Aeronautical Institute of Bangladesh (AIB) : Fundamentals of Human Factors

Aeronautical Institute of Bangladesh (AIB)
Chapter 01
FUNDAMENTALS OF HUMAN FACTORS
1.0 INTRODUCTION
1.1 MEANING OF HUMAN FACTORS
1.2 SCOPE OF HUMAN FACTORS AND ERROR MANAGEMENT
1.3 HUMAN FACTORS MODELS
1.4 HUMAN FACTORS IN AVIATION
1.5 ORIGINS OF HUMAN FACTORS IN AVIATION
1.6 THE RELATIONSHIP BETWEEN HUMAN FACTORS AND ERGONOMICS.
1.7 THE IMPORTANCE OF HUMAN INPUT INTO AIRCRAFT MAINTENANCE

ACTIVITIES
1.8 THE IMPORTANCE OF AN EFFECTIVE HUMAN FACTORS PROGRAM IN

A MAINTENANCE ORGANISATION.
1.9 AN INTEGRATED APPROACH TO HUMAN FACTORS AND SAFETY
1.10 THE COST EFFECTIVENESS OF IMPLEMENTING HF ROGRAMS IN

ORGANISATIONS.
1.11 REGULATORY ASPECTS OF HUMAN FACTORS IN AVIATION

ENGINEERING
1.12 THE IMPORTANCE OF TRAINING IN REDUCING MAINTENANCE

ERRORS
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Human Performance & Limitations
1.0 INTRODUCTION
(a) Human performance and limitations centre around what is most commonly
termed as "Human Factors". It is, in broader sense, the Human Factors and
Error Management which applies common sense and substantiated scientific
knowledge on the way we go about our daily work.
(b) As the title suggests, the information on this course centre around the actions
and inactions of the individual in the work place and considers systems that
are designed to discover and correct errors before they have any negative
impact on safety.
(c) The principles associated with this subject area reflect the fact that as humans
we all make errors. If we can accept that we all make errors, then a policy of
zero error tolerance is unlikely to be an effective safeguard against any errors
eventually having harmful effects on operations. Therefore, a policy of error
Management is much more likely to result in safe operations. This subject
then is concerned about recognizing the myriad of factors that affect us as
humans, both positively and negatively.
(d) An understanding of the predictable human capabilities and limitations and

the application of this understanding are the primary concerns of Human
Factors.
1.1 MEANING OF HUMAN FACTORS
1.1.1 What is Human Factors?
(a) Human Factors as a term and as a subject has to be clearly defined. But no
single definition seems to meet all of the needs.
(b) As a term, it may be applied to any factor related to humans as the central
part of a working environment.
(c) In any working situation, human element is the most flexible, adaptable and
valuable part of it; but it is also most vulnerable to influences, which can,
adversely affect its performance. An understanding of this nature, predictable
capabilities and limitations of humans and the applications of this
understanding in real-life working situations are the primary concerns of
human factors. There has been research and investigations on Human
Factors and it has evolved as a complete subject. That has been
progressively developed, refined and institutionalized since the end of the last
century and is backed by a vast store of knowledge which can be used by
those concerned with enhancing the safety of the complex system which is
today's civil aircraft
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1.1.2 Some remarkable definitions of HF:
(a) Professor Elwyn Edwards (1988) proposed: "Human Factors is an applied

technology that is concerned with optimizing the relationships between people
and their activities by the systematic application of the human sciences,
integrated within the framework of systems engineering".
[Elwyn Edwards as referenced in ICAO Human Factors Digest No.1. (1989).
ICAO]
(b) "Human Factors refers to the study of human capabilities and limitations in the
workplace. Human Factors include, but are not limited to, such attributes as
human physiology, psychology, work place design, environmental conditions,
human-machine interface, and more. Human Factors researchers study
system performance. That is, they study the interaction of humans, the
equipment they use, the written and verbal procedures and rules they follow,
and the environmental conditions of any system."
[FAA Human Factors Guide for Aviation-MaIntenance]
(c) "Within the FAA, human factors entails a multidisciplinary effort to generate
and compile information about human capabilities and limitations and apply
that information to equipment, systems, facilities, procedures, jobs,
environments, training, staffing, and personnel management for safe,
comfortable, effective human performance." [FAA]
(d) "Human Factors and ergonomics and engineering psychology are roughly
equivalent terms used for the field of science concerned with the optimization
of the; relationship between people and the machines they operate through
the systematic application of human sciences integrated within the framework
of systems a engineering. Human Factors has been more widely used in the
USA, ergonomics r has been more widely used outside of the USA, and
engineering psychology has been more widely used in academia”
[Jensen, R. (1997) Opening address for the 9th International Symposium on
Aviation Psychology. Ohio University, USA.]
(e) "Human Factors focuses on human beings and their interaction with products,
equipment, facilities, procedures, and environments used in work and every-
day living. The emphasis is on human beings (as opposed to engineering,
where the emphasis is more on strictly technical engineering considerations)
and how the design of things influences people. Human Factors, then, seeks
to change the things people use and the environments in which they use
these things to better match the capabilities, limitations, and needs of people."
[Sanders, M.S. and McCormick, J. (1993) Human Factors in Engineering and
Design. Mc Graw-Hill.]
(f) "Human factors refer to environmental, organizational and job factors, and
human and individual characteristics which influence behavior at work in a
way which can affect health and safety." [HSE. HSG487 January 2002]
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1.1.3 ICAO Definitions Relating to Human Factors
(a) "Human Factors Principles: Principles which apply to aeronautical design,

certification, training, operations and maintenance and which seek safe
interface between the human and other system components by proper
consideration to human performance." [ICAO Annex 6, part 1.]
(b) "Human performance: Human capabilities and limitations which have an

impact on the safety and efficiency of aeronautical operations." [ICAO Annex
6, part 1, Definitions]
(c) "Human Factors is about people: it is about people in their working and living
environments, and it is about their relationship with equipment, procedures
and the environment. Just as importantly, it is about their relationships with
other people. Human Factors involves the overall performance of human
beings within the aviation system; it seeks to optimize people's performance
through the systematic application of the human sciences, often integrated
within the framework of system engineering. Its twin objectives can be seen
as safety and efficiency."
[ICAO HF Training Manual, Part 2, paragraph 1.4.2]
(d) "Human factors is essentially a multi-disciplinary field, including but not limited
to: psychology, engineering, physiology, sociology and anthropometry." [ICAO
HF Training Manual; Part 2, paragraph 1.4.3]
(e) "Human Factors has come to be concerned with diverse elements of the
aviation system. These include human behavior and performance; decision-
making and other cognitive processes; the design of controls and displays;
flight deck and cabin layout; communication and software aspects of
computers; maps, charts and documentation; and the refinement of training.
Each of these aspects demands skilled and effective human performance."
[ICAO HF Training Manual; Part 2, paragraph 1.4.4]
(f) "Aviation Human factors are primarily oriented towards solving practical
problems in the real world. As a concept, its relationship to the human
sciences might well be likened to that of engineering to the physical sciences.
And, just as technology links the physical sciences to various engineering
applications, there are a growing number of integrated Human Factors
techniques or methods; these varied and developing techniques can be
applied to problems as diverse as accident investigation and the optimization
of pilot training." ICAO HF Training Manual
All of these definitions provide for a good understanding of the essence of human
factors which encapsulate the entire subject matter. Suffice to say that an attempt to
cover all aspects of human factors within one or two sentences is very difficult or
extremely long.
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1.1.4 Subset Definitions
There will also be a significant number of aspects of Human Factors that will
require definition throughout this course. In most cases the definitions will be
supplied at the requisite chapters of study. There are a couple of terms, however,
that requires to be familiar with right from the start. They are:
 Ergonomics: The study of work ("the study of man in his working environment").
 Anthropometrics: The science of measurement and the art of application that

establishes the physical geometry, mass properties, and strength capabilities of
the human body.
 Biomechanics: Addresses issues of movement, leverage, and strength. From a

biomechanical perspective, the human body is a series of physical links (bones)
connected at certain points (joints) that allow various movements. Muscles and
tendons provide the motive force for all movements. 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.
1.2 SCOPE OF HUMAN FACTORS AND ERROR MANAGEMENT
(a) Many different textbooks will provide different ranges of topic areas that the
authors believe fall in the Human Factors and Error Management category.
For example, Frank Hawkins, in one of the more original texts on the subject
titled "Human Factors in Flight", identified the following topics through Chapter
headings in 1987:
 Human Error
 Fatigue, Body Rhythms and Sleep
 Fitness and Performance
 Vision and Visual Illusions
 Motivation and Leadership
 Communication: Language and Speech
 Attitudes and Persuasion
 Training and Training Devices
 Documentation
 Displays and Controls
 Space and Layout
 Education and Application
 The Aircraft Cabin and its Human Payload
(b) The FAA Guide provides quite a different list of the elements of Human
Factors and Error Management as outlined below:
Detection and Perception Stereotypical Behavior

Early and Frequent Testing Errors Stress
Systems Approach Usability
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Habituation Compatibility Limitations

Human Capabilities and Limitations Understandability
Performance Shaping Factors Effectiveness
Physical Compatibility User Population
Anthropometry Vigilance
Biomechanics Workload and so on
Work Physiology
1.3 HUMAN FACTORS MODELS
1.3.1 General
(a) Fundamentals of human factors are better understood by different models

postulated by experts.
(b) In this section, some models of human factors will be highlighted as a
beginning of the basic elements of the subject.
1.3.2 The SHEL Model
(a) Perhaps the most common way of expressing complex systems is to use
simple models to illustrate the ideas. In aviation, Elwyn Edwards (1972)
proposed the SHEL model to identify the components and interactions within
our complex industry. The acronym had the following meanings:
Software: the manuals, rules, procedures, spoken words, etc., which are part
and parcel of standard operating procedures in an organization;
Hardware: the aircraft, machinery, tools, control and display systems;
Environment: the physical, social and economic climate in which the
organization and individuals operate; and
Liveware: the human beings - engineers, flight crew, cabin crew, ground crew,
management and administration people - in the system.
(b) Human factors concentrates on the interfaces between the human (the 'L' in
the centre box i.e. Liveware) and the other elements of the SHEL model (see
Figure 1.1), and from a safety viewpoint, where these elements can be
deficient, e.g.:
S: misinterpretation of procedures, badly written manuals, poorly designed

checklists, untested or difficult to use computer software
H: not enough tools, inappropriate equipment, poor aircraft design for
maintainability'
E: uncomfortable workplace, inadequate hangar space, extreme
temperatures, excessive noise, poor lighting
L: relationships with other people, shortage of manpower, lack of
supervision, lack of support from managers
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Figure 1.1 SHEL Model
(c) 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 jeopardize safety.
(d) 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.
However, we can work around that unreliability by providing good training,
procedures, tools, duplicate inspections, etc. We can also reduce the potential
for error by improving aircraft design such that, for example, it is physically
impossible to reconnect something the wrong way round.
(e) Notably, Liveware is the hub of the SHEL model of Human Factors. The
remaining components must be adapted to and matched with this central
component.
(f) Liveware-Hardware: This interface is the most commonly considered when

speaking of human-machine systems: the design of seats to fit the sitting
characteristics of the human body; of displays to match the sensory and
information-processing characteristics of the user; of controls with proper
movement, coding, and location. The interactions between individuals and the
machinery or tools that they used requires some major rethinking to reduce
the error rate. Controls that required extreme physical strength, displays that
were easy to misread and hours of boring monitoring contributed to high error
rates in these interactions.
The user may not be aware of an L-H deficiency, even when it finally leads to
disaster, because the great virtue of human adaptability may mask the effects
of such a deficiency. However, the deficiency continues to exist and may
constitute a potential hazard. Human Factors Ergonomically deals mostly,
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although not exclusively, with issues arising from this interface.

User friendly controls and displays and a better understanding of the relative
strengths of humans and machines provided a platform for reducing error
rates considerably. Alarm systems were also provided to keep operations
within the established parameters.
(g) Liveware-Software: This encompasses the interface between humans and

the non-physical aspects of the system such as procedures, manual and
checklist layout, symbology, and computer programs. The problems may be
less tangible than those involving the L-H interface and consequently more
difficult to detect and resolve (e.g. misinterpretation/misunderstanding of
technical literature or symbology). Many of the manuals engineers were
expected to use were not user friendly, policies were interpreted differently by
different supervisors and rules were often ignored because they conflicted
with common sense.
A real need existed to improve communication and publications as well as to

put in checks and balances to pick up errors before they left the workshop.
(h) Liveware-Environment: The human-environment interface was one of the

earliest recognized in flying. Initially, measures taken were aimed at adapting
the human to the environment (e.g. by using helmets, flying suits, oxygen
masks and G suits). Later, attempts were made to alter the environment to
match human requirements (e.g. by applying pressurization, air-conditioning,
and soundproofing). Today, new challenges have raised, notably ozone
concentrations and radiation hazards at high flight levels, and the problems
associated with disturbed biological rhythms and sleep due to high-speed
transmeridian travel. Since illusions and disorientation are involved in many
aviation occurrences, the L-E interface must also consider perceptual errors
induced by environmental conditions (e.g. illusions occurring during approach
and landing).
In the maintenance of aircraft, Engineers are often asked to work in hostile

physical conditions without satisfactory protective equipment and asked to
take responsibility for safety aspects that are compromised by lack of funding
for the right equipment.
The aviation system operates within the context of broad managerial, political,
and economic constraints. These aspects of the environment interact with the
human via this interface. Although modifications to these factors are generally
beyond the function of Human Factors practitioners, they should be
considered and addressed by those in management with the ability to do so.
In many cases, errors were significantly reduced just by providing the right
safety wear. For example ramp staff, which was often distracted by high noise
levels, could concentrate on their responsibilities much more effectively while
wearing the right grading of ear protection. Occupational health and safety
legislation has been enacted in many countries now to reduce error (and
injury) rates at the interaction between Liveware and the Environment.
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1.3.3 The SHELL Model
(a) In 1984, Frank Hawkins proposed that the interactions between people were
also a significant arena for error generation. He proposed the addition of
another Liveware to the model to take account of the interactions between
people at both the macro and micro level. This became the SHELL Model.
(Figure 1.2)
Figure 1.2 SCHELL Model
(b) Liveware-Liveware: This is the interface between people. Maintenance and

aircrew training and proficiency testing have traditionally been conducted on
individual basis. If each individual engineer/air crewmember was proficient,
then it was assumed that the team of maintenance/operation team comprising
those individuals would also be effective. This is not always the case. So,
attention has been increasingly tuned to breakdown of teamwork. Function as
groups and group interactions play a role in determining behavior and
performance. Through this L-L, Human Factors concentrates on errors
caused by miscommunication between individuals, poor teamwork in small
group situations, and ineffective leadership by supervisors and managers that
generates errors on the workshop floor. Staff management relationships are
also within the scope of this interface.
(c) Training and recognition of individual capabilities within the work environment
were coupled with redundancy systems to pick up on errors caused by
misunderstandings became a significant part of the human factors research
efforts to improve safety, effectiveness and efficiency.
(d) For the cockpit environment, Human Factors Digest No. @ describes current
industry approaches to deal with issues associated with this interface. (i.e.
CRM program)
1.3.4 The SCHELL Model
In 1994, Professor Graham Hunt from Massey University in New Zealand proposed
that all of these interactions necessarily take place within a cultural context. While
many commentators see this aspect as part of the environment, Professor Hunt
believes that the organisational, national and ethnic backgrounds of individuals play
a profound part in the interactions of the SHELL model and are currently not
addressed satisfactorily in most cases. He has proposed the SCHELL (pronounced
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skell) model. This is still a debatable point. (Figure 1.3)
Figure 1.3 SHELL model
1.4 HUMAN FACTORS IN AVIATION
(a) In the early days of powered flight, the design, construction and control of
aircraft predominated. The main attributes of the first pilots were courage and
the mastery of a whole new set of skills in the struggle to control the new
flying machines. As the technical aspects of flight were overcome bit by bit,
the role of the people associated with aircraft began to come to the fore. Pilots
were supported initially with mechanisms to help them stabilize the aircraft
and later with automated systems to assist the crew with tasks such as
navigation and communication. With such interventions to complement the
abilities of pilots, aviation human factors were born.
(b) The term "human factors" is used in many different ways in the aviation
industry. The term is, perhaps, best known in the context of aircraft cockpit
design and Crew Resource Management (CRM). However, those activities
constitute only a small percentage of aviation-related human factors as
broadly speaking it concerns any consideration of human involvement in
aviation.
(c) 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. This does not imply that human factors issues
were not present before these dates nor that human error did not contribute to
other incidents; merely that it took an accident to draw attention to human
factors problems and potential solutions.
1.5 ORIGINS OF HUMAN FACTORS IN AVIATION
1.5.1 General
(a) Many people would argue that the development of Human Factors is
necessarily as old as the development of aviation. This is because Human
Factors are part and parcel of any development in aviation and therefore their
development would be considered parallel. This is, however, a fairly simplistic
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view and it would be fair to say that Human Factors, as a discipline is a

reasonably modern initiative. That is not to say that elements of Human
Factors such as those coming under the headings of Anthropometrics or
Biomechanics have not been taken into account well before the term "Human
Factors" was associated with them.
(b) World War II: World War II probably provided the genesis of subject areas
that we now consider to be part of Human Factors. By that we mean that
specific research was conducted on aeroplane operations and maintenance
with the prime intention of reducing accident and incident rates. In 1939, Sir
Frederick Bartlett in his Cambridge University laboratories was the first to
build aircraft cockpit mockups and simulators for the prime purpose of
conducting experiments that would reduce pilot error during training as well as
war operations. Early researchers made significant safety advances through
Human Factor applications, though these were primarily in the fields of
anthropometrics, biomechanics and biophysiology.
(c) Post War Developments: Shortly after the war, in 1949, the Ergonomics
Research Society was founded in England. This Society was the foundation of
what later became the Ergonomic Society and the prime repository of Human
Factors research from all over Europe. Meanwhile, a similar body was
undertaking work in the United States. This body first took on the name
"Human Factors Society" in 1957 and became the centre of research for
Human Factors throughout North America. In many respects, these two
organizations developed in parallel and even replicated each other's work. It
wasn't until recently that they joined into a single entity that we now know as
"The Human Factors and Ergonomic Society".
(d) Human Factors really started to get the attention of decision makers in
aviation following the major disaster at Tenerife in 1977 when a KLM 747 ran
into a Pan American 747 during takeoff at Los Rodeos airport. This accident
was the catalyst for KLM to engage a number of academics under the
direction of Captain Frank Hawkins to put together the first course ("KHUFAC"
standing for KLM Human Hawkins aimed at educating flight crew on reducing
and managing errors through knowledge of Human Factors concepts. Also in
the late 70's, there were a number of accidents and incidents to US carriers
that resulted in insurance companies asking for the airlines to rethink their
educational strategies of flight crew. Cockpit Resource Management (CRM)
courses were the result of these deliberations and they were actively taken up
by most airlines in the world who could see a tangible benefit in educating
their flight crew in Human Factors concepts.
(e) Modern Focus: Following two significant mishaps in England, Cockpit

Resource Management transformed into Crew Resource Management. The
two specific incidents involved scenarios in which the cabin crew had
information that could well have averted disaster but it was not passed on to
the captain in time to do so. Cabin crew then became an integral part of the
safety equation on modern airliners and they too were required to attend
Human Factors courses with the express intention of reducing and managing
human error. It did not take long for senior management personnel in airlines
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to realize that in fact these Human Factors elements played a significant role
in the success or failure of their entire organization. The term "Corporate
Resource Management" or "Company Resource Management" was coined by
some to reflect the fact that these Human Factors skills should be taught to
everyone in the organization. This is in effect what have become Human
Factors and Error Management today. Many regulatory authorities have also
gone so far as to require such courses to be taken for licensing purposes. You
are attending one of those courses now.
1.5.2 Who is promoting Human Factors?
(a) It is important to note that Human Factors is evolving on a daily basis. At

present, ICAO has led the requirement for including Human Factors amongst
the professional licensing examinations by providing syllabi of training in
Human Factors. Most of the leading aviation nations have now included
Human Factors in their licensing examinations.
(b) Universities around the world are also continually conducting research studies
specifically aimed at reducing errors in aviation. This includes improved
aerodynamics and better engine performance, but in many cases, specifically
targets Human Factor elements that they perceive as having a major impact
on safety. The reason for this is fairly obvious when we consider that human
error is variously reported as being the primary causes of between 70% and
86% of all aviation accidents. It makes sense then to suggest that an
improvement in Human Factor disciplines should lead to a reduced error rate.
(c) Major aviation training organizations, whether flight crew, engineering or air
traffic control, have also taken the read by including Human Factors in their
training syllabi. One of the major advantages of this development is a
transition of the teaching of Human Factors from the university academicians
who generally conducted the research, to practitioners who work in the field
every day. This is seen as making the Human Factors concepts much more
accessible and with direct application to the engineer in the workshop.
(d) Human Factors as a discipline is now being discovered outside the aviation
arena as well. Many of the principles that you will cover during this course are
now also starting to be applied to such various professions as anesthetists, oil
rig workers and nuclear power plant employees. Again, we expect these
developments will have positive spin off effects for those of us in the aviation
industry.
1.6 THE RELATIONSHIP BETWEEN HUMAN FACTORS AND ERGONOMICS.
(a) The term ergonomics was derived from the Greek words ergon (work) and
nomos (natural law), and was coined in 1949 by Professor Hywell Murrel who
defined it as "the study of man in his working environment". This definition
comes very close to the definition of Human Factors proposed by Professor
Elwyn Edwards (mentioned earlier).
(b) While in many countries the terms ergonomics and Human Factors are used
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interchangeably, there is a small difference in emphasis. Human Factors has

acquired a wider meaning, including aspects of human performance and
system interfaces which are not generally considered in the mainstream of
ergonomics. ICAO Digest No. 1 proposes that the two terms be considered
synonymous, to preclude dwelling on academic or semantic considerations
and to avoid confusion; however, it indicates that the term ergonomics is used
in many States to refer strictly to the study of Hunan-machine system design
issues. From this perspective, ergonomics is the study of the principles of
interaction between human and equipment, for the purpose of applying them
in design. Ergonomics studies human attributes, determining what
requirements in hardware and software result from the characteristics of the
activities involved. It attempts to solve the problem of adapting technology and
working conditions to humans.
(c) In terms of maintenance engineering, separating the two definitions is not

really appropriate. This is because in aviation as distinct from other contexts,
the work that was done in the United States under the banner of Human
Factors and the work that has been done in Europe under the banner of
Ergonomics covers the same subject areas.
(d) In aviation maintenance engineering, we now use the terms interchangeably.

That is, they are synonymous or mean the same thing.
1.7 THE IMPORTANCE OF HUMAN INPUT INTO AIRCRAFT MAINTENANCE

ACTIVITIES
(a) Humans and machines have different strengths and weaknesses and
recognition of these differences goes a long way to giving the right jobs to
people and the right jobs to machines thereby reducing the chance of errors.
McCormick (1976) proposed the following lists for consideration:
(b) Humans are better in their ability to:
 Sense very low levels of certain kinds of stimuli: visual, auditory, tactile,
olfactory, and taste.
 Detect stimuli against high-noise-level background, such as blips on a
cathode-ray-tube radar display with poor reception.
 Recognize patterns of complex stimuli that may vary from situation to
situation, such as objects in aerial photographs and speech sounds.
 Sense unusual and unexpected events in the environment.
 Store (remember) large amounts of information over long periods of time
(better for remembering principles and strategies than masses of detailed
information).
 Retrieve pertinent information from storage (recall), frequently retrieving
many related items of information; but reliability of recall is low.
 Draw upon varied experience in making decisions; adapt decisions to
situation requirements; act in emergencies. (Does not require previous
"Programming" for all situations.)
 Select alternative modes of operation, if certain modes fail.
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 Reason inductively, generalizing from observations.

 Apply principles to solutions of varied problems.
 Make subjective estimates and evaluations.
 Develop entirely new solutions.
 Concentrate on most important activities, when overload conditions require.
 Adapt physical response (within reason) to variations in operational
requirements.
(c) Machines are generally better in their abilities to:

 Sense stimuli that are outside the human's normal range of sensitivity, such
as x-rays, radar wavelengths, and ultrasonic vibrations.
 Apply deductive reasoning, such as recognizing stimuli as belonging to a
general class (but the characteristics of the class need to be specified)
 Monitor the pre-specified events, especially when infrequent (but machines
cannot improvise in case of unanticipated types of events).
 Store coded information quickly and in substantial quantity (for example, large
sets of numerical values can be stored very quickly).
 Retrieve coded information quickly and accurately when specifically
requested (although specific instructions need to be provided on the type of
information that is to be recalled).
 Process quantitative information following specified programs.
 Make rapid and consistent responses to input signals.
 Perform repetitive activities reliably.
 Exert considerable physical force in a highly controlled manner.
 Maintain performance over extended periods of time (Machines typically do
not "fatigue" as rapidly as humans).
 Count or measure physical quantities.
 Perform several Programmed activities simultaneously.
 Maintain efficient operations under conditions of heavy load (humans have a
relatively limited channel capacity).
 Maintain efficient operations under distractions.
(d) The point is that the system needs both humans and machines to interact in
synergy each utilizing the strengths of the other to provide total system safety.
The human is an integral part of the system.
1.8 THE IMPORTANCE OF AN EFFECTIVE HUMAN FACTORS PROGRAM IN

A MAINTENANCE ORGANISATION.
(a) Humans have performance limitations, therefore they make errors. Effective
Human Factors Programs train staff and put systems in place to pick up those
errors therefore; those errors don't result in delays, incidents or accidents.
(b) Fewer errors by engineer’s means reduced delays, incidents and accidents.
Therefore, the company is safer and more cost efficient.
(c) A safer, more cost efficient, company means:

- Fewer delays
- Fewer injuries
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- Better company performance

- And therefore, better job security for its workers.
1.9 AN INTEGRATED APPROACH TO HUMAN FACTORS AND SAFETY
1.9.1 Integrated Approach
(a) Human factors initiatives will be more effective if they are integrated within
existing company processes, and not treated as something additional or
separate or short-term. Human factors initiatives have sometimes failed in the
past because they have been marginalized and regarded as a temporary
'fashion'. Much of human factors, in the context of maintenance organizations
and JAR145 requirements, are common sense, professionalism, quality
management, safety management i.e. what organizations should already
have been doing all along.
(b) The "human factors" initiatives in the context of JAR145 are really "safety and
airworthiness" initiatives, the aim being to ensure that maintenance is
conducted in a way that ensures that aircraft are released to service in a safe
condition. The organization should have a safety management system in
place, many of the elements of which will need to take into account human
factors in order to be effective.
(c) Ideally, human factors best practice should be seamlessly and invisibly
integrated within existing company processes, such as training, quality
management, occurrence reporting and investigation, etc. Sometimes it is a
good idea to re-invent an initiative under a new name if it has failed in the
past, but you should be cautious about unnecessarily duplicating functions
which may already exist (e.g. occurrence reporting schemes / quality
discrepancy reporting etc.). It may only be necessary to slightly modify
existing processes to meet the JAR145 human factors requirements.
(d) Human factors training is probably an exception to the advice given above, in
that it is usually so new and different to any existing training that it warrants
being treated as a separate entity, at least for initial training. Recurrent
training, however, is probably better integrated within existing recurrent
training.
(e) Having stated that it doesn't matter what you call the initiatives, as long as
they are done, this report will go on to refer to a "human factors program" only
in as far as it is a useful term to cover the elements which need to be
established within an organization to address human factors issues. The
majority of these elements are addressed by JAR145 or the JAA MHFWG
report.
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1.9.2 Elements of a Human Factors Program
(a) Figure 1.4 (adapted from ATA Specification 113: Maintenance Human Factors
Program Guidelines) shows how the various elements of a human factors
program should interact:
(b) The key elements of human factors programmed are:
 Top level commitment to safety and human factors.

