
 Communicating (usually orally) for both the reception and correct interpretation of
information as well as for sending information and instructions, often through the
barriers of language and radio noise. Effective communicating also requires a
feedback mechanism to confirm understanding.
 Problem solving to resolve deviations from plans (e.g. developing conflicts) and to
cope with unforeseen circumstances such as system outages or aircraft emergencies.
 Decision making for not only the timely selection of the best alternative course of
action for a particular situation, but also to appreciate how that decision will affect
subsequent traffic. Simply put, not only must the traffic flow safely and expeditiously,
it must continue to be orderly.
 Motivation to adhere to high standards. Although controllers generally take great pride
in their profession, there is little research to demonstrate the effects of job irritants,
such as unsuitable procedures, inadequate equipment, or poor rostering, on their
desire and ability to do a good job.

APP4 - 6
The Controller’s Workplace

Controllers work in a physical environment, whether it is in a control tower or an IFR

control unit, that is generally benign in terms of temperature, humidity, light and noise.
Generally, the controller’s workstation is purpose-built incorporating all necessary
communications, job aids and information displays with varying degrees of automation.
Nevertheless, controllers regularly face work-space conditions which are fraught with potential
for human errors (e.g. equipment malfunctions, displays that are difficult to read or interpret,
workload, frequency congestion, personal discomfort).

ATC workspaces must remain safe and efficient under the most demanding working
conditions, including peak air traffic demands, partial or total system degradations, shortages
in staffing, and around-the-clock operations. Poor decisions about work station design set in
place the latent unsafe conditions that will eventually facilitate controller errors. This applies
particularly to decisions about the displays and codings, the types and sensitivities of control
and input devices, the layout of the equipment, communications channels available and the
means to activate them, and the perceived relationships between displays and the input
devices. Something as simple as an ill-fitting headset can compromise the effective transfer of
information vital to safe operations.

Increasingly, ATC workstations incorporate the latest automated features and functions,
such as automatic dependent surveillance and controller-pilot data link communications.
Previously hitherto, much of the information transmitted between one controller and another
and between pilots and controllers was by speech, and the message formats included formal
acknowledgements that messages were received and understood. Now, more information is
being transmitted automatically between aircraft and ground systems, between satellites and
computers and through various other communication systems without the direct participation
or involvement of the controller. Recognizing the vulnerability of ATC to human error, ICAO’s
Air Navigation Commission directed the Secretariat to place special emphasis on Human
Factors issues that may influence the design, transition and in-service use of future CNS/ATM
systems. Subsequently, ICAO published Human Factors Guidelines for Air Traffic
Management (Doc 9758).

APP4 - 7
Workload

The rapid, continued growth in air traffic on a global scale is outpacing the ability of most
ATC systems to modernize and grow to handle the increasing volumes and complexity of
traffic. Shortages of qualified controllers are widespread. These shortages are often
exacerbated by the high attrition in ATC training systems and the difficulty of attracting people
with the requisite aptitudes, due in part to low pay scales and poor working conditions in many
States. Thus, the ageing controller workforce is frequently working excessive overtime to cope
with the shortage of controllers. Ironically, for many controllers, overtime provides the means
for achieving an acceptable level of remuneration.

With widespread staff shortages in many facilities, supervisors are spending a

disproportionate amount of time at a control position. In addition to frequently lacking the
required levels of proficiency, regular line controllers of supervisors performing controller duties
are not available to provide real-time supervision. Thus, they often fail to maintain a large
perspective of changing traffic conditions and to make timely, strategic decisions for opening
and closing sectors.

Teamwork

Much of the controller’s work is performed independently; there is little collective decision
making except, perhaps, in an emergency. Nevertheless, there is an increasing awareness of
the need for teamwork in ATC, particularly for teams of one to four individuals able to blend
their skills with others in the group to provide mutual support and assistance when needed.
For the stability of the group, each must perform in a predictable, conformist way. Each
controller would tacitly understand what teammates know and what they will do under the
circumstances. There may be little overt communication among them, but rather a broad,
mutual understanding.

Given the growth in CRM training for flight crews around the world, there has been a
collateral recognition of the need for improved teamwork by air traffic controllers. The
overriding goal of Team Resource Management (TRM) training has been the enhancement of
the liveware-liveware interfaces of the controller through the development of five sets of
competencies:

APP4 - 8
  Enhancing decision-making skills;
 Developing effective interpersonal communication styles;
 Developing leadership/followership abilities;
 Engendering a ‘team’ concept for enhanced operational performance; and
 Dealing with stress.

Judgement

Judgement can be considered as a sense applied to making correct decisions. In

making a decision, a controller must consider all the factors which have (or should have) an
impact on the outcome of the decision. When controllers properly recognize, analyse and
evaluate all the factors and subsequently make the most appropriate decision, they have
demonstrated good judgement. However, many of the factors addressed elsewhere in this
chapter, such as stress, boredom and fatigue, can impair judgement and thereby facilitate
errors in judgement. These involve:

 Doing something that should not have been done or not doing something that
should have been done;
 Not doing enough when more should have been done or doing too much when
less was required; or
 Acting too early when there should have been a delay or acting without delay
when this was required

Feedback is important for recognizing errors in judgement and initiating mitigating action.
Failure to recognize the error allows an increase in the potential for further errors in judgement
based on the misinformation created by the initial error. However, acknowledging the initial
error may depend on the attitude of the controller. Some controllers consistently demonstrate
thought patterns that make such admissions of error difficult and must learn to recognize these
patterns in their own behaviour and correct them.

Air traffic control has been frequently cited as a stressful occupation because of the high
task demands, time pressures and the potential consequences of errors, all of which may be
APP4 - 9
exacerbated by purported equipment inadequacies and shortages of qualified controllers. On
the other hand, some would argue that by virtue of their selection, training and experience,
controllers are better equipped than many people to cope with stress and that indeed some
seem to thrive on it. Nevertheless, in some States, there has been a notable incidence of
stress-related illness.

The nature of ATC does include some inherent aspects that are conducive to personal
stress:

 Increasing workload versus resource availability;

 Shift work;
 Overtime to compensate for shortages in the skilled controller workforce;
 Change as new equipment and procedures are introduced, often with
inadequate attention to the effects of Human Factors on normal human
performance;
 Age in that older controllers tend to burn out and lose their adaptability to shift
work;
 Domestic difficulties relating to shift work or life-style choices;
 Post traumatic or critical incident stress following a serious loss of separation

Boredom

Related to stress is the issue of boredom which perhaps arises from over-familiarity with
repetitive tasks or prolonged periods of simple monitoring or otherwise low workload.
Controllers tend to be high achievers, seeking challenge for their personal satisfaction.
Boredom tends to increase as controller skill and experience increase. When time drags,
controllers may invent procedures or diversions to make the time pass more quickly. The
increasing forms of automated assistance in ATC may have the unintended effect of increasing
boredom. To some extent, boredom can be alleviated by giving the controller some discretion
over controlling the work flow, including the choice of how much automation to use.

APP4 - 10
Shift work

Shift work is an inevitable requirement for maintaining around-the-clock flight operations.

As explained elsewhere in this manual, disruptions to personal circadian rhythms can seriously
affect human performance. Changing shifts has the same effects on the body as trans
meridian. Studies support rotating shift patterns rather than working several consecutive
nights, but shift patterns should move in the direction of a longer biological day, in other words,
to later shifts rather than earlier ones.

In addition to the normal physiological effects on performance, shift work can induce
domestic problems for the shift worker. Obtaining sufficient restorative sleep during the rest
cycle may be difficult and family relations may suffer.

Fatigue

Controllers are subject to acute fatigue from working a particularly demanding shift, such
as one with a high volume and complexity of traffic, and they may be subject to chronic fatigue
due to the cumulative effects, over a long period, of excessive workloads, inadequate rest
periods, inadequate restorative sleep, personal stress, etc. In any case, fatigue can adversely
affect controller performance. In particular, judgement may be impaired resulting in poor
planning and decision making. Some controllers exacerbate the effects of fatigue by choosing
work schedules that maximize their number of consecutive days off duty or by volunteering for
excessive overtime.

Management has a role to play in minimizing the deleterious effects of fatigue, including
attention to:

 Adequate rest breaks during each shift;

 Meal breaks;
 Shift length;
 Scheduling of shift changes;
 Use of overtime, etc.

APP4 - 11
Language

English is the commonly used language of aviation. In principle, its universal use as
recommended by ICAO (Annex 10, Volume II, 5.2.1.2) should reduce the scope of
misunderstandings and subsequent errors. However, for most controllers English is their
second or third language. Naturally, their ability to discriminate nuances when listening to
radiotelephony (perhaps from a pilot whose first language is not English) and their ability to
compose and transmit messages, other than with standard phraseology such as “cleared to
land”, frequently do not meet the intent of the Recommended Practice. The challenge of
communicating effectively is magnified by noisy backgrounds, poor radio reception, accents,
frequency congestion and so on. Thus, the accident record contains many examples where
inadequate information transfer was causal or contributory, even when all parties were fully
functional in English.

Information Transfer

The ATC system may be thought of as an information management system in which

nearly all information changes rapidly over short period of time. Coordinating with each other,
controllers must direct and provide advisory services to pilots and airport vehicles. This is
conducted almost exclusively by means of voice messages over a radio telephone (R/T).
Notwithstanding technical advances in the quality of radio equipment, R/T procedures have
changed little in the past fifty years. The following are some of the more common human
performance variables that compromise the communication process, thereby facilitating losses
of aircraft separation.

a) Non-standard phraseology. The correct use of standard phraseology in ATC is

vital to the safe and expeditious flow of orderly air traffic. Yet, investigations into
ATC occurrences consistently reveal a high frequency of significant deviations from
the use of standard phraseology.
b) Callsign confusion. Given the profusion of operators during recent years, aircraft
with similar-sounding callsigns or flight numbers frequently arrive concurrently in
congested terminal areas. Considering that similar types of equipment fly on similar

APP4 - 12
 route structures and operate on the same radio frequency, it is not surprising that
the wrong aircraft is sometimes acting on a clearance or instruction meant for
another aircraft.
c) Inadequate coordination. Coordination can take many forms: verbal
communication between controllers, appropriate marking of flight progress strips,
physically pointing out traffic or other body gesture, and in many cases, when
handing off from one sector to another coordination may be automated. Yet,
breakdowns in coordination with other controllers, both inside and outside the unit,
frequently contribute to losses of separation. As traffic increases, and more sectors
are opened, paradoxically there is an associated increase in workload because of
the need to coordinate with an increasing number of adjacent sectors.
d) Language. Much has already been said about the language issue. Inadequate
understanding of the language of air traffic control is exacerbated by accelerated
speech rates and poor enunciation during busy periods, poor R/T discipline, and
use of non-standard phraseology.
e) Readback/hearback problems. Breakdowns in effective information transfer are
frequently caused by inaccurate readback of clearances. The readback requirement
varies by State leading to frustrations for both controllers, who either do or do not
expect a readback, and by pilots, who are accustomed or not accustomed to
providing a readback. Although readback errors can be related to poor radio
reception, workload pacing factors, external noise, distractions etc. most often
readback errors are due to expectancy whereby pilots and controllers only hear
what they want to hear.
f) Frequency congestion. Increasing air traffic in an ATC system of relatively limited
capacity can lead to frequency congestion. At such times, speech rates increase,
messages are delayed, call sign confusion may set in, readbacks are completed
without adequate attention to the verification process, and language difficulties
exacerbate comprehension necessitating repeated messages, etc.

