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3 Greatest Threats/ Human Factors
The study of Human Factors and the compilation of The Dirty Dozen do not corelate. Each of the Dirty Dozen point directly at the Technician as the “Fault” in the system. It is for this reason that I believe the Dirty Dozen is an outdated Human Factors resource. The FAA’s compilation was good for it’s time and had an impact that led us to a more holistic approach to Human Factors. “While many people assume that human factors in maintenance refers to the actions of mechanics, the MRM program admits to several major areas where maintenance errors can occur. These areas are (a) equipment design and manufacture; (b) manufacturers’ documentation and procedure writing; (c) airline procedures and work areas; and (d) mechanic training and performance.” Kinnison, H. A., & Siddiqui, T. (2013). Sidney Dekker is one of the most recognized scholars on the topic of Human Factors, in most of his writing and lectures he reasons that the human error is not the ending point or conclusion of an error, it’s the place you begin the investigation. “Although most in aviation human factors embrace this view in principle, practice often leads us to the old view of human error which sees human error as the chief threat to system safety. I discuss two practices by which we quickly regress into the old view and disinherit Fitts and Jones: (1) the punishment of individuals, and (2) error classification systems.” (Dekker, 2019)
“Not having enough people, equipment, documentation, time, parts, etc., to complete a task. Improve supply and support— • Order parts before they are required. • Have a plan for pooling or loaning parts.” (FAA, 2012) Because the focus here is on the technician making a “mistake” the common perception is that this is the technician’s fault. The Lack of Resources is most likely the outcome of a broken management structure that is responsible for equipment, tech data and parts readiness as we have learned about in our textbook. “How maintenance people perform is only part of the problem; the facilities in which they work, the equipment they encounter, and the forms, processes and procedures they use are all subject to human actions and, therefore, to human error. And the errors are not always due to the mechanic.” Kinnison, H. A., & Siddiqui, T. (2013).
“Shortage of the training, information, and/or ability to successfully perform. Don’t guess, know— • Use current manuals. • Ask when you don’t know. • Participate in training.” (FAA, 2012) In some instances mechanics simply should not perform the task due to the lack of knowledge. It is a well-known fact that one of the least valued departments in an operation is training. Even at the job I currently have at a Part 147 School no formal training has been done for over 2 years. This has been the trend I have seen across the industry even when I was the Maintenance Training Manager of a Part 135 Operation, the training budget was the first to suffer in a down turn and when we were busy training ceased due to workload. “For any problem or condition that cannot be accommodated by the first two rules above or one that is limited due to various constraints, such as design limits, trade-offs, or budget requirements as discussed in Chap. 1 of this book, the designers must provide the users, operators, and mechanics—as well as other human elements involved—with sufficient education and training on the system to resolve any human factors– related problems that could arise from improper understanding of the design.” Kinnison, H. A., & Siddiqui, T. (2013).
“Expected, yet unwritten, rules of behavior. Help maintain a positive environment with your good attitude and work habits— • Existing norms don’t make procedures right. • Follow good safety procedures. • Identify and eliminate negative norms.” (FAA, 2012) This is truly a place that needs to be focused on more, from the aspect of the technician. From a technician’s standpoint many of the “Dirty Dozen” Human Factors are not directly related to daily tasks, but “Norms” are a direct outcome of the work environment.
As far as Aviation Maintenance goes Human Factors and The Dirty Dozen are attributed to the whole team, starting with aircraft, tolling and facility design, management structures including the CEO through non- certificated technicians. Often times the Dirty Dozen comes off as a blame the technician as the end user, while the wholistic view sees human error as a symptom. “The two ways of looking at human error are that we can see human error as a cause of failure, or we can see human error as a symptom of failure.” Woods et al., (1994) Philippians 2:4 is a good verse that encompasses Human Factors as it moves a person to view another person’s value. “Let each of you look not only to his own interests, but also to the interests of others.” Barker, K. (1973).
Being in the aircraft maintenance business means we are in the safety business as everything we do is based on a foundation of safety and it shows. Nonetheless, human errors are inevitable, and certain circumstances make them especially likely. Human error has been documented as a primary contributor to more than 80 percent of maintenance errors involving human factors (Administration et al., 2012). In my experience over the last 25 years in a FAR 121 operation fatigue, complacency, and distraction are three human factors that are the greatest threat to our craft.
