Module 09

HUMAN FACTORS

Pag.
 Module 09 – Human Factor

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 Module 09 – Human Factor

Table of contents

09.01 General.

09.02 Human Performance and limitations.

09.03 Social Psychology.

09.04 Factors affecting performance.

09.05 Physical environment.

09.06 Tasks.

09.07 Communication.

09.08 Human error.

09.09 Safety management.

09.10 The ‘Dirty Dozen’ and risk mitigation.

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 Module 09 – Human Factor

Chapter 09.01

GENERAL

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HF definition

Definition of Human Factors: the Human Factor is the study of the

human behavior in complex technological systems whose aim is to keep
the risk under control.

Human behavior: the human behavior is understood as every action a

person does. This is not only related to the fulfilment of a task but also
to the act of speak, too.

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 Module 09 – Human Factor

HF definition

To understand what determines and conditions our behavior, we need

to understand many sciences:

• Psychology studies the cognitive process (such as attention,

perception, memory, decision taking, etc.) and emotions.
• Physiology and Medicine study the function of the human body.
• Ergonomics, Anthropometry, and Biomechanics contribute to the
optimization of the relation between man and his complex working
environment. They are useful in designing instruments and displays,
according to human characteristics.
• Engineering studies the way to make communications systems and
software programs easily accessible by the workers.

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 Module 09 – Human Factor

SHELL model

SHELL model is an organisation scheme to explain the aircraft

accidents/incidents.

The SHELL model is an acronym, whose letters are the capital letters of
each subject area:

L: Liveware, standing for the man.

S: Software, standing for procedures and rules. (wrong interpretation of
the procedures, badly written handbooks).
H: Hardware, standing for aircraft and instruments (inadequate
equipment, insufficient instruments).
E: Environment, standing for environment, both physical and
organizational one (too noise, fumes, poor safety culture, company
profit).
L: Liveware, standing for people around us, such as colleagues
(communication, supporting manager).
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 Module 09 – Human Factor

SHELL model

The Shell model is

represented by a cross, with
L (Liveware) in its middle,
representing the man.

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 Module 09 – Human Factor

SHELL model

Problems between different elements:

L-H: insufficient instruments, inadequate equipment, unsuitable designing of the

workbenches, hardly accessible working areas;

L-E: not very comfortable places of work, too loud noises, insufficient lightning,
fumes, extreme temperatures, etc;

L-L: the faults of communication between colleagues, or during the shift change,
insufficient staff, lack of supervision, lack of supporting managers,etc;

L-S: a wrong interpretation of the procedures, badly written handbooks, badly

constructed check list, misunderstanding of the software.

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HF evolution

The first studies on the Human factor started in 1910 (in England).

During World War I the aircraft became more and more eleborated.
There is the problem about staff training. During World War II the study
on Human factor was strengthened, the focus moved to the
psychological aspects in order to solve some of the operating problems.

In 1977, in Tenerife, a catastrophic accident shocked the world of

aviation, which involves two Boeing, one of the Pan Am and the other of
the KLM.

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HF evolution

After 1977, KLM started first seminars on resources management in the

cockpit, called CRM (Crew Resources Management).
The aim was to understand the behavior of the crew in order to prevent
from errors and accidents. CMR was very important, but it contained a
basic error: assuming that only pilots were responsible for the safety.

In the Nineties the study of the human factor started getting in the
world of maintenance thanks to the MRM courses (Maintenance
Resources Management). They stand to maintenance as CRM courses
stand to pilots.

In 2003 the human factor training has been made compulsory by the
European regulations.

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 Module 09 – Human Factor

Accidents and incidents quote

About 70% of all the accidents and the mishaps are due to human
errors, made in one part of the process. They may be errors made by
pilots, by air-traffic controllers, by maintenance technicians, by planner
engineer, by ramp men, etc.

Technology is essential to safety but it wasn’t able to reduce the

percentage of accidents caused by the human errors.

The maintenance error plays a role of about 12%-15% → European

sources point out that 15%, in 70% of the accidents due to human
factor, are due to maintenance errors.

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Murphy law

Each accident is caused by multiple causes. The accidents are caused by

many little errors and events. They cause catastrophic effects when they
link up together.

Each reported accident was foreseeable and it could have been avoided
if the chain of the events had been broken →The maintenance error is
one of the rings of the chain.

A quote from Murphy law: If something can happen, sooner or later it

will happen.
Murphy Law reminds us that if something is possible, it is possible it
happens just in those situations and just to us.

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 Module 09 – Human Factor

Chapter 09.02

HUMAN PERFORMANCE AND LIMITATIONS

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 Module 09 – Human Factor

Information processing

The term information processing describes the way our brain analyzes
the information, gives it the right meaning, remembers it and acts in
consequence.

We can compare our mental system to a computer system.

For a human being the information processing consists of reception

phase, through our sense-organs such as the eye and the ear, of a data
transmission system, represented by nerves, of a data processor
represented by our brain.

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Information processing

Processing information is a
very complex and articulate
process and it requires the
use of simplified schematic
models.

The brain needs to

understand the meaning of
the received information
but it has not necessarily to
memorize it.

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Mental model

The outcome of the information process is a mental model of reality.

With the aim of safety, the mental model must essentially be as true as
possible to the operating reality.

