Human Factors - taken seriously?

[Bus429]

I wonder how many aviation organisations, whether involved in maintaining, flying, ATC, etc, really take Human Factors training seriously? How many of you have attended such training and identified with, for example, The Dirty Dozen? We all sit and discuss the problems and then, after the course, it is back to work and it all starts again. I believe most organisations (in my experience) pay lip service to any requirement but the commercial consideration is paramount. How many organisations really push the limit and fly aircraft that should really be on the ground until they are fixed?

Happy New Year!

[phd]

Based on my admittedly limited experience, most airlines do not spend money on anything unless they are forced to by the CAA or DTLR, or have to in order to retain passenger confidence and therefore revenue. Reduction of human factor related incidents and accidents is not perceived to be of high priority by many airlines even though the CAA have stated that human fallibility presents the greatest threat to future flight safety around the world. The trouble is that improving human reliability through inputs such as more regular refresher training, sympathetic crew rostering, better ergonomics and software design, increased rest and recuperation periods, more hotac to reduce fatigue, increased manpower levels etc. all cost large sums of money for which there is no direct financial gain, the safety benefits are not immediately apparent and these measures are not mandated by the authorities. Until these types of improvements are forced upon the industry they will not happen as most airlines perceive the current level of risk to be low and therefore acceptable. The Tombstone Imperative will dictate what happens next. If there are increasing numbers of catastrophes in which human factors continue to be implicated then the authorities may apply more pressure in the airlines for greater spending in this area. If not then the status quo will persist. The more far-sighted airlines such as Britannia, Virgin and Air Canada are leading in this area because they realise that although there are no short-term gains from better management of human factors, the long-term gains in terms of improved customer confidence, better corporate image, greater employee motivation, involvement and loyalty, reduced hangar and ramp rash, and reduced risk of aircraft hull losses and fatalities are priceless.

[Bus429]

Well said, fishbed. JAR 66 (Engineer licensing)mandates HF as a module and JAR 145 makes provision for refresher training covering the issue (although I think this may have changed a little). CASA in Australia are also mandating it as part of the AMEL module. The sad fact is, unless forced to, organisations will only pay attention if there is a cost reduction or profit imperative. In some respects there could be. H F training and awareness is not limited to CRM, FOQA or the maintenance environment. It should cover every facet of the industry. Humans are themselves human factors.
Aviation is not as structured or as disciplined as the layperson may believe. Margins are tight and volume counts. The old adage of making a small fortune (have a large one and start an airline) probably holds true. There is enough evidence that humans, by being human, are fundamentally part of most incidents or accidents. Over the last few years, I have become increasingly alarmed at the way commercial pressure, or fear of management sanction, has influenced engineering decisions. I am also concerned that airworthiness authorities seem in some cases rather relaxed over the issue. They seem to set deliberately broad requirements and leave it to the industry do all the work. Not all sectors of the industry are inclined to meet other than the minimum requirements.

[birdy32]

I’m around quiet a wile and it was worse before we get pushed into this JAA stuff, now we have to fulfill at least the min requirements. OK the courses are sh…. and usually not very helpful at the end. I did a couple of them and I have to say the best one was in Oxf…..and sponsored by CRX.


@bus429
“How many organisations really push the limit and fly aircraft that should really be on the ground until they are fixed!”

We (kraut’s or germans) HAD a very good system and our safety standards were very high, but since the JAA is kicking the ball the company is ahead of the game!!! So I am not really a friend of the JAA it will pushes the standards down to the minimum and the bad thing is: now there is always a JAR66 Certif. tosser around to pen the snags off.

[Bus429]

I was chatting with a colleague the other day and we both agreed that standards have indeed dropped. Maybe I'm looking through eyes dulled by only 25 years in the industry, but I can remember aircraft (albeit less sophisticated than those I work with now)staying in the hangar until they were fixed. An aircraft did not leave a "C" (or Block) check with deferred defects in the book. Of course, defects can be recorded elsewhere! I know most of us probably work for commercial entities but this industry must consider that regulatory requirements, such as they are, must prevail and that commercial considerations must take a back seat.
I know, I'm dreaming...

[ 02 January 2002: Message edited by: Bus429 ]</p>

[Bockyaud]

Well chaps just for your information, the good ol' JAA have released JAR-145 NPA-12 and guess the topic. That's right HF. The document is 33 pages long and also introduces JAR-145.47 which is all about production planning. There is also some harmonisation with the Feds in the USA as well.

I am actually a firm believer in the JAR's for several reasons. Perhaps the least intangible but still important reason is that we are all working to a supposedly level playing field and we are all talking about it. That's great as it shows the average guy in the hangar or line has a greater awareness of the requirements. The old BCAR's for instance good as they may have been, were complex and so less well understood.

