M-9 Human Factors: Aviation Training Hub
M-9 Human Factors: Aviation Training Hub
M-9
HUMAN FACTORS
Introduction .................................................................................................................................................. 5
General.......................................................................................................................................................... 5
The Need to Take Human Factors into Account ....................................................................................... 5
Incidents Attributable to Human Factors/Human Error ......................................................................... 13
Murphy's Law .......................................................................................................................................... 18
Human Performance and Limitations ......................................................................................................... 20
Vision....................................................................................................................................................... 20
Hearing .................................................................................................................................................... 32
Information Processing ........................................................................................................................... 44
Attention and Perception ....................................................................................................................... 46
Memory................................................................................................................................................... 49
Claustrophobia and Physical Access ....................................................................................................... 50
Social Psychology ........................................................................................................................................ 52
Responsibility: Individual and Group ...................................................................................................... 52
Motivation and De-Motivation ............................................................................................................... 53
Peer Pressure .......................................................................................................................................... 54
"Cultural" Issues ...................................................................................................................................... 57
Team Working ......................................................................................................................................... 58
Management........................................................................................................................................... 61
Supervision and Leadership .................................................................................................................... 62
Factors Affecting Performance ................................................................................................................... 63
Fitness / Health ....................................................................................................................................... 63
Stress: Domestic and Work-related ........................................................................................................ 64
Time Pressure and Deadlines .................................................................................................................. 66
Workload: Overload and Underload ....................................................................................................... 68
Sleep and Fatigue, Shiftwork .................................................................................................................. 70
Shift Work ............................................................................................................................................... 74
Alcohol .................................................................................................................................................... 74
Medication .............................................................................................................................................. 76
Drug Abuse .............................................................................................................................................. 77
Physical Environment.................................................................................................................................. 79
Noise and Fumes ..................................................................................................................................... 79
Illumination ............................................................................................................................................. 79
Introduction
Statistics tell us that human error causes around 70% of today's aviation accidents. If one
considers that airplanes are designed, manufactured and maintained by humans, this figure goes
up to 100%.
Human factors (also referred to as Human Performance) is a relevant topic whenever a human
being is involved in the field of aviation. It is the aim of this subject to understand the human
body and recognize its weaknesses to prevent negative influences on the operations within the
industry.
This book will provide readers with a straightforward explanation on the importance of human
factors. The human senses and its limitations will be addressed followed by social psychological
factors such as teamwork, responsibility, peer pressure etc. We will also be discussing several
factors which affects performance, the different categories of tasks, environmental and
workplace hazards. Finally, emphasis on effective and efficient communication is addressed in
detailed as well as human errors and ways to mitigate them.
General
Human factors is a branch of science that concerns itself with the role of humans in complex
technological systems as well as with the design of equipment, technological aids or machinery.
Its goal is to optimize the working environment to increase safety and comfort.
Fadier & Ciccotelli found in 1999 that the significance of humans increases with a rise in the
degree of automation, while their knowledge decreases since interaction with the system is
limited to supervisory activities. The fact that automation becomes increasingly relied upon in
safety-critical areas is the reason for the increasing human significance.
On a wider scale, studies concerning human factors find various circumstances that can influence
the performance of humans. Aspects from the following scientific areas can be applied:
• Clinical Psychology
• Anthropology
• Experimental Psychology
• Computer Science
• Cognitive Science
• Safety Engineering
• Medicine
• Organizational Psychology
• Instructional Psychology
• Industrial Engineering
Education and training on all aspects of human factors is essential to improve flight safety and
efficiency. The development of human factors was driven by the cooperation of major airlines,
aerospace agencies (e.g. ICAO and NASA) as well as national authorities and universities.
Logo of ICAO
Logo of NASA
Training in human factors is now an integral part of European aviation regulations. Employees in
maintenance organizations have to participate in mandated training courses every two years.
Participants are made aware of human factors and limiting influences, hence learning to
recognize and evaluate risk at an early stage and initiate appropriate countermeasures.
In 1972, a psychologist named Edwards presented a concept of the interface between flight crew
and other parts of the airspace environment. This concept is called SHELL Concept and it
consists of the elements; Software, Hardware, Environment and Liveware. Later on, Capt. Frank
Hawkins modified this model by adding another "L" (Liveware) to it (SHELL), to emphasize the
significance of interpersonal relations.
It is a conceptual model that clarifies the scope of human factors and assists in understanding the
relationships between aviation system resources, workplace environment and the human
component in the aviation system.
The SHELL model adopts a systems perspective that suggests that humans are on rare occasions
the sole cause of an accident. The systems perspective considers a variety of contextual and task-
related factors that interact with the human operator within the aviation system to affect operator
performance. As a result, the SHELL model considers both active and latent failures in the
aviation system.
The SHELL model describes the relationship between an individual (L) and four main factors:
software (S), hardware (H), and liveware (L) in an aviation environment (E). It represents the
array of human factors involved at different interface levels in a simplified and schematic way.
The following example shows how technological development can lead to problems and how
simple the solutions to eliminate risk may be.
Example
World War Il led to an enormous increase in aviation research and development. The call for
ever faster and more capable airplanes drove engineers in their task to find new solutions. Over
the course of a few years, the top speeds of aircraft rose by up to 30096 and the number of
switches and instruments by 350%. The number of accidents caused by pilot error rose by a
similar percentage. One of the most frequent errors was for the pilot to retract the landing gear
instead of extending the landing flaps. During incident investigations, it was found that these
errors only occurred with certain types of airplane such as the Lockheed P-47, Boeing B-17,
North American P-25 or Curtis C-46. The psychologist Alphonse Chapanis was tasked with
examining the cause of these incidents. He found that the accidents were caused by the fact that
the landing gear and flaps levers were situated next to each other and could have easily been
confused. He found a simple solution that was easy to implement: Placing a wheel on the end of
the landing gear lever and a triangle to the end of the flaps lever, making them distinguishable by
touching and looking at them. This standard is still used in today’s aircraft and has become a
certification criterion for building aircraft.
Serious errors are often caused by a combination of human information processing, social
circumstances and operational factors. In order to find all the relevant connections between the
causal factors of incidents, a multi-layer analysis can be conducted consisting of the following
layers:
The aircraft manufacturer Boeing investigated a total of 122 incidents in 1993. The incidents
examined took place between 1989 and 1991. The investigation board found that 56% of human
errors were caused by (deliberate) omission. Another 30% were a result of incorrect installations.
Boeing conducted another study in finding the leading source of error in cooperation with nine
maintenance organizations. The following were the results:
The Australian aviation authority conducted a study of the factors mentioned in 1993. The study
analyzed airline incidents and found the following distribution of contributing factors:
• Pressure 21 %
• Fatigue 13 %
• Coordination 10 %
• Training 10 %
• Monitoring 9 %
• Defective Equipment 8 %
• Environment 5 %
• Incorrect Documentation 5 %
• Flawed Processes 4 %
The results show how vital continuous training in human factors is for safety in aviation. Well
trained and sensitized employees can identify these negative factors which could have an impact
on their own performance and that of other colleagues.
Further development of safety relevant aspects requires an open and trustful interaction between
the members of any organization. Employees can only be motivated to report risk and make
improvements if the safety philosophy is actively supported by management.
All aviation incidents and accidents are documented and analyzed in order to find their cause.
This process helps authorities and manufacturers find risk factors, allowing them to take suitable
countermeasures. The responsible authorities, such as the U.S. NTSB (National Transport Safety
Board) and local civil aviation authorities create and publish reports of these incidents, in which
the prime causes and contributing factors leading up to an incident are outlined. Aviation
professionals should take notice of these reports since they give valuable input to improve
operational processes as well as to develop their own skills.
Human error has led to many incidents and accidents in the history of aviation. The following
section lists and analyzes some examples.
Example 1
On May 23 2008, an Airbus A300 lines up for takeoff at Cologne/Bonn Airport in Germany. At
a speed of 110 knots, the crew hear a loud noise on the aircraft's left side. They abort takeoff and
return to the parking position. After shutting down the airplane, they find substantial damage to
the left engine's core cowling, with both halves bent backward and cracked in numerous places.
The cause was identified as a forced rupture of the cowling locks as well as missing springs in
the locks. The engines were subjected to maintenance work the night before, after which the
engine nacelles were not properly closed by the maintenance personal. During the takeoff run,
the airstream entered below the cowling, bursting it open.
Example 2
On August 28 2009, an Antonov AN-12 airplane was loaded with cargo at Munster-Osnabruck
Airport. During start-up of engine number 3, the right main landing gear carrier breaks. The
airplane was manufactured in 1967, but the concerned landing gear was installed in 1993. The
landing gear carrier is a tube design, with axle attachment points welded to its end. During the
incident investigation, it became clear that the inner surface of the carrier tube was heavily
corroded and that the rupture originated from a thumbnail-sized crack. This crack occurred due
to the humidity within the carrier and the recurring loads during takeoffs and landings. The
investigation could not find any indication of maintenance carried out on the assembly. This
fuels the assumption that the incident was due to a lack of maintenance and repair.
Example 3
June 7 2010, takeoff of an Embraer ERJ 170 from Munster-Osnabruck Airport. After actuating
the landing gear lever, the First Officer noticed that the right main landing gear was not
retracting correctly. The cockpit crew receive the visual and acoustic alarm "LG LEVER
DISAG". After going through the checklist, the crew managed to extend and lock the complete
landing gear, which was confirmed by three green lights on the respective panel. While still
working the checklist, the crew received a "HYD 2 LO Press "warning", prompting them to
perform a safety landing at Frankfurt airport. After landing, they found the following damage to
the airplane:
During the fatigue testing process carried out by the manufacturer to determine the airplane's
lifetime, the retraction actuator's support fitting obtained first cracks after 8281 simulated flight
cycles. Further testing proved that in the worst case a rupture of the support fitting, the landing
gear could not be retracted any longer. Due to these results, the manufacture's design change was
classified as a Service Bulletin, not an Airworthiness Directive. It was recommended to change
the Support Fitting after 5000 flights. The incident aircraft was the last in the operator's fleet that
had not been retrofitted as specified in the service bulletin. The support fitting broke after the
8,641 flight cycle.
Murphy's Law
"If anything can go wrong, it will. " - this common saying stands for a serious area of modern
technology. It stands for knowledge, experience and the application of error prevention
strategies. According to Murphy’s Law, it is always a human who is responsible in some way.