 A company policy on human factors.
 Human factors training (of all appropriate personnel, including managers - not
just certifying staff).
 Reporting, investigation and analysis scheme(s) which will allow reporting of
errors, actual & potential safety risks, inaccuracies and ambiguities with
Maintenance Manuals, procedures or job cards (not just those which have to
be reported as Mandatory Occurrence Reporting (MOR)s).
 A clear disciplinary policy stressing those genuine errors will not result in
punishment.
 Human factors and ergonomics audits, Line Operations Safety Audits (LOSA)
(of workplaces, lighting, noise, tooling, adequacy of procedures, actual
compliance with procedures, manpower, adequacy of planning, etc.).
 The resources and willingness to act upon the findings arising from
occurrence reports and audits, and to provide fixes where appropriate.
 A mechanism for reporting problems to the Type Certificate Holder.
 A mechanism for ensuring that internal procedures and work instructions are
well designed and follow best practice.
 A means of providing feedback to staff on problems and fixes.
 Abolition of any 'double standards' concerning procedural violations.
 A policy for management of fatigue.
 Motivation of staff to support the initiatives.
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Figure 1.4
(c) Health and safety would normally be considered separate to human factors, at
least in the UK, although there are areas of overlap.
1.10 THE COST EFFECTIVENESS OF IMPLEMENTING HF ROGRAMS IN

ORGANISATIONS.
(a) There are two primary reasons for including Human Factor programs in
organizations. They are Safety and Cost.
(b) Safety has two aspects to it.
(i) First and foremost is public safety. Organizations that are better trained
and present fewer errors in their routine and emergency work present a
safer option to the travelling public. Passengers prefer to travel with a
safer airline.
(ii) And second is on-the-job safety for maintenance workers reduced error
rates are reflected in the injury rates amongst staff and less down time
for workers. It is worth noting here that those injuries aren't always
physical. More on that subject is given later in the course.
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Cost savings are a bit more tangible than safety as a reason to

implement HF programs and therefore easier to identify with. It is very
difficult to prove to an accountant that you saved an accident from
occurring but it is easier to show book figures that show definitive cost
savings. Ironically, the biggest cost savings are in reduced accident
rates, it is just that in ultra-safe systems such as aviation, the accident
rates are so small that they become statistically insignificant.
- There are cost savings through fewer operational delays and quicker
turnaround times for equipment.
- And there are reduced costs through less downtime on equipment
and workers caused by errors.
(c) In summary, the overall cost of maintenance is reduced by implementing HF

programs in organizations. Many airlines (as for example SIAEC and its
parent company, SIA) run many Human Factor programs within the different
branches of the organization with justified cost effectiveness.
1.11 REGULATORY ASPECTS OF HUMAN FACTORS IN AVIATION

ENGINEERING
Human performance and Limitations (i.e. Human Factors) relevant to the

duties of aircraft maintenance is a new subject of knowledge mandated by the
ICAO in Annex 1 and by the CAAB in ANO.
1.12 THE IMPORTANCE OF TRAINING IN REDUCING MAINTENANCE

ERRORS
(a) Public and personal safety relies on competent individuals and systems
working together to meet specific safety standards. It is difficult to
overestimate the importance of training in this process. In many respects
individuals are a product of the training they receive and apart from a few
innate abilities and a large number of experiences, what the individuals learn
through training reflects their capability and their competence.
(b) For example, it would not be cost effective of an organization to purchase

expensive, highly specialized equipment (a common requirement in aviation),
if they didn't get their personnel trained appropriately on that machinery.
Further, these personnel can risk serious injury to themselves or to airline
passengers if they are not competent in operating the machinery.
(c) In the same way, all training is primarily aimed at reducing errors of one form
or another. This Human Factors course is just another example of the
company providing training to you with the intention of reducing maintenance
errors that may have occurred if you had not undertaken this training.
(d) Time will tell whether it has been successful.
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Chapter-2
INCIDENTS ATTRIBUTABLE TO HUMAN FACTORS/ ERRORS
2.0 INTRODUCTION
2.1 HUMAN FACTORS BEHIND ACCIDENTS/INCIDENTS: SOME STATISTICS
2.2 AN OUTLINE OF INCIDENTS/ACCIDENTS ATTRIBUTABLE TO HUMAN

FACTORS / HUMAN ERRORS
2.3 APPRECIATION OF HUMAN FACTORS BEHIND ACCIDENTS AND

INCIDENTS
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2.0 INTRODUCTION
(a) This chapter is designed for an appreciation why we go to the lengths we do

to present courses such as this. As we discussed in the last chapter, with the
cost effectiveness of introducing Human Factors programs in organizations,
the major focus was on safety. Although followed closely by the cost issues,
safety has always been the primary rationale for such programs.
(b) To that end, it is important to identify a few of the incidents and accidents that
have been instrumental in bringing about positive change in our industry. The
first few sections will look at a few of those key events along with their
investigations and the subsequent sections will outline very broadly some of
the human factor elements that have been found to be causal in aviation
accidents and incidents in general.
2.1 HUMAN FACTORS BEHIND ACCIDENTS/INCIDENTS: SOME STATISTICS
(a) In 1940, it was calculated that approximately 70% of all aircraft accidents
were attributable to man’s performance, that is to say human error.
(b) International Air Transport Association (IATA) reviewed the situation 35 years
later, they found that there had been no reduction in the human error
component of accident statistics. (Figure 2.1).
OTHER
CAUSES
30%
HUMAN FAILURE
Flight Crew, ATC,
Maintenance, Aircraft
Design, etc.70%
Figure 2.1 The dominant role played by human performance in civil aircraft
accidents Source: IATA, 1975
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(c) A study was carried out in 1986, in the USA by Sears, looking at significant
accident causes in 93 aircraft accidents. These were as follows:
Causes/major contributory factors Percentage

of accidents in which this
was a contributing factor
 Pilot deviated from basic operational procedures 33

 Inadequate cross-check by second crew member 26
 Design faults 13
 Maintenance and inspection deficiencies 12
 Absence of approach guidance 10
 Captain ignored crew inputs 10
 Air traffic control failures or errors 9
 Improper crew response during abnormal conditions 9
 Insufficient or incorrect weather information 8
 Runways hazards 7
 Air traffic control/crew communication deficiencies 6
 Improper decision to land 6
(d) As can be seen from the list, maintenance and inspection deficiencies are one
of the major contributory factors to accidents.
(e) The UK CAA carried out a similar exercise in 1998 looking at causes of 621
global fatal accidents between 1980 and 1996. Again, the area "maintenance
or repair oversight /error /inadequate " featured as one of the top 10 primary
causal factors.
(f) It is clear from such studies that human factors problems in aircraft
maintenance engineering are a significant issue, warranting serious
consideration.
2.2 AN OUTLINE OF INCIDENTS/ACCIDENTS ATTRIBUTABLE TO HUMAN

FACTORS / HUMAN ERROR
2.2.1 Introduction
(a) During the late 1970's, there was a spate of heavy airliner accidents that
made headlines around the world. Following are some of those headline
makers:
 KLM and PAN AM jumbo jets at Tenerife in 1977,

 Air New Zealand DC 10 at Mount Erebus in Antarctica in 1979,
 British Airways Trident midair collision with the Inex Adria DC 9 over Zagreb in
1976.
 United Airlines Flight 173 which crashed just short of the runway at Portland,
Oregon in the United States on December the 28th, 1978.
 Accident to Boeing 737, (Aloha flight 243), Maui, Hawaii, April 28 1988;
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 Accident to BAC One-Eleven, G-BJRT (British Airways flight 5390), over

Didcot, Oxfordshire on 10 June 1990;
 Incident involving Airbus A320, G-KMAM at London Gatwick Airport, on 26
August 1993;
 Incident involving Boeing 737, G-OBMM near Daventry, on 23 February 1995.
2.2.2 Aloha Accident
(a) The accident involving Aloha flight 243 in April 1988 involved 18 feet of the
upper cabin structure suddenly being ripped away in flight due to structural
failure.
(b) The Boeing 737 involved in this accident was examined in the maintenance
before flight by two of the engineering inspectors. One inspector had 22 years
experience and the other, the chief inspector, had 33 years experience.
Neither found any cracks in their inspection.
(c) Post- accident analysis determined there were over 240 cracks in the skin of
this aircraft at the time of the inspection. The ensuing investigation identified
many human-factors-related problems leading to the failed inspections. The
report cited the following specific contributing factors:
 Maintenance, inspection - Improper.
 Company maintenance personnel supervision - Inadequate.
 Company / operator management - inadequate surveillance of operation.
(d) These findings brought about a plethora of Human Factors issues as people
tried to answer the question: "How did these experienced engineers make
these errors?"
(e) As a result of the Aloha accident, the US instigated a program of research

looking into the problems associated with human factors and aircraft
maintenance, with particular emphasis upon inspection,
2.2.3 BAC 1-11 Incident
(a) On June 10th 1990 in the UK, a BAC 1-11 (British Airways flight 5390) was
climbing through 17,300 feet on departure from Birmingham International
Airport when the left windscreen, which had been replaced prior to flight, was
blown out under the effects of cabin pressure when it overcame the retention
of the securing bolts, 84 of which, out of a total of 90, were smaller than the
specified diameter. The commander was sucked halfway out of the
windscreen aperture and was restrained by cabin crew whilst the co-pilot flew
the aircraft to a safe landing at Southampton Airport. The Shift Maintenance
Manager (SMM), shorthanded on a night shift, had decided to carry out the
windscreen replacement himself. He consulted the Maintenance Manual (MM)
and concluded that it was a straightforward job. He decided to replace the old
bolts and, taking one of the bolts with him (a 7D), he looked for replacements.
The store man advised him that the job required 8Ds, but since there were not
enough 8Ds, the SMM decided that 7Ds would do (since these had been in
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place previously). However, he used sight and touches to match the bolts
and, erroneously, selected 8Cs instead, which were longer but thinner. He
failed to notice that the countersink was lower than it should be, once the bolts
were in position. He completed the job himself and signed it off, the
procedures not requiring a pressure check or duplicated check.
(b) There were several human factors issues contributing to this incident,
including perceptual errors made by the SMM when identifying the
replacement bolts, poor lighting in the stores area, failure to wear spectacles,
circadian effects, working practices, and possible organizational and design
factors.
2.2.4 Incident in UK, August 1993
An incident in the UK in August 1993 involved an Airbus 320 which, during its first
flight after a flap change, exhibited an undemanded roll to the right after takeoff. The
aircraft returned to Gatwick and landed safely. The investigation discovered that
during maintenance, in order to replace the right outboard flap, the spoilers had been
placed in maintenance mode and moved using an incomplete procedure; specifically
the collars and flags were not fitted. The purpose of the collars and the way in which
the spoilers functioned was not fully understood by the engineers. This
misunderstanding was due, in part, to familiarity of the engineers with other aircraft
(mainly 757) and contributed to a lack of adequate briefing on the status of the
spoilers during the shift handover. The locked spoiler was not detected during
standard pilot functional checks.
2.2.5 Boeing incident in UK, February 1995
In the UK in February 1995, a Boeing 737-400 suffered a loss of oil pressure on both
engines. The aircraft diverted and landed safely at Luton Airport. The investigation
discovered that the aircraft had been subject to borescope inspections on both
engines during the preceding night and the high pressure (HP) rotor drive covers had
not been refitted, resulting in the loss of almost all the oil from both engines during
flight. The line engineer was originally going to carry out the task, but for various
reasons he swapped jobs with the base maintenance controller. The base
maintenance controller did not have the appropriate paperwork with him. The base
maintenance controller and a fitter carried out the task, despite many interruptions,
but failed to refit the rotor drive cover. No ground idle engine runs (which would have
revealed the oil leak) were carried out. The job was signed off as complete.
2.2.6 Portland Oregon Accident: 1972
A synopsis of this accident shows that the DC 8 did not have the three green lights
indicating that all the landing gear was down and locked and ready for landing when
they were on final approach. The flight crew requested an overshoot and some time
to circle of the unpopulated marsh area some 10 miles from the airport, while they
sorted out the problem. The crew became totally immersed in solving the problem
and neglected to notice their fuel status. It transpires that they ran out of fuel and
were unable to make it to the airfield. This had all of the hallmarks of the Everglades
accident in 1972, where 99 lives were lost for a 60-cent light bulb.
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2.2.7 Accident at Kegworth
(a) The British Midlands 737-400 accident at Kegworth also became a key event
in the development of Human Factors in aviation. In this case, an almost
brand new Boeing 737-400, on climb out from London's Heathrow airport on
its way to Belfast suffered, what appeared to be engine damage on number 1
(the left hand) engine. The flight crew shut down the number 2 (right hand)
engine and the aircraft eventually crashed on the M1 motorway.
(b) The investigation revealed that things weren't quite as simple as first thought.
As the aircraft was climbing through 28, 300 feet the outer panel of one blade
in the fan of the number 1 (left) engine detached. This gave rise to a series of
compressor stalls in the number 1 engine, which resulted in airframe
shuddering, ingress of smoke and fumes to the flight deck and fluctuations of
the number 1 engine parameters.
(c) Believing that the number 2 engine had suffered damage, the crew throttled
that engine back and subsequently shut it down. The shuddering caused by
the surging of the number 1 engine ceased as soon as the number 2 engine
was throttled back, which persuaded the crew that they had dealt correctly
with the emergency. They then shut down the number 2 engine. The number I
engine operated apparently normally after the initial period of severe vibration
and during the subsequent descent.
(d) The crew initiated a diversion to East Midlands Airport and received radar
direction from air traffic control to position the aircraft for an instrument
approach to land on runway 27. The approach continued normally, although
with a high level of vibration from the No 1 engine, until an abrupt reduction of
power, followed by a fire warning, occurred on this engine at a point 2.4 nm
from the runway. Efforts to restart the No 2 engine were not successful.
(e) The aircraft initially struck a field adjacent to the eastern embankment of the
M1 motorway and then suffered a second severe impact on the sloping
western embankment of the motorway.
(f) Of the eight crew and 118 passengers on board that day, 39 passengers died
in the accident and a further 8 passengers died later from their injuries. Of the
other 79 occupants, 74 suffered serious injury.
(g) The cause of the accident was that the operating crew shut down the number
2 engine after a fan blade had fractured in the number 1 engine. This engine
subsequently suffered a major thrust loss due to secondary fan damage after
power had been increased during the final approach to land.
(h) The following contributing factors were cited by the Air Accident Investigation
Bureau of the United Kingdom as contributing factors:
 The combination of heavy engine vibration, noise, shuddering and an

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associated smell of fire were outside their training and experience.

 They reacted to the initial engine problem prematurely and in a way that
was contrary to their training.
 They did not assimilate the indications on the engine instrument display
before they throttled back the # 2 engine.
 As the # 2 engine was throttled back, the noise and shuddering associated
with the surging of the # 1 engine ceased, persuading them that they had
correctly identified the defective engine.
 They were not informed of the flames which had emanated from the # 1
engine and which had been observed by many on board, including 3 cabin
attendants in the aft cabin.
2.2.8 British Airways 737 caught fire on the ground
This accident followed another disaster when a British Airways 737 caught fire on the
ground at Manchester. Forty-three people died that day and though the passengers
and cabin crew could see the seriousness of their situation, none of this urgency was
transmitted to the pilots in the cockpit who were oblivious to the mayhem going on
behind them because they couldn't see it.
2.2.9 Air Ontario Flight 1363 Accident

(a) An Air Ontario flight of a Fokker F28-1000 Fellowship which crashed near
Dryden, Ontario, Canada on 10 March 1989 immediately after take-off. The
aircraft crashed after only 15 seconds because it was not able to achieve
enough altitude to clear the trees beyond the end of the runway due to ice and
snow on the wings, causing the death of 21 of 65 passengers and 3 of 4 crew
members.
(b) The investigation revealed that an unserviceable Auxiliary Power Unit (APU),
and no available external power unit at Dryden Regional Airport, led to
questionable decision-making which were critical factors leading to the crash
of Flight 1363. If the engine had been turned off, they could not be restarted
again due to the unserviceability of the APU and lack of external power.
Therefore, the port engine (#1) was left running during the stopover in
Dryden. Snow was falling gently that afternoon and a layer of 0.6 to 1.3
centimeters of snow had accumulated on the wings. The wings needed to be
de-iced before takeoff, but the Fokker F-28 aircraft is never supposed to be
de-icing while the engines are running due to the risk of toxic fumes getting
into the cabin of the aircraft. The pilot therefore did not request to have the
wings de-iced; at the time airline instructions were unclear on this point but
the subsequent report was very critical of this decision.
(c) Fuel needed to be loaded and was done with the engine running while
passengers were on board (known as a hot refuel). Off-loading and reloading
passengers would have taken considerable time and the longer the aircraft
stayed on the ground the greater was the need for the wings to be sprayed
with de-icing fluid. In order to prevent further delay and greater possibility for
build up on the wings, the pilot decided to have the aircraft fuelled while the
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engine was running and with passengers on board. Although this is a very
dubious procedure, it was not then, and still is not, prohibited by Transport
Canada. Airline instructions were also inconsistent.
(d) The accident investigation showed that competitive pressures caused by

commercial deregulation cut into safety standards and that many of the
industry’s sloppy practices and questionable procedures placed the pilot in a
very difficult situation. The report also stated that the aircraft should not have
been scheduled to refuel at an airport which did not have proper equipment
and that neither training nor manuals had sufficiently warned the pilot of the
dangers of ice on the wings. The investigation blamed Transport Canada for
letting Air Ontario expand into operation of bigger, more complicated aircraft
without detecting the deficiencies of their existing aircraft.
(e) As a result of the crash of Air Ontario Flight 1363, and the resulting
investigation, many significant changes were made to the Canada Aviation
Regulations. These included not only new procedures regarding re-fuelling
and de-icing but also many new regulations intended to improve the general
safety of all future flights in Canada.
2.2.10 Eastern Airlines Aircraft In flight Engine Shutdown
(a) At 0856, on May 5, 1983, Eastern Air Lines, Inc., Flight 855, a Lockheed L-
1011 with 10 crewmembers and 162 passengers on board, departed Miami
International Airport en route to Nassau, Bahamas. About 0915:16, while
descending through 15,000 feet, the low oil pressure light on the No. 2 engine
illuminated. The No. 2 engine was shut down, and the captain decided to
return to Miami to land.
(b) The airplane was cleared to Miami and began a climb to FL 200. While en
route to Miami, the low oil pressure lights for engines Nos. 1 and 3
illuminated. At 0928:20, while at 16,000 feet, the No. 3 engine flamed out. At
0933:20, the No. 1 engine flamed out while the flight crew was attempting to
restart the No. 2 engine.
(c) The airplane descended without power from about 13,000 feet to about 4,000
feet, at which time the No. 2 engine was restarted. The airplane made a one-
engine landing at Miami International Airport at 0946. There were no injuries
to occupants.
(d) The National Transportation Safety Board (NTSB) determines that the
probable cause of the accident was the omission of all the O-ring seals on the
master chip detector assemblies leading to the loss of lubrication and damage
to the airplane's three engines as a result of the failure of mechanics to follow
the established and proper procedures for the installation of master chip
detectors in the engine lubrication system, the repeated failure of supervisory
personnel to require mechanics to comply strictly with the prescribed
installation procedures, and the failure of Eastern Air Lines management to
assess adequately the significance of similar previous occurrences and to act
effectively to institute corrective action.
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(e) Contributing to the cause of the accident was the failure of Federal Aviation
Administration maintenance inspectors to assess the significance of the
incidents involving master chip detectors and to take effective surveillance
and enforcement measures to prevent the recurrence of the incidents
2.3 APPRECIATION of HUMAN FACTORS behind ACCIDENTS and

INCIDETNS
2.3.1 Human Factors leading to accidents/incidents
(a) The accidents/incidents illustrated above instigated questions: "How did these
experienced engineers make these errors?" or "What are the causes of their
mistakes?"
(b) Aircrews and ground crews, specially the engineers involved in maintenances
on aircraft in ALOHA accident in UK were considered by their companies to
be well qualified, competent and reliable employees. Instead of these facts,
they did in that way.
(c) Investigation revealed that, all of the incidents were characterized by the
following:
 There were staff shortages;

 Time pressures existed;
 All the errors occurred at night;
 Shift or task handovers were involved;
 They all involved supervisors doing long hands-on tasks;
 There was an element of a "can-do " attitude;
 Interruptions occurred;
 There was some failure to use approved data or company procedures;
 Manuals were confusing;
 There was inadequate pre-planning, equipment or spares.
2.3.2 Appreciation of Human Factors Course:
(a) Accidents/incidents also raise the questions: "What could be done not to
commit such mistakes?"
(b) Cockpit Resource Management (CRM): Investigators, United Airline staff

and other professional, pilots, after accident in PORTLAND OREGON were
understandably appalled that some of their own could make such a basic
error. Further, United Airlines was getting some fairly negative press at this
stage and to their credit, decided to do something about it. The airline
analyzed the problem areas that had been contributing factors to the accident
and created what became known as a "Cockpit Resource Management
Workshop" which they required all of their flight crew to attend. This was an
innovative requirement but immediately yielded positive results to the extent
that a range of other airlines instigated their own programs very soon
afterwards. As time went on, it is fair to say that insurance companies began
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to take the prerogative and actually required airlines to undertake CRM

training before their insurance would be validated. To United Airlines' credit,
they shared their experiences and results with the aviation safety community
which enabled a much quicker dissemination of safety initiatives than would
be the case if those courses were kept or held in confidence. The first CRM
workshops concentrated on communication issues as these were seen to be
the primary causal factors in some of the better known aircraft accidents.
Assertiveness training for first officers was generally included as an element
of the course within the context of the authority gradient across the cockpit.
Some CRM facilitators could see the benefits of including further subject
matter in these workshops and over time, many of the subjects that we
classify today as Human Factors were included in the workshops. Subjects
such as stress management, fatigue management, leadership and teamwork
were common in CRM courses though there was no specific formulae and
airlines included the material that they, or their advisors, felt most appropriate.
(c) Crew Resource Management: The British Midlands 737-400 accident at

Kegworth also became a key event in the development of Human Factors in
aviation. This accident and others led directly to the inclusion of cabin crew in
CRM courses and a change in the emphasis from cockpit to crew. This is still
the case with most airlines today and indeed, in some organizations, it has
been extended to Corporate Resource Management or Company Resource
Management to take account of all of those contributing personnel outside the
flight crew.
(d) Human Factors for maintenance crew: The engineers came to prominence
in Human Factor terms with the unusual incident involving Aloha Airlines
Flight 243 on April 28th, 1988.
(e) CCC + HPIM + MRM: Continental Airlines first came up with the term "Crew
Coordination Concept" (CCC) to include engineers in their Crew Resource
Management workshops. An Air Ontario accident at Dryden in Ontario led to a
specific course called "Human Performance in Maintenance” (HPIM) and the
current evolution of these programs has become “Maintenance Resource
Management" (MRM) which is organization specific rather than generic. It has
the added advantage of just targeting those issues that relate to maintenance
engineers rather than flight crew and cabin crew as well.
2.3.3 THE HUMAN FACTORS ELEMENTS THAT CAN BE EVIDENT WHEN

CARRYING OUT SPECIFIC AIRCRAFT MAINTENANCE TASKS SUCH AS
INSPECTION OF AGING AIRCRAFT AND OTHER REPETITIVE AND
BORING ACTIVITIES.
(a) The HPIM initiative following the Air Ontario accident led to maintenance
engineering focus groups identifying what has been termed 'the Dirty Dozen"
of maintenance engineering. These are all human factors. They are:
 Lack of Communication
 Complacency
 Lack of Knowledge
 Distraction
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 Lack of teamwork
 Fatigue
 Lack of Resources
 Pressure
 Lack of Assertiveness
 Stress
 Lack of Awareness
 Norms
(b) With respect to lack of communication, this has been a well established cause
of error in the aviation industry and had been included on CRM courses since
they first began, so it is no surprise to see this as one of the Dirty Dozen. Lack
of communication in this context means not passing on information, either
written or oral, and more particularly, passing on information but not being
sure that it has been understood properly.
(c) Complacency is a real danger for engineers. Following the Aloha Airlines
Incident, the FAA issued an Airworthiness Directive (AD) requiring the close
visual inspection of 1300 rivets on every single Boeing 737. If ever there was
an opportunity for complacency in the inspection business, it was provided by
the FAA in this case.
(d) In terms of lack of knowledge, it is impossible to know all there is to know in

the maintenance engineering business. In the absence of specific knowledge,
it is a human trait to fill in the gaps with "good enough" actions or do nothing,
hiding behind the expression "I didn't know what to do".
(e) Distractions in the engineering business are common. Irrespective of whether

the distraction is you're your home life or just a friend at work interrupting what
you are doing, distractions have been cited on many occasions as the reason
for checks or steps being missed during an engineering process.
(f) Teamwork, or rather the lack of it, has already been cited a number of times
on this course as a major source of error. We are all members of a number of
teams and it is important that we play our role in each team to the best of our
ability.
(g) Fatigue has been recognized as a source of error for a long time but we work
in a 24 hour industry and the demands are high. Education would seem to be
the major countermeasure to this problem at the moment but more on that
later.
(h) Lack of resources is unlikely to be a problem in this organization but there will
be times when you say 'I wish I had just one more person to help us with this
job' or 'where are the spare floodlights when you need them'. It is easy to
improvise but it is also easy to get caught out improvising.
(i) Pressure comes in many and varied forms. Time pressure, for example, will
always be part of the aviation industry and particularly for engineers. An
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aircraft cannot make any money when it is on the ground and the sooner it
can be turned around the better. Peer pressure can see you working late
hours at the expense of your family life and the expectations of your
managers can lead to pressures to work harder or continue your education
outside the normal working day. These can all reduce your attention to detail
when it is most needed - a prime breeding ground for errors.
(j) Lack of assertiveness is generally a result of the hierarchy or rank structure in

an organization. There are both formal and informal versions. The formal ones
are normally part of the company or profession structure while the informal
ones are related to where you perceive yourself amongst your peers and your
organization. There is an inclination for individuals to react according to their
status rather than to their competence or ability. This is a big issue when it
comes to inspection and checking, which are two of the prime roles of
maintenance engineers.
(k) Stress is part and parcel of our everyday lives. Despite urban mythology to
the contrary, we cannot leave stress from our personal lives behind when we
go to work, and simple things such as an argument with your wife or girlfriend
at home in the morning can result in errors at work
(l) Situational awareness is-also a big problem in the aviation industry and we
have a whole chapter at the end of this course devoted specifically to
situational awareness.
(m) Norms are a part of the culture of an organization and each organization has
sets of norms which are positive and those which are negative. The trick is to
enhance the positive and suppress the negative.
2.3.4 SAFETY CHAIN
(a) In all of the examples above, the accident or incident was preventable and
could have been avoided if any one of a number of things had been done
differently. In some cases, a number of Individuals were involved and the
outcome could have been modified if any one of them had reacted or queried
a particular action. In each situation however, the individuals failed to
recognize or react to signs of potential hazards, did not react as expected of
them, or allowed themselves to be diverted from giving their attention to the
task in hand, leaving themselves open to the likelihood of committing an error.
(b) As with many incidents and accidents, all the examples above involved a
series of human factors problems which formed an error chain (see Figure
2.2) 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.
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Figure 2.2: The Error Chain. (Source: Boeing)
(c) 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.
2.3.5 Murphy's Law
(a) 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. It is required to convince individuals or organizations of the need to
look at human factors issues, recognize risks and to implement
improvements, rather than merely to pay “Lip-service” to human factors.
"Murphy's Law" can be regarded as the notion: "If something can go wrong,
it will”
(b) If everyone could be persuaded to acknowledge Murphy's Law, this might

help overcome the "it will never happen to me” belief that many people hold. It
is not true that accidents only happen to people who are irresponsible or
'sloppy'. The incidents and accidents described in this chapter show that
errors can be made by experienced, well-respected individuals and accidents
can occur in organizations previously thought to be "safe".
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Chapter 3
HUMAN PERFORMANCE & LIMITATIONS
3.0 INTRODUCTION
3.1 HUMAN IN THE HF MODEL
3.2 HUMAN PERFORMANCE AS PART OF THE MAINTENANCE

ENGINEERING SYSTEM
3.3 VISION
3.4 HEARING
3.3 LISTENING PROCESS
3.6 INFORMATION PROCESSING
3.7 CLAUSTROPHOBIA, PHYSICAL ACCESS AND FEAR OF HEIGHTS
3.8 PERFORMANCE SHAPING FACTORS
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3.0 INTRODUCTION
(a) A maintenance engineer as a human being is the central part of any

engineering system. In aviation, which is considered to be an ultra-safe
system, the performances, abilities and limitations of individuals in the system
can have a direct bearing on the total safety of the system. In our last module,
we noted that two inspectors missed some cracks in an aging 737 at Aloha
Airliner. That singular event has caused widespread change in the system
because we have now recognized the importance of each and event
individual engineer in the system.
(b) 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, judgment
and decision making.
3.1 HUMAN IN HF MODEL
(a) As discussed in chapter-1, human (Liveware) is at the centre of the model.

