Chapter 1:- FUNDAMENTAL HUMAN FACTORS

CONCEPTS
This chapter introduces human factors and explains its importance to the
aviation industry. Study of the effects of human conditions like stress, fatigue,
complacency and other similar factors and their effects on the working
environment is the main purpose behind the study of human factors.

Human performance is cited as a causal factor in the majority of aircraft

accidents. If the accident rate is to be decreased, Human Factors issues in
aviation must be better understood and Human Factors knowledge more broadly
and proactively applied. Human factors directly cause or contribute to many
aviation accidents.

What is “Human Factors”?

The term “human factors” is used in many different ways in the aviation
industry. ’Human factors’ is an umbrella term for several areas of research that
include human performance, technology and human/computer interaction. It is a
profession that focuses on how people interact with products, tools, procedures
and any processes likely to be encountered in the modern world.
HUMAN FACTORS - The applied science which studies people working
together in concert with machines. It refers to the study of human capabilities
and limitations in the workplace.
Human factors researchers study system performance. That is, they study the
interaction of maintenance personnel, the equipment they use, the written and
verbal procedures and rules they follow, and the environmental conditions of
any system. The aim of human factors is to optimise the relationship between
maintenance personnel and systems with a view to improving safety, efficiency
and well-being.

Simply spoken, the term ’human factors’ involves working to make the
environment function in a way that seems natural to people. Human Factors
knowledge should be applied and integrated during the systems design and
certification stages, as well as during the operational personnel certification
process, before the systems and the people become operational. The expansion
of Human Factors awareness presents the international aviation community with
the single most significant opportunity to make aviation both safer and more
efficient.

The Need to Take Human Factors into Account

Aviation safety relies heavily on maintenance. When it is not done correctly, it

contributes to a significant proportion of accidents and incidents. The most
important human factor used in maintenance and flight operations is our ability
to learn from experience and mistakes. The basic rule is if it has gone wrong
once, it will probably go wrong again. Over the years mistakes have been made
in aircraft maintenance that has had a negative influence on the safety and
economics of operation. After such events engineers, managers and mechanics
try to develop procedures to ensure that these mistakes do not occur again. If
this is impossible or unrealistic then they try to find ways to make sure the
effects of any maintenance error are minimized.
Figure No: 1 – The need to take human factors into account

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

known that some three out of four accidents result from performance errors
made by apparently healthy and properly certificated individuals. The sources
of some of these errors may be traced to poor equipment or procedure design or
to inadequate training or operating instructions. But whatever the origin, the
question of human performance capabilities and limitations and human
behaviour is central to the technology of Human Factors. The cost, both in
human and financial terms, of less than optimum human performance has
become so great that a makeshift or intuitive approach to Human Factors is no
longer appropriate. Safety being the ultimate objective of all those involved in
aviation, its logical follow-up is to ensure a proper level of Human Factors
knowledge throughout the industry.

Human Factors Applications in Aviation Operations

Control of Human Error
To contain and control human error, one must first understand its nature. There
are basic concepts associated with the nature of human error, the origins of
errors can be fundamentally different and the consequences of similar errors can
also be significantly different. While some errors are due to carelessness,
negligence or poor judgement, others may be induced by poorly designed
equipment or may result from a normal reaction of a person to a particular
situation. The latter kind of error is likely to be repeated and its occurrence can
be anticipated.
The control of human error requires two different approaches. First, it is
necessary to minimize the occurrence of errors by: ensuring high levels of staff
competence designing controls so that they match human characteristics
providing proper checklists, procedures, manuals, maps, charts, SOPs, etc. and
reducing noise, vibration, temperature extremes and other stressful conditions.
Training programmes aimed at increasing the co-operation and communication
between crew members will reduce the number of errors (the total elimination
of human error is a difficult goal, since errors are a normal part of human
behaviour). The second avenue to the control of human error is to reduce the
consequences of the remaining errors by cross-monitoring and crew co-
operation. Equipment design which makes errors reversible and equipment
which can monitor or complement and support human performance also
contribute to the limitation of errors or their consequences.

Information processing
Before a person can react to information, it must first be sensed there is a
potential for error here, because the sensory systems function only within
narrow ranges. Once information is sensed, it makes its way to the brain, where
it is processed, and a conclusion is drawn about the nature and meaning of the
message received. This interpretative activity is called perception and is a
breeding ground for errors. Expectation, experience, attitude, motivation and
arousal all have a definite influence on perception and are possible sources of
errors. After conclusions have been formed about the meaning of a message,
decision-making begins. Many factors may lead to erroneous decisions: training
or past experience, emotional or commercial considerations fatigue, medication,
motivation and physical or psychological disorders. Action (or inaction) follows
decision. This is another stage with potential for error, because if equipment is
designed in such a way that it can be operated wrongly, sooner or later it will be.
Once action has been taken, a feedback mechanism starts to work. Deficiencies
in this mechanism may also generate errors.