On the other hand, there are some factors which cannot be controlled by man and that may lead
to something going wrong, e.g. uncontrollable actions by co-workers.
Murphy’s Law
The law, in its well-known form, was phrased by US Air Force Engineer Captain Murphy in
1949. At that time, he was participating in a rocket sled experiment instituted to find out the
amount of acceleration the human body can handle.
Rocket Sledge
The experiment failed because one of the employees placed the sensors the %Tong way around,
preventing them from gathering data during the test run. Captain Murphy phrased the basic
concept along the lines of "If there's more than one way to do a job one of those ways result in
disaster.'
The short version of this law mainly refers to technological systems or experimental
arrangements. It is the basis for proactive strategies in computer science or quality management.
In aviation, the fail-safe principle, duplex systems or redundancy are all ways of minimizing the
potential consequences of Murphy’s Law.
Vision
The human brain gathers approximately 80% of the information about its environment by sight.
Around a quarter of the human brain is involved in processing that input. These numbers serve to
show that vision is the most important sense humans have at their command. It can recognize
large objects like buildings or mountains as well as small things, like an ant, within the blink of
an eye. It distinguishes around 10 million shades of colors. Even the slightest amount of light
triggers a reaction within the eye.
Humans recognize shapes, outlines, contrast, movement, objects, and persons. The visual system
processes a significant stream of information originating from the eyes, providing a coherent
image of our surroundings. It cooperates with other areas of the brain, filtering and evaluating
sensory impressions and linking them with memories or experiences.
Over time, the performance of the visual system may fade, which, in most cases, can be
counteracted by wearing glasses. The ability of the visual system to recognize colors may
diminish or other eye diseases may impair its performance. Therefore, regular eye checks are
vital as they provide the opportunity to recognize possible problems early on.
In aviation maintenance we depend on good eyesight as a major part of our job consists of
reading documentation and conducting visual checks. Using suitable protection devices such as
goggles is an integral part of workplace safety to protect the eyes from numerous hazards.
However, our visual system does not always work correctly. It is essential to be aware of the
limitations and weaknesses in order to prevent potential mistakes.
In order to understand how vision works it is useful to know the anatomy of the eye. The human
eye consists of the eyeball and several other components such as the eyelids, conjunctiva, eye
muscles, nerves and a tear system. The eyeball lies in the eye socket and is covered by the upper
and lower eyelids, which distributes the tear fluid evenly over the conjunctiva. Six muscles
control
the eyeball and allow its movements up and down, left and right - even limited forward and
backward movement is possible.
The sclera consists of dense elastic fibers that give the eyeball, together with the internal eyeball
pressure its round shape; in addition, the sclera protects the eye from damage that may be caused
by knocks or blows.
In the frontal region of the eye, the sclera becomes transparent and free from fibers, forming the
cornea, which refracts light together with the lens and the vitreous body.
The third layer, the retina, covers the eye from the inside and contains the light-sensitive
photoreceptor cells crucial for visual perception. The photoreceptors join to nerve fibrils, which
exit the eyeball at the optic disc where neither rods nor cones are placed. This causes a break in
the
visual field called the "physiologic blind spot", the point where the information is transported to
the brain to be processed in the visual cortex.
In the center of the eye's retina, there is a small, oval indentation (3 mm in diameter), which is
surrounded by an arched, scar-like frame. This spot on the retina is known as the fovea centralis
or
"yellow spot." The human eye's well-developed vision and its ability to see colors and read
alphanumeric information is due to this small region of the retina.
The vitreous body accounts for two-thirds of the eyeball's size and consists of a gelatin-like
mass.
Separated by the iris and connected by the pupils and two ocular chambers located in front of the
vitreous body, the anterior and posterior chambers. These chambers are both filled with aqueous
humour, a liquid that provides the transparent lens, which has neither vessels nor nerves, with
nutrients and oxygen. The eyeball pressure is constantly kept at 10- 21mmHg. Higher figures can
cause chronic damage to the retina and its light-sensitive photoreceptor cells.
Let's follow the route of light along the visual axis, from the moment it strikes the cornea to the
reaction triggered in the retina's light-sensitive photoreceptor cells.
The Cornea
The light initially contacts the watch glass-shaped, curved, translucent cornea. The light rays are
refracted during the passage from the air into the cornea. The cornea's radius of curvature
determines the actual degree of refraction. In most eyes, approximately 70% of total refraction
takes place here.
The amount of light that reaches the retina depends on the size of the pupil. The size of the pupil
is changed by the iris muscles. The pupil's contract when they are exposed to brightness and
dilate slowly when adapting to the darkness (dark adaptation).
The amount of pigment in the iris determines the color of the eyes. If someone has a lot of
pigment the eyes are brown. If someone has low levels of pigment the eyes are either blue or
gray.
The ciliary body which surrounds the lens and holds it, consists of the ciliary muscle and the
ciliary zonules (fibrous strands). The ciliary zonules are attached to the lens and flatten when the
ciliary muscle is relaxed - crucial for distance vision. When the muscle is contracted, the
sphincter narrows and thus reduces the tension in the ciliary zonules, causing the flexible
crystalline lens to return to its natural, spherical shape. This state of the lens, which leads to
higher light refraction, is needed for focusing on objects nearby. The process of adjusting visual
acuity by changing the shape of the lens is called "visual accommodation". The lens' flexibility
reduces as it hardens later in life (beyond 45 years of age). At this point, its capacity to adjust for
extreme close-up vision and the accommodation for range vision decreases.
The Retina
The retina is the light-sensitive inner lining of the eye containing photoreceptor cells which are
essential for visual perception. The photoreceptor cells transform light stimuli into nerve stimuli
that are transmitted to the human brain via the eye nerve.
The photoreceptor cells in the retina consist of two different components - rods and cones, whose
names are attributable to their actual physical shape. The cones handle day and color vision
(photopic vision) while the rods are in charge of night vision (scotopic vision). The
transformation of light stimuli to nerve stimuli is achieved through certain visual pigments inside
the photoreceptor cells, which change when exposed to light, thus stimulating nerves.
The photoreceptor cells at the retina consist of two different cell components - rods and cones,
whose names are attributable to their actual physical shape. The cones are responsible for day
and color vision (photopic vision) while the rods are in charge of night vision (scotopic vision).
Cones
Cones are the color sensitive photoreceptor cells of the eye and only function well at good light
level. They are primarily found around the fovea, the center of the retina. In this area the
concentration of cones is exceptionally dense, at approximately 150, 000 cones per mm2. In the
central visual field the visual discrimination is at its best but deteriorates rapidly peripherally,
Colors fade at dusk - to rise again at dawn. The cones also use certain visual pigments to
determine colors. The peripheral visual field is practically color blind, increasing with distance
from the fovea and decreasing with luminescence on the retina. However, the vision is not
affected by this because the brain executes a trick whereby color patterns are projected from the
central visual field to its peripheral counterpart in the visual cortex.
Rods
Rods are the light sensitive photoreceptor cells of the eye and are primarily found at the outer
edges of the retina. They are responsible for vision at low light levels and the peripheral vision.
Rods do not translate color very well, that is why everything at low light levels seem to have
little to no color.
The rods use visual purple, which builds up when darkness increases and changes the rods'
sensitivity to light (known as "dark adaptation"). In chemical terms, the visual purple consists of
rhodopsin (made of opsin and retinal), which is a compound of hydrocarbon and protein. When
light strikes the retina, rhodopsin dissociates and the process of dark adaptation begins again.
Vitamin A is essential for the regeneration of visual purple. Deficiencies in vitamin A and
possibly vitamin B and C may decrease night vision performance.
The optical properties of the receptors are summarized in the following table:
Visual Impairment
The term visual impairment refers to the inability to see objects clearly. This can be color
blindness, night blindness or reduced visual acuity (i.e. clarity of vision).
Refractive Errors
• Short-sightedness (myopia) — means that the distance between the lens and the retina is
larger than normal. The light that comes into the eye does not focus on the retina, but
instead falls in front of the retina. Distant objects appear blurred, while close objects are
still clearly visible. Concave lenses can correct this condition.
• Long-sightedness (hyperopia) — means that the distance between the lens and the retina
is smaller than normal. This results in the image being created behind the retina. Distant
objects are still seen clearly, while close objects appear blurred. Convex lenses can
rectify this condition.
• Presbyopia — although this condition is similar to farsightedness, they are not the same.
It is an age-related condition in which the lens becomes less flexible. Close objects will
appear blurry and adjusting focus between close and far-away objects can be difficult.
• Astigmatism — is a common type of vision defect. The image is blurred due to an
anomaly in the curvature of the cornea. The deformed cornea is oval rather than
spherical. Almost every human being has slight astigmatism, which is automatically
corrected by the central nervous system. Cylindrical lenses correct pronounced
astigmatism.
To compare the aforementioned kinds of refractive error (ametropia), certain "view values" are
assigned. A person with a 20/20 vision sees clearly at 20 cm distance from an object. A person
with a 20/ 40 vision sees those objects clearly from a distance of 20 cm that a healthy person
could see clearly from a distance of 40 cm.
Color Blindness
Color blindness or color vision deficiency is the decreased ability to perceive differences
between some of the colors that others can distinguish. An observer's ability to process color
information determines the contribution that color contrast can make to form perception. Color
blindness does not affect visual acuity.
Normal trichromatic (three-color) color vision allows the viewer to identify color differences in
the entire spectral range. However, the color discrimination can be difficult for people with color
blindness or even impossible if the information is not transmitted redundantly (e.g. by shape,
size, temporal characteristics or brightness). People with poor color sight often have trouble
distinguishing between red and green, and are thus colloquially color blind. Significantly more
men than women suffer from color blindness, the proportion of colorblind men amounts to
approximately 10%.
In the center of the eye's macula region, the retina has a small, oval indentation (3 mm in
diameter), which is surrounded by an arched, scar-like frame. This spot on the retina is known as
the fovea centralis or "yellow spot. " The human eye's well-developed vision and its ability to see
colors and read alphanumeric information is attributable to this small region of the retina (sharp
central vision).
In bright light, the eyes rely on central vision (cones of the fovea), which allows for focusing and
color vision. Angular movement is perceived around the fovea, in the peripheral vision, which is
essential for noticing moving objects.
Neither cones nor rods exist in the physiological blind spot, the spot of the retina where the optic
nerve leaves the eye. However, this does not affect the visual perception, due to the presence of
binocular vision (two-eyed vision) as the generated images are superimposed and form an overall
picture of the brain.
