Safety Management Systems

for aviation: a practical guide

SMS 6
Human factors
and human
performance

3rd Edition
ISBN 978-1-76137-011-3 (Print)
ISBN 978-1-76137-012-0 (PDF)

© 2022 Civil Aviation Safety Authority.

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2207.4488
 SMS 6Human factors and human performance 1

Contents

SMS and human factors 2

Understanding human factors 4
Understanding errors and error management 9
SMS human factors integration 21
Human factors training 35
2 SMS 6Human factors and human performance

image: Civil Aviation Safety Authority

SMS and human Human factors and human performance

is, as a result, an integral part of safety

factors management and is necessary in order to

understand, identify and mitigate risks as
well as optimise the human contribution
Your organisation’s safety performance is
to safety.
significantly affected by how you personally
view your responsibilities towards safety Historically, the human contribution to
and how that view interacts with others. In aviation safety was largely focused on
managing safety, you need to understand the errors and violations of individuals
and address how people contribute to that adversely affect safety. More
organisational safety. recently, there has been a focus on the
positive contribution to safety, resilience,
Over the past 100 years or so, we have
and efficiency made by individuals. An
discovered that relatively few accidents
individual’s ability to adapt is often the
result purely from technical failures. In
reason that the system is successful
around 70–80 per cent of cases, deficiencies
despite interruptions and disturbances,
in human performance contributed directly
such as storms, mechanical emergencies,
to the outcome. Consequently, the greatest
and economic downturns. Current human
potential for reducing aviation accidents lies
performance focus recognises the value
in understanding the human contribution to
in assessing and understanding human
safety performance.
factors, not only when things go wrong,
but also when things go right.
 SMS 6Human factors and human performance 3

Throughout
aviation people
are both the
source of risks and
an integral part
of identifying and
managing risks.

image: Civil Aviation Safety Authority

Consideration of human factors and • interactions between these variable

human performance is important in safety influences are difficult or impossible
management as people can be both a to predict
source and solution to safety risks through: • the consequences of variable human
• contributing to an incident or accident performance will differ according to the
through variable performance due to task being performed and the context.
human limitations
No matter the difficulties, managing human
• anticipating and taking appropriate factor aspects within your organisation has
actions to avoid hazardous situations a positive impact on safety management
• solving problems, making decisions, and by reducing errors and improving
taking actions to mitigate risks. communication, reducing work related
injuries, increasing employee satisfaction,
Integrating human factors into your SMS
and ensuring balanced workloads. Human
gives you a framework to ensure you
factor safety management integration aims
systematically identify and analyse any
to ensure that work procedures and policies
human factor issues and resolve them.
within your organisation are compatible
Assessing risks associated with human
with human capabilities, training is
performance can be more complex than
sufficient, the workforce is competent, and
assessing the risk factors associated with
there is enough spare capacity to deal with
technology or the environment because:
emergency situations.
• human performance is highly variable,
with a wide range of interacting
influences, internal and external to the
individual
4 SMS 6Human factors and human performance

Understanding important upside is our human capacity

to be flexible and adaptable when solving

human factors complex problems, and often resolving

situations with limited information.

The terms human factors, human Although humans will always make errors
performance, non-technical skills, and there is clear evidence from accident
ergonomics are sometimes confused and statistics, line observations and research
regularly used interchangeably. This is studies, of the benefit of human factors-
not surprising as they are closely linked, based mitigation measures. Aircraft
however they can be distinguished as systems and equipment, documentation,
follows: procedures, and training which have had
• Human factors is the application of human factors inputs have been successful
what we know about human beings in limiting the number and effect of errors.
including their abilities, characteristics, This results in your entire system being
and limitations, the design of procedures more resilient.
and equipment people use, and the The primary focus of any human factors
environment in which they function and initiative is to improve safety and efficiency
the tasks they perform. by reducing and managing human error.
• Human performance is how people
perform tasks and represents the human
contribution to safety performance. Human performance
• Non-technical skills relate to behavioural principles
skills or techniques that ensure There are five key human performance
individuals can function successfully as principles that identify how individuals’
team members to diminish threats and performance is influenced by different
errors within the operating environment. factors. These are:
• Ergonomics is considered a subset of • people’s performance is shaped by their
human factors that focuses specifically capabilities and limitations
on designing technical systems, products,
• people interpret situations differently
and equipment to meet the physical
and perform in ways that makes sense
needs of the user.
to them
The study of human factors involves • people adapt to meet the demands of
applying scientific knowledge about the complex and dynamic work environments
human body and mind. This enables a
• people assess risks and make trade-offs
better understanding of human capabilities
and limitations so there is the best possible • people’s performance is influenced by
fit between people and the systems in working with other people, technology,
which they operate. Human factors includes and the environment within which
social and personal skills, for example they work.
communication and decision making, These principles interact and overlap and
which complement technical skills and are do not represent unconnected human
important for safe and efficient aviation. performance building blocks. Instead, they
There are both upsides and a downside to provide different insights and perspectives
human factors and human performance. to provide a multi-dimensional picture of
The downside is the capacity to make human performance. Having awareness of
errors or mistakes. However, the equally these principles can help to shape, improve,
 SMS 6Human factors and human performance 5

