Module 9A - Human Factors - Updated

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020
GCAA 147
CAR 66
CAT A
Module 9A
Human Factors
AIRACRAFT MAINTENANCE ENGINEER TRAINING NOTES
These training notes have been issued to you on the understanding that they are intended for your
guidance, to enable you to assimilate classroom and workshop lessons and for self-study. Although
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amendments will be forwarded to you once your training course is completed. It must be
emphasised that these training notes do not in any way constitute an authorised document for use
in aircraft maintenance.
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1. Introduction
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Description Page no.

1 Introduction 1-1
2 Human Performance and Limitations 2-1
2.1 Human Performance and Limitations as Part of Maintenance Engineering System 2-1
2.2 Vision 2-2
2.3 Hearing 2-5
2.4 Information Processing 2-8
3 Social Psychology 3-1
3.1 The Social Environment 3-1
3.2 Responsibility: Individual and Group 3-2
3.3 Motivation and De-Motivation 3-3
3.4 Peer Pressure 3-5
3.5 Culture Issues 3-6
3.6 Team Working 3-8
3.7 Management, Supervision and Leadership 3-9
3.8 Maintenance Resources Management (MRM) 3-11
1. Introduction
5

4 Factors Affecting Performance 4-1
4.1 Fitness and Health 4-1
4.2 Stress: Domestic and Work Related 4-3
4.3 Time Pressure and Deadlines 4-6
4.4 Workload – Overload and Underload 4-7
4.5 Sleep. Fatigue and Shift Work 4-10
4.6 Alcohol, Medication and Drug Abuse 4-14
5 Physical Environment 5-1
5.1 Noise 5-1
5.2 Fumes 5-2
5.3 Illumination 5-3
5.4 Climate and Temperature 5-4
5.5 Motion and Vibration 5-5
5.6 Confined Spaces 5-6
5.7 Working Environment 5-7
1. Introduction
6

6 Tasks 6-1
6.1 Physical Work 6-2
6.2 Repetitive Tasks 6-4
6.3 Visual Inspection 6-5
6.4 Complex System 6-6
7 Communication 7-1
7.1 Communication within Between Teams 7-3
7.2 Work Logging 7-5
7.3 Currency – Keeping up to date 7-9
7.4 Dissemination of Information 7-11
8 Human Error 8-1
8.1 Error Models and Theories 8-2
8.2 Types of Error in Maintenance Tasks 8-10
8.3 Implications of Error (i.e. Accidents) 8-14
8.4 Avoiding and Managing Errors 8-16
1. Introduction
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9 Safety Management System 9-1
INTRODUCTION
HUMANPHYSICS
FACTORS OF ATMOSPHERE
1. Introduction
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This chapter introduces human factors and explains its importance to the aviation industry. It examines the relationship
between human factors and incidents largely in terms of human error and “Murphy’s Law” (i.e. if it can happen, one day it will).
The Need To Take Human Factors Into Account

• In the early days of powered flight, the design, construction and control of aircraft predominated. The main attributes of the
first pilots were courage and the mastery of a whole new set of skills in the struggle to control the new flying machines.
• As the technical aspects of flight were overcome bit by bit, the role of the people associated with aircraft began to come to the
fore. Pilots were supported initially with mechanisms to help them stabilise the aircraft, and later with automated systems to
assist the crew with tasks such as navigation and communication. With such interventions to complement the abilities of pilots,
aviation human factors was born.
• As stated in the Foreword, an understanding of the importance of human factors to aircraft maintenance engineering is
essential to anyone considering a career as a licensed aircraft engineer. This is because human factors will impinge on
everything they do in the course of their job in one way or another.
What is “Human Factors”?

• The term “human factors” is used in many different ways in the aviation industry.
• The use of the term “human factors” in the context of aviation maintenance engineering is relatively new. Aircraft accidents
such as that to the Aloha aircraft in the USA in 1988 and the BAC 1-11 windscreen accident in the UK in June 1990 brought the
need to address human factors issues in this environment into sharp focus.
• Some authors refer to the subject as ‘human factors’ and some as ‘ergonomics’. Some see “human factors” as a scientific
discipline and others regard it as a more general part of the human contribution to system safety. Although there are simple
definitions of human factors such as: “Fitting the man to the job and the job to the man”, a good definition in the context of
aviation maintenance would be:
1. Introduction
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• "Human factors" refers to the study of human capabilities and limitations in the workplace. Human factors
researchers study system performance. That is, they study the interaction of maintenance personnel, the
equipment they use, the written and verbal procedures and rules they follow, and the environmental
conditions of any system. The aim of human factors is to optimise the relationship between maintenance
personnel and systems with a view to improving safety, efficiency and well being”.
 Human physiology;
 Psychology (including perception, cognition, memory, social interaction, error, etc.);
 Work place design;
 Environmental conditions;
 Human-machine interface;
 Anthropometrics (the scientific study of measurements of the human body).
The Shell Model

• A model which is often used is the SHEL model, a name derived from the initial letters of its components:
 Software (e.g. maintenance procedures, maintenance manuals, checklist layout, etc.);
 Hardware (e.g. tools, test equipment, the physical structure of aircraft, design of flight decks,
positioning and operating sense of controls and instruments, etc.);
 Environment (e.g. physical environment such as conditions in the hangar, conditions on the line, etc.
and work environment such as work patterns, management structures, public perception of the
industry, etc.);
 Liveware (i.e. the person or people at the centre of the model, including maintenance engineers,
supervisors, planners, managers, etc.). Figure 1

1. Introduction
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• Human factors concentrates on the interfaces between the human (the ‘L’ in the
centre box) and the other elements of the SHEL model1 (see Figure 1), and - from a
safety viewpoint - where these elements can be deficient, e.g.:
• As will be covered in this document, man - the “Liveware” - can perform a wide range
of activities. Despite the fact that modern aircraft are now designed to embody the
latest self-test and diagnostic routines that modern computing power can provide,
one aspect of aviation maintenance has not changed: maintenance tasks are still
being done by human beings. However, man has limitations. Since Liveware is at the
centre of the model, all other aspects (Software, Hardware and Environment) must
be designed or adapted to assist his performance and respect his limitations. If these
two aspects are ignored, the human - in this case the maintenance engineer - will not
perform to the best of his abilities, may make errors, and may jeopardise safety.
• Thanks to modern design and manufacturing, aircraft are becoming more and more
reliable. However, it is not possible to re-design the human being: we have to accept
the fact that the human being is intrinsically unreliable.
Incidents and Accidents Attributable To Human Factors / Human Error Figure 2

• In 1940, it was calculated that approximately 70% of all aircraft accidents were The dominant role played by
attributable to man’s performance, that is to say human error. When the human performance
International Air Transport Association (IATA) reviewed the situation 35 years later, in civil aircraft accidents Source:
they found that there had been no reduction in the human error component of IATA, 1975
accident statistics (Figure 2).
Maintenance and inspection deficiencies 12%
1. Introduction
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• As can be seen, maintenance and inspection deficiencies are one of the major contributory factors to accidents.
• It is clear from such studies that human factors problems in aircraft maintenance engineering are a significant issue.
• In all incidents, the engineers involved were considered by their companies to be well qualified, competent and reliable
employees. All of the incidents were characterised by the following:
 There were staff shortages;
 Time pressures existed;
 All the errors occurred at night;
 Shift or task handovers were involved;
 They all involved supervisors doing long hands-on tasks;
 There was an element of a “can-do” attitude;
 Interruptions occurred;
 There was some failure to use approved data or company procedures; Figure 3
 Manuals were confusing; The Error Chain
 There was inadequate pre-planning, equipment or spares.
Source: AAIB, 19881
Incidents and Accidents - A Breakdown in Human Factors

• The accident or incident was preventable and could have been avoided if any one of a number of things had been done
differently.
• As with many incidents and accidents, a series of human factors problems which formed an error chain (see Figure 3). If any
one of the links in this ‘chain’ had been broken by building in measures which may have prevented a problem at one or more
of these stages, these incidents may have been prevented.
If we can break just one link of the chain, the accident does not happen
1. Introduction
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• Further chapters in this document aim to help the aircraft maintenance engineer to identify where the vulnerable areas
might be within the maintenance ‘link’, how to identify them, and to provide an introduction to those human factors
practices and principles which should prevent the error chain reaching a catastrophic conclusion.
Murphy’s Law
• There is a tendency among human beings towards complacency. The belief that an accident will never happen to “me” or to
“my Company” can be a major problem when attempting to convince individuals or organisations of the need to look at
human factors issues, recognise risks and to implement improvements, rather than merely to pay ‘lip-service’ to human
factors. “Murphy’s Law” can be regarded as the notion: “If something can go wrong, it will.”
• If everyone could be persuaded to acknowledge Murphy’s Law, this might help overcome the “it will never happen to me”
belief that many people hold.

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2. Human Performance and Limitations
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2.1 Human Performance as Part of the Maintenance Engineering System
The intention of this chapter is to provide an overview of those key physical and mental human performance characteristics
which are likely to affect an aircraft maintenance engineer in his working environment, such as his vision, hearing, information
processing, attention and perception, memory, judgement and decision making.
• Engineers themselves have certain capabilities and limitations that must be considered.
• Man, can also fail to function properly in certain situations. Physically, humans become fatigued, are affected by the cold, can
break bones in workplace accidents, etc. Mentally, humans can make errors, have limited perceptual powers, can exhibit poor
judgement due to lack of skills and knowledge, etc. In addition, human performance is also affected by social
• and emotional factors.
• The aircraft engineer is the central part of the aircraft maintenance system. It is therefore very useful to have an understanding
of how various parts of his body and mental processes function and how performance limitations can influence his
effectiveness at work.

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2.2 Vision
The Basic Function of the Eye
• In order to understand vision, it is useful first to know a little about the anatomy of the eye (see Figure 4). 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. Here the 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. Here, the electrical impulses are interpreted and an image is perceived.
Figure 4

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2.2 Vision
Factors Affecting Clarity of Sight
• 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
• Before considering factors that can influence and limit the performance of the eye, it is necessary to describe visual acuity.
Visual acuity is the ability of the eye to discriminate sharp detail at varying distances.
• 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.
• Various factors can affect and limit the visual acuity of the eye. These include:
 Physical factors such as:
o Physical imperfections in one or both eyes (short sightedness, long sightedness),
o Age.
 The influence of ingested foreign substances such as:
o Drugs,
o Medication,
o Alcohol,
o Cigarettes.