A decrease in the uncorrected visual acuity may occur at any time with progressing age.
However, it is likely to be noticeable only much later, not until approximately 50 to 60 years of
age. Visual acuity is affected by a wide range of stimulus and observer variables. It is degraded
by the following:
• Dim lighting
• Low contrast of the target
• Depiction of the target in the visual field (small size, remoteness, narrow profile, etc.)
• Lack of angular movement
The brain puts the images together and also takes into account how much the eyes are pointing
inward (i.e. are converging), in order to figure out how far away the object is. This is known as
stereopsis" and provides precise information on the depth relationships of objects in a scene.
Stereopsis, the binocular form of depth perception, is typically used at distances of 20 ft. or less.
As your finger moves away from your nose, the convergence of the eyes gets less and less. If you
are looking at distant mountains, both eyes see the same image and both are pointing straight
forward, so the only way to judge which mountain is farther to use other techniques, dependent
on monocular cues.
Binocular vision can be labeled as unsuitable for distances more than 200 m since vision uses the
stereoscopic depth cue of retinal disparity to perceive an object's depth relative to the fixation
point of the two eyes. At close and near range, this provides a high degree of depth
discrimination and even at tens of meters from the observer enables relative depth perception for
larger objects. However, allowing for the typical streamlined frontal area of aircraft and their
high closing speeds, the scope of binocular vision must be thought of as useless.
Monocular vision principally describes an individual with only one eye, or when a binocular
applicant's best corrected distant visual acuity in the weaker eye is no better than 20/200 (0.1). A
monocular person is forced to use monocular cues for depth perception as well as a binocular
person when fixating on objects that are further away than 200 m - the distance where
convergence is zero and both are equally dependent on monocular cues.
In short, binocular vision is primary for the perception of depth at close to medium distance and
monocular vision is used for distances farther away.
Parallax Error
A parallax error is a displacement in the apparent position of object viewed from two different
lines of sight, with meters and gauges this can result in wrong measurements if not taken
carefully. To avoid parallax error, one should pay special attention that measurements are taken
with a straight viewing angle relative to the instrument.
Some instruments have a mirror build in their scale, which warns the user of any parallax error
by showing the image of the reflection of the needle. If the observer sees a reflection of the
needle, it means the observer is not viewing the needle with a straight angle.
Other methods of avoiding parallax error are by simply using digital instruments which show the
measurements in plain numbers.
Hearing
Hearing describes the acoustic perception of sound with the ears. Sound is a mechanical wave
that is an oscillation of pressure transmitted through a solid, liquid, or gas substance, composed
of frequencies within the range of hearing and of a sufficient level to be heard. Vibrations can be
perceived within a frequency range of 50 to 1/10 Hz, while the human ear can perceive sounds
between 16 Hz and 20 kHz.
Since we have two ears, we can determine the direction of a sound and direct the hearing in a
certain direction. Also, we can track the movement of a sound source. However, the function of
the ear is not limited to only hearing, the ear is also responsible for balance and sensing
acceleration.
In order to understand how the ear works it is useful to know its anatomy. The ear consists of
several parts which can be split into three different sections; the outer ear, the middle ear and the
inner ear. The next paragraph will elaborate on the components and functions of each section.
The ear is embedded in the petrous bone of the skull and consists of the components as indicated
in the images below -to make sense of the following, refer to the image below for a more
detailed explanation.
Outer Ear
The outer ear is the external part of the ear and consists of the pinna (auricle) and the auditory
canal. The acoustic properties of the outer ear substantially boost sound pressure at the eardrum,
especially for the frequency range of speech between 2000 and 5000 Hz.
Middle Ear
The middle ear consists of the eardrum (tympanic membrane) with three tiny bones (ossicles),
called hammer (malleus), anvil (incus) and stirrup (stapes), all situated in the tympanic cavity.
These tiny bones transmit the vibrations from the eardrum further to the fluid of the inner ear.
The middle ear also contains two muscles which help to protect the ear from high intensity sound
by means of an acoustic reflex. When these muscles are presented by strong stimuli they will
contract, stiffening the ossicles and reducing the ability to transmit vibrations. This stiffening
reduces the sound by about 20 dB for up to 15 minutes. The middle ear is usually filled with air
which is refreshed by the Eustachian tube. The Eustachian tube connects the middle ear with the
throat and serves the function of pressure equalization.
Inner Ear
The inner ear is connected to the middle ear by the malleus (hammer). The inner ear is buildup
out of a peculiarly shaped labyrinth with two different functional sections: First, the vestibular
system, including the three semicircular canals and the otolith organ with the utricle and saccule.
And secondly, the cochlea with the Organ of Corti.
The cochlea is a tube of about 3-5 cm long that is coiled like a snail shell and is filled with a fluid
called perilymph. A plate of bone runs through the cochlea and an inner tube that is filled with a
fluid called endolymph. These structures divide the outer tube of the cochlea into two separate
chambers.
Because the fluids in the ear are practically incompressible, it is necessary to have some way of
relieving the pressure created due to the traveling wave in the fluid. It is the flexible skin called
the "round window” which acts as a pressure relief valve.
The pinna collects and amplifies sound waves on their way through the external auditory canal to
the eardrum (A), causing it to vibrate (B). The auditory ossicles, attached to the eardrum, boost
sound pressure on conversion into mechanical vibration (C). Any sound makes the stirrup beat
the elastic membrane of the oval window (D) forming a fluid traveling wave in both perilymph
and endolymph inside the cochlea, stimulating the sensory cells of the basilar membrane. The
undulation of the extremely fine sensory hairs and the tectorial membrane in the Corti organ (E2)
create electric impulses which are then transferred via the auditory nerve to the brain (F) to be
processed and interpreted.
Different sections of the basilar membrane and the organ of Corti vibrate dependent on
wavelength and amplitude of a stimulus (El). The human ear can thus perceive various sound
frequencies, whereas a difference in volume depends on the actual load of the electric potentials.
If sound is perceived in one ear before the other, the brain can locate its source.
Within the inner ear, the cochlea is responsible for the perception of sound. The vestibular organ
with semicircular canals and otoliths (utricle and saccule) is designated to keep one's balance and
spatial orientation. The cavity inside the cochlea contains two elastic tubes, each filled with
different fluids. The inner tube is filled with endolymph (color-coded "blue") and encloses the
basilar membrane of the Corti organ. The outer tube is filled with perilymph (color-coded
"yellow") and almost completely encases the former.
Cochlea
The endolymph-filled passageways of the cochlear duct house the organ of Corti. The organ of
Corti is the actual auditory organ, which is located in the middle section on a vibratory
membrane, the basilar membrane. The organ of Corti contains auditory sensory cells, so called
hair cells, which transform the sound waves in the fluid into nerve signals.
Proper transmission of sound in the middle ear can only be achieved, when it is filled with air at
atmospheric pressure. The Eustachian tube, maintains atmospheric pressure in the tympanic
cavity. It opens and closes automatically when talking or swallowing and, due to their funnel-
shaped structure, when climbing. However, when the Eustachian tube fails to open during
descend, an increasing pressure difference is experienced causing the elastic eardrum to bulge
towards the inside changing the auditory sensitivity. An increased stiffness in the mechanical
transmission system of the middle ear is the consequence, whereby the transmission loss is
greater for low frequencies and has been observed to be of the order of 20dB for frequencies
below 1,000 Hz.
Allergies, colds or flu may inflame the walls of the Eustachian tubes making them difficult to
open. Increasing pressure difference, as in rapid descents or during scuba diving impairs hearing
and may be quite painful or even rupture the tympanic membrane when altitude compensation is
hindered.
Hearing Loss
Noise is any form of acoustic sound considered either annoying or harmful to health. Despite
sound intensity, duration of exposure, frequency distribution, and noise-free rest periods, the
individual sensitivity to noise largely determines whether a noise-induced hearing impairment
will occur. The differences from one person to another are vast in this context - the same noise
level may result in a hearing impairment for one person, while others are unaffected by it.
Hearing impairments can occur when people do not even realize that they have been exposed to
extensive
Hearing loss is a degree of impairment of the ability to capture sound. It is classified in four
major categories.
The same definitions are not always used, but most common are the following stages of hearing
loss:
• Mild — On average, the quietest sounds that people can hear with their better ear are
between 25 and 40dB. People who have mild hearing loss have some difficulties keeping
up with conversations, especially in noisy surroundings.
• Moderate — On average, the quietest sounds heard by people with their better ear are
between 40 and 70dB. People who have moderate hearing loss have difficulty keeping up
with conversations when not using a hearing aid.
• Severe — On average, the quietest sounds heard by people with their better ear are
between 70 and 95dB. People who have severe hearing loss benefit from powerful
hearing aids, but often they rely heavily on lip-reading even when they are using hearing
aids. Some also use sign language.
• Profound — On average, the quietest sounds heard by people with their better ear are
from 95dB or more. People who have profound hearing loss are very hard of hearing and
rely mostly on lip-reading, and sign language.
Both, the noise-induced hearing loss as well as age-related hearing, relate primarily to the high
frequencies. In most languages, high frequencies define the language, so many people hear this
noise, but they just cannot easily make out what they mean. They particularly have problems
The next image shows three photos of the cochlea with corresponding audiograms. Photo (A)
depicts a healthy cochlea, whose basilar membrane is well supplied with blood. There is no
evidence of impairment, as confirmed by the appropriate audiogram. Photo (B) represents the
cochlea of a person suffering from presbycusis. The sectoral damage of the basilar membrane
between the cochlea's entrance and the white tick mark is evident. The corresponding audiogram
indicates the typical threshold drop at high frequencies, which confirms the damage. Photo (C) in
the image shows a cochlea damaged by excessive noise exposure. A comparison with photo (A)
accentuates the dimension of destruction — the sensory cells are incapable of regenerating
themselves and collapsed, causing irreversible hearing loss. The audiogram confirms deafness in
the important frequency ranges relevant for speech.
Audiograms
To the general public, noise is merely unwanted sound, an annoyance. But call it acoustical
overexposure, acoustic overstimulation, or excessive noise, sounds can be sufficiently strong,
sufficiently long lasting, and involve certain frequencies so that they can cause hearing loss and
damage to the inner ear. The following table summarizes effects of environmental noise on
hearing in reference to sound level in dB(A):
• Diseases or illness
Mumps may result in a profound sensorineural hearing loss, measles and meningitis
accompanied by high fever may damage the auditory nerve or the cochlea, to name only a
few. Tumors in every part of the ear can hamper hearing or cause deafness.
