Human Factors incidents

[S76Heavy]

Hi all,

don't want to identify myself nor my employer but lately we have had a run of HF related incidents that have so far only caused minor damage but had the potential for, certainly in one case, catastrophic failure.

All of these involve people not noticing what they were supposed to notice in for example preflight checks and maintenance checks.

We're looking forward to a meeting with probably some form of bollocking from management, telling us to shape up or else, but does anyone have any practical ideas for us on the workfloor on how to focus everyone's attention back onto the basics?

After all, we're supposed to be professionals and these sort of errors should not be made, and if they are made, picked up by coworkers.

But they were not.

Any ideas most welcome.

[jolly girl]

Hi 76H,
I'm sorry to hear of your troubles.
I am reminded of Sidney Dekker's article "When you lose SA, what replaces it" Unfortunately, my copy is loaned out so I can't provide any quotes.
You may also want to look in to Patrick Hudson's work on managing non-compliance (not what it sounds like, check with a buddy for his slides from CHC SQS) and also Deitrich Mansey's work on complacency (complacency as re-directed attention).
Hope this helps,
Jolly

[Tarq57]

But isn't it simply human, to make simple errors?

An HF awareness during investigation of said errors should (in an ideal world) produce realistic procedures and/or training to either prevent said error from occurring, or mitigating the seriousness of any consequence.

Does this not happen at your workplace?
I mean, are we talking genuine HF-style events, or is it more along the lines of a casual approach to safety related things?

The impression I get from the OP is that when it comes to safety at your organisation, the answer from above is along the lines of "The floggings will continue until morale improves."

[Brian Abraham]

S76Heavy, you seem to be suggesting that you have something of an endemic problem due to a disengaged workforce. For whatever reason - working conditions (fatigue, maintenance in poor lighting conditions), poor accomodation, lousy food, quality of people employed, lack of training etc etc Do a google on "human factors disengaged workforce". I'm sure you must already have a fair idea as to what's going on. Whatever is the underlying issue at work, it's mainly a management problem and their task to resolve, and a bollocking of the shop floor staff is not going to resolve an endemic problem, only make it worse. Unfortunately, as Tarq57 suggests, management these days does work on the priciple "The floggings will continue until morale improves."

Have a look at Serious about improving morale?

Good luck.

[S76Heavy]

Ouch, that article hits close to home.

Yes, we have a morale problem and no immediate solution due to a divided workforce caused by the way the organisation is structured.
Divisions that should be cooperating are effectively competing against each other.

Thanks for your suggestions, we'll try and get some workfloor empowerment going.

[Sciolistes]

S76Heavy,

From my experience, it does seem that lax flight standards are inextricably linked to morale. But I think it more insidious than that, if it were just morale then one would expect just the OTP to nosedive and the amount of fuel carried to go up. But what was happening was also during the critical phases of flight. I believe this indicates a kind of mental exhaustion related to the extremely fluid situation we find ourselves in with no communication or contact with management until something undesirable happens.

[S76Heavy]

It seems clear that the FSO already has all the answers before the investigations (interviews with all crew on base) have begun in earnest. Previous experience with several operators accounts for nothing and we were encouraged to come up with ideas, as long as we kept it shorter than 10 minutes. And those 10 minutes included his elaboration of why he felt our ideas were rubbish..

So it's up to us crews to get our act together despite management, and deal with the situation that has arisen. For it's our necks on the line.

But yes, mental exhaustion is something to be very aware of, with frequent roster changes, changes of base and changes of A/C type.

[Piltdown Man]

...telling us to shape up or else...

Obviously nothing to do with ****e management then, you have to be a totally crap workforce. I reckon you should all be sacked... or there again maybe you need new a new style of management.

So it's up to us crews to get our act together despite management, and deal with the situation that has arisen.

Well that's a very brave and noble suggestion, but the "system" is the responsibility of your management. Even if they sack every one of you, the system still remains - the same faults, errors and traps. The only way forward is for both of you to work together to find a solution. Your management should be grateful they have employees who are willing to help.

PM

[jolly girl]

76,
Does your org do HFACS analyses of incidents? I suspect it would be an interesting exercise in the environment you describe. Some folks at NASA recently added a 'social influence' branch to the tree... it is available in the journal Human Factors, or, if you don't have access feel free to PM me and I could send it to you.
Best of luck,
J.

[S76Heavy]

jolly girl,

PM sent.