Human is generally considered the most critical as well as the most flexible
component in the system. Yet people are subject to considerable variations in
performance and suffer many limitations, most of which are now predictable in
general terms. The other components of the system (indicated in the SHELL
model) must be carefully matched with them if stress in the system and
eventual breakdown is to be avoided. In order to achieve this matching, an
understanding of the characteristics of this central component is essential.
(b) Important characteristics of the Liveware are as follows:
 Physical size and shape: In the design of workplace and equipment, a vital
consideration involves body measurements and movements, which may vary
according to factors such as age, ethnicity and gender. Human Factors inputs
must be provided at an early stage in the design process, and data for these
inputs are available from anthropometry, biomechanics, and kinesiology.
 Physical needs: People's requirements such as for food, water and oxygen
are indicated in human physiology and biology.
 Input characteristics: Humans possess various sensory systems for
collecting information from the world external as well as internal to them,
enabling them to respond to events and carry out the required task. But all
senses may be subjected to degradation for one reason or another, and the
sources of knowledge include psychology and physiology.
 Information processing: Again, these human functions have limitations.
Poor instrument and alerting system design has frequently resulted from a
failure to take into account the capabilities and limitations of human
information processing. Factors such as stress, motivation and short- and
long-term memory are involved. Psychology and cognitive sciences are the
sources of background knowledge
 Output characteristics: Once information is sensed and processed,
decisions are made and messages are sent to muscles to initiate the desired
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response. Responses may involve a physical control movement or the

initiation of some form of communication. Acceptable control forces and
direction of movement have to be known, and biomechanics, physiology and
psychology provide the background knowledge.
 Environmental tolerances: Environmental factors such as temperature,
vibration, pressure, humidity, noise, time of day, amount of light and G-forces
can affect human performance and well-being. Heights, enclosed spaces and
a boring or stressful work environment can influence human behavior and
performance. Background information is available from medicine, psychology,
physiology and biology.
3.2 HUMAN PERFORMANCE AS PART OF THE MAINTENANCE

ENGINEERING SYSTEM
(a) Just as certain mechanical components used in aircraft maintenance

engineering have limitations, engineers themselves have certain capabilities
and limitations that must be considered when looking at the maintenance
engineering 'system'. For instance, rivets used to attach aluminum skin to a
fuselage can withstand forces that act to pull them apart. It is clear that these
rivets will eventually fail if enough force is applied to them. While the precise
range of human capabilities and limitations might not be as well-defined as
the performance range of mechanical or electrical components, the same
principles apply in that human performance is likely to degrade and eventually
'fail' under certain conditions (e.g. stress).
(b) Mechanical components in aircraft can, on occasion, suffer catastrophic

failures. 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 judgment due to lack of skills and
knowledge, etc. In addition, unlike mechanical component, human
performance is also affected by social and emotional factors. Therefore failure
by aircraft maintenance engineers can also be to the detriment of aircraft
safety.
(c) 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.
3.3 VISION
3.3.1 General
Vision might seem to be an unusual human performance to be considering here as it

is almost impossible to become an engineer without satisfactory vision but the fact is
that our normal vision has many more limitations that affect our performance than we
usually realize. In considering this issue, we will identify some advantages of using
appropriate visual discrimination methods for design decisions; we will distinguish
between good and bad visual clues and look at some of the physiology and anatomy
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or the eye that leads to these points.
3.3.2 Visual Discrimination
(a) To consider visual discrimination, we will use displays to provide examples of

the type of discrimination we are concerned with in respect of human
limitations and how different display designs can and should be used for
different purposes in a maintenance engineering context.
(b) In your role as a maintenance engineer, you will be required to interpret a

number of different visual displays. We have designated them here as:
 Check displays.
 Qualitative as in quality displays
 Quantitative as in quantity displays, and
 Labels, instructions and warnings.
(c) Check displays are most common in the engineering business to indicate
whether the machinery they are using is on or off. In principle, these displays
are used so that someone can make a very quick, almost unconscious check
that the condition they are after exists. Traffic lights are a classic example.
You don't need to take time to think that you have to stop if the traffic light is
red, you just stop because it is red. The same is true of operating machinery.
Operators will invariably check that they have power to the machinery through
a status light that will show red for off and green for on or no-light if the power
isn't applied and a steady light if it is.
(d) Quantitative displays measure quantity. If you want to know how much of
something is somewhere then you need a quantitative display. A fuel gauge
tells you how much fuel is in the aircraft, or your car and an air speed indicator
or speedometer tells you how fast you are going and a voltmeter tells you how
much life is left in your battery. Each of these is a quantitative display.
(e) A quantitative display will give you exact information in figures within the limits
of the measuring devices being used. Qualitative displays provide the
opportunity for the reader to see at a glance what is happening. For example,
it is fairly easy to tell from a graphical representation whether things are going
up or going down. You can read the trend information from a qualitative
graph. The value of these displays is once again in minimizing the time it
takes to interpret the information that is being presented. It is also designed to
reduce misinterpretation by presenting intuitive expressions of what needs to
be known.
For example, if your car's petrol gauge is in the red, you probably don't need
to know exactly how much petrol is there, but you do know that you need to
get to the petrol station fairly quickly.
(f) Quite often you will find that qualitative and quantitative displays are
combined. An air speed indicator in an aircraft, for example, has red zones,
orange zones and green zones. While it contains the exact information in
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terms of the aircraft's airspeed, a quick glance can tell the pilot whether it is
safe to rotate the aircraft or extend the flaps, etc.
(g) Labels, instructions and warnings are fairly self-evident. They provide specific
information for a specific case and on most occasions, that information is
additional to what is normally available.
(h) Cautions and warning signs are fairly common around a workshop due to the
potential harm that machinery, fluids or tools can cause individuals who are
not familiar with their use. These days, occupational health and safety
regulations quite often mandate when labels, instructions and warnings need
to be evident, but suffice to say their intention is to prevent mishaps from
occurring in specific situations.
(i) Effective display:
There are a number of standards or norms that most of these types of

displays adhere to common norms include red for stop or danger, green for go
or good, and a red bar across an item to show that it is not wanted or is
prohibited from a particular area.
Some of the considerations for effective displays are as follows:
 Color
 Light/Dark
 Contrast
 Legibility and typography
Color has obvious connotations that we all accept but there are different times
and places when the right color is appropriate. Red, for example, is
considered as the no-go or stop / danger area for displays but it is also the
color of joy and luck in many societies. This means that using the right color
for the right message is extremely important.
The lightness or darkness also has a bearing on how displays are received by
individuals. A light pastel shade does not have the forcefulness or authority of
a bright shining color.
Contrast serves to make signs more noticeable. The classic contrasts are
red/green, blue/yellow and black/white. These are also the combinations of
color blindness found in humans.
Font sizes and types for script also make a significant difference.
3.3.3 Anatomy of the Eye:
(a) In order to understand vision, it is useful first to know a little about the
anatomy of the eye (Figure 3.1). 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
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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 3.1: The Human Eye
(b) The Cornea: The cornea is a clear 'window' at the very front of the eye. The
cornea acts as fixed focusing device. The shape of the cornea bending the
Incoming light rays achieves the focusing. The cornea is responsible for
between 70%and 80 % of the total focusing ability (refraction) of the eye.
(c) The Iris and Pupils: The iris (the colored part of the eye) controls the amount
of light that is allowed to center the eye. It does this by varying the size of the
pupil (the dark area in the centre of the iris). The size of the pupil can be
changed very rapidly to cater for changing light levels. The amount of light can
be adjusted by a factor of 5:1.
(d) The Lens: After passing through the pupil, the light passes through the lens.
Its shape is changed by the muscles (cillary muscles) surrounding it which
results in the final focusing adjustment to place a sharp image onto the retina.
The change of shape of the lens is called accommodation. In order to focus
clearly on a near object, the lens is thickened. To focus on a distant point, the
lens is flattened. The degree of accommodation can be affected by factors
such as fatigue or the ageing process.
When a person is tired accommodation is reduced, resulting in less sharp

vision (sharpness of vision is known as visual acuity).
(e) The Retina:
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(i) The retina is located on the rear wall of the eyeball. It is made up of a
complex layer of nerve cells connected to the optic nerve. Two types of light
sensitive cells are found in the retina. These are rods and cones. The central
area of the retina is known as the fovea and the receptors in this area are all
cones. It is here that the visual image is typically focused. Moving outwards,
the cones become less dense and are progressively replaced by rods, so that
in the periphery of the retina, there are only rods.
Cones function in good light and are capable of detecting fine detail and are color-
sensitive, This means the human eve can distinguish about 1000 different shades of
color.
Rods cannot detect color. They are poor at distinguishing fine detail, but good at
detecting movement in the edge of the visual field (peripheral vision). They are much
more sensitive at lower light levels. As light decreases, the sensing task is passed
from the cones to the rods. This means in poor light levels we see only in black and
white and shades of gray.
(ii) At the point at which the optic nerve joins the back of the eye, a “blind spot”
occurs. This is not evident when viewing things with both eyes (binocular
vision), since it is not possible for the image of an object to fall on the blind
spots of both eyes at the same time. Even when viewing with one eye
(monocular vision), the constant rapid movement of the (saccades) means
that the image will not fall on the blind spot all the time. It is only when viewing
a stimulus that appears very fleetingly (e.g. a light flashing), that the blind spot
may result in something not being seen. In maintenance engineering, task
such as close visual inspection or crack detection should not cause such
problems, as the eye or eyes move across and around the area of interest
(visual scanning).
3.3.4 Factors Affecting Clarity of Sight
(a) The eye is very sensitive in the right conditions (e.g. clear air, good light; etc.),
In fact, the eye has approximately 1.2 million nerve cells leading from the
retinas to the area of the brain responsible for vision, while there are only
about 50,000 from the inner-ears making the eye about 24 times more
sensitive than the ear.
(b) 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.
(c) An individual with acuity of 20/20 vision should be able to see at 20 feet that
which the so-called 'normal ' person is capable of seeing at this range. It may
be expressed in meters as 6/6 vision. The figures 20/40 mean that the
observer can read at 20 feet that a 'normal ' person can read at 40 feet.
(d) Various factors can affect and limit the visual acuity of the eye. These include:
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Physical factors such as:
 physical imperfections in one or both eyes (short sightedness, long

sightedness),
 age.
The influence of injested foreign substances such as:
 drags
 medication,
 alcohol,
 cigarettes.
Environmental factors such as:
 amount of light available;

 clarity of the air (e.g. dust, mist, rain, etc.).
Factors associated with object being viewed such as:
 size and contours of the object,

 contrast of the object with its surroundings,
 relative motion of the object,
 distance of the object from the viewer,
 the angle of the object from the viewer.
(e) Each of these factors will now be examined in some detail.
3.3.5 Physical Factors
(a) Long sight: known as Hypermetropia is caused by a shorter than normal

eyeball which means that the image is formed behind the retina (Figure 3.2).
If the cornea and the lens cannot use their combined focusing ability to
compensate for this, blurred vision will result when looking at close objects.
Figure 3.2: A convex lens will overcome long sightedness by bending light
inwards before it reaches the cornea.
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(b) Short sight, known as Myopia is where the eyeball is longer than normal,
causing the image to be formed in front of the retina (Figure 3.3). If the
accommodation of the lens cannot counteract this then distant objects are
blurred.
(c) Other visual problems include:
 Cataracts: clouding of the lens usually associated with aging;

 Astigmatism: a misshapen cornea causing objects to appear irregularly
shaped;
 Glaucoma: a buildup in pressure of the fluid within the eye which can
cause damage to the optic nerve and even blindness;
 Migraine: severe headaches that can cause visual disturbances
Figure 3.3: A concave lens will overcome short sightedness by bending light
outwards before it overshoots the cornea.
(d) Finally as a person grows older, the lens becomes less flexible meaning that it
is unable to accommodate sufficiently. This is known as presbyopia and is a
form of long sightedness. Consequently, after the age of 40, spectacles may
be required for near vision, especially in poor light conditions. Fatigue can
also temporarily affect accommodation, causing blurred vision for close work.
3.3.6 Foreign Substances
Vision can be adversely affected by the use of certain drugs and medications,
alcohol, and smoking cigarettes. With smoking, carbon monoxide that builds
up in the bloodstream allows less oxygen to be carried in the blood to the
eyes. This is known as hypoxia and can impair rapidly the sensitivity of the
rods. Alcohol can have similar effects, even hours after the last drink.
3.3.7 Environmental Factors
(a) Vision can be improved by increasing the lighting level, but only up to a point,
as the law of diminishing returns operates. Also, increased illumination could
result in increased glare. Older people are more affected by the glare of
reflected light than younger people. Moving from an extremely bright
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environment to a dimmer one has the effect of vision being severely reduced
until the eyes get used to less light being available. This is because the eyes
have become light adapted. If an engineer works in a very dark environment
for a long time, his eyes gradually become dark-adapted allowing better visual
acuity. This can take about 7 minutes for the cones and 30 minutes for the
rods. As a consequence, moving between a bright hanger (or the inside of an
aircraft) to a dark apron area at night can mean that the maintenance
engineer must wait for his eyes to adjust (adapt). In low light conditions, it is
easier to focus if you look slightly to one side of an object. This allows the
image to fall outside the fovea and onto the part of the retina, which has many
rods. In Figure-6 a concave lenses will overcome short sightedness by
bending light outwards before it reaches the cornea.
(b) Any airborne particles such as dust, rain or mist can interfere with the
transmission of light through the air, distorting what is seen. This can be even
worse when spectacles are worn, as they are susceptible to getting dirty, wet,
misted up or scratched. Engineers who wear contact lenses (especially hard
or gas-permeable types) should take into account the advice from their
optician associated with the maximum wear time usually 8 to 12 hours and
consider the effects which extended wear may have on the eyes, such as
drying out and irritation. This is particularly important if they are working in an
environment that is excessively dry or dusty, as airborne particles may also
affect contact lens wear. Goggles should be worn where necessary.
3.3.8 The Nature of the Object Being Viewed
(a) 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. Visual cues
often refer to the comparison of objects of known size to unknown objects. An
example of this is that we associate small objects with being further away.
Similarly, if an object does not stand out well from its background (i.e. it has
poor contrast with its surroundings), it is harder to distinguish its edges and
hence its shape. Movement and relative motion of an object, as well as
distance and angle of the object from the viewer, can all increase visual
demands.
3.3.9 Color Vision
(a) Although not directly affecting visual acuity, inability to see particular colors
can be a problem for the aircraft maintenance engineer. Amongst other
things, good color vision for maintenance engineers is important for:
 Recognizing components;
 Distinguishing between wires;
 Using various diagnostic tools;
 Recognizing various lights on the airfield (e.g. warning lights).
(b) Color defective vision is usually hereditary, although may also occur as a
temporary condition after a serious illness.
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Color-defective vision (normally referred to incorrectly as color blindness) affects

about 8% of men but only 0.5% of women. The most common type is difficulty in
distinguishing between red and green. More rarely, it is possible to confuse blues
and yellows.
(c) There are degrees of color defective vision, some people suffering more than
others. Individuals may be able to distinguish between red and green in a
well-lit situation but not in low light conditions. Color defective people typically
see the colors they have problems with as shades of neutral grey.
(d) Aging also causes changes in color vision. This is a result of progressive
yellowing of the lens, resulting in a reduction in color discrimination in the
blue-yellow range. Color defective vision and its implications can be a
complex area and care should be taken not to stop an engineer from
performing certain tasks merely because he suffers from some degree of
color deficient vision. It may be that the type and degree of color deficiency is
not relevant in their particular job. However, if absolutely accurate color
discrimination is critical for a job, it is important that appropriate testing and
screening be put in place.
3.3.10 Vision and the Aircraft Maintenance Engineer
(a) It is important for an engineer, particularly one who is involved in inspection

tasks, to have adequate vision to meet the task requirements. As discussed
previously, age and problems developing in the eye itself can gradually affect
vision. Without regular vision testing, aircraft maintenance engineers may not
notice that their vision is deteriorating.
(b) In the UK, the CAA has produced guidance which states:
"A reasonable standard of eyesight is needed for any aircraft engineer to

perform his duties to an acceptable degree. Many maintenance tasks require
a combination of both distance and near vision. In particular, such
consideration must be made where there is a need for the close visual
inspection of structures or work related to small or miniature components. The
use of glasses or contact lenses to correct any vision problems is perfectly
acceptable and indeed they must be worn as prescribed. Frequent checks
should be made to ensure the continued adequacy of any glasses or contact
lenses. In addition, color discrimination may be necessary for an individual to
drive in areas where aircraft maneuver or where color coding is used, e.g.in
aircraft wiring. Organizations should identify any specific eyesight requirement
and put in place suitable procedures to address these issues."
(c) Often, airline companies or airports will set the eyesight standards for reasons
other than aircraft maintenance safety, e.g. for insurance purposes, or for
driving on the airfield.
(d) Ultimately, what is important is for the individual to recognize when his vision
is adversely affected, either temporarily or permanently and to consider
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carefully the possible consequences should they continue to work if the task
requires good vision.
3.4 Hearing
3.4.1 General
(a) Hearing or auditory system is one of the most important systems of a human.
(b) The ear performs two quite different functions. It is used to detect sounds by
receiving vibrations in the air, and secondly, it is responsible for balance and
sensing acceleration of these two, the hearing aspect is more pertinent to the
maintenance engineer, and thus it is necessary to have a basic appreciation
of how the ear works,
(c) Like the visual system, auditory system may suffer a wide range of limitations.
3.4.2 The anatomy of the Ear
(a) As can be seen in Figure 3.4, 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 recognize as sounds.
(b) Outer Ear: The outer part of the ear directs sounds down the auditory canal,
and on to the eardrum .The sound waves will cause the eardrum to vibrate.
(c) Middle Ear: Beyond the eardrum is the middle ear which transmits vibrations
from the eardrum by way of three small bones known as the ossicles, to the
fluid of the inner ear. The middle ear also contains two muscles which help to
protect the ear from sounds above 80 dB by means of the acoustic or aural
reflex, reducing the noise level by up to 20 dB. However, this protection can
only be provided for a maximum of about 15 minutes, and does not provide
protection against sudden impulse noise such as gunfire. It does explain why
a person is temporarily deafened for a few seconds after a sudden loud noise.
The middle ear is usually filled with air which is refreshed by way of the
Eustachian tube which connects this part of the ear with the back of the nose
and mouth. However this tube can allow mucus to travel to the middle ear
which can build up, interfering with normal hearing.
(d) Inner Ear: Unlike the middle ear, the inner ear is filled with fluid. The last of
the ossicles in the middle ear is connected to the cochlea .This contains a fine
membrane (the basilar Membrane) covered in hair-like cells which are
sensitive to movement in the fluid. Any vibrations they detect cause neural
impulses to be transmitted to the brain via the auditory nerve.
The amount of vibration detected in the cochlea depends on the volume and pitch of
the original sound.
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Figure 3.4: The human ear
3.4.3 Performance and Limitations of the Ear
(a) 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,
(b) Volume (or intensity) of sound is measured in decibels (dB). Table 3.1 shows
intensity levels for various sounds and activities.
3.4.4 Impact of Noise on Performance
(a) 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).
Activity Approximate Intencity

level in Decibels (dB)
Rustling of leaves/ whisper 20
Conversation at 2m 50
Typewriter at 1m 65
Car at 15m 70
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Lorry at 15m 75
Power Mower at 2m 90
Propeller aircraft at 300m 100
Jet aircraft at 300m 110
Standing near a propeller aircraft 120
Threshold pain 140
Immediate hearing damage results 150
Table 3,1: Typical sound levels for various activities
(b) Intermittent and sudden noises 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. This subject is discussed further in Chapter 5.
3.4.5 Hearing impairment
(a) 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.
(b) The UK “Noise at Work” regulations-1 (1989) imposes requirements upon

employers. They stipulate three levels of noise at which an employer must
act:
(i) 85 decibels (if normal speech cannot be heard clearly at 2 meters),

employer must;
 assess the risk to employees' hearing,
 tell the employees about the risks and what precautions are proposed,
provide their employees with personal ear protectors and explain their use.
(ii) 90 decibels (if normal speech cannot be heard clearly at 1 meter) employer
must:
 do all that is possible to reduce exposure to the noise by means other than
by providing hearing protection,
 mark zones where noise reaches the second level and provide recognized
signs to restrict entry.
(iii) 140 decibels (noise causes pain).
(c) The combination of duration and intensity of noise can be described as noise
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dose. Exposure to any sound over 80 dB constitutes a noise dose, and can be
measured over the day as an 8 hour Time Weighted Average sound level
(TWA).
For example, a person subjected to 95 decibels for 3.5 hours, then 105 decibels for
0.5 hours, then 85 decibels for 4 hours, results in a TWA of 93.5 which exceeds the
recommended maximum TWA of 90 decibels.
(d) Permanent hearing loss may occur if the TWA is above the recommended
maximum.
It is normally accepted that a TWA noise level exceeding 85 dB for 8 hours is

hazardous and potentially damaging to the inner ear. Exposure to noise in excess of
115 decibels without ear protection, even for a short duration, is not recommended.
3.4.6 Hearing Protection
(a) Hearing protection is available, to a certain extent, by using ear plugs or ear
defenders.
Noise levels can be reduced (attenuated) by up to 20 decibels using ear plugs and
40 decibels using ear muff. However, using ear protection will tend to adversely
interfere with verbal communication. Despite this, it must be used consistently and
as instructed to be effective.
(b) It is good practice to reduce noise levels at source, or move noise away from
workers. Often this is not a practical option in the aviation maintenance
environment. Hearing protection should always be used for noise, of any
duration, above 115 dB. Referring again to Table-1, this means that the
aviation maintenance engineer will almost always need to use some form of
hearing protection when in reasonably close proximity (about 200 - 300m) to
aircraft whose engines are running.
3.4.7 Presbycusis
Hearing deteriorates naturally as one grows older. This is known as presbycusis.

This affects ability to hear high pitch sounds first, and may occur gradually from the
30's onwards. When this natural decline is exacerbated by Noise Induced Hearing
Loss, it can obviously occur rather sooner.
3.4.8 Hearing and the Aircraft Maintenance Engineer
(a) The UK CAA makes the following recommendations regarding hearing:
"The ability to hear an average conversational voice in a quiet room at a

distance of 2 meters (6 feet) from the examiner is recommended as a routine
test. Failure of this test would require an audiogram to be carried out to
provide an objective assessment. If necessary, a hearing aid may be worn but
consideration should be given to the practicalities of wearing the aid during
routine tasks demanded of the individual."
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(b) it is very important that the aircraft maintenance engineer understands the
limited ability of the ears to protect themselves from damage due to excessive
noise. Even though engineers should be given appropriate hearing protection
and trained in its use, it is up to individuals to ensure that they actually put this
to good use. It is a misconception that the ears get used to constant noise: if
this noise is too loud, it will damage the ears gradually and insidiously. Noise
in the workplace is discussed further in Chapter 5.
3.5 LISTENING PROCESS
3.5.1 General
(a) Hearing is a passive process which theoretical just involves the mechanics of
the sensation caused by noise in the vicinity of the human ear. Listening, on
the other hand, requires the full information processing activity that we will
describe later in this module to take place. We have to attend to what is heard
by the senses and place it into the short term or working memory for
consideration.
(b) Listening involves selecting, attending, understanding and responding:
(i) Selecting: we select what we want to listen to from all the sounds around
us.
(ii) Attending: we must pay attention to the sound.
(iii) Understanding: this is the process of assigning meaning to the sound.
(iv) Responding: a response may be remembering what you have heard or it
may be taking action.
3.5.2 Active Listening Process
(a) In order for you to listen properly you must engage in what we call active
listening.
(b) For active listening, it is needed for an individual to:
 Get prepared by thinking about the topic being discussed;

 Stay involved by focusing in what the speaker is saying not on what you want
to say;
 Keep an open mind about the subject and in particular be willing to accept
alternative views to your own;
 Review and evaluate by putting the information into different words that
provide the same meaning; and,
 Give feedback though appropriate responses.
(c) There are many barriers to active listening. For example:
-Too much information

- Listening shouldn’t be a passive activity
- Boring subject;
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- Concentrating on your own views;

- Being easily distracted by other influences;
- Criticizing the delivery rather than the content.
(d) In summary,
- Listening shouldn't be a passive activity

- Restate or paraphrase what the other person is saying
- Provides clarification and assists accuracy
- Focus on verbal and non-verbal feedback
- Factors such as body position or posture, tone of voice, and physical
appearance can be quite revealing.
3.6 INFORMATION PROCESSING
3.6.1 General
(a) The previous sections have described the basic functions and limitations of
two of the senses used by aircraft maintenance engineers in the course of
their work. 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,
(b) As people interact with their environment, senses are used in acquiring
information that are subsequently processed and applied.
(c) We have five senses. Some people claim a sixth sense which is intuition and
there is no doubt many people have some intuition.
(d) The five senses are:
 Sight: through the visual system using our eyes as the primary sensor.
 Hearing: through the auditory system using our ears.
 Touch: feel through the skin are said to use the integument.
 Taste: is sensed via the gustatory system using the tongue as the primary
source of sense.
 Smell: is through our noses using the olfactory system.
3.6.2 An Information Processing Model
(a) 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 3.5.
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Figure 3.5: A functional model of human information processing
3.6.3 Sensor 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.
3.6.4 Attention and Perception
(a) Having detected information, our mental resources are concentrated on

specific elements -this is attention.
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Attention can be thought of as the concentration of mental effort on sensory or

mental events.
(b) Although attention can move very quickly from one item to another, it can only
deal with one item at a time. Attention can take the form of:
 Selective attention,
 Divided attention
 Focused attention
 Sustained attention.
(c) Selective attention occurs when a person is monitoring several sources of

input, with greater attention being given to one or more sources which appear
more important. A person can be consciously attending to one source whilst
still sampling other sources in the background. Psychologists refer to this as
the “cocktail party” effect: whereby you can be engrossed in a conversation
with one person but your attention is temporarily diverted if you overhear your
name being mentioned at the other side of the room, even though you were
not aware of listening in to other people's conversations. Distraction is the
negative side of selective attention.
(d) Divided attention is common in most work situations, where people are
required to do more than one thing at the same time. Usually, one task suffers
at the expense of the other, more so if they are similar in nature. This type of
situation is also sometimes referred to as time sharing.
(e) Focused attention is merely the skill of focusing one's attention upon a single
source and avoiding distraction.
(f) Sustained attention as its name implies, refers to the ability to maintain
attention and remain alert over long periods of time, often on one task. Most
of the research has been carried out in connection with monitoring radar
displays, but there is also associated research which has concentrated upon
inspection tasks.
(g) Attention is influenced by arousal level and stress. This can improve attention
or damage it depending on the circumstances. This is covered in more detail
In Chapter 5.
(h) Perception involves the organization and interpretation of sensory data in

order to make it meaningful, discarding non-relevant data, i.e. transforming
data into information. Perception is a highly sophisticated mechanism and
requires existing knowledge and experience to know what data to keep and
what to discard, and how to associate the data in a meaningful manner.
Perception can be defined as the process of assembling sensations into a useable

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

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 the image formed on the retina is inverted and two dimensional, yet we see the
world the right way up and in three dimensions.
 If the head is turned, the eyes detect a constantly changing pattern of images, yet
we perceive things around us to have a set location, rather than move chaotically.
3.6.5 Decision Making
(a) Having recognized coherent information from the stimuli reaching our senses,
a course of action has to be decided upon. In other words decision making
occurs.
Decision making is the generation of alternative courses of action based an available

information, knowledge, prior experience, expectation, context, goals, etc and
selecting one preferred option. It is also described as thinking, problem solving and
judgment.
(b) This may range from deciding to do nothing, to deciding to act immediately in
a very specific manner. A fire alarm bell, for instance, may trigger a well-
trained sequence of actions without further thought (i.e. evacuate);
alternatively, an unfamiliar siren may require further information to be
gathered before an appropriate course of action can be initiated.
(c) We are not usually fully aware of the processes and information which we use
to make a decision. Tools can be used to assist the process of making a
decision. For instance, in aircraft maintenance engineering, many documents
(e.g. maintenance manuals, fault diagnosis manuals), and procedures are
available to supplement the basic decision making skills of the individual.
Thus, good decisions are based on knowledge supplemented by written
information and procedures, analysis of observed symptoms, performance
indications, etc. It can be dangerous to believe that existing knowledge and
prior experience will always be sufficient in every situation as will be shown in
the section entitled 'Information Processing Limitations.
(d) Finally, once a decision has been made, an appropriate action can be carried
out. Our senses receive feedback of this and its result. This helps to improve
knowledge and refine future judgment by learning from experience.
3.6.6 Memory
(a) Memory is critical to our ability to act consistently and to learn new things.
Without memory, we could not capture a 'stream ' of information reaching our
senses, or draw on past experience and apply this knowledge when making
decisions.
Memory can be considered to be the storage and retention of information,

experiences and knowledge, as well as the ability to retrieve this information.
(b) Memory depends on three processes:

 Registration: the input of information into memory;
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 storage : the retention of information;

 retrieval: the recovery of stored information.
(c) It is possible to distinguish between three forms of memory:
 ultra short-term memory (or sensory storage);

 short term memory (often referred to as working memory)
 long term memory.
(d) Ultra short-term memory has already been described when examining the
role of sensory stores. It has duration of up to 2 seconds (depending on the
sense) and is used as a buffer, giving us time to attend to sensory input.
(e) 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. As the following
example shows, capacity of short term memory can be enhanced by splitting
information in to 'chunks ' (a group of related items).
A telephone number, e.g. 01222555234, can be stored as 11 discrete digits, in which

case it is unlikely to be remembered. Alliteratively, it can be stored in chunks of
related information, e.g.in the UK, 01222 may be stored as one chunk, 555 as
another, and 234 as another, using only 3 chunks and therefore, more likely to be
remembered. In mainland Europe, the same telephone number would probably be
stored as 01 22 25 55 23 4, using 6 chunks, The size of the chunk will be determined
by the individual's familiarity with the information (based on prior experience and
context), thus in this example, a person from the UK might recognize 0208 as the
code for London, but a person from mainland Europe might not.
(f) The duration of short term memory can be extended through rehearsal
(mental repetition of the information) or encoding the information in some
meaningful manner (e.g. associating it with something as in the example
above).
(g) 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 programs, problem solving skills and plans for achieving various
activities;
 abilities, such as language comprehension.
(h) Information in long-term memory can be divided into two types: (i) semantic
and (ii) episodic.
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(i) Semantic memory refers to our store of general, factual knowledge about
the world, such as concepts, rules, one’s own language, etc. It is
information that is not tied to where and when the knowledge was
originally acquired.
(ii) Episodic memory refers to memory of specific events, such as our past
experiences (including people, events and objects). We can usually place
these things within a certain context. It is believed that episodic memory is
heavily influenced by a person's expectations of what should have
happened, thus two people's recollection of the same event can differ.
3.6.7 Motor Programs
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 programs and are ingrained routines that have been established through
practice. The use of a motor program reduces the load on the central decision
maker. An often quoted example is that of driving a car: at first, each individual
action such as gear changing is demanding, but eventually the separate actions are
combined into a motor program and can be performed with little or no awareness.
These motor programs allow us to carry out simultaneous activities, such as having
a conversation whilst driving.
3.6.8 Situation Awareness
(a) Although not shown explicitly in Figure 8, the process of attention, perception
and judgment should result in awareness of the current situation.
Situation awareness is the synthesis of an accurate and up-to-date mental model of

one’s environment and state, and the ability to use this to make predictions of
possible future states.
(b) Situation awareness has traditionally been used in the context of the flight
deck to describe the pilot 's awareness of what is going on around him, e.g.
where he is geographically, his orientation in space, what mode the aircraft is
in, etc. In the maintenance engineering context, it refers to:
 the perception of important elements, e.g. seeing loose bolts or missing
parts, hearing information passed verbally; .
 the comprehension of their meaning, e.g. why is it like this? Is this how it
should be?
 the projection of their status into the future, e.g. future effects on safety,
schedule, airworthiness.
An example an engineer seeing (or perceiving) blue streaks on the fuselage. His
comprehension may be that the lavatory fill cap could be missing or the drain line
leaking. If his situation awareness is good, he may appreciate that such a leak could
allow blue water to freeze, leading to airframe or engine damage.
(c) As with decision making, feedback improves situation awareness by informing

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us of the accuracy of our mental models and their predictive power. The ability
to project system status backward, to determine what events may have led to
an observed system state, is also very important in aircraft maintenance
engineering, as it allows effective fault finding and diagnostic behavior.
Situation awareness for the aircraft maintenance engineer can be
summarized as:
 the status of the system the engineer is working on;

 the relationship between the reported defect and the intended rectification;
 the possible effect on this work on other systems;
 the effect of this work on that being done by others and the effect of their
work on this work.
This suggests that in aircraft maintenance engineering, the entire team needs to
have situation awareness: not just of what they are doing individually, but of their
colleagues’ activities as well.
3.6.9 Information Processing Limitations
(a) The basic elements of human information processing have now been
explored. It is important to appreciate that these elements have limitations. As
a consequence, the aircraft engineer, like other skilled professionals, requires
support such as reference to written material (e.g. manuals).
(b) Attention and Perception:
(i) A proportion of 'sensed' data may be lost without being 'perceived'. An

