HUMAN FACTOR AND

ERROR MANAGEMENT
By: Erbert Darell Decena
HFEM Continuation……… 2nd Day
• High Lights:
 Process and Culture
 Team Work
 Leadership
 Maslow’s Hierarchy of needs
 Simple and Complex Machine
 Error Management
 Definition of Terms
 Error and Violation
 Slips and Lapses
 GEMS
 Latent Error vs. Active Error
 Decision Making
 Swiss Cheese
 Dirty Dozen
Culture Issue

General
What spring to mind when hear the expression
“culture issues”? Do you think about “the company?”
The imagine shows various “culture” of a company:
• “Safety culture”
• “Technical Culture”
• “business culture”
• “culture within the teams and groups”
• And “location culture”
 Culture Issues

• How do the circles interact with each

other? The head of the organization does
not define every culture – many
“cultures” develop independently.

• However, the head of the organization is

in the best position to influence all
cultures.
Safety Culture
Safety Culture
Team Work
Team Work

General
- Within a society there are many groups, for example: Men between 18 and 25,
Women with a university degree, Red hair children \...
- In aircraft maintenance there are also numerous groups:
 The group of mechanics
 The group of electrons
 Line maintenance personnel, etc.
Team vs. Group
- Does a “team of mechanics” exist? What distinguishes the team from the group?
- Alternatively, a team can consist of members working in parallel to achieve the
goal.
- A team consist of a recognition of team.
- The goal defines the composiotion of a team.
- The cohesion and functioning of the team must be maintained.
Team Work
Team Work
Maintenance Team and important lubricants

• What is necessary to keep a team together?

Communication
Cooperation
Coordination
And Mutual Support
 Communication

• Is very important, and should not be underestimated as a factor in

carrying out safe and efficient maintenance work. Communication
problems are the main cause of maintenance errors in aviation.
 Cooperation

• Is an important “adhesive” for the team.

Openness, honestly and fairness in crease
cohesion and mutual respect. Members of
the team must treat dis-agreements with
respect, and team leaders should play an
active and important role in solving them.
 Coordination means:

1. Delegating: Tasks must be clearly and fairly

allocated according to the abilities of the team
members.
2. Checking: delegated tasks must be monitored
and
3. Priorities must be set: Priorities should be
subject to change if difficulties or new
circumstances arise.
Mutual Support

• Is the “heat” of every team. It forms the basis for

team identity. Every member introduces his own
strengths and weaknesses into the team. The art
is to employ everyone according to his abilities,
and to compensate for his weak points. It is a
part of mutual support to point out somebody’s
mistake realistically and constructively, and to be
of assistance regarding solutions.
Mutual Support
Team Work
Management, Supervision and Leadership

• General
 In large organizations, leadership is found on various levels. Management lays
down company policy, makes business decisions and has little direct contract
with the employees and their work.
 Supervisors serve as a link between management and the work groups or teams.
They put directives into practice and are responsible for personnel planning in
their respective areas.
 Team leaders are in direct contact with the workers and their work. Differing
leadership approaches are needed in various job areas.
 Work group leaders are often under pressure as they are the link between the
management and the teams.
 On the one hand the company management provides them with economic data,
customer orders and procedures.
 On the other hand there is feedback coming from the teams, such as reporting
off sick, unforeseen difficulties and unscheduled tasks.
 The art of work group leadership is to mediate between both sides.
 Matters of Safety

• What is the relationship between

management and safety?
• You frequently hear the words US and
THEM.
• We must succeed in making safety OUR
affair.
• Each level plays its part in this. Think of
“safety culture’!
Management, Supervision and Leadership
Factors Affecting Performance

• Fitness/Health
• Stress: Domestic and work related:
• Time pressure and deadlines:
• Workload: overload and underload:
• Sleep and fatigue, shiftwork:
• Alcohol, Medication, drug abuse.
Introduction

General
• There are many factors that can lead to a reduction in human performance.
In this chapter the following subject are coverd:
• Health and fitness, stress, workload, sleep, fatigue and shift work, as well
as alcohol, medicines and drug abuse.
Illegal Drugs