This does not depend only on the information coming from our sense
organs, but it depends also on the way they are interpreted.

Some psychological factors, not only related to stress, as it apparently

appears, can also influence the process. It is in general easier to adapt
the world and what we are living to our mental model, instead of
bringing it somehow into question.

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Situation Awareness

The term situation awareness is related to the operator awareness about the
whole operational situation in relation to its possible and probable developments.

The degree of professional experience tends also to influence the kind of error that
can be done in case of loss of Situation Awareness.

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Decision making

The expression decision

making means the process
more or less conscious,
through which we consider
our available information
and we decide to undertake
an action, instead of
another, or decide not to
act.

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Vision

The eye is a sphere, with a part in direct touch with the outer world. The
eye has got a natural contact lens, called cornea, in charge of focusing.

The light gets through the cornea and gets into the pupil that is a hole in
the middle of the eye. According to the strength of the light the pupil
changes its dimension. This enables an adjustment of the quantity of
light that actually can get into the eye.

Then the light passes through a lens, called crystalline, behind the pupil.
The crystalline is a system that enables focusing, working as a lens that
changes its curvature, according to the change of distance of the
objects. The crystalline, changing its curvature, permits the image to fall
down on the retina.

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Vision

In the eye backside there is the retina, which is the film where the
image imprints. Retina consists of light-sensitive cells, called
photoreceptors.

There are two kinds of photoreceptors, cones and rods.

The cones are in charge of colors identification, of the minutely vision
and of the photonic vision since they are stimulated by the light.
The rods enable night vision, in condition of insufficient brightness. The
rods are also in charge of peripheral vision “tail of eye”.

They have different reaction time: the rods have longer reaction time
(until 30 minutes). The cones have a short reaction time (until 7
minutes).

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Vision

Concerning maintenance activities, you need to pay attention when you

do a task in dark environments, as during the analysis with a contrast
medium.

Before undertaking a visual inspection, you need to enter the darker

room and let your eyes get accustomed → Generally when you get into
the dark environment you need to wait for your eyes adaptation.

You do not have to stare at the objects because in this case the image
falls on the fovea where there are not rods.

So you need to move your eyes, making a scanning, to let the image fall
on the rods in order to be recognized.

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Hearing

The ear is the organ of the sense of hearing, which fulfils two different
functions: it is in charge of detecting sounds and it plays a major role in
the sense of balance.

Sounds are conveyed to the brain that is in charge to interpret the

received signals. This process gives a meaning to the sound message.

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Hearing

The ear is divided into three

parts: the outer ear, the
middle ear and the inner
ear.

These parts are called in

this way due to their
anatomy and because the
sound information is carried
in different ways.

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 Module 09 – Human Factor

Hearing

Outer ear
It collects the sound waves and transmits it in a mechanical way. It
consists of the pinna, by the ear canal and by the eardrum. The eardrum
is a thin membrane that closes the canal and works as a drum.
Middle ear
It transmits in a mechanical way. The middle ear is a cavity that includes
three small bones, called incus, malleus and stirrup.
Inner ear
It changes sound waves into chemical and electric impulses. Then they
are sent, through the acoustic nerve, to the cerebral cortex. The
vibration of the stirrup makes the cochlea vibrate. In this way the fluid
inside it begins to move and its movement makes the cells move.

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Hearing

The noise increases the risk in a working environment because it can:

• Annoy
• Cause speech interferences
• Cause accidents
• Cause fatigue.

Noise causes difficulty in concentration on tasks, regardless of the

nature of noise, such as steady, sudden or repeated. As time goes by,
noise can get a person so nervous to provoke a complete loss of
concentration.

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Hearing protection

There is a rule governing worker

exposure to noise, providing for
limits on the intensity of the noise
and on time of exposure.

If the noise is between 85 and 90

decibels, it is necessary the use of
PPE (Personal Protective
Equipment), during the work
activities for at least 8 hours.
Instead, if the noise is more than
115 decibels, hearing damage is
immediate.

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Perception

Perception is, on first approximation, an immediate mechanism that

allows putting together the information. It lets us have a first awareness
of the meaning of the information coming from the outer world.

Perception is the first step of interpretation of the information.

Perception can be influenced and conditioned by many factors that can

be related to the intrinsic characteristics of the object, to the attribution
of particular meaning, to the state of mental tiredness, etc.

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Claustrophobia, physical access and fear

of height
Claustrophobia, physical access
So discomfort suffered in some small places becomes extreme, it is
known as claustrophobia.
It is quite possible that susceptibility to claustrophobia is not apparent
at the start of employment. It may come about for the first time
because of an incident when working within a confined space.

Fear of height
Working at significant heights can also be a problem for some aircraft
maintenance engineers, especially when doing ‘crown’ inspections (top
of fuselage, etc.). Some engineers may be so uncomfortable that they
are far more concerned about the height, and holding on to the access
equipment, than they are about the job in hand.

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Attention

We can distinguish among

different kinds of attention,
related to the different ways
we pay attention.

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Attention

Focused Attention (or channel attention): it is the attention we pay to a

small group of information, avoiding to get distracted by other
information. It is also called channel or tunnel attention.

Multi-task Attention: the divided or multi-task attention is the attention

we pay when we do many activities at the same time and each of them
requires a certain degree of specific attention.