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

which will confirm this model and, not consciously, reject Information which suggests
that this model is incorrect.
(ii) There are many well-known visual 'illusions' which illustrate the limits of
human perception. Figure 3.6 shows how the perceptual system can be
misled into believing that one line is longer than the other, even though a ruler
will confirm that they are exactly the same.
Figure 3.6: The Muller-Lyer Illusion
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(iii) Figure 3.7 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.
Figure 3.7: The importance of context.
(iv) 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 3.8.
Figure 3.8: The effects of expectation
(v) At first, most people tend to notice nothing wrong with the sentence. Our
perceptual system sub-consciously rejects the additional "THE ".
As an illustration of how expectation, can affect our judgment, the same video of a
car accident was shown to two groups of subjects. One group were told that in
advance that they were to be shown a video of a car crash; the other told that the car
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had been involved in a “bump”. Both groups were asked to judge the speed at which
the vehicles had collided. The first group assessed the speed as significantly higher
than the second group.
(vi) 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.
3.6.10 Decision Making, Memory Motor Programs
(a) Attention and perception shortcomings can clearly impinge on decision

making. Perceiving something incorrectly may mean that an incorrect decision
is made, resulting in an inappropriate action. Figure-8 also shows the
dependence on memory to make decisions. It was explained earlier that
sensory and short-term memory has limited capacity, both in terms of capacity
and duration. It is also important to bear in mind that human memory is
fallible, so that information:
 may not be stored;

 may be stored incorrectly;
 may be difficult to retrieve.
(b) 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).
Information in short-term memory is particularly susceptible to interference, an
example of which would be trying to remember a part number trying to recall
a telephone number.
(c) 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. For instance, an aircraft
maintenance engineer may think that he will remember a torque setting
without writing it down, but between consulting the manual and walking to the
aircraft (possibly stopping to talk to someone on the way), he may forget the
setting or confuse it (possibly with a different torque setting appropriate to a
similar task with which he is more familiar). Additionally, if unsure of the
accuracy of memorized information, an aircraft maintenance engineer should
seek to check it, even if this means going elsewhere to do so. Noting
something down temporarily can avoid the risk of forgetting or confusing
information. However, the use of a personal note book to capture such
information on a permanent basis can be dangerous, as the information in it
may become out-of-date.
In the Boeing-737 double engine oil loss incident, the AAIB report stated:
"Once the Controller and fitter had got to their task and found that this supportive
material [Task Cards and AMM extracts] was not available in the workpack, they
would have had to return to Base Engineering or to have gone over to the Line
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Maintenance office to get it. It would be, in some measure understandable for them
to have a reluctance to re-cross the exposed apron area on a winter’s night to obtain
a description of what they were fairly confident they knew anyway. However, during
the course of the night, both of them had occasion to return to the Base Maintenance
hangar a number of times before the task had been complete. Either could,
therefore, have referred to or even drawn the task descriptive papers before the job
was signed off. The question that should be addressed, therefore, is whether there
might be any factors other than overconfidence in their memories, bad judgment or
idleness which would dispose them to pass up these opportunities to refresh their
memories on the proper and complete procedures.
3.7 CLAUSTROPHOBIA, PHYSICAL ACCESS AND FEAR OF HEIGHTS
3.7.1 General
Although not peculiar to aircraft maintenance engineering, working in restricted

space and at heights is a feature of this trade. Problems associated with physical
access are not uncommon. Maintenance engineers and technicians often have to.
access, and work in, very small spaces (e.g.in fuel tanks), cramped conditions (such
as beneath flight instrument panels, around rudder pedals), elevated locations (on
cherry-pickers or staging), sometimes in uncomfortable climatic or environmental
conditions (heat, cold, wind, rain, noise).This can be aggravated by aspects such as
poor lighting or having to wear breathing apparatus. The physical environments
associated with these problems are examined further in Chapter 5.
3.7.2 Physical Access and Claustrophobia
(a) There are many circumstances where people may experience various levels
of physical or psychological discomfort when in an enclosed or small space,
which is generally considered to be quite normal. When this discomfort
becomes extreme, it is known as claustrophobia.
Claustrophobia can be defined as abnormal fear of being in an enclosed space.
(b) It is quite possible that susceptibility to claustrophobia is not apparent at the

start of employment. It may come about for the first time because of an
incident when working within a confined space, e.g. panic if unable to
extricate oneself from a fuel tank. If an engineer suffers an attack of
claustrophobia, they should make their colleagues and supervisors aware so
that if tasks likely to generate claustrophobia cannot be avoided, at least
colleagues may be able to assist in extricating the engineer from the confined
space quickly, and sympathetically. Engineers should work in a team and
assist one another if necessary, making allowances for the fact that people
come in all shapes and sizes and that it may be easier for one person to
access a space, than another. However, this should not be used as an excuse
for an engineer who has put on weight, to excuse himself from jobs which he
would previously have been able to do with greater ease!
3.7.3 Fear of Heights
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(a) Working at significant heights can also be a problem for some aircraft
maintenance engineers, especially when doing 'crown' inspections (top of
fuselage, etc.). Some engineers may be quite at ease in situations like these
whereas others may be so uncomfortable that they are far more concerned
about the height, and holding on to the access equipment, than they are about
the job in hand. In such situations, it is very important that appropriate use is
made of harnesses and safety ropes. These will not necessarily remove the
fear of heights, but will certainly help to reassure the engineer and allow him
to concentrate on the task in hand. The FAA's hiskyway website provides
practical guidance to access equipment when working at height. Ultimately, if
an engineer finds working high up brings on phobic symptoms (such as
severe anxiety and panic), they should avoid such situations for safety's sake.
However, as with claustrophobia, support from team members can be helpful.
Shortly before the Aloha accident, during maintenance, the inspector needed ropes
attached to the rafters of the hangar to prevent falling from the aircraft when it was
necessary to inspect rivet lines on top of the fuselage, Although unavoidable, this
would not have been conducive to ensuring that the inspection was carried out
meticulously (nor was it, as the subsequent accident investigation revealed). The
NTSB investigation report stated.
“Inspection of the rivets required inspectors to climb on scaffolding and move along
the upper fuselage carrying a bright light with them; in the case of an eddy current
inspection, the inspectors needed probe, a meter, and a light. At times, the inspector
needed ropes attached to the rafters of the hangar to prevent falling from the
airplane when it was necessary to inspect rivet lines on top of the fuselage. Even if
the temperatures were comfortable and the lighting was good, the task of examining
the area around one rivet after another for signs of minute cracks while standing on
scaffolding or on top of the fuselage is very tedious. After examining more and more
rivets and finding no cracks, it is natural to begin to expect that cracks will not be
found.”
(b) Managers and supervisors should attempt to make the job as comfortable and
secure as reasonable possible (e.g. providing knee pad rests, ensuring that
staging does not wobble, providing ventilation in enclosed spaces, etc.) and
allow for frequent breaks if practicable.
3.8 PERFORMANCE SHAPING FACTORS
3.8.1 General
In this section, we will attempt to indentify and describe the internal and external
factors that have an impact on shaping the performance of aircraft maintenance
engineers. The split between internal and external Performance Shaping Factors
(FSFs) is a deliberate one to explain that there are some aspects of performance
shaping factors that we actually can’t control ourselves. This does not mean that we
have to be any less aware of them, because it is that awareness that allows us to
take account of those issues and put further safety barriers in place to trap any
errors that may occur.
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3.8.2 Internal and External PSFs
(a) We will also take this internal/ external split a step further and consider both
positive and negative performance shaping factors. The reason for this is to
attempt to make the point that performance can actually be enhanced if the
PSFs are positive even though we spend more time concentrating on the
negative aspects because it is the errors that are generated by the negative
aspects that we are trying to manage.
(b) Internal PSFs relate to the individual. The can be physiological, as in having
some physical bearing on you as an individual, or psychological, as in
affecting the way you think or feel, or indeed they could be social elements
that have a more widespread effect on your life. Specifically, they relate to a
particular individual and no two individuals will have exactly the same PSFs
though they may share some similarities. For example, co-workers may be
expecting to attend a wedding party that evening and are quite excited about
the prospect. This is likely to affect the work of both of them though not
necessarily in the same way. One might be quite distracted as he or she goes
about their work, while the other might be hurrying through their work in order
to finish early.
(c) External PSF's, on the other hand, are outside of the control of the individual.
The work environment (as in work space) and organizational factors can have
a large bearing on the performance of individuals. A simple example would be
the quality and power of the computers that employees are issued with to
conduct their work.
(d) It is also important to recognize that PSF's can be both positive and negative
though we mostly consider just their negative context, if we are trying to
prevent errors.
3.8.3 Positive and Negative Internal PSFs
(a) Some positive internal PSF's could include the motivation that an individual
gets from his or her superiors and peers, the friendships that they have in the
workplace, and in many respects, how well they feel they are trained to do the
job. Most people are happier doing a job that they know how to do well rather
than one in which they are a bit worried they might get into trouble over if they
don't get it right.
(b) Negative internal performance shaping factors are those which have a
negative effect on being able to perform properly. For example, if you have
had an argument with your wife or girlfriend it is likely to be causing you some
stress and distracting you from doing the job properly. If you don't get on with
your co-workers, so well it can become a chore to come to work each day and
even harder to be effective and performing at your best.
(c) Of course the opposite of being competent at your job becomes a negative
PSF. If you are always worried about whether you are doing things right or
whether or not you are going to get into trouble because you are not much
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good at a certain task then that will also negatively affect your work.
3.8.4 Positive and Negative External PSFs
(a) There are also positive and negative external PSFs, Positive external PSFs
make it easy to do your job properly. A well appointed, clean and well laid out
workshop is likely to get better performance out of the workers than one which
is unkempt. The quality of the tools and machinery that engineers are
expected to use makes a difference and an interested management can make
a significant difference to the workplace performance of individuals.
(b) On the negative side, having to work in conditions that are too hot or too cold
for long periods, and having to perform with unsatisfactory training and
equipment will definitely affect performance but not in the way management
would prefer. This is a prime breeding ground for errors and it is important that
you are able to recognize them so that something can be done about them.
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Chapter 4
SOCIAL PSYCHOLOGY
4.1 INTRODUCTION
4.2 THE SOCIAL ENVIRONMENT
4.3 RESPONSIBILITY: INDIVIDUAL AND GROUP
4.4 MOTIVATION AND DE MOTIVATION
4.5 PEER PRESSURE
4.6 CULTURE ISSUES
4.7 TEAM WORKING
4.8 MANAGEMENT, SUPERVISION AND LEADERSHIP
4.9 MAINTENANCE RESOURCE MANAGEMENT (MRM)
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4.0 INTRODUCTION
(a) This chapter will cover a range of topics associated with the workplace and
draw together issues relating to the social context in which the aircraft
maintenance engineer works.
(b) The outstanding issues include:
• Social Environment of the Organization

• Individual and Group Responsibilities
• Motivation
• Peer Pressures
• Cultural Issues
• Aspects of team working, supervision and leadership
(c) The emphasis will be on how performance is affected by each of these things,
and most particularly the causal part that these issues play in maintenance
engineering errors.
(d) With respect to the individual and group responsibility we will attempt to
describe what is meant by a "troubled employee" and factors or symptoms
that may identify such a person; describe factors that may be found in an
effective employee assistance program operating in a maintenance
organization.
(e) In motivation, we will discuss some of the factors that contribute to motivation
and demotivation and some of the elements of personnel demotivation.
(f) Peer pressure will describe how conflict may arise in an organization, its
effects on morale and how it may be effectively managed.
(g) Culture is a very complicated subject and only a few aspects will be
considered here. Specifically, it will describe what is meant by sexual
harassment, its effects on employees and how it should be dealt with should it
arise in the workplace. A description of what is meant by stereotypes and
stereotypical behavior will also be provided, where such behavior may have a
negative impact on safety.
(h) In the section on teamwork, we will identify factors, good and bad, that affect
team performance, describe how effective teams or team working can reduce
maintenance errors and describe principles of effective team dynamics within
an organization and how operation of an effective team may be identified.
(i) As with the culture issues, we will not attempt to cover all the aspects of
Management, Supervision and Leadership.
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4.1 THE SOCIAL ENVIRONMENT
(a) Aircraft maintenance engineers work within a “System". There are various
factors within this system that impinge on the aircraft maintenance engineer,
ranging from his knowledge, skills and abilities (discussed in the previous
chapter), the environment in which he works (dealt with in Chapter 5), to the
culture of the organization for which he works. Even beyond the actual
company he works for the regulatory requirements laid down for his trade
clearly impact on his behavior. All aspects of this system may contribute
towards errors that the engineer might make.
(b) The vast majority of aircraft maintenance engineers work for a company,
either directly, or as contract staff. It is important to understand how the
organization in which the engineer works might influence him. Every
organization or company employing aircraft maintenance engineers will have
different "ways of doing things". This is called the organizational culture.
They will have their own company philosophy, policies, procedures, selection
and training criteria and quality assurance methods. Culture will be discussed
further in a separate section in this chapter.
(c) The impact of the organization may be positive or negative. Organizations

may encourage their employees (both financially and with career incentives),
and take notice of problems that their engineers encounter, attempting to
learn from these and make changes where necessary or possible. On the
negative side, the organization may exert pressure on its engineers to get
work done within certain timescales and within certain budgets. At times,
individuals may feel that these conflict with their ability to sustain the quality of
their work. These organizational 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.
4.2 RESPONSIBILITY: INDIVIDUAL AND GROUP
4.2.1 General:
(a) An aircraft maintenance engineer is a responsible person by the nature of the

job. Clearly, the engineer plays a part in the safe and efficient passage of the
travelling public when they use aircraft. [If someone is considered responsible,
he is liable to be called to account as being in charge or control of, or
answerable for something].
(b) Within aircraft maintenance, responsibility should be spread across all those
who play a part in the activity. This ranges from the accountable manager who
formulates policy, through management that set procedures, to supervisors,
teams of engineers and individuals within those teams. Flight crews also play
a part, as they are responsible for carrying out preflight checks and walk-
around and highlighting aircraft faults to maintenance personnel.
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Figure-1 The maintenance System. Source: Boeing, adapted by Baines, 2001
4.2.2 Working as an Individual or as a Group
(a) Traditionally, in the maintenance engineering environment, responsibility has

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

teams in the workplace. These may be shift teams, or smaller groups within a
shift. A team may be made up of various engineering trades, or be structured
around aircraft types or place of work (e.g. a particular hangar). Although
distinct tasks may be assigned to individuals within a team, the responsibility
for fulfilling overall goals would fall on the entire team. Team working is
discussed in more detail in later in this chapter.
4.2.3 Individual Responsibility
(a) All aircraft maintenance engineers are skilled individuals having undertaken
considerable training. They are normally to work in a highly professional
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environment and generally to have considerable pride in their work and

contribution to air safety.
(b) All individuals, regardless of their role, grade or qualifications should work in a
responsible manner. This includes not only Aircraft Maintenance Engineers
(AMEs), but also non-licensed staff. Airworthiness requirements in the ANO
details the certification responsibilities of AMEs and state that "The certifying
engineer shall be responsible for ensuring that work is performed and
recorded in a satisfactory manner ".
(c) Likewise, non-certifying technicians also have a responsibility in the

maintenance process. An organization approved in accordance with ANO
must establish the competence of every person, whether directly involved in
hands-on maintenance or not. The CAAB has ruled out that an organization
shall make provision on maintenance records or work sheets for responsible
person(s) involved to sign for the work. Thus, it provides the traceability to
those who were involved in the job. The AME is then responsible for any
adjustment or functional test and the required maintenance records are
satisfied before making the legal certification.
4.2.4 Group or Team Responsibility
(a) Group responsibility has its advantages and disadvantages. The advantages
are that each member of the group ought to feel responsible for the output of
that group, not just their own output as an individual, and ought to work
towards ensuring that the whole ‘product’ is safe. This may involve cross-
checking others ' work (even when not strictly required), politely challenging
others if you think that something is not quite right, etc.
(b) The disadvantage of group responsibility is that it can potentially act against
safety, with responsibility being devolved to such an extent that no one feels
personally responsible for safety (referred to as diffusion of responsibility).
Here, an individual, on his own, may take action but, once placed within a
group situation, he may not act if none of the other group members do so,
each member of the group or team assuming that 'someone else will do it.
This is expanded upon further in the section on peer pressure later in this
chapter (4).
[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 his own, he was 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.]
(c) Other recognized phenomena associated with group or team working and
Responsibility for decisions and actions which aircraft maintenance engineers
should be aware of are discussed below:
(i) Intergroup conflict in which situations evolve where a small group may act
cohesively as a team, but rivalries may arise between this team and others
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(e.g. between engineers and planners, between shifts, between teams at

different sites, etc.).This may have implications in terms of responsibility, with
teams failing to share responsibility between them. This is particularly
pertinent to change of responsibility at shift handovers, where members of the
outgoing shift may feel no `moral' responsibility for waiting for the incoming
shift members to arrive and giving a verbal handover in support of the written
information on the work cards or task sheets, whereas they might feel such
responsibility when handing over tasks to others within their own shift.
(ii) Group polarization is the tendency for groups to make decisions that are
more extreme than the individual members ' initial positions. At times, group
polarization results in more cautious decisions. Alternatively in other
situations, a group may arrive at a course of action that is riskier than that
which any individual member might pursue. This is known as risky shift.
Another example of group polarization is groupthink in which the desire of
the group to reach unanimous agreement overrides any individual impulse to
adopt proper, rational (and responsible) decision-making procedures.
(iii) Social loafing has been coined to reflect the tendency for some individuals to
work less hard on a task when they believe others are working on it. In other
words, they consider that their own efforts will be pooled with that of other
group members and not seen in isolation.
(d) Responsibilities is an important issue in aircraft maintenance engineering, and

ought to be addressed not only by licensing, regulations and procedures, but
also by education and training, attempting to engender a culture of shared,
but not diffused, responsibility.
4.2.5 TROUBLED EMPLOYEE
4.2.5.1 General
(a) In this section, we will concentrate on the issues of work colleagues who for
one reason or another, are finding that they are going a bit tough. The focus
will be on our responsibility as workmates to either help them ourselves, or
get them the appropriate help, which invariably the company will be able and
willing to supply. The first point is to know when something is going on in a
work colleague's life that could affect his performance. It is rare that
individuals will be able to recognize that their troubles are affecting their work
and research has shown that we, as individuals, are often the last to accept
that we have a problem.
(b) The term ' troubled employees' is used as a generic term to imply one
workmates who could probably use a bit of a helping hand if it was offered. So
how are we going to recognize him or her? They don't always have the
hangdog (Guilty) expression of the fellow as shown in the slide. There are,
however, some behavioral signposts. These are:
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 Degraded performance;
 Poor attendance;
 Changes in attitude and physical appearance;
 Increase in health and safety hazards.
Figure-2 Trouble Employ
(i) Degraded performance: The first aspect that should give some concern is
degraded performance. That is his or her work is not up to the usual
standard. That can be evidenced by:
 Decreased productivity
 Unacceptable or irregular work
 Diminished ability to concentrate
 Increase in failed inspections
 Sloppy work
 Increase in judgment errors
 Signs of increased fatigue
 Poor reliability
(ii) Poor attendance:
 Excessive sick leave

 Increased leave abuse e.g. before and after weekends
 Frequent and unexplained disappearances and on-the-job absences
 Unscheduled vacation
 Early leaving, extended lunch breaks and repeated tardiness
 Frequent complaints of vaguely defined illnesses
(Ill) Changes In attitude and physical appearance: This aspect does not
mean to say that we rush in to save someone as soon as they turn up without
an ironed shirt. These are indicators only. When you start putting a few of
them together it may be a sign of someone who could use a little help and it
is part of the responsibility of each and every one of us to help our colleagues
in the workplace when they need it.
 Uncharacteristic anger or belligerence

 Unprovoked emotional outbursts and irritability
 Sudden changes in mood
 Blaming others for own shortcomings
 Avoiding colleagues and supervisors
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 Deteriorating personal appearance and hygiene.

 Preoccupation with personal problems, e.g. increased personal phone
calls
(iv) Increase health and safety hazards: None of us would hesitate to run to
the aid of a colleague if we could see a physical danger looming up on him. It
is the same with psychological danger. If we can see the problem early
enough and get our colleagues out of the way of danger then it is likely that
we will save them; otherwise, there will be a lot of trouble in the long run will.
 Increased number of on-the-job accidents or injuries

 Careless handling and maintenance of equipment
 Needless risk taking
 Disregard for others' safety
4.2.5.2 Assistance Programs
(a) Employee Assistance Program refers to a broad range of company programs

helping employees deal with various problems, including emotional and
financial distress and substance dependency.
(b) Since 1988, the FAA rules have required aviation employers to establish
Employee Assistance Programs (EAPs). These EAP requirements are limited
to drug and alcohol use and treatment for misuse. Generally, EAPs in other
industries address a broad array of performance-related issues, including
mental, emotional, financial, marital, and even physical problems. While this
isn't the case in all countries, most responsible companies will have some
variations on these FAA requirements.
(c) Employee Assistance Programs (EAPs) invariably include some type of

counseling. Both individual and group counseling require a trained counselor
to identify and help clients solve problems. Counselors must undergo
specialized training to be effective. Group counseling is not something that
can be undertaken by Human Resource facilitators or others conducting
group meetings or focus groups.
(d) In general there are 4 types of Employee Assistance Programs.
(i) In-house model: In this type of EAP, the company employs and directly
supervises the staff. The in-house model is usually run by the Human
Resources Department and is the likely first port of call for solving problems
quickly and easily. An example would be a support program for employees
giving up smoking.
(ii) Out-of-house model: In this type of EAP, the company contracts with a
supplier for employee assistance staff and services. The out-of-house model
is generally used when troubles have become a bit more entrenched and we
are trying not to bring any unwanted attention to individuals. An example
might include relational problems that require the help of a psychologist to sort
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out.
(iii) Consortium model: In this model, several companies jointly fund and
develop a collaborative EAP. The Consortium model is generally favored by
professional groups where they organize expertise to support common
problems in their industry. A union, for example, might contract Alcoholics
Anonymous to help when there is prevalence of alcohol abuse in their
profession.
(iv) Affiliate model: In this model, a company contracts with a single vendor
supplying EAP services. The vendor subcontracts with professional staff
members wherever EAP services are required. This arrangement allows the
vendor to supply services to the company, even in locations where the vendor
does not have an office. The big advantage of this model is that the company
deals with only one vendor, regardless of the locations needing services.
4.3 MOTIVATION AND DEMOTIVATION
4.3.1 General
In this section, we will focus on different aspects of motivation and identify some of
the factors, which contribute to personal demotivation in working environment.
4.3.2 Human Motivation
(a) Motivation can be thought of as a basic human drive that arouses, directs and
sustains all human behavior. Generally, we say that a person is motivated if
he is taking action to achieve something.
(b) Motivated behavior is goal-directed, purposeful and no human behavior

occurs without some kind of motivation.
(c) It is largely the motivation, which determines what an employee actually does
in any given situation. Thus "motivation reflects the difference between what a
people can do and what he will do".
(d) Motivation is usually considered to be a positive rather that a negative force in

that it stimulates one to achieve various things. However, just because
someone is motivated, this does not mean to say that he is doing the right
thing. For instance, many criminals are highly motivated for instance.
Motivation is difficult to measure and predict. We are all motivated by different
things, for example, an artist might strive over many months to complete a
painting that he may never sell, whereas a businessman may forfeit all family
life in pursuit of financial success.
(e) With respect to aviation safety, being appropriately motivated is vital. Ideally,
aircraft maintenance engineers ought to be motivated to work in a safe and
efficient manner, However, many factors may cause conflicting motivations to
override this ideal. For instance, the motivation of some financial bonus or
demotivation of working outdoors in extreme cold weather might lead to less
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consideration of safety and increase the likelihood of risk taking, corner

cutting, violating procedures and so on. Aircraft maintenance engineers
should be aware of conflicting motivations that impinge on their actions and
attempt to examine their motivations for working in a certain way.
4.3.3 Theories of Motivation: Maslow's Hierarchy of Needs
(a) 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 realize our full potential in life known as self-
actualization needs (fulfilling ambitions, etc.).
Figure-4.1 shows the hypothetical hierarchical nature of the needs we are

motivated to satisfy. The theory is that the needs lower down the hierarchy
are more primitive or basic and must be satisfied before we can be motivated
by the higher needs. For instance, you will probably find it harder to
concentrate on the information in this document if you are very hungry (as the
lower level physiological need to eat predominates over the higher level
cognitive need to gain knowledge).There are always exceptions to this, such
as the mountain climber who risks his life in the name of adventure. The
higher up the hierarchy one goes, the more difficult it becomes to achieve the
need. High level needs are often long- term goals that have to be
accomplished in a series of steps.
(b) An aircraft maintenance engineer will fulfill lower level needs by earning
money to buy food, pay for a home and support a family. They may well be
motivated by middle level needs in their work context (e.g. social groups at
work, gaining status and recognition).
[An interesting experiment on motivation was carried out in 1924 at the Hawthorne
Works of the Western Electric Company in Chicago. Here, the management altered
various factors such as rest periods, lighting level working hours, etc. and each time
they did so, performance improved, even when the apparent improvements were
taken away! This suggested that it was not the improvements themselves which
were causing the increased production rates, but rather the fact that the staff felt that
management were taking notice of them and were concerned for their welfare. This
phenomenon is known as the Hawthorne effect.]
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Figure-4.1 Maslow’s hierarchy of needs
4.3.4 Factors of Motivation
(a) We all need some sort of motivation to do our job. In most cases it consists of
our pay packet each week but there are a whole range of motivators for doing
any task.
(b) Most particularly it is worth noting that different people are motivated by
different incentives. It is very uncommon to find a motivator that will affect all
people the same way.
(c) While money is a prime motivator in many respects, once the basic needs are
covered there is a real change in people's attitude towards it. Someone who is
saving up for a new computer or a new car might be very motivated to earn a
bit of extra cash whereas someone with a new bride or a new child might
much rather some extra time off to spend with their family.
(d) There are caveats to this. People can be offered incentives to work until they
become dangerous and sometimes the motivation to earn extra money or
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recognition from management might override the recognition that they have
become too tired to do their job properly and pose a danger to themselves
and others.
(e) Extrinsic Motivation: Extrinsic motivation usually comes in the form of

tangibles that everyone can see. Rewards and awards are the most common
form of extrinsic motivators and are commonly used by organizations when
short-term changes in work effort are required.
(f) Intrinsic motivation: Intrinsic motivators are much more powerful in the long
item and always come from the individual themselves. These are also very
often associated with the professionalism of individuals. Professionalism, in
this case means always doing the right thing even when nobody else is
looking.
(g) Highly motivated people tend to show the following characteristics:
 high performance and results being consistently achieved

 the energy, enthusiasm and determination to succeed
 co-operation in overcoming problems;
 willingness to accept responsibility;
 willingness to accommodate change.
4.3.5 Demotivation
(a) There are the positive and negative aspects of motivation and for every
positive side there is of course a negative side. The previous paragraphs have
indicated some motivators, such as rewards and awards, so what then are the
de-motivators, the negative aspects?
(b) If recognition for doing something good is a motivator then making sure that
everyone knows you have made a mistake can be a big de-motivator. If
reward is a motivator then punishment is a de-motivator and ridicule has a
special place as the opposite of status as a motivator. It can really make sure
people don't want to be part of the team.
(c) People who are de-motivated lack motivation, either intrinsically or through a
failure of their management to motivate the staff who works for them.
Demotivated 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.
(d) However, care should be taken when associating these characteristics with
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lack of motivation, since some could also be signs of stress.
(e) There is much debate as to the extent to which financial reward is a motivator.
There is a school of thought which suggests that whilst lack of financial
reward is a de-motivator, the reverse is not necessarily true. The attraction of
the extra pay offered to work a `ghoster' [i.e. a back-to-back-shift] can be a
strong motivator for an individual to ignore the dangers associated with
working when tired.
(f) The motivating effects of job security and the de-motivating impact of lack of
job security is also an area that causes many debates. The 'hire and fire'
attitude of some companies can, potentially, be a major influence upon safety,
with real or perceived pressure upon individuals affecting their performance
and actions. It is important that maintenance engineers are motivated by a
desire to ensure safety (Maslow's 'self-esteem/self respect), rather than by a
fear of being punished and losing their job (Maslow's 'security). It is possible
that the "can do" culture, which is evident in some areas of the industry, may
be generate the expectancy that if individuals do not 'deliver', they will be
punished (or even dismissed) and, conversely, those who do 'deliver '
(whether strictly by the book or not, finding ways around lack of time, spares
or equipment) are rewarded and promoted. This is not motivation in the true
sense but it has its roots in a complex series of pressures and drives and is
one of the major influences upon human performance and human error in
maintenance engineering.
4.4 PEER PRESSURE
4.4.1 General
(a) In the working environment of aircraft maintenance, there are many pressures
brought to bear on the individual engineer. We have already discussed the
influence of the organization, of responsibility and motivational drives. In
addition to these, there is the possibility that the aircraft maintenance engineer
will receive pressure at work from those who work with him. This is known as
peer pressure.
(b) 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.
(c) For example, an individual engineer may feel that there is pressure to cut
corners in order to get an aircraft out by a certain time, in the belief that this is
what his colleagues would do under similar circumstances. There may be no
actual pressure from management to cut corners, but subtle pressure from
peers, e.g. taking the form of comments such as "You don't want to bother
checking the manual for that. You do it like this, would constitute peer
pressure.
(d) 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.
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4.4.2 Experiments in Conformity
(a) S. Asch (1951) in works for the research on Effects of Group Pressure upon
the Modification and Distortion of Judgment, carried out several experiments
investigating the nature of conformity, in which he asked people to judge
which of lines A,B &C was the same length as line X.(see Figure 4.2),He
asked this question under different conditions:
 Where the individual was asked to make the judgment on his own;
 Where the individual carried out the task after a group of 7-9 confederates
of Asch had all judged that line A was the correct choice. Of course, the
real participant did not know the others were "stooges "
(b) In the first condition, very few, mistakes were made (as would be expected of
such a simple task with an obvious answer). In the latter condition, on
average, participants gave wrong answers- on one third of the trials by
agreeing with the confederate majority. Clearly, participants yielded to group
pressure and agreed with the incorrect 'group ' finding (however, it is worth
mentioning that there were considerable individual differences; some
participants never conformed, and some conformed all the time).
Figure 4.2 An experiment to illustrated Conformity. (Source: Asch, 1951
(c) Further research indicated that conformity does not occur with only one
confederate (as then it is a case of 'my word against yours'). However, it is
necessary to have only three confederates to one real participant to attain the
results that Asch found with 7-9 confederates.
(d) The degree to which an individual's view is likely to be affected by conformity

or peer pressure depends on many factors including:
 culture (people from country ‘x’ tend to conform more than those from country
‘y’)
 gender (men tend to conform less than woman)
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 self-esteem (a person with low self-esteem is likely to conform more);

 familiarity of the individual with the subject matter (a person is more likely to
conform to the majority view if he feels that he knows less about the subject
matter than they do);
 the expertise of the group members (if the individual respects the group or
perceives them to be very knowledgeable he will be more likely to conform to
their views)
 the relationship between the individual and group members (conformity
increases if the individual knows the other members of the group, i.e. it is a
group of peers).
4.4.3 Countering Peer Pressure and Conformity
(a) 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.
However, this can be very difficult. After Asch’s experiments, when asked,
many participants said they agreed with the majority as they did not want to
appear different or to look foolish.
(b) Conformity is closely linked with 'culture ' (described in the next section). 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 new corners. In other words, it is important for an
organization to engender a positive approach to safety throughout their
workforce, so that peer pressure and conformity perpetuates this. In this
instance, peer pressure is clearly a good thing. Too often, however, it works in
reverse, with safety standards gradually deteriorating as shift members
develop practices which might appear to them to be more efficient, but which
erode safety. These place pressure, albeit possibly unwittingly, upon new
engineers joining the shift, to do likewise.
4.4.4 Peer pressure and conflict in an organization.
(a) Peer pressure, as with most social psychology subjects, has both positive and
negative aspects. Peer pressure can, for example, have a particularly good
effect. For example friends in a car might warn the driver that he or she is
breaking the speed limit and thereby bring down their speed. Not only does
this reduce the chances of an accident and/or the damage if an accident does
occur, but it might be as simple as saving that driver from a speeding fine.
(b) Positive peer pressure can also bring about better performance in the
workplace. For example, having a small side competition on who will make
the least mistakes in a rivet check might see everybody going through the
whole check without making any mistakes.
(c) The negative side of peer pressure can be quite disastrous, both socially and
in the workplace. Those same people in the speeding car could in fact, urge
on the driver to go faster still. At some stage, the driver's reactions will not be
quick enough to save the occupants of the car when something unexpected
happens, like a truck backing out of a blind side road or a child runs across
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the road without looking.
(d) The work environment has the same problems. If the competition was set to
see who could finish their allocated rivets first, then in fact, the likelihood of
mistakes would increase exponentially with the speed at which the job was
being done.
(e) Conflict in the workplace: Conflict in the workplace is normally brought

about by the fear when morale is low. When morale is high, conflict of any sort
is rare and people aren't afraid of speaking up and providing constructive
criticism. Just the opposite is true when morale is low. All criticism is taken
personally and peer aspects are seen as ganging up on individuals. Worse
still, is that attitude is taken from the workplace into the home where it can
have equally disastrous effects on the family. Management of conflict has to
be open and honest. Protagonists need to feel that they are being included in
all aspects of the resolution and often that resolution goes far beyond just
patching up an argument between colleagues. It requires the restoration of
morale and the removal of any fear that a similar situation will occur again.
Management of conflict requires buy-in to the solution from all of the workers
in the area where the conflict occurred or we are setting up a breeding ground
for errors.
4.5 CULTURE ISSUES
4.5.1 General:
(a) There are remarkable impacts of cultural issues on workplace. In this section,
we will discuss outstanding issues of culture and their impact. It is to note that
sexual harassment is becoming a big issue in the workplace. We will discuss
the issue of sexual harassment respect to culture and stereotypical behavior.
(b) In terms of cultural issues, there are a number of different cultures that need
to be recognized. They are:
 National culture;
 Professional culture;
 Organization culture;
 Safety culture; and
 Just culture.
(c) With respect to national culture, a number of norms have to be taken into
account. Specifically, they are:
 History: Nation and State