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2.2 Vision
• Environmental factors such as:

o Amount of light available,
o Clarity of the air (e.g. dust, mist, rain, etc.).
• Factors associated with object being viewed such as:
o Size and contours of the object,
o Contrast of the object with its surroundings,
o Relative motion of the object,
o Distance of the object from the viewer,
o The angle of the object from the viewer.
The Nature of the Object Being Viewed

• Many factors associated with the object being viewed can also influence vision. We use information from the objects we are
looking at to help distinguish what we are seeing. These are known as visual cues.
Colour Vision
• Although not directly affecting visual acuity, inability to see particular colours can be a problem for the aircraft maintenance
engineer.
• Colour defective vision is usually hereditary, although may also occur as a temporary condition after a serious illness.
• Ageing also causes changes in colour vision.
Vision and the Aircraft Maintenance Engineer
• It is important for an engineer, particularly one who is involved in inspection tasks, to have adequate vision to meet the task
requirements.
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2.3 Hearing
The Basic Function of the Ear

• 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.
• As can be seen in Figure 5, the ear has three divisions: outer ear, middle ear and inner ear. These act to receive vibrations
from the air and turn these signals into nerve impulses that the brain can recognise as sounds.
Figure 5

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2.3 Hearing
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). Table 1 shows intensity levels for various sounds and activities.
Table 1
Typical sound
levels for various
activities

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2.3 Hearing
Impact of Noise on Performance

• Noise can have various negative effects in the workplace. 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. In
addition, high frequency noise generally has a more adverse affect on performance than lower frequency. Noise tends to
increase errors and variability, rather than directly affect work rate.
Hearing Impairment
• 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. Thus, 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.
Hearing Protection
• Hearing protection is available, to a certain extent, by using ear plugs or ear defenders.
Presbycusis
• Hearing deteriorates naturally as one grows older. This is known as Presbycusis

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2.4 Information Processing
This section examines the way the information gathered by

the senses is processed by the brain. The limitations of the
human information processing system are also considered.
Information processing is the process of receiving information
through the senses, analysing it and making it meaningful.
An Information Processing Model

• Information processing can be represented as a model. This
captures the main elements of the process, from receipt of
information via the senses, to outputs such as decision
making and actions. One such model is shown in Figure 6.
Figure 6
A functional
model of human
information
processing

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Sensory Receptors and Sensory Stores

• Physical stimuli are received via the sensory receptors (eyes, ears, etc.) and stored for a very brief period of time in sensory
stores (sensory memory). Visual information is stored for up to half a second in iconic memory and sounds are stored for
slightly longer (up to 2 seconds) in echoic memory. This enables us to remember a sentence as a sentence, rather than merely
as an unconnected string of isolated words, or a film as a film, rather than as a series of disjointed images.
Attention and Perception

• Having detected information, our mental resources are concentrated on specific elements - this is attention. Attention is
influenced by arousal level and stress. Perception involves the organisation and interpretation of sensory data in order to make
it meaningful, discarding non-relevant data.
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.
• This may range from deciding to do nothing, to deciding to act immediately in a very specific manner.
• We are not usually fully aware of the processes and information which we use to make a decision.
• Finally, once a decision has been made, an appropriate action can be carried out.

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Memory
• Memory is critical to our ability to act consistently and to learn new things. Memory can be considered to be the storage and
retention of information, experiences and knowledge, as well as the ability to retrieve this information.
• Memory depends on three processes:
 Registration - the input of information into memory;
 Storage - the retention of information;
 Retrieval - the recovery of stored information.
• It is possible to distinguish between three forms of memory:
a) Ultra short-term memory (or sensory storage);
b) Short term memory (often referred to as working memory)
c) Long term memory.
• Ultra short-term memory has already been described when examining the role of sensory stores. It has a duration of up to 2
seconds (depending on the sense) and is used as a buffer, giving us time to attend to sensory input.
• Short term memory receives a proportion of the information received into sensory stores, and allows us to store information
long enough to use it (hence the idea of ‘working memory’). It can store only a relatively small amount of information at one
time, i.e. 5 to 9 (often referred to as 7 ±2) items of information, for a short duration, typically 10 to 20 seconds.

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• The capacity of long-term memory appears to be unlimited. It is used to store information that is not currently being used,
including:
 Knowledge of the physical world and objects within it and how these behave;
 Personal experiences;
 Beliefs about people, social norms, values, etc.;
 Motor programmes, problem solving skills and plans for achieving various activities;
 Abilities, such as language comprehension.
• Information in long-term memory can be divided into two types: (i) semantic and (ii) episodic. Semantic memory refers to
our store of general, factual knowledge about the world, such as concepts, rules, one’s own language, etc. Episodic memory
refers to memory of specific events, such as our past experiences (including people, events and objects
Motor Programmes
• If a task is performed often enough, it may eventually become automatic and the required skills and actions are stored in long
term memory. These are known as motor programmes.
Situation Awareness
• The process of attention, perception and judgement should result in awareness of the current situation.
• Situation awareness has traditionally been used in the context of the flight deck to describe the pilot’s awareness of what is
going on around him
 The perception of important elements
 The comprehension of their meaning
 The projection of their status into the future, e.g. future effects on safety, schedule, airworthiness.
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• Situation awareness for the aircraft maintenance engineer can be summarised as:
 The status of the system the engineer is working on;
 The relationship between the reported defect and the intended rectification;
 The possible effect on this work on other systems;
 The effect of this work on that being done by others and the effect of their work on this work.
Information Processing Limitations

The basic elements of human information processing have now been explored. It is important to appreciate that these elements
have limitations.
• Attention and Perception
 A proportion of ‘sensed’ data may be lost without being ‘perceived’.
• There are many well-known visual ‘illusions’ which illustrate the limits of human perception.
Figure 7
The Muller-Lyer
Illusion
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• Figure 10 illustrates that we can perceive the same thing quite

differently (i.e. the letter “B” or the number “13”). This shows the
influence of context on our information processing.
Table 7
The importance of context.
• In aviation maintenance it is often necessary to consult documents

with which the engineer can become very familiar. It is possible that
an engineer can scan a document and fail to notice that subtle
changes have been made. He sees only what he expects to see
(expectation). To illustrate how our eyes can deceive us when
quickly scanning a sentence, read quickly the sentence below in
Figure 8.
Figure 8
The effects of expectation
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• At first, most people tend to notice nothing wrong with the sentence. Our perceptual system sub-consciously rejects the
additional “THE”.
• Expectation can also affect our memory of events. The study outlined above was extended such that subjects were asked, a
week later, whether they recalled seeing glass on the road after the collision. (There was no glass). The group who had been
told that they would see a crash, recalled seeing glass; the other group recalled seeing no glass.
• Decision Making, Memory, and Motor Programmes
• a) Attention and perception shortcomings can clearly impinge on decision making. It is also important to bear in mind that
human memory is fallible, so that information:
 May not be stored;
 May be stored incorrectly;
 May be difficult to retrieve.
• All these may be referred to as forgetting, which occurs when information is unavailable (not stored in the first place) or
inaccessible (cannot be retrieved).
• It is generally better to use manuals and temporary aides-memoires rather than to rely upon memory, even in circumstances
where the information to be remembered or recalled is relatively simple.

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3. Social Psychology
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3.1 The Social Environment
The previous chapter considered the abilities and limitations of the individual. This
chapter draws together issues relating to the social context in which the aircraft
maintenance engineer works.
• Aircraft maintenance engineers work within a “system”. As indicated in Figure 9,

there are various factors within this system that impinge on the aircraft
maintenance engineer, ranging from his knowledge, skills and abilities the
environment in which he works, to the culture of the organisation for which he
works. Even beyond the actual company he works for, the regulatory
requirements laid down for his trade clearly impact on his behaviour. All aspects
of this system may contribute towards errors that the engineer might make.
• This is called the organisational culture. They will have their own company
philosophy, policies, procedures, selection and training criteria, and quality
assurance methods.
• The impact of the organisation may be positive or negative. These organisational

stresses may lead to problems of poor industrial relations, high turnover of staff,
increased absenteeism, and most importantly for the aviation industry, more
incidents and accidents due to human error. Figure 9
The Maintenance
System
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3.2 Responsibility: Individual and Group
• Being an aircraft maintenance engineer is a responsible job. If someone is considered responsible, they are liable to be called
to account as being in charge or control of, or answerable for something.
Working as an Individual or as a Group
• The maintenance engineer work is considered individual rather than the group or team.
Individual Responsibility
• All aircraft maintenance engineers are skilled individuals having undertaken considerable training. They work in a highly
professional environment and generally have considerable pride in their work and its contribution to air safety.
Group or Team Responsibility
• Group responsibility has its advantages and disadvantages. The advantages are that each member of the group ought to feel
responsible for the output of that group, not just their own output as an individual, and ought to work towards ensuring that
the whole ‘product’ is safe.
The disadvantage of group responsibility
• Is that it can potentially act against safety, with responsibility being devolved to such an extent that no-one feels personally
responsible for safety. Social psychologists have carried out experiments whereby a situation was contrived in which someone
was apparently in distress, and noted who came to help. If a person was on their own, they were far more likely to help than if
they were in a pair or group. In the group situation, each person felt that it was not solely his responsibility to act and assumed
that someone else would do so.
 Other recognised phenomena associated with group or team working and responsibility for decisions and actions which
aircraft maintenance engineers should be aware of are:
o Intergroup conflict
o Group polarisation
o Social loafing
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3.3 Motivation and De-motivation
Motivated behaviour is goal-directed, purposeful behaviour, and no human

behaviour occurs without some kind of motivation underpinning it.
Motivation can be thought of as a basic human drive that arouses, directs
and sustains all human behaviour.
Motivation is usually considered to be a positive rather than a negative force
in that it stimulates one to achieve various things.
Maslow’s Hierarchy of Needs

• Possibly one of the most well known theories which attempts to describe
human motivation is Maslow’s hierarchy of needs. Maslow considered
that humans are driven by two different sets of motivational forces:
 Those that ensure survival by satisfying basic physical and
psychological needs;
 Those that help us to realise our full potential in life known as self-
actualisation needs (fulfilling ambitions, etc.).
• Figure 10 shows the hypothetical hierarchical nature of the needs we are
motivated to satisfy. The theory is that the needs lower down the
hierarchy are more primitive or basic and must be satisfied before we can
be motivated by the higher needs. For instance, you will probably find it
harder to concentrate on the information in this document if you are very Figure 10
hungry . The Maintenance
System
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3.3 Motivation and De-motivation
De-motivation
• Highly motivated people tend to show the following characteristics:
 High performance and results being consistently achieved;
 The energy, enthusiasm and determination to succeed;
 unstinting co-operation in overcoming problems;
 Willingness to accept responsibility;
 Willingness to accommodate change.
• People who are de-motivated lack motivation, either intrinsically or through a failure of their management to motivate the
staff who work for them. De-motivated people tend to demonstrate the following characteristics:
 Apathy and indifference to the job, including reduced regard for safety whilst working;
 A poor record of time keeping and high absenteeism;
 An exaggeration of the effects/difficulties encountered in problems, disputes and grievances;
 A lack of co-operation in dealing with problems or difficulties;
 Unjustified resistance to change.