• Illegal drugs, as well as the “legal drug” alcohol, can lead to loss of license
according to EASA Part 66.B.500

• And of course, drug use is a criminal offense in many countries. Most

company security checks discover any court records involving illegal drugs.
Fitness and Health

At the medical on entering employment, basic fitness was

ascertained.
The employer takes responsibility for this.
You are responsible for maintaining your fitness.
A rule of thumb may help for medicines:
 You are not fit for work if the instructions in the packet say you should not
drive a car!
Fitness and Health
 Stress

 General
 Stress – a word often used in our society. Today, “stress” has become almost
a measure of performance. The more you are under stress, the more you
have managed to do.

 What is stress, anyway?

 You are affected by a particular incident – the so – called stressor.
 Your reaction to the stressor is know as stress response.
• You are affected by a particular incident – the so - called stressor.
• Your reaction to the stressor is known as stress response.
 If there is an immediate reaction which eliminates the stress,
you feel good. “I’ve done it!” We can call this type of stress
“positive stress.”
 If the physical reaction finds no release, the stress
“messengers” are stored in the body, resulting in adverse
consequences. This is “negative stress”.
Stress
Negative Stress

• When we talk about stress, we usually mean adverse or “negative

stress”.
• What are some typical stressors? There are two main groups:
1. External factors, such as:
 Noise, environmental poisons or overstimulation, for example from watching
too much television and etc.
2. Internal Factors, such as:
 Anger, sorrow, performance, physical exertion and sickness.
What are the Effects of Negative Stress?

The physical reaction always begins in the same way:

Typical stress hormones, such as adrenaline, are produced in
excess, followed by an increase in blood pressure.
The reactions that follow vary from individual to individual.
People may react to stress hormones and increased blood pressure
with headache, sleeplessness, heart trouble, stomach pains,
diarrhea, skin irritation, allergies, tenseness or muscle cramp.
Typical psychological stress reaction are: nervous unrest,
irritability and sleep disorders.
Counter Measures

1. Accept that some stress is useful in achieving a certain level of performance.

2. Do not take on too much. Stress is often self – made – by putting too many
demands on yourself at work, at home or in your leisure time. Regarding
leisure time stress you should heed the advice “It’s better not to overdo it”.
3. Fight stress. This can be done in two ways.
 Reduce the stressors, which means:
 Do not overestimate problems:
 Do not try to solve problems when under severe stress. You can Think more clearly and your
concentration is better when you are relaxed.
 Try to reduced tension through such methods as yoga and relaxation through self-hypnosis and
secondly….
 Transform stress into physical activity,
 i.e. do sports, go for a walk, or do physical work that you enjoy.
Negative Stress
Negative Stress – Reactions and Counter
Measures
Workload

Your workload depends on three things:

1. The task itself – the physical and mental demands which are
made.
2. The accompanying conditions, such as precision, time frame,
outside control, environmental factors, and
3. Yourself. How goods is your ability and knowledge, your
experience in the field, your health and fitness and your
emotional state, such as stress level, mood and degree of
stimulation.
Arousal

 Stimulation, also known as arousal, influences your performance.

 Performance may suffer considerably if you are over – or under – stimulated.
 Only if stimulation is in the middle ground can peak performance be achieved.
 But what is the right level of stimulation? That is a very individual thing and also
depends on your daily conditions.
 What causes a slump in performance? If we are not stimulated sufficiently, our
attention becomes blunted and we are overcome by indifference or boredom
during an activity. If we are inundated by stimulation, our attention tries to
focus itself only on the most important things at the expense of the total
performance of our brains.
 In the case of extreme over – stimulation we are no longer aware of new
information. This can also be s stressor!
Workload
Overload

If you recall the factors of workload – namely the task itself, the
accompanying conditions and yourself – it quickly becomes clear
where overload starts.
Imagine an activity which you find easy and enjoyable. Now
reduce the time allowed for it by 50%. What has happened to your
load?
Under certain circumstances you are no longer able to complete
the task.
Overload

