CHAPTER 08

Human Error

Md Jalal Uddin Rumi

Assistant Professor
Department of Aeronautical Engineering, MIST
Objective
No one is perfect, human
errors will occur.
By understanding the root
causes of human error we
can reduces them and
limit their effects when
they inevitably happen.
 Understanding Human Error

It has long been acknowledged that human performance is at

times imperfect.
Nearly two thousand years ago, the Roman philosopher Cicero
cautioned, "It is the nature of man to error."
It is an unequivocal fact that whenever men and women are
involved in an activity, human error will occur at some point.
It is clear that aircraft maintenance engineering depends on
the competence of technicians/mechanics/engineers.
 Understanding Human Error
In the past, aircraft components and systems were
relatively unreliable.
Modern aircraft, by comparison, are designed and
manufactured to be highly reliable. As a consequence, it
is more common nowadays to hear that an aviation
incident or accident has been caused by "human error."
 Error Models and Theories
The types of error that it is possible to make:
• Design errors versus operator-induced errors
• Variable versus constant errors
• Reversible versus irreversible errors
• Slips, lapses, and mistakes
• Skill, rule, and knowledge-based behaviors and associated
errors
• The "Swiss Cheese Model"
 Design-Versus Operator-Induced Errors
Errors may have been made before an aircraft ever leaves the
ground by aircraft designers.
This may mean that, even if an aircraft is maintained and
flown as it is designed to be, a flaw in its original design may
lead to operational safety being compromised.
Alternatively, flawed procedures put in place by airline,
maintenance organization, or air traffic control management
may also lead to operational problems.
 Grounding of B737 Max Fleet
Boeing hustled in 2015 to catch up to Airbus A320 Neo and certify its new
737 MAX, Federal Aviation Administration (FAA) managers pushed the
agency’s safety engineers to delegate safety assessments to Boeing itself,
and to speedily approve the resulting analysis.
But the original safety analysis that Boeing delivered to the FAA for a new
flight control system on the MAX — a report used to certify the plane as
safe to fly — had several crucial flaws.
That flight control system, called MCAS (Maneuvering Characteristics
Augmentation System), is now under scrutiny after two crashes of the jet
in less than five months resulted in global grounding of entire fleet.
 Requirement of new flight control system
:MCAS

Going against a long Boeing tradition of giving the pilot complete control of
the aircraft, the MAX’s new MCAS automatic flight control system was
designed to act in the background, without pilot input.

It was needed because the MAX’s much larger engines had to be placed
further forward on the wing, changing the airframe’s aerodynamic lift.

Designed to activate automatically only in the extreme flight situation of a

high-speed stall, this extra kick downward of the nose would make the plane
feel the same to a pilot as the older-model 737s.
 Variable Versus Constant Errors
There are two types of human error:
• variable and
• constant.
Variable errors in (A) are random in nature,
whereas the constant errors in (B) follow
some kind of consistent, systematic (yet
erroneous) pattern.
The implication is that constant errors may
be predicted and therefore controlled,
whereas variable errors cannot be predicted
and are much harder to deal with.
 Variable Versus Constant Errors
If we know enough about the nature of the task, the environment it is
performed in, the mechanisms governing performance, and the nature
of the individual, we have a greater chance of predicting an error.
A engineer/technician is more likely to make an error at 3 A.M., after
having worked 12 hours, than at 10 A.M. after having worked only 2
hours."
It is possible to refine these predictions with more information, but
there will always be random errors or elements which cannot be
predicted.
 Reversible Versus Irreversible Errors
Another way of categorizing errors is to determine whether they are reversible or
irreversible. The former can be recovered from, whereas the latter typically cannot be.

For example, if a pilot miscalculates the fuel he/she should carry, he/she may have to
divert to a closer airfield, but if he accidentally dumps his fuel, he/she may not have
many options open to him.