If you look at the democratic process for issuing new rules, I think it can only be a good thing which is accountable to industry and passengers alike. Happy New Year!

[birdy32]

@bockyaud

well you are right, but that’s on the paper!!
The JAR makes live much easier for most of the companies and lower the standards as well. OK, it won’t lower the standards in Italy, Switzerland (sorry but that’s the truth) or ……., but take a closer look to England, Germany or Ireland.

Example: I did a 3 1/2 years apprenticeship as an Aircraft Engineer covering A&C&E and most of the avionics as well. I worked afterwards 5 years (minimum 3 years) as an Engineer Level 1 (more or less a B1) and than I went through a 6 months training to get my German Inspector License + several exams to pass the type ratings. And now after 17 years I am B1 (maybe C soon) and far too expensive for many companies.

And now the “bad” example (in my eyes):
The biggest company in good old Germany took most of the youngsters and put them on a Level 1 Course and after a couple month’s (min. six) they are B1 or B2. At the end, some of them rushed through within 4 years and a few month including apprentice. ???


I am not talking about fairness or money, but it’s a question of safety in my eyes and very often I am afraid to see who is running the show.

[Bus429]

Bockyard - I think you will find the latest issue of JAR 145 has, as a result of the consultative process, pared the proposals of NPA 12 right down. I'll have a look at the latest issue later on and get back to you.

[Blacksheep]

Meanwhile, back on the subject of Human Factors, surely the problem is that current legislation is aimed at the wrong people? Human Factors is a high level managerial issue way beyond the influence of LAEs or even junior management. All the important HF issues are governed by company policy - manning levels, working hours, training, equipment standards and so on. The budget rules - after all companies are answerable only to their shareholders (in theory anyway) and profit is the sole reason for any company's existance.

No, human factors is not taken seriously, neither by the companies nor by the regulators. After listening to to a presentation by the man from the CAA I'm not sure they even understand what HF is all about themselves.

**********************************
Through difficulties to the cinema

[phd]

Blacksheep - your last comments are perceptive and pertinent. Without top level airline management commitment towards tackling the HF nut the industry will not make the breakthrough in aircraft accident reduction that the CAA and other regulators are looking for. As with safety in other industry sectors such as road, sea and rail transport - the hardware has become more and more reliable, the procedures and information handling systems are developing and improving all the time, but the poor old Mark 1 human being has not really evolved much since the stone age. Airline managers must realise that employees are not robots or production units, but are normal people who make normal mistakes, which within our unforgiving working environment can unfortunately lead to catastrophic outcomes. The aviation industry must start building error tolerant flying systems rather than error inducing ones. The commercial imperative will always mean that companies strive to maximise the productivity of their capital assets and labour. Therefore everybody involved - pilots, cabin crew, controllers, ground handlers etc. are all subtly pressurised to squeeze more and more into an ever shrinking pot. Far from this helping to reduce the numbers of errors made it is more likely to increase them. To overcome this tendency there needs to be a total sea-change in the thinking at Board Level - much as is now going on within the rail sector post Southall and Hatfield. The CAA have published CAP 712 which sets out how airlines should start pro-actively managing safety as a corporate issue and within this arena human fallibility - both at management level and at the sharp end must be taken account of. This however requires dynamic safety leadership from the highest echelons of power within the organisation. Not much of that about.

[Bus429]

I once attended a training seminar at which John Goglia (?), former board member of the NTSB spoke. His theme was maintenance error and the avoidance, or rather reduction, thereof. He cited circumstances surrounding the implementation of MEMS/MEDA type and human factors programmes within various US airlines and maintenance organisations. Acceptance by production staff and middle management was no problem but some programmes failed because top management failed to "buy into" it, i.e. there was no top level commitment.
This only strengthens my convictions that commercial considerations override all others.

[phd]

Bus429 - I know John Goglia well and he is a great protagonist of the human centred approach to flight safety, particularly within the critical area of aircraft maintenance. Clearly commercial realities affect all companies, including airlines, and influence the decisions and actions taken. However failure to manage risk exposures effectively, such as in the cases of Barings Bank, Kings Cross, Herald of Free Enterprise, Southall, Hatfield, and most recently Independent Insurance Company can have an even bigger impact. In the cases of Barings and Independent the companies paid the ultimate price for failure to manage risk and they no longer exist. All stock market listed companies are now required to demonstrate compliance with the requirements of the Turnbull Committee which made recommendations following the Barings collapse. These requirements in simple terms stipulate that Boards of Directors of companies must apply proper corporate control systems for reducing risks and managing safety in the same way that they control budgets/finance or anything else for that matter. The intention of Turnbull's recommendations is to ensure that operational risks are regularly and properly reviewed at Board level so that decisions which can ultimately affect safety are not merely taken on the grounds of short term commercial considerations. It is only a matter of time before all corporate bodies will have to start placing much greater emphasis on competent safety management from the Board level down.