and maximise the performance of your Some of these limitations are physiology
SMS. The human performance principles and we easily recognise or understand
apply generally to all humans involved in them. For example, people cannot function
your organisation, across the individual, the well without adequate sleep and nutrition.
team, and at organisational levels. They cannot lift very heavy weights,
cannot see in the dark, and are subject
to involuntary responses under stress.
Human performance We need to however be aware that these
limitations physiological limitations can be aggravated
in aviation when flying at altitude or
As identified in the first human performance
working in highly complex environments.
principle, people’s performance is shaped
Such as when inflight, with decreased
by their capabilities and limitations. All
oxygen delivery to organs, including sensory
human beings have limitations, including
organs, can result in problems with night
both physical and cognitive limitations,
vision or impaired decision-making.
which cannot simply be overcome through
motivation, sheer will or having a positive Other limitations are cognitive and can be
safety behaviour mindset. However, for harder to recognise. For example, people
all their limitations, when well supported, cannot always remember what they were
people can manage novel situations, told. Nor can they always immediately
adapting their skills to safely manage the solve complex calculations in their heads,
operation. or maintain attentiveness when they are
stressed, bored, fatigued, or cognitively
Human performance limitations are
overloaded.
often known as personal or individual
factors which influence performance While sensory and information processing
and are potential error producing or limitations can lead to perceptual illusions,
error promoting conditions. When these and to the failure to notice subtle changes
individual factors are present, they in the environment, especially when
can interact with other situational and attention is focused elsewhere or when
organisational factors, increasing the experiencing spatial disorientation.
likelihood of human error. These factors
Furthermore, people’s performance is
however if proactively evaluated and
highly variable. No one can perform at the
addressed can be optimised to improve
same level all the time, and the level at
performance and reduce human error risks.
which people can perform certain types
Some well-known human performance of tasks changes throughout the day. For
limitations include: example, people’s overall performance
• stress deteriorates when they are ill, bored,
stressed, or fatigued.
• fatigue impairment
• alcohol and other drug impairment The performance limitation of fatigue
impairment is recognised as a specific
• physical health
safety issue in aviation. It should be
• mental wellbeing and psychological addressed within your SMS as a distinct
conditions human performance risk accordingly,
• sensory capacity (visual and auditory) regardless of any fatigue management
• information processing capacity regulations for certain groups of aviation
professionals. This enhanced awareness
• attention and vigilance
of fatigue risk in aviation is because of the
• memory
6 SMS 6Human factors and human performance

insidious nature of fatigue and its well- The outer letters, SHEL, represent four
known impacts on safety performance. satellite components:
When identifying, assessing, and managing
S = software: the procedures, training and
fatigue risks organisations must consider
other support aspects of tasks or work
the basic scientific principles relating to
design.
fatigue impairment and how they will
manage these to ensure personal are H = hardware: the equipment, tools and
not performing safety critical tasks while technology used in work.
impaired by fatigue. These basic scientific
E = environment: the environmental
principles include:
conditions in which work occurs, including
• the need for sleep the organisational and national cultures
• sleep loss and recovery influencing interaction.
• circadian effects on sleep and L = liveware: the interrelationships
performance, and between humans at work.
• the influence of workload.
Which are surrounding the main
component of:
The SHELL model L = liveware: the human operating within
Several models have been developed to the system.
support the understanding and assessment The SHELL model represents the way the
of human factors on safety performance. whole system influences how individuals
The SHELL model is well-known and used by behave. Any breakdown, disconnect or
the International Civil Aviation Organization absence between components can lead to
(ICAO). The model illustrates the impact human performance problems.
and interaction of the different system
For example, an accident where
components on humans and emphasises
communication breaks down between
the need to consider human factors as an
pilots in the cockpit, or engineers at shift
integrated part of safety risk management.
handover, would be characterised by the
The model illustrates the relationship model as a liveware-liveware breakdown.
between the human at the centre of Situations where pilots or engineers
the model surrounded by workplace or disregarded a rule or do not follow a
organisational components. standard operating procedure would
be characterised as a liveware-software
breakdown.
An analysis of these interactions can
assist your organisation in both the
development of processes and procedures
or introduction of new systems and also in a
reactive sense during an investigation of an
incident, for example.
 Case study SMS 6Human factors and human performanceCase study 7

image: VH-TFU at Bamaga Aerodrome on a previous flight (Photo courtesy of ATSB)

Controlled flight into terrain According to the Australian Transport Safety

Bureau (ATSB) investigation report, the
This case study illustrates some key human accident was the result of controlled flight
factors issues arising from the controlled into terrain. This means that an airworthy
flight into terrain accident at Lockhart River, aircraft under the control of the flight crew
Queensland, in 2005. was flown unintentionally into terrain,
On 7 May 2005, a Fairchild Aircraft Inc. possibly with the crew unaware how close
SA227-DC Metro 23 aircraft, with two pilots the aircraft was to the ground.
and 13 passengers, was being operated on The investigation report identified a range
an IFR regular public transport service from of contributing and other human factors
Bamaga to Cairns, with an intermediate safety issues including:
stop at Lockhart River, Queensland.
• the crew commenced the Lockhart River
At 11:43:39 (AEST), the aircraft crashed runway 12 approach, even though they
in the Iron Range National Park on the were aware that the co-pilot did not have
north-western slope of South Pap, a the appropriate endorsement and had
heavily timbered ridge, approximately limited experience of conducting this type
11km north-west of the Lockhart River of instrument approach
aerodrome. At the time of the accident, • the descent speed, approach speed and
the crew were conducting an area rate of descent were greater than those
navigation global navigation satellite system specified for the aircraft in the operator’s
(RNAV [GNSS]) non-precision approach to operations manual
runway 12. The aircraft was destroyed by
• during the approach, the aircraft
the impact forces and an intense, fuel-fed,
descended below the segment minimum
post-impact fire. There were no survivors.
safe altitude for its position on the
approach

ATSB Transport Safety Investigation Report 200501977: ‘Collision

with terrain; 11km NW Lockhart River Aerodrome’.
8 SMS 6Human factors and human performanceCase study

• the aircraft’s high rate of descent, and • Hardware–liveware: the aircraft was
the descent below the segment minimum not fitted with any terrain awareness and
safe altitude, were not detected or warning system, such as an enhanced
corrected by the crew before the aircraft ground proximity warning system.
collided with the terrain • Environment (culture)–liveware:
• the crew probably experienced a very there were significant limitations in the
high workload during the approach operator’s flight crew training program,
• the crew possibly lost situational such as the superficial or incomplete
awareness of the aircraft’s position along ground-based instruction, no formal
the approach training for new pilots in the operational
use of a GPS, no structured training on
• the pilot in command (PIC) had a
minimising the risk of controlled flight
previous history of conducting RNAV
into terrain, and no structured training
(GNSS) approaches with crew without
in crew resource management in a
appropriate endorsements and operating
multi-crew environment. There was
the aircraft at speeds higher than those
also a lack of independent evaluation
specified in the operations manual
of training and checking, and a culture
• the co-pilot had no formal training and suggesting disincentives and restricted
limited experience to act effectively opportunities to report safety concerns
as a crew member during the type of about management decisions.
approach conducted into Lockhart River.
• Environment–liveware: the crew
If we now apply the SHELL model to the experienced a very high workload during
Lockhart River accident, we can see that the approach. The lack of visibility and
there was a poor fit between several poor weather also contributed to their
different components in the SHELL model. poor situational awareness.
What led to the accident goes far beyond • Liveware–liveware: the PIC did not
the actions of the PIC alone: detect and correct the aircraft’s high rate
of descent, and the descent below the
• Software–liveware: there were
segment minimum safe altitude before
contradictory and unclear procedures
the aircraft crashed. The co-pilot did not
for conducting instrument approaches.
have the appropriate endorsement and
The company operations manual
had limited experience of this type of
did not provide clear guidance on
instrument approach.
approach speeds, or when to select
aircraft configuration changes during an This example illustrates how important it is
approach. It also had no clear criteria for to understand the human contribution to
a stabilised approach, nor standardised an accident in context, rather than simply
phraseology for crew members to labelling what somebody did as ‘operator
challenge others’ safety-critical decisions. error’. This analysis enables a deeper and
more directed review of causal factors of
the accident which ultimately leads to better
organisational safety in the future.
 SMS 6Human factors and human performance 9