A well designed system or procedure should mean that errors made by aircraft
maintenance engineers are reversible. Thus, if a engineer installs a part incorrectly, it
should be spotted and corrected before the aircraft is released back to service by the
supervisory procedures in place.
 Error Types
Errors can be classified in many ways. The most well-
known of these are :
• Slips
• Lapses
• Mistakes
 Slips
Slips typically occur at the task execution stage. Slips
can be thought of as actions not carried out as intended
or planned, for example transposing digits when
copying out numbers, or mis-ordering steps in a
procedure.
 Lapses
Lapses typically occur at the storage (memory) stage.

Lapses are missed actions and omissions, (i.e. when

somebody has failed to do something due to lapses of
memory and/or attention or because they have
forgotten something; for example, forgetting to replace
an engine cowling).
 Mistakes
Mistakes typically occur at the planning stage.

Mistakes are a specific type of error brought about by a faulty

plan/intention, that is, somebody did something believing it to
be correct when it was, in fact, wrong.

For example an error of judgement such as mis-selection of

bolts when fitting an aircraft windscreen.
 Violations
Violations sometimes appear to be human errors, but they differ from
slips, lapses and mistakes because they are deliberate "illegal" actions
(i.e., somebody did something knowing it to be against the rules).
An example is deliberately failing to follow proper procedures. Aircraft
maintenance engineers may consider that a violation is well
intentioned, (e.g., "cutting corners") to get a job done on time.
However, procedures must be followed appropriately to help
safeguard safety.
 Violation in Aircraft Maintenance
There are four types of violations:
• Routine violations
• Situational violations
• Optimizing violations
• Exceptional violations
 Routine violations
Routine violations are things which have become "the normal way of doing
something” within the person's work group (e.g., a maintenance team).
They can become routine for a number of reasons, technicians may believe
that procedures may be over prescriptive and violate them to simplify a task
(cutting corners), to save time and effort.

Examples of routine violations are not performing an engine run after a

borescope inspection ("It never leaks"), or not changing the "O" seals on the
engine gearbox drive pad after a borescope inspection ("They are never
damaged").
 Situational violations
Situational violations occur due to the particular factors that exist at the time, such
as time pressure, high workload, unworkable procedures, inadequate tooling, and
poor working conditions.
These occur often when, in order to get the job done, technicians consider that a
procedure cannot be followed.
An example of a situational violation is an incident which occurred where the door of
a B747 came open in-flight. A technician with a tight deadline discovered that he
needed a special jig to drill off a new door torque tube.
The jig was not available, so the technician decided to drill the holes by hand on a
pillar drill. If he had complied with the maintenance manual he could not have done
the job and the aircraft would have missed the service.
 Optimizing violations
Optimizing violations involve breaking the rules for
"kicks." These are often quite unrelated to the actual task.
The person just uses the opportunity to satisfy a personal
need.
An example of an Optimizing violation would be a
technician who has to go across the airfield and drives
there faster than permitted.
 Exceptional violations
Exceptional violations are typified by particular tasks or
operating circumstances that make violations inevitable,
no matter how well intentioned the engineers or
technicians might be.

They can be the result of a conscious decision to violate

or an instinctive reaction to the situation.
 Types of Behaviors
Human performance and behavior depends on the training, education, and
personality of each individual. The personality of an individual is preformed
long before entry into the workplace but abilities, performance and behavior
can be modified.
The behavior of aircraft maintenance engineer can be broken down into three
distinct categories:
1. Skill-based behavior
2. Rule-based behavior
3. Knowledge-based behavior
Each of these behavior types have specific errors associated with them.
 1. Skill-based Behavior

Skill-based behaviors are those that rely on stored

routines or motor programs that have been learned with
practice and may be executed without conscious thought.
Examples of skill-based errors are :
A. Action slips
B. Environmental capture
C. Reversion.
 1A. Action slips
Action slips as the name implies are the same as slips,
(i.e., an action not carried out as intended).
The example given in next slide may consist of a
technician realizing he needs a certain wrench to
complete a job but, because he is distracted by a
colleague, picks up another set to the wrong torque and
fails to notice that he has tightened the bolts incorrectly.
 1B. Environmental capture
Environmental capture may occur when an engineer carries
out a certain task very frequently in a certain location.
Thus an engineer used to carrying out a certain
maintenance adjustment on an Airbus A320, may
inadvertently carry out this adjustment on the next A330 he
works on (and he has not made a conscious decision to
operate the skill).
 1C. Reversion
Reversion can occur once a certain pattern of behavior has been
established, primarily because it can be very difficult to abandon or
unlearn it when it is no longer appropriate.