What do you do if an electrica l system is overloaded? You reduce the

load before the fuse blows. It sounds simple, but that is exactly the
solution for human overload. Why is it so difficult to reduce this load?
Just think which actions are necessary….
 It is important to find agreement within your team.
 It is better to assess the situation correctly before an overload develops.
 Early intervention, for example in time schedules and job planning, helps to prevent
overload.
Good ideas and short-cuts often result from an overload. Such ideas
should be discussed among the team in low-stress environment.
Underload

• Do workers usually complain about underload? Not usually, but it is a

potential problem. Underload is undemanding work.
• The risky combination of boredom and no challenge can lower your
attention to the quality of the task. Be careful in such cases. Find
additional responsibilities matched to your knowledge and abilities.
• The greatest risk of underload is that attention deteriorates. Along with
boring routine activities this can happened extremely quickly.
• Another risk is declining motivation. If you are always given tasks which
demand too little of you – physically as well as mentally – you can easily
have the feeling: “they don’t think I’m up to it!”
OverLoad and UnderLoad
• Real teamwork can help, in the same way as with overload.
 For example, talk in the group about:
 Training, gaining experience,
 Improvements
 And sensible short – cuts and completing unfinished task.
 In short: Use the time and team resources to get fit for the next “big load”.
 It is sure to come!
 Fatigue

• General
 Former US President, William Clinton, once
said that every bad decision he ever made was
made when he was tired.
 Fatigue is often a result of lack of sleep.
 But there are many additional factors that
affect your levels of “alertness”.
 The Airline industry operates around the globe,
where it is always somewhere morning,
afternoon, and nighttime. The industry does
not rest! That is fact!
Fatigue

• It is also a fact that humans need sleep. Sleep is like a logistical supply.
• If you lose it or disrupt it, you must pay for it.
• All humans need rest! This requirement does not very among cultures of
the world. Some cultures sleep more that others. The US is an example
of a culture that does not sleep enough.
• For example, a recent survey by the National Sleep Foundation showed
that 2 of 3 Americans from the US do not get 8 hours of sleep. 1 in 4
Americans say that they are sleepy at work a few days each week.
• And, it is estimated that 20% of US auto accidents are related to fatigue.
• Think about that the next time you drive home from the night shift!
Effects

We list here some of the effects of fatigue.

 First of all, it degrades your work performance.
 Fatigue can affect the quality of your judgement.
 Fatigue slows your reaction time.
 Fatigue affects your ability to solve problems.
 Your memory is not as good when you are tired.
 Fatigue can affect your mood and your general attitude about the job and you co-
workers.
 Fatigue and loss of sleep have much the same effect as alcohol. In fact, scientist have
demonstrated that driving while fatigued can be compared to driving while drinking.
 20 hours of wakefulness has the same effect on driving performance as drinking 2 beer or 2
wines!
 Excessive Fatigue can affect your long – term health.
 Fatigue is a serious matter for you and for your safe and efficient work
Fatigue
Alertness

• “Alertness” is a term that encompasses all aspects of rest and readiness

for work. Alertness may be seen as a range.
• On one end you can be well-rested, highly alert and ready for work.
• Your safety margin is increased.
• At the other end of the range is fatigue. You may have insufficient sleep.
• You may be physically and mentally tired. You are not fully fit for duty.
And, you may be unsafe. “Fatigue” is a lack of energy, a weariness or
tiredness.
• Fatigue is a normal and important human response to physical
exhaustion, emotional stress, or to lack of sleep.
• It can lead to error and other unsafe conditions.
Types of Fatigue

• There are two types of fatigue: A cute fatigue and chronic fatigue.
 A cute Fatigue is associated with temporary loss of sleep or temporary
exhaustion from brief periods of too much physical or mental work. It is
temporary and of short duration. Sometimes acute fatigue many be
associated with too much partying the night before. The party cause you to
stay awake throughout the night and, sometimes, there may be too much
alcohol. The alcohol causes disturbed sleep. Thus, you suffer from a
morning or day of acute fatigue.
Acute Fatigue