Understanding the wrong route wasting your time.

Similarly, a pilot forgetting to perform

errors and error a checklist can be picked up by another

crew member or a warning system on the

management aircraft. Likewise, a maintenance error

can be discovered by a dual inspection.
The term ‘near-misses’ describes errors
Human error is a normal and natural part
that occur but are corrected before
of everyday life as it is generally accepted
any damage or harm is caused.
that we will make errors every day. In fact,
research suggests that we make between Some people refer to the terms human
three to six errors every waking hour, factors and human error as if they are the
regardless of the task being performed. same. However, human error is really the
outcome or consequence of our human
While this may appear to be many errors,
performance limitations, the human factor.
the good news is that the vast majority have
no serious consequences because they are Therefore, human error involves all those
automatically self-corrected. In most cases situations where what you planned to do
somebody or something reminds us of what did not happen. For example, forgetting
we should be doing, or the errors we make to set the parking brake in your car, or
do not involve a potential safety hazard. hitting the brakes in wet and slippery road
conditions.
Imagine that you drive the wrong way to
the local shops. As you leave home, you
turn down the wrong street and realising
this, you alter your course (self-correction),
or the passenger in your car reminds us ‘Making errors is
of where we were going, or you continue about as normal as
breathing oxygen.’
James Reason

image: Civil Aviation Safety Authority

10 SMS 6Human factors and human performance

Unintentional errors, violations, and unsafe acts

Human error can be divided into either intentional or unintentional actions.
• Intentional actions: actions that involve conscious choices. These actions
are largely due to judgement or motivational processes.
• Unintentional actions: those in which the right intention or plan is
incorrectly carried out, or where there is a failure to carry out an action.
These actions typically occur due to attention or memory failures.
The figure below illustrates the difference between unintentional and
intentional actions:

Adapted from Human Error, J. Reason, Cambridge University Press,

Cambridge (1992).
 SMS 6Human factors and human performance 11

Unintentional actions
Unintentional actions are those that are identified as acceptable human errors. They
provide your organisation with a learning opportunity and because of this response helps
to promote a positive safety culture. These acts should not result in punitive actions and
should instead lead to an analysis of the contributing factors that led to the slip, lapse or
mistake. The analysis should identify any mitigating actions your organisation can take to
reduce the potential for reoccurrence.

Error type Description

Slips Are errors made when you don’t pay attention, or your plan is incorrectly
carried out. For example, you intend to drive to the shops, but turn the way
you usually do to go to work.

Lapses Occur because you fail to carry out an intended action, usually due to a
memory failure. For example, you forget to buy something at the shops or
forgetting to check that the undercarriage locking pins are in place.

Mistakes Occur when you plan to do something, and carry out your plan accordingly,
but it does not produce the outcome you wanted. For example, the shop
you went to does not sell the item you are looking for.
This is often because your knowledge was inadequate, or the rules you
applied in deciding what to do were inappropriate.
This type of error is at times identified as an intentional action error
because often the actions taken are intentional. However, when a mistake
occurs due to inadequate knowledge or inappropriate rule application the
outcome is identified as being unintentional and falls into an overarching
unintentional category of errors.
12 SMS 6Human factors and human performanceCase study Case study

image: iStockphoto

Forgetting to latch fan Similar incidents have occurred on at least

seven other occasions worldwide. It was
cowl door identified during the investigation that the
On 20 January 2000, as an Airbus A-320 engineers had been called away during
aircraft rotated on take-off from London’s performing the maintenance task on the
Gatwick Airport, both fan cowl doors engine. When they returned to complete
detached from the Number 1 engine the task, including locking the fan cowl,
and struck the aircraft. The doors were they returned to the incorrect aircraft on
destroyed, and localised damage resulted to the bay next to the aircraft in question. This
the engine and its pylon, the left wing, the resulted in a failure to identify that the task
left flaps and slats, the fuselage, and the fin. had not been completed, although they
believed they had.
An investigation identified that although
(Ref. UK AAIB Bulletin 7/2000)
the doors were likely closed following
maintenance, they were not securely
latched resulting in the accident. When the
doors are closed, there are no conspicuous
alerting cues to indicate they are unlatched
and no indication on the flight deck.
 SMS 6Human factors and human performance 13

Intentional actions
Unlike unintentional actions, intentional actions or violations involve deliberately,
and consciously, departing from known and established rules or procedures.
For example, choosing to skip a step in a standard operating procedure so you can
complete a task faster.
Within your SMS these are the types of actions that may, depending on their contributing
factors, result in some degree of punitive action along with organisational learnings
to prevent reoccurrence. The table below explains the different violation types and their
main causes.

Violation type Main causes

Routine: result when a violation becomes what is • We think the rules are
normally done i.e., the norm within the workplace unnecessary or too rigid.
or for an individual. • We are poorly supervised.
Routine violations are often short cuts taken to help
get the job done quickly, more easily, or perhaps more
efficiently and become part of the routine for that task.
They are frequent, known and often become condoned.
Unless you monitor and control this behaviour, it can
lead to a culture that tolerates violations and ultimately
degrades your safety culture.
Given many processes and procedures are learnt ‘on
the job’, new employees often accept routine violations
as ‘normal’ procedure as they know no different.