APP4 - 13
Surveillance Systems

ATC tends to be of two types: procedural separation and separation radar control with
lower separation criteria based on primary or secondary radar systems. Today vast areas of
the world, including most oceanic control, are covered only by procedural control. The
controller has no plan view of the air traffic situation but instead relies on creating a mental
picture of it by monitoring (often outdated) flight progress strips. New satellite-based
technologies are being developed and implemented which may provide the necessary up-to-
date surveillance data for controllers, such as automatic dependent surveillance and controller-
pilot data link communications.

Automated Equipment

The gathering, storage, compilation, integration, presentation and communication of

information are essential processes in ATC, and all of them can be aided by automation. New-
generation equipment provides more accurate, reliable and up-to-date data about the position
of each aircraft, its plans and intentions, its flight level and speed, and its flight progress. Long-
term trends are for more information about each aircraft and reduced separation between
aircraft requiring reduced delays in dealing with aircraft. This will lead to controllers having less
time to deal with each aircraft. Software for conflict prediction and conflict resolution is being
incorporated in some of this equipment.

Some of the human considerations to be taken into account when designing and
implementing automated systems include:

 Maintenance of controller expertise for manually handling traffic in the event of

system degradation;
 Maintenance of the controller’s mental picture of the evolving situation;
 Acceptable controller workloads, in terms of both volume and complexity;
 Maintenance of controller job satisfaction;
 Maintenance of unambiguous task-sharing and assignment of responsibilities
between controllers;

APP4 - 14
  Integration of proven, traditional practices with new technological capabilities (e.g.
Paper progress strips versus electronic progress strips);
 Effects of system reliability on the trust necessary for the controller to use the new
equipment;
 Availability of pertinent information to other controllers on the team;
 Human-machine interface considerations (e.g. Visual displays, input devices,
physical layouts, equipment sensitivities, system logic, warnings and alerts)

Successful introduction of automation depends on the approach taken at the design stage
where considerable compromise is required to balance considerations such as operational
requirements, desirable features, technological feasibility and cost. Multidisciplinary teams,
including end-users, engineers, human performance specialists, and so on must work together
to develop and test prototypes in actual operational conditions.

Ageing Equipment

Although much new, highly automated equipment is being introduced around the world,
in many ATC facilities ageing equipment is a problem. Partial or total system failures interrupt
reliable service, sometimes at the most inopportune times. Difficulties in the maintenance of
old technology, such as the procurement of spare parts, capacity and compatibility limitations,
all can seriously compromise the effectiveness of ATC processes and frustrate the most
diligent controllers.

Often, and particularly for most trans-oceanic flights, controllers maintain their mental
picture of the air traffic situation based on pilot position reports. These reports are often delayed
due to difficulties reporting through garbled high frequency radios or through a third party such
as a flight service specialist. Controllers who lack automated aids for keeping track of traffic
control large numbers of aircraft by managing paper progress strips in a tray.

Situational Awareness

Maintaining the mental picture is so important to controllers that a few more words about
situational awareness from the perspective of the controller are warranted. Situational

APP4 - 15
awareness may be considered from three levels of cognition: perceiving the situation,
comprehending the significance of the situation and finally, projecting the situation into the
future to make effective plans for dealing with the situation.

Some of the factors that the controller must continuously integrate to maintain a valid
mental picture include:

 Air traffic;
 Current and forecast weather, including local effects;
 Terrain, including obstacles and altitude restrictions;
 Performance capabilities of different aircraft types;
 Operating characteristics of particular operators;
 Availability and limitations of navigation aids;
 Aerodrome conditions;
 Airport services available;
 ATC equipment capabilities;
 Current operating procedures, restrictions, and accepted practices; and
 Current capabilities of immediate colleagues and adjacent sectors

Many of the changes under development or implementation in ATC with respect to

automation have the potential for affecting how controllers develop and maintain their
situational awareness. For instance:

 Many of the verbal messages exchanged between controllers and

between pilots and controllers are being replaced by transmitted data
which appears only in visual form (e.g. Data link);
 Changing workload and work rate, affecting how the mental picture is
assembled and refreshed;
 Replacement of paper flight strips with an electronic mode, also affecting
how the mental picture is assembled and its strength relative to concurrent
messages.

APP4 - 16
SELECTION AND TRAINING OF CONTROLLERS

One way of reducing the scope for errors in ATC is to ensure the availability of sufficient
numbers of qualified controllers, possessing all the requisite knowledge, abilities and skills for
the various tasks. This requires an effective system for screening enough candidates of
sufficient demonstrated aptitude and intelligence to enter ATC training, the conduct of an
efficient ab initio training scheme, as well as the maintenance of an efficient recurrent training
programme to keep infrequently used skills sharp or for acquiring new skills.

The job tasks and functions of controllers have been critically examined on a broad basis,
but there is some commonality in the conclusions about the requirements for becoming a
successful controller. These include general intelligence, spatial and abstract reasoning,
numerical ability, memory skills, task sharing, verbal fluency and manual dexterity.
Furthermore, age, medical history, eye-sight, hearing, emotional stability and educational
background are also relevant as selection criteria for controllers. To varying degrees, national
ATC selection schemes incorporate variations on these themes.

The objective of ATC training is to ensure that controllers possess the required
knowledge, skills and experience to perform their duties safely and efficiently, in accordance
with established standards. As for most training for complex skills, ATC training is progressive,
building gradually from first principles to increasingly complex concepts. Classroom instruction
is augmented by practical training, in laboratories or simulators, to develop skills in applying
newly- acquired knowledge, procedures and work practices. Increasingly, computer assisted
instruction will be used to help the candidates quickly develop the requisite background
knowledge. As soon as practicable, the candidates begin on-the-job training (OJT) acquiring
practical experience while working with experienced controllers in centres and towers.

Notwithstanding the need for OJT, implementing an effective OJT programme remains a
significant challenge. The task of the OJT coach is demanding and not all controllers are suited
to be good coaches. Coaching must be recognized as a specialist task, requiring controllers
who are not only good at their jobs but who have an aptitude and an interest in coaching junior
controllers. OJT coaches, must also receive specialized training in how to be an effective coach
while continuing to perform their ATC duties.

APP4 - 17
 National systems for qualifying neophyte controllers vary. Some systems qualify
controllers early in their training but limit their scope of duties to particular specialties such as
approach control. They may upgrade to other specialties later in their careers. Others systems
require qualification across all or most positions to which the controller may eventually be
assigned. Regardless of the qualification method, training must ensure competence in
handling high levels of traffic at the required work positions. A knowledge of basic ATC
practices and procedures is essential even in sophisticated systems, since safety may depend
on such knowledge in the event of a system failure. Regular, additional training may be needed
to maintain the controller’s proficiency in the manual functions needed should the system fail.
Refresher training and competency checks are also required to ensure that the controller
retains the professional knowledge and skills that are used infrequently in automated systems
but may nevertheless still be needed.

An important part of the ATC training challenge concerns upgrading controller

capabilities, often to cope with equipment modernization programmes or other system
changes. Here, controller retraining is required, generally incorporating both formal instruction
as well as OJT. Another frequently overlooked aspect of controller training concerns team
effectiveness. Most training is aimed at individual controllers. Recently, however, there have
been developments, particularly in Europe, in including team processes in ATC training
curricula

FUTURE CHANGES AFFECTING ATC

It has been mentioned that ATC throughout the world is undergoing significant changes
much of which are based on new technology. ICAO’s vision is for a future air navigation system
comprising communications, navigation, surveillance and air traffic management (CNS/ATM)
based on a complex and interrelated set of technologies dependent mainly on satellites. While
new technology has the potential to mitigate some of the human performance problems of
earlier technologies, it introduces a new set of conditions capable of compromising safe human
performance.

APP4 - 18
Data link

Data link has been used for many years for providing operational data to the operator
(e.g. engine monitoring data). It now has the potential for reliably overcoming many of the
deficiencies of voice communications, particularly those of HF radios in oceanic control.
Controller pilot data link communication will permit the automatic handling of digital information
transfer, with a hard copy for the recipient. However, early experience has shown that use of
data link does not improve the timeliness of communications, and does introduce several
unforeseen and undesirable effects, such as lack of acknowledgement of message receipt,
potentially delayed consideration of the message by the receiver, no means to convey the
sense of urgency (as exists with voice communications), and absence of reinforcement of the
message through a read-back process.

Free Flight

The basis of the CNS/ATM system is the Global Navigation Satellite System (GNSS)
permitting (in theory) access to a reliable navigation signal from all parts of the globe except
for the polar regions. This liberates the aircraft to fly direct routes, without reference to ground-
based navigation aids and predetermined routes. However, without reliable, fail-safe systems
for conflict prediction and resolution, the potential of “free flight” will not likely be attained.
Emerging practices requiring controller and pilot cooperation now facilitate the maintenance of
safe separation in some situations. A major shift in operating philosophy may be required as
more responsibility for maintaining adequate separation is transferred from the controller to the
cockpit.

Surveillance

CNS/ATM introduces a new surveillance tool, Automatic Dependent Surveillance

(ADS), whereby the aircraft’s position (as derived from GNSS signals) is relayed digitally to
ATC permitting the creation of a radar-like picture of the traffic. For now, however, ADS will not
permit a reduction of separation standards approximating those for radar. In advanced versions

APP4 - 19
of ADS (ADS-B) the aircraft will broadcast the signal for use by other aircraft as well as ATC.
Appropriately equipped aircraft will be able to assemble the ADS-B data to form a plan view of
the current traffic situation for display in the cockpit. Again, the issue of responsibility for
maintaining aircraft separation (pilots or controllers?) arises.

Successful implementation of these new technologies will require coordinated and

parallel development of the various subsystems of CNS/ATM and the collaboration of
controllers, pilots and human performance specialists, as well as the many champions of new
technology — the engineers, the carriers and the manufacturers. Overlooking human
performance problems in any one element may compromise the integrity and safety of the
entire system.

Another major change with safety implications concerns the management of ATS.
Traditionally, ATS has been provided by the government, but in an increasing number of
States, management of ATS is being consigned by government to some form of private or
corporate enterprise. In principle, this is a healthy change, which draws a clear demarcation
between the government’s role as regulator and the role of service provider. The traditional
dual-role of government creates a potential conflict of interest. The risk is that the pursuit of
profit may be allowed to undermine safety. On the other hand, the application of sound
business practices, including comprehensive safety management, offers the potential to
systematically improve the interfaces between the ATC service providers, the users and the
regulators.

For the controllers, one thing is sure, any fundamental change in management (and
management philosophy) will change the existing culture of the organizations involved. By their
nature, controllers are conservative, trusting the proven methods of the past and being highly
suspicious of change.

SUMMARY

Safety in aviation will continue to be highly dependent on the reliability of ATS. That
reliability will be directly linked to the ability of ATC planners and managers to incorporate the
many lessons of history regarding the impact of Human Factors on controller performance.

APP4 - 20
 Maintaining around-the-clock services, under periods of both extremely high and low
workloads, using modern (often unproven) equipment interfacing with some rather antiquated
ATC systems, while transcending the problems of language, radiotelephony, and others, will
continue to pose significant challenges. However, in the final analysis, the integrity of the ATC
system will be dependent on the quality of the training and supervision that the controllers
receive. Inadequacies in either area will permit the pernicious effects of the unsafe conditions
described in this chapter to compromise controller performance, and thus system safety.