• The cure for acute fatigue is simple – get some rest and sleep. On
the average you should have 8 hours of sleep each night. Treat
sleep like money in the bank. If you borrow from the bank you
must eventually pay it back. If you sleep 5 hours one night you
have to sleep a bit more the subsequent nights.
Chronic Fatigue

• Chronic fatigue is more serious than Acute fatigue. Chronic fatigue

is long term, and the recovery is slow. The symptoms are the same
as Acute fatigue but they reoccur daily. You are always fatigued.
• The causes of Chronic Fatigue are not as straightforward as Acute
fatigue, often resulting from physical sickness or some ongoing
emotional stress. If you are always tired, you may have Chronic
Fatigue.
 When Chronic fatigue is a likely problem one must seek the advice of a
professional in sleep discovers. Many General Practice Doctors do not have
the specialized training to properly diagnose and treat Chronic Fatigue.
Fatigue: “Routine Maintenance”

• Most maintenance personnel underestimate the seriousness of fatigue and its

effects on performance. In turn, they overestimate their ability to overcome
fatigue. It is relatively easy to avoid fatigue. Here is a list of Guidelines.
 Strive to obtain 8 hours of sleep per night. Keep a sleep record for 2 weeks and see how
you do.
 Set a routine for going to bed and for waking up.
 Quality exercise prevents fatigue. It keeps your body in good condition and it helps you
rest.
 Sleep experts suggest to avoid caffeine and excessive alcohol before going to bed.
 You should eat a balanced diet throughout the day.
 Put the correct “fuel” in your tank! (Mineral water, fruit drinks)
 Turn off the lights and the television. A dark and quit room promotes sleep.
 Regarding shift work, it is best to sleep before your work shift rather than after the shift.
 Fatigue: “None-Routine Maintenance”

• Although you may take all the appropriate steps to avoid fatigue, there are accessions
when you cannot avoid it.
• In those cases you must work smart to avoid fatigue-related errors.
 Often you may get so tired that you are too stubborn to admit your fatigue. Face the fact that fatigue
is a normal human response to physical and/or mental exhaustion.
 It is good to remain physically active when you are fatigued. Move around, exercise and stretch (best
in fresh air) when you feel tired.
 Conversation and caffeine are both good ways to stay awake.
 There are many things that you can do to promote alertness at work. Take “good break”. A small
amount of exercise, like a walk, will help during a break. Working with a partner helps promote
alertness. Eat your balanced meals on a regular schedule and drink water and fruit drinks.
 Caffeine is a legal drug that works to keep you alert, but don’t overstretch it! Drink caffeine before
you are tired.
 When it is hard to remain alert, try to schedule the tedious/boring tasks early in the shift when you are
most alert.
 Remember that alertness is a “fitness for duty” issue.
 It is a requirement that you come to work for Duty. When you have alertness challenges, ask your co-
workers to assist you. In turn, you should help co-workers who have an occasional lapse in alertness.
Fatigue
 Maslow's Hierarchy of Needs

• Maslow's hierarchy of needs is a motivational theory in psychology

comprising a five-tier model of human needs, often depicted as
hierarchical levels within a pyramid.
• From the bottom of the hierarchy upwards, the needs are:
physiological (food and clothing), safety (job security), love and
belonging needs (friendship), esteem, and self-actualization.
• Needs lower down in the
hierarchy must be
satisfied before
individuals can attend to
needs higher up.
 Complex Systems

• All modem aircraft can be seen as “complex

system”. Within this system there are many
individuals system and components which are
complexity themselves. This complexity will
increase even more in the future, as the trend
goes from mechanical operation towards
advanced electronic systems.
• The future will be dominated by integrated
mechatronics, which will be even more
complex, although trouble shooting will be far
easier.
 Basic System
• Purpose, configuration and function of a basic system
are usually easy to comprehend for an aircraft
technician.
• Routine work, trouble shooting and diagnosis should
be relatively simple – but the respective manuals
must be consulted nevertheless.
Complex Systems