[Blacksheep]

"Safety attitudes refer to individual and collective beliefs about hazards and the importance of safety, together with the motivation to act on those beliefs....A minimal requirement here would be for senior management to hold a realistic view of the world and of the short- and long-term hazards entailed by the organization's activities..." [Pidgeon N.(1991) Safety Culture & Risk Management, Journal of Cross-Cultural Psychology 22,1, 129-140]

Citing B.A. Turner [Turner B.A.(1978) Man-made disasters. London:Wykeham] Pidgeon also stated that "These difficulties are often compounded with technical malfunctions and operating errors, with the result that an unnoticed situation is generated, counter to [both] the accepted beliefs about hazards and to established safety norms and procedures..."

In other words, the responsibility for safety management lies with senior management, who must make themselves aware of the real risks involved in their operations and not allow an unnoticed danger to creep in, despite apparently effective existing monitoring procedures. We should never forget that the Chernobyl disaster was predicated by a test of the plant's safety systems!

Currently our industry has a strong dedication to safety and safe working practices. Nevertheless mistakes are made and accidents result, often when staff are working in unusual circumstances or while tired by long hours or lack of rest. The fact that we get away with it most of the time leads to the practices becoming SOP and then the "unnoticed danger" has crept in. Management must not allow such situations to develop or more importantly not predicate them by exerting pressure on engineering departments to perform with less than optimal staffing levels. After all, most people do not willingly work until they drop - even for the best overtime rates: they do so because it is the expected group norm. Expecting lower level supervision to be responsible for HF management is at best myopic and at worst criminal negligence.

**********************************
Through difficulties to the cinema

[ft]

Bus429,
I have had some insight into the work with HF in our national ATC organizatin and they're taking HF VERY seriously indeed. Education at all levels, blame free deviation reporting and investigation, HF considerations all the way through the development process of new systems (well... with some exceptions I think) etc etc.

EuroControl are involved as well although I don't really know how much of an impact the HF work has made there.

I also read that in the Scandinavian countries, it was decided to step away from the normal practice of making (almost) all information available to the public in the case of aviation incident reports. This in order to keep the incident reports coming in spite of the tabloids and sensationalist reporters describing every reported incident as a near disaster.

There's light in the darkness!

Cheers,
/ft

(Edit due to pre-caffeine lysdexia)

[ 08 January 2002: Message edited by: ft ]</p>

[phd]

ft - good to hear that ATC are taking HF issues so seriously. Unfortunately commercial aviation is a 'system' of many parts that must all work in harmony to achieve accident free operation. Any system is only as good as its weakest point and I am of the opinion that there are many such weak points re. human reliability in engineering, flight operations and ground operations. The Singapore 747 'wrong runway' crash and the recent SAS MD80 crash at Milan due to a runway incursion show just how vulnerable to human error the aviation system still is. I believe Bus 429 is right to imply that there is lots of talk about HF in these disciplines but precious little action. Airlines will not budge unless forced to by JAA/CAA. The first step would be to insist on all airline Chief Executives attending a two-day FAA/JAA/CAA backed conference on human factors to frighten the cr@p out of them. Then we might see a little more urgency in this area.

------------------------------------------------

Pobody's nerfect

[ft]

Fisbhed,
yes, unfortunately it is very much a weakest link scenario. However, good ATC might in many cases be the safety barrier taking a bit of load off the weakest link. Good point about the first step. In the future, I for one hope that all involved entities will have an appointed Quality Manager/Quality Management Dept who/which is a separate entity and NOT under the control of the management handling commercial considerations in flight/line operations.

Cheers,
/ft

[Lockstitch]

Mes Amis--I looked in on this post anticipating sharing the warmth of the illustrious company of hairy arsed graunchers.Instead I find a bunch of mad scientists.Wot have you guys been reading?.

[Blacksheep]

Lockstitch,

I'll take being called a "Mad Scientist" as a compliment but in fact my @rse is hairy and my knuckles are permanently scarred from working at arms length in confined spaces with my nose shoved up against the skin. Under all the sociology, we are talking about getting better working conditions for hairy @rsed maintenance people. The root of 'human error' maintenance lapses is the fatigue and stress imposed by the working conditions and odd hours that are too often found in the engineering world. Our regulators impose strict controls on the working conditions and hours of pilots. Rightly so, and it isn't simply a matter of 'looking after the boys' it is an honest attempt to reduce the incidence of 'pilot error' accidents. But as the 'pilot error' rate falls, the proportion of accidents due to maintenance errors naturally increases, which ought to focus greater efforts onto the reduction of human error in engineering.