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Attention

Selected Attention: selective attention is the one ordinary used. The

brain makes normally a selection among all information coming from
our sense organs, even if its level of attention is very low → this kind of
attention does not require a particular degree of concentration and it
doesn’t get you tired.

Sustained Attention: sustained attention is the one you have to pay for
long. In general, you do not always pay a high degree of concentration.
Attention intensity on what you are doing depends mostly on the
orderliness of the activity. The higher is the habit of carrying out specific
activities, the lower is the degree of attention you pay. On the contrary,
the newer is the action, unknown or dangerous, the higher is the
attention you pay.

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Memory

Our brain has more or less temporary stockrooms that let us understand
information, associate them the right meaning and remember them
when necessary.

The brain has 3 kinds of memory:

• The sensory memory
• The short-term memory or working memory
• The long-term memory.

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Memory

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Memory

Sensory memory: when the information is received by our sense organs

it is kept for a very short time in a first memory (sensory memory).
Sensory memory oversees binding information together, to give it a first
meaning.

Short term memory: the Short-Term Memory (STM) or better told

working memory, is a memory that works on information, putting them
and getting them out from the permanent memory. The STM can keep
and rework only a small quantity of Information.

Long-term memory: the Long-Term Memory (LTM) is a permanent

storehouse, where all information collected during a lifetime are stored.
The information written in the long-term memory is permanent.

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Memory

The long-term memory can be divided into declarative (explicit) and procedural
(implicit) memory.

The declarative memory can be further divided in episodic and semantic.

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 Module 09 – Human Factor

Chapter 09.03

SOCIAL PSYCHOLOGY

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 Module 09 – Human Factor

Responsibility

Individual Responsibility: the main advantage of individual responsibility

is that an engineer/technician understands clearly tasks assigned to him
and it is his job to do them. The main disadvantage of any emphasis
upon personal responsibility is that this may overlook the importance of
working together as a cohesive team or group to achieve goals.

Group Responsibility: the advantages of group responsibility are that

each member of the group ought to feel responsible for the output of
that group, not just their own output as an individual, and ought to
work towards ensuring that the whole ‘product’ is safe.
The disadvantage of group responsibility is that it can potentially act
against safety, with responsibility being devolved to such an extent that
no-one feels personally responsible for safety (referred to as diffusion of
responsibility).

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Motivation
Motivation is a determinant factor for the effectiveness of the professional
performance and for this reason it must be highly considered. It represents the
difference between what an individual is able to do and what he will do. According to
the position in the pyramid of needs, human behavior is motivated.

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Safety culture

The culture of an organization represents the leading structure of the

organization. Different cultures should not contrast one another, and it
is essential to put always safety subjects at first.

The culture of safety must have the following characteristics:

• The culture of safety is the engine that constantly drives the
organization to achieve an outright security.
• The culture of safety does not forget the risk and reminds
organization members that human beings can make errors.
• It creates an atmosphere of confidence, where people are
encouraged to give information about safety.
• It is a culture that clearly expresses the demarcation line between
acceptable and unacceptable behaviors.

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Team work

The term working group is used to describe a group of people who

interact with a common aim.

In order to be a successful group, it is essential to divide up duties and

responsibilities. In other words, each person must know what his/her
task is. The presence of a superintendent in charge to lead and to
manage the group is also required.

A maintenance working group can be composed of:

• A team of technicians, working on a specific task, on board of the
same aircraft
• A group working on the same shift
• A group working in the same location.

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Team work

Conformism: the term conformism is referred to the tendency of the

single person to conform to what he imagines the others expect from
him. This characteristic is positive because it lets the individual fit into
the group he joins. But it will can be also very dangerous.

Peer pressure: the term peer pressure is used to describe the tendency
of colleagues to make the others conform to a certain kind of behavior
or to the group opinions. This tendency may be expressed in different
forms, like hurrying someone to speed up activities, pushing others to
conform to habits in contrast with safety, such as taking shortcuts during
routine activities and not to consult the handbook, sometimes using
irreverent sentences like: “Do you really believe to consult the
handbook for such a simple task? Please...”

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Team work

Polarization: the polarization is the group tendency to take the most

extreme decisions regardless of the single individual ones. This is what
in everyday language is said: “there is strength in numbers”, which
means that, if in a group you find ideas corresponding to yours own, you
feel supported. By influencing one another, you can bring the group
towards stronger choices and in some cases extremes.

Social laziness: the social laziness is the tendency to devolve tasks to the
other members of the group. This tendency becomes extreme if there
isn’t a clear subdivision of duties and tasks. The social laziness has been
studied in the behavior of crews.

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Relational skills

To work successfully in a
group, it is necessary to know
rules, but this is not enough. It
is also necessary to develop
relational abilities and to
address to other people in a
positive way.
Main relational skills
expressed by a successful
group are communication,
cooperation, coordination and
mutual support.

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 Module 09 – Human Factor

Relational skills

Communication: in a group you are required to communicate efficiently.

Above all the essential thing is an effective communication of
information about safety. A good communication helps the group
integration, and it creates a good working mood.

Cooperation: it is the ability “to work in team”, to keep together a well-

mixed group, to create positive spirit of cooperation and to respect the
others. It is mainly up to the leader to succeed in keeping the group
together letting the cooperation among people be easy.