• When dealing with complex systems the aircraft technician must be

familiar with the purpose of the system at least.
• Configuration and function are usually quite difficult to understand
completely.
• In order to maintain such systems you need s specific training.
• Here it is important to observe a balance of detailed technical
knowledge and analytic proceeding during trouble shooting.
• Manuals and released procedures are of an even greater importance than
in the case of comparable basic systems. Today the documentation of
the manufacturers is put together according to the most advanced
standards.
• They enable the technician to perform his work or to facilitate it.
Complex System
Complex System
 Error Management
• Aviation increasingly uses error management strategies to improve safety. Error
management is based on understanding the nature and extent of error,
changing the conditions that induce error, determining behaviors that prevent or
mitigate error, and training personnel in their use.
 Managing error in aviation

• Managing error in aviation

• Given the ubiquity of threat and error, the key to safety is their
effective management. One safety effort is training known as crew
resource management (CRM). This represents a major change in training,
which had previously dealt with only the technical aspects of flying. It
considers human performance limiters (such as fatigue and stress) and
the nature of human error, and it defines behaviors that are
countermeasures to error, such as leadership, briefings, monitoring and
cross checking, decision making, and review and modification of plans.
Crew resource management is now required for flight crews worldwide,
and data support its effectiveness in changing attitudes and behavior
and in enhancing safety.
 ERRORS and VIOLATIONS

• Effective SMS implementation by the product or service provider is

dependent upon a clear, mutual understanding of errors and violations
and the differentiation between the two.

• The difference between errors and violations lies in intent.

 An error is unintentional;

 A violation is a deliberate act or omission to deviate from

established procedures, protocols, norms or practices.
 ERRORS

• An action or inaction by an operational person that leads to

deviations from organizational or the operational person’s
intentions or expectations.

• Humans will commit errors regardless of the level of

technology used, the level of training or the existence
of regulations, processes and procedures.

• An important goal is to set and maintain defenses to

reduce the likelihood of errors and, just as importantly,
reduce the consequences of errors when they do occur.

• To effectively accomplish this task, errors must be

identified, reported and analyzed so that appropriate
remedial action can be taken.
Errors

• Errors can be divided into two categories:

• a) Slips and lapses – are failures in the execution of the intended action.

• Slips are actions that do not go as planned, while lapses are memory failures. For
example, operating the flap lever instead of the (intended) gear lever is a slip. Forgetting a
checklist item is a lapse.

• b) Mistakes – are failures in the person’s plan of action.

• Even if execution of the plan were correct, it would not have been possible to achieve the
intended outcome.
 Three strategies for the control of HUMAN ERROR

(1)Error reduction strategies

Human Error

(2)Capturing strategies

(3)Error tolerance strategies

 Three strategies for the control of human error

1. Error reduction strategies Prevent at the

source of the error by reducing or eliminating
the contributing factors.

 Human-centered design
 Ergonomic factors
 Training
Three strategies for the control of human error

2.) Capturing strategies

Prevent once the error has already
been made, capturing the error
before it generates adverse
consequences.

 Checklist
 Task cards
 Flight strips
…
Three strategies for the control of human error

3. Error tolerance strategies

Prevent to increase the ability of a
system to accept errors without
serious consequence.

 System redundancies

 Multiple inspection process

Strategies for the control of human error safety
risk management
The performance of personnel is
generally influenced by
organizational, regulatory and
environmental factors.
Safety risk management must include
consideration of organizational
policies, processes and procedures
related to communication, scheduling
of personnel, allocation of resources
and budgeting constraints (since these
may contribute to the incidence of
error)
Errors………..are like mosquito…..
To fight them…….you have to drain their
breeding grounds!!
Inadequate
defenses

Inadequate
Training

Poor
Design

Conflicting
Goals
 V I O LAT I O N

Violation
-”a deliberate act of willful
misconduct or omission resulting in a
deviation from established regulations,
procedures, norms or practices”

Non-compliance is not necessarily the

result of a violation because
deviations from regulatory
requirements or operating
procedures may be the result of an
error.
Violation

• is an intentional action that results in

noncompliance with known rules, policies,
procedures or acceptable norms.
In matters of safety a violation can mean
“unsafe act”
 Mistake

Is just nothing other than a wrong

judgement leading to unwanted results.
Slips and Lapses

• When the appropriate action is carried out incorrectly, the error is

classified as a SLIP. A slip is a failure of execution or control - for
example, substituting one action for another one in the
procedure.