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3.4 Peer Pressure
• In the working environment of aircraft maintenance, there are many pressures brought to bear on the individual engineer. Is
the possibility that the aircraft maintenance engineer will receive pressure at work from those that work with him. This is
known as peer pressure. Peer pressure is the actual or perceived pressure which an individual may feel, to conform to what he
believes that his peers or colleagues expect.
• Peer pressure thus falls within the area of conformity. Conformity is the tendency to allow one’s opinions, attitudes, actions
and even perceptions to be affected by prevailing opinions, attitudes, actions and perceptions.
Countering Peer Pressure and Conformity

• The influence of peer pressure and conformity on an individual’s views can be reduced considerably if the individual airs their
views publicly from the outset.
• Conformity is closely linked with ‘culture’. It is highly relevant in the aircraft maintenance environment where it can work for or
against a safety culture, depending on the attitudes of the existing staff and their influence over newcomers

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3.5 Culture Issues
The culture of an organisation can be described as ‘the way we do things here’. It is a group or company norm.
Figure 11
The influences on an organisation’s culture
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3.5 Culture Issues
• Culture is not necessarily always generated or driven from the top of an organization (as one might think), but this is the best
point from which to influence the culture.
Safety Culture
• Professor James Reason describes the key components of a safety culture, summarised as follows:
 The ‘engine’ that continues to propel the system towards the goal of maximum safety health, regardless of the
leadership’s personality or current commercial concerns;
 Not forgetting to be afraid;
 Creating a safety information system that collects, analyses and disseminates information from incidents and near-misses
as well as from regular proactive checks on the system’s vital signs;
 A good reporting culture, where staff are willing to report near-misses;
 A just culture - an atmosphere of trust, where people are encouraged, even rewarded, for providing essential safety
related information - but in which they are clear about where the line must be drawn between acceptable and
unacceptable behaviour;
 A flexible culture;
 Respect for the skills, experience and abilities of the workforce and first line supervisors;
 Training investment;
 A learning culture - the willingness and the competence to draw the right conclusions from its safety information system,
and the will to implement major reforms when their need is indicated.
Social Culture
• The influence of social culture (an individual’s background or heritage) can be important in determining how an individual
integrates into an organisational culture.

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3.6 Team Working
The Concept of A Team

• Teams may comprise a number of individuals working together towards one shared goal. Alternatively, they may consist of a
number of individuals working in parallel to achieve one common goal. Teams generally have a recognised leader and one or
more follower(s)
Important Elements of Team Working

• For teams to function cohesively and productively, team members need to have or build up certain interpersonal and social
skills. These include communication, co- operation, co-ordination and mutual support
• Communication
 Communication is essential for exchanging work-related information within the team. For example, a team leader must
ensure that a team member has not just heard an instruction, but understood what is meant by it.
• Co-operation
 ‘Pulling together’ is inherent in the smooth running of a team. Disagreements must be handled sensitively by the team
leader.
• Co-ordination
 Co-ordination is required within the team to ensure that the team leader knows what his group members are doing. The
team leader must ensure that no individual is assigned a task beyond his capabilities. Further important aspects of co-
ordination are agreement of responsibilities.
• Mutual Support
 Mutual support is at the heart of the team’s identity. The team leader must engender this in his team.

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3.7 Management, Supervision and Leadership
Management, supervision and leadership are all skills that a team leader requires. Of course, management is also a function within
an organisation
The Management Role

Managers, particularly those working as an integral part of the ‘front line’ operation, may be placed in a situation where they may
have to compromise between commercial drivers and ‘ideal’ safety practices (both of which are passed down from ‘top
management’ in the organisation).
The Supervisory Role

• Supervision may be a formal role or post (i.e. a Supervisor), or an informal arrangement in which a more experienced engineer
‘keeps an eye on’ less experienced staff. The Supervisor is in a position not only to watch out for errors which might be made by
engineers and technicians, but will also have a good appreciation of individual engineer’s strengths and weaknesses, together
with an appreciation of the norms and safety culture of the group which he supervises.
• It can be difficult for supervisory and management staff to strike the right balance between carrying out their supervisory duties
and maintaining their engineering skills and knowledge (and appropriate authorisations), and they may get out of practice.
• Also, there is unlikely to be anyone monitoring or checking the Supervisor, because:
• Of his seniority;
• He is generally authorised to sign for his own work (except, of course, in the case where a duplicate inspection is
required);
• He may often have to step in when there are staff shortages and, therefore, no spare staff to monitor or check the tasks;
• He may be ‘closer’ (i.e. more sensitive to) to any commercial pressures which may exist, or may perceive that pressure to a
greater extent than other engineers.
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3.7 Management, Supervision and Leadership
Characteristics of a Leader
• There are potentially two types of leader in aircraft maintenance: the person officially assigned the team leader role (possibly
called the Supervisor), an individual within a group that the rest of the group tend to follow or defer to (possibly due to a
dominant personality, etc.).
• A good leader in the maintenance engineering environment needs to possess a number of qualities:
 Motivating his team;
 Reinforcing good attitudes and behaviour;
 Demonstrating by example;
 Maintaining the group;
 Fulfilling a management role.

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3.8 Maintenance Resource Management (MRM)
MRM is not about addressing the individual

human factors of the engineer or his
manager; rather, it looks at the larger system
of human factors concerns involving
engineers, managers and others, working
together to promote safety. MRM has many
similarities to CRM, although the cockpit
environment and team is somewhat different
from that found in aircraft maintenance.
One of the early MRM training programmes

was developed by Gordon Dupont for
Transport Canada1. It introduced “The Dirty
Dozen”, which are 12 areas of potential
problems in human factors. A series of
posters has been produced, one for each of
these headings, giving a few examples of
good practices or “safety nets” which ought
to be adopted. These are summarised in
Table 2 and addressed in most maintenance
human factors programmes.
Table 2
Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020 Examples of Potential Human Factors Problems from the “Dirty Dozen”
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3.8 Maintenance Resource Management (MRM)
Table 2
Examples of Potential Human
Factors Problems from the
“Dirty Dozen”

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4. Factors Affecting Performance
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4.1 Fitness and Health
The performance abilities include fitness and health, stress, time pressures, workload, fatigue and the effects of medication,
alcohol and drugs. These subjects are discussed in this chapter.
Fitness and Health

• The job of an aircraft maintenance engineer can be physically demanding. In addition, his work may have to be carried out in
widely varying physical environments, including cramped spaces, extremes of temperature, etc.
• There are two aspects to fitness and health: the disposition of the engineer prior to taking on employment and the day-to-day
well being of the engineer once employed.
Pre-employment Disposition
• Some employers may require a medical upon commencement of employment. This allows them to judge the fitness and
health of an applicant.
Day-to-Day Fitness and Health

• Fitness and health can have a significant affect upon job performance (both physical and cognitive). Day-to-day fitness and
health can be reduced through illness (physical or mental) or injury. “Fitness: In most professions there is a duty of care by the
individual to assess his or her own fitness to carry out professional duties. Many conditions can impact on the health and
fitness of an engineer and there is not space here to offer a complete list. However, such a list would include:

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4.1 Fitness and Health
 Minor physical illness (such as colds, ‘flu, etc.);

 More major physical illness (such as HIV, malaria, etc.);
 Mental illness (such as depression, etc.);
 Minor injury (such as a sprained wrist, etc.);
 Major injury (such as a broken arm, etc.);
 Ongoing deterioration in physical condition, possibly associated with the ageing process (such as hearing loss, visual
defects, obesity, heart problems, etc.);
 Affects of toxins and other foreign substances (such as carbon monoxide poisoning, alcohol, illicit drugs, etc.).
Positive Measures
• Aircraft maintenance engineers can take common sense steps to maintain their fitness and health. These include:
 Eating regular meals and a well-balanced diet;
 Taking regular exercise (exercise sufficient to double the resting pulse rate for 20 minutes, three times a week is often
recommended);
 Stopping smoking;
 Sensible alcohol intake (for men, this is no more than 3 - 4 units a day or 28 per week, where a unit is equivalent to half a
pint of beer or a glass of wine or spirit);
• Finally, day-to-day health and fitness can be influenced by the use of medication, alcohol and illicit drugs. These are covered
later in Section 6.

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4.2 Stress: Domestic and Work Related
Stress is an inescapable part of life for all of us.

• Stress can be defined as any force, that when applied to a system, causes some significant modification of its form, where
forces can be physical, psychological or due to social pressures.
• From a human viewpoint, stress results from the imposition of any demand or set of demands which require us to react, adapt
or behave in a particular manner in order to cope with or satisfy them. Up to a point, such demands are stimulating and
useful, but if the demands are beyond our personal capacity to deal with them, the resulting stress is a problem.
Causes and Symptoms

• Stress is usually something experienced due to the presence of some form of stressor, which might be a one-off stimulus (such
as a challenging problem or a punch on the nose), or an on-going factor (such as an extremely hot hangar or an acrimonious
divorce). From these, we get acute stress (typically intense but of short duration) and chronic stress (frequent recurrence or of
long duration) respectively.
• Different stressors affect different people to varying extents. Stressors may be:
 Physical - such as heat, cold, noise, vibration, presence of something damaging to health (e.g. carbon monoxide);
 Psychological - such as emotional upset (e.g. due to bereavements, domestic problems, etc.), worries about real or
imagined problems (e.g. due to financial problems, ill health, etc.);
 Reactive - such as events occurring in everyday life (e.g. working under time pressure, encountering unexpected
situations, etc.).

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• In brief, the possible signs of stress can include:

 Physiological symptoms - such as sweating, dryness of the mouth, etc.;
 Health effects - such as nausea, headaches, sleep problems, diarrhoea, ulcers, etc.;
 Behavioural symptoms - such as restlessness, shaking, nervous laughter, taking longer over tasks, changes to appetite,
excessive drinking, etc.;
 Cognitive effects - such as poor concentration, indecision, forgetfulness, etc.;
 Subjective effects - such as anxiety, irritability, depression, moodiness, aggression, etc.
Domestic Stress
• Pre-occupation with a source of domestic stress can play on one’s mind during the working day, distracting from the working
task.
• Domestic stress typically results from major life changes at home, such as marriage, birth of a child, a son or daughter leaving
home, bereavement of a close family member or friend, marital problems, or divorce.
Work Related Stress

• Aircraft maintenance engineers can experience stress for two reasons at work: because of the task or job they are undertaking
at that moment, or because of the general organisational environment.

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Stress Management
• Once we become aware of stress, we generally respond to it by using one of two strategies: defence or coping. Defence
strategies involve alleviation of the symptoms (taking medication, alcohol, etc.) or reducing the anxiety (e.g. denying to
yourself that there is a problem (denial), or blaming someone else).
• Coping is the process whereby the individual either adjusts to the perceived demands of the situation or changes the
situation itself. Good stress management techniques include:
 Relaxation techniques;
 Careful regulation of sleep and diet;
 A regime of regular physical exercise;
 Counselling - ranging from talking to a supportive friend or colleague to seeking professional advice.