The ICAO safety oversight auditor is well situated to comment on the effectiveness of the
State in implementing ATS systems consistent with accepted Human Factors principles.
Indicators that the ICAO safety oversight auditor might watch for regarding the regulator’s and
management’s commitment to improving Human Factors performance in ATS include:

 Quality of selection criteria, initial and recurrent training, and retention

programmes for air traffic controllers;
 Provision of a work environment (including the associated equipment and
procedures) that is sensitive to the natural capabilities and limitations of ats
personnel;
 Human factors awareness programmes and atc team resource management
training programmes;
 Availability of qualified first-line supervisors to provide defence-in-depth for
active controllers;
 Error reporting and trend analysis systems aimed at the identification of
systemic safety deficiencies;
 The means for deciding on and effecting any necessary changes to reduce
or eliminate identified safety deficiencies; and
 A blame-free (or error tolerant) safety culture

With this background information in mind, ICAO safety oversight auditors responsible for
ATC issues are referred to Chapter 10 for more specific instructions for auditing the effective
implementation of SARPs and best industry practices relating to Human Factors and to
Doc 9735.

APP4 - 21
 APPENDIX 5

HUMAN FACTOR IN AIR NAVIGATION SYSTEM PROVIDER (ANSP)

Introduction

Lapses in human performance are cited as casual factors in the majority of accidents. If
the accident rate is to be decreased, Human Factors must be better understood and Human
Factors knowledge more broadly applied. Increasing awareness of the importance of aviation
Human Factors presents the international aviation community with a single most significant
opportunity to make aviation both safer and more efficient. The purpose of this appendix is to
introduce Air Traffic Safety Personnel (ATSEP) to fundamental Human Factors concepts in Air
Navigation System (ANS).

The meaning of Human Factors

Human Factors as a term has to be clearly defined because when these words are used
in the vernacular they are often applied to any factor related to humans. The human element
is the most flexible, adaptable and valuable part of the aviation system, but it is also the most
vulnerable to influences which can adversely effect its performance. Throughout the years,
some three out of four accidents have resulted from less than optimum human performance.

Human Factors is a technology which deals with people: it is about people in their working
and living environments, and it is about their relationship with machines, equipment and
procedures. Just as important, it is about their relationship with each other as individuals and
in groups. It involves the overall performance of human beings within the Air Navigation
System. Human Factors seeks to optimize the performance of people by 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.

Human Factors has come to be concerned with diverse elements of the ATSEP in the
ANS. These include human behaviour; decision-making and other cognitive processes; the

APP5 - 1
maintenance and repair of electronic systems; the installation and/or modification of electronic
systems; communication and software aspects of computers; as well as training.

Cultural differences have been recognized as issues of concern to Human Factors. The
subject has been studied by many Human Factors specialists

Human Factors in the ANS for the ATSEP is primarily oriented toward solving practical
problems in the real world. There are a growing number of integrated Human Factors
techniques or methods; these varied and developing techniques can be applied to problems
as diverse as accident investigation and the optimization of personnel training.

It is most important that all concerned with the operation and administration of the ANS
recognize the inevitability of human error. No person, whether designer, engineer, manager,
controller or ATSEP can perform perfectly at all times. Also, what could be considered perfect
performance in one set of circumstances might well be unacceptable in another. Thus, people
need to be seen as they really are; to wish that they be intrinsically “better” or “different” is
futile, unless such a wish is backed by a recommendation for remedial action. Such a
recommendation can be further supplemented by the provision of means to achieve better
design, training, education, experience, motivation, etc., with the objective of positively
influencing relevant aspects of human performance.

An understanding of the predictable human capabilities and limitations and the

applications of this understanding are the primary concerns of Human Factors. Human Factors
has been progressively developed, refined and institutionalized since the end of the last
century, and is now backed by a vast store of knowledge which can be used by those
concerned with enhancing the safety of the complex system which is today’s civil air transport
system.

Awareness

Awareness is the essential first phase and usually comprises instructional presentations
focusing on the roles of interpersonal and group factors of the ATSEP. A useful way of
beginning the awareness phase might be to introduce ATSEP skills as they pertain to

APP5 - 2
communication, situation awareness, problem solving, etc… It is important to recognize that
awareness is only a first step; classroom instruction alone will probably not significantly alter
ATSEP attitudes and behavior in the long term.

Intermediate Objectives
Topic The students should be able Level Content
to:
Introduction to Human Factors
1. Introduction 1) Consider the necessity to 2 Module objectives,
constantly extend his knowledge. Presentation
of the general concept of
training
for Human Factors.
Impact on rapid
evolution, new
technology, upgrade of
systems,
new procedures

Psychological, Medical,
2) List factors which can affect 1
Physiological, Social,
personal and team performance Organizational,
Communication,
Stress, Human error,
Working
methods, To maintain
knowledge
Working Knowledge and Skills
ATSEP 1) Explain the importance of 2 Assure safety, Licensing
knowledge and maintaining and updating
skills professional knowledge and skills
for ATSEP

APP5 - 3
 2) Maintain and update 3 New system, new
professional procedures,
knowledge and skills to retain monitoring system,
competence in the technical and maintenance
operational environment procedure, new
technology,
upgrade of old system
(radar,
navaids, communication,
processing, hardware,
software)

3) List the available means to 1 Personal study, Briefing,

maintain professional knowledge seminars, courses,
and skills technical
periodic, technical
books, OJT,
simulation, Computer
based
training, E-learning,
visits
Psychological Factors
Cognitive 1) Describe the factors which 2 Stress, learning,
influence decision making knowledge, fatigue,
alcohol, drugs,
distraction, interpersonal
relations, team resource,
management, working
environment,
redundancies

APP5 - 4
 2) Relate human performance to 4 Problems which will
decision making affect decision making:
problems related
to learning new things,
problems related to high
level of concentration,
problems related to
high stress level and
fatigue, problems related
to changes in the
working environment or
in the organization
Medical
1. Fatigue 1) Describe the effect of fatigue 2 Lack of concentration,
on human performance irritability, frustration

2) Identify the influence on fatigue 3 Making frequent

in self and in others mistakes, unable to
concentrate, being of
bad humor all the time,
sleeping disorders,
eating disorders

3) Respond to indications of 3 Take time off, rest for

fatigue in an appropriate manner short period of time
consult professional help
2. Fitness 1) Interpret one's own fitness and 5/1 Physical and mental
recognize signs of lack of fitness
personal fitness

2) Describe actions to be taken 2

APP5 - 5
 when aware of a lack of personal
fitness
3. Work 1) Describe the influence of the 2 Work environment,
environment work environment ergonomics, effects of
noise, electromagnetic
waves, tools
4. Alcohol and drugs 1) Explain the influence of alcohol 2 Nervous system,
and drugs on human medication
performance

Organizational and Social factors

1. Human relation 1) Interpret the factor involved in 5 Feeling of being useful in
human relation and the factors of the organization,
work satisfaction teamwork, being listen to

2) Apply social and 3 Feeling of being part of

Organizational factor to work with the team, leadership,
other team members respect of others
2. Team Resource 3) State the principle and 1
Management objectives of TRM
3. Group dynamics 1) Identify the professional 3 Role of members,
relationships between members responsibilities within the
of the ATSEP group. team, benefits of having
other team members to
rely on, safety aspects,
assistance in abnormal
and difficult situations.

2) Identify reasons for conflict and 3 Roles poorly defined,

actions to prevent it and prevent goals poorly identified,
repetition bad planning, too many

APP5 - 6
 leaders or not enough,
respect of others,
divergence in values

3) Take account of the Team 2

Resource Management
programs
Communication
1. Written report 1) Record information by writing 3 ATSEP Technical report,
effectively log-books, system
degradation reports,
specification, System
manager report

2) Pass information by writing 3 Be concise, clear, use

effectively proper level of language
with proper technical
terms.
2. Verbal 1) Describe human 2 Different languages,
communication communication theory technical language
(English)

2) Characterize the factors 2 Some cognitive factors

which affect verbal such as:
communication lack of knowledge of the
procedures, of the
technical terms,
Some affective factors
such as:

APP5 - 7
 being shy, feelings of not
being listen to, not being
part of the group, not
being assertive
Some physiological
factors: such as
stuttering, low voice
level, poor eye contact
while talking

3) Use language effectively in 3 Technical “jargon”

the practice of technical
matters
Stress
1. Stress 1) Take account of the effects on 2 Stress and its symptoms
stress in self and in others,
during on line
intervention, during
maintenance, during
training (stress on
instructor and student)
2. Helplessness 1) Respond of feeling of 3 Normal and abnormal
helplessness situation
3. Stress 1) Act to relieve or minimize 3 The effect of personality
Management stress in self and/or others in coping with stress,
benefits of active stress
management

2) Obtain assistance in stressful 3 Benefits of offering and

situations accepting help in stress
situations

APP5 - 8
 3) Recognize the effects of 1 For self and for others in
stressful events abnormal situations

4) Consider the benefits of 2 CISM

Critical Incident Stress
Management

5) Explain the procedures used 2 National and local

in case of problem on system technical and operational
or incident procedures and/or
regulation, counselling
human element
Human Error
1. Human Error 1) Explain the relationship 2 Number and
between error and safety combination of errors
2) List the different types of error 1
3) Differentiate between errors 2
and violation
4) Describe error-prone 2
conditions
Working Methods
1. Efficiency 1) Consider, from a human 2 Own workload, safety,
factors point of view, the factors many projects, economy,
affecting efficiency in the ecology, new
provision of installation, technology, customer
commissioning and maintenance requirements
of CNS equipment

APP5 - 9
 MINISTRY OF TRANSPORTATION INDONESIA
AGENCY OF HUMAN RESOURCES DEVELOPMENT ON TRANSPORTATION
CENTER FOR HUMAN RESOURCES DEVELOPMENT ON CIVIL AVIATION

FUNDAMENTAL HUMAN
FACTORS CONCEPTS
 OBJECTIVES

The student able to explain Fundamental

Human Factors Concepts

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 Learning Points

• The Meaning Of Human Factors

• The Industry Need For Human Factors
• Human Factors Applications In Aviation Operations

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HUMAN FACTOR

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 THE MEANING OF
HUMAN FACTORS

"Human Factors is concerned to optimize the relationship

between people and their activities, by the systematic
application of human sciences, integrated within the
framework of systems engineering“ by Professor Edwards

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 THE MEANING OF
HUMAN FACTORS

THE DISCIPLINES OF HUMAN FACTORS

Human Factors is about people in their
living and working situations; about their
relationship with machines, with
procedures and with the environment
about them; and also about their
relationships with other people.

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 THE MEANING OF
HUMAN FACTORS

A Conceptual Model of Human Factors

Some of the more important characteristics are the following:
• Physical and shape
• Physical needs
• Input characteristics
• Information processing
• Output characteristic
• Environment tolerances

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 THE MEANING OF
HUMAN FACTORS

A Conceptual Model of Human Factors

o Software
o Hardware
o Environment
o Liveware
o Liveware, other
persons

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 THE INDUSTRY NEED
FOR HUMAN FACTORS

The industry need for Human Factors is based on its impact on two broad areas, these
areas are:
• Effectiveness of the system
 safety
 efficiency

• Well-being of operational personnel.

 fatigue
 body rhythm disturbance
 sleep deprivation or disturbance.

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 THE INDUSTRY NEED
FOR HUMAN FACTORS

The Tenerife accident 1977

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 HUMAN FACTORS APPLICATIONS IN
AVIATION OPERATIONS

Errors at the model interfaces

o Software
o Hardware
o Environment
o Liveware
o Liveware, other
persons

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 HUMAN FACTORS APPLICATIONS IN
AVIATION OPERATIONS

Errors at the model interfaces

The interface between Liveware and
Hardware (human and machine) is a frequent
source of error: knobs and levers which are
poorly located or lack of proper coding create
mismatches at this interface

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 Errors at the model
interfaces
In the Liveware-Software interface,
delays and errors may occur while seeking
vital information from confusing,
misleading or excessively cluttered
documentation and charts.

L S
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 Errors at the model
interfaces
Errors associated with the Liveware-Environment
interface are caused by environmental factors (noise,
heat, lighting and vibration) and by the disturbance of
biological rhythms in long-range flying resulting from
irregular working/sleeping patterns.