• Heredity
Genetic makeup or defects may make an individual more susceptible to hearing loss.
• Aging
Exposure to sounds within normal levels over the years will eventually make the cells of
the inner ear languish.
• Smoking
A number of researchers has reported an association between smoking and high-
frequency hearing loss. Cigarette smoke has been implicated as a direct ototoxin (i.e. a
toxic substance harmful to the ear) or as an inducer of ischemia through the production of
carboxyhemoglobin, vasospasm or promotion of arteriosclerosis. The observed
association between hearing loss and smoking implies that there may be a cumulative and
permanent effect.
• Medication
Drugs, such as the antibiotic gentamycin and certain chemotherapy drugs, can damage
the inner ear. Transient tinnitus can occur if very high doses of aspirin, other pain
relievers or drugs against malaria or loop diuretics are taken.
• Toxic substances and solvents
Lead, mercury as well as crude oil or avgas and pesticides or herbicides can contaminate
the tissues of the inner ear.
• Physical trauma
Physical damages, either to the ear itself or to the cerebral area that processes aural
information is vulnerable to hearing loss or tinnitus, either temporary or permanent.
However, all of the above factors together carries less weight, compared to the exuberant share
of NIHL.
Occupational Exposure
Occupational exposure is the most common cause of noise-induced sensorial hearing loss. It
threatens the hearing of aircraft technicians, pilots, military personnel, fire-fighter, police
officers, construction and factory workers, musicians, farmers, and truck drivers, among others.
The Occupational Safety and Health Administration (OSHA) states that about 17% of production
workers or 1.6 million people have at least mild hearing loss resulting from occupational noise
exposure. In addition, one million or 11% have a moderate hearing impairment and nearly half a
million or 5% have moderate to severe hearing loss. Since the onset of hearing loss is insidious
and painless, most people tend to hazard the consequences until they end in deafness. They
wouldn't listen until they are unable to listen.
The reason for this common behavior is that the human ear has a remarkable ability to
discriminate and 'hear out' some sounds from a background of other sounds, although there are
limits to this ability. Through a process known as "masking", noise can make a sound inaudible.
"Partial masking" can cause the speech from a headset used in a particular ambient noise to seem
quieter than the same speech at the same volume setting but without the background noise. This
is similar to the effect experienced when listening to the car radio while driving fast on the
motorway and after coming to a stop at the end of a tailback. The radio seems to be
uncomfortably loud, whereas it was comfortable against the background noise when driving fast.
Thus, hearing can be impaired in several ways in each of the five steps above. With conductive
hearing loss (CHL) the problem is to be found in the first two steps; and a sensorineural hearing
loss (SNHL), normally a noise induced hearing loss (NIHL), is assignable to the latter three steps
of the above list.
The aviation environment is characterized by multiple sources of noise, both on the ground and
in the air. Noise is produced by aircraft equipment, power plants, transmission systems, jet
efflux, propellers, rotors, hydraulic and electrical actuators, cabin conditioning and pressurization
systems, cockpit advisory and alert systems, communications equipment, etc. In addition, noise
can also be caused by the aerodynamic interaction between ambient air (boundary layer) and the
surface of the airframe, wings, control surfaces, and landing gear.
There are three basic sources for the noise that affects aircraft technicians:
• Engines
• Propeller
• Aircraft systems (e.g. hydraulic pumps, pneumatic systems, etc.)
• Equipment (tools, vehicles, etc.)
Precautions That May Be Taken to Reduce the Probability of Onset of Hearing Loss
• Intensity
• Frequency
• Exposure time
• Proper use of protective equipment (e.g. headset, ear plugs)
The most straightforward means of reducing noise and to prevent hearing loss is to wear ear
protection. They come in numerous shapes and sizes varying from simple earplugs to advanced
noise canceling headsets.
Information Processing
• Smell
• Hearing
• Sight
• Taste
• Touch
The term information processing captures the reception and analysis of stimuli by these senses as
well as their output in the form of decisions or actions. Information processing can be visualized
in a functional model as seen below:
Humans continuously occupy themselves with exploring and recognizing the world around them.
The first step of information is always the perception of an event by the different sensory organs.
The type and scope of information a human can absorb depends on the capabilities and limits of
the sensory organs. There are different processes the brain uses to recognize the collected data.
Psychologists distinguish between two types of perception processes, bottom-up and top-down
processes. These processes are directly related, forming an important component of recognition.
Sometimes, bottom-up processes are involved in recognition, other times, top-down processes
dominate
Attention
When we recognize information, our mental resources concentrate on processing them. This
process is called attention. We can only pay attention to one bit of information at a time. The
extent of our attention depends on the level of excitement and stress and can be affected
positively as well as negatively by those factors.
• Selective Attention — Occurs when monitoring multiple sources of data. If one or more
of the sources seem more interesting and important, they will receive more attention
• Shared Attention — Is practiced when a human is forced to work on multiple similar
tasks at a time
• Focused Attention — Is the capability of a human to concentrate on a single source of
data and filter out the distractions
• Continuous Attention — Describes the capability of a human to focus his attention and
alertness on a e task for long periods of time
Perception
The term "perception" describes the interpretation of information that has been captured by our
senses with the aim of giving it a meaning. Perception depends on the brain's ability to keep
important data, filter and forget unimportant data and making a connection between new data
and past events in one's memory. In short, perception is a process of assembling sensory
information into a usable representation of the world around us.
Attention
Humans have problems with distributing their attention to multiple tasks. This means that
controlled processes cannot take place simultaneously. This circumstance is called Divided
Attention Deficit. A typical everyday example is when we are driving our car through city traffic
while having a conversation with our passengers. As soon as there is a critical situation, like a
car suddenly brakes in front of you, you divert your attention and pause the conversation.
The cause of this lies in the limitations of the mental capacity available to us. Humans can only
fulfill multiple tasks at a time if these tasks do not require the same resources or if the resources
can be distributed. This is called a "resource conflict".
Perception
However, it is important to understand that there are certain limitations to our perception; what
we perceive is not necessarily correct. A proportion of the sensed information may be filtered out
or becomes lost in the processing in the brain.
People may totally oversee a dangerous situation or make assumptions about the situation with
prior knowledge and experiences Therefore, it is crucial to be aware that what you perceive is
not necessarily true and it is essential to keep this in mind when making decisions.
A good method of making people aware of limitations of our perception is with the help of
illusions.
The following image illustrates two lines that appear to be different in length, however, if you
put a ruler beside each of the lines you will find out that they are actually the same size.
Line illusion
The next illusion illustrates that our brain can trick us, when we have certain expectations and
then assumes the outcome.
When you read the sentence really quick you won't notice the additional "A".
Text Illusion
Memory
The term memory describes the ability to store, sort and access information that has been
captured in the past. The stored information is the result of a conscious and subconscious
learning processes.
Depending on the duration of storage, we distinguish between the sensory memory, short-term
memory and long-term memory:
Sensory Memory — Also called ultra-short-term memory, stores information for a few
milliseconds. New information reaches the brain through receptors, where it is stored for an
interim period. It enables us, for example, to repeat things we have just heard.
Short Term Memory — Also called working memory. It is the center of information
processing. It stores small amounts of information in an active and accessible state. Information
is accessible and stored in the short-term memory for up to 60 seconds. If information needs to
be stored for longer periods, it has to be transferred to the long-term memory. The short-term
memory/s capacity is limited. It can store about 7 chunks of information at a time.
Long Term Memory — The permanent data storage system of the human brain. The long-term
memory has to be trained continuously in order to be capable of absorbing new information. The
conscious process of circulating and accessing memory from the working memory transfers this
information to the long-term memory.
The short-term memory can be further split up into the following three systems:
2. Articulatory Loop — The articulatory loop stores verbal information, which can
remain accessible for extended periods if continuously repeated
3. Central Executive — The central executive manages the other two systems and links
the information stored in these systems with the long-term memory
The long-term memory has different storage partitions for different types of information. Its
capacity does not seem to be limited and some information is stored for a lifetime. Forgetting
pieces of information does not mean a complete information loss but is influenced by disrupted
synaptic connections, which is caused by the process of absorbing new information.
The specific way information is organized in the long-term memory It is not well understood,
however, one theory is that information is clustered into groups (e.g. colors, shapes, fruits,
vegetables etc.). Another theory, the so called "semantic network theory?' contends that
information is organized in a network of interconnected concepts. The network is not necessary
structured in hierarchies but is loosely connected (e.g. a particular scent can trigger memories of
your youth).
The long-term memory can be further split into the following two components:
1. Declarative memory — Also called knowledge memory which saves facts and events
that can be recalled consciously. It is divided into the semantic memory (global
knowledge, knowledge about personal facts) and episodic memory (events and facts from
an individual's life).
People who have claustrophobia should notify their colleagues before performing such a task and
if necessary abstain from doing so. Creating large access points, good ventilation and lighting
and having a second person as a backup makes working in confined environments more secure
and helps to prevent anxiety.
The term claustrophobia stems from the Latin word "claustrum", which means "closure".
Claustrophobia is a rather common phobia, with about 5-7% of the population suffering from it.
Depending on the strength of the anxiety, the impact of claustrophobia on everyday life varies
from person to person. People suffering from this condition avoid elevators, confined spaces or
driving through tunnels. In strong cases, even wearing tight clothes can lead to a state of anxiety.
Severe claustrophobia is treated with therapy and drugs if it limits daily life to a significant
extent.
Fear of Heights
Working at significant heights can be uncomfortable for some people even to such an extent that
they cannot focus on their job at hand. Taking the right safety measures when working at height,
such as wearing a safety harness can ease the feeling of anxiety. People who fear heights should
notify their colleagues or possibly abstain from doing the task at hand. However, the support of a
team member can certainly ease one's mind when performing such tasks.
Social Psychology
Either a group or an individual can carry responsibility. The term responsibility describes the
duty related to a certain task to ensure that, within a defined area, the necessary steps are taken
and no harm is done. If someone carries responsibility it is said, he is accountable and in charge
of his tasks.
Individual Responsibility
Group/Team Responsibility
The shared responsibilities in a group or team has it pros and cons. On the positive side, the
advantages are that each member feels responsible for the output of the group (e.g. in a sports
team, people fancy to win a match together and not solely play for their own scores.).
