The
dirty dozen of human factors is another model used to describe the most common
causes of human factors errors that lead to aviation accidents and incidents.
In
the late 1980s and the early 1990s, a large number of aviation
maintenance-related accidents and incidents has occurred. Due to the
contribution of human factors errors in the aviation accidents and incidents
that time, Gordon During -who was working for transport of Canada- developed
dirty dozen model in 1993.
He
identifies twelve human factors which degrade people's performance and lead to
human errors.
The twelve human factors are lack of communication,
lack of teamwork, lack of assertiveness, complacency, fatigue, stress, lack of
knowledge, lack of resources, lack of awareness, distraction, pressure, and
norms.
|
THE
DIRTY DOZEN OF HUMAN FACTORS |
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1- Lack of Communication |
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2- Lack of teamwork |
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3- Norms |
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4- lack of assertiveness |
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5- complacency |
|
6- Fatigue |
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7- stress |
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8- lack of knowledge |
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9- lack of resources |
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10- lack of awareness |
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11- distraction |
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12- Pressure |
In
the previous week, I published my article which was titled pear model human factors. In this article, I will explain another human factor model which
affects your performance and suggested some simple mitigating strategies.
Note : you may like reading SHELL model human factor.
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hope you find my website a rich source of aviation articles and you share my
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The Dirty Dozen Human Factors | aviation maintenance
As
I mentioned before, these twelve human factors are known as the dirty dozen. It
was adopted by the aviation industry as a simple model to discuss aircraft
maintenance errors that occurred by aircraft maintenance technicians.
It
is important to know the dirty dozen human factors, recognize their symptoms
and avoid them.
Aircraft
maintenance technicians must learn from the errors caused by dirty dozen.
Note:
You may not know the federal aviation administration dirty dozen. Click here.
1- Lack of Communication
Communications
occur between aircraft maintenance technicians and many people (such as management, pilots, parts suppliers,
aircraft servicers). Through the daily communication process, it may be a
potential for misunderstanding or omission. For example, the maintenance
department may participate in a lack of communication by inadequate/ineffective
communication of new roles, maintenance procedures, etc.
But
communication between aircraft maintenance technicians may be more important
than all kinds of communications. Lack of communication between aircraft
technicians could lead to a maintenance error and result in aircraft accidents
and incidents. Errors may happen where the maintenance procedures - related to
aircraft- are performed by more than one maintenance technician.
Mitigation
- Maintenance technicians must properly use maintenance logbooks and worksheets to communicate with one another and explain what work has and has not been completed. Because errors may happen during changing shifts with poorly written communication logs.
- Maintenance technicians must discuss exactly what had been and needs to be completed for the next shift.
- Maintenance technicians must not assume that the work had been completed. They must use the maintenance instructions and work tasks cards.
2- Lack of teamwork
Teamwork
makes the dream work, in the aviation industry work tasks and operations are
team affairs. The large an aviation organization becomes, the more common this
contributing factor is.
Teamwork
is associated with improved safety in the workplace. teamwork in the workplace
involves every Aircraft maintenance technician understanding and gearing on
actions to be taken.
Lack
of teamwork is a failure to work together to accomplish a shared goal.
Personality differences in the workplace no it is let outside the workplace,
and aviation organizations should emphasize that a lack of teamwork can ultimately
affect aviation safety.
In
this factor, I should impress its importance. it is boring if we work alone.
even if there are some individuals with less experience, we should lead, teach,
and inspire. But if you, have I sleepy manager it is terrible, keep working
with your team. Bad managers will be changed one day. the change will be a huge
one.
Let
us back to our subject, lack of teamwork makes all jobs within an aviation
organization more difficult and, in aviation maintenance, could result in a miscommunication
that affects the airworthiness of the aircraft.
Mitigation
• Discuss how a task should be done.
• Make sure everyone understands and agrees.
• Trust your teammates
• Always look out for co-workers with safety in mind.
3- Norms
Norms
are unwritten rules or tolerated by most of the Aircraft maintenance
technicians’ groups “shifts”. Norms in workplaces develop over time, through
experience, and often under the influence of specific organizational culture.
Norms
are short of “normal”, or the way things are done around and organization. It
can be good or bad.
Good
norms, that support workplace safety, and the bad norms that lead to not
compliance with standard operating procedures and maintenance
workshop manuals.
For
example, not using work checklists by Aircraft maintenance technicians during
an aircraft maintenance repair.
To
reduce maintenance errors occurred due to norms, aviation organizations must
provide a work environment that is resistant to human factors errors, it is a
role of the safety management system (SMS), of which human factors training in
aviation is a part.
Mitigation
• Everyone must follow the same approved standard
• Many actions may seem normal, make sure it is correct.
• The easiest way to repair things, or to accomplish something may
not be the standard.
• Identify and eliminate negative norms.
• Write a voluntary safety report to alert the safety management system manager, make sure your SMS manual supports a voluntary reporting
system.
4- Lack of assertiveness
Assertiveness
is the ability to express your feelings, opinions, beliefs, and needs in a
positive, productive manner and should not be confused with being aggressive.
You
may believe something is wrong and dangerous to do so, be confident, lack of
assertiveness occurs when an aircraft maintenance technician is not
self-confident enough to speak up for their right and ideas.