L E
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 Errors at the model
interfaces
In the Liveware-Liveware interface, the focus is on the
interaction between people because this process affects crew
effectiveness. This interaction also includes leadership and
command, and shortcomings at this interface reduce
operational efficiency and cause misunderstandings and
errors.

L L
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 HUMAN FACTORS APPLICATIONS IN
AVIATION OPERATIONS

Information processing
Before a person can react to information, it must
first be sensed; there is a potential for error here,
because the sensory systems function only within
narrow ranges. Once information is sensed, it
makes its way to the brain, where it is processed,
and a conclusion is drawn about the nature and
meaning of the message received

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HUMAN FACTORS APPLICATIONS IN
AVIATION OPERATIONS

Controlling human error

The control of human error
requires two different
approaches :
a) minimize the occurrence of
errors
b) reduce the consequences of
the remaining errors
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 HUMAN FACTORS APPLICATIONS IN
AVIATION OPERATIONS

Training and evaluation

Training is a process aimed at developing specific skills,
knowledge or attitudes for a job or a task

There are two major types of training

devices:
• training aids
• training equipment

8/25/2020
Introduction to Safety Management - Ejusticia 18
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HUMAN FACTORS APPLICATIONS IN
AVIATION OPERATIONS

Leadership

A leader is a person whose ideas

and actions influence the thought
and the behaviour of others. The
leader becomes a means of
change and influence.
8/25/2020
19

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 HUMAN FACTORS APPLICATIONS IN
AVIATION OPERATIONS

Personality and attitudes

Personality deep-rooted
characteristics which define a
person, and they are very stable and
resistant to change.

On the other hand, attitudes are

more susceptible to change through
training.
8/25/2020
20

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 HUMAN FACTORS APPLICATIONS IN
AVIATION OPERATIONS

Communication
Effective communication, which includes all transfer of information, is essential for the safe operation of
flight.
There are several hazards which reduce the quality of
communications:
- failures during the transmitting process
- difficulties caused by the medium of transmission
- failures during receiving
- failures due to interference between the rational and
emotional levels of communication
- physical problems in listening or speaking
- use of English among native and non-native speakers;
and
- encoding/decoding/noise.
8/25/2020
21

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 HUMAN FACTORS APPLICATIONS IN
AVIATION OPERATIONS

Crew coordination
Crew co-ordination is the advantage of teamwork
over a collection of highly skilled individuals:

- an increase in safety by redundancy

to detect and remedy individual
errors; and
- an increase in efficiency by the
organized use of all existing
resources, which improves the
inflight management.

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HUMAN FACTORS APPLICATIONS IN
AVIATION OPERATIONS

Motivation
There is a relationship between
expectancy and reward as motivators
It is important for high performers to see
that they are in a better position than
poor performers to achieve a reward,
otherwise motivation may decline.
Job satisfaction motivates people to
higher performance.

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 HUMAN FACTORS APPLICATIONS IN
AVIATION OPERATIONS

Documentation
With reference to documentation,some basic aspects
require Human Factors optimization:

a) written language
b) typography
c) the use of photograph diagrams, charts or tables
replacing long descriptive text

d) the working environment in which the document is

going to be used

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 HUMAN FACTORS APPLICATIONS IN
AVIATION OPERATIONS

Workstation design
The flight deck should be considered as a
system, as opposed to a collection of
particular aspects or systems such as
hydraulic, electrical or pressurization

Proper matching of working areas to human dimensions and characteristics is important -

for instance, size, shape and movements of the body provide data used to ensure
adequate visibility in the flight deck, location and design of controls and displays, and
seat design

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 HUMAN FACTORS APPLICATIONS IN
AVIATION OPERATIONS

Cabin design

Human size and shape are relevant in

the design of cabin equipment
emergency equipment design
seats and furnishings
jump seats and rear-facing seats

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 HUMAN FACTORS APPLICATIONS IN
AVIATION OPERATIONS

Visual performance and collision avoidance

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 Summary

The Meaning Of Human Factors

The meaning of Human Factors explain about :
• the definition of Human Factors
• the disciplines of Human Factors
• the conceptual model of Human Factors

The Industry Need For Human Factors

The industry need for Human Factors is based on its impact on two broad areas,
these areas are:
• Effectiveness of the system, including safety and efficiency
• Well-being of operational personnel, including fatigue, body rhythm
disturbance and sleep disturbance
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 Summary

Human Factors Applications In Aviation Operations

Human Factor applications in aviation operation contains :
• Errors at the model interface
• Information processing
• Controlling human error
• Training and evaluation
• Leadership
• Personality and attitudes
• Communication
• Crew coordination
• Motivation
• Documentation
• Workstation design
• Cabin design
• Visual performance and collision avoidance

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 MINISTRY OF TRANSPORTATION INDONESIA
AGENCY OF HUMAN RESOURCES DEVELOPMENT ON TRANSPORTATION
CENTER FOR HUMAN RESOURCES DEVELOPMENT ON CIVIL AVIATION

HUMAN ELEMENT
(AVIATION PHYSIOLOGY)
 OBJECTIVES

The student able to explain Human Element in

Aviation Physiology

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 Learning Points

• Limitation of senses
• Sleep disturbance and deficits
• Diet, health and well-being
• Fasting
• Alcohol and other drugs
• Blood donation
• Ageing
• Mental health
• Pregnancy

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 LIMITATION OF THE SENSES

Vision
The basic structure of the eye is similar to a simple camera with an
aperture (the iris), a lens and a light sensitive surface (the retina).

Light enters the eye through the cornea, then passes through the iris and
the lens and falls on the retina.

Light stimulates the light-sensitive cells on the retina (rods and cones) and
these pass small electrical impulses by way of the optic nerve to the visual
cortex in the brain. Electrical impulses are interpreted and an image is
perceived
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LIMITATION OF THE SENSES

Basic Function of the eye o Cornea

o Iris and Pupil
o Retina
o Fovea
o Blind spot

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 LIMITATION OF THE SENSES

Factors can affect and limit the visual acuity of the eye
Physical factors
Physical imperfections in one or both eyes (short sightedness, long sightedness).

1. Hypermetropia
Long sight known as Hypermetropia is caused by a shorter than normal eyeball
which means that the image is formed behind the retina

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 LIMITATION OF THE SENSES

2. Myopia
Short sight - known as Myopia is where the eyeball is
longer than normal, causing the image to be formed in front
of the retina. If the accommodation of the lens cannot
counteract this then distant objects are blurred
Myopia

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 LIMITATION OF THE SENSES

3. Presbyopia
Person grows older, the lens becomes less flexible meaning
that it is unable to accommodate sufficiently. This is known as
presbyopia and is a form of long sightedness. After the age
of 40, spectacles may be required for near vision, especially
in poor light conditions.

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 LIMITATION OF THE SENSES

Environmental factors
Moving from an extremely bright environment to a dimmer
one has the effect of vision being severely reduced until the
eyes get used to less light being available. This is because
the eyes have become light adapted
Works in a very dark environment for a long time, the eyes
gradually become dark adapted allowing better visual
acuity. This can take about 7 minutes for the cones and 30
minutes for the rods
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 LIMITATION OF THE SENSES

Factors associated with object being viewed

Size and contours of the object

Contrast of the object with its surroundings
Relative motion of the object
Distance of the object from the viewer
The angle of the object from the viewer
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 LIMITATION OF THE SENSES

HEARING
The ear performs two quite different functions. It is used to
detect sounds by receiving vibrations in the air, and
secondly, it is responsible for balance and sensing
acceleration. Of these two, the hearing aspect is more
pertinent to the maintenance engineer and thus it is
necessary to have a ba sic appreciation of how the ear
works

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LIMITATION OF THE SENSES

Ear Structure

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 LIMITATION OF THE SENSES

Performance and Limitations of the Ear

The performance of the ear is associated with the range of

sounds that can be heard both in terms of the pitch
(frequency) and the volume of the sound. The audible
frequency range that a young person can hear is typically
between 20 and 20,000 cycles per second (or Hertz), with
greatest sensitivity at about 3000 Hz. Volume (or intensity)
of sound is measured in decibels (dB).
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 LIMITATION OF THE SENSES

In the Ministry of Manpower decree number PER.13/MEN/X/2011, they stipulate limit of noise intensity as
follows: Exposure time per day Noise Intensity Limit in dBA
8 Hours 85
4 88
2 91
1 94
30 Minutes 97
15 100
7,5 103
3,75 106
1,88 109
0,94 112
28,12 Seconds 115
14,06 118
7,03 121
3,52 124
1,76 127
0,88 130
0,44 133
0,22 136
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139
 LIMITATION OF THE SENSES

VESTIBULAR SYSTEM

The vestibular system of the ear consists of the semi-

circular canals which detect angular accelerations of the
body, and the otolith organs, the utricle and saccule, which
detect linear acceleration or deceleration.

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 LIMITATION OF THE SENSES

Semi-Circular Canals

There are three fluid-filled, semi-circular canals in each ear.

The canals are oriented in three planes, each at right angles
to the other two. Their names are the Lateral Canal, the
Anterior Canal and the Posterior Canal

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 LIMITATION OF THE SENSES

Semi-Circular Canals

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 LIMITATION OF THE SENSES

Otoliths
The otolith organs are small sacs located
in the vestibule. Sensory hairs project
from each macula into the otolith
membrane, an overlying gelatinous
membrane that contains chalk-like crystals
called otoliths. The otoliths are sensitive to
linear movement and the force of gravitiy

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LIMITATION OF THE SENSES

Common Vestibular Disorders

 Benign paroxysmal positional vertigo (BPPV)

 Labyrinthitis
 Vestibular neuritis
 Meniere’s disease
 Perilymphatic fistula (PLF)

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 LIMITATION OF THE SENSES

PROPRIOCEPTIVE

Proprioception also referred to

as kinaesthesia (or kinesthesia), is
the sense of self-movement and
body position. Proprioception is the
ability of our muscles and joints to
determine where they are in space

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 LIMITATION OF THE SENSES

TACTILE

The Tactile System, includes

multiple types of sensation from the
body - light touch, pain, pressure,
temperature, and joint and muscle
position sense (also called
proprioception)

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FATIGUE

What is Fatigue?

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FATIGUE

Fatigue is the state of feeling

very tired, weary or sleepy
resulting from insufficient
sleep, prolonged mental or
physical work, or extended
periods of stress or anxiety.

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 FATIGUE

Fatigue can be described as either acute or chronic

Acute fatigue results from short-term sleep loss or from short periods of heavy physical
or mental work. The effects of acute fatigue are of short duration and usually can be
reversed by sleep and relaxation.

Chronic fatigue syndrome is the constant, severe state of tiredness that is not relieved
by rest. The symptoms of chronic fatigue syndrome are similar to the flu, last longer
than six months and interfere with certain activities. The exact cause of this syndrome is
still unknown.

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 FATIGUE

The effects of fatigue as:

 reduced decision making ability,  unable to stay awake (e.g., falling asleep while
 reduced ability to do complex planning, operating machinery or driving a vehicle),
 reduced communication skills,  increased tendency for risk-taking,
 reduced productivity or performance,  increased forgetfulness,
 reduced attention and vigilance,  increased errors in judgment,
 reduced ability to handle stress on the job,  increased sick time, absenteeism, rate of turnover,
 reduced reaction time - both in speed and  increased medical costs, and
thought,  increased incident rates.
 loss of memory or the ability to recall details,
 failure to respond to changes in
surroundings or information provided,
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 SLEEP DISTURBANCES
AND DEFICITS

How much sleep do people need? It varies, but

on average studies say we need at least 7 to 9
hours every day. Studies have reported that most
night workers get about 5 to 7 hours less sleep
per week than the day shift. (You can accumulate
a sleep "debt", but not a surplus.)