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4.3 Time Pressure and Deadlines
There is probably no industry in the commercial environment that does not impose some form of deadline, and consequently
time pressure, on its employees. In addition, time pressure may be self- imposed, in which case engineers set themselves
deadlines to complete work (e.g. completing a task before a break or before the end of a shift).
Management have contractual pressures associated with ensuring an aircraft is released to service within the time frame specified
by their customers.
The Effects of Time Pressure and Deadlines. As with stress, it is generally thought that some time pressure is stimulating and may
actually improve task performance. However, it is almost certainly true that excessive time pressure will cause more errors.
Managing Time Pressure and Deadlines

• Time pressures can make ‘corner-cutting’ a cultural norm in an organisation. Sometimes, only an incident or accident reveals
such norms.
• Those responsible for setting deadlines and allocating tasks should consider:
 Prioritising various pieces of work that need to be done;
 The actual time available to carry out work (considering breaks, shift handovers, etc.);
 The personnel available throughout the whole job (allowing a contingency for illness);
 The most appropriate utilisation of staff (considering an engineer’s specialisation, and strengths and limitations);
 Availability of parts and spares.

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4.4 Workload - Overload and Underload
The preceding sections on stress and time pressure have both indicated that a certain amount of stimulation is beneficial, but that
too much stimulation can lead to stress or over-commitment in terms of time.
Before going on to discuss workload, it is important to consider this optimum level of stimulation or arousal.
Arousal
• Arousal in its most general sense, refers to readiness of a person for performing work. To achieve an optimum level of task
performance, it is necessary to have a certain level of stimulation or arousal. This level of stimulation or arousal varies from
person to person.
Figure 12
The influences on an
organisation’s culture

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Factors Determining Workload

• The degree of stimulation exerted on an individual caused by a task is generally referred to as workload, and can be separated
into physical workload and mental workload.
• Workload is subjective (i.e. experienced differently by different people) and is affected by:
 The nature of the task, such as the:
o Physical demands it requires (e.g. strength required, etc.);
o Mental demands it requires (e.g. complexity of decisions to be made, etc.).
 The circumstances under which the task is performed, such as the:
o Standard of performance required (i.e. degree of accuracy);
o Time available to accomplish the task (and thus the speed at which the task must be carried out);
o Requirement to carry out the task at the same time as doing something else;
o Perceived control of the task (i.e. is it imposed by others or under your control, etc.);
o Environmental factors existing at time (e.g. extremes of temperature, etc.).
 The person and his state, such as his:
o Skills (both physical and mental);
o His experience (particularly familiarity with the task in question);
o His current health and fitness levels;
o His emotional state (e.g. stress level, mood, etc.).
Overload
Overload occurs at very high levels of workload (when the engineer becomes over aroused). As highlighted previously,
performance deteriorates when arousal becomes too high and we are forced to shed tasks and focus on key information. Error
rates may also increase.
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Underload
• Underload occurs at low levels of workload (when the engineer becomes under aroused). It can be just as problematic to an
engineer as overload, as it too causes a deterioration in performance and an increase in errors.
Workload Management
• The essence of workload management in aircraft maintenance should include:
 Ensuring that staff have the skills needed to do the tasks they have been asked to do and the proficiency and experience
to do the tasks within the timescales they have been asked to work within;
 Making sure that staff have the tools and spares they need to do the tasks;
 Allocating tasks to teams or individual engineers that are accomplishable (without cutting corners) in the time available;
 Providing human factors training to those responsible for planning so that the performance and limitations of their staff
are taken into account;
 Encouraging individual engineers, supervisors and managers to recognise when an overload situation is building up.
• If an overload situation is developing, methods to help relieve this include:

 Seeking a simpler method of carrying out the work (that is just as effective and still legitimate);
 Delegating certain activities to others to avoid an individual engineer becoming overloaded;
 Securing further time in order to carry out the work safely;
 Postponing, delaying tasks/deadlines and refusing additional work.

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4.5 Sleep, Fatigue and Shift Work
What Is Sleep?
• 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 five stages of sleep:
 Stage 1: This is a transitional phase between waking and sleeping. The heart rate slows and muscles relax. It is easy to wake
someone up.
 Stage 2: This is a deeper level of sleep, but it is still fairly easy to wake someone.
 Stage 3: Sleep is even deeper and the sleeper is now quite unresponsive to external stimuli and so is difficult to wake. Heart
rate, blood pressure and body temperature continue to drop.
 Stage 4: This is the deepest stage of sleep and it is very difficult to wake someone up.
 Rapid Eye Movement or REM Sleep: Even though this stage is characterised by brain activity similar to a person who is
awake, the person is even more difficult to awaken than stage 4. It is therefore also known as paradoxical sleep. Muscles
become totally relaxed and the eyes rapidly dart back and forth under the eyelids. It is thought that dreaming occurs during
REM sleep.
• Stages 1 to 4 are collectively known as non-REM (NREM) sleep. Stages 2-4 are categorised as slow-wave sleep and appear to
relate to body restoration, whereas REM sleep seems to aid the strengthening and organisation of memories. Sleep deprivation
experiments suggest that if a person is deprived of stage 1-4 sleep or REM sleep he will show rebound effects. This means that in
subsequent sleep, he will make up the deficit in that particular type of sleep. This shows the importance
• of both types of sleep.
• As can be seen from Figure 13, 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. Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020
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Figure 13
Typical cycle of stage 1-4 (NREM)
sleep and REM sleep in the course
of a night.

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Circadian Rhythms
Circadian rhythms are physiological and behavioural functions and processes in the body that have a regular cycle of approximately a
day (actually 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.
• Figure 14 shows the circadian rhythm for body temperature.
Figure 14
The Circadian Rhythm for Internal
Body Temperature

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Although there are many contributory factors, it is noteworthy that a number of major incidents and accidents involving human
error have either occurred or were initiated in the pre-dawn hours, when body temperature and performance capability are both at
their lowest.
Fatigue
• Fatigue can be either physiological or subjective. Physiological fatigue reflects the body’s need for replenishment and restoration.
It is tied in with factors such as recent physical activity, current health, consumption of alcohol, and with circadian rhythms. It can
only be satisfied by rest and eventually, a period of sleep. Subjective fatigue is an individual’s perception of how sleepy they feel.
This is not only affected by when they last slept and how good the sleep was but other factors, such as degree of motivation.
• Fatigue is typically caused by delayed sleep, sleep loss, desynchronization of normal circadian rhythms and concentrated periods
of physical or mental stress or exertion. In the workplace, working long hours, working during normal sleep hours and working on
rotating shift schedules all produce fatigue to some extent.
• Symptoms of fatigue (in no particular 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 elated and energetic;
 Diminished standards of own work.
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Continuity of Tasks and Shift Handovers

• Many maintenance tasks often span more than one shift, requiring tasks to be passed from one shift to the next. The outgoing
personnel are at the end of anything up to a twelve hour shift and are consequently tired and eager to go home. Therefore,
shift handover is potentially an area where human errors can occur.
Sleep, Fatigue, Shift Work and the Aircraft Maintenance Engineer

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

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4.6 Alcohol, Medication and Drug Abuse
• It should come as no surprise to the aircraft maintenance engineer that his performance will be affected by alcohol,
medication or illicit drugs. states:
• Alcohol
 Alcohol acts as a depressant on the central nervous system, dulling the senses and increasing mental and physical
reaction times. It is known that even a small amount of alcohol leads to a decline in an individual’s performance and may
cause his judgement to be hindered.
 Alcohol is removed from the blood at a fixed rate and this cannot be speeded up in any way (e.g. by drinking strong
coffee). In fact, sleeping after drinking alcohol can slow down the removal process, as the body’s metabolic systems are
slower.
 The affects of alcohol can be made considerably worse if the individual is fatigued, ill or using medication.
• Medication
 Any medication, no matter how common, can possibly have direct effects or side effects that may impair an engineer’s
performance in the workplace.
 There is a risk that these effects can be amplified if an individual has a particular sensitivity to the medication or one of
its ingredients. Medication is usually taken to relieve symptoms of an illness.
o Analgesics are used for pain relief and to counter the symptoms of colds and ‘flu. Paracetamol, aspirin and
ibuprofen are the most common.
o Antibiotics (such as Penicillin and the various mycins and cyclines) may have short term or delayed effects which
affect work performance.

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4.6 Alcohol, Medication and Drug Abuse
o Anti-histamines are used widely in ‘cold cures’ and in the treatment of allergies (e.g. hayfever). Most of this group
of medicines tend to make the user feel drowsy.
o Cough suppressants are generally safe in normal use, but if an over-the-counter product contains anti-histamine,
decongestant.
o Decongestants (i.e. treatments for nasal congestion) may contain chemicals.
o ‘Pep’ pills are used to maintain wakefulness.
o Sleeping tablets (often anti-histamine based) tend to slow reaction times and generally dull the senses.
 Melatonin (a natural hormone) deserves a special mention. Although not available without a prescription, it is classed as
a food supplement in the USA.
Drugs
• Illicit drugs such as ecstasy, cocaine and heroin all affect the central nervous system and impair mental function.
They are known to have significant effects upon performance and have no place within the aviation
maintenance environment.
• Smoking cannabis can subtly impair performance for up to 24 hours. In particular, it affects the ability to
concentrate, retain information and make reasoned judgements, especially on difficult tasks.

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5. Physical Environment
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5.1 Noise
The aircraft maintenance engineer can expect to work in a variety of different environments, from ‘line’ (generally outside the
hangar) to ‘base’ (usually inside a hangar or workshop), in all types of weather and climatic conditions, day and night.
It can be annoying, can interfere with verbal communication and mask warnings, and it can damage workers’ hearing (either
temporarily or permanently).
General background noise can be ‘filtered out’ by the brain through focused attention. Otherwise, for more problematic noise,
some form of hearing protection (e.g. ear plugs and ear muffs) is commonly used.
It is important that noise does not impair their ability to communicate, as this could obviously have a bearing on the successful
completion of the task (i.e. safety). Common sense dictates that important matters are discussed away from noisy areas.

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5.2 Fumes
Some fumes will be obvious as a result of their odour, whereas others have no smell to indicate their presence. Some substances
will be benign most of the time, but may, in certain circumstances, produce fumes (e.g. overheated grease or
oils, smouldering insulation).
Fumes can cause problems for engineers mainly as a result of inhalation, but they can also cause other problems, such as eye
irritation. The fumes cannot dissipate easily and it may be appropriate to use breathing apparatus.

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5.3 Illumination
In order that aircraft maintenance engineers are able to carry out their work safely and efficiently, it is imperative that their work
be conducted under proper lighting conditions.
When working outside during daylight, the engineer may have sufficient natural light to see well by.
Within the hangar, general area lighting tends to be some distance from the aircraft on which an engineer might work, as it is
usually attached to the very high ceiling of these buildings.
Poor ambient illumination of work areas has been identified as a significant deficiency during the investigation of certain
engineering incidents. It is equally important that lighting in ancillary areas, such as offices and stores, is good.
Relying on touch when lighting is poor is no substitute for actually being able to see what you are doing. If necessary, tools such as
mirrors and borescopes may be needed to help the engineer see into remote areas.

