A
t a recent nondestructive testing (NDT) task group meeting, the topic of human factors came up, and it took me back to my previous position as a Federal Aviation Administration (FAA) repair man. Part of my responsibilities then was to help develop a training manual as a companion to our repair station and quality control manual. At that time the Handbook Bulletin for Airworthiness Order 8300.10 required that human factors be included in the training program.
Human factors typically depend on many influences, and numerous FAA documents offered suggestions about what these could be. However, none applied to our small compressor-blade repair facility.
Luck struck when our local Flight Standards District Office (FSDO) held a two-day Aviation Safety Program workshop, and one of the topics on the agenda was human factors. The facilitator defined human factors as “the discipline of optimizing the relationship between people and their activities by the systematic application of the human sciences, integrated within the framework of system engineering.” He also defined human error as “where there is general agreement that a person should have done something other than what they did.” Most important to our facility were the 12 human factors that can cause human error:
• Lack of communication
• Lack of resources
• Complacency
• Pressure
• Lack of knowledge
• Lack of assertiveness
• Distraction
• Stress
• Lack of teamwork
• Lack of awareness
• Fatigue
• Norms
The following is a synopsis of each of the human factors described during the presentation.
Lack of communication. This is possibly the most critical human-factor issue that has contributed to aviation accidents. Either someone assumed that someone else had done his job, or he wasn’t given proper instructions. Employees must communicate before, during, and at the end of each task, and detailed information must be passed along at the shift change.
Lack of resources. Important resources include money, people, time, tools, and data or knowledge, to name a few. Making sure that we have correct tools for the job is just as important as having the proper parts. Technical data are another critical resource. If we can’t find the data, we need to ask a supervisor or technical representative. When we have the proper resources for the task at hand, there is a greater chance that we will do a better and more efficient job.
Complacency. This can occur from a lack of sufficient stress. We all know that too much stress can lead to confusion and fixation. However, too little stress can cause a person to be bored and complacent. When a person becomes complacent, not only does the person’s stress level for the task decrease, but their performance decreases also. Error or complacency can be lessened by always following written instructions, procedures, or specifications. Do not attempt to do work from memory, and never sign off on work that you are not totally sure you have completed.
Pressure. This can affect our judgment during critical moments. Pressure to complete the job is part of the stress that motivates us to do the job. Positive stress is the extra stimulation that helps us perform at our best. Negative stress occurs when pressures pile up and become uncomfortable. A few ways to reduce pressure is to put everything into perspective, be sure the pressure is not self-induced, communicate your concerns to someone in a position to make a difference, or ask for extra help.
Lack of knowledge. Aircraft systems are so complex and integrated that it is next to impossible to perform the necessary tasks without substantial technical training and reference sources. It has been suggested that if we make the effort to study one hour a day for a year on the subject of our profession, we will be among the top 15 percent of knowledgeable persons within our profession. Make a daily commitment to spend a small part of everyday reading subjects that affect you in your daily job to avoid falling victim to the lack-of-knowledge human factor.
Lack of assertiveness. Assertiveness can be defined as standing up for rights and expressing feelings in an honest, open, appropriate, and direct way that will not violate another person’s rights. Assertive individuals can pursue their own goals, protect their own rights, and achieve results without violating the rights of others. Assertiveness can be said to be the middle ground between aggressiveness and passiveness. One way to practice assertiveness is to refuse to compromise your standards and do what is right, even when no one supports you.
Distraction. Psychologists have identified distraction as the No. 1 cause of forgetting. We humans are always thinking ahead, both consciously and subconsciously. If we are distracted to the point of interruption during a task or procedure, when we return to the job, we often think we are further along than we actually are. Errors from distraction can be lessened by always finishing a task or marking the incomplete work, double-inspect the work yourself or have someone else do it, and when you return to the job, always go three steps back and use a detailed check sheet.
Stress. Stress is a blessing and a curse. It’s a blessing because it motivates us to perform, and a curse because it can adversely affect our health, both mentally and physically. Stress can be created from family changes, work, or personal or financial issues. Recognizing the early warning signs can give us a chance to use stress-reduction or coping techniques. Some early signs are disruptions in eating patterns and sleep habits, errors in judgment occurring more frequently, a decrease in concentration and increase in memory loss, personality changes, and stomach distress. Stress-reducing techniques work differently for different people, but one thing we can all do is consider going with change rather than resisting it. If job factors are creating stress, talk with your supervisor or someone in a position to make a difference; establish a balance between work, family, and recreation; smile more; and laugh. Laughter is a proven stress-coping mechanism.
Lack of teamwork. Lack of teamwork doesn’t just happen by mistake; a lot of constructive communication must take place by all departments involved to produce teamwork. When there is trust and good communication among employees, teamwork develops. A good team member wants everyone to succeed; we can start the process by praising the people we work with.
Lack of awareness. Reduced situational awareness can be an indication that one or more of the other human factors—such as fatigue, distraction, or lack of communication—are present. To maintain our awareness level during the day and throughout our careers, we can rely on our experience and training. Experience creates a mental file of how one interprets and responds to conditions and events. Use your experience to maintain a constant state of awareness.
Fatigue. This is the body’s normal reaction to physical or mental stresses of prolonged duration. Acute and operational fatigue is caused by hard work and long hours. Chronic fatigue however may be something that requires medical attention. Symptoms of fatigue can be attention reduced, memory diminished, mood becomes withdrawn, low situational awareness, long hours of labor or high intensity stress. The three most important ways of dealing with fatigue are regular sleep, a well-balanced diet, and a regular exercise program.
Norms. In the context of these “dirty dozen” human factors, norms mean, “Our group has a better way to do the job than the written instruction, procedure, or specification.” This could also be considered tribal memory, which consists of unwritten rules enforced by the group, peer pressure, or habit. Always work as per the instructions, or have the instructions changed. At least if things go badly, we can say we were following the published procedure.
Human factors should be considered when the designing and operating any NDT facility. Doing so will contribute to an efficient and effective NDT process.
Comments
Human Errors
Great summary. I'm looking for more details on human errors, determining causes of human errors, and the resulting remedies.
Thanks - L. Finley