HUMAN FACTORS

THE DIRTY DOZEN

1. LACK OF COMMUNICATION – FAILURE TO TRANSMIT, RECEIVE OR PROVIDE SUFFICIENT

INFORMATION FROM ONE PARTY TO ANOTHER OR IN COMPLETING A TASK.
EX. TENERIFE AIRPORT DISASTER WAS DUE TO THE LACK OF COMMUNICATION
BETWEEN THE TWO AIRCRAFTS AND THE ATC TOWER.

2. COMPLACENCY – FAILURE TO THOROUGHLY PERFORM A TASK DUE TO REPEATED EXPERIENCE

CAUSING AN ATTITUDE OF OVERCONFIDENCE.
EX. SKIPPING AN INSPECTION DUE TO UNCRITICAL ASSUMPTIONS.

3. LACK OF KNOWLEDGE – SHORTAGE IN TRAINING OR INTELLECT RESULTING TO POOR TASK

EXECUTION.
EX. FIDDLING WITH AIRCRAFT COMPONENTS WITHOUT PROPER TRAINING OR
KNOWLEDGE.

4. DISTRACTIONS – ANYTHING THAT WOULD RENDER ONES ATTENTION ELSEWHERE FROM THE
TASK AT HAND.
EX. CONTROL TOWER OPERATOR CONVERSING WITH COLLEAGUES WHILE GUIDING
AIRCRAFTS DURING LANDING.

5. LACK OF TEAMWORK – LACK OF UNISON AMONGST THE WORKFORCE WHICH CAN RESULT IN
FAILURE
EX. FIRST OFFICER UNCOOPERATIVE WITH THE CAPTAIN’S WORK AND DECISIONS IN
FLIGHT.

6. FATIGUE – EXHAUSTION THAT CAN LEAD TO THREATENINGLY POOR PERFORMANCE

EX. BACK TO BACK FLIGHTS THAT CAN LEAD TO PILOT FATIGUE THAT MAY INCUR AN
ACCIDENT.

7. LACK OF RESOURCES – INSUFFICIENT LABOR FORCE, EQUIPMENT, COMPONENTS, ETC.

EX. USAGE OF CHEAP SUB-STANDARD COMPONENTS IN AIRCRAFT MAINTENANCE/
REPAIR.

8. PRESSURE – REAL OR PERCEIVED FORCES THAT DEMANDS A HIGH STANDARD OF

PERFORMANCE.
EX. PILOTS PRESSURING AERONAUTICAL ENGINEERS TO CLEAR AN AIRCRAFT WITHOUT
PROPER INSPECTION OR MAINTENANCE.

9. LACK OF ASSERTIVENESS – FAILURE TO POINT OUT ERRORS IN ORDERS, ACTIONS, ETC.

EX. FIRST PILOT KNOWING THE CAPTAIN’S CHOICE IS WRONG BUT NOT PREVENTING IT.
10. STRESS – AN EMOTIONAL FACTOR THAT CAN CAUSE PHYSICAL OR MENTAL TENSION.
EX. ENGINEER AT WORK, WHILE ALSO DEALING WITH PROBLEMS OUTSIDE OF WORK.

11. LACK OF AWARENESS – FAILURE TO RECOGNIZE A CERTAIN SITUATION AND DEAL WITH IT EARLY
ON.
EX. LACK OF AWARENESS BY THE KLM PILOT THAT ANOTHER AIRCRAFT WAS ON THE
OPPOSITE SIDE OF THE RUNWAY.
12. NORMS – UNWRITTEN RULES FORMED WITHIN AN ORGANIZATION THAT DICTATES RIGHT AND
WRONG ACTIONS.
EX. COMPROMISING A TASK BY DOING SOMETHING ACCUSTOMED RATHER THAN THE
STANDARD EXECUTION.

EX.