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5.4 Climate and Temperature
Humans can work within quite a wide range of

temperatures and climatic conditions, but performance is
adversely affected at extremes of these. Thus, when it is
either too cold and/or wet or too hot and/or humid,
performance
diminishes.
Hangars used to house aircraft together with office

accommodation should be such as to ensure the working
environment permits personnel to carry out work tasks in
an effective manner. Temperatures should be maintained
such that personnel can carry out required tasks without
undue discomfort.
Figure 15
Environmental conditions can affect physical
The relationship between climate,
performance. Extreme environmental conditions may
also be fatiguing, both physically and mentally.
temperature and performance

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5.5 Motion and Vibration
Aircraft maintenance engineers often make use of staging and mobile access platforms to reach various parts of an aircraft. As
these get higher, they tend to become less stable.
Any sensation of unsteadiness may distract an engineer, as he may concentrate more on keeping his balance than the task.
Furthermore, it is vitally important that engineers use mobile access platforms properly in order to avoid serious injury.
The range between 50-150 Hz is most troublesome for the hand and is associated with Vibratory-induced White Finger Syndrome
(VWF). Pneumatic tools can produce troublesome vibrations in this range and frequent use can lead to reduced local blood flow
and pain associated with VWF.

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5.6 Confined Spaces
Good illumination and ventilation within the confined space will reduce any feelings of discomfort. In addition, appropriate safety
equipment, such as breathing apparatus or lines must be used when required.

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5.7 Working Environment
Various factors that impinge upon the engineer’s physical working environment have been highlighted in this chapter. Apart from
those already discussed, other physical influences include:
• Workplace layout and the cleanliness and general tidiness of the workplace (e.g. storage facilities for tools, manuals and
information, a means of checking that all tools have been retrieved from the aircraft, etc.);
• The proper provision and use of safety equipment and signage (such as nonslip surfaces, safety harnesses, etc.);
• The storage and use of toxic chemical and fluids (as distinct from fumes) (e.g. avoiding confusion between similar looking
canisters and containers by clear labelling or storage in different locations, etc.).
The working environment comprises the physical environment the social environment and the tasks that need to be carried out.
Each of these three components of the working environment interact, for example:
• Engineers are trained to perform various tasks;
• Successful task execution requires a suitable physical environment;
• An unsuitable or unpleasant physical environment is likely to be de-motivating.
Aircraft maintenance engineering requires all three components of the working environment to be managed carefully in order to
achieve a safe and efficient system

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5.7 Working Environment
Figure 16
Components of the ‘working
environment

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6. Tasks
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Licensed aircraft engineering is a specialist occupation undertaken by men and women who have received appropriate training.
The possible paths into the profession are shown in Figure 17.
Figure 17
Routes to becoming a Licensed
Aircraft Engineer

6. Tasks
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6.1 Physical Work
Planning
• Blindly starting a task without planning how best to do it is almost certainly the best way to invite problems. Before
commencing a task, an individual engineer, engineering team or planner should ask themselves a number of questions. These
may include:
 Do I/we know exactly what the task is that has to be done?
 Are the resources available to do it effectively (safely, accurately and within the time permitted)? Where resources
include:
o Personnel;
o Equipment/spares;
o Documentation, information and guidance;
o Facilities such as hangar space, lighting, etc.
 Do I/we have the skills and proficiency necessary to complete the task?
• Information about specific tasks should be detailed on job cards or task sheets.
• It is generally the shift supervisor’s job to ensure that the resources are available for his staff to carry out their tasks.
• Although management have a responsibility to ensure that their engineers have suitable training, at the end of the day, it is up
to the individual engineer to decide whether he has the necessary skills and has the proficiency and experience to do what he
has been asked to do. He should not be afraid to voice any misgivings, although it is recognised that peer and management
pressure may make this difficult.

6. Tasks
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6.1 Physical Work
Physical Tasks
• From a biomechanical perspective, the human body is a series of physical links (bones) connected at certain points (joints) that
allow various movements. Muscles provide the motive force for all movements, both fine and gross. This is known as the
musculoskeletal system. The force that can be applied in any given posture is dependent on the strength available from
muscles and the mechanical advantage provided by the relative positions of the load, muscle connections, and joints.
• Clearly we are all different in terms of physical stature and strength and as a consequence, our physical limitations vary.
Attempting to lift a heavy object which is beyond our physical capabilities is likely to lead to injury. The use of tools generally
make tasks easier.
• Engineers should try to take their allocated breaks.
• Missing a break in an effort to get a job done within a certain time frame can be counterproductive, as fatigue diminishes
motor skills, perception, awareness and standards.

6. Tasks
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6.2 Repetitive Tasks
Repetitive tasks in aircraft maintenance engineering typically refer to tasks that are performed several times during a shift, or a
number of times during a short time period.
The main danger with repetitive tasks is that engineers may become so practised at such tasks that they may cease to consult the
maintenance manual, or to use job cards. Thus, if something about a task is changed, the engineer may not be aware of the
change. Complacency is also a danger, whereby an engineer may skip steps or fail to give due attention to steps in a procedure.
Making assumptions along the lines of ‘Oh I’ve done that job dozens of times!’ can occur even if a task has not been undertaken
for some time.

6. Tasks
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6.3 Visual Inspection
• Visual inspection can be described as the process of using the eye, alone or in conjunction with various aids to examine and
evaluate the condition of systems or components of an aircraft..
• Aircraft maintenance engineers may use magnifiers and borescopes to enhance their visual capabilities. The engineer may
accompany his visual inspection by examining the element using his other senses (touch, hearing, smell, etc.).
• Visual inspection is often the principal method used to identify degradation or defect in systems or components of aircraft.
Although the engineer’s vision is important, he also has to make judgements about what he sees.
• There are various steps that an engineer can take to help him carry out a reliable visual inspection. The engineer should:
 Ensure that he understands the area, component or system he has been asked to inspect (e.g. as specified on the work
card);
 Locate the corresponding area, component or system on the aircraft itself;
 Make sure the environment is conducive to the visual inspection task
 Conduct a systematic visual search, moving his eyes carefully in a set pattern so that all parts are inspected;
 Examine thoroughly any potential degradation or defect that is seen and decide whether it constitutes a problem;
 Record any problem that is found and continue the search a few steps prior to where he left off.
• Visual inspection requires a considerable amount of concentration. Long spells of continuous inspection can be tedious and
result in low arousal.
• Engineers may find it beneficial to take short breaks between discrete visual inspection tasks, such as at a particular system
component, frame, lap joint, etc. This is much better than pausing midway through an inspection.
• Finally, non-destructive inspection (NDI) includes an element of visual inspection, but usually permits detection of defects
below visual thresholds. Various specialist tools are used for this purpose, such as the use of eddy currents and fluorescent
penetrant inspection (FPI).

6. Tasks
1-3
6-6
6.4 Complex System
• Any complex system can be thought of as having a wide variety of inputs. The system typically performs complex modifications
on these inputs or the inputs trigger complex responses. There may be a single output, or many distributed outputs from the
system.
Table 3
Example of increasing
complexity - the aileron
system

6. Tasks
1-3
6-7
6.4 Complex System
• With a complex system, it should still be clear to an aircraft maintenance engineer what the system’s purpose is. However, its
composition and function may be harder to conceptualise - it is opaque to the engineer.
• To maintain such complex systems, it is likely that the engineer will need to have carried out some form of system-specific
training which would have furnished him with an understanding of how it works (and how it can fail) and what it is made up of
(and how components can fail).
• When working with complex systems, it is important that the aircraft maintenance engineer makes reference to appropriate
guidance material. This typically breaks down the system conceptually or physically, making it easier to understand and work
on.
• A single modern aircraft is complex enough, but many engineers are qualified on several types and variants of aircraft. This will
usually mean that he has less opportunity to become familiar with one type, making it even more important that he sticks to
the prescribed procedures and refers to the reference manual wherever necessary.

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7. Communication
7-1
1-3
Most people associate communication with verbal communication. For maintenance personnel, communication
encompasses much more than inter-team verbal interaction. Communication not only includes face-to-face interaction, but
also paperwork such as maintenance cards, procedures, work orders, and logs.
Such paperwork may provide a reasonable record of work completed and work yet to be completed but unless a strict
protocol for raising, completing and controlling it is adopted, the record may not capture all the activities to be undertaken
or the status at any point in time. In addition, because maintenance is an ongoing process independent of specific teams,
inter-team communication, especially between shifts, is extremely important.
In this way, asynchronous communication (communication which has a time delay between responses) is used to a greater
extent than real time, synchronous communication. Asynchronous communication is typified by a unique set of
characteristics, such as the lack of non-verbal communication cues (e.g. body language, verbal inflection, etc.). An example of
asynchronous communication at work in the hangar would be an e-mail message sent from the day supervisor to the night
supervisor. Other examples include memos left between shifts or passed between the shop and the hangar.
Mechanics, crew leaders, supervisors, and inspectors all must have the knowledge and skills to communicate effectively.
Because aviation maintenance may involve persons of different nationalities, because of flight crew/engineering interfaces or
the use of foreign contract staff, it is essential that as part of a good communication strategy a common language is
established. All parties involved must have a good understanding of the language used to ensure that communication is
effected. A lack of proper communication can have any or all of the following undesired consequences:
 The quality of work and performance may be reduced.
 Time and money may be lost as errors occur because important information is not
communicated or messages are misinterpreted.
Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020  Improper communication may cause frustration and high levels of stress.
7. Communication
7-2
1-3
To Improve Communication "Learn to Listen“
Don't:
1. Debate what is being said in your mind.
2. Detour i.e., look for a key word to change the subject.
3. Pre-plan: Now is not the time to be planning what you are going to say.
4. Tune out: Whatever is being said should be important enough to listen.
Do:
1. Ask questions
2. Paraphrase
3. Make eye contact
4. Use positive body language

7. Communication
1-3
• Written Communication
This is one of the more critical aspects of aviation maintenance, in terms of human factors, since inadequate logging or
recording of work has been cited as contributor to several incidents. In the B737 double engine oil loss incident1 in February
1995, for instance, one of the AAIB conclusions was:
“…the Line Engineer…had not made a written statement or annotation on a work stage sheet to show where he had got to in
the inspections”.
Granted, the reason for this was because he had intended completing the job himself and, therefore, did not consider that
detailed work logging was necessary. However, this contributed towards the incident in that:
“…the Night Base Maintenance Controller accepted the tasks on a verbal handover [and] he did not fully appreciate what had
been done and what remained to be done”.
It is not unusual for shift handovers to take place after the technicians concerned have left, in which case it is vital that
unfinished work is recorded in detail for the benefit of the incoming shift. Even if technicians think that they are going to
complete the job, it is always necessary to keep the record of work up-to-date just in case the job has to be handed over.