 Religion: Christianity, Islam, Judaism, Buddhism, Taoism, Sikh, Agnostic,
Atheist, etc.
 Politics: Autocratic, Democratic, Left, Right.
 Identity: Alliances and position in society
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(d) Professional culture in this context refers to the industry wide norms of
maintenance engineers. What is it about maintenance engineers that goes
with them no matter who they are working for or in fact, where they are
working anywhere in the world. Adjectives such as "hardworking", "fastidious",
"attention to details", come to mind of some people whereas "black hands",
"shift work" and "finicky" might come to the minds of others.
(e) Safety culture has very overt signs in the workplace. You just need to observe
the safety practices of the individual workers. For example, do the workers in
your organization naturally wear hearing protection when they go out onto the
ramp? If so, then there is probably a reasonable safety culture within the
organization. If individuals need to be told to put their safety gear on, then
there may be a problem.
(f) Just culture is a much newer aspect to the cultural values of organizations
and individuals. Just culture reflects the actions that are taken against
individuals who commit errors. If we break errors up into its four categories of
slips, lapses, mistakes and violations, a just culture only punishes violations
and puts systems in place to prevent other errors from having an effect on
safety.
4.5.2 Organizational Culture
(a) There can be a degree of mistrust of anything new in the workplace, (e.g. an
individual joining a company whose expertise has not yet been proven, or
contracting cut maintenance to another company, etc.).There may be a
tendency for groups within organization and the organization itself to think that
their own methods are the best and that others are not as good. This
viewpoint is known as the group or organization's culture.
(b) The culture of an organization can be described as "the way we do things

here". It is group or company norm.
(c) Figure 4.3 indicates that there can be an overall organizational culture, and a
number of different 'sub-cultures', such as safety 'culture, professional/
technical culture, etc. It is possible to exist cultural differences between sites
or even between shifts within the same organization. The prevailing culture of
the industry as a whole also influences individual organizations.
(d) 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.
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Figure 4.3 Organizations’ Culture
4.5.3 Safety Culture
(a) The ICAO Human factors Digest No.10, "Human Factors, Management and
Organization"(Circular 247), discusses corporate culture and the differences
between safe and unsafe corporate cultures.
(b) ICAO HF Digest 10 describes a safety culture as a "a set of beliefs, norms,
attitudes, roles and social and technical practices with minimizing exposure of
employees, managers, customers and members of the general public to
conditions considered dangerous or hazardous".
(c) Gary Eiff (1998) from Purdue University discusses safety culture in his paper
"Organizational culture and its effect on Safety". He suggests that "A safety
culture exists only within an organization where each individual employee,
regardless of their position, assumes an active role in error prevention",
stressing that "Safety cultures do not spring the life simply at the declaration
of corporate leaders".
(d) The culture of an organization can best be judged by what is done rather than
by what is said. Organizations may have grand 'mission statements’
concerning safety but this does not indicate that they have a good safety
culture unless the policies preached at the top are actually put into practice at
the lower levels. It may be difficult to determine the safety culture of an
organization by auditing the procedures and paperwork; a better method is to
find out what the majority of the staff actually believe and do in practice.
(e) Professor 'James Reason (1997) describes the key components of a safety
culture summarized 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;
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 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 behavior;
 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.
(f) A method for measuring attitudes to safety has been developed by the Health
and Safety Executive utilizing a questionnaire approach. Examples of the
statements which employees are asked the extent to which they agree are:
 It is necessary to bend some rules to achieve a target;

 Short cuts are acceptable when they involve little or no risk;
 I often come across situations with which I am unfamiliar;
 I sometimes fail to understand which rules apply;
 I am not given regular break periods when I do repetitive and boring jobs;
 There are financial rewards to be gained from breaking the rules.
The results are scored and analyzed to give an indication of the safety culture of the
organization, broken down according to safety commitment, supervision, work
conditions, logistic support, etc. In theory, this enables one organization to be
objectively compared with another.
4.5.4 Social Culture
(a) The influence of social culture (an individual’s background or heritage) can be
important in determining how an individual integrates into an organizational
culture. The way an individual behaves outside an organization is likely to
have a bearing on how they behave within it. Internal pressures and conflicts
within groups at work can be driven by underlying social cultural differences
(e.g. different nationalities, different political views, different religious beliefs,
etc.). This is an extremely complex subject, however, and in-depth discussion
is beyond the scope of this text.
(b) While safety culture has been discussed from the organizational perspective,
the responsibility of the individual should not be overlooked, Ultimately, safety
culture is an amalgamation of the attitude, beliefs and actions of all the
individuals working for the organization and each person should take
responsibility for their own contribution towards this cultural, ensuring that it is
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a positive contribution rather than a negative one.
4.5.5 Stereotypes
(a) Stereotypes and stereotypical behavior reflect the norms of a group of people.
Light switches are an example of population stereotypes. In New Zealand, we
flick the switch down to turn it on; in the US we flick it up. In Australia the hot
water tap on a washbasin is always on the left. You can get burnt presuming
that is the case in China where the hot tap is usually the closest to the hot
water cylinder. We drive naturally on the left hand side of the road but when
we visit Europe we try to hop in the passenger side of the car, we look the
wrong way for on-coming traffic and we try to drive in the wrong lane. In some
countries, wine is always served with dinner. In other countries, wine is
banned due to its alcohol content.
(b) Stereotypes are also part and parcel of the work environment. With
maintenance engineers, there has been a history of males only in the
workplace, and this has lead to some inappropriate behavior that these days
would be considered to be sexual harassment, whereas it was considered
normal behavior only a few years ago.
4.5.6 Sexual harassment
(a) Sexual harassment in the workplace has both social and legal concepts
associated with it. As men and women continue to work together in larger
numbers, the need for heightened awareness and sensitivity toward issues
related to sexual harassment intensifies. Behaviors such as sexually charged
jokes, lewd comments and innuendoes, leering, touching private body parts,
gender related insults, and demands for sexual favors continue to permeate
the workplace. Therefore, it is important for everyone to understand which
actions are appropriate rand which are inappropriate) in the changing context
of work.
(b) Power differences between men and women result from society's traditional
sex-role stereotyping and is a major cause of sexual harassment. A culture
tending to place males into greater positions of power than females would
expect to have women file a higher rate of sexual harassment complaints
because they occupy positions of less authority. When unequal power
relationships between the sexes are rooted in cultural experiences, work
contexts can provide a foundation legitimizing sexual harassment in the
workplace. The methods section in Chapter 11 of your guide provides some
techniques for dealing with sexual harassment such as: assertiveness;
redirection and reframing among others.
4.6 TEAM WORKING
4.6.1 General
(a) Tie responsibility of aircraft maintenance engineers within teams has been
discussed in section 4.3 and the influence of peers on the behavior of the
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individual highlighted in section 4.5.
(b) This section looks in more detail at team working in aircraft maintenance.
Identifies factors, good and bad, that affect team performance. We will also
describe how effective teams or team working can reduce maintenance
errors, describe principles of effective team dynamics within an organization
and how operation of an effective team may be identified.
4.6.2 The Concept of a Team
(a) A lot has been written on the concept of a team, and it is beyond the scope of
this document to give anything but a flavor of this.
(b) 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
recognized leader and one or more follower(s).Teams need to be built up
and their identity as a team needs to be maintained in some way.
(c) Whereas individualism encourages independence, teams are associated with

interdependence and working together in some way to achieve one or more
goals.
(d) A team could be a group of engineers working on a specific task or the same
aircraft, a group working together on the same shift, or a group working in the
same location or site. There are natural teams within the aircraft maintenance
environment. The most obvious is the supervisor and the engineers working
under his supervision. A team could also be an AME and unlicensed
engineers working subject to his scrutiny. A team may well comprise
engineers of different trades.
(e) There has been a great deal of work carried out on teamwork, in particular
"Crew Resource Management (CRM)" in the cockpit context and, more
recently, "Maintenance Resource Management (MRM)" in the maintenance
context. The ICAO Human Factors Digest No.12 "Human Factors in Aircraft
Maintenance and Inspection"(ICAO Circular 253), includes a Chapter on team
working, to which the reader is directed for further information. MRM is
addressed separately (section 8) since it covers more than just teamwork.
4.6.3 Important Elements of Tam Working
(a) Important elements of a team are:
 A team consists of a diverse group of people: Each member provides

specific and varying resources and abilities that broaden the team's
collective skills.
 Responsibilities are shared among members: Everyone facilitates team
activities and discussions. All members are, in effect, equal participants in
the team process.
 There is a team identity: It has a particular identity, personality, self-
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image, and sense of cohesiveness.

 It’s efforts are interconnected: The team constantly weaves and
coordinates the contributions of each member in order to develop a tighter
energy and focus.
 Members strive for mutually defined goals; There are intense and open
communication designed to develop group consensus. There is usually a
clear and elevating goal that motivates its members.
(b) 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
(c) Communication; Communication is essential for exchanging work-related

information within the team. For example, a team leader must ensure that a
team member has not just heard an instruction, but understood what is meant
by it. A team member must highlight problems to his colleagues and/or team
leader. Furthermore, it is important to listen to what others say. This is
covered in greater depth in Chapter 7.
(d) Co-operation: 'Pulling together' is inherent in the smooth running of a team.

Fairness and openness within the team encourage cohesiveness and mutual
respect. Disagreements must be handled sensitively by the team leader.
(e) Co-ordination: Co-ordination is required within the team to ensure that the
team leader knows what his group members are doing. This includes
delegation of tasks so that all the resources within the team are utilized.
Delegated tasks should be supervised and monitored as required. The team
leader must ensure that no individual is assigned a task beyond his
capabilities. Further important aspects of co-ordination are agreement of
responsibilities (i.e. who should accomplish which tasks and within what
timescale), and prioritization of tasks.
(f) Mutual Support: i) Mutual support is at the heart of the team's identity. The
team leader must engender this in his team. For instance, if mistakes are
made, these should be discussed and corrected constructively. ii) It is worth
noting that in many companies, line engineers tend to work as individuals
whereas base engineers tend to work in teams. This may be of significance
when an engineer who normally works in a hangar, finds himself working on
the line, or vice versa. This was the case in the Boeing 737 incident involving
double engine oil pressure loss, where the Base Controller took over a job
from the Line Maintenance engineer, along with the line maintenance
paperwork. The line maintenance paperwork is not designed for recording
work with a view to a handover, and this was a factor when the job was
handed over from the Line engineer to the Base Controller.
4.6.4 Some Advantages and Disadvantages of Team Working
(a) The discussion on motivation suggests that individuals need to feel part of a
social group. In this respect, team working is advantageous. However, the
work on conformity suggests that they feel some pressure to adhere to a
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group’s views, which may be seen as a potential disadvantage.
(b) Working as part of a team has a number of potential benefits which include:
 Individuals can share resources (knowledge, tools, etc.);

 They can discuss problems and arrive at shared solutions;
 They can check each others' work (either "officially "or "unofficially").
(c) The advantage of teams in the workplace is that they can significantly reduce
maintenance errors. They reduce errors by motivating individuals to do their
individual work better than they would if left to their own devices. This may be
because they want to be seen as an equal and effective member of the team
or because their performance is enhanced by the support offered by their
colleagues. It also reduces the impact of errors because team members tend
to cover each other's work and pick up on any errors before they become
accidents or incidents.
(d) Building effective teams is both difficult and time-consuming. While it is

sometimes difficult for a number of people just to get together and call
themselves a team, there is a big difference between a high performing team
and a low performing team. Team sports provide the best analogy of this. To
have a team work together so closely that they can win championships is
probably the epitome of good teamwork but every successful team will tell you
that the building process was both difficult and time consuming. It rarely just
happens.
(e) Conversely, team building can be both rewarding and productive if the
process takes place in a supportive organizational framework. In fact, the
McDonald's restaurant chain has been recognized as being able to build high
performing teams of individuals throughout the world. This is an example of
an organization putting the infrastructure in place to allow teamwork to
flourish.
(f) In summary, teamwork helps reduce maintenance errors by having the

individuals in the team:
 Looking after each other

 Covering each other’s errors
 Motivating each other for better performance
The whole result of a team process is better than the sum of the individual
results.
4.7 MANAGEMENT, SUPERVISION AND LEADERSHIP
4.7.1 General
(a) The previous section made frequent reference to the team leader.
Management, supervision and leadership are all skills that a team leader
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requires. Of course, management is also a function within an organization (i.e.

those managers responsible for policy, business decisions, etc.), as is the
supervisor (i.e. in an official role overseeing a team).
(b) Managers and supervisors have a key role to play in ensuring that work is
carried out safely. It is no good instilling the engineers and technicians with
'good safety practice, concepts, if these are not supported by their supervisors
and managers.
(c) Skilled management, supervision and leadership play a significant part in the
attainment of safety and high quality human performance in aircraft
maintenance engineering.
4.7.2 The Management Role
Line Managers, particularly those working as an integral part of the front line
operation, may be placed in a situation where they may have to compromise
between commercial drivers and ‘ideal’ safety practices (both of which are passed
down from ‘top management’ in the organization). For example, if there is a
temporary staff shortage, he must decide whether maintenance tasks can be safely
carried out with reduced manpower, or he must decide whether an engineer
volunteering to work a “ghoster” to make up the numbers will be able to perform
adequately. The adoption of Safety Management Principles may help by providing
managers with techniques whereby they can carry out a more objective assessment
of risk.
4.7.3 The Supervisory Role
(a) Supervision may be a formal role or post (i.e. a supervisor), or an informal

arrangement in which a more experienced engineer ‘keeps an eye on’ less
experienced staff. The Supervisor is in a position not only to watch out for
errors which might be made by engineers and technicians, but will also have a
good appreciation of individual engineer’s strengths and weaknesses,
together with an appreciation of the norms and safety culture of the group
which he supervises. It is mainly his job to prevent unsafe norms from
developing, and to ensure that good safety practices are maintained. There
can be a risk however, that the supervisor becomes drawn down the same
cultural path as his team without realizing. It is good practice for a supervisor
to step back from the day-to-day work on occasion and to try to look at his
charges performance objectively.
(b) 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 authorizations), and they
may get out of practice. In the UK Air Accidents Investigation Branch (AAIB)
investigation reports of the BAC1-11, A320 and B737 incidents, a common
factor was: “Supervisors tackling long duration, hands-on involved tasks”. In
the B737 incident, the borescope inspection was carried out by the Base
Controller, who needed to do the task in order to retain his borescope
authorization. Also, there is unlikely to be anyone monitoring or checking the
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supervisor, because:
 of his seniority;
 he is generally authorized 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 ‘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.
(d) It is not the intention to suggest that supervisors are more vulnerable to error;
rather that the circumstances which require supervisors to step in and assist
tend to be those where several of the 'defenses ' (see Chapter 8 Error) have
already failed and which may result in a situation which is more vulnerable to
error.
4.7.4 Characteristics of a Leader
(a) A leader in a given situation is a person whose ideas and actions influence
the thought and the behavior of others.
(b) There are potentially two types of leader in aircraft maintenance: the person
officially assigned the team leader role (possibly called the Supervisor),an
individual within a group that the rest of the group tend to follow or defer to
(possibly due to a dominant personality, etc.). Ideally of course, the official
team leader should also be the person the rest of the group defers to.
(c) A good leader in the maintenance engineering environment needs to possess

a number of qualities:
 Motivating his team;

 Reinforcing good attitudes and behavior;
 Demonstrating by example;
 Maintaining the group;
 Fulfilling a management role.
(i) Motivating the Team: Just as the captain of a football team motivates his
fellow players, the leader of a maintenance team must do likewise. This can
be done by ensuring that the goals or targets of the work which need to be
achieved are clearly communicated and manageable. For instance, the team
leader would describe the work required on an aircraft within a shift. He must
be honest and open, highlighting any potential problems and where
appropriate encouraging team solutions.
(ii) Reinforcing Good Attitudes and Behavior: When team members work
well (i.e. safely and efficiently), this must be recognized by the team leader
and reinforced. This might be by offering a word of thanks for hard work, or
making a favorable report to senior management on an individual. A good
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leader will also make sure that bad habits are eliminated and inappropriate
actions are constructively criticized.
(iii) Demonstrating by Example: A key skill for a team leader is to lead by

example. This does not necessarily mean that a leader must demonstrate that
he is adept at a task as his team (it has already been noted that a Supervisor
may not have as much opportunity to practice using their skills). Rather, he
must demonstrate a personal understanding of the activities and goals of the
team so that the team members respect his authority. It is particularly
important that the team leader establishes a good safety culture within a team
through his attitude and actions in this respect.
(iv) Maintaining the Group: Individuals do not always work together as good
teams. It is part of the leader's role to be sensitive to the structure of the team
and the relationships within it. He must engender a 'team spirit ' where the
team members support each other and feel responsible for the work of the
team. He must also recognize and resolve disputes within the team and
encourage co-operation amongst its members.
(v) Fulfilling a Management Role: The team leader must not be afraid to
lead (and diplomatically making it clear when necessary that there cannot be
more than one leader in a team).The team leader is the link between higher
levels of management within the organization and the team members who
actually work on the aircraft. He is responsible for co-ordinating the activities
of the team on a day-to-day basis, which includes allocation of tasks and
delegation of duties. There can be a tendency for team members to transfer
some of their own responsibilities to the team leader, and he must be careful
to resist this.
(d) In terms of the relationship between managers, supervisors and engineers, a

`them and us' attitude is not particularly conducive to improving the safety
culture of an organization. It is important that managers, supervisors,
engineers and technicians all work together, rather than against one another,
to ensure that aircraft maintenance improves airworthiness.
4.8 MAINTENANCE RESOURCE MANAGEMENT (MRM)
4.8.1 General
(a) The discussion of MRM in this text is intended only as an introduction to the
basic concepts. For in-depth information concerning MRM, the reader is
referred to the "Maintenance Resource Management Handbook "/ Robertson
and Watson (1998)
(b) The term 'Maintenance Resource Management ' became better known after
the Aloha accident in 1988, when researchers took Crew Resource
Management (CRM) concepts and applied them to the aircraft maintenance
environment. CRM concerns the process of managing all resources in and out
of the cockpit to promote safe flying operations. These resources not only
include the human element, but also mechanical, computer and other
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supporting systems. MRM has many similarities to CRM, although the cockpit
environment and team is somewhat different from that found in aircraft
maintenance. The FAA MRM handbook highlight the main difference between
CRM and MRM, and these are summarized in Table 4.1
(c) 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.
(d) One of the early MRM training programs was developed by Gordon Dupont
for Transport Canada. The program 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 summarized
in Table 4.2 and addressed in most maintenance human factors programs.
(e) The UK Human Factors Combined Action Group (UK-HFCAG) has suggested
a generic MRM which organizations may adopt. MRM training programs have
been implemented by several airlines and many claim that such training is
extremely useful in human factors and error management.
TABLE 4.1: Examples of the difference between CRM and MRM highlighted in the
FAA Maintenance Resource Management Handbook
MRM CRM
Human error
Errors send to be ‘active’ in that their The consequences of an engineer’s error

consequences follow on immediately are often not immediately apparent, and
after the error this has implications for training for error
avoidance.
Communication
Much of flight operations are Maintenance operations tend to be

characterized by synchronous, “face-to- characterized by “asynchronous”
face” communications, or immediate communications such as technical
voice communication (i.e. with ATC) over manuals, memos, advisory circulars.
the radio. Airworthiness Directives, work cards and
other non-immediate formats, Much of
the information transfer tends to be of a
non-verbal nature.
Team Composition
Flight crews are mostly homogenous by Maintenance staff are diverse in their
nature, in that they are similar in range of experiences and education and
education level and experience, relative this needs to be taken into account in a
to their maintenance counterparts. MRM program.
Teamwork
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Flight deck crew team size is small: two Maintenance operations are
or three members; although the wider characterized by large teams working on
team is obviously larger (i.e. cockpit crew disjointed tasks, spread out over a
& cabin crew, flight crew & ATC and hangar. In addition, a maintenance task
ground crew, etc.) may requires multiple teams (hangar,
planning department, technical library,
management) each with their own
responsibilities. Therefore MRM places
equal emphasis on inter-team teamwork
skills.
Situation awareness
The flight environment is quickly The maintenance environment, thought

changing, setting the stage for the hectic, changes slowly relative to flight
creation of active failures. Situation operations. In terms of situation
awareness in CRM is tailored to avoid awareness, engineers must have the
these errors; Line Oriented Flight ability to extrapolate the consequences
Training (LOFT) simulations provide flight of their errors over hours, days or even
crews with real-time, simulations to weeks. To do this, the situation
improve future situation awareness. awareness cues that are taught must be
tailored to fit the maintenance
environment using MRM-specific
simulations.
Leadership
Similar to teamwork issues, leadership Because supervisors or team leaders

skills in CRM often focus mainly on intra- routinely serve as intermediaries among
team behaviors or 'how to lead the team', many points of the organization, engineer
as well as followership skills. Inter- team leaders must be skilled not only in intra-
interaction is somewhat limited during team behaviors, but in handling team
flight, 'outsiders' (personnel from other shifts,
managers outside the immediate
workgroup, etc.) during any phase of the
maintenance problem. These
outsiders also vary widely in experience,
mannerisms, etc. A good MRM program
should take these into account
TABLE-4.2: Examples of Potential Human Factors Problems from the “Dirty Dozen
Errors in Maintenance” by G. Dupont. (1997)
Problem Example Potential Solutions

1. Lack of communication Use logbooks, worksheets, etc. to communicate and
remove doubt.
Discuss work to be done or what has been completed.
Never assume anything.
2. Complacency Train yourself to expect to find a fault.
Never sign for anything you didn't do (or see done)
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3. Lack of knowledge Get training on type.

Use up-to-date manuals.
Ask a technical representative or someone who knows.
4. Distraction Always finish the job or unfasten the connection.
Mark the uncompleted work.
Lock-wire where possible or use torque-seal.
Double inspect by another or self.
When you return to the job, always go back three steps.
Use a detailed check sheet.
5. Lack of teamwork Discuss what, who and how a job is to be done.
Be sure that everyone understands and agrees.
6. Fatigue Be aware of the symptoms and look for them in yourself
and others.
Plan to avoid complex tasks at the bottom of your
circadian rhythm.
Sleep and exercise regularly.
Ask others to check your work.
7 Lack of parts Check suspect areas at the beginning of the inspection
and AOG the required parts.
Order and stock anticipated parts before they are
required.
Know all available parts sources and arrange for pooling
or loaning.
Maintain a standard and if in doubt ground the aircraft.
8. Pressure Be sure the pressure isn't self-induced.
Communicate your concerns.
Ask for extra help.
Just say 'No'.
9. Lack of assertiveness If it's not critical, record it in the journey log book and
only sign for what is serviceable.
Refuse to compromise your standards.
Problem Example Potential Solutions
10. Stress Be aware of how stress can affect your work.
Stop and look rationally at the problem.
Determine a rational course of action and follow it.
Take time off or at least have a short break.
Discuss it with someone.
Ask fellow workers to monitor your work.
Exercise your body.
11. Lack of Think of what may occur in the event of an accident.
awareness Check to see if your work will conflict with an existing
modification or repair.
Ask others if they can see any problem with the work done.
12. Norms Always work as per the instructions or have the instruction
changed.
Be aware the "norms" don't make it right.
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Chapter 5
FACTORS AFFECTING PERFORMANCE
5.0 INTRODUCTION
5.1 FITNESS AND HEALTH
5.2 STRESS: DOMESTIC AND WORK RELATED
5.3 TIME PRESSURE AND DEADLINES
5.4 WORKLOAD-OVERLOAD AND UNDERLOAD
5.5 SLEEP, FATIGUE AND SHIFT WORK
5.6 ALCOHOL, MEDICATION AND DRUG ABUSE
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5.0 INTRODUCTION
(a) This chapter will examine factors that influence humans and their
performance in the workplace.
(b) There are many significant Human Factors elements that affect performance
Research suggests that an understanding of the factors that affect
performance provides maintenance engineers with strategies that enable
them to reduce the number of errors associated with their work. Shift work, for
example, has been part and parcel of the aviation maintenance trade since its
inception. Over the years, engineers have accepted the rosters given to them
unquestioningly. New evidence suggests that management of roster systems
can have a marked affect on the performance of engineers, both in terms of
productivity and reduced error rates.
(c) Similarly, issues about health and fitness: sleep and fatigue, workload, stress,
and alcohol and drug abuse have benefited markedly from the research
fraternity. Their application is only just starting to be applied to the discipline of
maintenance engineering and this is primarily done through the application of
Human Factors in the workplace.
5.1 FITNESS AND HEALTH
5.1.1 General
(a) 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. (as
discussed in the next chapter). There are at present no defined requirements
for physical or mental fitness for engineers or maintenance staff. ICAO Annex
1 states: "An applicant shall, before being issued with any licence or rating [for
personnel other than flight crew members, meet such requirements in respect
of age, knowledge, experience and, where appropriate, medical fitness and
skill, as specified for that licence or rating."
(b) In the UK, the ICAO requirements are enforced through the provision of
Article 13 (paragraph 7) of the Air Navigation order (ANO). This states: "The
holder of an aircraft maintenance engineer's licence shall not exercise the
privileges of such a licence if he knows or suspects that his physical or mental
condition renders him unfit to exercise such privileges."
(c) 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.
5.1.2 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 (and this may also satisfy
some pension or insurance related need). There is an obvious effect upon an
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engineer's ability to perform maintenance or carry out inspections if through poor

physical fitness or health he is constrained in some way (such as his freedom of
movement, or his sight). In addition, an airworthiness authority, when considering
issuing a licence, will consider these factors and may judge the condition to be of
such significance that a licence could not be issued. This would not, however, affect
the individual's possibility of obtaining employment in an alternative post within the
industry where fitness and health requirements are less stringent.
5.1.3 Day-to-Day Fitness and Health
(a) Fitness and health can have a significant effect upon job performance (both
physical and cognitive). Day-to-day fitness and health can be reduced through
illness (physical or mental) or injury.
[JAR 66.50 imposes a requirement that "certifying staff must not exercise the
privileges of their certification authorization if they know or suspect that their
physical or mental condition renders them unfit.]
(b) Responsibility falls upon the individual aircraft maintenance engineer to

determine whether he is not well enough to work on a particular day.
Alternatively, his colleagues or supervisor may persuade or advise him to
absent himself until he feels better. In fact, as the CAA 's Airworthiness Notice
No.47 (AWN47) points out, it is a legal requirement for aircraft maintenance
engineers to make sure they are fit for work: "Fitness: In most professions
there is a duty of care by the individual to assess his or her own fitness to
carry out professional duties. This has been a legal requirement for some time
for doctors, flight crew members and air traffic controllers. Licensed aircraft
maintenance engineers are also now required by law to take a similar
professional attitude. Cases of subtle physical or mental illness may not
always be apparent to the individual but as engineers often work as a member
of a team any sub-standard performance or unusual behavior should be
quickly noticed by colleagues or supervisors who should notify management
so that appropriate support and counseling action can be taken."
(c) Many conditions can impact on the health and fitness of an engineer and
there is not space here to offer a complete list. However, such a list would
include:
 Minor physical illness (such as colds, 'flu, etc.);

 More major physical illness (such as HIV, malaria, etc.);
 Mental illness (such as depression, etc.);
 Minor injury (such as a sprained wrist, etc.);
 Major injury (such as a broken arm, etc.);
 Ongoing deterioration in physical condition, possibly associated with the
aging 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.).
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(d) This document does not attempt to give hard and fast guidelines as to what
constitutes 'unfit for work'; this is a complex issue dependent upon the nature
of the illness or condition, its effect upon the individual, the type of work to be
done, environmental conditions, etc. Instead, it is important that the engineer
is aware that his performance, and consequently the safety of aircraft he
works on, might be affected adversely by illness or lack of fitness.
(e) An engineer may consider that he is letting down his colleagues by not going
to work through illness, especially if there are ongoing manpower shortages.
However, he should remind himself that in theory, management should
generally allow for contingency for illness. Hence the burden should not be
placed upon an individual to turn up to work when unfit if no such contingency
is available. Also, if the individual has a contagious illness (e.g. 'flu), he may
pass this on to his colleagues if he does not absent himself from work and
worsen the manpower problem in the long run. There can be a particular
problem with some contract staff due to loss of earnings or even loss of
contract if absent from work due to illness. They may be tempted to disguise
their illness, or may not wish to admit to themselves or others that they are ill.
This is of course irresponsible, as the illness may well adversely affect the
contractor's standard of work.
5.1.4 Positive Measures
(a) 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);
(b) 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.
5.2 STRESS: DOMESTIC AND WORK RELATED
5.2.1 General
(a) 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”.
(b) 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
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to deal with them, the resulting stress is a problem.
5.2.2 Causes and Symptoms
(a) Stress is usually something experienced due to the presence of some form of
stress, 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.
b) 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.).
(c) AWN47 points out that:
"A stress problem can manifest itself by signs of irritability, forgetfulness,

sickness, absence, mistakes, or alcohol or drug abuse. Management has a
duty to identify individuals who may be suffering from stress and to minimize
workplace stresses, Individual cases can be helped by sympathetic and skilful
counseling which allows a return to effective work and licensed duties."
(d) 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, diarrhea,
ulcers, etc.;
 Behavioral 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.
5.2.3 Domestic Stress