Coordination: it refers to the subdivision of roles, of duties and

responsibilities in order to accomplish the tasks. This area includes the
general organization, the distribution of individual working load and
priority settings.

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Management

So, a successful group

needs clear subdivisions of
tasks and roles, as well as a
person in charge to lead the
group and to verify that
everyone carries out his
task in an adequate way.

In big companies there are

different professional
figures, having the role of
leading people, at different
levels of the hierarchic
ladder.

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Management

Operating Manager: he manages people working on the field

(technicians).

Intermediate Manager: he is in charge of managing and coordinating

people managing the technicians.

Strategic Manager: he is on the top of he organization and carries out a

strategic management.

In operational reality it isn’t possible to apply an ideal safety. It is most

common to find a good compromize betweeen commercial principals
and safety principle.

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Team leader

The term leader means a person who can influence and lead the
behavior of the group, who generally is in the uppermost position in the
company.

Organizations chose people who are officially nominated as leader,

more specified as superintendent, chief group, supervisor, manager, etc.
This formal assignment should correspond to the person recognized as
leader by the group. But unfortunately it is not always so. The leader
chosen by the company, also called formal leader, does not always
correspond to the informal leader, the one chosen by the group.

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Team leader

Styles of leadership (team leader):

• Autocratic leader: he imposes his decisions → he doesn’t ask for the
opinion of the others
• Democratic leader: team behaviors are part of the decision-making
process and are involved in the project and that support the leader
in ensuring that the objectives of each individual coincide with those
of the company → this approach motivates the whole team and
makes the job more complex but also more engaging
Style of delegation: the team knows how to act and what to do and
leaves to the leader the sole responsibility of taking decisions.

A true leader will have to adopt a different style according to the

situation he is has to face.

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 Module 09 – Human Factor

Chapter 09.04

FACTORS AFFECTING PERFORMANCE

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Circadian rhythms

Another important physical

aspect to consider
concerning human
performances is the
metabolism of our body,
which is not always the
same, but it changes in a
day.

More precisely they change

during the 24-day hours.
These rhythms are called
CIRCADIAN RHYTHMS.

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Circadian rhythms

Circadian rhythms are

controlled by some deep
parts of our brain placed in
that area called limbic
system.

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Circadian rhythms

Morning type people

There are some people who prefer carry out the main part of their
activities during the morning because there they feel more active and
have stronger mental and physical energy. This type of people is called
MORNING TYPE: they have circadian rhythms anticipated with main
activation during the first part of the day.

Evening type people

There are some people struggling to activate themselves during the day,
while they work efficiently at the end of the day and in the evening.
They are people with late circadian rhythms. This typology of people is
called EVENING TYPE.

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Circadian rhythms

Main circadian rhythms

influencing the activity of
our organism.

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Circadian rhythms

Body temperature
As for machines the level of temperature shows the work that the
machine is carrying out. When the machine is hot it means that it is
working, when it is cold it means that it is at rest.
Also, for the human body, temperature shows the metabolism level or
better if it is working at the top or at the bottom level. Foe example a
decrease in temperature means a decrease of the mental performance.

Appetite
During the night, when you sleep, stimuli of hunger are inhibited,
because the organism is resting, and extra energy received by eating is
not necessary. On the contrary, wakefulness activates centers provoking
sensation of appetite, or hunger to put energy in the organism.

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Stress

In scientific field, the term

stress has a neutral meaning
and not a negative one. The
term stress relates to the
state of tension the human
organism is subjected, when
it is called to react to some
stimuli.

You usually realize your state

of tension (stress), when it is
very strong, and it starts to
have a negative influence.

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Stress

In presence of stress the body always reacts in the same way:

• There is a body tension
• There is a mind tension
• There is an emotional tension.

The organism reaction to the stress implies the activation of the

sympathetic and parasympathetic nervous system.
General Adaptation Syndrome phases are:
• Alarm
• Resistance
• Exhaustion.

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Workload

The term workload is referred to the load of work, or better to the

required engagement of a technician for carrying out of a specific task.

The engagement can depend on many variables, not easily measured.

They depend on training, on procedures, on presence of stressors, on
the kind of task and required standard.

Let’s imagine carrying out in two hours three easy and unimportant
tasks. If you decrease time, of one hour or thirty minutes, or if you
increase the importance, with difficult duties, the workload will increase
consequently. A particular stressor is represented by time pressure. One
consequence can be push technicians taking procedural shortcut, risking
this way to infringe the rules.

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Workload

There are then different levels of workload varying from very light to
very hard workload:
• Overload
• High load
• Normal workload
• Underload or insufficient workload.

Underload: this situation creates a very low level of mental activation.

Normal workload: the effort required is optimal.
High load: the work is carried out under pressure.
Overload: it is impossible to fulfill the task requirements.

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Sleep

Sleep is divided in two stages:

• The first part of the sleep is called NOT REM (NREM) sleep, called
also orthodox sleep, because both mind and body are in a condition
of rest.
• Later sleep changes becoming REM sleep, or paradoxical sleep,
because the body is deeply relaxed while the brain has an activity
similar to wakefulness. This stage is called REM that is the
abbreviation for Rapid Eyes Movement, for the typical movement of
the eyes that is its main characteristics.