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 SLEEP DISTURBANCES
AND DEFICITS
Insomnia
People who suffer from insomnia often complain that they cannot fall asleep, or
cannot stay asleep for a full night

Sleep Apnea

Most cases of sleep apnea are caused by a condition called "Obstructive Sleep
Apnea". Sleep apnea is a breathing disorder in which there are brief interruptions
(lasting a minimum of 10 seconds) in breathing during sleep. This condition is
caused by a narrowing (or collapse) of the throat or upper airway during sleep

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 SLEEP DISTURBANCES
AND DEFICITS

Restless Legs Syndrome

With restless legs syndrome, people report sensations of creeping, crawling,
pulling, or tingling which cause an irresistible urge to move their legs

Narcolepsy

Narcolepsy is a rare condition associated with sudden sleep "attacks" where

a person will have an uncontrollable urge to sleep many times in one day

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 SLEEP DISTURBANCES
AND DEFICITS

Other Situations
Substances such as nicotine, caffeine, and alcohol can affect the
quality of sleep. Caffeine can remain in the body for about 3 to 7
hours and may affect sleep

Jet lag
Jet lag is a condition that affects your energy and state of
alertness. It’s caused when your body’s natural clock, or circadian
rhythm, is disrupted by traveling to different time zones

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 DIET, HEALTH
AND WELLBEING

Your gut is home to the micro biome, trillions of bacteria, viruses,

fungi and other microbes which live mainly in your large intestine
or colon. They influence mood, weight and the immune system.
The micro biome weighs between one and two kilos and until
relatively recently was largely ignored

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 DIET, HEALTH
AND WELLBEING

Basics of Healthy Eating

Eating healthily and in moderation is important for weight control
and proper functioning of bodily processes. We need to eat to be
active and maintain our bodies, and a balanced diet with
adequate levels of essential nutrients to maintain good health.
These include proteins, fats, carbohydrates, vitamins, minerals
and trace elements. The typical Western diet is high in fats, sugars
and salt, and low in fibre
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 FASTING

Total population in Indonesia is about 240 million people, and

around 85% of the total population were a Moslem. Ramadhan
is a holy lunar month for Moslems. During Ramadhan, all
Moslem are required to fast. Refraining from eating and drinking
from sunrise to sunset

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 FASTING

Effect of Fasting

Decreased alertness
Increased fatigue
Irritability and impaired mood
Impaired memory
Decreased work performance

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 ALCOHOL AND
OTHER DRUGS

Alcohol, medication and drugs can be

adversely affect human body. For
operational personnel, the use of drugs
such as hypnotics, sedatives (including
antihistamines with a sedative effect) and
tranquillizers to induce sleep is usually
inappropriate, as they have an adverse
effect on performance when taken in
therapeutic doses for up to 36 hours after
administration

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ALCOHOL AND
OTHER DRUGS
Drug Common Side Effects
Alcohol A depressant that affects
concentration and coordination.
Antihistamines (allergies) Drowsiness, slower reaction time, disturbed balance.

Amphetamines (with appetite Stimulants such as amphetamines can make you anxious and
suppressant side-effects) uncoordinated. They can effect judgment and increase risk
taking
Barbiturates Noticeably reduce alertness.
Motion sickness drugs Drowsiness, depressed brain function, impact judgment and
decision making
Sulfa drugs Allergic reactions are common and include visual disturbances,
(antimicrobial) dizziness, slowed reaction time, depression.

Tranquilizers Slow reaction time,

drowsiness, reduced concentration and attention.

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 BLOOD DONATION

An adult body contains about six litres of blood. Just over half of this
is plasma which is the liquid medium in which the blood cells are
carried. There are three kinds of blood cell, each with different
function.
 The white blood cells
 Red blood cells
 Platelets

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 BLOOD DONATION

Red blood cells (erythrocytes) contain

hemoglobin which contains iron and is the major
component of the red cells. This has a strong
affinity for oxygen (and incidentally also for
carbon monoxide, the affinity being 210 to 250
times greater than for oxygen). Anemia is a
condition in which the number of red blood cells
is below normal and thus less oxygen can be
carried from the lungs to the tissues. For this
reason, it is recommended that flight crew
engaged in regular flying do not donate blood.

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AGEING

At the biological level, ageing results

from the impact of the accumulation
of a wide variety of molecular and
cellular damage over time. This leads
to a gradual decrease in physical and
mental capacity, a growing risk of
disease, and ultimately, death

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 MENTAL HEALTH

We can all feel sad, moody or low from time to time. However, some people
experience these feelings intensely, for long periods (weeks, months or even
years) for no apparent reason.
Depression is more than just a low mood—it’s a
serious mental illness affecting our physical health,
concentration levels, alertness, reaction time and
decision-making ability.
Some medications used to treat depression
and anxiety can impair performance by
impairing perception and causing sedation,
nausea, lack of balance, impaired sleep
and fatigue.
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 PREGNANCY

Pregnancy under normal circumstances can be

compatible with flying and controlling duties. However, the
certificate holder’s obstetrician should be made aware of
the relevant considerations of the aviation environment in
order to properly advise of the safety (or otherwise) of
flying or controlling when pregnant

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 PREGNANCY

Effect of aviation on condition

 Cosmic radiation, especially for long-haul high latitude flights

 Prolonged sitting in restricted posture
 Limited access to toilet facilities
 Risk of trauma from turbulence or accident
 Possible exposure to physical hazards, including radiation, noise,
fuels, and cabin air contamination.
 Adverse effect of vibration on fetus
Adverse effect of aerobatics

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 PREGNANCY

Effect of condition on aviation

Fatigue and daytime sleepiness Pregnancy-related nausea
Neurocognitive impairment, (‘morning sickness’)
including concentration, memory Anaemia
and speed of processing Postural hypotension and syncope
Mood lability Increasing abdominal size may
Decrease in visual acuity interfere with flight controls
Back and pelvis pain, especially Risk from miscarriage or premature
with prolonged sitting labour.
Pre-eclampsia and eclampsia
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 SUMMARY

Limitation of Senses can affect human performance. This condition

include: visual acuity, limitation of the ear, vestibular system,
proprioceptive, and tactile.

Another condition also can decrease human performance such as

fatigue, sleep disturbance and deficits, diet health and well-being,
fasting, alcohol and other drugs, blood donation, ageing, mental
health and pregnancy

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 MINISTRY OF TRANSPORTATION INDONESIA
AGENCY OF HUMAN RESOURCES DEVELOPMENT ON TRANSPORTATION
CENTER FOR HUMAN RESOURCES DEVELOPMENT ON CIVIL AVIATION

HUMAN ELEMENT
(AVIATION PSYCHOLOGY)
 OBJECTIVES

The student able to explain Human Element in

Aviation Psychology

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 Learning Points

• Human error
• Workload
• Human information processing
• Attitudinal factors
• Situational awareness
• Decision making
• Stress
• Currency vs Proficiency

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HUMAN ERROR

What is Error ?

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Chicago O’Hare 2006

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 HUMAN ERROR

Why talk about human error?

• Errors are a normal part

of human behaviour

Errors are at the core of

learning processes

Errors are at the core of

« to err is human » safety
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 HUMAN ERROR

In his book “Human Error”, Professor James Reason defines error

as follows:

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

those occasions in which a planned sequence of mental or
physical activities fails to achieve its intended outcome,
and when these failures cannot be attributed to the
intervention of some chance agency”.

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 HUMAN ERROR

Let’s have a new view of errors

Give up searching for « who is
responsible for »

In order to look for prevention

By ACCEPTING and UNDERSTANDING errors that were made:

Understand why they were made and no more who made them !
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 HUMAN ERROR

Two different perspectives on error

• Error as a deviation from intention

(the pilot - and psychologist - point of view):
"I didn't do what I wanted to do”
• Error as a deviation from a norm or a procedure (the
external - and industry - point of view) :
”He did not do what he should have done"

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 HUMAN ERROR

Errors and consequences of errors

the effects of
an
error depend
on
the
circumstances
in which they
occur
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HUMAN ERROR

Basic error
types
Attention failures / Ommissions
Slips
Misordering, etc
Unintended
actions
Memory failure / Losing place
Lapses
Omitting items, etc
Unsafe
Acts
Mistakes Rule-based / Knowledge-based
Intended
actions
Routine / Exceptional
Violation
Acts of sabotage

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 HUMAN ERROR

Remember...Violation is...

Violation :
Not applying a written rule or procedure
Intentional act

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HUMAN ERROR

Why do we make violation?

Habits To save time, save resources

(working comfort)
(routine deviation)

Because of incompatibility of
goals
To follow the standards
of the team

Because the procedures are sometimes

considered inappropriate
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HUMAN ERROR

Making violation: which impact on safety?

Loss of common references with colleagues and pilots

Creating wrong expectations

It is difficult to make sure there is no safety effect

Over assessment of own capabilities

Difficult to evaluate medium or long-term effects

May increase the risk of errors (loss of reference)

Slightly moving to routine

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HUMAN ERROR

Involuntary or non-
NO intentional action
Was there a prior NO Was there intention in
Intention to act? the action? Spontaneous or
YES subsidiary action
YES

Did the actions NO Unintentional action –

Proceed as planned? slip or lapse
YES
Did the actions
NO Intentional but
Achieve the desired
mistaken action
end?
YES
SUCCESSFUL ACTION

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 HUMAN ERROR

Find the right tuning

Procedures Always stick to procedures
are useless !

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 HUMAN ERROR

Errors and violations… Definitions

• An error is NOT intentional A violation is intentional
– You make an error when Intentional deviation from a
what you do differs from regulation or SOP
what you intended, Selective compliance
– .. or when what you Correcting an earlier error
intended was A violation can start as a
inappropriate one-off but become a habit,
You cannot decide not to a routine
commit an error. You can decide not to commit
a violation
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 HUMAN ERROR

The following is a refined discussion of human

errors which is more operationally oriented:
a) Procedural error
b) Communication error
c) Proficiency error
d) Operational decision error
e) Intentional non-compliance

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 HUMAN ERROR

Three strategies for error prevention, which is actually form of risk

mitigation, are briefly discussed below.

a) Error reduction strategies are intended to intervene directly at the

source of the error itself, by reducing or eliminating the contributing
factors to the error.
b) Error capturing assumes the error has already been made.
c) Error tolerance refers to the ability of a system to accept an error
without serious consequence.

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 HUMAN ERROR

Managing Violation
An effective strategy for managing violations will include the
establishment and maintenance of a effective management
systems that ensures, at a minimum, the following:
 Good leadership, planning, training, and resourcing.
 Both management and employees are aware of their
responsibilities and key risks related to their work and
understand how violations reduce vital safety margins.
 Existing violations are analysed to fully understand their
causes and any contributing human and organisational
factors.
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 HUMAN ERROR

 A change management process is established such that pre-determined and unexpected

changes are safety assessed to consider impact on human performance.
 Employees are invited and encouraged to participate in setting boundaries and limits, as
appropriate, of what is acceptable and unacceptable.
 A defined and measurable programme for workplace culture improvement is undertaken,
such that violations are not an acceptable option for employees.
 Appropriate communication and feedback systems are used to ensure all the above happens,
and employees really “feel it”.

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 WORKLOAD

Define Workload
– Physical workload
– Mental workload
Workload has to do with the amount of work
expected from an individual. In aviation, workload
generally implies mental effort as opposed to
physical effort. If the workload generated by a task
or set of tasks exceeds a person’s mental
capacity, performance will suffer.