A disadvantage of group responsibility is that it can be unfavorable for the output (i.e. safety),
the responsibility can defuse along the team members and no one feels personal accountable for
the safety because they assume someone else will take this responsibility. Not clearly distributed
responsibilities among personnel can create a situation where people do not fully commit to or
feel liable for the duties they carry out. All members of a group should cooperate to reach the
common goal of product safety. Individual sensitivities, claims or needs must come second to
this objective.
Motivation is the motive for people's actions, wishes and needs, it shapes the behavior of people.
Multiple factors influence the effectiveness and efficiency of an individual or team. Lacking
motivation is one of the most significant contributors to a loss in efficiency. In the occupational
field of aviation being motivated is essential, if all staff would be motivated to work in a safe and
efficient manner many accidents could have been prevented. Unfortunately, many factors
override this ideal (e.g. unfavorable working conditions, financial bonuses, conflicts between
people).
If the two central motives "need for competency" and "ability to act" are fulfilled, positive
motivation is the result, which in turn leads to efficiency gains. Only if group members find their
own goals in the team's common objectives will he contribute his skills and knowledge to the
common task on an ongoing basis.
Peer Pressure
Peer pressure causes individuals to change their attitude, behavior and beliefs (conformity) when
they are part of a group. These behavioral adjustments are sometimes a condition to be accepted
by the group.
Conformity Experiment
Solomon Asch, a social psychologist conducted several experiments investigating how social
pressure from a group affects individuals to conform to their beliefs. In his experiment people
had to judge the length of a line.
• First the participants did the test on their own; as expected most participants choose the
correct answer.
• In the second test several confederates of Asch took part in the experiment. These
confederates were biased by giving the wrong answer aloud. Most of the unknowing
participants neglected their own beliefs by choosing a false answer to conform with the
majority of the group.
The degree to which an individual is likely to show signs of peer pressure or conformity depends
on numerous factors including:
• Culture (people from some countries tend to be more susceptible for conformity)
• Gender (women tend to conform more than men)
• Age (younger and older people tend conform more easily than individuals in their 40's
and 50 s)
• Self-esteem (people with low self-esteem is more likely to conform)
• Knowledge (someone is more likely to conform with someone who has more knowledge
of the subject)
• Relations (someone is more likely to conform with a friend than with a stranger)
"Cultural" Issues
Culture within a company determines and influences the values, beliefs and behaviors that
people share with other members of a group. It selves to bond people together as members of a
group and to provide clues and cues as to how to behave. The culture within an organization is
captured rather well by the sentence "this is the way we do things around here."
Mistrust could arise from anything new in the workplace (e.g. a new employee joining the
company.). Furthermore, there could be friction between the different sub-cultures within the
company (e.g. between management and aircraft technicians). Different cultures have their own
methods whether they are good or bad. It is the responsibility of every employee to identify and
ignore the harmful standards of their company and promote the positive ones. Only conscious
and exemplary action can cause a shift in other people's paradigms.
Safety Culture
Safety culture is the set of enduring values and attitudes concerning safety issues, shared by
every member at every level of an organization. Safety culture refers to the extent to which every
person and every group of the organization:
Both human errors and organizational factors dominate the risks in aviation. Therefore, an
effective Safety Management System (SMS) must be capable of identifying and controlling these
"softer" and subtler issues. It must contain a statement of Safety Management (SM) policies and
principles together with the necessary safety assurance documentation and risk assessment
methodology. The characteristics necessary to manage the human and organizational aspects of
safety in a principled and beneficial manner are:
• Commitment
• Behavior
Awareness
• Adaptability
• Information
• Justness
Commitment reflects the extent to which every level of the organization has a positive attitude
towards safety and recognizes its importance. Top management should be genuinely committed
to keeping a high level of safety and giving employees motivation and the means to do so as
well.
Behavior reflects the extent to which every level of the organization behaves such as to maintain
and improve the level of safety. From the management side, the importance of safety should be
recognized and everything needed to maintain and enhance safety records should be put in place.
Awareness reflects the extent to which employees and management are aware of the risks for
themselves and for others involved in or affected by the organization's operations. Employees
and management should continuously be maintaining a high degree of vigilance concerning
safety Issues.
Adaptability reflects the extent to which employees and management are willing to learn from
past experiences and are able to take whatever action is necessary to enhance the level of safety
within the organization.
Information reflects the extent to which information is distributed to the right people in the
organization. Employees should be encouraged to report safety concerns. Work-related
information has to be communicated in the right way to the right people to avoid
miscommunication that could lead to hazardous situations.
Justness reflects the extent to which safe behavior and reporting of safety issues are encouraged
or rewarded and unsafe behavior is discouraged. Justness contains elements of the term "just
culture". Just culture is a social atmosphere where people are encouraged or even rewarded for
reporting safety-critical information and is a crucial characteristic in the framework of safety
culture.
Team Working
Concept of a Team
A team is a group of people who aim to reach a common goal. M11en forming a team, the
relationship between team members and superiors is established along with their responsibilities.
According to Bruce Tuckman's Group Phase Model (1965), groups go through the following five
phases:
1. Forming — Caution and politeness characterize this phase. The group members meet and
slowly get to know each other. Communication is low; each team member tries to find his
role and task within the group.
2. Storming — This phase sees the first conflicts and rivalries within the group as people
get more acclimatized within the group. It requires strong team leader who accompanies
this transition phase and mitigates any internal conflicts.
3. Norming — In this phase works becomes more organized. The team starts to mature and
critical issues are not experienced personally but are seen as task-oriented constructive
feedback.
4. Performing — The team is now creative, flexible and closely-knit. The team's energy
goes into solving problems, and the leader of the team can now shift its focus towards
delegating work instead of team coherence.
5. Adjourning — This is the final and termination phase. The team finishes its duties.
Members tend to lose their motivation. To make the idea of discontinuance of the team
more tolerable, members start to distance themselves. It is essential that the team leader
mitigates this deteriorating phase and ensures a positive ending.
Teams that work in a safe and efficient manner often have certain characteristics, the members of
the team are proficient in their work and have good social skills, other characteristics of teams
with
a good synergy, include:
In short this can be summed up in the elements of communication, co-operation and co-
ordination, the three C's of team building. It is essential for every individual who is part of a
team to understand these elements.
Risk-Shift
In teams with a high degree of camaraderie, members tend to produce a "risk-shift" when making
decisions. Risk-shift means that people in a team are likely to make riskier decisions opposed to
working as an individual
Management
The term "management" captures functional areas as well as the employees who hold these
positions within a company or organization. Typical management tasks include planning,
organization, leadership, and supervision. People holding these positions need to have the
respective management competency.
Management skills have a technical, social and analytical component. The social skills of a
manager have a substantial influence on team dynamics and the performance and well-being of
the employees. Social skills include guidance, motivation, communication, conflict-solving and
being a role model.
Employees who lead or supervise are usually qualified or trained for their role. Supervision aims
to monitor and continuously improve the work of teams or individual employees. Leading
employees supervise the work done with the aim of evaluating and improving the performance.
The attitude of a leader towards his group is characterized by the leadership style used. The
following are the three most common out of a multitude of leadership styles:
1. Authoritarian Leadership — The opinion of group members is not considered at all. The
relationship between leader and member is merely based on obedience.
3. Laissez-faire — This leadership style does not show any signs of leadership. The team
members enjoy a high degree of independence.
Fitness / Health
Fitness and health have a direct influence on physical and mental performance. By law,
employees of maintenance organizations are only allowed to carry out their work if they are
physically and mentally healthy. The respective section of EASA Part-66 reads: „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." It is, therefore, the employee's
responsibility to make the decision.
Regularly reflecting on one's physical condition and performance is essential. Think about your
responsibility for yourself, your colleagues and the safety of your work. Many factors may have
an adverse influence, for example:
• A cold or flu
• Serious illnesses
• Depression
• Light injuries
• Hearing or vision impairments
• Circulatory problems
Good health is the result of a healthy lifestyle, to which the following factors contribute:
Many people cannot put personal or work-related stress factors aside while at work. Stress is
caused by the presence of stressors, which can be singular or continuous stimuli. The two
primary forms of stress are acute and chronic stress. Acute stress is typically very intense and
persists for short periods. Chronic stress returns with a certain frequency over extended periods
of time. The following section lists different classes of stressors:
Personal stress occupies the mind while at work, distracting from the actual task at hand. It has a
direct influence on the quality and safety. Personal stress is often caused by events at home, such
as the birth of a child, a marriage, an ill family member or a divorce.
Work-related stress can have two causes: The work to be done, or the work environment. A
technician may feel stressed if he has to fulfill a difficult task under time pressure without any
support or guidance. Proper training and careful time management help prevent this type of
stress. Stress from the work environment is usually resulting from economic pressure, shift-work
or fear of losing one's job.
Continuous stress influences our health and manifests itself in distractibility, forgetfulness,
illness or frequent errors. Common symptoms of stress are:
One should familiarize themselves with stress management techniques. As soon as the first
symptoms of stress are felt they can be countered with two strategies; Stress defense and stress
management.
Stress defense means dampening the symptoms with medication, alcohol or suppressing the
anxiety by playing down problems. Management techniques help cope with the symptoms when
stressors cannot be eliminated and are the most responsible and reliable way of dealing with
stress. Some common techniques include:
• Relaxation techniques
• Regular sleep
• A balanced diet
• Talking to close people
• Physical activity
• Consulting a professional psychotherapist
• Talking to a trusted adviser at work
In any commercial environment there is some form of deadlines and consequently, that puts time
pressure on its employees. Aircraft maintenance is no exception to this, deadlines and dates
characterize the aviation industry.
However, the feeling of time pressure does not always derive from actual set deadlines;
employees can merely perceive the feeling of time pressure when carrying out certain tasks even
when no deadlines have been set. Time pressure can also be self-imposed, in which employees
can set certain targets for themselves (e.g. completing a task before the end of a shift or setting
his own records to complete a certain task).
Time pressure causes stress which is a major safety risk. Real and self-imposed pressure can be
significant drivers for error, it causes carelessness and makes people cut the corner in order to get
the task done in the given time.
Careful resource planning is an essential part of daily work. All members of an organization
concerned with planning should be aware of the importance of time and the pressures and
necessities influenced by it. Pressure arises when technicians are subject to unrealistic schedules.
Two constraints are always present at work: the pressure to meet deadlines and the obligation to
carry out work carefully in accordance with all specifications.