Piltdown Man,

at the moment just looking for survival. Not trying to change the system in Don Quichotte style. But if we don't get our act together, some of us will end up hurt, whatever management does or does not do in the meantime.

But looking at the official responses so far, the blame game is already on and that does nothing to inspire confidence in the process.

[jolly girl]

Just realized the article is open source:
http://www.lrdc.pitt.edu/publication...ureshf2009.pdf

Other HFACS articles:
HFACS, Inc. | HFACS Publications

J.

[PCars]

S76H,

How to focus everyone's attention back on the basics....hmmm:

The basics being - following company policies and procedure. If your companies' standard procedures been followed, the incidents wouldn't have occurred.

The focus being - deliberate, precise, coordinated actions by crew members, most of which should be routine.

I would look for small indicators that in and of themselves have very little impact, but when added together cause a non-compliance atmosphere. I will start a list and see if other ppruners can add to it from their experience:

-Showing up late and doing rushed work.
-Surfing the web/chatting/texting during preflight routines.
-Gossip about coworkers, especially which is negative toward those who do comply with procedure.
-Reading non-aviation material during work periods.
-No mentoring/feedback/detailed briefing or debriefing.

This partial list will help you get started thinking about the work culture as it is carried out day-to-day in your shop. Tell management your plan is to chip away at these to evolve into a better compliance culture. Also that you plan to recognize/elevate those that have a rock solid record of compliance. Also tell them that events naturally clump into groups and are not evenly spaced. There is probably evidence of this in your company such as no events occurred in the six months prior to when the clump first began.

Be aware of the downside of this approach. Whoever tolerated this decay of standards may be asked to step down. I know it's a movie and it's not a direct comparison, but for inspiration take another look at '12 O'clock High' with Gregory Peck. It will probably hit closer to the mark than academic HF papers/studies.

Regards,
Pcars

[S76Heavy]

Some good points, PCars. thing, but some points you make are unavoidable.

We are a public service unit, and as such do long shifts of standby, in which we do spend time looking at non-aviation stuff. It does not happen during preflight procedures.

There is no real gossiping, which I think is a credit to my coworkers.

There is some of the "rushed" feeling from changing rosters, which really do screw up many crewmembers' lives.
Not as much as an accident will, though.

Basically, there is a core of professionalism that has taken a hit recently. Nobody is condoning the latest failures, but management serves its own agenda rather than adressing the real issues, like changing A/C models, bases and rosters, causing (mental) fatigue.

But all good points to ponder and ensure we do not let our personal standards drop.

[jolly girl]

All-
I suggest HFACS because most of the HF events I have come in contact with have involved well-intentioned folks pushing the envelope to complete a mission. One of the strengths of HFACS is that is does allow investigation of contributors other than the individual actors involved in an incident - such as the physical and technological environment operations are conducted in, inappropriate planning by local management (scheduling, resource allocation, etc.), inadequate supervision (failure to provide adequate training, improper incentives, etc.) and resource management, climate and process at the corporate (or at least upper management) level. Personal readiness factors such as long-term physical and cognitive fatigue are included as well. Also, the HFACS schedule of errors and violations at the personal level folds in to Dekker and Hudson's models of Just Culture and schedules of responses to HF incidents (sourced earlier, if you need a copy PM me your e-mail). Both might be useful tools in the situation S76H describes.
J.

[AvMed.IN]

A viewpoint

S76H,
you may like to check a viewpoint on the matter under discussion at Teamwork – The essence of Safe Operations | Aviation Medicine :: Aerospace Medicine
thanks

[alf5071h]

I remain skeptical about the value of HFACS or similar categorization systems. They appear to place incidents / aspects into a box; this reactive approach might prejudice the underlying reasons - at risk from hindsight bias.
A more proactive alternative could be to remove ‘error’ from the investigation. The thread title is ‘human factors incidents’, not errors.
Hollnagel, Amalberti, and Woods provide interesting views of error; as I understand, one aspect replaces the concept of error with the variability of human performance.
Thus in seeking an understanding of recent events, you should consider how the individual or collective human performance varies, and what factors (the human factors) contribute to the variation, i.e. what is normal and what contributes to this normality.
Performance variation is normal; crossing an acceptable boundary of performance (analogous to error) depends on the contributions and interactions in the variability (functional resonance - Hollnagel), and where the boundary is placed – individually, collectively (professionally), or organizationally.