Training and evaluation

Education and training are seen here as two different aspects of the teaching
process. Education encompasses a broad-based set of knowledge, values,
attitudes and skills required as a background upon which more specific job
abilities can be acquired later. Training is a process aimed at developing
specific skills, knowledge or attitudes for a job or a task. Proper and effective
training cannot take place unless the foundations for the development of those
skills, knowledge or attitudes have been laid by previous education. Skills,
knowledge or attitudes gained in one situation can often be used in another. This
is called positive transfer. Negative transfer occurs when previous learning
interferes with new learning. It is important to identify the elements of training
which can induce negative transfer since a return to earlier learned practices
may occur in conditions of stress. Learning is an internal process and training is
the control of this process. The success or failure of training must be determined
by the changes in performance or behaviour which the learning produces.
A number of factors can interfere with the success of a training programme —
obvious ones like sickness, fatigue or discomfort as well as others like anxiety,
low motivation, poor quality instruction, an unsuitable instructor, inadequate
learning techniques or inadequate communication. It is cost-effective to observe
a systems approach to training. Its first step is to determine the training needs,
possibly through job task analyses. The second step provides a clear job
description and analysis. The objective of the training can then be formulated,
and criteria can be established for the selection of the trainees. Next, the course
content is determined, and the course implemented. Different methods include:
lectures, lessons, discussions, tutorials, audio-visuals, programmed instruction,
and computer-based training.

Incidents and Accidents Attributable To Human Factors / Human

Error

Usually in aviation maintenance, 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 recognise
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.

“THE ERROR ICEBERG”

An air traffic accident often has disastrous results. As a rule the background
and reasons are examined intensively. Often it can be determined that a number
of minor events added up to cause the accident.
This fact can be compared to an iceberg – only the tip is visible while the major
amount of events remains hidden below the surface.

The top section stands for the major, serious and catastrophic events that are
clearly visible and usually results in official (FAA, NTSB, LBA, CAA etc.)
investigation.

The middle section of the iceberg is the events occurring during operation, such
as in-flight shutdown, delays, aircraft accidents and personal injuries. These
may result in official investigation.

In bottom section are the unreported or low-level events. These are not known
outside the work area and may not even have to be reported within the
company.

SERIOUS EVENTS

COSTLY EVENTS

OTHER EVENTS

Figure No: 2 – The error iceberg

Airlines are already investigating serious, error related maintenance events. But
many more, less serious events exist below the surface.

As a result of the above, the possibility to interrupt the chain of events that
eventually can cause a serious accident is to be found “below the surface” in the
operation and low level areas.

An accident is a logical result of many incidents.

“THE ERROR CHAIN”

As with many incidents and accident, the error chain involves a series of human
factors problems which formed an error chain. 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. Many small errors accumulate over a period of time and lead to a
fatal accident or major damage.

These errors can be caused by any individual in the aviation environment.

MANAGEMENT

MAINTENANCE

FLIGHT
SAFETY
INCIDENT

CREW

Figure No: 3 – The error chain

If we can break just one link of the chain, the accident does not happen.
This means a sequence of errors which can lead to accident can be broken
by just avoiding one error in this sequence.

PEAR Model of Human Factors

Figure No: 4 – PEAR Model

Human Factors can be divided into four main topic areas using the memory
prompt ‘PEAR’.

Application of the mnemonic ‘PEAR’ makes recognition of Human Factors

(HF) even easier. It prompts recall of the four important considerations for HF
programs: People who do the job; Environment in which they work; Actions
they perform; Resources necessary to complete the job.

P stands for People (the humans in the system), with all our capabilities and
limitations. It includes senses such as vision and hearing; physical
characteristics such as strength and reach; as well as capabilities such as
memory, communication styles, decision making, supervision and teamwork
skills (leadership/followership etc.).

E stands for the Environment in which the work is done, not just the physical
environment, but also the organization itself. The physical environment includes
lighting, temperature, noise level and time of day. The organizational
environment covers issues such as supervision (quality and ratios), pressures
(time, commercial and production etc.), organization and safety culture and
existing organizational norms and how these will affect individual and team
performance and the potential for error. The organizational environment also
covers the leadership shown and the effectiveness of management in supporting
positive safety behaviours.

A represents the Actions people perform. Actions list the requirements of a job
to help to identify any specific areas that might increase the risk of error, such as
ambiguous information, or complex tasks that need specialist skills and
knowledge.

R is for the Resources necessary to perform the work. Resources are the
broadest component of PEAR. They can be defined as anything that the
maintenance technician needs to get the job done. Resources details both the
tangible items required and available, such as personnel, spares, technical
manuals, tooling, and personnel protective equipment (PPE), as well as less
tangible (but equally important) elements such as time and training availability.

Murphy’s Law

There is a tendency among human beings towards complacency. The belief that
an accident will never happen to “me” or to “my Company” can be a major
problem when attempting to convince individuals or organisations of the need
to look at human factors issues, recognise risks and to implement improvements,
rather than merely to pay ‘lip-service’ to human factors.

“Murphy’s Law” can be regarded as the notion: “If something can go wrong, it
will.”

One of the most important results of Murphy’s Law in the airline industry is the
requirement for separate inspection and maintenance procedures. This requires
an independent instructor to confirm that the mechanic has carried out all tasks
which, if not properly done, or if the wrong parts were used could pose a risk to
the safe operation of the aircraft.

Thus in aviation industry now most equipment and systems come with ‘fail
safes’ to prevent any incident in case of failure.

The following chapters will go into further detail why the need to consider
Human Factors is important not only to improve the safety and well-being
of personnel in workplace but also to improve the efficiency of maintenance
as well as the production and economy of the company.