When we wake up our brain needs a certain period of time to be

completely active. This period of transition between sleep and complete
wakefulness is called sleep inertia. Concerning safety, it’s better to pay
attention to it.

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Sleep: NREM

The NREM sleep is divided

in four stages, because in
each one of them the
electric waves produced by
brain have a different trend.

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Sleep: REM

The REM sleep lasts some

minutes (2-10 minutes). It
recurs several times during
the night → you get near
the awakening.

The REM and NREM phases

alternate → After some
hours of sleep the brain
doesn’t pass through
phases 3-4.

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Shift

In aviation world the maintenance activity is carried out on 24 hours of

a day.
For this reason it is normal for maintenance technicians to work also on
night shifts.

Night shifts are very dangerous for safety because at night the quality of
physical, but especially of mental performance decreases.
The investigations on aircraft accidents, whose cause is to be found in
an error in maintenance activities, have revealed that most of these
activities have been carried out during a nightshift.

For this reason it is necessary to make an optimal schedule of night

shifts.

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Shift

Shifts can be divided in 8 hours or 12 hours shifts. The most common shift
is 8 hours one. The shifts turnover is divided in fixed, weekly and
alternating and follows general rules.

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Shift

Fixed work
• Circadian rhythms keep the diurnal trend during the first 3 days of
night shift
• They start changing during the fourth night, but the adjustment is
not immediate
• After a maximum of 5 days of work you have at least 2 days of rest
(in these 2 days the organism takes at once its diurnal trend again).

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Shift

Weekly shift
• Weekly shifts are not optimal → After one week, just when the
organism begins getting used, the shift changes again → It makes
the rhythms to adjust again
• This shift causes a serious fatigue.

Alternating shift
• Shift type changes every 2 or 3 days
• These are the best shifts → over the 5 weekly working days there
are maximum 3-night shifts, one after the other, to give the lowest
fatigue of de-synchronization → the body keeps the diurnal rhythm

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Fatigue

From a working point of view, we define fatigue as a condition of

tiredness associated to long working hours or sleepless periods, or to
de-synchronized working rhythms, as in night shifts.

It corresponds to a decrease of ability in accomplishing a task, to

deterioration of the work quality, to accuracy and to the decline of
interest and motivation.

There are three types of fatigue:

• Sharp: short but intense
• Chronic: prolonged in time
• Cumulative: results of many periods of fatigue.

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Fatigue

For safety’s sake, it is fundamental learning to recognize consequences

of fatigue on the performance and to be able to avoid them:
• The level of attention
• The Judgment Ability
• Short Term Memory
• The visual acuity
• Motor faculties
• Relational faculties.

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Fatigue

Countermeasures:
• To follow general rules indicated for sleep health and for
management of fatigue
• When you work on shifts it is necessary that technicians fix the time
for meals and rest
• It is necessary to weigh up the effective possibility of carrying out
night overtime shifts.

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Medicines

Medicines are generally taken to cure some diseases. As general rule,

you have to consider that each medicine even if prescript by a doctor
may have collateral effects.

Antibiotics: this category of medicines doesn’t cause direct effects on

mental performance; they can cause a general condition of exhaustion.
And consequently, they can cause fatigue and concentration difficulty.
Painkillers: these medicines don’t cause alteration of mental faculties,
but if associated to other substances, they can interfere with the
cognitive performance.
Sleeping tablets: they are medicines that, by their nature, alter the
mental performance.

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Alcool and drugs

Alcohol is a substance that, by its nature, causes alterations to mental

functions. Of course, the degree of the alteration depends on the
quantity of alcohol drunk and, on the alcoholic, % of the drink.
Regarding safety, on the contrary, alcohol is totally contra-indicated. In
all organizations operating in the safety field, alcohol distribution in staff
restaurants should be forbidden, especially in aviation field.

Drugs are also substances altering mental functions. They are absolutely
contra-indicated for safety and drug-taking is forbidden for people
working in the aviation field.

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 Module 09 – Human Factor

Chapter 09.05

PHYSICAL ENVIRONMENT

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Noise

Noise is one of the riskiest stimuli in the maintenance environment.

Noise is defined as an unpleasant and annoying sound, especially if it is
loud. Noise is by nature stressful; namely, it is a stimulus that forces the
organism to a tension and to an adaptation.

If we are concentrating on performing a task while there are noises

around us, the effort is greater, because our brain has to reject the
background noise and place the task in the foreground.
As time passes concentration becomes increasingly difficult and a sense
of mental fatigue arises, which we often realize when the noise ceases.

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Noise

Noise in the workplace can have adverse effects in both the short and
the long term.

The main effects of noise are:

• Annoyance
• Interference during conversation
• Sleep disturbance
• Momentary reduction of mental efficiency
• Extra-auditory effects.

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Noise management

The organization is
responsible for putting
noise control systems in
place.

There are three levels for

reducing the exposure of
workers to noise.

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Noise management

First level - At the source

The noise level is reduced from the source using specific silencers.
Second level - Between the source and the worker
Insulation: this system consists in using absorbent materials that can be
placed between the noise source and the worker. The sound waves have
to firstly pass through this material before reaching the worker in
reduced form.
Echo absorption: this consists in placing absorbent materials on the
walls, roofs, floors and other surfaces that might reflect the sound
waves.
Third level - At worker level
Protective equipment like headsets and plugs can be provided if the
continuous noise is higher than 87 db.