Situational: occur when there is a gap between what • We don’t have enough
the rules or procedures require and what resources are help to do the job, or there
available or possible to be able to complete the task. is not enough time due to
poor planning.
When there is a lack of local resources, or a failure to
understand real working conditions, this may increase • We find that the
pressure on individuals to ignore procedures or break procedures are too
the rules to get the job done and achieve targets. complicated or onerous.
Situational violations represent individuals adapting to
problems in the workplace to still achieve their tasks.
14 SMS 6Human factors and human performance

Violation type Main causes

Optimising (personal or organisational): involve • We break a rule because

individuals doing something for personal goals it is more convenient
(self before safety), or simply for the associated for us personally.
thrills, or for kicks. For example, performing only • We are bored, or the
a cursory examination of the aircraft to get out of job is monotonous.
the cold weather quickly and return inside faster.
• We want to please the
Where there are incentives, such as a bonus for customer or get the
meeting production targets or increased on time job done for the boss
performance, this may encourage organisational or organisation.
optimising violations. For example, individuals
not following all the required procedural steps for
expedient turnarounds in aircraft where teams
are rewarded for faster on time performance.
Identifying organisational optimising violations
can assist in improving both productivity and safety
goals if brought out into the open, communicated
and discussed.

Exceptional: these are rare, one-off acts in novel or • There is a lack of a

unfamiliar situations, or actions individuals might take thorough, risk-based
to deal with an unusual situation. For example, ignoring approach to training in
the pre-landing checklist on final approach to take the anticipation of safety-
evasive action due to traffic conflict. critical scenarios.
• We are under extreme
pressure to perform.

Act of sabotage involves malevolent behaviour and • An individual fully

intentional actions to cause damage or harm. For intends to cause harm
example, not tightening a bolt to cause intentional to life or property.
structural failure.
 SMS 6Human factors and human performance 15

Managing error As individuals we are amazingly error

tolerant, even when we are injured or
If you want to find actual solutions for unwell. We are extremely flexible, robust,
the problems human errors cause, you creative, and skilled at finding explanations,
often need substantial integrated systemic meanings, and solutions, even in the most
changes. For example, you might have ambiguous situations. However, there is
to modify your maintenance rostering to a downside as the same properties that
combat fatigue or revise your flight manuals give human beings such robustness and
to make them easier to interpret. creativity can also produce errors or result
Another way is for you to build error in optimising or exceptional violations.
tolerance into your system thus limiting Our natural tendency to interpret partial or
the consequences of errors when they missing information can also cause us to
do occur. This involves adopting a misjudge situations in such a believable way
broad organisational approach to error that the misinterpretation can be difficult
management, rather than focusing solely on for us to discover. Therefore, designing
the individuals making the errors. systems that predict and capture error i.e.,
Error tolerance refers to the ability of a installing multiple layers of defences, is
system to function even after an error has more likely to prevent accidents that result
occurred. In other words, an error-tolerant from human errors and violations.
system is one in which the results of making Some organisational strategies to contain
errors are relatively harmless. Error tolerant and prevent errors, reduce the potential for
systems are an example of effective human catastrophic consequences, or methods for
factors integration and systems thinking to avoiding the error in the first place, are in
achieve enhanced safety performance. the tables following.

image: Civil Aviation Safety Authority

16 SMS 6Human factors and human performance

Error containment strategies

Error containment Sample strategies

Formalise acknowledgement • policy signed by the CEO stating the importance

that errors are ‘normal’ of reporting errors
• acknowledgement from senior management that
errors occur and encouragement of a just culture
to identify and manage errors
• safety investigation procedures acknowledging
the difference between intentional and
unintentional errors

Conduct regular systemic • periodic staff discussion groups to identify errors

analysis to identify and ways to manage them
common errors and build • task analysis to identify error potential and
stronger defences effectiveness of current controls

Identify the risk of potential • independent peer-on-peer confidential

errors through normal observation program
operations behavioural • safety mentoring and coaching programs to
observation programs identify task-specific potential errors

Identify potential single- • road testing of procedures to identify ease of

point failures (high risk) and comprehension and practical applications prior
build stronger defences to roll out
• ensure critical job roles have backup to avoid
over-reliance on specific individuals (redundancy)

Include the concept of shared • focus on good operational examples of situational

mental models in team- awareness and threat and error management in
based training initiatives recurrent human factors training
• focus on good examples of error capture at shift
handover at regular toolbox talks and safety chats
• use shift handover as an opportunity for team
problem solving, where the incoming shift, with fresh
eyes, may help to resolve any issues which have
occurred during the outgoing shift
 SMS 6Human factors and human performance 17

Error prevention strategies

Error prevention Sample strategies

Reinforce the stringent use • establish a ‘non-negotiable’ operational policy and

of checklists to combat safety standard stating checklists, not memory, are
memory limitations always to be used
• provide a mechanism for staff to report any failings
or difficulties with using checklists or standard
operating procedures so they can be reviewed and
updated if needed
• regular use of industry-based examples via safety
alerts demonstrating the perishable nature of
memory and potential outcomes

Standardise and • establish a technical committee that meets regularly

simplify procedures to identify opportunities to rationalise procedures
• ensure corrective actions from safety investigations
do not always rely on procedural changes

Identify jobs and tasks • focused fatigue countermeasures (e.g. breaks, staff
that are at risk of fatigue backup, supervisor monitoring etc.) on those jobs
impairment and introduce that are safety-critical
fatigue proofing strategies • proactively identify fatigue-producing rosters
through staff feedback

Use hazard or near-miss • establish a formal policy statement e.g. ‘a failure

reporting systems to identify to report is a violation’ and that reporting
error management lessons occurrences of genuine human errors will not
result in punitive actions
• regular feedback to staff via a newsletter or safety
meetings of near-miss examples reported

Decrease reliance on personal • regular industry benchmarking to identify ‘smart

vigilance via the strategic use technology’ to complement the human operator
of automation and technology

Adapted from Human Factors and Error Management training manual (September 2010). Leading Edge Safety Systems, in conjunction with
IIR Executive Development, Sydney.
18 SMS 6Human factors and human performance