When planning work or setting deadlines, the responsible employee should consider the
following points:
Above all, there is one rule that applies to any work conducted on aircraft: The proper and
complete execution of work stands above all time constraints. Delays reported in time shall
always be met with additional time resources to prevent stressful situations proactively.
Work Overload
Work overload is experienced when the task appears impossible to manage given the available
resources or when expectations are not met, which causes stress.
Overload situations are caused by overstimulation, like in very complex situations. People in this
situation tend to feel unable to make decisions. Ongoing states of overload impair the
individual's attention and therefore pose a significant safety risk.
Work Underload
Under stimulation causes work underload; people may feel unchallenged in a maladjusted work
environment or if they have chosen the wrong job. If not changed, this state can have
consequences such as fatigue, sluggish behavior, irritability, frustration or even symptoms of
depression. There are different kinds of underload: On one hand, employees may be
quantitatively unchallenged, meaning they do not have enough work. On the other hand, they
may feel qualitatively unchallenged when they do not get any exciting and challenging work.
According to the Yerkes-Dodson Law, there is a relationship between arousal (stimulation) and
performance. The law dictates that the performance increases with mental or physiological
stimulation, however, if levels of arousal become too high the performance decreases. If this
causality is illustrated graphically with a curve; it is seen that there is an optimum between work-
underload and work overload.
Analyzing employee's potential and developing their skills in a targeted manner contributes to
preventing both extremes. Work prioritization helps to tailor the demands to departments and
individual employees, thus increasing work efficiency and motivation.
What is Sleep
The average person requires eight hours of sleep. Sleep is regulated by the human body clock
also known as the circadian rhythm. The circadian rhythm is responsible for an even sleep-wake
cycle and is aligned with the change of day and night. It regulates the hormone balance of the
human body and with that the need for sleep. The following graphic shows the circadian
rhythm's influence on the human body.
• Stage one — The transitory phase between being awake and asleep. The heart frequency
decreases and the muscles relax. During this phase, one is easily woken.
• Stage two — The lightest stage of sleep, it is still easy to be awakened
• Stage three — A deeper stage of sleep. Heart frequency, blood pressure, and body
temperature drops further and one isn't as susceptible to external stimuli.
• Stage four — The deepest stage of sleep - it is difficult to awaken people in this stage of
sleep.
• Rapid Eye Movement (REM) — In this phase of sleep, our brain is as active as when
we are awake, even though it is harder to awake a person in this stage than in stage 4. The
muscles are entirely relaxed while the eyes start to move rapidly behind the closed
eyelids. It is assumed that people dream during this stage.
The individual stages of sleep alternate during the night. Phases 2, 3 and 4 serve for regeneration,
while the REM phase processes and anchors information in the memory. Going through both
types of sleep during the night is essential. The following chart shows how the higher stages of
sleep are reached during the first part of the night, while the share of REM increases over the
course of the sleeping period.
What is Fatigue
Fatigue has several definitions. Usually it is associated with tiredness or the overwhelming need
to sleep; however, it can also mean being emotionally exhausted. Fatigue is comparable to stress,
it is cumulative and can be caused by:
• A lack of sleep
• Poor quality of sleep
• Desynchronization of the circadian rhythm (e.g. jet lag)
• Excessive physical and emotional stress and anxiety
• Boring and repetitive tasks
Fatigue goes in hand with exhaustion and impaired attention. It has a direct influence on our
performance potential, it causes lethargy and shortens the attention span and ability to
concentrate. Someone suffering from fatigue can be unaware of the condition for an extended
period until a crisis forces realization. Even if the individual is aware that fatigue is a problem, it
often will not be openly admitted. This is because it appears to be a sign of weakness and an
admission to not being proficient for the job. It is important to recognize the symptoms of fatigue
Fatigue can be divided into two types, acute fatigue and chronic fatigue.
Acute fatigue — Is generally only short-term and is often due to a lack of sleep, a jet lag or
excessive physical and mental labor. Usually, it can be resolved with enough rest and a good
night of sleep.
It essential to understand some symptoms of fatigue in order recognize and act on it. Symptoms
of fatigue include:
• Tiredness
• Easily distracted
• Lack of awareness
• Irritability
• Lack of motivation
• Feelings of indifference
• Increased mistakes
• Diminished motoric skills
• Decrease in communication
• Feelings of lethargy
• Decreased reaction time
• Reduced short-term memory
• Diminished vision
• Headaches
• Loss of appetite
Fatigue can cause a phenomenon called microsleep; microsleep is when the person experiences
the first stage of sleep, possibly with their eyes still open. This may last for a fraction of a second
up to 30 seconds. The person can be unaware of the fact that he just experienced a microsleep
and continues work, which is especially dangerous when working with equipment such as
vehicles and automatic tools.
Effects of sleep deprivation can have similar effects to that of drinking alcohol; this means that
conducting complex tasks when you are fatigued is like drinking on the job and can be
considered irresponsible.
Furthermore, fatigue impairs the individual's memory; for example, a technician is more likely to
forget things e.g. inserting a downlock pin at the landing gear. In addition, the technician is more
prone to overseeing discrepancies during inspection.
• Sleep according to schedule, go to bed and wake up at the same time every day
• Avoid caffeine, nicotine and alcohol
• Exercise regularly
• Relax before bed
• Avoid television, computer and mobile screens before sleeping
• Sleep until sunlight
• Control your room temperature (i.e. a cool room)
• Sleep in a dark room
However, if fatigue cannot be prevented there are several methods to alleviate it, including:
Caffeine — Although not recommended to prevent fatigue it can, however, relieve the feeling of
fatigue. Caffeine is a mild central nervous stimulant and is commonly found in coffee and tea. It
has a half-life of several hours depending on the functioning of the liver. At moderate dosages
(250 mg) it improves psychomotor functions; high dosages (500 mg) only show side effects
without further functional improvements.
Power napping — Taking a power nap of 15 to 20 minutes can improve cognitive performance,
sleeping longer can result in the individual waking up groggy. Power napping is not for
everyone; few people can fall asleep within this short timeframe.
Regular Breaks — Taking regular breaks from your primary task helps to stay alert and manage
fatigue. Ensure that the final 10-15 minutes of your breaks are entirely restful and relaxing,
avoiding work-related and computer-based activities.
Sleep Apnea
Sleep apnea is a medical condition in which the individual stop breathing for ten seconds or
longer during sleep, which reduces the level of oxygen to the brain. The condition often goes
along with snoring. Many people do not realize their sleep has been disturbed, however, it causes
excessive daytime fatigue; it increases the risk of obesity, high blood pressure, stroke, heart
attack and diabetes.
There are many risks for developing sleep apnea, however, being overweight significantly
increases the susceptibility. It is recommended to see a doctor if you or your partner observes the
following symptoms:
Shift Work
Looking at commercial air traffic, the majority of take-offs and landings take place during the
day. The less demanding hours during the night are commonly used for maintenance and service
work. Because of this pattern, shift work is inevitable and usually consist of an early day and
night shift. Shift work has advantages and drawbacks. Many employees appreciate being able to
have multiple days off or have free time during the day. On the other hand, the following points
are seen as a drawback:
• The working hours and their negative impact on friendships and family life
• Working at times of reduced body performance capability
• Long-term de-synchronization of the body clock and insomnia
Night shift work generates considerable stress on aircraft technicians. During the night hours
when the body clock switches all systems to "sleep mode", the body will not perform at an
optimal level to perform mentally demanding work. Regular breaks and checking one's work are
essential during the night shift. Complicated and challenging tasks should be planned to be done
during the day hours when the employees' attention is at its best.
Alcohol
Alcohol has a damping effect on the central nervous system. It influences the senses and often
strengthens mental and physical reactions. It is proven that even the slightest amounts of alcohol
influences your performance and impairs your judgment. Methods such as drinking black coffee
cannot accelerate the metabolism of alcohol in a human body. It is therefore critical to allow for
a reasonable break between drinking alcohol and the start of work. Ingesting alcohol with
medication can have dangerous or even fatal consequences.
Sleep is affected negatively by drinking alcohol in the same way. It may seem more comfortable
to fall asleep after having consumed alcohol, the quality and duration of sleep are mostly
insufficient. The consequences of this effect can be felt the morning after a night of drinking.
The effects of alcohol on our system are not limited to only the moment of drinking, the
metabolization of alcohol may take several days.
Medication
Medication can have a direct influence on the body's performance. Medication in this sense is
defined as a substance used for therapeutic treatment and is only available at pharmacies with a
prescription.
Medications can suppress or alleviate symptoms of illness; this may make one feel ready for
work before the illness has subsided. It is therefore critical to carefully reflect on your health
before going back to work. Also, please note that some medication may interact with other
substances or medication.
• Analgesics - Used for pain therapy and fighting the symptoms of a cold or flu. The
products on the market are usually safe if dosed and used according to the manufacturer’s
instructions. They can pose the danger of not recognizing symptoms like a headache as a
sign of another illness.
• Antibiotics - This group of drugs has a short-term or delayed influence on human
performance. Antibiotics are usually used against infections. Taking antibiotics often has
multiple side effects such as stomach problems or constipation that render you incapable
of going to work.
• Sleeping Pills - Taking sleeping pills slows our reactivity and dampens the senses. The
duration of these effects varies from person to person.
Medication
Drug Abuse
A drug is a substance that can have physical and psychological effects. They may be stimulating,
calming or damping. When drugs are used the ability to think and move is generally impaired.
The changes might be slight but can lead to dangerous errors during safety-sensitive activities.
Legal Drugs
The availability and quality of these drugs are controlled by law, they are only available with a
prescription for medical purposes or are controlled by an age restriction.
Illegal Drugs
Illicit drugs don't have any form of quality control; this means that the users can never be sure
the drug they are taking is what they think it is. Possession of these illegal substances can result
in criminal prosecution.
Depressants - Also called downers, slow down the functions of the central nervous system,
making the users feel as if things are "slowing down". Small quantities of depressants can cause
the individual to feel more relaxed and less inhibited and a state of euphoria can be experienced.
