ADDRESSING YOUR HUMAN ERROR

The start of a new year is a good time to renew your commitment to flight and personal safety. For an excellent 2019: Don’t forget anything, don’t make mistakes, don’t hurt yourself or others, don’t have communication errors, be safe, etc.

There are at least two reasons that the above mentioned advice is not very useful. First, it is too broad to be useful. Second, the advice ignores that we are human and are inclined to make the errors stated. So, in theory the advice is valid but how do you implement it? This article offers practical and familiar methods to help minimize human error.

Addressing Human Error

We all know that human error contributes to about 80 percent of the negative events in aviation. That includes pilots, dispatchers, air traffic controllers, cabin crew, and of course maintenance/engineering personnel. Maintenance gets the “attribution” (aka “blame”) for an estimated 10-15 percent of major events. Then, 80 percent of the maintenance events are human error. There is a high safety payoff in reducing human error.

There are many reasons that the 80 percent figure has remained constant despite three+ decades of attention to the human factors topic. The continuing evolving reliability of new technology aircraft means they break less often and they require less maintenance, meaning that failed aircraft components are seldom the cause of a major event. Further, enlightened human factors-centered accident investigation methods/procedures are better at identifying human factors causes. In the past, human factors contributing factors may have been attributed to non-human factors causes.

Increased worker knowledge about human factors is evidenced by the nature of the reports submitted as part of the Aviation Safety Reporting System (ASRS) and to other voluntary reporting systems like the FAA Aviation Safety Action Program (ASAP). That does not mean that human factors errors are up. Instead, understanding and resultant remediation is up. Further, good safety management systems are recognizing the hazards/risk associated with human error.

Specific Action to Target Human Error

Below I offer five action categories to address common specific human factors challenges. Working to reduce our human error does not have to be overly complicated. You do not need more information to do the right thing. It is a matter of individual and organizational commitment. If you want additional information, the short suggestions are supplemented by guidance from the optional included websites. Most of the website links are brief articles offering “how-to” advice.

Fitness for Duty Actions:

Let’s start with this familiar topic. Physical and mental readiness is a primary target of opportunity. That begins with proper sleep. Specific actions to ensure fitness for duty are:

1. Sleep for seven to nine hours per 24-hour period. Proper naps count.
2. Minimize excessive food and alcohol prior to sleep.
3. Shift workers should try to sleep before rather than after work. Naps may help.
4. Find a sleep routine that works for you.
5. Beware of night shifts, duty time over 12 hours, and extended days of work without a day off.
6. For long-term sleep issues see a medical professional specializing in sleep disorders.

Procedural Errors:

The best way to avoid error is to combine fitness for duty with strict procedural compliance. Procedural noncompliance is the No. 1 cause of FAA administrative action. Specific actions to reduce procedural error are:

1. Commit to 100 percent procedural compliance for everyone.
2. Act to fix every inadequate procedure.
3. Do not let time pressure or distractions interfere with using the procedures and checklists.
4. Recognize that familiar as well as unfamiliar tasks require checklists and documentation.
5. Set a good example to work colleagues and always follow appropriate procedures.

Forgetfulness

How often do you forget to do something that leads to an unintended consequence? For me, I would say “too often.” Forgetfulness is a generic issue that affects all life functions including aircraft maintenance. The solution to forgetfulness is related to Fitness for Duty and Procedural Errors. Specific ways to avoid forgetting during maintenance work are:

1. Be mentally fit for duty. “Keep your eye on the ball.”
2. Strive to manage time. Rushing at the end leads to forgetting.
3. Always follow checklists and other procedures. (There is no regulation on forgetting but there is one on following procedures: 14 CFR Part 43, Section 43.13-1 B.
4. Do not rely on memory!
5. When distracted or interrupted go back a few steps.
6. Organize your tasks, tools, and environment, aka housekeeping. Recognize the threat when you are doing multiple tasks on multiple aircraft.

Failure to Communicate:

Miscommunication often leads to negative events, including disagreements/arguments. Miscommunication can happen at shift change or even while working a specific task. Communication is critical for every aspect of life and work. Good teamwork goes together with effective communication. Many publications offer advice on good communication practices. However, the rush and loud environments of some aviation maintenance makes effective communication an extraordinary challenge. Specifics actions for effective maintenance teamwork and communication are:

1. Discuss the entire task, in person if possible, before the work begins.
2. Assign and clarify responsibilities with individual and team expectations.
3. Identify the team leader (If everyone is in charge then no one is in charge).
4. Remember that communication requires clear, correct, and concise transmission, reception, and feedback.
5. Reserve time for questions and clarification.
6. Recognize the environmental and mental challenges in many maintenance work scenarios.

Support Your Organizational Safety Culture

A good safety culture is one that has a shared goal and values in the highest level of safety. Every worker in the organization should recognize and be able to verbalize their daily contributions to safety. Ideally, each worker should take professional and personal pride in their role regarding safety. We know how to do our jobs correctly to achieve safe work and safe flight. We must commit and strive to do that 100 percent of time!

Safety management systems (SMS) are a means to identify and mitigate safety hazards. A good safety culture reinforces the effectiveness of the SMS. The safety culture is less tangible than the SMS documents and meetings. What can you do to foster the safety culture? Specific actions that you can take to foster the safety culture are:

1. Be a champion to promote sections 1-4 above.
2. Take pride and satisfaction in your dedication to working safely and delivering a safe work product.
3. Speak up and communicate effectively when you see an opportunity for safety improvement.
4. Use voluntary reporting systems for both good and bad news.
5. Strive to cooperate in the safety management system activities.
6. Know that every employee owns a piece of the safety culture.