7. Communication
1-3
• CAP 562 Leaflet H-20 states:
“In relation to work carried out on an aircraft, it is the duty of all persons to whom this Notice applies to ensure that an
adequate record of the work carried out is maintained. This is particularly important where such work carries on beyond a
working period or shift, or is handed over from one person to another. The work accomplished, particularly if only disassembly or
disturbance of components or aircraft systems, should be recorded as the work progresses or prior to undertaking a
disassociated task. In any event, records should be completed no later than the end of the work period or shift of the individual
undertaking the work. Such records should include ‘open’ entries to reflect the remaining actions necessary to restore the
aircraft to a serviceable condition prior to release. In the case of complex tasks which are undertaken frequently, consideration
should be given to the use of pre-planned stage sheets to assist in the control, management and recording of these tasks. Where
such sheets are used, care must be taken to ensure that they accurately reflect the current requirements and recommendations
of the manufacturer and that all key stages, inspections, or replacements are recorded.”

7. Communication
1-3
7.2 Work Logging and Recording 7-5
The primary objective of handovers is to ensure that all necessary information is communicated between
the out-going and in-coming personnel. Effective task and shift handover depends on three basic elements:
1. The outgoing person’s ability to understand and communicate the important elements of the job or task being passed
over to the incoming person.
2. The incoming person’s ability to understand and assimilate the information being provided by the outgoing person.
3. A formalized process for exchanging information between outgoing and incoming persons and a place and time for
such exchanges to take place.
Organisations should have a recognised procedure for task and shift handovers which all staff understand and adhere to.
This procedure should be listed in the MOE
Whilst there is no specific requirement in JAR145 for time to be specifically rostered in to allow for an overlap of 20 or 30
minutes whilst a shift handover takes place, this would be considered good human factors practice
Whilst all essential information (especially the detailed status of tasks) should be recorded in written form, it is also
important to pass this information verbally in order to reinforce it. This is known as redundancy, or the ‘belt and braces’
approach
The Department Of Energy (DOE) shift handover standards stress two characteristics that must be present for effective shift
handover to take place: ownership and formality. Individuals must assume personal ownership and responsibility for the
tasks they perform. They must want to ensure that their tasks are completed correctly, even when those tasks extend across
shifts and are completed by somebody else. The opposite of this mental attitude is “It didn’t happen on my shift”, which
essentially absolves the outgoing person from all responsibility for what happens on the next shift
7. Communication
1-3
Formality relates to the level of recognition given to the shift handover procedures. Formalism exists when the shift handover
process is defined in the Maintenance Organization Exposition (MOE) and managers and supervisors are committed to
ensuring that cross-shift information is effectively delivered. Demonstrable commitment is important as workers quickly
perceive a lack of management commitment when they fail to provide ample shift overlap time, adequate job aids and
dedicated facilities for the handovers to take place. In such cases the procedures are just seen as the company covering their
backsides and paying lip service as they don’t consider the matter important enough to spend effort and money on.
• Aids to Effective Communication at Shift Handover
Research has shown that certain processes, practices and skills aid effective communication at shift handover.
People have to physically transmit information in written, spoken or gestured (nonverbal or body language) form. If only one
medium is used there is a risk of erroneous transmission The introduction of redundancy, by using more than one way of
communicating i.e. written, verbal or non verbal, greatly reduces this risk. For this reason information should be repeated via
more than one medium. For example, verbal and one other method such as written or diagrams etc.
The availability of feedback, to allow testing of comprehension etc. during communication increases the accuracy. The ability
for two-way communication to take place is therefore important at shift handover.

7. Communication
1-3
A part of the shift handover process is to facilitate the formulation of a shared mental model of the maintenance system,
aircraft configuration, tasks in work etc. Misunderstandings are most likely to occur when people do not have this same mental
’picture’ of the state of things. This is particularly true when deviations from normal working has occurred such as having the
aircraft in the flight mode at a point in a maintenance check when this is not normally done. Other considerations are when
people have returned following a lengthy absence (the state of things could have changed considerably during this time) and
when handovers are carried out between experienced and inexperienced personnel (experienced people may make
assumptions about their knowledge that may not be true of inexperienced people). In all these cases handovers can be
expected to take longer and should be allowed for.
Written communication is helped by the design of the documents, such as the handover log, which consider the information
needs of those people who are expected to use it. By involving the people who conduct shift handovers and asking them what
key information should be included and in what format it should be, it helps accurate communication and their ‘buy-in’
contributes to its use and acceptance of the process.
• Barriers to Effective Communication at Shift Handover

Research has also shown that certain practices, attitudes and human limitations act as barriers to effective communication at
shift handover.
i. Key information can be lost if the message also contains irrelevant, unwanted information. We also only have a limited
capability to absorb and process what is being communicated to us. In these circumstances it requires time and effort to
interpret what is being said and extract the important information. It is important that only key information is presented,
and irrelevant information excluded.
7. Communication
1-3
ii. The language we use in everyday life is inherently ambiguous. Effort therefore needs to be expended to reduce
ambiguity by:
 carefully specifying the information to be communicated e.g. by specifying the actual component, tooling or
document.
 facilitating two-way communication which permits clarification of any ambiguity (e.g. do you mean the inboard or
out board wing flap?)
iii. Misunderstandings are a natural and inevitable feature of human communication and effort has to be expended to
identify, minimize and repair misunderstandings as they occur. Communication therefore has to be two- way, with
both participants taking responsibility for achieving full and accurate communication.
iv. People and organizations frequently refer to communication as unproblematic, implying that successful
communication is easy and requires little effort. This leads to over-confidence and complacency becoming common
place. Organizations need to expend effort to address complacency by:
 Emphasizing the potential for miscommunication and its possible consequences

 Developing the communication skills of people who are involved in shift Handovers

7. Communication
1-3
7.3 Currency – Keeping up to Date 7-9
Aircraft maintenance engineers undertake an approved course to obtain the knowledge and basic skills to enter the
profession. This training is followed by instruction in more specific areas, such as maintenance of individual aircraft and
specific systems (as discussed in Chapter 7.4 on “Complex Systems”). However, the aviation industry is dynamic: operators
change their aircraft, new aircraft types and variants are introduced, new aircraft maintenance practices are introduced. As
a consequence, the engineer needs to keep his knowledge and skills up-to-date.
To maintain his currency, he must keep abreast of pertinent information relating to:
 New aircraft types or variants;
 New technologies and new aircraft systems;
 New tools and maintenance practices;
 Modifications to current aircraft and systems he works on;
 Revised maintenance procedures and practices.
Engineers are likely to keep up-to-date by:

 Undertaking update courses;
 Reading briefing material, memos and bulletins;
 Studying maintenance manual amendments

7. Communication
1-3
7.3 Currency – Keeping up to Date 7-10
Responsibility for maintaining currency lies with both the individual engineer and the maintenance organisation for which
he works. The engineer should make it his business to keep up-to-date with changes in his profession (remembering that
making assumptions can be dangerous). The organisation should provide the appropriate training and allow their staff time
to undertake the training before working on a new aircraft type or variant. It should also make written information easily
accessible to engineers and encourage them to read it. It is, of course, vital that those producing the information make it
easy for engineers to understand (i.e. avoid ambiguity).
From a human factors point of view, small changes to the technology or procedures concerning existing aircraft carry
potentially the greatest risk. These do not usually warrant formal training and may merely be minor changes to the
maintenance manual. Although there should be mechanisms in place to record all such changes, this presumes that the
engineer will consult the updates. It is part of the engineer’s individual responsibility to maintain his currency.

7. Communication
1-3
7.4 Dissemination of Information 7-11
As highlighted in the previous section, both the individual engineer and the organisation in which he works have a shared
responsibility to keep abreast of new information. Good dissemination of information within an organisation forms part of
its safety culture. Typically, the maintenance organisation will be the sender and the individual engineer will be the recipient.
Aircraft maintenance engineers need to plan the way work will be performed. Part of this process should be checking that
all information relating to the task has been gathered and understood. This includes checking to see if there is any
information highlighting a change associated with the task (e.g. the way something should be done, the tools to be used,
the components or parts involved)
There should normally be someone within the maintenance organisation with the responsibility for disseminating
information. Supervisors can play an important role by ensuring that the engineers within their team have seen and
understood any communicated information.
Communication is an active process whereby both the organisation and engineer

have to play their part.

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8. Human Error
1-3
8-1
• 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 err”.
• 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”.
• In the past, aircraft components and systems were relatively unreliable. Modern aircraft by comparison are designed and
manufactured to be highly reliable. As a consequence, it is more common nowadays to hear that an aviation incident or
accident has been caused by “human error”.

8. Human Error
1-3
• To appreciate the types of error that it is possible to make, researchers have looked at human error in a number of ways
and proposed various models and theories. These attempt to capture the nature of the error and its characteristics. To
illustrate this, the following models and theories will be briefly highlighted:
 Design- versus operator-induced errors;
 Variable versus constant errors;
 Reversible versus irreversible errors;
 Slips, lapses and mistakes;
 Skill-, rule- and knowledge-based behaviours and associated errors;
 The ‘Swiss Cheese Model’.
Design-Versus Operator-Induced Errors

• Errors may have been made before an aircraft ever leaves the ground by aircraft designers. This may mean that, even if
an aircraft is maintained and flown as it is designed to be, a flaw in its original design may lead to operational safety
being compromised.
• It is common to find when investigating an incident or accident that more than one error has been made and often by
more than one person.

8. Human Error
1-3
Variable Versus Constant Errors
• Professor Reason discusses two types of human error: variable and constant. It can be seen in Figure 22 that variable
errors in (A) are random in nature, whereas the constant errors in (B) follow some kind of consistent, systematic (yet
erroneous) pattern. The implication is that constant errors may be predicted and therefore controlled, whereas variable
errors cannot be predicted and are much harder to deal with.
• Target patterns of 10 shots fired by two riflemen. Rifleman A’s pattern exhibits no constant error, but large variable
errors; rifleman B’s pattern exhibit’s a large constant error but small variable errors. The latter would, potentially, be
easier to predict and to correct (e.g. by correctly aligning the rifle sight). Chapanis, 1951
Figure 18
Variable versus Constant Errors

8. Human Error
1-3
• An engineer is more likely to make an error at 3 a.m., after having worked 12 hours, than at 10 a.m. after having worked
only 2 hours.
Reversible Versus Irreversible Errors

• Another way of categorising errors is to determine whether they are reversible or irreversible. The former can be
recovered from, whereas the latter typically cannot be.
• A well designed system or procedure should mean that errors made by aircraft maintenance engineers are reversible.
Thus, if an engineer installs a part incorrectly, it should be spotted and corrected before the aircraft is released back to
service by supervisory procedures in place.
Slips, Lapses and Mistakes

• Reason highlights the notion of ‘intention’ when considering the nature of error, asking the questions:
 Were the actions directed by some prior intention?
 Did the actions proceed as planned?
 Did they achieve their desired end?
• Reason then suggests an error classification based upon the answers to these questions as shown in Figure 19.