Have individuals been subject to external changes – contributions to variability, or have individual performances, ability, motivation, etc, changed, or slowly eroded.
Similarly look at the boundaries of acceptable performance; have these changed. Have operations slowly drifted towards the edge of acceptability – normalization of deviance, or have circumstances changed that require the boundaries to be redefined.

We tend to fix only what we find; thus ask why / what five times; the ‘fix’ might be deeply buried in the system.

[larssnowpharter]

Let me preface my comments by saying that I am no longer connected with the aviation industry. I now work in the petrochemical industry as a sort of glorified internal consultant to one of the big boys. Part of my job involves facilitating incident investigation.

Depending on the event I use a number of techniques: Why Tree, Tap Root et al.

Where you have a rash of 'small incidents' these need to be examined in detail to get at the root cause. Think 'Iceberg Effect'. You seem to be doing your bit but it is disappointing that management feels that giving bollickings is the answer. It rarely is.

From your post you indicate that these errors are 'human'. The good news is that humans make errors; recent studies indicate somethink like six per day. Good systems allow these errors to be trapped.

I would enjoy doing a Why Tree (essentially an extension of the 5 Whys) on some of your incidents. Attempt to get beyong the what, and the who (where your management seems to have paused) to find the systems level failure. Definition, the one thing that, if fixed, would have resulted in the event not occuring.

I am not sure if your management would buy into employing a professional to have a go at this or, if they did, whether they would be prepared to accept the results and recommendations.

Good luck.

[jolly girl]

Hi alf,
As always, good points. I agree with you, HFACS and similar systems do have their limitations. And yes, in a perfect world, all leaders would utilize a the resilient, highly reliable model of operations proposed by Hollenagel, Woods, Levinson, Dekker, Alemberti, Weick, Sutcliffe and others to accommodate human variability and detect 'drift to failure' before things drift too far. However, and as 76's original post indicates, some leaders (managers?) have not reached this point, and still play the blame game. In these cases, HFACS (or SHELL, etc.) could be a useful tool to explore why the crew/maintainer in question made the decisions/took the actions they did, and the factors that affected a successful outcome, a sort of 'gateway drug', you might say, to a more mature exploration and accommodation of HF in the organization. It also has some traction as an investigation tool in the RW world; this may make it an easier 'sell' for 76 as he navigates his situation. Of course, as he indicated in an earlier post, the investigation is only as good as the information provided, and the organizational culture may be a limiting factor.
76, I hope all is going well on your end.
J.

[woptb]

I would suggest you not only have HF, human error issues, but also a level of non-compliance.
We all make errors & (for what we believe are good reasons) we don't always comply with procedures. Whether this is situational or the norm, at some stage we 'ALL' break the rules.
It seems like your organisation operates a blame/shame culture. You need a means of sharing experience regarding error & rule breaking. If you don't operate within a fair/just culture, no useful dialogue can take place.
HFACS & the Boeing MEDA (Maintenance Error Decision Aid) are useful, tools for improvement & education. Unfortunately the most elegant of investigations are useless unless results are acted upon & all players treated even handed’ly.
If people are punished for error, no one will highlight errors, few learn from them & eventually you'll end up with a catastrophic event.
You should have a confidential reporting scheme. If you’re EASA, your maintainers should fall under the mantle of an EASA Pt 145 maintenance organisation. All 145 organisations must operate some form of error management, error reporting system. If your organisations systems are nonexistent or don't work try CHIRPS, MOR & if the engineers mandated reporting system doesn't work they can do likewise.
It a shame but a lot of organisations are still only tick in the box compliant, the regulators need to get tough.

[larssnowpharter]

I remain skeptical about the value of HFACS or similar categorization systems. They appear to place incidents / aspects into a box; this reactive approach might prejudice the underlying reasons - at risk from hindsight bias.
A more proactive alternative could be to remove ‘error’ from the investigation. The thread title is ‘human factors incidents’, not errors.

Neverthless, man has been making errors ever since Adam took a bite out of the apple (or leaf depending on your belief system).

'Errare humanum est....'

The real challenge is in managing the errors. Research indicates that a normal, well trained individual will make around 6 'errors' a day.

Increasing automation has done its bit in taking out error but, or it least so it seems to me' there is now a reluctance to look too deeply into the HF side since Du Pont's Dirty Dozen. The commercial aviation industry is certainly pushing at the doors on fatigue.