Sadly, the regulators have so far only paid lip service to human factors with action limited to placing a human factors module into AME licence exams. Companies will do nothing unless and until they are obliged to do so. One day we will have aircraft that are ergonomically designed to assist maintenance. We will keep them airworthy in well lit, environmentally controlled work areas equipped with proper rest and refreshment facilities. Our hours of work will be controlled to ensure adequate rest periods after overnight working and 'double-shifts' will be a thing of the past. And one day, pigs will fly. The fact remains that for most of us, aircraft maintenance is performed in almost Victorian conditions. It is also a fact that a contributory factor to this is our own traditional engineering 'macho' attitude. Which might just be why the CAA have chosen to start with us rather than at the corporate level?

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Through difficulties to the cinema

[flapsforty]

Gentlemen, interesting topic of importance to everyone of us, intelligently discussed by people who care.

Thank you for putting this up, it's the kind of thing that makes pprune a learning experience.

[rowand]

Gentlemen, some interesting responses. Don't you think that the wheel has commenced turning on HF, albeit slowly? Can anyone define HF? It's all of what you have noted and more and like an ice-berg, how much of it is still unknown? You've spoken about Senior Management not understanding the risks of HF. I'm sure "they" do but as it has been so aptly put, the share holders expect their dividends. I believe that HF is being explored and the practioners of HF, that is those at the edge of development of HF are expanding the boundaries of the subject. What you can expect to see is that acceptance of HF principles will take a long time and training has to commence somewhere and at some time. What better time than now?. The mid-level and junior engineers of to-day are tomorrow's managers and they will be the ones to take the beliefs of HF to the next level of management. Mind you all this has to be done in a cost effective manner, otherwise no matter how strong the beliefs and good the intent, it won't be implemented.

What do you think?

[ 12 January 2002: Message edited by: dogday ]</p>

[groncher]

I worked for a company that was practically in the
forefront of embracing Human Factors, big program
citing the virtues, admitted that the bean counters were convinced by the dollar-saving potential, but so what? Many of us were thrilled
that our main goal-safety-would be heightened by
an understanding management that would now magically back us up on any call that had a remote
safety concern. They spent a bundle, even had
fuellers, catering, etc. on the training program.
This seems like a good idea after having a caterer
tell me he "didn't hit it that hard" after turning
a 146 aileron into a chip bag. I took training as
an "incident investigator" (Rat Patrol to some of
the non-believers). I would be paid up to 4 hours
overtime to investigate in-house incidents. All
results would be considered by a "board", and only
out-and-out negligence would be grounds for disciplinary action. In my opinion, the two main
results were: 1- all concerns went out the window when a Supervisors on-time-performance bonus was at stake 2- a lot of the guys laughed behind everyones backs after being absolved for incidents
that were well-known to be the result of incompetence. Roll out the "Company Norms" line,
and walk away with a smile. It is definitely one
thing to say you have a Human Factors Program, and
another thing altogether to implement one intelligently. I still believe very strongly in
the concept, but I think it needs a lot of work.
I remember reading about a program at Qantas, which left the developement of the program to a
group of Engineers, and it seemed to be, on paper
at least, one of the more "real" programs. It seems that HF can become one of those little industries of its own, and end up with too many
people involved that have no knowledge of what really takes place in Aircraft Maintenance. The
idea that it must start someplace is valid, but
perhaps accepting HF on other peoples terms is not
in the best interests of those directly involved.

[Greg Baddeley]

Our lot have just taken MEMS/MEDA on board, following a rather expensive incident - I don't think it was a reaction to the incident, we were already on the road to accepting MEMS/MEDA when it happened. The gods in the ivory towers have accepted it too, because they have been convinced of the potential cost saving. Time will tell!

Sad to say there are still many, many individuals who feel that punishment is the only way to reduce errors; it is changing, but slowly. I've made maintenance errors before, and so have all of you, and we'll all continue to do so. We're only human after all. It's just that sometimes you find out the error yourself, sometimes another person spots it, and occasionally it gets pointed out to everyone by the aircraft! If you get yourself an open culture on safety, everyone's a winner.

It will take time though..................

[polzin]

Dont look at the FAA in America for Human Factors. Day/ night differences dont exist. I needed a column in my log book for SWPFC, Sleep While Pilot Fin Command , when i was flying coast to coast in the USA at night. Years ago, about 5, there was a big meeting of FAA, companies and pilots to get modern rules. And that was that. Fini.

[Bus429]

Banana,

Fatigue has already been cited as a factor in several incidents/accidents. In these cases, if fatigue didn't cause the accident, it was contributory in the events leading up to it. More worrying is your quote from management about wishing to employ more staff but citing economic reasons for not doing so. The Accountable Manager (at least under JAR 145) is entirely responsible for matters such as this. On their heads be it, theoretically at least, if something goes wrong as a result their parsimonious policies.