These error management strategies are Managing violations firstly involves finding
broad safety management goals. More their root causes or contributing factors.
specific error management initiatives can Automatically punishing a violator is not
then be put in place based on different productive because the violation may be
error types. committed because of factors beyond the
individual’s control. While you should never
For example, the most common types of
tolerate dangerous and reckless behaviour,
errors (slips and lapses) involve attention,
poor work planning or insufficient allocation
vigilance, and memory problems. Therefore,
of resources may have led to some routine
developing procedures (checklists),
or situational violations. Any person in the
designing human-centred equipment
same scenario might have found it difficult
(alarms and warning devices) and training
not to commit a violation, this is known as
programs to raise awareness of human
the substitution test.
factors issues, are all common tools.
The substitution test involves asking
To reduce mistakes, getting your people to
yourself and the individual’s peers: ‘Given
better understand the rules and ensuring
the circumstances (including organisational,
an adequate transition time when rules are
situational and environmental factors) at
changed are useful strategies. You should
the time of the event, could you be sure you
also consider question and answer sessions
would not have committed the same, or a
or trialling new rules or procedures before
similar, unsafe act?’
implementation.
Some examples of organisational strategies
for managing error and violation types to
enhance safety performance are shown in
the table following.

image: Civil Aviation Safety Authority

 SMS 6Human factors and human performance 19

Management strategies by error type

Error type Sample strategies

Slips and lapses • avoid ‘over supervision’

(attention & memory) • reduce the likelihood of interruptions or
distractions that disrupt the workflow through
planning and scheduling

Rule-based mistakes • conduct routine question and answer discussion

(poor use of rules) sessions on the rules so they are understood, not
just followed blindly
• outline new rules when changing work activities so
the rationale (why another change?) is clear
• regularly check on those leading the task – are they
passing on bad habits?
• safety investigations include an analysis of why the
rules were wrongly used or not followed and do
not simply end when it has been identified that an
individual did not correctly follow a rule or procedure

Knowledge-based mistakes • staff have access to appropriate training and

(unfamiliarity or poor procedures, including recurrent training
knowledge) • ensure staff do not have too much information,
data, or paperwork as this can cause an information
overload resulting in selective attentional focus (or
tunnel vision). Practical checklist style summaries or
workflow diagrams are best.
20 SMS 6Human factors and human performance

Management strategies by violation type

Violation type Management tools

Routine • regularly rationalise or simplify rules e.g. do we

really need it? And if so, why?
• reward compliance with procedures, e.g. identified
in employee performance reviews or promoted via
safety standards awards across teams

Situational • make procedures realistic for the task

• involve staff in developing rules
• improve the level of supervision and resources
• in instances where resources are reduced or lacking
allow for extended time for task completion

Organisational • make rules easier to follow through simplification

optimising violation

Personal optimising violation • consider discipline through ‘a fair and just

culture‘ program

Exceptional • train employees for the unexpected to

avoid surprises
• regular training about what ‘good’ situational
awareness and critical decision-making skills look like

Act of sabotage • performance management

• disciplinary action
• prosecution

All violations • fair and just culture program

Adapted from Safety Wise Solutions Incident Cause Analysis Method (ICAM) Pocket Guide (Issue 5, October 2010).
Earth Graphics, Melbourne.
 SMS 6Human factors and human performance 21

SMS human • human resourcing levels are monitored

and adjusted to ensure there are enough

factors integration individuals to meet operational demands

• policies, processes, and procedures are
To create a robust and resilient SMS you established to encourage hazard and
need to consider human factors and how safety reporting
this influences overall safety performance. • safety data and safety information
Human factors and human performance are analysed to allow consideration of
principles have consequences for safety those risks related to variable human
management and actions, meaning human performance and human limitations.
factors should be integrated and embedded Particular attention to any associated
into your SMS. organisational and operational factors
can be made during the analysis
Historically many organisations have
understood human factors integration to • policies, processes, and procedures are
mean having personnel complete human developed that are clear, concise, and
factors or non-technical skills training. While workable, with the aim of:
training personnel in human factors and – optimising human performance
non-technical skills is an element of SMS – preventing inadvertent errors
integration there is much more involved
– reducing the unwanted consequences
than just this. Consideration of human
of variable human performance
factors and human performance influences
– continually monitoring the effectiveness
needs to be taken across all aspects of your
of these during normal operations
organisation’s SMS.
• ongoing monitoring of normal
The following are some common ways
operations including assessments of
in which safety management processes
whether processes and procedures
consider human factors:
are followed and, when they are not
• senior management is committed to followed, investigations are carried out to
creating a working environment that determine the underlying causes
optimises human performance and
• safety investigations include the
encourages personnel to actively engage
assessment of contributing human
in and contribute to the organisation’s
factors, examining not only behaviours
safety management processes. This can
but reasons for such behaviours (context),
be achieved by a clear policy statement
with the understanding that in most cases
and just reporting processes
individuals are doing their best to get the
• responsibilities of personnel with job done
respect to safety management are
• management of change processes include
constantly clarified to ensure common
consideration of the evolving tasks and
understanding and expectations
roles of the human in the system
• personnel are provided with information
• personnel are trained to ensure they are
and training by your organisation that:
competent to perform their duties, the
– describes the expected behaviours in effectiveness of training is reviewed, and
respect to the organisation’s processes training programs are adapted to meet
and procedures changing needs.
– describes what actions will be taken
by the organisation in response to
individual behaviours
22 SMS 6Human factors and human performance

It is unlikely that your SMS will

achieve its full potential for improving Human factors SMS integration
safety performance without a full checklist
understanding and application of human
F Human performance safety data
factors principles by all personnel to
is being collected, analysed, and
support a positive safety culture.
acted upon to improve safety
You can use the following human factors performance of the system.
SMS integration checklist on this page as a
F There is a process in place that
starting point for assessing how well you
encourages safety reporting.
have integrated human factors and human
Which enables identification
performance considerations into your SMS.
of human performance issues,
You can also demonstrate integration of resulting in lessons learned
human factors in your SMS by including and sharing lessons across the
considerations within each of the following organisation.
elements:
F There is a process in place for
• safety culture and management informing personnel of actions
commitment taken when things did not go to
• safety reporting and data analysis plan to reduce the likelihood of
• hazard identification, risk assessment reoccurrence.
and mitigation F There is a process for managing
• incident and accident investigation safety risks associated with
• management of change individuals’ fitness for duty,
including a process for returning
• design of systems and equipment
individuals to duty after an
• training of operational staff absence related to being unfit.
• job and task design.
F Training programs include
addressing individual
responsibilities, organisational
processes and procedures, and
their rationale.
F The change management process
includes appropriate human
performance considerations
in changes including human
performance training relevant
to changing roles and
responsibilities.
 SMS 6Human factors and human performance 23