Larger amounts of depressants can cause unconsciousness, vomiting and even death. Depressants
affect concentration and coordination and decreases the reaction time of the user. Common
depressants:
• Alcohol
• Cannabis
• Opioids or opiates (e.g. morphine, heroin, codeine and methadone)
• Barbiturates (e.g. amobarbital sodium, secobarbital sodium)
• Benzodiazepines (tranquilizers) (e.g. alprazolam, diazepam and clonazepam)
• GHB (gamma-hydroxybutyrate)
Stimulants - Also called uppers, speed up the functions of the central nervous system making
the users feel more awake, alert or confident. Stimulants increase the heart rate, blood pressure
and body temperature. Large quantities of stimulants can cause effects, such as seizures,
headaches, anxiety, stomach cramps and aggression. Common stimulants:
Mild
• Caffeine
• Nicotine
• Ephedrine
Strong
• Cocaine
• Methamphetamine
• Ephedrine
• Amphetamine
• MDMA/Ecstasy
Hallucinogens - Are perception altering substances, they can cause substantial subjective
changes in one's consciousness, thoughts and emotion. The effects of hallucinogens are not
consistent and hard to predict; the effects can vary between person, dosage and the mental state
of the individual. Effects of hallucinogens include paranoia, psychosis, increased creativity,
sensory distortions, euphoria and dilation of pupils. Common hallucinogens:
• LSD
• DMT (Dimethyltryptamine)
• MDMA/Ecstasy
• Psilocybin mushrooms
• Mescaline cactus
• Ketamine
Drugs like ecstasy, cocaine or heroin influence human performance drastically and present, along
with their addictiveness, a substantial safety risk. If the individual so requires certain legal drugs
used for therapeutic treatment, please inform a medical professional or your supervisor.
No Drugs
Physical Environment
Noise
Noise disturbs work and social interaction, such as conversations and can make us unaware of
audible warnings of equipment used for work. Noise above the threshold of 115dB leads to
permanent hearing damage. Running engines, rotors or passing vehicles often generate noise
levels between 85 and 90dB. Wearing hearing protection adjusted to the frequencies and noise
levels of the environment are critical to prevent permanent hearing damage.
Fumes
Exhaust gasses and smells often pose a special strain. Aircraft technicians regularly handle
dangerous substances such as oil, hydraulic fluid, paint or cleaning agents. Many of those
substances can generate strong smells. Others are neutral and cannot be smelled. Inhaling certain
substances may lead to health problems. Attention should be paid to symptoms like headaches or
dizziness and medical attention must be sought if required.
Illumination
Sufficient lighting is a prerequisite for safe and high-quality work. The human eye can only
capture all details if the environment is adequately lit. Bad lighting reduces the eyes' color vision
capability, increasing the risk of errors and the time required to perform a job.
Natural light produces the most pleasant working environment. During midday the technician
may have sufficient natural light; however, when working in the shadow, in cramped
compartments or during nighttime this is not always the case. In case of absence of sufficient
natural light; artificial lightning; such as fixed ceiling lights or a portable flashlight can aid the
technician.
The human body withstands a broad range of climatic conditions and temperatures. If the
conditions reach extreme levels, they hurt any human's performance. The most critical conditions
include:
• Cold
• Heat
• Wet conditions
• High humidity
Aircraft technicians who work both indoors in the hangar and outdoors on the apron are subject
to changing climatic conditions and temperatures as season's change. Hangars have to protect
against these extreme weather and temperatures. When working outside the hangar, suitable
workwear is a requirement, even if it may be hindering at times (e.g. gloves).
The body uses different methods to regulate its temperature to battle heat, the most obvious
being sweating which causes heat loss through evaporation; moreover, the body uses
vasodilation, the widening of blood vessels. Vasodilation brings more blood towards the skin
releasing excessive heat through heat radiation—like a radiator. With increasing humidity, the
effectiveness sweating decreases. At 100% humidity sweating becomes ineffective, because the
amount of water vapor the air can hold is saturated.
If the body fails to ventilate excessive heat, it can cause several complications among which:
• Heat stroke — Is the most dangerous implication; it can cause seizures, kidney failure or
even death if not treated.
• Heat exhaustion — Is closely related and is often the preceding condition to a heat stroke
if untreated. Often it is caused by a combination of heat, dehydration and a deficiency in
salts. Nausea, headache, thirst, weakness and confusion are typical symptoms.
• Heat syncope — The blood vessels widen as a response to heat; as a consequence, there
is a diminished blood flow to the vital organs causing several symptoms among which
headache, dizziness, nausea and fainting.
• Heat cramps — Are painful muscle spasms that result from a loss of large amount of salt
and water due to sweating.
• Heat rash — Is a skin condition that is attributable to overheating; it causes a prickly rash
that looks like tiny bumps surrounded by red skin. It can itch a lot, but is not dangerous.
Fortunately, the activities in aviation maintenance seldom lead to serious conditions such as heat
exhaustion or heat stroke.
To battle cold temperatures, the body has to isolate and generate warmth within the body to
prevent hypothermia. It does this by several methods the most obvious being shivering; other
means are decreasing the sweat production and narrowing of the blood vessels (i.e.
vasoconstriction).
The physiological response of vasoconstriction is most noticeable in the fingers and toes; they
will show area of paleness or redness. Prolonged exposure to cold conditions can result in the
extremities (i.e. hands and feet) being swollen or blistered, hindering movement. In extreme
situations when the body cannot keep up with the continued loss of heat; the body temperature
drops, slowing the heart rate and decreases or stops the distribution of the warm body fluids
towards the limbs. This results in that the body extremities become numb or in extreme cases
tissue death.
Maintenance technicians often have to work outside in the cold, especially in line maintenance.
Perhaps the job involves a repair on the fuel system, hand and even clothes can become wet with
fuel. As the fuel evaporates, it lowers the temperature of the skin and along with
vasoconstriction, it constricts the blood flow towards the skin. The symptoms mentioned earlier
such as red and paleness may progress beyond those early warning signs. Furthermore,
clumsiness may be a manifestation of exposure to cold; with suitable work-wear and immediate
warmth, one can prevent any serious complications.
It is often a necessity to use ladders or scissor lifts in order to reach working areas situated on the
upper segments of an airplane. These pieces of equipment tend to become unstable with
increasing height. If forces are applied, for example, to loosen a bolt, they start to rock or swing,
which may lead to distraction, insecurity or anxiety.
Vibrations are generated by rotating tools such as power drills as well as devices with rotating
components like generators. Another source of vibration is low-frequency noise, for example,
aircraft engines. They distract, divert concentration away from the actual task and can lead to
physiological problems. Vibrations with a frequency of between 0.5 and 20 Hz are particularly
dangerous for the human body as it absorbs them completely. Builders working with
jackhammers are at risk of suffering from „vibratory induced white finger - syndrome" (VNVF).
Frequencies between 50 and 150 Hz lead to local blood circulation problems and pain in the
hands.
Working Environment
The working environment can refer to a whole range of items that may help or hinder a
technician effectively do his work. This may include:
However, the working environment is used most specifically to the design and operation of
aircraft maintenance facilities and work area. The working environment should be designed to
facilitate any work carried out in that environment. Several factors improve safety and make
work more comfortable, including:
• Workplace layout
• Workplace tidiness
• Availability of safety equipment
• Separate warehouse areas for dangerous goods
Workplaces should be designed considering both social as well as operational factors. The
presence of resting areas, kitchens and toilets increase workplace comfort and the sense of
community among employees. On the other hand, workplaces should be functional and suitably
equipped.
Tasks
Physical Work
The activities involved in maintenance and servicing require excellent motor skills, precision,
flexibility and sometimes force. The human body with its structure of bones held together by
muscles and ligaments allows for different movements. When people age, muscles lose their
flexibility and bones lose their strength, which increases the risk of injuries. Modern computer-
based technology is used in the design of new aircraft, systems and assemblies are adjusted to
reflect human features such as height and strength. Hence, all areas of the aircraft should be
easily reachable and it should be possible to loosen bolts with a reasonable amount of force.
However, people are all different regarding physical stature and strength, so do vary their
limitations. It is recommended to abstain from any physical work that is above one's physical
capabilities to prevent injury; however, with the use of tools and the support of colleagues,
makes demanding physical work a lot easier.
Repetitive Tasks
Repetitive tasks can be tedious and monotonous. Most studies on repetitive tasks have been
carried out in manufacturing processes, where employees repeat the same tasks over and over
during their shift. In aircraft maintenance this could be for example checking the life jackets on
an aircraft during daily inspection.
Routine work leads to indifference, especially if deviations from the standard state are seldom.
Employees trained by routine run the risk of ignoring instructions or manufacturer's manuals.
Changes in these documents may therefore not be recognized. Taking regular breaks is key to
maintaining a high level of attention, as well as regular job changes to achieve variety in the
tasks assigned.
Visual Inspection
Different tools such as lamps, magnifying glasses or borescopes may be used to enhance visual
perception and judgment when conducting those checks. Experience and studying relevant
documents concerning the weaknesses of aircraft, like airworthiness directives, can further
improve judgment. The following factors also have a positive effect on the performance of visual
checks:
Visual checks require a high degree of concentration and may, therefore, be tiring and cause
boredom. Often this is the case when a technician does not expect to find any damage, the
technician briefly scans the to be inspected part or area and overlooks any damage in exquisite
detail. Motivate yourself by making it your mission to find damage during every visual check
you do.
Complex Systems
Large modern aircraft are complex technical systems. Different systems that are already complex
in their own right (e.g. flight controls or flight management computers) work together to provide
all necessary functions. These subsystems may work independently or are connected with other
systems since they require those systems' input.
It requires good and continuous training to be able to understand these systems. Regularly
staying informed about technical matters and the special issues of individual aircraft can give a
person confidence in their work and improves its quality.
Since the systematic characteristics of aircraft differ between types, it is a necessity for certifying
staff to only work on a few certain types they specialize on. Type ratings confirm these special
competencies in the EASA Part-66 license. The work to be done on an aircraft always has to
conform to the manufacturer's maintenance documentation in order to consider all technical
peculiarities of the aircraft.
Communication
Good communication is essential in any industry. A breakdown of communication has been
identified as the cause of many aviation incidents and accidents that could have been avoided.
"Communication" is defined as the transmission of information from one place to another. This
information may be a message, signal or thought. The sender and receiver of a message have to
speak the same language to understand each other to interpret the message.
• Active Listening: This technique has the purpose of giving the other party the feeling of
being understood, but also of giving the listener the chance to ask questions. It is useful to
slip into the other person's shoes, to see the world through their eyes. It is not necessary
to react or discuss anything immediately — it just may help to try' and understand the
counterpart's arguments. Active listening comprises eye contact, making sure people
recognize they are listened to. It is essential not to express any judgment or criticism for a
brief period. It is sometimes helpful to condense and repeat the most important points
during the conversation.
• I-Messages: Many people begin sentences with something like "You have to today".