.
(a) When aircraft maintenance engineers go to work, they cannot leave stresses
associated with home behind. Pre-occupation with a source of domestic
stress can play on one’s mind during the working day, distracting from the
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working task. Inability to concentrate fully may impact on the engineer’s task
performance and ability to pay due attention to safety.
(b) 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. It should be noted
that individuals respond to stressful situations in very different ways.
Generally speaking though, people tend to regard situations with negative
consequences as being more stressful than when the outcome of the stress
will be positive (e.g. the difference between being made redundant from work
and being present at the birth of a son or daughter).
5.2.4 Work Related Stress
(a) 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 organizational environment tress can be felt when carrying out
certain tasks that are particularly challenging or difficult. This stress can be
increased by lack of guidance in this situation, or time pressures to complete
the task or job (covered later in this chapter).This type of stress can be
reduced by careful management, good training, etc.
(b) Within the organization, the social and managerial aspects of work can be
stressful. Chapter 3 discussed the- impact on the individual of peer pressure,
organizational culture and management, all of which can be stressors. In the
commercial world that aircraft maintenance engineers work in, shift patterns,
lack of control over own workload, company reorganization and job
uncertainty can also be sources of stress:
5.2.5 Stress Management
(a) Once we become aware of stress, we generally response to it by using one of

two strategies defense or coping.
(b) Coping strategies involve dealing with the source of the stress rather than just
the symptoms (e.g. delegating workload, prioritizing tasks, sorting out the
problem, etc.).
(c) Unfortunately, it is not always possible to deal with the problem if this is
outside the control of the individual (such as during an emergency), but there
are well-published techniques for helping individuals to cope with stress.
Good stress management techniques include:
 Relaxation techniques;
 Careful regulation of sleep and diet;
 A regime of regular physical exercise;
 Counseling: ranging from talking to a supportive friend or colleague to
seeking professional advice.
(d) There is no magic formula to cure stress and anxiety, merely common sense
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and practical advice.
5.3 TIME PRESSURE AND DEADLINES
5.3.1 General
(a) There is probably no industry in the commercial environment that does not
impose some form of deadline, and consequently time pressure, on its
employees. Aircraft maintenance is no exception. It was highlighted in the
previous section that one of the potential stressors in maintenance is time
pressure. This might be actual pressure where clearly specified deadlines are
imposed by an external source (e.g. management or supervisors) and passed
on to engineers, or perceived where engineers feel that there are time
pressures when carrying out tasks, even when no definitive deadlines have
been set in stone. In addition, time pressure may be self-imposed, in which
case engineers set themselves deadlines to complete work (e.g. completing a
task before a break or before the end of a shift).
(b) Management have contractual pressures associated with ensuring an aircraft

is released to service within the time frame specified' by their customers.
Striving for higher aircraft utilization means that more maintenance must be
accomplished in fewer hours, with these hours frequently being at night.
Failure to do so can impact on flight punctuality and passenger satisfaction.
Thus, aircraft maintenance engineers have two driving forces: the deadlines
handed down to them and their responsibilities to carry out a safe job. The
potential conflict between these two driving pressures can cause problems.
5.3.2 The Effects of Time Pressure and Deadlines
(a) As with stress, it is generally thought that some time pressure is stimulating
and may actually improve task performance. However, it is almost certainly
true that excessive time pressure (either actual or perceived, external or self-
imposed), is likely to mean that due care and attention when carrying out
tasks diminishes and more errors will be made. Ultimately, these errors can
lead to aircraft incidents and accidents.
(b) It is possible that perceived time pressure would appear to have been a
contributory factor in the BAC 1-11 accident described in Chapter-2. Although
the aircraft was not required the following morning for operational use, it was
booked for a wash. The wash team had been booked the previous week and
an aircraft had not been ready. This would have happened again, due to
short-staffing, so the Shift Manager decided to carry out the windscreen
replacement task himself so that the aircraft would be ready in time.
(c) An extract from the NTSB report on the Aloha accident refers to time pressure
as a possible contributory factor in the accident: "The majority of Aloha's
maintenance was normally conducted only during the night. It was considered
important that the airplanes be available again for the next day's flying
schedule. Such aircraft utilization tends to drive the scheduling, and indeed,
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the completion of required maintenance work. Mechanics and inspectors are

forced to perform under time pressure. Further, the intense effort to keep the
airplanes flying may have been so strong that the maintenance personnel
were reluctant to keep airplanes in the hangar any longer than absolutely
necessary".
5.3.3 Managing Time Pressure and Deadlines
(a) One potential method of managing time pressures exerted on engineers is

through regulation. For example, FAA research has highlighted the need to
insulate aircraft maintenance engineers from commercial pressures. They
consider this would help to ensure that airworthiness issues will always take
precedence over commercial and time pressures. Time pressures can make
'corner-cutting' a cultural norm in an organization. Sometimes, only an
incident or accident reveals such norms (the extract from the Aloha accident
above exemplifies this).
(b) Those responsible for setting deadlines and allocating tasks should consider:
 Prioritizing 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 utilization of staff (considering an engineer's
specialization, and strengths and limitations);
 Availability of parts and spares.
(c) It is important that engineering staff at all levels are not afraid to voice
concerns over inappropriate deadlines, and if necessary, cite the need to do a
safe job to support this. As highlighted in Chapter 3, within aircraft
maintenance, responsibility should be spread across all those who play a part.
Thus, the aircraft maintenance engineer should not feel that the 'buck stops
here '.
5.4 WORKLOAD-OVERLOAD AND UNDERLOAD
5.4.1 General
(a) The preceding sections on stress and time pressure have both indicated that
a certain amount of stimulation is beneficial to an aircraft maintenance
engineer, but that too much stimulation can lead to stress or over-commitment
in terms of time. It is noteworthy that too little stimulation can also be a
problem.
(b) Before going on to discuss workload, it is important to consider this optimum

level of stimulation or arousal
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5.4.2 Arousal
(a) 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. There are people who are
overloaded by having to do more than one task at a time; on the other hand
there are people who appear to thrive on stress, being happy to take on more
and more work or challenges. Figure 5.1 shows the general relationship
between arousal and task performance.
(b) At low levels of arousal, our attention mechanisms will not be particularly
active and our performance capability will be low (complacency and boredom
can result). At the other end of the curve, performance deteriorates when
arousal becomes too high. To a certain extent, this is because we are forced
to shed tasks and focus on key information only (called narrowing of
attention). Best task performance occurs somewhere in the middle.
(c) In the work place, arousal is mainly influenced by stimulation due to work
tasks. However, surrounding environmental factors such as noise may also
influence the level of arousal. Figure 5.1 Optimum arousal leads to best task
performance
5.4.3 Factors Determining Workload
(a) An individual aircraft maintenance engineer can usually identify what work he
has to do quite easily. It is more difficult to assess how that work translates
into 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.]
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(b) As noted in the section on information processing in Chapter 3, humans have

limited mental capacity to deal with information. We are also limited
physically, in terms of visual acuity, strength, dexterity and so on. Thus,
workload reflects the degree etc which the demands of the work we have to
do it into our mental and physical capacities. Workload is subjective (i.e.
experienced differently by different people) and is affected by the nature of the
task, such as the:
 physical demands it requires (e.g. strength required, etc.);

 mental demands it requires (e.g. complexity of decisions to be made, etc.).
 the circumstances under which the task is performed, such as the:
 standard of performance required (i.e. degree of accuracy);
 time available to accomplish the task (and thus the speed at which the
task must be carried out);
 requirement to carry out the task at the same time as doing something
else;
 perceived control of the task (i.e. is it imposed by others or under your
control, etc.);
 environmental factors existing at time (e.g. extremes of temperature, etc.).
 the person and his state, such as his:
 skills (both physical and mental);
 his experience (particularly familiarity with the task in question);
 his current health and fitness levels;
 his emotional state (e.g. stress level, mood, etc.).
(c) As the workload of the engineer may vary, he may experience periods of
overload and underload. This is a particular feature of some areas of the
industry such as line maintenance.
5.4.4 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. Overload can occur for a wide range of reasons
based on the factors highlighted above. It may happen suddenly (e.g. if asked to
remember one further piece of information whilst already trying to remember a large
amount of data), or gradually. Although JAR145 states that "The JAR145 approved
maintenance organization must employ sufficient personnel to plan, perform,
supervise and inspect the work in accordance with the approval", and "the JAR145
organization should have a production man hours plan showing that it has sufficient
man hours for the work that is intended to be carried out", this does not prevent
individuals from becoming overloaded. As noted earlier in this section, it can be
difficult to determine how work translates into workload, both for the individual
concerned, and for those allocating tasks.
5.4.5 Underload
Underload occurs at low levels of workload (when the engineer becomes under
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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, such as missed information.
Underload can result from a task an engineer finds boring, very easy, or indeed a
lack of tasks. The nature of the aircraft maintenance industry means that available
work fluctuates, depending on time of day, maintenance schedules, and so forth.
Hence, unless stimulating 'housekeeping' tasks can be found, underload can be
difficult to avoid at times.
5.4.6 Workload Management
(a) Unfortunately, in a commercial environment, it is seldom possible to make

large amendments to maintenance schedules, nor eliminate time pressures.
The essence of workload management in aircraft maintenance should include:
 ensuring that staff has 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 recognize
when an overload situation is building up.
(b) 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.
(c) Thus, although workload varies in aircraft maintenance engineering, the

workload of engineers can be moderated. Much of this can be done by careful
forward planning of tasks, manpower, spares, tools and training of staff.
5.5 SLEEP, FATIGUE AND SHIFT WORK
5.5.1 What is Sleep?
(a) Man, like all living creatures has to have sleep. Despite a great deal of
research, the purpose of sleep is not fully understood.
(b) 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 characterized by five
stages of sleep:
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 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 continues 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
characterized 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.
(c) Stages 1 to 4 are collectively known as non-REM (NREM) sleep. Stages 2-4
are categorized as slow-wave sleep and appear to relate to body restoration,
whereas REM sleep seems to aid the strengthening and organization 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.
.
Figure-5.2: Different Types of Sleep
(d) As can be seen from Figure 5.2, 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. 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
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5.5.2 Circadian Rhythms
(a) Apart from the alternation between wakefulness and sleep, men have other
internal cycles, such as body temperature and hunger/eating. These are
known as circadian rhythms as they are related to the length of the day.
Circadian rhythms are physiological and behavioral functions and processes in the
body that have a regular cycle of approximately a day (actually about 25 hours in
man).
(b) Although, circadian rhythms are controlled by the brain, they are influenced
and synchronized by external (environmental) factors such as light.
An example of disrupting circadian rhythms would be taking a flight that crosses time
zones. This will interfere with the normal synchronization with the light and dark (day/
night). This throws out the natural link between daylight and the body is internal
clock, causing jet lag, resulting in sleepiness during the day, etc. Eventually
however, the circadian rhythm readjusts to the revised environmental cues.
(c) Figure 5.3 shows the circadian rhythm for body temperature. This pattern is
very robust, meaning that even if the normal pattern of wakefulness and sleep
is disrupted (by shift work for example), the temperature cycle remains
unchanged. Hence, it can be seen that if you are awake at 2-4 O'clock in the
morning, your body temperature is in a trough and it is at this time that is
hardest to stay awake. Research has shown that this drop in body
temperature appears to be linked to a drop in alertness and performance in
man.
(d) The engineer's performance at this 'low point' will be improved if he is well
rested, feeling well, highly motivated and well practiced in the skills being
used at that point. 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. These
include Three Mile Island, Chernobyl, and Bhopal, as well as the BAC1-11,
A320, and B737 incidents summarized in Chapter 2
5.5.3 Fatigue
(a) 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 also other factors, such as degree of motivation.
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Figure 5.3: The Circadian Rhythm for Internal Body Temperature
(b) Fatigue is typically caused by delayed sleep, sleep loss, resynchronization 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.
(c) 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;
 channeled 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 judgment and decision making leading to increased mistakes;
 abnormal moods -erratic changes in mood, depressed, periodically elated
and energetic;
 diminished standards of own work.
(d) AWN47 highlights the potential for fatigue in aircraft maintenance engineering:
"Tiredness and fatigue can adversely affect performance. Excessive hours of
duty and shift working, particularly with multiple shift periods or additional
overtime, can lead to problems. Individuals should be fully aware of the
dangers of impaired performance due to these factors and of their personal
responsibilities".
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5.5.4 Shift Work
(a) Most aircraft movements occur between 6 a.m. and 10 p.m. to fit in with the
requirements of passengers. Aircraft maintenance engineers are required
whenever aircraft are on the ground, such as during turn around. However,
this scheduling means that aircraft are often available for more significant
maintenance during the night. Thus, aircraft maintenance engineering is
clearly a 24 hour business and it is inevitable that, to fulfill commercial
obligations, aircraft maintenance engineers usually work shifts. Some
engineers permanently work the same shift, but the majority cycle through
different shifts. These typically comprise an 'early shift ', a 'late shift' or a 'night
shift', or a 'day shift' and a 'night shift' depending on the maintenance
organization.
(b) Advantages and Disadvantages of Shift Work: There are pros and cons to
working shifts. Some people welcome the variety of working different times
associated with regular shift work patterns. Advantages may include more
days off and avoiding peak traffic times when travelling to work. The
disadvantages of shift working are mainly associated with:
 working 'unsociable hours ',meaning that time available with friends,

family, etc. will be disrupted;
 working when human performance is known to be poorer (i.e. between 2
a.m. and 4 a.m.);
 problems associated with general resynchronization and disturbance of
the body’s various rhythms (principally sleeping patterns).
(c) Working at Night: Shift work means that engineers will usually have to work
at night, either permanently or as part of a rolling shift pattern. As discussed
earlier in this chapter, this introduces the inherent possibility of increased
human errors. Working nights can also lead to problems sleeping during the
day, due to the interference of daylight and environmental noise. Blackout
curtains and use of ear plugs can help, as well as avoidance of caffeine
before sleep.
In the B737 double engine oil loss incident, the error occurred during the night shift.
The accident investigation report commented that: "It is under these circumstances
that the fragility of the self monitoring system is most exposed because the safety
system can be jeopardized by poor judgment on the part of one person and it is also
the time at which people are most likely to suffer impaired judgment ".
(d) Rolling Shift Patterns: When an engineer works rolling shifts and changes
from one shift to another (e.g. 'day shift' to 'night shift'), the body's internal
clock is not immediately reset. It continues on its old wake-sleep cycle for
several days, even though it is no longer possible for the person to sleep
when the body thinks it is appropriate, and is only gradually resynchronized.
However, by this time, the engineer may have moved onto the next shift.
Generally, it is now accepted that shift rotation should be to later shifts (i.e.
early shift _ late shift _ night shift or day shift _ night shift) instead of rotation
towards earlier shifts (night shift _ late shift _ early shift).
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(e) 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
Hanover is potentially an area where human errors can occur. Whilst longer
shifts may result in greater fatigue, the disadvantages may be offset by the
fact that fewer shift changeovers are required (i.e. only 2 handovers with 2
twelve hour shifts, as opposed to 3 handovers with 3 eight hour shifts).Shift
Hanover is discussed further in Chapter 8 when looking at 'work logging and
recording'.
5.5.5 Sleep, Fatigue, Shift Work and the Aircraft Maintenance Engineer
(a) 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.
(b) As previously noted, fatigue is best tackled by ensuring adequate rest and
good quality sleep is obtained. The use of blackout curtains if having to sleep
during daylight has already been mentioned. It is also best not to eat a large
meal shortly before trying to sleep, but on the other hand, the engineer should
avoid going to bed hungry. As fatigue is also influenced by illness, alcohol,
etc., it is very important to get more sleep if feeling a little unwell and drink
only in moderation between duties (discussed further in the next
section).Taking over-the-counter drugs to help sleep should only be used as a
last resort.
(c) When rotating shifts are worked, it is important that the engineer is disciplined
with his eating and sleeping times. Moreover, out of work activities have to be
carefully planned. For example, it is obvious that an individual who has been
out night-clubbing until the early hours of the morning will not be adequately
rested if rostered on an early shift.
(d) Shift working patterns encountered by aircraft maintenance engineers may

include three or four days off after the last night shift. It can be tempting to
work additional hours, taking voluntary overtime, or another job, in one or
more of these days off. This is especially the case when first starting a career
in aircraft maintenance engineering when financial pressures may be higher.
Engineers should be aware that their vulnerability to error is likely to be
increased if they are tired or fatigued, and they should try to ensure that any
extra hours worked are kept within reason.
It is always sensible to monitor ones performance, especially when working

additional hours. Performance decrements can be gradual, and first signs of chronic
fatigue may be moodiness, headaches or finding that familiar tasks (such as
programming the video recorder) seem more complicated than usual.
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(e) Finally, it is worth noting that, although most engineers adapt to shift working,
it becomes harder to work rotating shifts as one gets older.
5.6 ALCOHOL, MEDICATION AND DRUG ABUSE
5.6.1 General
(a) It should come as no surprise to the aircraft maintenance engineer that his
performance will be affected by alcohol, medication or illicit drugs. Under both
UK and JAA legislation it is an offence for safety critical personnel to carry out
their duties whilst under the influence of alcohol or drugs. Article 13
(paragraph 8) of the UK ANO, states:
"The holder of an aircraft maintenance engineer's licence shall not, when

exercising the privileges of such a licence, be under the influence of drink or a
drug to such an extent as to impair his capacity to exercise such privileges."
(b) The current law which does not prescribe a blood/alcohol limit is soon to
change. There will be new legislation permitting police to test for drink or
drugs where there is reasonable cause, and the introduction of a
blood/alcohol limit of 20 milligrams of alcohol per 100 milliliters of blood for
anyone performing a safety critical role in UK civil aviation (which includes
aircraft maintenance engineers).
5.6.2 Alcohol
(a) 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 judgment (i.e. ability to gauge his
performance)to be hindered.
(b) 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.
(c) AWN47 provides the following advice concerning alcohol:

"Alcohol has similar effects to tranquilizers and sleeping tablets and may
remain circulating in the blood for a considerable time, especially if taken with
food. It may be borne in mind that a person may not be fit to go on duty even
8 hours after drinking large amounts of alcohol. Individuals should therefore
anticipate such effects upon their next duty period. Special note should be
taken of the fact that combinations of alcohol and sleeping tablets, or anti-
histamines, can form a highly dangerous and even lethal combination."
As a general rule, aircraft maintenance engineers should not work for at least eight
hours after drinking even small quantities of alcohol and increase this time if more
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has been drunk.
(d) The affects of alcohol can be made considerably worse if the individual is
fatigued, ill or using medication.
5.6.3 Medication
(a) Any medication, no matter how common, can possibly have direct effects or
side effects that may impair an engineer's performance in the workplace.
(b) 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. Hence, an
aircraft maintenance engineer should be particularly careful when taking a
medicine for the first time, and should ask his doctor whether any prescribed
drug will affect his work performance. It is also wise with any medication to
take the first dose at least 24 hours before any duty to ensure that it does not
have any adverse effects.
Medication can be regarded as any over-the-counter or prescribed drug used for

therapeutic purposes. Medication is usually taken to relieve symptoms of an illness.
Even if the drugs taken do not affect the engineer's performance, he should still ask
himself whether the illness has made him temporarily unfit for work.
(c) Various publications and especially AWN47 gives advice relevant to the
aircraft maintenance engineer on some of the more common medications.
This information is summarized below, however the engineer must use this
with caution and should seek further clarification from a pharmacist, doctor or
their company occupational health advisor if at all unsure of the impact on
work performance.
 Analgesics are used for pain relief and to counter the symptoms of colds and
'flu. In the UK, paracetamol, aspirin and ibuprofen are the most common, and
are generally considered safe if used as directed. They can be taken alone
but are often used as an ingredient of a 'cold relief' medicine. It is always
worth bearing in mind that the pain or discomfort that you are attempting to
treat with an analgesic (e.g. headache, sore throat, etc.) may be the symptom
of some underlying illness that needs proper medical attention.
 Antibiotics (such as Penicillin and the various mycins and cyclines) may
have short term or delayed effects which affect work performance. Their use
indicates that a fairly severe infection may well be present and apart from the
effects of these substances themselves, the side-effects of the infection will
almost always render an individual unfit for work.
 Anti-histamines are used widely in 'cold cures ' and in the treatment of
allergies (e.g. hayfever).Most of this group of medicines tend to make the user
feel drowsy, meaning that the use of medicines containing anti-histamines is
likely to be unacceptable when working as an aircraft maintenance engineer.
 Cough suppressants are generally safe in normal use, but if an over-the-
counter product contains anti-histamine, decongestant, etc., the engineer
should exercise caution about its use when working.
 Decongestants (i.e. treatments for nasal congestion) may contain chemicals
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such as pseudo-ephedrine hydrochloride (e.g. 'Sudafed') and phenylphrine.

Side-effects reported, are anxiety, tremor, rapid pulse and headache. AWN47
forbids the use of medications containing this ingredient to aircraft
maintenance engineers when working, as the effects compromise skilled
performance.
 'Pep' pills are used to maintain wakefulness. They often contain caffeine,
dexedrine or benzedrine. Their use is often habit forming. Over-dosage may
cause headaches, dizziness and mental disturbances.AWN47 states that "the
use of 'pep ' pills whilst working cannot be permitted. If coffee is insufficient,
you are not fit for work."
 Sleeping tablets (often anti-histamine based) tend to slow reaction times and
generally dull the senses. The duration of effect is variable from person to
person. Individuals should obtain expert medical advice before taking them.
(d) Melatonin (a natural hormone) deserves a special mention. Although not

available without a prescription in the UK, it is classed as a food supplement
in the USA (and is readily available in health food shops). It has been claimed
to be effective as a sleep aid, and to help promote the resynchronization of
disturbed circadian rhythms. Its effectiveness and safety are still yet to be
proven and current best advice is to avoid this product.
If the aircraft maintenance engineer has any doubts about the suitability of working
whilst taking medication, he must seek appropriate professional advice.
5.6.4 Drugs
(a) Illicit (illegal) 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. Of course, their possession and use are also illegal in the UK.
(b) Smoking cannabis can subtly impair performance for up to 24 hours. In

particular, it affects the ability to concentrate, retain information and make
reasoned judgments, especially on difficult tasks.
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Chapter - 6
PHYSICAL ENVIRONMENT
6.0 INTRODUCTION
6.1 NOISE
6.2 FUMES
6.3 ILLUMINASION
6.4 CLIMATES AND TEMPERATURE
6.5 MOTION AND VIBRATION
6.6 WORKING ENVIRONMENT
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6.0 INTRODUCTION
(a) The physical environment plays an important role in the maintenance

engineers' ability to do their job properly. It is included as a separate chapter
of human factors and error management because we, as humans, tend to just
do the best with what we have got given any set of circumstances.
Increasingly, this behavior is not acceptable in a safety conscious civil aviation
industry and organizations are necessarily looking at increased safety
performance and improved productivity. The physical environment, and in
particular, the maintenance engineer's sensitivity to his or her surroundings,
plays a major role in the number of errors that are committed by individuals
and the timeliness within which any job can be done satisfactorily.
(b) This chapter will not cover all aspects of the physical environment but rather
concentrate on a few that are recognized as a concern for aircraft
maintenance engineers. Noise, fumes and illumination will be covered
specifically before we look at more general topics of climate and temperature,
motion and vibration and the maintenance engineer's working environment.
(c) The expanded elements of this chapter will be:
Noise: Specifies various levels of noise in decibels at which various grades of

hearing protection are required; specify noise levels at which hearing damage may
or may not occur; describe how noise intensity and period of exposure to noise work
together to cause hearing damage; describe what is meant by the "action threshold"
for hearing protection; describe why it is important to wear proper hearing protection
when working around aircraft on the ramp.
Fumes: Recognizes catalysts for toxic fume generation and appropriate actions in
various circumstances with respect to self, work colleagues and the public; identify
other hazards due to fume generation.
Illumination: Describes how illumination of an object varies as a function of distance

from light source; describe what causes glare and give examples of how it may be
eliminated in a workshop; describe how shadows may be eliminated in lighting of a
workshop.
Climate and Temperature: Describes how temperature, humidity and airflow can
affect human performance and state the levels of tolerance people have to such.
elements.
Motion and Vibration: Describes possible debilitating effects of excessive

motion and/or vibration and the various countermeasures that can be employed by
individuals.
Working Environment: Describes how human performance can be positively

influenced by adopting a user or work centered approach to designing facilities for
carrying out aircraft maintenance activities; describe effects of a poorly designed
workplace on work output and human performance.
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6.1 NOISE
(a) The first point is that there are two separate issues associated with noise and
human factors. The first one we covered in some depth in Chapter 3 when we
described the workings of our information processing capability. In this
chapter we noted that we had a sensory memory, or sensory register, that
picked up a whole range of stimuli in the environment. One of those sensory
memories was associated with the auditory, or aural system. The aural
system used the ears and is our basis for hearing.
(b) Noise in this context is all of the sensory information that comes in through the
ears. We know from Chapter 3 that we need to attend to specific elements of
noise to listen to them, hence the first major issue associate with noise is the
discrimination between what is that we want to listen to and the rest of the
information that comes in through our auditory system. In general terms, the
unwanted information is called "noise".
(c) This chapter will concentrate on the physical aspects of noise, that is, the
manifestation of sound actually entering the ear and how much of it engineers
should be exposed to before it causes them problems. Noise is measured in
decibels and normally rated on a scale called the "A" scale. The amount of
noise that a worker can withstand for either short or long durations can be
measured on this scale and there is a lot of research to demonstrate what
levels are acceptable and what levels eventually cause damage to the hearing
system. Many countries now in fact legislate through occupational health and
safety guidelines how much noise on this scale is acceptable and over what
period. This is commonly called a "time weighted average". The generally
accepted thresholds that have been produced by the research is 85 dBA
(Action Threshold) before companies are required to begin an active program
of hearing conservation, and that at 90 dBA, hearing protection, individuals
must wear some form of hearing protection.
(d) Figure 6.1: Illustrates A-scale of noise. This is the A-scale that shows deci-
Bel (dBA) levels for common noises to provide some reference points.
(e) We will note that the zero point is the threshold of hearing. A whisper rates at
around 20dBA, a normal office environment at 45 dBA and a shouting voice at
100. The table presented provides an indication of the amount of time we can
spend at different sound levels without incurring permanent damage.
(f) The danger area is annotated to the left of the scale on the diagram from 85
dBA onwards for ambient noise. We can see that a jet aircraft rates well
above the action thresholds at 120 dBA. This means that at any time we may
be working around running jet engines in our profession as a maintenance
engineer, we should be wearing hearing protection. See Table 6.1.
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6.2 FUMES
(a) Fumes are an issue that is commonly ignored until after a disastrous event.
The reason for this appears to be the insidious (dangerous)or sneaky nature
in which fumes affect individuals. It is included here as part of the working
environment to raise the awareness of the possible dangers associated with
fumes in the workplace.
(b) The first point to make is that, the places that toxic fumes are most likely to be
generated, are most likely already signposted as dangerous areas. In most
cases, the items that would generate toxic fumes and/or be the catalyst for the
generation of toxic fumes are often dangerous or toxic chemicals themselves,
in solid or liquid form. In these cases, they are likely to be well signposted
through regulation. Examples are battery bays, storage areas for petroleum
based lubricants, and acid baths. In each of these cases we would expect the
mandatory signposting informing workers of the associated dangers with
particular reference to their flammability, which is normally brought about by
fire regulations.
(c) These warnings, however, do not often include the dangers associated with
any fumes that are generated by such places, but one should assume that
such storage places or work places will emit toxic fumes should they catch fire
and/or change their status from solids or liquids to gas. Areas of particular
concern include:
 Composites
 Degreasers and solvents
 De-icing fluids
 Fuels and flammables
(d) Apart from these well-known items, there is the possibility of toxic fume
generation by a range of ordinary every day products once a fire starts.
Examples include the plastics in computers, compounds used for upholstery
in the office chairs and a number of compounds in everyday clothing.
(e) If we have any doubt, we should undertake an emergency egress and worry
about whether we were correct or not afterwards. As for passengers on an
aircraft, workers on the job should also be informed about emergency egress,
to use the proper terminology. In particular, formal egress instructions require
we are to look after ourselves in the first instance. We can't help others if we
are on the floor of the workshop after being overcome by fumes. Once the
safety is assured, we can raise the alarm and help others where possible
without putting ourselves in danger. For fume generation, one of the most
important requirements is to be able to supply as much accurate information
as possible to the experts so that they can make an informed decision on how
to handle the problem. Sites of possible toxic fume generation are no place to
be a hero. It requires specialist knowledge on antidotes as well as special
breathing apparatus to overcome the problem.
(f) Some other hazards associated with fume generation include:

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Insidious toxicity: This is where the fumes are odorless or are below the
smelling threshold of humans and gradually sneak up on workers without their
knowledge. An example would include carbon monoxide poisoning by leaving
space.
Air pollution: is self-explanatory. The dark clouds emanating from burning

rubber are testament to the air pollution capability of fumes. What is less well
known is that air pollution doesn't need to be visible to be very dangerous.
Again, carbon monoxide is an example.
Egress accidents: These occur when exit from the workspace is not orderly
or panic occurs. There is a lot of documented evidence that people can get
very badly injured during evacuation from a building.
6.3 ILLUMINASION
6.3.1 General
(a) The sense of sight also gives us some problems in the our primary source of
sensory organ and we have discussed some illusions that one may suffer
from;, there are also other aspects that can cause us problems. In general this
is to do with illumination.
(b) Illumination in the workplace provides us with the capability to be able to see
things clearly or not as the case may be. It is included here as part of the
physical environment because it has been cited as a causal factor in so many
accidents and incidents. It has also been fairly well scrutinized in terms of
research for improving illumination in the workplace and Chapter 5 of the FAA
Guide has a particularly good synopsis of the issues associated with lighting
in the workplace and is specifically addressed at the problems of maintenance
engineers.
(c) Illumination is the technical measurement of how much light is falling on an

object which necessarily has an impact on how well we can see it.
(d) From Chapter 5 of the FAA Guide, "the source of luminance is a light of some
type. Permanent light sources in facilities are generally fixed to a ceiling or
wall. As we move away from these light sources, the intensity of illumination
decreases. In fact, it decreases predictably as the square of the distance. If
we double the distance between an object and a light source, the luminance
measured at the object drops to one-fourth its previous level." It suggests that
the best source of luminance is not direct light but rather an even diffuse
lighting which requires a number of light sources.
(e) It also states that, "Regardless of the placement of light fixtures, the floor area
beneath the wing of a large transport aircraft is likely to be shielded from full
direct lighting. To raise, the illumination level in such areas, the hangar's
ceiling, walls, floors, and fixed equipment must be painted so that they reflect
a good part of the light falling on them. Reflectance is normally specified in
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'percent'. A reflectance value of 50% means that the surface reflects half of
the light falling on it."
6.3.2 Direct Glare
(a) As an aspect of illumination, direct glare onto our sight sense organs, the rods
and cones on our retina, can cause us serious problems as well. Direct glare
occurs when people look directly at light sources. It causes most problems
when the glare falls directly onto the fovea of the eye where we pick up most
of our visual information. The-chapter on Human Performance and Limitations
discussed the fovea as the area on the retina with the greatest concentration
of rods and particularly cones and as such picks up the most light.
(b) Problems caused by direct glare increase as the light sources get closer to a '
viewer's normal line of sight. The worst performance problems occur when a
light source is directly in the viewer's line of sight. These problems decrease
as the light source is raised above the line of sight. See figure-6.2 illustrating
the glare zones.
(c) The so-called "direct glare zone" is taken as that between 0 and 45 degrees
above the line of sight. In practice, light sources should be placed at the
highest available angle to the viewer's line of sight.
6.3.3 Indirect Glare
(a) Indirect glare is much less of a problem but it is nonetheless a source of error.
It is caused by light being reflected from highly reflective surfaces.
(b) The effects of indirect glare, while not generally as debilitating as those of
direct glare, can reduce performance. Direct sunlight shining on a stainless
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steel bench can be both distracting and inhibit our ability to see in the shadow
areas of the machinery we are working on. This is because the iris of the eye
contracts to reduce the amount of light entering the eye so as not to damage
the photoreceptors. What it means though is that our eye no longer picks up
anything in the areas that aren't well illuminated.
(c) Indirect glare is however, relatively easy to control. This can be done by:
 Coating reflecting surfaces with flat paint,

 Moving light sources out of locations where they cause reflections,
 Equipping light sources with diffusers or polarizing lenses.
6.4 CLIMATE AND TEMPERATURE
(a) Humans have been able to work to some extent or other in just about every
environment on Earth. This has not always been the case though and much of
it has to do with the range of temperatures in which we can work. The human
body has a fairly narrow set of parameters and in many parts of the world we
have had to wait for technology to provide us with the capability to modify the
local climate through heating or cooling before any productive work could be
done.
(b) In the modern world, we tend to rely on air conditioning systems to cool the
working environment down for us in the tropics and heaters to warm things up
for us in more temperate parts of the world.
(c) Without these climate modifications we quickly become susceptible to error

both physically and mentally. Differences don't have to be extreme, just
outside our normal comfort zone, for us to have a diminished performance.
The further the climate and temperature is outside the normal comfort zone,
the more debilitating the effects. See Figure-6.4 illustrating the human
comfort zone.
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(d) Establishing a safe and comfortable working environment requires the

maintenance of a worker's internal body temperature ("core" temperature)
within a certain narrow range. Various environmental and work factors affect
body temperature. Both the core temperature and the subjective feeling of
comfort are affected by:
 Air temperature,
 Radiant heat,
 Humidity,
 Air velocity,
 Type of work, and
 Clothing
6.5 MOTION AND VIBRATION
(a) Motion and vibration in the aviation industry are more considered to be
hazards for the pilots. The engineer does however; get involved in a number
of tasks that can be subjected to some major motion or vibration input. A
simple example would include test flying an aircraft following maintenance
work but there are any number of equipment types used by engineers that
could cause problems.
(b) Motion sickness is an obvious problem and while it does not last for a long
time, it can prevent any work from taking place at all while the sufferer comes
to terms with it.
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(c) Distraction is the most common issue associated with motion and vibration
and the source of many errors of omission.
(d) Habituation can also be bought on by both motion and vibration and there is a
particularly fatiguing aspect to prolonged exposure to either which once again
leads to error being made unintentionally by engineers.
(e) The best countermeasure to these possible effects is awareness. If engineers

are alerted to the possibility and probability that their work will be negatively
affected by such things, they are more likely to be vigilant and call in support
to check the work they are doing.
(f) Most sets of Standard Operating Procedures (SOPS) will ensure that the
procedures don't set engineers up to be caught in these traps and in many
countries, the OSH (Occupational Safety & Health) guidelines are equally
cautious about the possible debilitating effects of motion and vibration.
(g) There is also medication available now to suppress the effects of motion
sickness.
6.6 WORKING ENVIRONMENT
6.6.1 General
(a) Workplace design and job design are usually treated separately; however, it is
difficult to change a workplace without changing the way a job is done.
Likewise, even slight changes in a job's structure or content can drastically
affect what is an appropriate workplace. In this section we will consider the
two issues or workplace design and job design where a workplace design
centers on the task and the job design centers around the worker and how
they might achieve the required work.
(b) The argument will suggest that:
 Workplace redesign improves:
1. Posture
2. Productivity
3. Quality
4. Safety
 Job redesign:
1. Increases job satisfaction

2. Reduces process errors (therefore improves safety)
6.6.2 Workplace design
(a) Examples of poor workplace design can be found in many maintenance

operations. Due to an aircraft's structural design, components may not be
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easily accessible, resulting in:
1. Awkward postures,
2. Restricted space for movement, and
3. Decreased safety and performance.
(b) In workshops, postural problems can be caused by:
1. Benches located at inappropriate heights,

2. Heavy power tools with ill-designed handles, and
3. Uncomfortable chairs.
(c) Appropriately designed workplaces with well-chosen access stands, benches,

chairs, and tools can improve both safety and productivity.
(d) Improving lighting that reduces the need for close viewing improves working
posture.
(e) Applying an ergonomics audit to the broad spectrum of maintenance and

inspection jobs can reveal examples of poor and of good design for
elimination and emulation, respectively.
6.6.3 Job Design
(a) Aircraft inspection and maintenance are part of a complex activity chain that
includes scheduling, planning, and cleaning. For such tightly-scheduled
activities, safe and efficient outcomes require that team members work
together smoothly and intelligently. The consequences of poor job design
include errors, delays, and frustration.
(b) When activities are not well-coordinated or when workers are unaware of how
tasks are linked together, good teamwork cannot exist. Symptoms of poor job
design include
1. Disputes over who has authority;

2. Physical interference between activities, such as inspection and
cleaning; and,
3. Inability to respond smoothly to unplanned events, such as
discovering an unusual structural defect.
(c) The symptoms also appear when team members are interviewed or surveyed
to determine their job satisfaction and frustrations.
(d) Extreme job design problems are measured by absenteeism, rapid workforce
turnover, and union grievances. This is in fact one of the most expensive
issues associated with maintenance engineering. The cost of retraining
somebody or of employing a new person once someone has left due to
dissatisfaction is fairly major. Not only do we lose the experience associated
with the incumbent, but also employing somebody new then requires both
training and experience to reach the same level of competence or expertise.
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These are usually hidden costs in an engineering firm because most human
resource departments count the numbers, i.e. "bums in seats", as distinct from
the competence and capabilities. That becomes the problem of the line
manager.
Figure-6.5 Components of the 'working environment'
(e) An example provided Chapter 6 of the FAA Guide gives a situation in which
both workplace design and job design were addressed. In maintenance
engineering, facility that specialized in complex electronic component
assembly, changes were made over an 18-month period. At the end of this
time, productivity was up by 5%, quality of workmanship had improved by
50%, job satisfaction had increased by 60% and workplace injuries had all but
been eliminated.
(f) Both work design and job design can improve performance but to attend to
one of them either at the expense of the other or just as a standalone item is
unlikely to reap the benefits of doing both. By that it is suggested that if a work
redesign can bring about a 5% increment in productivity improvement and job
redesign can bring about a 7% improvement, the probably improvement of
doing both is more than additive.
(g) In summary, the days of achievement-based workplace environments that

concentrate solely on output of individuals have been replaced by a more
holistic attitude to the working environment. This includes both workplace
design and job design with a human-centered approach and the total
organizational output of those that improve these are as in substantially higher
than those with an achievement based approach to their working
environment.
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Chapter 7
TASKS
7.0 INTRODUCTION
7.1 PHYSICAL WORK
7.2 REPETITIVE TASKS
7.3 VISUAL INSPECTION
7.4 COMPLEX SYSTEMS
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7.0 INTRODUCTION
(a) In this chapter we will consider some of the more day-to-day workings of the
maintenance engineer's job. We will analyze aspects of the physical work that
must be undertaken to get the job done and some of the aspects of this that
lead to both injury and error.
(b) We are all aware that people can hurt their backs lifting heavy weights, or fall
off ladders that haven't been positioned correctly, and this section will provide
some insight into strategies for preventing those injuries from occurring.
(c) We will take this aspect a little further in a section on repetitive tasks, which is
a special case that can lead to error and injury. There are two separate
aspects to repetitive task that we will need to address. The first is the physical
aspect of doing the same thing again and again using the same muscles in
the same way. The second aspect will reflect our mental capacity to maintain
concentration when required to undertake the same tasks over and over
again.
(d) Visual inspection will be a special case of this and will also take up a section
on its own. By its very nature, visual inspection lends itself to error that has
been traditionally blamed on the individuals when in fact we are all susceptible
to making those same types of errors. This will be followed by a consideration
of the requirements of the maintenance engineer's job as a complex system
and what tools we might have available to us that can provide improvements
to the total system.
7.1 PHYSICAL WORK
7.1.1 Planning
(a) 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:
i) Do I/we know exactly what the task is that has to be done?

ii) Are the resources available to do it effectively (safely, accurately and within
the time permitted)? Where resources include:
• personnel;
• equipment/spares;
• documentation, information and guidance;
• facilities such as hangar space, lighting, etc.
ii) Do I/we have the skills and proficiency necessary to complete the task?
(b) Information about specific tasks should be detailed on job cards or task
sheets. These will indicate the task (e.g. checks or inspection, repair,
replacement, overhaul) and often further details to aid the engineer (such as
maintenance manual references, part numbers, etc.).
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If the engineer is in any doubt what needs to be done, written guidance material is
the best resource. Colleagues may unintentionally give incorrect or imprecise
direction (the exception to this is discussing problems that arise that are not covered
in the guidance material).
(c) It is generally the shift supervisor's job to ensure that the resources are
available for his staff to carry out their tasks. As noted in Chapter 4, (Time
Pressure and Deadlines), it is likely that, within a shift or a team, various sub-
tasks are allocated to individuals by the supervisor. Alternatively, he may
encourage a team to take ownership of the tasks that need to be completed,
giving them the discretion to manage a package of work (as noted in Chapter
4(Team Working). Exactly 'who does what' is likely to be based on factors
such as individuals' specialization (i.e. A&C or avionics) and their experience
with the task.
(d) Although management has 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 recognized that peer and management
pressure may make this difficult.
7.1.2 Physical Tasks

(a) Aircraft maintenance engineering is a relatively active occupation. Regardless
of the job being done, most tasks tend to have elements of fine motor control,
requiring precision, as well as activities requiring strength and gross
manipulation.
(b) 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.
As an engineer gets older, the musculoskeletal system stiffens and muscles become
weaker. Injuries become more likely and take longer to heal. Staying in shape will
minimize the effects of aging, but they still occur.
(c) It is important that maintenance tasks on aircraft are within the physical
limitations of aircraft maintenance engineers. Boeing use a computerized tool,
based on human performance data (body sizes, strengths, leverages, pivots,
etc), to ensure that modern aircraft are designed such that the majority of
maintenance engineers will be able to access aircraft equipment, apply the
necessary strength to loosen or tighten objects, etc. (i.e. designed for ease of
maintainability).
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(d) 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, and in some situations, may make a task
achievable that was hitherto(up till now) outside our physical powers (e.g.
lifting an aircraft panel with the aid of a hoist).
(e) As noted earlier, physical work over a period of time will result in fatigue. This
is normally not a problem if there is adequate rest and recovery time between
work periods. It can, however, become a problem if the body is not allowed to
recover, possibly leading to illness or injuries. Hence, 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. As a consequence, work may slow and mistakes may occur that need to
be rectified.
(f) As discussed earlier, it is very important that engineers should try to ensure
that their physical fitness is good enough for the type of tasks, which they
normally do.
7.2 REPETITIVE TASKS
(a) Repetitive tasks can be tedious and reduce arousal (i.e. be boring). Most of
the human factors research associated with repetitive tasks have been carried
out in manufacturing environments where workers carry out the same action
many times a minute. This does not generally apply to maintenance
engineering.
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, e.g. in the course of a week. An example of this would be the checking life
jackets on an aircraft during daily inspections.
(b) Some engineers may specialize in a certain aspect of maintenance, such as

engines. As a result, they may possibly carry out the same or similar tasks
several times a day.
(c) The main danger with repetitive tasks is that engineers may become so
practiced 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, especially if it is to check something which is rarely found to be
wrong, damaged or out of tolerance. This applies particularly to visual
inspection, which is covered in greater detail in the next section.
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[In the Aloha accident report, the NTSB raised the problem of repetitive tasks: "The
concern was expressed about what kinds of characteristics are appropriate to
consider when selecting persons to perform an obviously tedious, repetitive task
such as a protracted NDI inspection. Inspectors normally come up through the
seniority ranks. If they have the desire, knowledge and skills, they bid on the position
and are selected for the inspector job on that basis. However, to ask a technically
knowledgeable person to perform an obviously tedious and exceedingly boring task,
rather than to have him supervise the quality of the task, may not be an appropriate
use of personnel”.
(d) Making assumptions along the lines of “Oh I have done that job dozens of
times!” can occur even if a task has not been undertaken for some time. It is
always advisable to be wary of changes to procedures or parts, remembering
that 'familiarity breeds Contempt'.
7.3 VISUAL INSPECTION
(a) Visual inspection is one of the primary methods employed during

maintenance to ensure the aircraft remains in an airworthy condition.
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
(b) 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.). He may also manipulate the element being inspected to make
further judgments’ about its condition. For instance, he might feel a surface for
unevenness, or push against it to look for any unanticipated movement.
(c) As pointed out earlier, good eyesight is of prime importance in visual

inspection, and it was noted that the UK CAA have provided some guidance
on eyesight in AWN47. Amongst other things, this calls for glasses or contact
lenses to be used where prescribed and regular eyesight checks to be made.
(d) 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 judgments about what he sees. To do this, he
brings to bear training, experience and common sense. Thus, reliable visual
inspection requires that the engineer first sees the defect and then actually
recognizes that it is a defect. Of course, experience comes with practice, but
telltale signs to look for can be passed on by more experienced colleagues.
Information such as technical bulletins is important as they prime the inspector of

known and potential defects and he should keep abreast of these. For example, blue
staining on an aircraft fuselage may be considered insignificant at first sight, but
information from a Technical Bulletin of 'blue ice ' and external toilet leaks may
make the engineer suspicious of a more serious problem.
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(e) 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
(considering factors described in Chapter 6: "Physical Environment", such
as lighting, access, etc.);
 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.
(f) Visual inspection requires a considerable amount of concentration. Long

spells of continuous inspection can be tedious and result in low arousal. An
engineer's low arousal or lack of motivation can contribute to a failure to spot
a potential problem or a failure in recognizing a defect during visual
inspection. The effects are potentially worse when an inspector has a very low
expectation of finding a defect, e.g. on a new aircraft.
(g) Engineers may find it beneficial to take short breaks between discrete visual
inspection tasks, such as at a particular system component, frame, lap joint,
etc. This is much better than pausing midway through an inspection.
The Aloha accident highlights what can happen when visual inspection is poor. The
accident report included two findings that suggest visual inspection was one of the
main contributors to the accident.
 "There are human factors issues associated with visual and non-
destructive inspection which can degrade inspector performance to the
extent that theoretically detectable damage is overlooked”.
 'Aloha Airlines management failed to recognize the human performance

factors of inspection and to fully motivate and focus their inspector force
toward the critical nature of lap joint inspection, corrosion control and crack
detection."
(h) 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).
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7.4 COMPLEX SYSTEMS
(a) All large modern aircraft can be described as complex systems. Within these
aircraft, there are a myriad(countless) of separate systems, many of which
themselves may be considered complex, e.g. flying controls, landing gear, air
conditioning, flight management computers. Table 7.1 gives an example of
the breadth of complexity in aircraft systems.
Any complex system can be thought of as having a wide variety of inputs. The
system typically performs complex modifications on these inputs or the inputs trigger
complex responses. There may be a single output, or many distributed outputs from
the system.
(b) The purpose, composition and function of a simple system are usually easily
understood by an aircraft maintenance engineer. In other words, the system is
transparent to him. Faultfinding and diagnosis should be relatively simple with
such systems (although appropriate manuals etc. should be referred to where
necessary).
(c) 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 conceptualize -it is opaque to the engineer.
(d) To maintain such complex systems, it is likely that the engineer will need to
have carried out some form o system-specific training which would have
furnished him with an understanding of how it works (and how it can fail) and
what it is made up of (and how components can fail). It is important that the
engineer understands enough about the overall functioning of a large,
complex aircraft, but not so much that he is overwhelmed by its complexity.
Thus, system-specific training must achieve the correct balance between
detailed system knowledge and analytical troubleshooting skills.
Table 7.1: Example of increasing complexity-the aileron system
TYPE OF NATURE OF SYSTEM

AILERON
Simple aileron Direct connection from control column to control surface;

direct movement.
Servo tab Direct connection from control column to servo tab,
aileron aerodynamic movement of surface.
Powered aileron Connection from control column to servo valve via input;
hydraulic movement of surface; feedback mechanism;
position indication.
Powered aileron As above but with interface to spoiler input system to
/ roll spoiler provide additional roll capability.
Fly-by-wire No connection from control column to surface. Electrical
aileron system command signal to electro-hydraulic servo valve on
actuator; signal modified and limited by intermediate
influence of flight control computer.
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(e) With complex systems within aircraft, written procedures and reference
material become an even more important source of guidance than with simple
systems. They may describe comprehensively the method of performing
maintenance tasks, such as inspections, adjustments and tests. They may
describe the relationship of one system to other systems and often, most
importantly, provide cautions or bring attention to specific areas or
components. It is important to follow the procedures to the letter, since
deviations from procedures may have implication on other parts of the system
of which the engineer may be unaware.
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.
(f) In modern aircraft, it is likely that the expertise to maintain a complex system
may be distributed among individual engineers. Thus, avionics engineers and
A&C engineers may need to work in concert to examine completely a system
that has an interface to the pilot in the cockpit (such as the undercarriage
controls and indications).
(g) A single modern aircraft is complex enough, but many engineers are qualified
on several types and variants of aircraft. This will usually mean that he has
less opportunity to become familiar with one type, making it even more
important that he sticks to the prescribed procedures and refers to the
reference manual wherever necessary. There is a particular vulnerability
where tasks are very similar between a number of different aircraft (e.g.
spoiler systems on the A320, B757 and B767 1), and may be more easily
confused if no reference is made to the manual.
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Chapter 8
COMMUNICATION
8.0 INTRODUCTION
8.1 PROCESS OF COMMUNICATION
8.2 MODES OF COMMUNICATION
8.3 COMMUNICATION WITHIN AND BETWEEN TEAMS
8.4 COMMUNICATION PROBLEMS
8.5 WORK LOGGING AND RECORDING
8.6 KEEPING UP-TO-DATE
8.7 DISSEMINATION OF INFORMATION
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8.0 INTRODUCTION
(a) Good communication is important in every industry. In aircraft maintenance

engineering, it is vital. Communication, or more often a breakdown in
communication, is often cited as a contributor to aviation incidents and
accidents. It is for this very reason that it has its own importance in the Human
Factors course. Various aspects of communication that affect the aircraft
maintenance engineer are highlighted in this section.
(b) Broadly defined, communication is the process of meaningful interaction

among persons in an organization, resulting in meanings being perceived and
understanding effected among such persons.
Communication is defined in the Penguin Dictionary of Psychology as:
"The transmission of something from one location to another. The 'thing' that
is transmitted may be a message, a signal, a meaning, etc. In order to have
communication both the transmitter and the receiver must share a common
code, so that the meaning or information contained in the message may be
interpreted without error".
8.1 PROCESS OF COMMUNICATION
(a) We are communicating almost constantly, whether consciously or otherwise.

An aircraft maintenance engineer might regularly communicate:
 Information;
 Ideas;
 Feelings;
 Attitudes and beliefs
(b) As the sender of a message, he will typically expect some kind of response
from the person he is communicating with (the recipient), which could range
from a simple acknowledgement that his message has been received (and
hopefully understood), to a considered and detailed reply. The response
constitutes feedback.
(c) The communication process can be shown in the following model:
SOURCE/RECEIVER ENCODE MESSAGE CHANNEL DECODE RECEIVER/SOURCE
MENTAL FILTER
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8.2 MODES OF COMMUNICATION
8.2.1 Different modes
As can be seen in the above definition, communication can be:
 Verbal/spoken -e.g. a single word, a phrase or sentence, a grunt;

 Written/textual -e.g. printed words and/or numbers on paper or on a
screen, hand written notes;
 Non-verbal -
 Graphic e.g. pictures, diagrams, hand drawn sketches, indications on a
cockpit instrument;
 Symbolic e.g. “thumbs up”, wave of the hand, nod of the head;
 Body language e.g. facial expressions, touch such as a “pat on the
back”, posture.
8.2.2 Verbal and Written Communication
(a) Generally speaking, verbal and written communication is purposeful. For a

spoken or written message to be understood, the sender has to make sure
that the receiver:
 Is using the same channel of communication;

 Recognizes and understands his language;
 Is able to make sense of the message's meaning;
(b) The channel of communication is the medium used to convey the message.
For spoken communication, this might be face-to-face, or via the telephone.
Written messages might be notes, memos, documents or e-mails.
(c) In the UK it is expected that aircraft maintenance engineers will communicate

in English. However, it is also vital that the message coding used by the
sender is appreciated by the recipient so that he can decode the message
accurately. This means that engineers must have a similar knowledge of
technical language, jargon and acronyms.
(d) Assuming the channel and language used are compatible, to extract meaning,
the engineer has to understand the content of the message. This means that
it has to be clear and unambiguous. The message must also be appropriate to
the context of the workplace and preferably be compatible with the receiver's
expectations. Where any ambiguity exists, the engineer must seek
clarification
8.2.3 Non-Verbal Communication
(a) Non-verbal communication can accompany verbal communication, such as a

smile during a face-to-face chat. It can also occur independently, for instance
a colleague may pass on his ideas by using a sketch rather than the use of
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words. It can also be used when verbal communication is impossible, such as

a nod of the head in a noisy environment.
(b) Non-verbal communication is also the predominant manner by which systems

communicate their status. For instance, most displays in the aircraft cockpit
present their information graphically.
(c) Body language can be very subtle, but often quite powerful. For example, the
message "No” accompanied by a smile will be interpreted quite differently
from the same word said whilst the sender scowls.
8.3 COMMUNICATION WITHIN AND BETWEEN TEAMS
8.3.1 General
As noted in previous chapters, aircraft maintenance engineers often work as teams.

Individuals within teams exchange information and need to receive instructions,
guidance, etc. Moreover, one team will have to pass on tasks to another team at shift
handover. An engineer needs a good understanding of the various processes of
communication, as without this, it is impossible to appreciate how communication
can go wrong.
8.3.2 Communication within Teams
(a) Individual aircraft maintenance engineers need to communicate:
 Before starting a task -to find out what to do;

 During a task to discuss work in progress, ask colleagues questions,
confirm actions or intentions, or to ensure that others are informed of
the maintenance state at any particular time;
 At the end of a task -to report its completion and highlight any
problems.
(b) Spoken communication makes up a large proportion of day-to-day

communication within teams in aircraft maintenance. It relies both on clear
transmission of the message (i.e. not mumbled or obscured by background
noise) and the ability of the recipient of the message to hear it (i.e. active
listening followed by accurate interpretation of the message). Good ...
communication within a team helps to maintain group cohesion.
(c) Spoken messages provide considerable flexibility and informality to express

work-related matters when necessary. The key to such communication is to
use words effectively and obtain feedback to make sure your message has
been heard and understood.
(d) It is much less common for individuals within teams to use written
communication. They would however be expected to obtain pertinent written
information communicated by service bulletins and work cards and to
complete documentation associated with a task.
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8.3.3 Communication between Teams
(a) Communication between teams is critical in aircraft maintenance engineering.

It is the means by which one team passes on tasks to another team. This
usually occurs at shift handover. The information conveyed will include:
 Tasks that have been completed;

 Tasks in progress, their status, any problems encountered, etc.;
 Tasks to be carried out;
 General Company and technical information.
(b) Communication between teams will involve passing on written reports of tasks
from one shift supervisor to another. Ideally, this should be backed up by
spoken details passed between supervisors and, where appropriate,
individual engineers. This means that, wherever necessary, outgoing
engineers personally brief their incoming colleagues. The written reports
(maintenance cards, procedures, work orders, logs, etc.) and warning flags
/placards provide a record of work completed and work yet to be completed.
In other words, they provide traceability (see Section 2 below). Furthermore,
information communicated at shift handover ensures good continuity. It is
important that handovers are not rushed, so as to minimize omissions.
8.4 COMMUNICATION PROBLEMS
(a) There are two main ways in which communication can cause problems.
These are lack of communication and poor communication. The former is
characterized by the engineer who forgets to pass on pertinent information to
a colleague, or when a written message is mislaid. The latter is typified by the
engineer who does not make it clear what he needs to know and
consequently receives inappropriate information, or a written report in barely
legible handwriting. Both problems can lead to subsequent human error.
(b) Communication also goes wrong when one of the parties involved makes
some kind of assumption. The sender of a message may assume that the
receiver understands the terms he has used. The receiver of a message may
assume that the message means one thing when in fact he has
misinterpreted it. Assumptions may be based on context and expectations,
which have already been mentioned in this chapter. Problems with
assumptions can be minimized if messages are unambiguous and proper
feedback is given.
(c) Many factors, including those mentioned above, may affect communication.
Following is a list of factors that may act as the barriers of effective
communication:
1. Status Relations 2. Perceptions 3. Inference 4. Hearing what we expect

5. Same thing having different meanings 6. Jargon 7. Emotions 8. Size of
organizations 9. Physical condition 10. Organizational blocks 11. Faulty
listening 12. Incomplete message-information overload 13. Dilution
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14. Distortion/ Interpretation
(d) Basic rules of thumb to help aircraft maintenance engineers minimize poor
communication
 think about what you want to say before speaking or writing;

 speak or write clearly;
 listen or read carefully;
 seek clarification wherever necessary.
8.5 WORK LOGGING AND RECORDING
(a) This is one of the most critical aspects of communication within aviation
maintenance, since inadequate logging or recording of work has been cited as
a contributor to several incidents.
(b) In the B737 double engine oil loss incident 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 ". 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”.
(c) Even if engineers think that they are going to complete a job, it is always
necessary to keep the record of work up-to-date just in case the job has to be
handed over. This may not necessarily be as a result of a shift change, but
might be due to a rest break, illness, the need to move to another (possibly
more urgent) task, etc.
(d) The exact manner in which work should be logged tends to be prescribed by
company procedures. It is usually recorded in written form. However, there is
no logical reason why symbols and pictures should not also be used to record
work or problems, especially when used for handovers. There are many
cases where it may be clearer to draw a diagram rather than to try to explain
something in words (i.e. 'a picture is worth a thousand words ').
(e) The key aspects of work logging and recording are captured in the CAA's
Airworthiness Notice No.3 (AWN3). This 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
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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."
(f) New technology is likely to help engineers to record work more easily and
effectively in the future. ICAO Digest No. 12, "Human Factors in Aircraft
Maintenance and Inspection", refers to hand-held computers and an
Integrated Maintenance Information System (IMIS). It points out that these
devices are likely to encourage the prompt and accurate recording of
maintenance tasks.
(g) Modern technology is also being implemented to improve the transfer of

information in maintenance manuals to worksheets and work cards. These
help to communicate pertinent information to engineers in an accessible and
useable format. A contributory factor in the B737 double engine oil loss
incident was that the information which should have prompted the engineer to
carry out a post-inspection idle engine run to check for leaks was in the
maintenance manual but not carried over to the task cards.
8.6 KEEPING UP-TO-DATE
(a) 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. 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.
(b) 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;
 Revise maintenance procedures and practices.
 Engineers are likely
 Undertaking update courses;
 Reading briefing material, memos and bulletins;
 Studying maintenance manual amendments
(c) Responsibility for maintaining currency lies with both the individual engineer
and the maintenance organization for which he works. The engineer should
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make it his business to keep up-to-date with changes in his profession