Safety culture and The standard set and displayed by

management regarding safety culture has
management commitment been shown to have a significant influence
Of all the human factors influencing on human performance through both
individuals’ behaviour, one of the most attitudes and actions of personnel. Your
powerful is your organisation’s safety organisation’s culture affects how safety is
culture. An organisation’s safety culture has perceived, valued, and prioritised by both
been shown to be a key predictor of safety managers and personnel.
performance. It influences how effectively
Underpinning this is a sound ‘just culture’
an organisation manages its safety risks and
that recognises personnel will make
how your managers and employees behave
and interact. mistakes and errors and they should not be
punished for doing so. While accepting that
The effectiveness of safety management human errors are likely to be made there
depends largely on the degree of senior also needs to be a clear understanding
support and management commitment of what is deemed appropriate and
to create a working environment that inappropriate safety behaviours. Wilful or
optimises human performance and negligent actions degrading safety need to
encourages personnel to actively engage in be followed up and may result in some level
and contribute to your organisation’s safety of individual performance management,
management processes. which is different to the treatment of
To address the way that your organisation unintentional lapses, errors, or mistakes.
influences human performance there
A documented safety policy that identifies
must be senior level support to implement
and promotes positive safety behaviours
effective safety management. This includes
is only the first step to human factors
management commitment to create the
integration within your safety culture. Your
right working environment and the right
management team must also be committed
safety culture to address human factors. This
to demonstrate your safety culture values
will ultimately influence the attitudes and
in their own actions and support personnel
behaviours of everyone in your organisation.
when they also demonstrate positive safety
For example, a workplace with a positive behaviours. This is the second step. This
safety culture is where safe and professional is the ‘walking the talk’ human factors
practices are not only expected normal influence of safety culture.
behaviours but are routinely reinforced
and supported by management, even
when there are considerable time and
customer pressures present. In this type
of organisation, personnel will tend to ‘do Punishing an
it by the book’ and take the time to ensure
appropriate work practises, inspections, individual for making
cross-checks, and signoffs are carried out. an error undermines
The organisation’s positive safety culture
has influenced human performance. If, safety culture and
however, management overlooks routine can prevent the
shortcuts and workarounds taking place to
enable quicker turnarounds and faster task development of
completion, a ‘near enough is good enough’ effective safety risk
attitude will prevail. This could ultimately
result in the acceptance of lower standards
mitigations.
of work and degraded safety performance.
24 SMS 6Human factors and human performance

Safety reporting systems Your safety reporting system should not

only collect information about notifiable
and data analysis occurrences and incidents, but also hazards,
People ultimately create safety, either near-misses and errors that otherwise
directly via their actions or indirectly via might have gone unnoticed. Your voluntary
design of processes, equipment, and hazard and safety reports are enhanced
systems. Therefore, the need to collect through a positive safety culture where
and analyse human performance data is people feel empowered and supported to
central to safety management. This type report when errors, lapses or mistakes have
of information can be collected in various been made without fear of retribution.
types of data sources, including mandatory
Ensure your staff are aware of, and know
and voluntary hazard reports and accident
how to report, even the most minor events
or incident investigations. When analysing
to help avert more serious incidents.
human performance data, it is important
Systems to encourage open reporting based
to look at both what went wrong and what
on trust, acceptance and motivation include:
went right.
• non-punitive, confidential hazard and
The main objective of any safety data incident reporting systems
collection and analysis system is to
• formal and informal meetings to discuss
make events, hazards, safety trends and
safety concerns
their contributing factors visible and
understandable so that you can take • feedback from management about action
effective corrective action. Analysing safety taken because of hazard and incident
data represents an important opportunity reports or safety meetings.
to examine the interactions between the The following checklist shows the key
human and other system components. human factors issues to consider in safety
Generally, the same decision-making, reporting and data analysis.
communication breakdown and distraction
problems you see in a serious accident you
will also see in minor occurrences.
 SMS 6Human factors and human performance 25

Human factors and safety reporting F Do you give personnel a template

and data analysis checklist representing the level of detail
and provide reference points
Safety reporting
or examples that make your
F Do the procedures for reporting expectations clear?
hazards, near misses and safety
F Do you have a designated event
occurrences encourage personnel
report coordinator who is seen as
to report errors and violations?
credible and trustworthy?
F Is there a clear non-punitive safety Data analysis
reporting policy signed by the CEO?
F Do you use an error classification
F Is there a simple, user-friendly system to at least identify the
system for reporting occurrences? difference between errors and
violations?
F Does the organisation have a policy
of a strict timeframe for feedback F Do you periodically inform
to the author of the report (Within people of the significance of their
48 hours? Within 72 hours?) reporting, and how the data is
being used?
F Is there an option for personnel to
submit confidential reports if the F Do you track and trend errors from
issue is particularly sensitive? the reporting system?
F Do managers’ meetings with F Do you use this information to
personnel regularly explain why it identify areas of high risk where
is important to obtain feedback on corrective actions can be taken to
errors and events? Do you describe reduce error?
management expectations and
discuss how information will be F Do you use data from the reports
used? in ongoing training and lessons
learned?
F Do you provide examples of
hypothetical reports?
26 SMS 6Human factors and human performanceCase study Case study

image: Civil Aviation Safety Authority

Human factors and hazard On inspecting the stairs, the safety manager
finds that there are no signs on them to
management remind operators to activate the wheel
A simple example of considering human brake. It is also identified that there are
factors issues in the hazard management no visual cues to indicate when the wheel
process is outlined in this case study. brakes have been activated, meaning when
standing back from the stairs it is difficult to
A pilot notices the mobile aircraft stairs
tell if the brakes are on or not.
being left unsecured, and the potential for
the stairs to hit the aircraft, particularly in Simple human factors solutions would
strong wind. The pilot reports this concern include installing a sign prompting
via the company hazard reporting process. operators to secure the wheel brake, have
The company safety manager considers the backside of the brake mechanism
the human factors issues involved, and, coated in a reflective hi-vis tint that can
in talking with ramp staff, finds out that only be seen when in the upright locked
sometimes people forget (memory lapse) to position, and to ensure that all airport staff
secure the wheel brake properly. are regularly reminded of the danger of
unsecured stairs.
 SMS 6Human factors and human performance 27

Hazard identification
Your hazard identification program can reveal potential or actual errors and their
underlying causes. This requires looking beyond the error itself and instead identifying
the underlying contributing factors that have caused an error to occur.
The table below gives examples of questions to ask in relation to hazard management
and human factors influence.

