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TRAINING MANUAL
HUMAN FACTORS

ERROR INVESTIGATION
EXERCISES

HUMAN ERROR
THE POTENTIAL FOR HUMAN ERROR
The study of human factors is very much concerned with identifying those aspects of
behaviour that result in people making mistakes or errors, some of which could result in
accidents or incidents of various kinds. Limitations in human capacity to perceive, attend to,
remember, process and act on information are all relevant in the context of human error.
The HSE's publication, 'Human factors and industrial safety' (HS(G)48, 1989), identifies a
number of factors that can contribute to human error and the resulting accidents. These
include the following.
i)

Inadequate information People do not make errors merely because they are
careless or inattentive. Often they have understandable (albeit incorrect)
reasons for acting in the way they did. One common reason is ignorance of
the production processes in which they are involved and of the potential
consequences of their actions.

ii)

Lack of understanding This often arises as a result of a failure to

communicate accurately and fully the stages of a process that an item has been
through. As a result, people make presumptions that certain actions have been
taken when this is not the case.

iii)

Inadequate design Designers of plant, processes or systems of work must

always take into account human fallibility and never presume that those who
operate or maintain plant or systems have a full and continuous appreciation of
their essential features. Indeed, failure to consider such matters is, itself, an
aspect of human error.
Where it cannot be entirely eliminated, error must be made evident or difficult.
Compliance with safety precautions must be made easy. Adequate
information as to hazards must be provided. Systems should 'fail safe'. that is,
refuse to produce in unsafe modes of operation.

iv)

Lapses of attention The individual's intentions and objectives are correct and
the proper course of action is selected, but a slip occurs in performing it. This
may be due to competing demands or (limited) attention. Paradoxically,
highly skilled performers, because they depend on finely tuned allocation of
their attention, to avoid having to think carefully about every minor detail,
may be more likely to make a slip.

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v)

Mistaken actions This is the classic situation of doing the wrong thing under
the impression that they are right. For example, the individual knows what
needs to be done, but chooses an inappropriate method to achieve it.

vi)

Misperceptions Misperceptions tend to occur when an individual's limited

capacity to give attention to competing information under stress produces
'tunnel vision' or when a preconceived diagnosis blocks out sources of
inconsistent information. There is a strong tendency to assume that an
established pattern holds good so long as most of the indications are to that
effect, even if there is an unexpected indication to the contrary. One potent
source of error in such situations is an inability to analyse and reconcile
conflicting evidence deriving from an imperfect understanding of the process
itself or of the meaning conveyed by instruments. Full analysis of the
preventative measures required involves the need for people to understand the
process as well as technical and ergonomic considerations concerned with
instrumentation.

CAUSES OF ERRORS
There are a multitude of factors which can and will contribute to errors being committed:
Here are some of them:
i)

Stress

ii)

Fatigue

iii)

Complacency

iv)

Communication

v)

Ignorance

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

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STRESS
w

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

30 - 40% of this is stress related

(C.B.I. 1994)

ALCOHOLISM costs over 2.2 billion per year in terms of premature death,
sickness absence, unemployment and N.H.S. treatment
STRESS

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

1.

i)

Stress is not nervous tension

ii)

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

iii)

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

iv)

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

v)

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

OCCUPATIONAL STRESSORS
Most is not all of us will recognise and readily relate to the following list of stress
factors:
i)

NEW WORK PATTERNS

ii)

NEW TECHNOLOGY

iii)

PROMOTION

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v)
DEREGULATION

2.

vi)

DOWN SIZING

vii)

JOB DESIGN

viii)

BOREDOM

HUMAN FACTORS

ix)

NOISE

x)

TEMPERATURE

xi)

INCREASED COMPETITION

xii)

LONGER HOURS

xiii)

REDUNDANCY

xiv)

EARLY RETIREMENT

xv)

ACQUISITION

vi)

MERGER

xvii)

MANNING LEVELS

xviii)

INSECURITY

xix)

LIGHTING

xx)

ATMOSPHERE/VENTILATION

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PRESSURE
Pressure at work to complete the job is part of stress which motivates us to do the job.
We all know that if we have two weeks to do a 2 hour job, it is likely that we will do
the job on the last available day. WHY? There was no pressure (Stress) to complete
the job until the last day when you will see most of the pressure to do a job comes
from within ourselves. The boss may say "I need the aircraft by 5 pm", but if the
timescale is unreasonable and you don't say anything, then YOU, not the boss, are
responsible for the pressure. The monkey on your back is yours because you have
accepted it.
How to deal with pressure
Since pressing is a form of stress, the same advice applies.