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Illumination

Inappropriate or insufficient lighting can lead to an increase in mistakes

in tasks as well as an increase of the time required to complete them.
With a better illumination an increasing of the performance is possible,
speeding up activities and reducing errors.

Lighting means the quantity of light that reaches a surface or an object.

It depends on the light emitted by each light source and on their aiming.
It can be subdivided into:
• Base lighting, i.e. of the structure and of the environment in general,
such as the hangar
• Additional and dedicated lighting, specific for a task, such as for
instance Non- Destructive Checks (NDCs) or borescope inspections.

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Illumination problems

Reverberation occurs when the lighting intensity is too high. This

phenomenon can cause a reduction of visual perception, distortion of
colors, fatigue and irritation.

Direct reverberation: the direct reverberation zone is defined as that

area between 0 and 45 degrees in relation to our field of view line, in
which a strong light is received. It therefore occurs when a light directly
strikes our field of view.
Indirect reverberation: it is caused by light reflected on surfaces.
Indirect reverberation is relatively easy to control by coating reflecting
surfaces with matt paint and moving light sources away from areas that
cause reflection.

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Fumes

By nature, aircraft maintenance takes place in an environment with a

high presence of fumes and emissions.

Fumes are caused by combustion, overheating or emissions from

chemical substances.
The presence of certain fumes is detected by their smell; conversely,
others cannot be detected, as they are practically odorless.

Fumes represent a problem for the engineer in terms of both health and
performance. They can also cause local irritations such as irritation of
the eyes.

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Temperature

It is important to understand the effects of temperature on the safety

and performance of works.

Regardless of individual preference, cold stress is more insidious, as it

prevents manual dexterity. Though hot stress is often perceived as more
fastidious, from the point of view of the maintenance task, hot stress
does not significantly interfere with manual dexterity.

In addition, the sensation of comfort is affected not only by the

temperature but also by the humidity rate. → When the humidity rate
exceeds 50%, also the intensity of the degrees perceived increases.

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Vibration

Vibrations in aeronautical maintenance are caused using percussion

equipment or tools with repetitive movements. Also, low noise
frequencies like those caused by an engine can cause vibrations.

Vibrations ranging between 0.5 Hz and 20 Hz are problematic because

they are absorbed by the human body. Vibrations within the 50-150 Hz
range, such as those caused by pneumatic guns, cause the white finger
syndrome.

The harmfulness of vibrations depends on the characteristics and the

conditions in which they are transmitted: extension of the contact area
with the object that vibrates, the vibration frequency, the direction of
propagation and the exposure time.

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Working environment

Among the further factors of the working environment that affect

performance, we can mention the following:
• Cleanliness and tidiness of the workplace, structures for storing and
keeping the tools used, presence of manuals and access to
information, continuous checking that the used tools are put back in
their special housings to avoid inconveniences and FOD (Foreign
Object Debris)
• Use of adequate safety equipment and non-slip surface procedures,
safety slings
• Use and storage of chemical substances and toxic fluids, clear
differentiation of the containers to avoid confounding the contents,
use of clear labels, storage in separate places of containers that can
be confused, etc.

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 Module 09 – Human Factor

Chapter 09.06

TASKS

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Physical and mental work

Before starting each maintenance task, it is necessary to plan what it

must be carried out. It is advisable to follow some support check lists.

For example, the technician can try to answer the following questions
before starting a task:
• Do I exactly know what the task is about and how it would be
carried out?
• Are sources, instruments, people, equipment, documentation and
supports available to carry out the task in a successful way?
• Am I sufficiently skilled to accomplish the task?

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Repetitive and routine tasks

Repetitive tasks are composed by parts of an action that are always

repeated in the same way. Routine tasks instead are often carried out,
every day, or many times in one shift or in one week (daily checks).

The repetitive and the routine tasks require an average cognitive effort.
In order to carry out these tasks a certain level of mental elaboration is
required. It is necessary to pay a higher attention than during physical
tasks. The ever-similar repetition of the actions causes a natural fall of
attention.

In order to avoid it, it is necessary to follow check lists and procedures.

When possible, it is necessary to make short breaks in order to relieve
the possible boredom.

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Complacency

The tendency to work with an

excessive self-confidence, which
leads to avoiding the procedure
checks is called complacency.

Complacency deals with the idea

of excess of self-confidence →
The complacency put the safety
at risks.

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Visual inspection

The visual inspection can be described as the process of examining and

assessing the conditions of a system or of a component, using only the
sight, with or without the help of instruments. It is one of the main and
most important methods used in maintenance to guarantee the
airworthiness of an aircraft.

The main instruments used for a visual inspection are:

• Small mirrors or magnifiers
• Torches or drop-lights
• Borescopes
• Optical fibers
• Camcorders
• Laptops with optical screen.

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Complex system

All the skills we exert to carry out a work in a complex system require a
very high cognitive effort and a very high level of processing
information. The activity of searching breakdowns is a classic example.
Analysis of the problem, diagnosis, problem solving, reasoning, decision
making are all very high cognitive skills that are used when carrying out
tasks in a complex system.