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 WORKLOAD

Mental Workload
• A function of a person’s information processing abilities
• Humans have limited information processing capacity
• More information arrives at the brain than can be processed
• Mental resources are finite and must be allocated to the tasks

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 WORKLOAD

Mental Workload
Concept of Workload

– Momentary workload
vs
– Cumulative workload

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 WORKLOAD

There are two types of mental workload :

– Momentary workload. The workload existing at a single point in time, may
exceed an individual’s capacity to cope. Momentary workload can
exceed information processing capabilities. Example : an in-flight
emergency
– Cumulative workload. Less complex tasks in some period of time, may
exceed an individual’s capacity to cope. Cumulative workload can lead to
stress and fatigue, and then performance problems. Example: Series of
flight in a day
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WORKLOAD

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 WORKLOAD

Measuring Mental Workload

• Physiological measures
– Blood pressure
– Heart rate
– Pupil dilation

• Dual/secondary task (laboratory testing)

– Measure performance on an easy task
– Measure performance on a difficult task
– Perform two tasks simultaneously and observe impairment in
easy task performance
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 WORKLOAD

Self Report Measures

– Cooper-Harper rating scale
– Subjective Workload Assessment Technique
(SWAT)
– NASA Task Loading Index (TLX) rating scale
– The Crew Status Survey
– The AFFTC Revised Workload Estimate Scale

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 WORKLOAD

Working Memory & Workload

Moderate task demand,
Low stress

Low workload

Moderate task demand,

High stress

High workload

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 WORKLOAD

Workload Management Strategies:

– Chunking, reduces the number of items to be remembered
– Segmentation
– Prioritisation
– Training & practice
– Use of checklists & standard operating procedures
– Good communications
– Delegate when due

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 HUMAN INFORMATION
PROCESSING

Human information processing model

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HUMAN INFORMATION
PROCESSING

Count the number of “F” in

the following text :

FINISHED FILES ARE THE RE-

SULT OF YEARS OF SCIENTIF-
IC STUDY COMBINED WITH THE
EXPERIENCE OF YEARS

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HUMAN INFORMATION
PROCESSING

FINISHED FILES ARE THE RE-

SULT OF YEARS OF SCIENTIF-
IC STUDY COMBINED WITH THE
EXPERIENCE OF YEARS

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HUMAN INFORMATION
PROCESSING

PARIS

IN THE

THE SPRING

Please write down what you have

seen.
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 HUMAN INFORMATION
PROCESSING

Attention
Having detected information, our mental resources are concentrated on specific
elements this is attention. Attention can be thought of as the concentration of
mental effort on sensory or mental events

Attention can take the form of

• Selective attention
• Divided attention
• Focused attention
• Sustained attention

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 HUMAN INFORMATION
PROCESSING

Decision Making

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 judgment.

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 HUMAN INFORMATION
PROCESSING

Perception
Involves the organization 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

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 HUMAN INFORMATION
PROCESSING

Perception is both a ‘bottom up’

and a ‘top down’ process
‘Top down’ or
concept dependant
= what we are
looking for

We mainly perceive
what we want to
perceive ! ‘Bottom up’ or
stimulus dependant
= what the world sends
to our senses

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 HUMAN INFORMATION
PROCESSING

Memory
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

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HUMAN INFORMATION
PROCESSING

Test Your Memory… during 10 S

581215192226293336404347

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HUMAN INFORMATION
PROCESSING

Memory processes

581215192226293336404347
Chunks
58 12 15 19 22 26 29 33 36 40 43 47
581 215 192 226 293 336 404 347
Associations
Automatic recall
Reorganisation /, catégorisation
Try to find a logical organisation (+3 et +4)
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 ATTITUDINAL FACTORS

Personality

Personality can be described as the inner

person. It is personality that makes each
person an individual. Personality is :
 What person is born with
 What a person acquires in the formative
years from family, friends and education

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 ATTITUDINAL FACTORS

Motivation
There are many additional forms of personal motivation. One such motivational
factor is job satisfaction. Enhancing job satisfaction is not easy. An increase in
financial reward only has temporary effect on increasing job satisfaction. The
longer lasting factors usually relate to relationship, working environment, and
the nature and variety of tasks.

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 ATTITUDINAL FACTORS

Motivation
To satisfy the human needs there is an order of priority. Maslow introduced a
triangle of human needs.

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 ATTITUDINAL FACTORS

Culture
"Culture encompasses religion, food, what we
wear, how we wear it, our language, marriage,
music, what we believe is right or wrong, how
we sit at the table, how we greet visitors, how
we behave with loved ones, and a million
other things," Cristina De Rossi.

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 SITUATIONAL AWARENESS

Situation awareness requires continual questioning, cross-checking, refinement

and updating of perception.

Factors that reduce SA include:

■ Insufficient communication
■ Fatigue and/or stress
■ Task overload
■ Task underload
■ ‘Press-on-regardless’ philosophy
■ Degraded operating conditions.
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 SITUATIONAL AWARENESS

10 Clues to loss of situational awareness

a. Ambiguity: information from two or more sources that doesn’t agree.
b. Fixation: focusing on any one thing to the exclusion of everything else.
c. Confusion: uncertainty about a situation (often accompanied by anxiety or psychological discomfort).
d. Failure to fly the plane: everyone is focused on non-flying activities.
e. Failure to look outside: everyone is looking down.
f. Failure to meet an expected checkpoint on flight plan or profile.
g. Failure to adhere to standard operating procedures.
h. Failure to comply with limitations, minimums, regulations etc.
i. Failure to resolve discrepancies: contradictory data or personal conflicts.
j. Failure to communicate fully and effectively: vague or incomplete statements.

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 SITUATIONAL AWARENESS

A Model of Situational Awareness

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 SITUATIONAL AWARENESS

Situational Awareness and Safety

The link between poor situational awareness and

accidents has been well documented in aviation.
According to FAA statistics, spatial disorientation and
loss of situational awareness cause up to 15–17 per cent
of fatal general aviation crashes annually (about 2.5 per
cent of the total). More significantly, nine out of 10 cases
of spatial disorientation result in a fatality. Most of these
mishaps occur when pilots are flying at night and/or
intentionally, or inadvertently flying in instrument
meteorological conditions (IMC).

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 DECISION MAKING

Decision-making is a process for reaching a judgement or selecting an option to

address or resolve a situation.

Decision-Making Process
Decision-making generally has four components:
■ Defining the problem
■ Considering the options
■ Selecting and implementing the options
■ Reviewing the outcome.

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 DECISION MAKING

Characteristics of Decision-Making
Decisions made in stressful or high arousal situations have a number of
characteristics in common:
 Any decision made has a ‘deadline’. It is only valid for a short time in
changing conditions
 A decision is only effective if it can be implemented within the time available
 The value of the decision depends upon understanding the situation
 Usually a decision is irreversible and cannot be undone.

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 DECISION MAKING

Factors Influencing Decision-Making

Two sources of bias generally affect our ability to
make good decisions:
■ Social influences
■ Situational limitations

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 DECISION MAKING

Social influences

Research and accidents demonstrate that people tend to comply with

social pressure to avoid rejection or to gain social approval.

Individuals are frequently influenced by the dominant opinions of a

group or team and sometimes accept illogical decisions to avoid
conflict. Studies on group conformity suggest that the second-highest
member of a group is usually the most conforming member.

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 DECISION MAKING

Situational limitations
Situational limitations can affect our ability to make a sound
decision including :
a)Stress
b)Time pressure
c)Fatigue

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 STRESS

There are many types of stress. Typically in the aviation environment there are two distinct types - acute
and chronic.

Acute stress arises from real-time demands placed on our senses, mental processing and physical
body; such as dealing with an emergency, or working under time pressure with inadequate resources.

Chronic stress is accumulated and results from long-term demands placed on the physiology by life’s
demands, such as family relations, finances, illness, bereavement, divorce, or even winning the lottery.

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 STRESS

Effect of stress on Human Performance

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 STRESS

Stressor
Stress affects human performance, sometimes positively and sometimes negatively.
Although ubiquitous, stress is difficult to quantify. The concern here is with decreases in
human performance caused by anything that affects the way we live and work. These
things are called “stressors”.
The aviation environment is particularly rich in potential stressors. In the early days of
aviation, the stressors of concern to flight crews were created by the environment (noise,
vibration, temperature, humidity and acceleration forces) and were mainly physiological
in nature. Today, they include such things as irregular working and resting patterns and
disturbed circadian rhythms associated with long-range, irregular or night-time flying.

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 STRESS

Stress Management
Practical actions for coping with stress include:
• managing your time effectively • recognizing the physical signs of tightening
• avoiding over commitment—working within your up in response to stress and learning how to
limitations relax mentally and physically when feeling
• discussing your problems with others so they can tense
offer support • recognizing and responding to factors which
• eating healthily are combining to cause stress
• ensuring you are well rested and getting plenty of • staying hydrated
sleep to avoid fatigue • exercise and staying physically fit.
• maintaining your sense of humor—being able to
laugh about things helps maintain a positive
mental state
• practicing mindfulness meditation—there are many
helpful apps online

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 CURRENCY VS PROFICIENCY

Currency and proficiency have similar definitions and they do complement each
other, but neither one is a replacement for the other. Being current means that
you have met the requirements to act as a pilot in command of an aircraft within a
certain time period. Being proficient means, according to Webster's College
Dictionary, "fully competent in any art, science, or subject." You can be current
without being a proficient pilot, but if you are proficient, most likely you have also
met the currency requirements to get to that point.

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 Summary

At this section, we already discussed about Human Factor in

Aviation Psychology including : Human error, workload, human
information processing, attitudinal factors, situational
awareness, decision making, stress, currency vs proficiency. All of
that factor potentially causing incident or accident in aviation.

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 MINISTRY OF TRANSPORTATION INDONESIA
AGENCY OF HUMAN RESOURCES DEVELOPMENT ON TRANSPORTATION
CENTER FOR HUMAN RESOURCES DEVELOPMENT ON CIVIL AVIATION

HUMAN – HARDWARE
RELATIONSHIP
OBJECTIVES

The student able to explain

Human – Equipment Relationship

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 Learning Points

• Ergonomics
• System Approach Safety
• Human Dimensions
• Displays And Controls
• Alerting And Warning Systems
• Personal Comfort
• Cockpit Visibility And Eye-reference Position
• Motor Workload

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ERGONOMIC

WHAT IS Ergonomics??

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 ERGONOMIC

“Ergonomics" derives from the Greek words 'ergon" (work) and

"nomos" (natural law)

“The study of the efficiency of persons in

their working environment”

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ERGONOMIC

Ergonomics is the study of

the principles of interaction
between human and
equipment, for the purpose
of applying them in design
and operations.

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System Approach
Safety
The following set of example questions illustrates how an ergonomist
may proceed when designing systems:

• What inputs and outputs must be provided to satisfy systems

goals?
• What operations are required to produce system outputs?
• What functions should the person perform in the system?
• What are the training and skills requirements for he human
operators?
• Are the tasks demanded by the system compatible with human
capabilities?
• What equipment interfaces does the human need to perform the
job?
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 System Approach
Safety
The control of human error requires two different
approach
First Minimize the occurrence of errors
For example, errors may be reduced by ensuring a high level of
staff competence; by designing controls and displays so that they
match human characteristics; by providing proper checklists,
procedures, manuals, maps and chart; by controlling noise,
vibration, temperature extremes and other stressful conditions;
and by providing mining and awareness programmes aimed at
increasing co-operation and communication among crew
members
Total elimination of human error is not a realistic goal, since errors are a normal part of
human behaviour
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 System Approach
Safety

Second Minimize the impact or consequences of

errors
Providing safety buffers such
as cross monitoring, crew co-
operation and fail-safe
equipment design

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 Human Dimensions

Some of the basic characteristics of humans are those

associated with the size and shape of the various pans of the
body and with their movements.