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i)

Stop and assess the situation

ii)

Look at the situation rationally

iii)

What is the reality of the situation? Can I safely complete my work on

time?

iv)

Have I communicated my concern in a concise and rational way?

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v)
What is the worst thing
that can
happen to me?
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Listen to your rational mind

vi)

Has this happened before and what can I do better?

vii)

What is the best rational plan

viii)

Speak up and ask for help or extra time as required

Act

Often the error of pressure is due to an error of not communicating properly and
trying to make do.
3.

LACK OF AWARENESS
Lack of awareness, differs from lack of knowledge in that it occurs to engineers who
often are very knowledgeable but fail to reason the possible consequences to what is
normal good maintenance practice.
For example: An engineer mounts a fire extinguisher on a bulkhead as per normal
maintenance practices, but fails to realise that in a crash, the person sitting in front of
the bulkhead will remove the extinguisher with his head!!
It is not easy to be aware of all the consequences of a maintenance action, yet,
particularly when one modifies anything on an aircraft, one must work to examine all
possible outcomes.
A court of law is no place to explain why it is that you did not realise.

4.

COMPLACENCY
Self-satisfaction accompanied by a loss of awareness of the dangers
Because of the repetitive nature of a lot of aviation maintenance work,
complacency is an ever-present danger. As a person becomes complacent his
stress level, for that task, decreases and with it his performance. A greater
stimulus will be required in order to obtain a response.
With complacency can come Expectancy, where the AME will often see what
he expects to see and not what is actually there. If other factors are also
present such as fatigue, resources and stress (from a different source) then the
chance of an error becomes very real.

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The error of complacency can be lessened by:

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

work from memory.

ii)

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

going to find a crack" or whatever.
Awareness is your strongest advocate in preventing complacency.

5.

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

6.

i)

proper use of detailed check lists

ii)

flagging incomplete work

iii)

witness marks

iv)

dual or independent inspection

v)

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

FATIGUE
Fatigue is the body's normal reaction to a physical or mental stress of prolonged
duration. Its onset is insidious and the symptoms are not always recognised until the
person has reached a high degree of fatigue. There are two types of fatigue:
6.1

Acute Fatigue:
is the result of intense physical or mental activity at a single task. It is of short
duration, measured in hours, and is cured with a good night's sleep.

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Chronic Fatigue:

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is caused over a period of time and takes much longer to recover from. Each person has a

personal level of ability to withstand fatigue which slowly diminishes as the person ages.
6.3

Causes of Fatigue:
Some of the things that can induce fatigue are:

6.4

i)

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

ii)

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

iii)

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

iv)

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

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

v)

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

vi)

Vibration can also cause fatigue. If for prolonged periods and of

sufficient intensity, it will cause headaches and muscle discomfort.
However unlike noise, vibration is not known to cause any permanent
damage although "white hand" from chain saw vibration and rivet guns
can become permanent if ignored long enough.

vii)

Strong Lighting and to a lesser degree, poor lighting will contribute to

fatigue. The normal symptom is a headache, and if bad or long
enough, eyestrain.

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

An Enhanced Stimulus is required in order to respond.

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

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Attention isHUMAN
reducedFACTORS

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The person begins to overlook basic task elements.

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

Memory is diminished
The person begins to have inaccurate recall.
The person forgets peripheral tasks.
The person begins to revert to "old" habits.

iv)

Mood becomes withdrawn

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

Persons who work a midnight shift should be particularly aware of the

symptoms as most persons have a normal low (circadian rhythm-time of day
effect) between 0300 and 0500.
Fatigue, as seen by its detrimental effects, can easily lead to a maintenance error, especially if
the person isn't aware he is suffering from it.
7.

SHIFT WORK
Have you ever noticed how some people seem to breeze through shiftwork with little
difficulty while others have a hard time? There are certain individual differences that
have been shown to cause these different reactions to shiftwork. Even if you don't
work on shifts, you might find that the information is useful anyway since we all
occasionally experience the sleepless night or stressful day not unlike that
experienced by shiftworkers.
Approximately 23% of all workers in the service sector work on shifts. Not all
shiftwork creates difficulties, but some, especially 24-hour-a-day, 7-day-a-week
operation, can create problems such as poor quality of sleep and disruption of daily
biological rhythms.
Accordingly, the two major complaints from most shiftworkers are: lack of sleep and
fatigue. But some individuals adapt readily to shiftwork while others manage to get
by and still others can never adjust. A look at some of the reasons behind these
individual differences in adaption will highlight steps that may be taken to improve
our ability to manage the difficulties caused by shiftwork.
7.1

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Individual Differences
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FACTORS
Younger people apparentlyHUMAN
handle the
physical demands of shiftwork better,
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but older workers handle the social and interpersonal problems more

effectively, and extroverted, outgoing people seem to adapt more easily to

shiftwork than introverted types. The remainder of this section will look at
techniques that can be used by anyone, regardless of age or personality type,
to help improve the quality of sleep and reduce fatigue.