Thus an engineer may accidentally carry out a procedure that he has

used for years, even though it has been recently revised.

This is more likely to happen when people are not concentrating or

when they are in a stressful situation.
 2. Rule-based Behavior
Rule-based behavior is generally fairly robust. This is why the use of
procedures and rules is emphasized in aircraft maintenance.
However, errors here are related to the use of the wrong rule or
procedure.
For example, an engineer may misdiagnose a fault and thus apply
the wrong procedure, thus not clearing the fault. Errors here are
also sometimes due to faulty recall of procedures. For instance, not
remembering the correct sequence when performing a procedure.
 3. Knowledge-based Behavior

Errors at the knowledge-based performance level are related to

incomplete or incorrect knowledge or interpreting the situation
incorrectly.
An example of this might be when an engineer attempts
unfamiliar repair task and assumes they can "work it out."
Once he has set out in this way, they are likely to take more notice
of things that suggest they are succeeding in their repair, while
ignoring evidence to the contrary (known as confirmation bias).
 The "Swiss Cheese Model"
Professor Reason's invented "Swiss cheese" model. In his research,
Professor Reason has highlighted the concept of "defenses" against
human error within an organization, and has coined the notion of
"defenses in depth."
Examples of defenses are duplicate inspections and pilot pre-flight
functional checks that help prevent to "trap" human errors,
reducing the likelihood of negative consequences.
It is when these defenses are weakened and breached that human
errors can result in incidents or accidents.
if an error has breached the engineering defenses, it
reaches the flight operations defenses (e.g., in flight
warning) and is detected and handled at this stage.
However, occasionally in aviation, an error can breach
all the defenses (e.g., a pilot ignores an in flight
warning, believing it to be a false alarm) and a
catastrophic situation ensues.
 Errors Associated With Visual Inspection
There are two particular types of error which are referred to particularly in the context of
visual inspection:
– Type 1 errors
– Type 2 errors
A Type 1 error occurs when a good item is incorrectly identified as faulty. Type 1 errors are
not necessarily a safety concern, except that it means that resources are not being used most
effectively, time being wasted on further investigation of items which are not genuine faults.

A Type 2 error occurs when a faulty item is missed. Type 2 errors are of most concern since, if
the fault (such as a crack) remains undetected, it can have serious consequences (as was the
case in the Aloha accident, where cracks remained undetected).
 Professor Reason's Study of Aviation Maintenance Engineering

Professor Reason analyzed the reports of 122 maintenance

incidents occurring within a major airline over a 3 year
period. He identified the main causes as being:
• Omissions (56%)
• Incorrect installation (30%)
•Wrong parts (8%)
• Other (6%)
 Implications of Errors

In the worst cases, human errors in aviation

maintenance can and do cause aircraft accidents.
However, as portrayed in next slide, accidents are the
observable manifestations of error. Like an iceberg
which has most of its mass beneath the water line, the
majority of errors do not result in actual accidents.
Errors that do not cause accidents but still cause a problem are known as incidents. Some
incidents are more high profile than others, such as errors causing significant in-flight events
luckily, or because of the skills of the pilot, did not become accidents.
Other incidents do not become serious because of defenses built into the maintenance system.
However, all incidents are significant to the aircraft maintenance industry, as they may warn of
a potential future accident should the error occur in different circumstances.
 Error Management
• Minimize the error liability of the individual or the team
• Reduce the error vulnerability of particular tasks or task elements
• Discover, assess, and then eliminate error-producing (and violation-producing)
factors within the workplace
• Diagnose organizational factors that create error-producing factors within the
individual, the team, the task, or the workplace
• Enhance error detection
• Increase the error tolerance of the workplace or system
• Make latent conditions more visible to those who operate and manage the system
• Improve the organization’s intrinsic resistance to human fallibility
 Summary
No one is perfect, errors will occur. By understanding
the root causes of human error, we can reduce them
and limit their effects when they inevitably happen.