Failure
to speak up or document concerns about work instructions, supervisors’ orders,
or the actions of others may lead to violations of maintenance documented
procedures.
Lack
of assertiveness in failing to alert others when something is going wrong can
result in many fatal accidents.
Mitigation
• Improve your skills of learning, communication and expressing
safety concerns, and offering positive solutions
• Do not let something that you know is wrong continue by ignoring
it.
• Provide clear feedback when a risk or danger is perceived.
• Allow co-workers to give their opinion and always accept
corrective criticisms.
5- complacency
This
insidious case of maintenance error usually occurred as aircraft maintenance
technicians become overconfident and rely on pattern recognition for
maintenance failures interpretation. Overconfidence leads to
complacency.
For example, repeating tasks such as inspections can
be ignored or skipped because maintenance technicians have performed a task
several times without ever finding fault.
Mitigation
• Never sign for any work that has not been performed by yourself.
• Do not take yourself for granted, whatever your experience.
• Communicate when in doubt.
• Always double-check your work.
6- Fatigue
Fatigue
is a feeling of tiredness, reduced energy, and increased effort to perform
tasks effectively and without error. It is a major human factor that has
contributed to many maintenance errors as a result of the accident.
Mitigation
•
Be aware of the symptoms and look for them in yourself and co-workers.
•
Forfeit complex tasks if you know you are exhausted.
7- Stress
Stress
is the subconscious response to the demands placed upon us. This does not only
relate to the work environment but our personal lives also. Furthermore, it can
be a physical, chemical, or emotional factor that causes physical, or mental
tension.
Stress
can lead to maintenance errors when it is excessive as it acts as a distraction
and reduces concentrations levels when performing complex maintenance tasks.
Mitigation
• A positive and strong persona helps build confidence and better
control over our reactions.
• Take a short break when needed
• Discuss with a co-worker and ask them to monitor your work.
• Eat healthy food and do exercises.
8- Lack of knowledge
In
aviation maintenance, technology is changing every time, this contributor to
aviation maintenance error is more common than we think. Lack of knowledge
means a shortage of training, information, and/or ability to perform the tasks
successfully.
Lack
of knowledge when performing aircraft maintenance can result in a faulty repair
that can have catastrophic results.
Mitigation
• Only fix aircraft parts that you are trained to fix.
• Use an up-to-date maintenance manual.
• If you don’t know how to fix something, ask for help from an
aircraft maintenance technician who does.
9- Lack of resources
The
fact is when the proper resources – such as enough manpower, equipment,
documentation, time, parts, etc.- are available and to hand, there is a great
chance that aircraft maintenance technicians will complete a task more
effectively, correctly, and efficiently.
Lack
of resources to safely carry out a maintenance task has caused many fatal
accidents. For example, an aircraft is dispatched without a functioning system
that normally would not be a problem, suddenly, encounters circumstances where
it does become a major problem.
Mitigation
•
Order parts before they are required.
•
Have a plan for pooling or loaning parts
•
Preserve all equipment through proper maintenance.
10- Lack of awareness
Lack
of awareness is a failure to recognize a situation, understand what it is, and
predict the possible results. In other meaning, it is a failure to recognize
all the consequences of an action or lack of foresight.
In
aviation maintenance, it is not unusual to perform the same maintenance tasks
repeatedly.
After
completing the same task multiple times, it is easy for aircraft maintenance
technicians to become less vigilant and develop a lack of awareness for what
they are doing and what is around them. Each time a task is completed it must
be treated as if it were the first time.
Mitigation
•
Fully understand the maintenance procedures needed to complete a task.
•
Even if you are highly proficient in a task, ask co-workers to check your work.
•
Make sure there are no conflicts with an existing repair or modifications.
11- Distraction
This
is anything that takes your mind off the task at hand for an instant. When work
resumes, the technician may skip over a detail -forgetting things, including
what has or has not been done in a maintenance task - that needs attention.
This
contributing factor is known to be responsible for at least 15 percent of all
aviation accidents.
Mitigation
•
Use a detailed checklist.
•
Go back 3 steps when restarting the work.
•
Never leave tools or parts lying around. Secure them before leaving the area.
12- Pressure
Pressure
- to fix things - to be on time is ever-present in aviation maintenance.
Aircraft maintenance technicians are very time-sensitive and many maintenances
decisions center around that fact.
Aircraft
maintenance technicians should not allow time pressure to get in the way of
finishing aircraft maintenance safely.
Mitigation
•
Ensure that the pressure is not self-induced.
•
Communicate concerns.
•
Ask for extra help.
•
Put safety first.
Summary
It
is vital to know the dirty dozen, how to perceive their side effects,
furthermore,
above all, know how to stay away from or contain blunders created by the dirty
dozen. Understanding the cooperation between authoritative, work gathering, and
individual factors that might prompt blunders and mishaps, aircraft maintenance
technicians can figure out how to forestall or oversee them proactively later
on.
I
hope I have simply conveyed the information. I'm so glad you're sharing this
article now. Many thanks in advance.
Reference
1- FAA, Chapter
14, Human Factor [ AMT Handbook Addendum Human Factors]