7.2

The Role of Sleep

Although the role of sleep is not fully known, it is generally agreed that sleep
is not necessarily a passive state. there are a number of things that happen
during sleep that do not seem to happen when we are awake. For example,
body temperature, breath rate, heart rate, and blood pressure all drop during
sleep, while the secretion of human growth hormone and other anabolic
hormones (hormones that are involved in the cell building process) seem to
increase.
Thus the role of sleep may be to serve a rebuilding function by restoring
certain enzymes and chemicals needed in our bodies. However, it is possible
that not all of sleep is necessary for restoration. Sleep researcher James Horne
suggests that there are two sleep drives, the first being "obligatory" sleep
comprising the first five hours or so. The second sleep drive is "facultative"
and probably serves to pass time during the early morning hours when there is
nothing to do anyway.
In other words, Horne suggests that if we normally sleep eight hours then the
last three hours of sleep really only pass time. The main work of sleep is done
after approximately five hours. so even if we don't get a full night's sleep,
chances are we are getting enough to recharge our systems.
Many of us who experience sleep deprivation on a continuous basis, however,
might not agree. Five hours sleep per night does not seem to be enough,
especially if we usually sleep longer. We could, as Horne suggests, practise
getting by with only five or six hours of sleep per night, but once we establish
a pattern of sleep, it is often hard to break.
7.3

Physical Fitness
Physically fit individuals adapt to shiftwork better for a number of reasons:
they can handle the physical demands of shiftwork better, and regular
physical exercise promotes better sleep and helps to manage stress.
Remember that fitness activities can be anything from running marathons to
gardening, depending upon your interests and experience. Even low levels of
physical fitness seem to promote better health, which in turn can combat some
of the negative effects of shiftwork.

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RESOURCES
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8.

ERROR INVESTIGATION EXERCISE

Resources, or more appropriately the 'lack of' resources have been the cause of many
an accident. Engineers are notorious for making do with less than adequate resources.
The lack of up to date manuals can cause and error especially in these rapidly
changing times and how often does an engineer have to make difficult decisions due
to the lack of materials. In difficult times, lack of material may lead to an engineer to
let something go a little longer, against his better judgement.
Sometimes the resource needed is an expensive special tool that is seldom used.
Work is carried out without the proper tool and can cause a maintenance error if it is
not done properly. There have been cases where the person who can procure the tool
is unaware that it is even required. an engineer was heard to say "I asked for the tool
two years ago and I still haven't got it", while the Production Director wasn't aware
that the request was ever made.
One of the most common lack of resources is adequate lighting for their task in hand.
Engineers often depend heavily on flashlights perched on some part of the aircraft to
carry out a task when only a few meters away is a proper portable light.
Some facilities, especially as we move north, have woefully inadequate heat in winter.
It is easy to make a mistake when you are cold and miserable and all your
subconscious is thinking about is getting warm.
Do not be afraid to ask for help when needed and ensure that you have done
everything you can to obtain the necessary resources.
9.

COMMUNICATION
MEANING:
The exchange of information
9.1

To Improve Communication
"Learn to Listen"

9.2

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Don't:
i)

Debate what is being said in your mind.

ii)

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

iii)

Pre-plan: Now is not the time to be planning what you are

going to say.

iv)

Tune out: Whatever is being said should be important enough

to listen.
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Do:

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i)

9.4

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Ask questions

ii)

Paraphrase

iii)

Make eye contact

iv)

Use positive body language

THIS IS COMMUNICATION?
I have to tell you that
what you heard and
what I said are
two different things and
that what you think
I said is definitively
not what I meant.
THE SECRET TO GOOD COMMUNICATION

You have
2 Ears
+

2 Eyes

+ 1 Mouth
5

Use them in that order and proportion.

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LACK OF KNOWLEDGE

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In these times of ever changing technology, it is not difficult to come upon a task
HUMAN FACTORS

which you lack the knowledge. To counteract this, aircraft companies attempt to
provide the correct amount of detail to their manuals or workcards without boring you
with complacency.
The key to the "lack of knowledge" error is to understand each step of what you are
doing, or talk to someone who does. Technical reps are paid good money to keep you
out of trouble.
If it's new, don't be afraid to ask. Don't learn by mistakes and remember Murphy's
Law if you have any doubts.

Murphy's law
-

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

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