8. Human Error
1-3
Figure 19
Error types based on intention
Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020 Successful Action

8. Human Error
1-3
• The most well-known of these are slips, lapses and mistakes.
• Slips can be thought of as actions not carried out as intended or planned, e.g. ‘transposing digits when copying out
numbers, or misordering steps in a procedure.
• Lapses are missed actions and omissions, i.e. when somebody has failed to do something due to lapses of memory
and/or attention or because they have forgotten something, e.g. forgetting to replace an engine cowling.
• Mistakes are a specific type of error brought about by a faulty plan/intention, i.e. somebody did something believing it to
be correct when it was, in fact, wrong, e.g. an error of judgement such as mis-selection of bolts when fitting an aircraft
windscreen.
• Slips typically occur at the task execution stage, lapses at the storage (memory) stage and mistakes at the planning stage.
• Violations sometimes appear to be human errors, but they differ from slips, lapses and mistakes because they are
deliberate ‘illegal’ actions, i.e. somebody did something knowing it to be against the rules (e.g. deliberately failing to
follow proper procedures). Aircraft maintenance engineers may consider that a violation is well-intentioned, i.e. ‘cutting
corners’ to get a job done on time. However, procedures must be followed appropriately to help safeguard safety.
Skill-, Rule- and Knowledge-Based Behaviours and Associated Errors

• The behaviour of aircraft maintenance engineers can be broken down into three distinct categories: skill-based, rule-
based and knowledge-based behaviour.
• “Skill-based behaviours are those that rely on stored routines or motor programmes that have been learned with
practice and may be executed without conscious thought.

8. Human Error
1-3
• Rule-based behaviours are those for which a routine or procedure has been learned. The components of a rule-based
behaviour may comprise a set of discrete skills.
• Knowledge-based behaviours are those for which no procedure has been established. These require the [aircraft
maintenance engineer] to evaluate information, and then use his knowledge and experience to formulate a plan for
dealing with the situation.”
• Each of these behaviour types have specific errors associated with them.
• Examples of skill-based errors are action slips, environmental capture and reversion. Action slips as the name implies are
the same as slips, i.e. an action not carried out as intended.
Figure 20
below shows example of an Action Slip

8. Human Error
1-3
• Environmental capture may occur when an engineer carries out a certain task very frequently in a certain location.
• Reversion can occur once a certain pattern of behaviour has been established, primarily because it can be very difficult
to abandon or unlearn it when it is no longer appropriate. Thus, an engineer may accidentally carry out a procedure that
he has used for years, even though it has been recently revised. This is more likely to happen when people are not
concentrating or when they are in a stressful situation.
• Errors here are related to the use of the wrong rule or procedure. Errors here are also sometimes due to faulty recall of
procedures. For instance, not remembering the correct sequence when performing a procedure.
• Errors at the knowledge-based performance level are related to incomplete or incorrect knowledge or interpreting the
situation incorrectly.
The ‘Swiss Cheese Model

• Reason has highlighted the concept of ‘defences’ against human error within an organisation, and has coined the notion
of ‘defences in depth’. Examples of defences are duplicate inspections, pilot pre-flight functional checks, etc., which help
prevent to ‘trap’ human errors, reducing the likelihood of negative consequences. It is when these defences are
weakened and breached that human errors can result in incidents or accidents. These defences have been portrayed
diagrammatically, as several slices of Swiss cheese (and hence the model has become known as Professor Reason’s
“Swiss cheese” model) (see Figure 21).
• Some failures are latent, meaning that they have been made at some point in the past and lay dormant. This may be
introduced at the time an aircraft was designed or may be associated with a management decision. Errors made by front
line personnel, such as aircraft maintenance engineers, are ‘active’ failures. The more holes in a system’s defences, the
more likely it is that errors result in incidents or accidents, but it is only in certain circumstances, when all holes ‘line up’,
that these occur.
8. Human Error
1-3
Figure 21
Reason’s Swiss Cheese Model.
Source: Reason, 1990

8. Human Error
1-3
Any maintenance task performed on an aircraft is an opportunity for human error to be introduced. Errors in aircraft
maintenance engineering tend to take two specific forms:
i. An error that results in a specific aircraft problem that was not there before the maintenance task was initiated;
ii. An error that results in an unwanted or unsafe condition remaining undetected while performing a maintenance task
designed to detect aircraft problems, i.e. something is missed.
Errors During Regular and Less Frequent Maintenance Tasks

• A large proportion of maintenance tasks are fairly routine, such as regular, periodic checks on aircraft. Thus, engineers
will use a certain set of procedures relatively frequently and, as noted in the previous section, slips and lapses can occur
when carrying out procedures in the busy hangar or line environment. “Repetitive Tasks” noted that engineers will often
become so accustomed to doing a regular, often repeated task, that they will dispense with written guidance altogether.
It would be unrealistic and unnecessarily time consuming to expect them to constantly refer to familiar guidance
material. However, errors may occur if they do not keep up-to-date with any changes that occur to these frequently used
procedures. These routine tasks are also prone to complacency, environmental capture and rule-based errors.
• When undertaking less frequently performed tasks, there is the possibility of errors of judgement. If the engineer does
not familiarise or refamiliarise himself properly with what needs to be done, he may mistakenly select the wrong
procedure or parts.

8. Human Error
1-3
Violation in Aircraft Maintenance
• It is an unfortunate fact of life that violations occur in aviation maintenance. Most stem from a genuine desire to do a
good job. Seldom are they acts of vandalism or sabotage. However. They represent a significant threat to safety as
systems are designed assuming people will follow the procedures. There are four types of violations:
 Routine violations;
 Situational violations;
 Optimising violations;
 Exceptional violations.
• Routine violations are things which have become ‘the normal way of doing something’ within the person’s work group
(e.g. a maintenance team). They can become routine for a number of reasons: engineers may believe that procedures
may be over prescriptive and violate them to simplify a task (cutting corners), to save time and effort.
• Situational violations occur due to the particular factors that exist at the time, such as time pressure, high workload,
unworkable procedures, inadequate tooling, poor working conditions. These occur often when, in order to get the job
done, engineers consider that a procedure cannot be followed.
• 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.
• Exceptional violations are typified by particular tasks or operating circumstances that make violations inevitable, no
matter how well intentioned the engineer might be.

8. Human Error
1-3
Errors Due to Individual Practices and Habits
Where procedures allow some leeway, aircraft maintenance engineers often develop their own strategies or preferred way
of carrying out a task. Often, a ‘good’ rule or principle is one that has been used successfully in the past. These good rules
become ‘rules of thumb’ that an engineer might adopt for day-today use. Problems occur when the rule or principle is
wrongly applied. In addition, engineers may pick up some ‘bad rules’, leading to bad habits during their working life, as a
driver does after passing his driving test.
Errors Associated With Visual Inspection

There are also two particular types of error which are referred to particularly in the context of visual inspection, namely
Type 1 errors and Type 2 errors. A Type 1 error occurs when a good item is incorrectly identified as faulty; a Type 2 error
occurs when a faulty item is missed. Type 1 errors are not a safety concern per se, except that it means that resources are
not being used most effectively, time being wasted on further investigation of items which are not genuine faults. Type 2
errors are of most concern since, if the fault remains undetected, it can have serious consequences.
Reason’s Study of Aviation Maintenance Engineering

• Reason analysed the reports of 122 maintenance incidents occurring within a major airline over a 3 year period. He
identified the main causes as being:
 Omissions (56%)
 Incorrect installation (30%)
 Wrong parts (8%)
 Other (6%)

8. Human Error
1-3
It is likely that Reason’s findings are representative for the aircraft maintenance industry as a whole. Reason illustrates this
with a simple example of a bolt and several nuts (see Figure 22), asking the questions (a) how many ways can this be
disassembled? (the answer being 1) and (b) how many ways can it be reassembled? (the answer being about 40,000,
excluding errors of omission!).
Figure 22
Reason’s Bolt and Nuts
Example.
8. Human Error
1-3
8.3 Implications of Errors (i.e. Accidents) 8-14
In the worst cases, human errors in aviation maintenance can and do cause aircraft accidents. However, as portrayed in
Figure 23, accidents are the observable manifestations of error. Like an iceberg which has most of its mass beneath the
water line, the majority of errors do not result in actual accidents
Figure 23
The “Iceberg Model” of Accidents
8. Human Error
1-3
8.3 Implications of Errors (i.e. Accidents) 8-15
Thankfully, most errors made by aircraft maintenance engineers do not have catastrophic results. This does not mean that
this might not be the result should they occur again.
Errors that do not cause accidents but still cause a problem are known as incidents. Some incidents are more high profile
than others, such as errors causing significant in-flight events that, fortuitously, or because of the skills of the pilot, did not
become accidents. Other incidents are more mundane and do not become serious because of defences built into the
maintenance system. However, all incidents are significant to the aircraft maintenance industry, as they may warn of a
potential future accident should the error occur in different circumstances. As a consequence, all maintenance incidents
have to be reported to the Civil Aviation Authority Mandatory Occurrence Reporting Scheme (MORS). These data are used to
disclose trends and, where necessary, implement action to reduce the likelihood or criticality of further errors. The
Confidential Human Factors Incident Reporting Programme (CHIRP) scheme provides an alternative reporting mechanism for
individuals who want to report safety concerns and incidents confidentially.
It is vital that aircraft maintenance engineers learn from their own errors and from the errors made by others in the
industry. These powerful and persuasive lessons are the positive aspects of human error.
However, blame does not necessarily act as a positive force in aircraft maintenance: it can discourage engineers from
‘coming clean’ about their errors. They may cover up a mistake or not report an incident. It may also be unfair to blame the
engineer if the error results from a failure or weakness inherent in the system which the engineer has accidentally
discovered.

8. Human Error
1-3
8.4 Avoiding and Managing Errors 8-16
Whilst the aircraft maintenance engineering industry should always strive towards ensuring that errors do not occur in the
first place, it will never be possible to eradicate them totally. Therefore all maintenance organisations should
aim to ‘manage’ errors. Error management seeks to:
 Prevent errors from occurring;
 Eliminate or mitigate the bad effects of errors
Reason refers to the two components of error management as: (i ) error containment and (ii) error reduction.
To prevent errors from occurring, it is necessary to predict where they are most likely to occur and then to put in place
preventative measures. Incident reporting schemes (such as MORS) do this for the industry as a whole. Within a
maintenance organisation, data on errors, incidents and accidents should be captured with a Safety Management System
(SMS), which should provide mechanisms for identifying potential weak spots and error-prone activities or situations.
Output from this should guide local training, company procedures, the introduction of new defences, or the modification of
existing defences.
According to Reason, error management includes measure to:
 Minimise the error liability of the individual or the team;
 Reduce the error vulnerability of particular tasks or task elements;
 Discover, assess and then eliminate error-producing (and violation producing)
 Factors within the workplace;
 Diagnose organisational factors that create error-producing factors within the individual, the team, the task or the
workplace;
 Enhance error detection;
 Increase the error tolerance of the workplace or system;
 Make latent conditions more visible to those who operate and manage the system;
 Improve the organisation’s intrinsic resistance to human fallibility. Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020
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9. Safety Management Systems (SMS)
1-3
9-1
An SMS regulation is an integrated system which contains policies, procedures, people and technology in order to work
towards improving safety by identification, assessment, control and elimination of hazard and risks.
What is Safety?
Safety is the state in which the risk of harm to persons or property damage is reduced to an acceptable level through a
continuing process of hazard identification and risk management.
Post Holder SMS
The organization shall appoint a properly educated, trained and experienced individual who can develop effective safety
management system. He/she should have direct access to the accountable manager in case of safety related matters. The
post holder SMS shall be accepted by the GCAA. He/she shall not have other position within the organization unless it is
approved by GCAA.
Post Holder function
- Managing SMS implementation
- Hazard identification and performing risk analysis
- Monitoring corrective actions and evaluating their results
- Providing periodic reports on the organization safety performance
- Maintaining records and safety documentation
- Planning staff safety training
- Providing independent advice on safety matters
- Monitoring safety concern in the aviation industry and their impact on the organization operation.
- Managing process for SDCPS such as safety reporting.
- Advising safety review board(SRB) on safety issues; in case organization has established such a board.