Anthropometry is concerned with

human dimensions such as
weight, Statute, limb size and
other specific measures such as
seated eye height and reach when
seated with and without restraining
devices (such as a shoulder
harness).

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Human Dimensions

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DISPLAYS AND CONTROLS

In the case of displays, the transfer of information

goes from the Equipment to the Liveware. Controls
are used to transfer information and commands in
the other direction, from the Liveware to the
Equipment.

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DISPLAYS

Visual displays may be dynamic (e.g.

altimeters and attitude indicators) or
static (e.g. placards, signs, and
charts).

Displays may also be

tactile/kinaesthetic or auditory

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 DISPLAYS

The information must be readable, which means that total

words or groups of letters and numerals are
comprehensible

Readability is generally a function of factors such as

character style, type form (e.g. uppercase or italics), size,
contrast and spacing.

the size of the displayed information (e.g. scales and

icons) must be positively related to the viewing distance
(i.e. the longer the viewing distance, the larger the scale
or icon size)

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 Control

Controls are means for the human operator Different types of controls perform different
to transmit messages or command inputs functions: they may be used to transmit discrete
to the machine. information or continuous information

Function/force Type of control

Discrete functions and/or low Push buttons, toggle switches, and rotary
switched
Continuous function and/or forces Rotary knobs, thumb wheels, small levers or
low cranks
High control forces Handwheels and large levers, large cranks
and foot pedals

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 Control

Another basic requirement for controls, from the

ergonomics point of view, is their location within
the work area.

Other design considerations include:

• control display ratio, which is the ratio
between the amount of change in a display in
response to a control input and the amount of
change in the control effected by the operator;
• the direction of movement of display element
(e.g. a pointer) relative to the direction of
control movement

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 ALERTING AND WARNING
SYSTEMS

Warnings signify a condition requiring an immediate crew action for maintaining the safety of the system,
and their colour coding is normally RED
Cautions imply a condition which may become an emergency if allowed to progress or deteriorate. These
usually require the appropriate, but not immediate, attention, and their coding is AMBER.
Advisories are generally for information only, and may or may not require crew action. Their coding may be
BLUE. WHITE, or GREEN.

Three basic principles apply to the design of flight deck warning systems:

 they should alert the crew and draw their attention;

 they should report the nature of the condition: and

 preferably they should provide guidance regarding

the appropriate action required.

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 ALERTING AND WARNING
SYSTEMS

Advisories, cautions, and warnings on the flight deck can be grouped into four broad categories:

 those which inform about performance, or departures from operational envelopes or safe flight
profiles (e.g. for stall, overspeed and ground proximity): they are usually of high urgency;
 those which inform about aircraft configuration (e.g. landing gear and flap positions);
 those which inform about the status of aircraft systems; these include limiting bands and flags on
instruments; and

 those related to communications (e.g. SELCAL and interphone).

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PERSONAL COMFORT

Temperature Illumination Humidity

Pressure Vibration Noise

Position

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 COCKPIT VISIBILITY AND
EYE-REFERENCE POSITION

The design eye position is an important reference

point which helps to determine placement of
equipment such as displays.

Proper consideration must be given to chis

misalignment of pilot and control so that it does
not lead to hazardous conditions during
operations.

Viewing distance issues are particularly

applicable to persons wearing glasses. Viewing
distances are also particularly relevant to "glass
cockpits"

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 MOTOR WORKLOAD

Motor workload characterized the flight which

was largerly performed using automatic flight
systems
Motor workload was expecienced by the
modeled pilot, not due to manual flight control
tasks, but rather to the autopilot commands
such as pull-down gears and extension of
flaps, which were specified in the approach,
landing, and go-around procedure.

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 Summary

The main factor in Human-Hardware relationship include :

ergonomics, system approach safety, human dimensions, displays
and controls, alerting and warning systems, personal comfort,
cockpit visibility and eye-reference position, motor workload

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 Thank you

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 MINISTRY OF TRANSPORTATION INDONESIA
AGENCY OF HUMAN RESOURCES DEVELOPMENT ON TRANSPORTATION
CENTER FOR HUMAN RESOURCES DEVELOPMENT ON CIVIL AVIATION

HUMAN – SOFTWARE
RELATIONSHIP
OBJECTIVES

The student able to explain

Human – Software Relationship

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 LEARNING POINTS

• Standard Operating
Procedure
• Written Material
• Operational Aspect of
Automation

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Standard Operating
Procedure

A Standard Operating Procedure (SOP) provides a step by step guide

to effectively and safely carry out operations.

A particular SOP must not only achieve the task at hand but also be
understood by a crew of various backgrounds and experience within
the organisation.

SOP's can also be developed as time goes by to incorporate

improvements based on experience, accidents, near misses or
innovations from other manufacturers or operators to suit the
needs of a particular organisation.

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 Standard Operating
Procedure

Deviation from a standard procedure may lead to an

unexpected and unsafe outcome.

Intentional deviations and inadvertent deviations from

SOPs have been identified as causal factors in many
aircraft accidents and incidents

Crew Resource Management (CRM) and Team

Resource Management (TRM) are not effective
without adherence to SOPs

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System Approach
Safety

Written Materials

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Written Materials

How are SOP's developed?

There is generally a framework which
provides a logical structure to build an SOP,
however to allow for flexible operations it can
be a fluid arrangement. The four P's
provides this framework from which
management and operators can communicate
the most effective manner in which to
conduct operations.

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Written Materials

The Four P's Model

• Philosophy
• Policies
• Procedures
• Practices

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Written Materials

Management

Phylosophy

Policies

Procedures
Standardization
Training and Quality
Control
Demands/Tasks Individualism

Experience
Beliefs
Crew Values
Attitudes
Environment

Policies Techniques

System Outcome

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 Automation

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Operational Aspect of
Automation

What is
Automation ?

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 Operational Aspect of
Automation

The dictionary clearly defines automation as "the

use of computers to control a particular process in
order to increase reliability and efficiency, often
through the replacement of employees”

Definitions basically focus on two aspects - the

introduction of "computers" and the implications
on "humans" in the performance of a task.

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 Operational Aspect of
Automation
Design Philosophies
Two distinct approaches to the design of automation began to emerge; these
are referred to as the technology-centred and human-centred approaches.

Technology-centred automation seeks to overcome the limitations of

human performance by replacing human functioning with machine
functioning.
By contrast, human-centred automation seeks to enhance the capabilities
of, and compensate for, the limitations of human performance. The
philosophy is not to replace human functioning, but rather to enhance
human effectiveness

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 Operational Aspect of
Automation

Staying in the loop

There are concerns that technology-
centred automation has taken human ‘out
of the loop’
Designers have now realised that the goal
of eliminating human error from the cockpit
is unrealistic and unachievable.

The maxim ‘as long as we are human we

will continue to make mistakes’ has held
true through the history of flight
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Operational Aspect of
Automation

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Operational Aspect of
Automation

Systems design over the past 10-

15 years has been more human-
centred than in the past, with an
emphasis on training personnel to
recognize and manage errors,
rather than making futile attempts
to eliminate them.

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 Operational Aspect of
Automation

Automation-induced complacency
Automation-induced complacency has
been identified as a factor in many aircraft
accidents, particularly in those involving
aircraft with sophisticated glass cockpits

We are hesitant to intervene at the first

signs of trouble as we have a high level of
trust in the system to correct itself, and
often leave it until it is too late to intervene.

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 Operational Aspect of
Automation
Workload reduction and crew complement

Wiener suggests the three key objectives of

automation are to:

 reduce physical and cognitive workload

 allow to spend less time ‘head down’ in the
cockpit
 lessen the workload to allow a reduction in
minimum crew complement.

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 Operational Aspect of
Automation
Training
 Personnel must be provided with opportunities to refine the
knowledge and practice the skills required to recover from
automation malfunctions
 training and checking should address this topic directly
during initial and recurrent training. Opportunities should
include cognitive and manipulative skills practice and
opportunities to train to proficiency.
 Training and checking standards for flight path
management must support, and be consistent with,
automation policy and in accordance with SOPs for each
type.
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 SUMMARY

Human – Software Relationship discussed about

the interface between human as a liveware and
software including :
• Standard Operating Procedure
• Written Material
• Operational Aspect of Automation
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 MINISTRY OF TRANSPORTATION INDONESIA
AGENCY OF HUMAN RESOURCES DEVELOPMENT ON TRANSPORTATION
CENTER FOR HUMAN RESOURCES DEVELOPMENT ON CIVIL AVIATION

INTER-PERSONAL
RELATIONSHIP
OBJECTIVES

The student able to explain

Inter-personal Relationship

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 LEARNING POINTS

• Communication
• Communication Error
• Teamwork
• Team management

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Communication

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 Communication

Most researchers and human factors

practitioners agree that communication is
characterized by two issues

■ The transfer of information from one party

to another
■ The transfer of meaning.

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 Communication

Communication is the process of sharing

information within a shared interpretative
framework which allows that information to be
meaningful and useful.

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 Communication

Relevance to safety
When pilots, air traffic controllers,
dispatchers and other frontline staff talk to
each other using the right protocols, the
risk of accidents and incidents reduces
significantly

There are many examples where confusion between the sender and
receiver of information has resulted in tragic aircraft accidents, as illustrated
by the case study below.

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 Communication

The communication process

The communication process involves a
message or communication being sent by
the sender through a communication
channel to a receiver. The sender must
encode the message (the information being
conveyed) into a form appropriate to the
communication channel, and the receiver
then decodes the message to understand
its meaning and significance.

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Communication

Communication
Models

One-way Two-way
communication communication

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 Communication

Types of
communication

Written Verbal Non-verbal

Phraseology
communication communication communication

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 Communication

Professional language
Zagreb centre, I’ll
Turkish 324 stop calling you
stop calling Zagreb as soon as
me Zagreb, you stop calling me
I am Frankfurt Turkish, I'm American!

• Radio-communication is fragile (we

don’t see the other party)
• We need to compensate for this
disadvantage
• Phraseology and read-back
are essential protections

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 Communication

Barriers to Effective Communication

Barriers in communication can occur at any point in the

communication process:

 In the sender’s message: e.g. using jargon or non-

standard phraseology which some individuals may not
be familiar with
 In the outside environment: e.g. when background
noise interferes with the transmission of the message;

 In receivers themselves: e.g. the receiver does not

want to hear a message, or has such a high workload
that a message is not completely received.
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 Communication

COMMUNICATION ERRORS
Types of errors Examples
Senders’ errors
Omitting communication Clipping call signs
Passing on incomplete/ambiguous information Not adequately defining an abnormal situation to ATC

Passing on incorrect information Call-sign confusion

Senders’/receivers’ errors
Failing to reach a clear and mutual understanding Confusion about assigned runway

Failing to follow recognised sequence for communication Using non-standard phraseology or jargon

Failure to use correct units of speech Excessive use of abbreviations/acronymns

Poor elocution/failing to speak clearly Rushing or mumbled speech
Failing to read back messages Failure to read back mandatory pieces of information to ATC requiring
further communication to resolve

Receivers’ errors
Not responding correctly to communication An aggressive response to ATC
Mis-recording information communication Writing down an incorrect QNH
Not listening (partial or total message) Tuning out due to high workload

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 Communication

Many other factors influence effective communication in safety critical

industries such as aviation, including:
• attitudes
• conflicts and pressures
• culture
• fatigue
• gender
• high workload
• inadequate language proficiency
• interruptions
• personality
• physical conditions
• stress
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 Communication

Verbal Communication Error

There are numerous verbal communication errors • poor use of pace and tone
and contributing factors, including: • poor use of volume to suit the environment
• environmental aspects (noise, distractions, • technical factors (equipment and transmission
stress) medium)
• failure to demonstrate understanding (receiver) • use of uncommon accent
• failure to listen • use of uncommon language and/or phraseology
• failure to plan clear communication of message
• failure to test meaning (receiver) or
understanding (transmitter)
• incongruence between verbal and nonverbal
communication.
• lack of emphasis of importance and/or urgency
• physiological reasons (speech and/or hearing)

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 Communication

Safety-critical communication

In most industries, safety-critical communication can occur in the following situations:

• Shift/crew handovers
• Communications during emergencies
• Any form of remote communication
• Communication of hazards and risks to contractors
• Use of radios
• Plant/equipment labelling and identification

• Communication of changes to procedures.

