Blog posts tagged in Human Factors

Introduction

Why people break rules, particularly if the outcome can be negative and even dangerous? What is it that makes a worker break the rules or commit a violation?

A great deal of research has been undertaken during the last 25 years with the focus looking at the view of errors in different way.

Rather than Human error being considered the ultimate cause of system failure, it is important to understand the context in which the error was committed. (For example, was it deliberate or related to Pressure, Fatigue, Stress or any of the other “Dirty Dozen”?)

Violations – Personal or Organizationally Optimizing?

To reduce exposure to violations and errors, a broad range of organisational interventions may be required.

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Steven Bentley MD of SAS www.sassofia.com considers the potential for HF Error with an EASA/GCAA compliant CAMO

Introduction

The Primary Roles of the CAMO are Maintenance Planning, Technical Records, Reliability & Engineering. Each “Role” brings the challenges of how we can ensure enough attention to both personal and organisational responsibility, when we consider the potential for HF error.

HF Example – Stress Caused by Pressure from “Poor Planning”

We are not considering here that it could be the Maintenance Planning Worker who is stressed – however this is of course a possibility, and we should always make sure that our team members have the appropriate level of “Competence” for the role.

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Introduction

A large percentage of the work involved in performing inspection and modification of aircraft fuel tanks and their systems is typically carried out with the fuel tank itself. Such tasks require maintenance personnel to physically enter the tank, where significant environmental hazards exist.

Fuel Tank related work is one of the most difficult challenges an aircraft maintenance worker may face. Not only the challenge of physical entry and moving around within the tank, the additional challenge of multiple hazards including health and safety hazards, most notably oxygen deficiency, flammability, explosion and the toxic effects of fuel vapours.

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Within the workplace the consequences of human failure can be significant, unfortunately, we are all capable of error regardless of our training or motivation.

A human error is an action or decision which was not intended, however it is important to consider that human failure is not random. There are two main types of human failure: errors and violations.

Errors often occur highly trained procedures where the person carrying them out does not need to concentrate on what they are doing (Improved design can reduce their likelihood and provide a more error tolerant system).

Violations are rarely malicious (sabotage) and usually result from an intention to get the job done as efficiently as possible. Getting to the root cause of any violation is the key to understanding and hence preventing the violation.

Organisation Obligations

The potential for Human Error should be managed proactively and should be addressed as part of a wider risk assessment process.

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What do we mean by Safety Culture within an Organisation?

Safety Culture is the way safety is perceived, valued and prioritized within an organisation.

Safety Culture reflects the true commitment to safety at all levels in the organisation.

James Reason described it as "how an organisation behaves when no one is watching".

Safety Culture is a combination of a range of drivers including organisational norms, national cultural beliefs and professional attitudes. It reflects people attitude and believe towards the importance of safety.

How important is Safety Culture?

A Positive Safety Culture Matters because it provides a focus on how the organisation approaches incident recording, incident analysis, staff training and the integration of maintenance safety and operational safety priorities.

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What does EASA require for your Competence Assessment Process?

The organisation shall establish and control the competence of personnel involved in any maintenance, management and/or quality audits in accordance with a procedure and to a standard agreed by the competent authority.

In addition to the necessary expertise related to the job function, competence must include an understanding of the application of human factors and human performance issues appropriate to that person's function in the organisation.

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Firstly to understand that both System and Process audits are in fact compliance audits then to understand that a System typically consists of multiple processes. 

Next to consider that when we perform an audit it is in effect performed against a "standard” such standard could be for example directly taken from the applicable aviation regulations, or it could be an organisational standard which is referenced to the aviation regulations, but enhanced in some way to meet the organisations specific objective. 

The best way to deal with such an endeavour is to start by looking at the system in total and comparing it against the regulatory requirement to ensure that there are no “gross” errors.

Tagged in: Audit Human Factors
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It is accepted within our aviation community, that the vast majority of aviation accidents (at least 80%) are directly caused by human action or more precisely by human error. However it would be wrong for us to assume that this is simply a manifestation of personal carelessness or even incompetence, rather we should try to consider that the human error itself is actually the final element of a chain of events.

In fact a major element which hitherto was not given sufficient consideration is the role of the organisation in aircraft incidents and accidents. Often the root cause or contributing factors are embedded within the organisations process and procedures. Unfortunately with hindsight we are often able to understand the existence of numerous latent “exposures” (sometimes too late!).

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