9. Safety Management Systems
1-3
9-2
SRB functions:
-They monitor how effective SMS is.
-They monitor if any corrective action is taken in timely manner.
-They monitor safety performance against organization safety policy.
-They monitor how effective safety supervision is.
-They make sure that appropriate resources are allocated to achieve safety performance.
-They develop strategic direction which should be coordinated throughout the whole organization.
-Strategic directions may be coordinated through safety action group (SAG) which consist line managers and front line
personnel and it is chaired by line managers.
-They review the effectiveness of previous safety actions and safety promotion.
SAG functions:
- SAG will be reporting to SRB and will take directions from them.
- Post Holder SMS may be included in SAG.
- They are established as a standing group in any functional areas and assist Post holder SMS or SRB.
- More than one SAG may be established which depends on the scope of work.
- They assist post holder SMS in
1. overseeing operation performance within the functional area to build up safety awareness. They as well coordinate
the resolution of mitigation strategies.
2. Assess the safety impact about introducing operational changes or new technologies.
3. Coordinate the implementation of corrective actions and makes sure that the action is taken in a timely manner.
4. Oversee safety promotion activities in order to increase awareness of safety issues among employees.

9. Safety Management Systems – Emergency response plan
(ERP) 1-3
9-3
Emergency Response Plan (ERP)
It is a plan which outlines procedures and tasks to be performed in order to prevent incidents and accidents and to ensure
preparedness in case any incidents or accidents occurs. ERP should be documented in format of a manual or it can be as well
included in SMS manual. If the ERP is documented separately, it should be then cross linked with SMS manual.
ERP responsibilities:
-Ensure an orderly, safe and efficient transition from normal to emergency operation.
-Ensure delegation of emergency authority.
-Ensure authorization by key personnel for actions which is in the plan.
-Ensure coordination of efforts to cope with the emergency.
-Ensure that the responsibilities, roles, actions of various personnel are defined and that the personnel are trained.
-ERP should be tested periodically and results should be reviewed to improve its effectiveness.
-They should take into consideration:
1.Policies
2.Organization
3.Notifications
4.Initial response
5.Additional assistance
6.Crisis management center (CMC)
7.Records
8.Accident site
9.News media
10.Formal investigation
9. Safety Management Systems – SMS Documentation
1-3
9-4
SMS Documentation
-The organization shall develop SMS manual which should be endorsed by the accountable manager and should be acceptable to GCAA
in order to demonstrate compliance to this section.
-There should be a system of record keeping which allow adequate storage and traceability of all the SMS related records. These records
should be kept in a manner which ensures protection from damage, alteration, theft. Records should be accessible. Paper system should
be efficient and computer system should have one back up which should be updated from 24h of any new entry. Backup should be
stored in different location. These records are as follow:
1.The results of each hazard assessment
2.Safety performance indicator, targets and related charts.
3.Record of completed or in progress safety assessment.
4.SMS internal review or audit records
5.Safety promotion records
6.Personnel SMS training
7.SMS implementation plan
8.SMS meeting minutes
-SMS manual indicates the organization approach to safety management.
-It describes matters such as safety policy and objectives, SMS requirement, SMS processes and procedures, accountabilities,
responsibilities, and authorities for SMS processes and procedures.

9. Safety Management Systems – Safety Risk Management
1-3
9-5
Safety Risk management
Safety risk management includes hazard identification, safety risk assessment and mitigation process.
What is risk?
The chance that the hazard will result in damage or harm.
For instance, a Toxic chemical is a hazard and Toxic chemical stored in damaged container is a Threat and likelihood and
severity of chemical spill is a Risk.
SAFETY RISK ASSESSMENT – SAFETY RISK INDEX
SEVERITY OF AN OCCURRENCE PROBABILITY OF ITS OCCURRENCE
Safety Risk Index = Severity x Probability

9. Safety Management Systems – Safety Risk Management
1-3
9-6
Risk Severity Risk probability
Severity of Occurrences Probability of Occurrence
Aviation Meaning Value Aviation definition Meaning Value
definition
Catastrophic Equipment destroyed, multiple deaths 5 Frequent Likely to occur many 5
times (Several aircraft
Hazardous Serious injury, major equipment 4 in fleet within year)
damage, a large reduction in safety
margins
Occasional Likely to occur some 4
Major Serious incident , injury to persons, a 3 times (1 aircraft within
significant reduction in safety margins year)
Minor Nuisance, aircraft AOG, minor injury to 2
person Remote Unlikely, but possible 3
to occur (on an aircraft
Negligible Little consequence 1 once or twice in ten
years)
Improbable Very unlikely to occur 2

(might occur within
lifetime of aircraft)
Extremely improbable Almost inconceivable 1

that the event will
occur

9. Safety Management Systems – Hazard Identification
1-3
9-7
Hazard identification
Hazard can be identified through proactive methods of safety data collection as a result of accident or incident investigation.
(reactive) and predictive methodologies. Sources of hazard identification can be internal or external to the organization. Internal
means internal audits and external can be sources from industry accident reports, GCAA ROSI report, GCAA audits, information
exchange system.
In order to make sure that the data flows continuously, internal safety reporting system may be established which consist of
following:
1.Collection and evaluation of errors.
2.Corrective and preventive actions to be taken internally.
3.Feedback to organization safety training.
4.And investigation process to identify the factors which contributed to these occurrences, identify adverse trends, to establish
root cause.
The hazard identification will contain following:
-Design factors
-Human performance limitations
-Procedures and operating practices.
-Communication factor such as media and language.
-Organizational factors such as recruitment, training and personnel.
-Operational environment factors
-Regulatory oversight factors

9. Safety Management Systems
1-3
9-8

9. Safety Management Systems – Safety Assurance
1-3
9-9
Safety Assurance
Safety assurance consist of processes and activities which is undertaken by the organization to determine whether the SMS is
operating in accordance with the expectations and requirements. The organization should continuously monitor its internal
processes and the environment to detect changes that may introduce emerging safety risks. Quality assurance focuses on the
organization`s compliance with regulatory requirements as well as controlling the effectiveness of safety risk controls.
Safety performance monitoring and measurement
Safety performance monitoring and measurement should be established by the organization through establishment of Safety
performance indicator (SPI) and Safety performance targets (SPT).
SPT: Sometimes referred as goals or objectives, the safety performance targets are determined during the planning phase. They are
set so as to ensure the achievement of the acceptable level of safety considered desirable and realistic for the individual operator.
An example of desirable safety, communicated in absolute terms is: less than 1 fatal accident per 1 000 000 operating hours.
SPI: Safety indicators are linked to the safety performance targets. They enable the organization to measure and demonstrate the
achievement of the set target levels. The safety performance indicators should be easy to measure.
*SPI and SPT, action plans and alert levels should be agreed with GCAA.
If an organization is not able to establish SPT and SPI, they shall establish initiatives that aim at continuous improvement. If these
targets breach, the organization shall report it to GCAA and submit a corrective plan accordingly.
The safety performance shall be provided to GCAA in a form and manner established by the GCAA along with statistical data
required for GCAA to establish and monitor State Acceptable Level of Safety Performance (ALoSP).
SMS evaluation is a part of safety performance monitoring processes and system and in order to have continuous acceptance by
GCAA, they should be satisfied that the proposed SPIs are appropriate to the organization activities prior to agreement. The
agreement is made between the principal inspector of GCAA and the organization after reviewing SPIs and SPTs. GCAA should be
monitoring SPTs and State ALoSP, in order to accomplish that, organization should submit flight hours, engine hours, cycles, number
of movements.
9. Safety Management Systems – Safety Promotion
1-3
9-9
Safety Promotion
Training and education
SMS training should be done by the organization for the personnel to make sure that their duties performance is effective. The
scope of training shall be appropriate to the involvement of each person in the SMS. This training includes:
-Organization safety policies, goals and objectives.
-Organization safety roles and responsibilities
-Basic safety risk management
-Safety reporting system
-Safety management support
-Lines of communication
-Recurrent training
-The accountable manager training should be at high level providing an understanding of the SMS and its relationship to the
organization business strategy.

9. Safety Management Systems – Safety Communication
1-3
9-9
Safety communication
The safety communication develops an adequate safety culture in an organization. The safety communication shall:
-Ensure personnel are aware of SMS.
-Conveys safety critical information.
-Explains why safety actions are taken.
-Explains why safety procedures are introduced and changed.
Safety communication can be done through:
-Newsletter
-Presentation
-Safety notices
-Safety awareness posters
-Lectures
-Workshops
-Meetings between staff and accountable managers and senior managers.

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Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

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Vision Concept Aviation Training Institute www.trainbyvision.com

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

Description Page no.

Description Page no.

Description Page no.

Description Page no.

The Need To Take Human Factors Into Account

What is “Human Factors”?

The Shell Model

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

Incidents and Accidents Attributable To Human Factors / Human Error Figure 2

Incidents and Accidents - A Breakdown in Human Factors

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

The Basic Function of the Eye

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

Factors Affecting Clarity of Sight

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

• Environmental factors such as:

The Nature of the Object Being Viewed

The Basic Function of the Ear

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

Performance and Limitations of the Ear

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

Impact of Noise on Performance

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

This section examines the way the information gathered by

An Information Processing Model

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

Sensory Receptors and Sensory Stores

Attention and Perception

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

Information Processing Limitations

• Figure 10 illustrates that we can perceive the same thing quite

• In aviation maintenance it is often necessary to consult documents

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

• Aircraft maintenance engineers work within a “system”. As indicated in Figure 9,

• The impact of the organisation may be positive or negative. These organisational

Motivated behaviour is goal-directed, purposeful behaviour, and no human

Maslow’s Hierarchy of Needs

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

Countering Peer Pressure and Conformity

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

The Concept of A Team

Important Elements of Team Working

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

The Management Role

The Supervisory Role

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

MRM is not about addressing the individual

One of the early MRM training programmes

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

Module 9A – Human Factors _ Issue 2 Rev 1 _ January 2020

Fitness and Health