Human factors and hazard F Is your hazard reporting process

management checklist user-friendly?
F Do you consider human factors F Does your reporting process prompt
and human performance issues in users to consider human factors and
general risk assessments where human performance issues? What
hazards are identified? errors might result if the hazard is
not managed well?
F Are the human factors issues
involved with hazards understood? F Have you identified the human
factors issues with the greatest
F Are different error types associated
implications for safety or
with hazards recognised?
performance?
F Are the workplace factors that
F Is there a standard process to
increase the error potential for
investigate and analyse human
hazards, such as high workload,
factors issues?
distractions or inadequate
equipment availability or design, F Do you include human factors risks
considered? on your risk register?
F Do you consider human performance F Do you keep clear records of how
issues in regular staff workshops you have resolved these human
identifying potential safety hazards? factors risks?
28 SMS 6Human factors and human performance

Operator error is
rarely the root cause
of an occurrence.
image: iStockphoto | vaeenma
Usually, some
underlying systemic
issue is hiding
Incident and accident behind it.
investigation
Make sure your investigation procedures
detail how human factors considerations
are included. The main purpose of Investigators and analysts need to
investigating an accident or incident is recognise that identifying an event simply
to understand what happened, how it as human error offers little insight. To
happened, and why it happened, to prevent gain further insight, analysis of safety
similar events in future. Use a model such occurrences includes an in-depth evaluation
as the PEAR model, the SHELL model, or that requires a thorough understanding
James Reason’s accident causation ‘Swiss of the context in which the error occurred,
cheese’ model or some other investigation including organisational, situational, and
framework and consider human error, both environmental factors.
at the individual and organisational levels.
The following checklist may be useful to
Your investigators need to be trained assist you in assessing how well you have
in relevant human factors and human considered human factors in your safety
performance concepts including design investigation system.
procedures to be able to establish which
human performance factors might have
contributed to an event.
 SMS 6Human factors and human performance 29

Human factors and incident/accident F Do you identify immediate causes

investigation checklist (active failures) and contributing
factors at job, individual and
F Do you use a systemic investigation
organisational levels?
model (e.g. Reason model) to
investigate occurrences that goes F Are your recommendations and
beyond just identifying what corrective actions accepted and
happened and asks why it happened effective in addressing immediate
i.e. it identifies the contributing and underlying or contributing
factors. factors of the occurrence?
F Is the investigation process clearly F Do you review recommendations
defined via supporting procedures and corrective actions to ensure they
and checklists, which identifies the have been effective in preventing
need to consider human factors recurrence of or reducing the risk?
contributions?
F Do you provide feedback to those
F Do those who investigate incidents affected by the occurrence or
and accidents have human factors recommendations?
training, specifically in relation to the
F Do you use information from the
application of error identification,
incident management system to
capture and management?
update and review risk assessments?
F Does your investigation methodology
encourage investigators to determine
why human failures occur?

Management of change Some simple questions to consider during

change management to keep human
Any major change within your organisation performance challenges front of mind are:
has the potential to introduce or increase
• Does the change alter tasks performed by
human factors issues. For example, changes
your personnel or how they interact with
in machinery, equipment, technology,
others within your organisation?
procedures, organisational structure,
or work processes are all likely to affect • Does the change imply processing of new
performance and cause distractions. information, require new knowledge, or
new skill sets by those involved in the
When an organisation makes any significant new process?
changes to its business practices, operating
• Does the change involve new technology
procedures or operating environment,
or automation?
the implications for human performance
risks should be the focus of performance • Does the change take place in parallel
monitoring during and after implementing with other changes?
the change. If you answer yes to any of the questions,
You must carefully consider the magnitude then additional human performance risk
of change. How safety-critical is it? mitigations or controls need to be included
What is its potential impact on human in your change risk assessment to address
performance? Consider human factors these areas.
issues especially during the transition
period of the change.
30 SMS 6Human factors and human performanceCase study Case study

image: iStockphoto

Aircraft fleet retirement To manage human factors issues during the

transition period, the operator:
A low-capacity air transport operator
• offers confidential counselling and
decides to retire its existing fleet of nine
financial advice to those affected
aircraft as part of its expansion program.
Some of the flight crews are made • uses a normal (LOSA-like) operations
redundant and are not offered positions flight crew observation program to
on the new aircraft type. The CEO of the identify human factors issues
operator determines that a structured • regularly communicates identified human
change management program is required factors hazards and associated risk
to minimise disruption to operations and controls to personnel
ensure a smooth transition. There are • provides affected staff with weekly
significant human factors issues associated summaries of the change process to keep
with this change process, such as: them informed.
• redundant flight crew are distracted by
their job uncertainty but are having to
continue to operate as effective crew
members for some time
• retained flight crew are distracted by the
new aircraft type
• both types of flight crew are still having
to perform as a coordinated team during
flight operations.
 SMS 6Human factors and human performance 31

The following checklist may be useful to assist you in assessing how well you have
considered human factors in your change management process.

Human factors and management of F Are there enough people to carry

change checklist out the everyday work and respond
to any unplanned, unusual, or
F Is there a clear policy and procedure
emergency situations during the
prompting consideration of human
transition and change periods?
factors issues as part of the change
management process? F Do you take employee morale into
account before, during and after
F Do you plan and stagger these
the change?
changes carefully, to avoid too many
simultaneous changes? F Do managers ask if the changes are
working, or whether there are any
F Do you assess human factors risks
problems?
and opportunities resulting from the
change (where you want to get to)? F Has the company made changes in a
Do you assess human factors risks way that employees can easily adapt
arising from the process of change to and cope with? (Although some
(how you get there) during the changes are small, their effects can
planning process? be cumulative and suddenly create
a problem).
F Do you explain the need for change,
and consult or involve employees in F Do you carry out a full review prior
the change process? to going live with changes to systems
to double check that you have
F Are the planned changes clear to all
addressed any potential for error?
those affected?
F Do you actively consult with key
personnel (and contractors) before,
during and after the change?
32 SMS 6Human factors and human performance