(remembering that making assumptions can be dangerous). The organization
should provide the appropriate training and allow their staff times 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).
(d) 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, on this presumes that the engineer will
consult the updates. It is a part of the engineer's individual responsibility to
maintain his currency.
8.7 DISSEMINATION (distribution) OF INFORMATION
(a) As highlighted in the previous section, both the individual engineer and the
organization in which he works have a shared responsibility to keep abreast of
new information. Good dissemination of information within an organization
forms part of Anecdotal (subjective) evidence describes a case where a
certain maintenance procedure was "proscribed "(i.e. prohibited) in a service
bulletin. The technician reading this concluded that the procedure was
"prescribed "(i.e. defined, laid down) and preceded to perform the forbidden
action, its safety culture (Chapter 3, section 5). Typically, the maintenance
organization will be the sender and the individual engineer will be the
recipient.
(b) It was noted in earlier chapter, that an aircraft maintenance engineer or team
of 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)
(c) There should normally be someone within the maintenance organization 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.
(d) Poor dissemination of information was judged to have been a contributory

factor to the Eastern Airlines accident in 1983. The NTSB accident report
stated: "On May 17, 1983, Eastern Air Lines issued a revised work card 7204
[master chip detector installation procedures, including the fitment of 0-ring
seals", the material was posted and all mechanics were expected to comply
with the guidance. However, there was no supervisor/ follow-up to insure that
mechanics and foremen were incorporating the training material into the work
requirements. Use of binders and bulletin boards is not an effective means of
controlling the dissemination of important work procedures, especially when
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there is no accountability system in place to enable supervisors to ensure that

all mechanics had seen the applicable training and procedural information."
(e) Communication is an active process whereby both the organization and

engineer have to play their part. It is imperative that engineers working
remotely from the engineering base (e.g. on the line) familiarize themselves
with new information (on notice boards, in maintenance manuals, etc.) on a
regular basis.
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Chapter 9
HUMAN ERROR
9.0 INTRODUCTION
9.1 ERROR MODELS AND THEORIES
9.2 TYPES OF ERROR IN MAINTENANCE TASKS
9.3 IMPLICATIONS OF ERRORS (i. e. ACCIDENTS)
9.4 AVOIDING AND MANAGING ERRORS
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9.0 INTRODUCTION
(a) 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". It is an unequivocal fact that whenever men and
women are involved in an activity, human error will occur at some point.
(b) In his book "Human Error', Professor James Reason defines error as follows:
"Error will be taken as a generic term to encompass all those occasions in
which a planned sequence of mental or physical activities fails to achieve its
intended outcome, and when these failures cannot be attributed to the
intervention of some chance agency”,
(c) It is clear that aircraft maintenance engineering depends on the competence

of engineers. Many of the examples presented in Chapter 2 "Incidents
Attributable to Human Factors/Human Error" and throughout the rest of this
document highlight errors that aircraft maintenance engineers have made
which have contributed to aircraft incidents or accidents.
(d) 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".
(e) The following quotation illustrates how aircraft maintenance engineers play a
key role in keeping modern aircraft reliable: "Because civil aircraft are
designed to fly safely for unlimited time provided defects are detected and
repaired, safety becomes a matter of detection and repair rather than one of
aircraft structure failure. In an ideal system, all defects which could affect flight
safety will have been predicted in advance, located positively before they
become dangerous, and eliminated by effective repair. In one sense, then, we
have changed the safety system from one of physical defects in aircraft to one
of errors in complex human-centered systems"
(f) The rest of this chapter examines some of the various ways in which human
error has been conceptualized. It then considers the likely types of error that
occur during aircraft maintenance and the implications if these errors are not
spotted and corrected. Finally, means of managing human error in aircraft
maintenance are discussed.
9.1 ERROR MODELS AND THEORIES
9.1.1 General:
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 attempts to capture the nature of the errors and its characteristics. To
illustrate this, the following models and theories will be briefly highlighted:
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 Design-versus Operator-induced errors;

 Variable versus Constant errors;
 Reversible versus Irreversible errors;
 Slips, lapses and mistakes;
 skill, rule and knowledge-based behaviors and associated errors;
 The 'Swiss Cheese Model'.
9.1.2 Design versus Operator-Induced Errors
(a) In aviation, emphasis is often placed upon the error(s)of the front line
operators, who may include flight crew, air traffic controllers and aircraft
maintenance engineers.
(b) However, 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. Alternatively, flawed
procedures put in place by airline, maintenance organization or air traffic
control management may also lead to operational problems.
(c) 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. It may be that,
only when a certain combination of errors arises and error 'defences'
breached (see the 'Swiss Cheese Model') will safety be compromised.
9.1.3 Variable versus Constant Errors
(a) In his book "Human Error", Professor Reason discusses two types of human
error i.e. variable and constant. It can be seen in Figure 9.1 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. If we
know enough about the nature of the task, the environment it is performed in,
the mechanisms governing performance, and the nature of the individual, we
have a greater chance of predicting an error.
(b) 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
(c) However, it is rare to have enough information to permit accurate predictions;

we can generally only predict along the lines of" re-assembly tasks are more
likely to incur errors than dismantling tasks", or "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". It is possible to refine these predictions with
more information, but there will always be random errors or elements, which
cannot be predicted.
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Figure 9.1: Variable versus Constant Errors.
9.1.4 Reversible versus Irreversible Errors
(a) Another way of categorizing errors is to determine whether they are reversible
or irreversible. The former can be recovered from, whereas the latter typically
cannot be. For example, if a pilot miscalculates the fuel he should carry, he
may have to divert to a closer airfield, but if he accidentally dumps his fuel, he
may not have many options open to him.
(b) 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.
9.1.5 Slips, Lapses and Mistakes
(a) 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?
(b) Reason then suggests an error classification based upon the answers to
these questions as shown in Figure 9.2.
(c) 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 disordering steps in a procedure.
Lapses are missed actions and omissions, i. e. when somebody has failed to do
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something due memory to lapses of memo 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 judgment such as miss-selection of bolts when fitting an aircraft
windscreen.
(d) Slips typically occur at the task execution stage, lapses at the storage
(memory) stage and mistakes at the planning stage.
(e) 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.
9.1.6 Skill, Rule and Knowledge-Based Behaviors and Associated Errors
(a) The behavior of aircraft maintenance engineers can be broken down into
three distinct categories: skill-based, rule-based and knowledge-based
behavior.
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(b) Green Etal defines these: "Skill-based behaviors are those that rely on stored
routines or motor program that have been learned with practice and may be
executed without conscious thought. Rule-based behaviors are those for
which a routine or procedure has been learned. The components of a rule-
based behavior may comprise a set of discrete skills. Knowledge-based
behaviors 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."
(c) Each of these behavior types have specific errors associated with them.
(d) 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. The example given in Figure 9.3 may
consist of an engineer realizing he needs a certain wrench to complete a job
but, because he is distracted by a colleague, picks up another set to the
wrong torque and fails to notice that he has tightened the bolts incorrectly.
(e) Environmental capture may occur when an engineer carries out a certain task
very frequently in a certain location. Thus, an engineer used to carrying out a
certain maintenance adjustment on an Airbus A300, may inadvertently carry
out this adjustment on the next A300 he works on, even if it is not required
(and he has not made a conscious decision to operate the skill).
(f) Reversion can occur once a certain pattern of behavior 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.
(g) Rule-based behavior is generally fairly robust and this is why the use of
procedures and rules is emphasized in aircraft maintenance. However, errors
here are related to the use of the wrong rule or procedure. For example, an
engineer may misdiagnose a fault and thus apply the wrong procedure, thus
not clearing the fault. Errors here are also sometimes due to faulty recall of
procedures. For instance, not remembering the correct sequence when
performing a procedure.
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(h) Errors at the knowledge-based performance level are related to incomplete or

incorrect knowledge or interpreting the situation incorrectly. An example of
this might be when an engineer attempts an unfamiliar repair task and
assumes he can 'work it out'. Once he has set out in this way, he is likely to
take more notice of things that suggest he is succeeding in his repair, while
ignoring evidence to the contrary (known as confirmation bias).
9.1.7 The 'Swiss Cheese Mode!'
(a) In his research, Reason has highlighted the concept of 'defences' against
human error within an organization, and has coined the notion of 'defence 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 9.4).
(b) 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
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errors result in incidents or accidents, but it is only in certain circumstances,

when all holes 'line up, that these occur. Usually, if an error has bleached the
engineering defences. It reaches the flight operations defences (e. g. in flight
warning) and is detected and handled at this stage. However, occasionally in
aviation, an error can breach all the defences (e. g. a pilot ignores an in flight
warning, believing it to be a false alarm) and a catastrophic situation ensues.
(c) Defenses in aircraft maintenance engineering will be considered further in

Section- 9.4.
9 .2 YPES OF ERROR IN MAINTENANCE TASKS
9.2.1 General
(a) As aircraft maintenance engineers are human, errors in the industry are
inevitable. 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.
(b) Examples of errors highlighted in (i) in the box above are incorrect installation
of line-replaceable units, failure to remove a protective cap from a hydraulic
line before re- assembly or damaging an air duct used as a foothold while
gaining access to perform a task. Examples of errors in (ii) are a structural
crack unnoticed during a visual inspection task or a faulty avionics box that
remains on the aircraft because incorrect diagnosis of the problem led to
removal of the wrong box. The actual error type responsible can be any of
those highlighted in the previous section of this document.
9.2. 2 Errors during Regular and Less Frequent Maintenance Tasks
(a) 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. In Chapter 7, discussing "Repetitive Tasks", it is 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.
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(b) When undertaking less frequently performed tasks, there is the possibility of
errors of judgment. If the engineer does not familiarize or re-familiarize himself
properly with what needs to be done, he may mistakenly select the wrong
procedure or parts.
9.2.3 Violation in Aircraft Maintenance
(a) It is an unfortunate fact of life that violations occur in aviation maintenance.

Most stems 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;
 Optimizing violations;
 Exceptional violations.
(b) 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.
(c) 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.
(d) Optimizing 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.
(e) Exceptional violations are typified by particular tasks or operating

circumstances that make violations inevitable, no matter how well intentioned
the engineer might be.
(f) Examples of routine violations are not performing an engine run after a
borescope inspection ("it never leaks, or not changing the '0' seals on the
engine gearbox drive pad after a borescope inspection ("they are never
damaged').
(g) An example of a situational violation is an incident, which occurred where the

door of a B747 came open in-flight. An engineer with a tight deadline
discovered that he needed a special jig to drill off a new door torque tube. The
jig was not available, so the engineer decided to drill the holes by hand on a
pillar drill. If he had complied with the maintenance manual he could not have
done the job and the aircraft would have missed the service. An example of
an optimizing violation would be an engineer who has to go across the airfield
and drives there faster than permitted.
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(h) Time pressure and high workload increase the likelihood of all types of
violations occurring. People weigh up the perceived risks against the
perceived benefits; unfortunately the actual risks can be much higher.
9.2.4 Errors Due to Individual Practices and Habits
(a) 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-to-day use. Problems occur when the rule or principle is wrongly applied.
For example, aircraft pipe couplings are normally right hand threads but
applying this 'normally good rule' to an oxygen pipe (having a different thread)
could result in damage to the pipe. Also, there can be dangers in applying
rules based on previous experience if, for example, design philosophy differs,
as in the case of Airbus and Boeing. This may have been a factor in an A320
locked spoiler incident, where subtle differences between the operation of the
spoilers on the A320 and those of the B767 (with which the engineers were
more familiar) meant that actions which would have been appropriate on the
B767 were inappropriate in the case of the A320.
(b) 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. An
example of applying a bad rule is the British Rail technician in the Clapham
train accident who had acquired the practice of bending back old wires rather
than cutting them off and insulating them.
9.2.5 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; 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 (such as a crack) remains undetected, it can have
serious consequences (as was the case in the Aloha accident, where cracks
remained (undetected).
9.2.6 Reason's Study of Aviation Maintenance Engineering
(a) Reason analyzed 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%)
(b) It is likely that Reason's findings are representative for the aircraft
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maintenance industry as a whole. Omissions can occur for a variety of

reason, such as forgetting, deviation from a procedure (accidental or
deliberate), or due to distraction. The B737 double engine oil loss incident, in
which the HP rotor drive covers were not refitted, is an example of omission.
Incorrect installation is unsurprising as there is usually only one way in which
something can be taken apart but many possible ways in which it can be
reassembled. Reason illustrates this with a simple example of a bolt and
several nuts (see Figure 9.5), 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!).
(c) In the BAC1-11 accident in June 1990, the error was fitting the wrong bolts to
the windscreen. This illustrates well the category of 'wrong parts'.
9.3 IMPLICATIONS OF ERRORS (i.e. ACCIDENTS)
(a) In the worst cases, human error in aviation maintenance can and do cause
aircraft accidents. However, as portrayed in Figure 9.6, 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.
(b) 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.
(c) Errors that do not cause accidents but still cause a problem are known as
incidents. This subject was introduced at the beginning of this document in
Chapter 2, "Incidents Attributable to Human Factors/Human Error", which
gave examples of aviation incidents relating to aircraft maintenance errors.
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
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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 UK 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. In the UK, the Confidential Human Factors Incident Reporting
Program (CHIRP) scheme provides an alternative reporting mechanism for
individuals who want to report safety concerns and incidents confidentially.
(d) It is likely that the greatest proportion of errors made by AMEs spotted almost
immediately they are made and corrected. The engineer may detect his own
error, or it may be picked up by colleagues, supervisors or quality control. In
these cases, the engineer involved should (it is hoped) learn from his error
and therefore (it is hoped) be less likely to make the same error again.
(e) 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.
(f) When an error occurs in the maintenance system of an airline, the engineer
who last-worked on the aircraft is usually considered to be 'at fault'. The
engineer may be reprimanded, given remedial training or simply told not to
make the same error again. 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 (for example, a latent failure such as a poor
procedure drawn up by an aircraft manufacturer possibly an exceptional
violation).
(g) The UK Civil Aviation Authority has stressed in Airworthiness Notice No. 71
(Issue 1, 20 March 2000) that it "seeks to provide an environment in which
errors may be openly investigated in order that the contributing factors and
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root causes of maintenance errors can be addressed". To facilitate this, it is

considered that an unpremeditated or inadvertent lapse should not incur any
punitive action, but a breach of professionalism may do so (e. g. where an
engineer causes deliberate harm or damage, has been involved previously in
similar lapses, attempted to hide their lapse or part in a mishap, etc.).
9.4 AVOIDING AND MANAGING ERRORS
(a) 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 organizations
should aim to 'manage' errors.
Error management seeks to:
 Prevent errors from occurring;

 Eliminate or mitigate the bad effects of errors
(b) Reason refers to the two components of error management as: (i) error
containment and (ii) error reduction.
(c) To prevent errors from occurring, it is necessary to predict where they are
most a 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 organization, 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.
(d) According to Reason, error management includes measure to:
 Minimize 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 organizational 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 organization's intrinsic resistance to human fallibility.
(e) It would be very difficult to list all means by which errors might be prevented
or minimized in aircraft maintenance. In effect, the whole of this document
discusses mechanisms for this, from ensuring that individuals are fit and alert,
to making sure that the hangar lighting is adequate.
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(f) One of the things likely to be most effective in preventing error is to make sure
that engineers follow procedures. This can be effected by ensuring that the
procedures are correct and usable, that the means of presentation of the
information is user friendly and appropriate to the task and context, that
engineers are encouraged to follow procedures and not to cut corners.
(g) Ultimately, maintenance organizations have to compromise between

implementing measures to prevent, reduce or detect errors, and making a
profit. Some measures cost little (such as renewing light bulbs in the hangar);
others cost a lot (such as employing extra staff to spread workload). Incidents
tend to result in short term error mitigation measures but if an organization
has no incidents for a long time (or has them but does not know about them or
appreciate their significance), there is a danger of complacency setting in and
cost reduction strategies eroding the defences against error. Reason refers to
this as "the unrocked boat" (Figure 9.7).
(h) It is important that organizations balance profit and costs, and try to ensure
that the defences which are put in place are the most cost-effective in terms of
trapping errors and preventing catastrophic outcomes.
(i) Ultimately, it is the responsibility of each and every aircraft maintenance

engineer to take every possible care in his work and be vigilant for error (see
Chapter 3, Section-1). On the whole, aircraft maintenance engineers are very
conscious of the importance of their work and typically expend considerable
effort to prevent injuries, prevent damage, and to keep the aircraft they work
on safe.
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Chapter 10
HAZARDS IN WORKPLACE
10.0 INTRODUCTIONS
10.1 POTENTIAL HAZARDS IN AIRCRAFT MAINTENANCE ENGINEERING
10.2 RELEVANT LEGISLATION AND THE MAINTENANCE ORGANISATION’S

RESPONSIBILITIES
10.3 ENGINEER'S INDIVIDUAL RESPONSIBILITIES
10.4 DEALING WITH EMERGENCIES
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10.0 INTRODUCTION
Hazards in the workplace tend to be a health and safety issue, relating to the
protection of individuals at work. All workplaces have hazards and aircraft
maintenance engineering is no exception. Health and safety is somewhat separate
from human factors and this chapter therefore gives only a very brief overview of the
issues relating the aircraft maintenance engineering.
10.1 POTENTIAL HAZARDS IN AIRCRAFT MAINTENANCE ENGINEERING
(a) There may be potential hazards in the aircraft maintenance industry and it is
impossible to list them all here. However, a thorough health and safety
appraisal will reveal the hazards. Physical hazards may include:
 Very bright lights (e. g. from welding);

 Very loud sounds (sudden or continuous);
 Confined or enclosed areas;
 Working at significant heights;
 Noxious substances (liquids, fumes, etc.);
 Excessive temperature (i. e. too cold or too hot);
 Moving equipment, moving vehicles and vibration.
(b) Many of these have been addressed earlier in this document (e.g. Chapter 6
"Physical Environment").
10.2 RELEVANT LEGISLATION AND THE MAINTENANCE ORGANISATION 'S

RESPONSIBILITIES
(a) The UK Health and Safety Executive (HSE) have responsibility for overseeing
safety in the workplace. The Health and Safety at Work Act 1974 and
accompanying Regulations are the relevant legislation and the HSE produce
publications and leaflets summarizing various aspects. The Health and Safety
at Work Act 1974 places a responsibility on employers to produce a written
statement of general policy with respect to the Health and Safety at Work of
its employees. The employer is also obliged to bring to the notice of all its
employees this policy together with the organization and arrangements in
force for carrying out that policy. Thus, in an aircraft maintenance
organization, the health and safety policy might include statements applicable
to the organization such as the need to:
 Carry out assessments of work including inspections to determine Health and

Safety risks;
 Provide safe working practices and procedures for plant, machinery, work
equipment, materials and substances;
 Inform employees and other persons including temporary workers of any risk;
 Provide suitable training and/or instruction to meet any Health and Safety
risks;
 Develop and introduce practices and procedures to reduce risks to Health and
Safety including the provision of special protective devices and personal
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protective equipment;
 Provide for the welfare of employees;
 Discuss with and consult employee representatives on Health and Safety
matters.
(b) Maintenance organizations should appoint someone with health and safety
responsibilities.
In brief, a maintenance organization has a duty under health and safety legislation
to;
 Identify hazards in the workplace;

 remove them where possible;
 mitigate the risks to employees.
(c) If hazards cannot be removed from the workplace, employees should be

made aware that they exist and how to avoid them. This can be effected
through training and warning signs. To be effective, warnings signs must:
 clearly identify the hazard(s);

 describe the danger (i.e. electric shock, radiation, etc);
 inform employees what to do or not to do.
(d) The sign must attract an engineer’s attention, it must be visible and it must be
understandable to the people it is aimed at. Additionally, in the maintenance
industry, it must be durable enough to remain effective, often for years, in
areas where dust and the elements can be present.
(e) Positive recommendations are more effective than negative ones. For
example, the statement "Stay behind yellow line on floor" is better than "Do
not come near this equipment". Warning signs should contain a single word
indicating the degree of risk associated with the hazard: DANGER denotes
that the hazard is immediate and could cause grave, irreversible damage or
injury. CAUTION indicates a hazard of lesser magnitude. The sign should also
detail how to avoid or manage the risk. CAUTION signs are generally yellow
and black. DANGER signs use red, black and white.
10.3 ENGINEER'S INDIVIDUAL RESPONSIBILITIES
(a) The legislation notes that every individual in a workplace also has health and
safety responsibilities.
Every aircraft maintenance engineer should be aware that he can influence the
safety of those with whom he works.
(b) Thus, in an aircraft maintenance organization, the health and safety policy
might include statements applicable to engineers such as the need to:
 Take reasonable care of the health and safety of themselves and others who
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may be affected by their acts or omissions at work;

 Co-operate with the maintenance organization to ensure that statutory
requirements concerning health and safety at work are met;
 Work in accordance with any safety instruction and/or training received;
 Inform their supervisor or management of work situations that represent an
immediate or potential danger to health and safety at work and any
shortcomings in protection arrangements;
 Not interfere intentionally or recklessly with, nor misuse, anything provided in
the interests of health and safety.
(c) The attitude of an individual engineer, team or maintenance organization (i.e.

organizational culture )can have a significant impact on health and safety.
Individuals who display an anti-authority attitude, are impulsive, or reckless
are a danger in aircraft maintenance.
(d) Safety in the Working Environment: Engineers should ensure that they
keep the working environment safe. Clutter, rubbish, etc. is not only a
nuisance to others, but can constitute a danger (e.g. a trip hazard, fire hazard,
etc.). In addition, engineers should be careful when working on the line not to
leave objects when a job has been completed. Foreign Object Damage
(FOD)is a risk to aircraft operating at an airfield.
(e) Safety When Working On Aircraft: Before operating or working on aircraft

system, an engineer should carry out clearance checks around moveable
surfaces (e.g. flying controls, landing gear, flaps, etc.). Deactivation
procedures should be followed (e.g. pull circuit breakers, isolate valves,
disconnect power, etc.). Notification of deactivation through the provision of
adequate placard in key locations is essential to inform others of system
status.
10.4 DEALING WITH EMERGENCIES
(a) Careful handling of health and safety in the maintenance environment should
serve to minimize risks. However, should health and safety problems occur,
all personnel should know as far as reasonably practical how to deal with
emergency situations. Emergencies may include:
 An injury to oneself or to a colleague;

 A situation that is inherently dangerous, which has the potential to cause
injury (such as the escape of a noxious substance, or a fire).
(b) Appropriate guidance and training should be provided by the maintenance

organization. The organization should also provide procedures and facilities
for dealing with emergency situations and these must be adequately
communicated to all personnel. Maintenance organizations should appoint
and train one or more first aiders.
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(c) The basic actions in an emergency are to:
i) Stay calm and assess the situation

 Observe what has happened;
 Look for dangers to oneself and others;
 Never put oneself at risk.
ii) Make the area safe
 Protect any casualties from further danger;
 Remove the danger if it is safe to do so (i. e. switching off an electrical current
if an electrocution has occurred);
 Be aware of one’s own limitations (e. g. does not fight a fire unless it is
practical to do so).
iii) Assess all casualties to the best of one’s abilities (especially if one is a
qualified first aider)
 Call for help
 Summon help from those nearby if it is safe for them to become involved;
 Call for local emergency equipment (e. g. fire extinguisher);
 Call for emergency services (ambulance or fire brigade, etc. ).
 Provide assistance as far as one feels competent to.
(d) Emergency drills are of great value in potentially dangerous environments.

Aircraft maintenance engineers should take part in these wherever possible.
Knowledge of what to do in an emergency can save lives.
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Chapter 11
SITUATION AWARENESS
11.0 INTRODUCTION
11.1 SITUATION AWARENESS IN WORKPLACE
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11.0 INTRODUCTION
(a) Situation awareness has become a bit of a buzzword in the aviation industry
over the last five years or so and it is as important now as it ever was.
(b) As a concept it has been fairly difficult to define but it can be broken down into
three distinct elements. They are:
1. Perception
2. Comprehension
3. Projection
(c) Perhaps the best way to try to explain these elements of situation awareness
are to provide an analogy that you are likely to be familiar with. This analogy
will have you driving or cycling along the road.
11.1 SITUATION AWARENESS IN WORKPLACE
11.1.1 An Analogy
(a) Situation awareness in the traffic can be divided into the three elements
suggested here of perception, comprehension and projection.
(b) Perception: The perception aspect is keeping an eye and ear on what is
happening around you. It means that you are picking up the nearest four cars
or trucks or buses behind you, the four in front of you and the four around you.
Your perception will pick up the fact that the "car 3" in front of you has put on
their brake lights, the truck behind you has a blinker on to try to change lanes
in front of the bus and that the red car on your right is speeding up. Your
perception will also pick up that the traffic light, 150 yards ahead, is green;
that there are 5 people looking to cross the road, about a hundred meters
ahead; and that there seems to be some roadwork’s closing one of the lanes
in the opposite direction traffic which is forcing them to bunch up and even
stray onto the wrong side of the road's centre line markings. All of these things
are relevant events to you driving safely and they are constantly changing.
(c) Comprehension: The second aspect is comprehension. This means making

some judgments on what the car brake lights mean on the "car 3" in front, on
the likelihood of the truck being able to change lanes, of the people trying to
dash across the road and whether the light will be green or red by the time
you reach it.
(d) Projection: The third aspect is projection in which you project that you will
need to brake slowly yourself to adjust for the "car 3" in front of you, that when
you do, you will be passed by the red car, the truck and then the bus on your
right. This will prevent the pedestrians from attempting to cross the road but
that the light will turn red before you get there and you will need to come to a
halt before continuing.
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11.1.2 SITUATION AWARENESS IN ACTION
(a) Based on those three aspects of situation awareness described above, you
use your ability, experience, and training (within the current workload, i.e. the
other things you might be trying to do such as talking on the cell-phone) to
make a decision.
(b) In this case you would decide to put your brakes on gradually to slow you
down rather than stop and this would be translated into action. The action
here would be to take your foot off the accelerator pedal and apply gentle
pressure to the brakes while maintaining your direction.
(c) So where do we go wrong in terms of situation awareness? To maintain our

analogy and look at our three elements, we can see the opportunity for there
to be a loss of situation awareness. At the perception level, we may not have
picked up that the bus was increasing speed behind us or that there was in
fact a motorcyclist in front of the bus, meaning that the truck couldn't change
lanes. Your mental model could have led you astray in that there might have
been plenty of time for the pedestrians to attempt to cross the road or that the
truck and the bus were in fact attempting to trade places behind you.
Projecting what might occur is also an area where we can lose our SA
(Situation Awareness). Being caught out slowing down for a red light when the
light is still green is not uncommon.
(d) Failures in situation awareness have been linked to conditions which lead to
reductions in the safety of flight, flight delays, ground damage, and other
problems that directly increase costs. In certain severe cases, the viability of a
company has been affected by situation awareness errors.
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(e) The results of poor situation awareness can be seen in a variety of common
maintenance-related errors. These include loose objects left in an aircraft,
missing fuel and oil caps, loose panels and other unsecured parts, and pre-
flight pins not removed prior to operation.
(f) Putting together observed cues to form a proper understanding of

malfunctions is a challenging and significant problem in diagnostic activities.
For example: in more that 60% of cases, an incorrect avionics component is
replaced in an aircraft. In team oriented environments, such as aviation
maintenance, the level of situation awareness within and among teams is an
issue of concern. Aviation maintenance tasks are typically coordinated within
teams and among teams on different shifts or in different geographic
locations. The overall goal of providing aircraft safety can be compromised if
any team member loses a sufficient level of situation awareness.
(g) Situation awareness is one of the foundation concepts of MRM (Maintenance

Resource Management). Typically, we think of situation awareness in terms of
the individual engineer. However, many of the most common maintenance
errors involve the loss of situation awareness among different individuals,
often across different teams or shifts. The concept of team situation
awareness relates to maintaining a collective awareness of important job
related conditions.
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Aeronautical Institute of Bangladesh (AIB) : Fundamentals of Human Factors

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Aeronautical Institute of Bangladesh (AIB)

1.1 MEANING OF HUMAN FACTORS

1.2 SCOPE OF HUMAN FACTORS AND ERROR MANAGEMENT

1.3 HUMAN FACTORS MODELS

1.4 HUMAN FACTORS IN AVIATION

1.5 ORIGINS OF HUMAN FACTORS IN AVIATION

1.6 THE RELATIONSHIP BETWEEN HUMAN FACTORS AND ERGONOMICS.

1.7 THE IMPORTANCE OF HUMAN INPUT INTO AIRCRAFT MAINTENANCE

1.8 THE IMPORTANCE OF AN EFFECTIVE HUMAN FACTORS PROGRAM IN

1.9 AN INTEGRATED APPROACH TO HUMAN FACTORS AND SAFETY

1.10 THE COST EFFECTIVENESS OF IMPLEMENTING HF ROGRAMS IN

1.11 REGULATORY ASPECTS OF HUMAN FACTORS IN AVIATION

1.12 THE IMPORTANCE OF TRAINING IN REDUCING MAINTENANCE

(d) An understanding of the predictable human capabilities and limitations and

1.1 MEANING OF HUMAN FACTORS

1.1.1 What is Human Factors?

1.1.2 Some remarkable definitions of HF:

(a) Professor Elwyn Edwards (1988) proposed: "Human Factors is an applied

1.1.3 ICAO Definitions Relating to Human Factors

(a) "Human Factors Principles: Principles which apply to aeronautical design,

(b) "Human performance: Human capabilities and limitations which have an

1.1.4 Subset Definitions

 Anthropometrics: The science of measurement and the art of application that

 Biomechanics: Addresses issues of movement, leverage, and strength. From a

1.2 SCOPE OF HUMAN FACTORS AND ERROR MANAGEMENT

Detection and Perception Stereotypical Behavior

Habituation Compatibility Limitations

1.3 HUMAN FACTORS MODELS

(a) Fundamentals of human factors are better understood by different models

1.3.2 The SHEL Model

S: misinterpretation of procedures, badly written manuals, poorly designed

Figure 1.1 SHEL Model

(f) Liveware-Hardware: This interface is the most commonly considered when

although not exclusively, with issues arising from this interface.

(g) Liveware-Software: This encompasses the interface between humans and

A real need existed to improve communication and publications as well as to

(h) Liveware-Environment: The human-environment interface was one of the

In the maintenance of aircraft, Engineers are often asked to work in hostile

1.3.3 The SHELL Model

Figure 1.2 SCHELL Model

(b) Liveware-Liveware: This is the interface between people. Maintenance and

1.3.4 The SCHELL Model

skell) model. This is still a debatable point. (Figure 1.3)

Figure 1.3 SHELL model

1.4 HUMAN FACTORS IN AVIATION

1.5 ORIGINS OF HUMAN FACTORS IN AVIATION

view and it would be fair to say that Human Factors, as a discipline is a

(e) Modern Focus: Following two significant mishaps in England, Cockpit

1.5.2 Who is promoting Human Factors?

(a) It is important to note that Human Factors is evolving on a daily basis. At

1.6 THE RELATIONSHIP BETWEEN HUMAN FACTORS AND ERGONOMICS.

interchangeably, there is a small difference in emphasis. Human Factors has

(c) In terms of maintenance engineering, separating the two definitions is not

(d) In aviation maintenance engineering, we now use the terms interchangeably.

1.7 THE IMPORTANCE OF HUMAN INPUT INTO AIRCRAFT MAINTENANCE

(b) Humans are better in their ability to:

 Reason inductively, generalizing from observations.

(c) Machines are generally better in their abilities to:

1.8 THE IMPORTANCE OF AN EFFECTIVE HUMAN FACTORS PROGRAM IN