Malaysian Institute of Aviation Technology

9.0 Human Factor

DO YOU
AGREE ?

Present

HUMAN
FACTORS

Source: Royal Aeronautical Society Human Factors Group

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Aircraft accident photo

• Aircraft collision on the runway.

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9.0 Human Factor

Aircraft accident photo
• Aircraft struck by flock of birds. Takeoff aborted but aircraft
overran.

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9.0 Human Factor

Aircraft accident photo

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9.0 Human Factor

Aloha flight 243 ( April 1988 )

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9.0 Human Factor

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1.1 The Need To Take Human Factors

Into Account
• What is “Human Factors”?
• Definition:
• In the context of aviation maintenance it is referred to as
“the study of human capabilities and limitations in the
workplace.”

• Aim: To optimise the relationship between maintenance

personnel and systems with a view to improve safety,
efficiency and well-being.
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1.1 The Need To Take Human Factors

Into Account
• OBJECTIVES:
 IMPROVE HUMAN PERFORMANCE
 IMPROVE SAFETY
 REDUCE THE NEED FOR TRAINING &
RETRAINING
 IMPROVE USER SATISFACTION
 REDUCE HUMAN ERROR
 REDUCE COSTS

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1.1 The Need To Take Human Factors

Into Account
From the survey and investigation on the aircraft
accident and incident attributed to human factor.

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1.1 Need to address human factor

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1.1 The Need To Take Human Factors

Into Account
• Basically definition describes Human Factor as relation
between.
– Humans and humans.
– Humans and machines.
– Humans and working processes
– Humans and their environment.
Also describes as:
Human capabilities and limitation
Interaction between human entity and the systems
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1.1 Need to address human factor

Post-holders
management Managers
•supervisor
Technical staff Certifying staff
Technicians
mechanics
Tech-support
personnel Planners
Engineers
Technical records staff
Quality control
Quality control and
Assurance staffs
Other staff
Specialized staff.
Human factors trainers
Store department staff.
Purchasing department staff.
Ground equipment operator
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1.2 TRAITS OF HUMAN FACTORS

 Human Factors include such elements or traits as:
 human physiology (normal functions of humans)
 psychology (incl. perception, cognition, memory,
social interaction, error, etc.)
 work place design
 environmental conditions
 human-machine interface
 anthropometrics (the scientific study of
measurements of the human body

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1.3 Shell Model

Tools, test equipment, aircraft
structure, flight deck designs,
H positioning of controls and
Hardware
instruments, etc.
Maintenance Physical
procedures, Liveware environment (e.g.
maintenance S YOU
E conditions in
manuals, checklist Software Environment
hangar, conditions
layout, etc. on the line) and
work environment
Maintenance engineers, L (i.e. work patterns,
supervisors, planners, Liveware management
managers, etc. structures, public
perception of
industry, etc.)
Figure 1 SHEL Model. Source: Edwards, 1972 (as referenced in ICAO Human Factors Digest No.1, Circular 216 (1989))

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1.3 Shell Model

• Adverse affect when:
– S: misinterpreted, badly written manual, poor design
check list, difficult to use.
– H: not enough tools, inappropriate equipment, poor
aircraft design for maintainability.
– E: uncomfortable workplace, inadequate hangar space,
extreme temperature, excessive noise, poor lighting.
– L: relationship with other people, shortage of man power,
lack of supervision, lack of support for management.

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1.4 Accident attributed to human factor

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1.4 Accident attributed to human factor

• About 80% of all aviation accidents are caused by human

errors.
100%
Reason for aircraft fatal accident
80%

60%

40%

20%

0%
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1.4 Accident attributed to human factor

• ACCIDENTS
– 20%  MECHANICAL FAILURE
– 80%  HUMAN ERROR

• EXAMPLES:
» AAIB Bulletin 5/97, British Airways, B747, GBDXK,
Gatwick, November 1996 (DOOR HANDLE MOVE TO
OPEN POSITION)

» NTSB/AAR-84/04. Eastern Airlines, L-1011, N334EA,

Miami, May 1983
(OIL SEAL MASTER CHIP DETECTOR)

• THE GROWTH OF AIRLINE INDUSTRY HAS EXCEEDED THE INCREASE

IN THE NUMBER OF A/C TECHNICIANS

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1.4 Accident attributed to human factor

Hull loss accidents from 1995 - 2004
Flight crew

Aircrew

Weather

Misc/ other

Maintenance

Airport/traffic ctrl

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1.4 Accident attributed to human factor

Incident
happened
during
jacking
this
Boeing
747

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1.4 Accident attributed to human factor

Fender Bender
Accident cause by
ground equipment.

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1.5 The Error Chain

Accident
• Chain of events
• Multiple contributing causes
that can lead to an accident.
• Rarely does an accident have
a single cause.

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1.5 The Error Chain

Effective Management System

Preventing any contributing Crew

cause will prevent the accident
Management

Maintenance

If we can break just one link in the chain, the accident doesn’t happen
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1.6 MURPHY’S LAW

• Tendency of human being towards complacency.

• Can be regarded as notation “if something can go wrong it will”.

• It is not true incidents or accidents ONLY happen to people who

are irresponsible or sloppy.

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1.6 MURPHY’S LAW

• Simply means when an a/c parts can possibly be

installed incorrectly, someone will do it.

• Many times these maintenance error are not discovered

until the a/c is in flight

• Read as ‘if there are two or more ways to do something,

and one of those ways can result in a catastrophe, then
some one will do it’

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1.6 MURPHY’S LAW

Others murphy’s law:

A. If anything simply cannot go wrong, it will

anyway.
B. If everything seems to be going well, you
have obviously overlooked something.
C. Every solution breeds new problems
D. It is important to make anything foolproof
because fools are so ingenious.

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THANK YOU
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