These sentences make the recipient feel patronized or misunderstood and trigger
defensive reactions - the recipient wants to give his point of view. Since it is not possible
to change others that quickly, it is important to talk of oneself. You should try to
emphasize your feelings, needs and wishes. There are a few basic rules for how to form I-
messages:
Keeping records and documentation of work is the most important form of written
communication in aircraft engineering. Proper documentation helps to describe complete or
partly finished work in order to hand them over to colleagues in an orderly fashion. Describing
problems often requires words as well as pictures or drawings. It is obligated by law for any
aviation technician to document his work to the full formal and textual requirement given in the
certified operation manual. Records and documents must be filled in after completing the
respective job, but at the latest before the end of the shift. Filling out the forms within a short
period after having completed the job makes sure no details are left out, avoiding gaps or breaks
of information.
Keeping Up to Date
Technicians have the responsibility to maintain and develop their knowledge and skillset
actively. Their employer must support them in these activities. The constant stream of new
technologies, as well as changes in standards and legislation, raise the requirement for regular
training activities and independent research.
Even the smallest changes within manuals, regulations and procedures contain a potential for
significant risk. Changes do not always trigger a training course - they should be appropriately
documented and made known to the respective employees.
Maintenance organizations must make sure all technicians work up to the latest standards. They
have an obligation to ensure that all the documentation for all aircraft types they are certified for
is up to date and all revisions are incorporated.
Dissemination of Information
Responsibility for the acquiring and distributing of new information is split between the
maintenance organizations and its technicians. Well prepared and up to date information
contributes to a good safety culture in the company.
Generally, the company acts as the sender and the technician as the recipient of information. It
should be clear who is responsible for collecting and spreading information within the company
and the measures that have to be in place that ensures information is delivered to the concerned
staff. The distribution of information within the company may happen via e-mails, conversations
or databases. Employees must confirm that they have received and understood the message
regardless of which channel is used.
Human Error
There are three main categories of human error types which include: slips, lapse and mistake.
Slip — A slip describes the unplanned execution of certain tasks, for example when specific
procedural steps are carried out in the wrong order.
Lapse — A lapse describes forgotten and omitted steps in the working process. These errors are
most common when the memory fails, or there is not enough attention paid.
Defenses, barriers and safeguards are an essential part of system design. High-reliability systems
have several defensive layers (yellow slices directly placed behind the green ones) some are
engineered (e.g. alarms, physical barriers, automatic shutdowns, safeguards), others rely on
people (e.g. aircraft technicians, engineers and supervisors) and others depend on procedures and
administrative controls.
Their function is to protect potential victims and assets from local hazards. For the most part,
they do this very efficiently, but there are always weaknesses. In an ideal world, each layer
would be intact. In reality, however, they are more like slices of Swiss cheese, containing many
holes (i.e. flaws). Unlike in cheese, these holes are continually opening, shutting and shifting
their location in relation to the measures and actions taken from individuals in the system and the
conditions in the environment.
The presence of holes in any one "slice" (i.e. area of activity) do not necessarily cause an
accident. Usually, this only happens when the holes in many layers momentarily line up to
permit a trajectory towards hazard.
The holes in the defenses arise for two reasons: active failures and latent conditions. Nearly all
adverse events involve a combination of these two sets of factors.
Active failures — Are the unsafe acts committed by the people directly engaged in the
operation. They take a variety of forms: slips, lapses, fumbles, mistakes and procedural deviants.
Active failures have a direct and usually short-lived impact on the integrity of the defenses.
Latent failures — Are the unavoidable structural and functional weaknesses of the system. They
arise from decisions made by the designers, builders, procedure writers and top-level
management. All such strategic decisions have the potential for introducing deficiencies into the
system. Latent conditions have two kinds of adverse effect: they can translate into error-
provoking conditions within the local workplace (e.g. time pressure, understaffing, inadequate
equipment, fatigue and inexperience) or they can create long-lasting holes or weaknesses in the
defenses (e.g. untrustworthy alarms and indicators, unworkable procedures, design and
construction deficiencies). Latent conditions, as the term suggests, may lie dormant within the
system for many years before they combine with active failures and random conditions to create
an accident opportunity.
A special kind of error is a violation. At first sight it seems to be an accidental error but must
actually be categorized as an illegal action. A violation is an action carried out by a person
despite that person knowing that action violates existing rules or procedures. 'Cutting corners' to
complete a task faster can be described as a violation. It is important to understand that
procedures and rules serve as a guideline and means of support to perform a task while
complying with the existing safety aspects.
Behavior can be broken down into three categories: skill based, rule and knowledge-based
behavior. Each of these types of behavior has specific errors associated with them.
Skill-Based Behavior
This behavior relies on stored routines or motor programs that have been learned and that one
can execute without conscious thought. Errors associated with skill-based behavior tend to occur
during repetitive and routine activities and include action slips, memory lapses, environmental
capture and reversion based errors.
• Action slip is the same as the term "slip" as mentioned above slip (i.e. the unplanned
execution of certain tasks). For example, a technician needs to torque a bolt with a torque
wrench, while the technician sets the specific torque he gets distracted by a colleague and
sets the wrong torque and incorrectly torques the bolt while presuming doing a correct
action.
• Memory lapse is the same as the aforementioned term lapse (i.e. forgotten and omitted
steps in the working process). For example, when a technician forgets to perform an
action, they had intended to perform at some time in the future. Such as, forgetting to
reset certain circuit breakers after performing maintenance on a system.
• Environmental capture may occur when performing a specific task in a particular location
very often. For example, a technician is used to switch a particular switch to select a
specific function on aircraft A, the technician may inadvertently select the same switch
on aircraft B when in fact, it has a different function.
• Reversion may occur when a certain pattern of behavior has been established and it is
difficult to unlearn or abandon certain procedures, even when it is no longer appropriate
to use. For example, a technician carries out certain procedures for a task he has did for
years on end, even though the procedures had a recent revision, this is more likely to
occur when an individual is not concentrating or is in a stressful situation.
Knowledge-Based Behavior
This behavior is based on existing knowledge and experiences to fix unforeseen situations, that
are not known, for which the individual does not know the existing rules or procedures.
An example of this might be when a technician attempts a specific repair task and assumes he
can work it out based on the available information. There is a tendency that the technician
searches for evidence that supports the idea that everything is working out and ignores the
negative influences (confirmation bias), which forms a potential risk for error.
Rule-Based Behavior
This behavior is robust as it relies on existing procedures and rules, hence why it is commonly
used in aircraft maintenance. Errors associated with this behavior may occur when an individual
applies inadequate rules to a situation or misapplies a good rule. For example, a technician may
misdiagnose a fault when troubleshooting and applies the wrong corrective procedure.
Errors within the occupational field of aviation are inevitable. Any maintenance performed on an
aircraft is an opportunity for human error to be introduced.
These errors that occur during maintenance work tend to take two specific forms:
An example for the first point could be the incorrect installation of line-replaceable units or a
failure to pull the correct circuit breakers causing a dangerous situation for the technicians. For
the latter point an example could be that structural damage goes unnoticed during a visual
inspection or an incorrect diagnosis due to overlooking of information leading to the removal of
the wrong component.
According to the British aviation authority the following seven points are the most common
errors resulting from maintenance work:
• Incorrect installation
Implications of Errors
The Iceberg Model is often used to describe that errors often cause less visible events; the idea is
that most visible accidents are only the tip of the iceberg, however, as portrayed in the
illustration below, a significant portion of error is hidden under the waterline and is not directly
apparent.
Errors results in costs and can lead to serious incidents or accidents. Airlines estimate their losses
as result of maintenance errors to amount to approximately 1,000,000 U.S. Dollars.
Over the course of ten years, the American NTSB has collected data about incidents and
accidents in general aviation that can be traced back to maintenance errors. The findings were
published in the report "General Aviation Maintenance - Related Accidents" containing the
following figures:
Results of errors
Even though aviation strives for complete safety, the occurrence of errors cannot entirely be
ruled out. Technicians should learn from their mistakes, develop new strategies, adapt new
procedures and act as role models for their colleagues. The fundamental objective of an airline or
maintenance organization is to deliver the service for which the organization was created. Air
passengers expect airlines to be reliable, comfortable and safe. The absence of the first two is
annoying and uncomfortable; absence of the latter may be lethal.
The managerial staff of an airline must provide the technology required to achieve the system
production goals, the necessary training for the employees and the adequate procedures and
regulations to dictate system and people's behavior. In case of poor earnings prospects, senior
management of the organization could come into conflict with the allocation of production goals
(delivery of services) vs. protection goals (safety).
To successfully navigate the practical drift from the desired baseline performance, organizations
require navigational aids which procure the necessary information in order to negotiate currents
and obstacles. Mature safety management requires the integration of reactive, proactive and
predictive safety data capture systems, a judicious combination of reactive, proactive and
predictive mitigation strategies, and the development of reactive, proactive and predictive
mitigation methods. This system is called the operational Safety Management System (SMS).
To improve communication at all levels, management should always have a sympathetic ear for
the people on the front line of the operation in order to receive first-hand information or well-
intended suggestions. One should not forget the role-model function of managers. This has been
proven to exert the most significant influence on safety behavior of highly qualified staff.
Human performance can both be positively and negatively influenced by different factors. The
psychologist DuPont developed a matrix for investigating accidents in 1993. It indicates 12
common preconditions for human error, called the 'Dirty Dozen'.
Applying this matrix to the working environment identifies potentially risky situations and
enables the conscious implementation of countermeasures.
An aircraft technician's workplace contains numerous potential dangers to his safety and health,
some of which include:
It is crucial for employees to be aware of potential dangers and to sensitize them accordingly
with training and regular safety notes. Employees must take measures to protect themselves from
dangers in the workplace. For example, this is achieved by wearing earplugs or protective
clothing. Warning signs should clearly indicate dangerous area in which precautionary measures
must be taken.
Whenever danger cannot be eliminated, employees must be made aware of it and the respective
measures must be taken. This should all take place in close cooperation with the safety specialist
that also supports the company with the following measures:
Despite cautious behavior, health and safety relevant problems may arise. The following
situations can be described as emergencies:
It is important to maintain composure at all times, giving priority to the own protection and
safety. Measures like performing first aid or using a fire extinguisher shall only be carried out if
the risk is acceptable. An emergency call should always contain the following details:
• Who is calling?
Name, location, possibly the own phone number
• "What happened?
Fire, accident, injuries, events, stay calm