In order to carry out the maintenance of complex systems it is necessary

for a technician to be specifically trained on the systems, their
composition and their functioning. The training must provide the right
balance between detailed knowledge of the system and techniques of
analysis of the breakdown.

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 Module 09 – Human Factor

Chapter 09.07

COMMUNICATION

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Definition

Communication can be defined as a stream of information. This process

gets started by the sender, which can be a human being, I.E., a
technician telling something to a colleague, or something organized, like
a notice from the company put on a board or sent via internet. The
subject getting the information is the receiver.

When the sender communicates with the receiver but has no real time
answer, this is called a one-way communication. The technician reads
the note but can’t reply or eventually clarify any doubt immediately.

When the sender transmits something, and the receiver is capable of a

prompt reply we can talk of a two ways communication. When two
technicians are talking, they are giving each other information and any
of them can ask questions and reply.

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Definition

Synchronous communication takes place in real time, and it is

commonly used by pilots and flight controllers.
Errors can occur, following Reason model, and they have immediate
consequence on flight operations.

Asynchronous communication does not take place in real time. This kind
of communication is typical of maintenance. Notices, messages,
guidelines, job cards are written and read later on by technicians.
Following Reason model, errors can occur, but they do not have
immediate consequence and are therefore latent. This is especially true
for pilots and maintenance technicians

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Functions

Communication has three main functions:

• To give information. Through manuals, notes, reports and job cards.
But also a colleague, a supervisor, an engineer could be a useful
source of additional information.
• To create relationships. Communication is the way to create
relationships and when they are of a good quality this can help to
establish a friendly and cooperative environment, fundamental for
an effective flow of information and for an exchange of points of
view. This guarantees adequate levels of safety.
• To perform tasks. Communication is the way by which staff carries
out tasks, applying written advices, sharing duties, sending and
receiving information etc.

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Verbal and non verbal communication

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Errors in communication

During handover, the errors may occur due to:

• Lack of communication. When a technician forgets to pass important
details or if a message is diverted. This can happen, for example,
when a written message is left in the wrong place and not seen by
the receiver.
• Poor communication. When the technician does not clarify all his
needs receiving then inappropriate information, or else when a
written report is filled in a barely legible handwriting.

Simple rules to be followed in order to avoid poor and inefficient

communication are: speak and write clearly, listen and read carefully
and ask for explanations any time you feel the need.

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Effective communication

To perform an effective
written communication
there is a 4 C rule to be
followed:
CLEAR: communication
must be written in a legible
handwriting, capital letters
CORRECT: it must refer to
manuals and procedures
COMPLETE: no information
has to be left out
CONCISE: communication
must be synthetic, no
unnecessary details.

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Keeping up to date

An aeronautical technician must constantly update his skills. To do this

he needs to know:
• New aircraft and certified variants
• New equipment and new maintenance practices
• Changes made to aircraft he’s working on
• Reviewed maintenance procedures.

There are many ways to spread information: hand given documents,

notices on boards, company intranet or Authority or internet web sites.

When the information is particularly important the company may

require the technician to sign a receipt.

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 Module 09 – Human Factor

Chapter 09.08

HUMAN ERROR

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Error definition

Generally, the term error means any action that departs from what has
been programmed or expected.

Here, by error, we mean an action that departs from an expected

standard and that can jeopardize safety. Generally, the error is
unintentional, in the meaning that the person who makes it has no
intention of doing so.

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Error classification

Over the years, much commitment has been devoted to error

classification in order to understand its nature and the factors that can
help it to arise:
• Design or operator-induced error
• Variable or constant error
• Reversible or irreversible error
• Omission, commission and extraneousness errors
• Slips, Lapses and Mistakes.

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Error classification

Design or operator-induced errors

• Design errors → errors made in design or production
• Operator-induced errors → errors made by the operator that works
on the aircraft.

Variable or constant errors

• Variable errors → random errors
• Constant errors → errors that occur with a certain frequency.

Reversible or irreversible errors

• Reversible errors → errors can be corrected
• Irreversible errors → errors cannot be connected.

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Error classification

Omission, commission and extraneous errors

• Omission → missing action
• Commission → incorrect performance of a task (true and proper
error)
• Extraneous error → extraneous action to plans.

Slips, Lapses and Mistakes

• Slip → inattention error (little attention)
• Lapses → memory errors (momentary and transient)
• Mistakes → more complex execution (high degree of attention) →
programming and planning errors.

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Violation definition

Violations means conscious deeds that depart from the rule, and which
can involve a safety hazard.

In most cases, persons do not commit violations with the intention of

sabotage.

To the contrary, in some way they assume they are following a better
strategy than the one specified, violating with the purpose of saving
time or to avoid a pointless rule.

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Rasmussen model

One of the most well-

known models which are
helpful for understanding
and classifying human
errors is Rasmussen’s.

In any case they do not

think they are
compromising safety.

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Rasmussen model

This model connects errors on the basis of three different levels of behaviour:

Skill-based. This is the least binding level on the cognitive plane. The actions
accomplished are carried out automatically, without conscious attention and
are the result of a lot of practice.

Rule-based. This level concerns the application of well-known rules or

procedures in familiar situations. Conscious attention is devoted because
people recover rules stored in the memory to apply them.