Design of systems and

Human factors and systems design
equipment and equipment checklist
Poorly thought-out equipment design can F always refer to international
have a major impact on the performance standards for user-centred design
of your personnel. You should always
ensure that there is a good fit between F where possible, design systems
the equipment and those using it. and equipment to be error
As discussed above in this booklet, tolerant rather than relying on the
good ergonomics is a key factor in the human to adapt to the new system
liveware to hardware relationship. F identify all the ways in
The design of equipment such as which people can potentially
displays and control systems, alarm interact with the system
systems, signals, and warnings, as well as F assess any risks associated
automated systems, may involve significant with those interactions
human factors risks. These days, aircraft
manufacturers spend a lot of time ensuring F ensure you have management
that human factors criteria influence the strategies for any identified risks
design of aircraft controls, displays and F continually review equipment
other equipment on board. design and how you use
However, occasionally a human factors it to identify any human
issue is missed, coming to light through performance issues
organisational safety reporting or via
incident investigation.
These issues do not apply only to aircraft
controls, but also to equipment used
around an aircraft, such as the aerobridge,
mobile stairs, maintenance tools and
equipment, baggage trolleys etc. Before
committing funds to buying new equipment,
test it out with the actual users first. They
will soon tell you what they think about it.
 SMS 6Human factors and human performance 33

image: Adobe Stock | Gorodenkoff

Task and job design

Human factors and job
Task and job design can significantly affect and task design
human performance. Tasks involving
excessive time pressure, a complex F identify safety-critical tasks,
sequence of operations, relying overly those who perform them and the
on memory, or that are physically or environment in which the tasks
mentally fatiguing, are likely to negatively will be performed (the context)
affect performance. F design the task objectives,
Task design is essentially about task sequences, and actions
matching. Make sure that tasks and to be performed
activities are appropriate and suited to your F structure the task so it
personnel’s’ capabilities, limitations, and supports safe performance
personal needs. by the individual and team
F consider the working
environment so it supports
safe performance of the task
F assess the potential risks
associated with non-compliance,
human capabilities, and limitations
F implement risk management
strategies to manage identified
human performance risks
F evaluate human performance
and safety performance
against the stated objectives
34 SMS 6Human factors and human performanceCase study Case study

image: Civil Aviation Safety Authority

Aircraft normal checklist The operator designed a new checklist

with the help of flight crew with the
A regional airline found recurring problems following features and implemented it
with a version of their aircraft’s normal across the operation:
checklist. Flight crew found that the design
• specific checklist usage rules
of the checklist resulted in overly wordy,
‘scripted’ briefings with unnecessary talking, • changed checklist responses to reflect the
and some of the checklist items were systems configuration more accurately
technically outdated and too long. The • tactile (feel) checks associated with some
operator found this could lead to human checklist responses
performance issues such as inappropriate • additional checklist items at transition
checklist item responses, conditioned or (pressurisation) to ensure more effective
automatic responses, and missed items. memory prompting.
The new checklist also formed part
of dedicated training modules in the
operator’s cyclic program and a line
maintenance training program was
also implemented.
 SMS 6Human factors and human performance 35

Human factors Human factors training should focus on

providing aviation safety-critical personnel

training with an understanding of human factors

principles and non-technical skills to
manage the prevention and consequences
Human factors training while not being
of human error. This implies that
the sole source of human factors safety
making errors is normal and expected.
management integration is a key aspect
The consequences of error are just as
of integration. It is important that your
important as the causes. Knowledge and
personnel understand that human factors
awareness of human factors principles
and human performance principles
help shape, improve, and maximise human
apply to them and to everybody else.
performance within the aviation system.
It is also important for your personnel
to understand that being aware of the Human factors principles training should
consequences of the human performance include:
principles does not make a person • safety culture
immune to them.
• human performance principle basics
It is common in various parts of the • stress and stress management
aviation industry to talk about ‘human
• fatigue and fatigue management
factors training’ when referring to specific
• workload management.
training topics such as threat and error
management (TEM), crew resource
management (CRM) and non-technical
skills (NTS). However, human factors and
NTS are different training elements.
Consider identifying
Your organisation should ensure your
training program for safety-critical
examples of desired
personnel covers both fundamental behaviours as
human factors principles as well as
well as undesired
non-technical skills elements. The
differentiation between the two are: behaviours when
• human factors principles are directed developing training
towards meeting human performance
knowledge requirements focusing on
and educational
understanding human performance materials.
limitations and influences when working
within a broader system
• non-technical skills relate to applied
human performance competencies
via behavioural skills or techniques
that ensure individuals can function
effectively as team members to
mitigate threats and errors within the
operating environment.
36 SMS 6Human factors and human performance

While the initial emphasis should be upon Wherever practicable your human factors
knowledge and comprehension of human training should be incorporated into your
factors principles, you should also include already existing training systems. Human
appropriate operational behaviours and factors training forms a part of your SMS
skills training. This is the NTS element of and should also be integrated across all
your training program. NTS are applied aspects of safety and personnel training.
specific human competencies which may Human factors training is directed at
minimise human error in aviation. These preventing and managing risks in dynamic
include but are not limited to: operational contexts. It therefore has
• communication relevance, not just for meeting technical
training requirements, but for meeting
• teamwork
organisational safety management
• situational awareness responsibilities.
• decision making
You should continue to develop your safety-
• threat and error management critical personnel’s human performance
• human information processing. knowledge and non-technical skills as a
priority. It makes sense as non-technical
Non-technical skills can be considered as
skills are one of your primary defences in
the decision making and social skills which
reducing errors.
complement technical skills. For example,
inspecting an aircraft engine using a For more information on human factors
borescope is a technical skill performed and safety behaviours see the following
by an engineer. However, maintaining CASA guides:
situational awareness (attention to the
Safety behaviours: human factors for
surrounding environment) during the
pilots | Civil Aviation Safety Authority
inspection of a wing, to avoid tripping over
(casa.gov.au)
hazards, is a non-technical skill.
Safety behaviours: human factors for
Before training operational staff in human
engineers resource kit | Civil Aviation Safety
factors principles and non-technical skills,
Authority (casa.gov.au)
do a training needs analysis, so that you
know which error management measures
to target to which groups, individuals,
and teams.
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casa.gov.au