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 Communication

Unreliable communication
Unreliable communication can result from a variety of problems
including:

• Missing information
• Unnecessary information
• Inaccurate information
• Poor or variable quality of information
• Misunderstandings

• Failing to carry forward information over successive shifts/crew

changes.

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 Communication

Managing Communication
There are certain communication principles common across all industries, and which should be adopted by
the entire workforce:
• Communicating effectively with all members of the workforce, both up and down the chain of
responsibility, to help ensure that risk management activities are sufficiently comprehensive and
understood.
• Endeavouring to raise awareness of potential hazards and risk issues amongst the workforce.
• Ensuring that all those involved with a project are aware of any risks to which they may be exposed, of
any relevant limitations inherent in the design or operating procedures, and of any implications for their
conduct.
• Discussing the reasons for incidents and near misses with the workforce, so that lessons can be learned.

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 Communication

A number of simple steps can assist in improving safety-critical communication:

• Carefully specify what key information needs to be communicated
• Eliminate unnecessary information
• Use aids (such as logs, computer displays) to help accurate communication
• Repeat the key information using different mediums, e.g. use both written and verbal
communication
• Allow sufficient time for communication, particularly at shift/crew handovers
• Encourage two-way communication with both the giver and recipient of the information
taking responsibility for accurate communication
• Encourage the asking of confirmation, clarification and repetition
• Encourage face-to-face communication wherever feasible
• Try to develop all employees’ communication skills
• Set standards for effective and safe communication.

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 Communication

ICAO’s document on aeronautical telecommunications (Annex 10, Volume II) provides rules and procedures
for pilot-controller communications. These guidelines and techniques for radio transmission highlight the
following objectives:

• carry out transmissions concisely in a normal conversational tone

• make full use of standard phraseologies whenever prescribed in ICAO documents and procedures

• speech-transmitting techniques shall be such that the highest possible intelligibility is incorporated in
each transmission.

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 Communication

Best-practice communication protocols

• Use correct radio procedures
• Read back clearances
• When in doubt, verify
• Use full call signs
• Be alert for similar call signs
• Use thoughtful radio technique
• Hear back
• Keep communication simple
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Teamwork

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 Teamwork

Teamwork means a dynamic process involving two

or more professionals with complementary
background and skills contributing in the most
effective way to the overall tasks and goals of the
team

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 Teamwork

Elements of Teamwork

Supporting others Exchanging

information

Solving conflicts Coordinating

activities

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 Teamwork

TEAM MANAGEMENT

Teamwork Skills Acknowledging

the whole team

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 Teamwork

Teamwork Skills
Research has identified a set of eight major teamwork skills that are beneficial for all team members:

• adaptability
• communication
• coordination
• decision making
• interpersonal relations
• leadership/team management
• performance monitoring/feedback

• shared situational awareness.

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 Teamwork

Acknowledging the whole team

Apart from teamwork skills, training and
competencies, one of the biggest
determinants of successful and sustained
teamwork is the motivation of the crew or
team.

It is important that when the ‘face’ of a team

has a success, there is also
acknowledgement of those who supported
the team behind the scenes, not just those
who are highly visible.

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 SUMMARY

Interpersonal relationship
discussed about the interface
between human including :
• Communication
• Communication Error
• Teamwork
• Team management

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 MINISTRY OF TRANSPORTATION INDONESIA
AGENCY OF HUMAN RESOURCES DEVELOPMENT ON TRANSPORTATION
CENTER FOR HUMAN RESOURCES DEVELOPMENT ON CIVIL AVIATION

THE OPERATING
ENVIRONMENT
OBJECTIVES

The student able to explain

The Operating Environment

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Learning Points

• View of Safety Culture

• The Aviation System
• General Model of Organizational Safety
• Culture and Safety
• Procedures and Safety
• Safe and Unsafe Organization

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VIEW OF SAFETY
CULTURE

WHAT IS SAFETY??

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 VIEW OF SAFETY
CULTURE

Safety is The state in which risks associated with

aviation activities, related to, or in direct support
of the operation are reduced and controlled to an
acceptable level.

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VIEW OF SAFETY
CULTURE

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VIEW OF SAFETY
CULTURE

Safety culture is about the extent to

which these values, attitudes,
beliefs and behaviours pervade the
organization.

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 VIEW OF SAFETY
CULTURE

What are the characteristics of a good safety culture? ICAO advocates that in an organization with a
strong safety culture:
• senior management places a strong emphasis on safety as part of the strategy of controlling risk
• decision makers and operational personnel hold a realistic view of the short- and long-term hazards
involved in the organization’s activities
• those in senior positions do not use their influence to force their views on others, or to avoid criticism
• those in senior positions create an organizational climate which is open to criticism, and fosters
comments and feedback from all employees
• there is an awareness of the importance of communicating relevant safety information at all levels of
the organization (both internally and with outside entities)
• there is promotion of appropriate, realistic and workable rules relating to hazards, to safety and to
potential sources of damage, with such rules being supported and endorsed throughout the
organization
• personnel are well trained and well educated and fully understand the consequences of unsafe acts.

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 VIEW OF SAFETY
CULTURE

Conversely, there are distinct symptoms of a poor safety culture. These are:
• the number of hazard reports is lower than • there is a strong tendency for employees
expected or management to focus on individual
• the appointed safety executive does not take blame— to focus on the ‘who’ rather than
responsibility for the safety program the ‘why’ of an incident
• there is active resistance to the safety program • there is resistance to change
• the number of high-risk safety incidents is not • safety information is not readily accessible
decreasing over time (or, is increasing) • safety managers do not communicate
• the number of workplace accidents is not important safety concerns (effectively)
decreasing over time (or, is increasing) • there is a lack of safety budget
• there are management silos • there is a high number of repeat safety
• upper management does not actively support the safety
incidents
program
• there is retaliation from managers or other employees
against people who report safety issues

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 VIEW OF SAFETY
CULTURE

Elements of Safety Culture

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 GENERAL MODELS OF
ORGANISATIONAL SAFETY

How to build Safety Culture

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 GENERAL MODELS OF
ORGANISATIONAL SAFETY

Accident Causation

An organization’s defences against failure are modelled as a series of barriers

(the Swiss cheese slices). The holes in the cheese slices represent individual
weaknesses in each part of the system and are continually varying in position
and size in each slice.

The system as a whole will produce failures when all of the holes in each
slice momentarily align. A hazard will pass through all of the holes in all of
the defences leading to a failure.

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 GENERAL MODELS OF
ORGANISATIONAL SAFETY

Reason’s Swiss Cheese Model

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 ORGANISATIONS
STRUCTURES AND SAFETY

Factors that can influence the effectiveness of organizational

structures:
a)Complexity

b)Standardization

c) Centralization

d)Adaptability to the environment

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CULTURE AND SAFETY

The majority of organizations today employ people from multiple cultural backgrounds,
which may be defined by their nationality, ethnicity, religion, and/or gender.

Aviation operations and safety rely on effective interaction between different

professional groups, each with its own professional culture. Hence, the organization’s
safety culture may also be significantly affected by the variety of cultural backgrounds
of the members of its workforce.

Managing safety within the aviation system therefore requires interaction with, and
management of, culturally diverse personnel. However, when implementing safety
management, managers should be capable of moulding their culturally-diverse
workforce into effective teams.

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 PROCEDURES AND SAFETY

Scott A. Snook's theory of practical drift is used to understand how performance of any system “drifts away”
from its original design. Tasks, procedures, and equipment are often initially designed and planned in a
theoretical environment, under ideal conditions, with an implicit assumption that nearly everything can be
predicted and controlled, and where everything functions as expected. This is usually based on three
fundamental assumptions that the:

a) technology needed to achieve the system production goals is available;

b) personnel are trained, competent and motivated to properly operate the technology as intended; and

c) policy and procedures will dictate system and human behaviour.

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 PROCEDURES AND SAFETY

Concept of practical drift

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 PROCEDURES AND SAFETY

Snook contests that practical drift is inevitable in any system, no matter how careful and well thought out its
design. Some of the reasons for the practical drift include:

a) technology that does not operate as predicted;

b) procedures that cannot be executed as planned under certain operational conditions;
c) changes to the system, including the additional components;
d) interactions with other systems;
e) safety culture;
f) adequacy (or inadequacy) of resources (e.g. support equipment);
learning from successes and failures to improve operations, and so forth.

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 SAFE AND UNSAFE
ORGANISATIONS

Safe organisations
Safe organisations are said to have the following traits:
• they pursue safety as one of the objectives of the organisation and regard safety as a major contributor in
achieving production goals
• they have developed appropriate risk management structures, which allow for an appropriate balance
between managing productivity and risk
• they enjoy an open, good and healthy safety organisational culture
• they possess a structure which has been designed with a suitable degree of complexity
• they have standardised procedures and centralised decision making which is consistent with the
objectives of the organisation and the characteristics of the surrounding environment
• they rely on internal responsibility rather than regulatory compliance to achieve safety objectives
• they respond to observed safety deficiencies with long-term measures in response to latent conditions as
well as short-term, localized actions in response to active failures.

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 SAFE AND UNSAFE
ORGANISATIONS

Corporate Culture
People have thought that organizations were beyond the influence of culture and were only influenced by
the technologies they utilize or the tasks they pursue. Research has demonstrated, however, that culture
deeply influences organizational behaviour. If an organization attempts to impart values or behaviours which
are in contrast with existing organizational/corporate culture or which are perceived to be in contrast with
corporate goals, achieving these values or behaviours will either take considerable time and effort or be
impossible altogether.

A corporate culture may also allow or prevent violations, since they take place in situations where the shared
values of individuals and the group favour certain behaviours or attitudes. In the simplest term, a group will
meet whatever norms are established for an organization and will do whatever it thinks or perceives
management really wants.

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 SAFE AND UNSAFE
ORGANISATIONS

Safe and unsafe corporate cultures

In general terms, the characteristics which define a safe culture and which decision-makers should observe
when modelling corporate safety culture include the following:
 senior management places strong emphasis on safety as part of the strategy of controlling risks;
 decision-makers and operational personnel hold a realistic view of the short- and long-term hazards
involved in the organization's activities;
 those in top positions do not use their influence to force their views or to avoid criticism about safety
issues;
 those in top positions implement measures to contain the consequences of identified safety deficiencies;
 those in top positions foster a climate in which there is a positive attitude towards criticisms, comments
and feedback from lower levels of the organization;
 there is an awareness of the - importance of communicating relevant safety information at all levels of the
organization (both within it and with outside entities)
 there is promotion of appropriate, realistic and workable rules relating to hazards, to safely and to potential
sources of damage. with such rules being supported and endorsed throughout the organization: and
 personnel are well trained and well educated and fully understand the consequences of unsafe acts.
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SUMMARY

Regardless of an individual’s cultural background,

effective safety management relies on a shared safety
culture, with everyone in the organization
understanding how they are expected to behave in
relation to safety and risk “even when no one is
watching”

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