When employees are exhausted mentally or physically their work performance will suffer. The most prevalent maintenance human factor is fatigue. As a technician, we are subjected to many different work schedule options. Aircraft typically fly during the day and get serviced on overnight visits. This requires individuals to work long hours and stay up overnight which will lead to fatigue. Another scheduling factor that will lead to fatigue is technicians are only required 24-hour time off in a seven-day work week. Despite the regulations limiting a technician’s time off he or she may work one shift preference or may have monetary motives, fatigue will not be prevented. When an individual is affected by a lack of proper sleep your ability to make decisions, be alert, and stay focused will be impacted. (Administration et al., 2012). In our craft this is unavoidable, I personally have experienced fatigue working overnight shifts for several years and countless amounts of overtime. This was all I was able to hold as a new technician and when you are starting a family as I was overtime opportunities were available on and off shifts. I remember taking field trips and working on CFM56 start issues in Des Moines Iowa for those extra time and a half hours to put a decent down payment on my first house. I burnt myself out and it didn’t matter how much sleep I received I still was tired. To mitigate these risks, we need to regulate work shifts, exercise daily, eat balanced meals and most importantly get an adequate good night of sleep so our bodies can recharge. There is no way we can ultimately win the fight with fatigue. The longer you stay awake, the more your performance will degrade until your body finally decides it has had enough and simply shuts down. Even though we can’t beat fatigue, there are some strategies that we can use to more effectively balance the demands of modern life with our body’s need for sleep.
A fatigued person may be easily distracted or maybe nearly impossible to distract. Distractions occur when anything other than the task at hand vies for your attention and make you more likely to forget things and lose track of your workflow. When we are working on any task, our mind has a natural tendency to think ahead. This is normal and not a bad trait until we are distracted. It is also the number one reason why we forget things and when returning to the task we can easily think we are further than we actually are. In today’s world, there are many distractions that are around us and we are constantly trying to do multiple things at once. I for one have been working remotely and face daily distractions with household items as simple as putting dishes away, popping in a load of laundry, and even tending to the family pet. These distractions lead to errors in my documentation which can lead to providing technicians with improper procedures. Regardless of their nature, numerous distractions may occur during the course of maintaining an aircraft. We must recognize that our attention is being diverted and remove the distractions and refocus to assure our work is correct. (Administration et al., 2012). Distractions can be prevented by following policies and procedures, identifying and limiting interruptions, and taking a few steps back to ensure that all elements are working properly. Having a checklist and being aware of our surroundings will help us prioritize and fully concentrate on one thing and do it well, rather than multiple tasks and do poorly at them.
Another unfortunate example of these threats in aviation is complacency. As noted in an article written by (Tolleson, 2007) “Complacency is alive and well today as experienced by pilots who take off on the wrong runways, inspectors who pencil whip, and mechanics who don’t use the checklists and current technical data.” When people perform the same tasks routinely, they may become over-confident, thinking the work is too easy. Consequently, they become less vigilant about checking for mistakes. A general relaxation of vigilance typically results and important signals will be missed, with the individual only seeing what he, or she, expects to see. We should always expect to find errors whether being a mechanic or inspector or a pilot who flies in and out of the same airport knowing which runway to use. As a technician, I was taxi & run qualified on the majority of our fleet. When moving any aircraft, we always wrote down and read back the instruction from air traffic control and adhered to procedures. Making a checklist and following procedures will increase our vigilance when performing a routine task. Also, being overconfident can be a trap that can lead to an accident, damages, and employee injuries. Overconfidence leads us to believe that nothing is wrong and consequently we fail to identify a potential safety issue. To combat complacency, we need to follow established policy and procedures, and use a checklist when completing tasks whether routine or not. Finally, lean on a teammate to cross-check your work, I continue to this day to ask colleagues to review and bounce ideas off of projects that I am working on. There are some good tools that we have in place to combat this threat, we just need to be vigilant and use them.
I picked these three treats of the dirty dozen because to me they run in parallel. If you are tired you will not be at your best in an environment where multiple things are happening. This can be dangerous if you are not mentally prepared. We all have different pressures and influences in our everyday life but remaining focused and taking the time needed to ensure that the correct decision is being made and the proper procedure is being followed will get the job done right. At the end of the day ensuring a safe work environment is a duty that all workers and management share. The safety of those working around you is in your hands (Kinnison & Siddiqui 2018). Unsafe choices that you make can injure both you and your coworkers. Everyone needs to take safety seriously, or everyone is at risk.
Peter ch5:8-9 reminds us to “Be alert and of sober mind. Your enemy the devil prowls around like a roaring lion looking for someone to devour. Resist him, standing firm in the faith, because you know that the family of believers throughout the world is undergoing the same kind of sufferings.” With human factors in aviation, we have to always be alert and prepared to resist deviation from policy and procedure to stay on task.