Knowledge-based. This is a matter of all those new and unknown situations in

which it is necessary to reason to find a solution. These require a high level of
concentration.

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Reason model

No accident has ever been

caused by only one person,
like for example an error
made by a pilot, but rather
by a long series of small
errors made in various parts
of the system.

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Reason model

The danger arises when the holes that represent the errors and
problems are lined up with one another. This way, they open the
passage so that a problem generated in more remote parts of the
system reaches front-line operation causing an accident.

James Reason defines this alignment of active and latent errors as the
accident trajectory.

The errors made by direct operators, such as pilots, air traffic controllers
and partly by engineers are called active failures.
These active errors have an immediate consequence on safety, as they
directly cause a failure, or in more serious cases, a true and proper
accident.

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Reason model
In the aviation system, errors are made also in other spheres, i.e. sectors not
directly linked with a critical event. These are called latent failures, as their
consequences are delayed in time. It is important to remember that latent failures
are the hardest to detect because they are made in sectors of the system not
directly connected with management of the aircraft.

Errors and problems are inherent in every part of the system: they must be
identified and blocked immediately through “safety barriers” to prevent them from
having consequences. The safety barriers are therefore the actions carried out to
solve the error.

The danger arises when the holes that represent the errors and problems are lined
up with one another. This way, they open the passage so that a problem generated
in more remote parts of the system reaches front-line operation causing an
accident. James Reason defines this alignment of active and latent errors as the
“accident trajectory”.

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Error management

Unfortunately, the objective

of never making a mistake
cannot be achieved,
because man by nature is
likely to err.

The organization must

therefore predict this
possibility as ingrained in
maintenance activities and
be structured to prevent
errors or prevent them
from having consequences.

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Error management

Error reduction
It is the lowering the likelihood of an error being made. It requires an
upstream intervention before the error made.
Error capture
It is the strategy presumes that the error has already been made. The
objective of intervention is to locate it before the aircraft flies. Example:
double checks.
Error tolerance
It is the capability of the system to absorb the error without it having
effects and therefore of annulling its consequences. Example:
redundancy of the system.

It is also important the OCCURRENCE REPORTING SYSTEM.

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 Module 09 – Human Factor

Chapter 09.09

SAFETY MANAGEMENT

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Safety Policy and Objectives

Employers should make safety an integral part of company values, demonstrating

their commitment daily.

the safety management system will be reviewed periodically to ensure it remains

relevant and appropriate to the organization.

SMS documentation may be a stand-alone manual or integrated into existing

record-keeping procedures

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Safety Management System in Aviation

a safety management system encompasses service provider activities involved in

safe aircraft operations, including organizational affairs such as legal, finance, and
human resources.

The concept of aviation safety management systems is clearly defined in the ICAO
Safety Management Manual (SMM).

Based on its latest version published in 2018, SMS implementation should

correspond to the size of the company and the complexity of the products or
services provided

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Safety Risk Management

In order to effectively control safety risks, designated staff should perform a

series of interconnected processes collectively called Safety Risk
Management (SRM)
1) System Description and Task Analysis.
2) Hazard Identification.
3) Risk Analysis.
4) Risk Assessment.
5) Risk Control.

• Safety Assurance (SA) is the component of safety management system

that deals with the monitoring of risk controls during operations.

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Safety Promotion

Interchangeably used with Safety Culture,

Safety Promotion is defined as the
activities that support the SMS
implementation in an organization such
as training, knowledge-sharing, and
communication.

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Just Culture
One key to the successful implementation of safety regulation is to attain a “just culture”
reporting environment within aviation organisations, regulators and investigation
authorities. This effective reporting culture depends on how those organisations handle
blame and punishment.
Only a very small proportion of human actions that are unsafe are deliberate (e.g. criminal
activity, substance abuse, use of controlled substances, reckless noncompliance, sabotage,
etc.) and as such deserve sanctions of appropriate severity. A blanket amnesty on all
unsafe acts would lack credibility in the eyes of employees and could be seen to oppose
natural justice. A “no-blame” culture per se is therefore neither feasible nor desirable.
What is needed is a “just culture”, an atmosphere of trust in which people are
encouraged, even rewarded, for providing essential safety-related information - but in
which they are also clear about where the line must be drawn between acceptable and
unacceptable behaviour.

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Professionalism and integrity

In aircraft maintenance, “Professionalism” can be interpreted as the willingness

to take responsibility for placing the safety and airworthiness needs of the
traveling public above individual self-interest. The above is evidence of Integrity.

the 4 C’s for the aviation professional:

• Competence in knowledge and skills in their field

• Commitment to a higher purpose

• Control of their own work

• Communication (written, verbal, and nonverbal other than written)

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 Module 09 – Human Factor

Chapter 09.10

THE ‘DIRTY DOZEN’ AND RISK-MITIGATION

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Dirty dozen

Mr. Dupont of the Canadian Aviation Authority carried out a thorough

investigation on the major aviation accidents and incidents, where the
cause was due to maintenance errors. The purpose was to identify
certain risk factors present in different accidents. This way he discovered
certain risk elements shared by all accidents, which characterized the
context in which the error was made.

He identified twelve of them and brought them together in the

following list, called Dirty Dozen.

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Dirty dozen

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Thank you for your attention.

Pag.