• When the action is simply omitted or not carried out, the error is
termed a LAPSE. A lapse is a failure of memory - for example,
forgetting the overall goal, or forgetting where you are in the
procedure.
GEMS

• The Generic Error-Modelling System intends to

• deeper understand the nature of mistakes,
• appreciate the details of the differences among error
types
• See and understand the “other side of the coin”
• Anticipate
3 GEMS of Errors

• Skill-based : Slips and Lapses

• Usually errors of inattention or misplaced attention
• Rule-based : Mistakes
• Usually a result of picking an inappropriate rule
• Caused by misconstrued view of state, over-zealous pattern matching, frequency
gambling, deficient rules
• Knowledge-based : Mistakes
• Due to incomplete/inaccurate understanding of system, confirmation bias,
overconfidence.
Alarming Stats of Error

• In raw frequencies, SB RB KB:

• 61% of errors are at skill-based level
• 27% of errors are at rule-based level
• 11% of errors are at knowledge-based level

Recognizing this data may have help us see

• Contributing factors:
• Fatigue
• Situation awareness
• Workload
• Training and experience/expertise
• Familiarity
 What are the different kinds of error

• The first type is active error, or the specific

individual activity that is an obvious event. The
second type is latent error, or the company issues
that lead up to the event. In this example the
active error was falling from the ladder.

• The Latent error was the broken ladder. Someone

should have replaced the broken ladder, or the
mechanic should have chosen not to use it.

• When you see latent conditions that may lead to

error you should report them
 Decision Making

• In aviation, decision making is the cognitive

process of selecting a course of action from
multiple alternatives.
The FOUR components of DECISION making

• Defining the problem

• Considering the options
• Selecting and implementing an option
• Reviewing the outcome.
Influence of a Decision

• Situational Awareness - a combination of availability of

information and the ability of the decision maker to interpret the
information (skills and professional knowledge)
• Experience - familiarity with similar, perhaps routine, situations.
• Social - social pressure, national and institutional culture.
• Situational limitations - Physiological & psychological pressures
(stress, fatigue, hypoxia etc.), time pressure
The Swiss Cheese Model
The Swiss Cheese Model

• Defenses against failure are

modelled as a series of barriers
(layers): the slices of Swiss
Cheese.

• The holes in the layers

represent failed or absent
hazard mitigation controls.

• Accidents happen when the holes in each of the slices

momentarily align, so that a hazard passes through the
different layers of defense, leading to the unwanted
outcome.
James Reason’s Swiss Cheese Model
Dirty Dozen
Lack of Communication
What are some of the corrective actions that
can be taken?
Lack of Teamwork
What are the corrective actions for lack of
teamwork
Norms
What are corrective actions for bad norm?
Pressure
What are the corrective actions for pressure?
Complacency
What are the corrective actions needed to
avoid errors of complacency?
Lack of Knowledge
What are the corrective actions for lack of
knowledge?
Lack of Awareness
What are the corrective actions for lack of
awareness?
Lack of Resources
What are the corrective actions for lack of
resources?
Distraction
What are the corrective actions needed to
overcome distractions?
Lack of Assertiveness
What are the corrective actions needed for
assertiveness?
Fatigue
What are the corrective actions for fatigue?
Stress
What can you do about Stress?
End Of Human Factor and Error Management

Thank you Philsca!

Don’t have a GOOD DAY! HAVE A GREAT DAY!
GOD BLESS EVERYONE!