HUMAN FACTOR

Human factors is one of the most used terms in the aviation industry. It was quoted
in the Civil Aviation Authority CAP 715 that aircraft accidents recorded from
around the world brought the need to address human factors issues in this
environment into sharp focus6. Human factor can be fairly described as a mistakes
or error that is cause by a human behaviour. It is also the largest causal factor of
accidents and so, it must be targeted for major safety efforts if an improved safety
records is to be achieved. From human factor, the concept grew into a more in
depth system that helps to improvise the aviation maintenance organization
working condition and such a new system are; safety culture and safety
management system are being implemented in to organization.
Safety Management System
Safety Management can be seen as a systematic implementation of Risk
management in the planning, control and supervision in the process to ensure safe
operations. In a publication by Civil Aviation Authority (CAA) on Safety Management
Systems for Commercial Air Transport Operations, CAP-712 it defines Safety
Management System as:
Safety Management is defined as the systematic management of the risks
associated with flight operations, related ground operations and aircraft engineering
or maintenance activities to achieve high levels of safety performance.
A Safety Management System is an explicit element of the corporate
management responsibility which sets out a companys safety policy and defines
how it intends to manage safety as an integral part of its overall business.
In short, safety management system is the processes and arrangements set by an
organization to manage the health and safety issues within an organization and
through such a method of using a system to manage those important function in the
organization; it can improve the performance of an organization and reduce the
risks any accidents.
In the aircraft maintenance industry, safety management plays an important role of
maintaining the satisfactory work output. Failure in this will cause a list of chain
effect that could possibly increase the chances of causing an aircraft accident. For
this reason, the Civil Aviation Authorities publish manuals on regards to this matter
and one of such is the CAP 712 which focuses specifically on the safety
management of the aviation industry to minimize the chances any factors that
causes risks.

A typical Safety Management Systems found in aviation industry should be made up

of 4 key components:
Safety Policy and Objectives;
An organization should have a safety policy that outlines the methods and
processes that they will use to achieve a positive result. It should declare the
principles and philosophies that lay the foundation of the organizations safety
culture and be communicated to all staff thorough the organization.
Safety Risk Management;
Safety risk management process starts with identification of hazards affecting the
aviation industry and by assessing the risk associated with the hazards in terms of
its seriousness and similarity to previous cases. When the risks are identified, only
then can we make the appropriate implementation of remedial actions to reduce the
level of risk as low as possible.
Safety Assurance;
Safety assurance assesses the safety performance of the organization and this will
allow continuous improvement to the organization. Through monitoring,
measurement and reviewing the safety of an organization, it is possible to create a
safety assurance within the organization and allow a continuous improvement of the
safety system.
Safety Promotion.
Promoting safety in an organization by means of training and educating employees
will rather increase their safety responsibilities. This is especially effective for
operational staffs, managers, supervisors, senior managers and the accountable
manager since they are the ones that are responsible for the main production line of
the company. Through training and continued maintenance of competence, it will
provide an opportunity to reinforce the safety policy and establish the proper
attitudes and behaviours for all levels of staff in the organization.
Safety Culture
Safety culture can be defined as the product of individual and group values,
attitudes, competencies and patterns of behaviour that determine their
commitment to the health and safety issues. An organization with a safety culture is
one that prioritizes the safety and the importance to manage them to reduce risk.
However, a safety culture is more than just avoiding accidents or reducing the
number of accidents, but an apparent measure of success in improving the safety of

employees within the organization. In the aircraft maintenance industry, it is to do

follow the correct procedures when carrying out a maintenance check or repairs.

Recognizing that accidents are preventable through following the key to achieving
that safety culture is in:
recognizing that accidents are preventable through following correct procedures and
established best practice;
constantly thinking safety; and
seeking continuous improvement
It is however, rare that new types of accidents to occur and many of those common
ones continue to occur are normally due to the unsafe acts of employees, or
technicians in these maintenance industry. These errors are usually the violation of
good practice of establish rules. Those who make these errors are often aware of
their foul actions but to cut a lengthy task short, they normally choose to take
short-cuts and this ultimately increase the risk of accidents occurring.
The central of a Safety Culture is a leadership that is capable of communicating
with everyone in the company as a means of actions and setting a standard to the
safety culture. Once everyone in the organization are capable of doing their job in a
safe ways and vigilance of the hazardous environment of the maintenance
organization, only then can they reach a new standard of safety driven through
attitudes. At the same time, as a leader they must actively encourage and
demonstrate regularly to encourage all employees to participate in order to achieve
a new level of safety.
A safety culture in an aircraft maintenance industry should consist of five
elements2:
An informed culture
In an informed culture the organization should collects and analyses relevant data,
and actively disseminates safety information to update on their safety management
system.
A reporting culture
Through cultivating an atmosphere where people have confidence to report safety
concerns without fear of blame. Employees must know that confidentiality will be
maintained and that the information they submit will be acted upon, otherwise they
will decide that there is no benefit in their reporting

A learning culture
In a learning culture, the organization is able to learn from its mistakes and make
improvements. It will also ensure that people understand the Safety Management
System processes at a personal level.
A just culture
A just culture, errors and unsafe acts will not be punished if the error was
unintentional. However, for those who act recklessly or take deliberate and
unjustifiable risks will still be subject to disciplinary action.
flexible culture
A flexible culture in the organization and the people in it are capable of adapting
effectively to changing demands.
Safety Management System with Safety Culture
In a term, safety culture lays the foundation of the safety management system
which can also be treated as the lifeblood of an organization. The safety culture can
influences how well its people and structure work together therefore it can
determines how successful an organization can be for the long term and short term
period at the same time. Safety culture in a maintenance organisation can be also
described as the way it operates and particularly in the way it manages safety. To
put it simply, a safety culture influences all important thing that go on in an
organization.
In order for Safety Management System to accomplish its goals, the organization
must first be able to establish a safety culture within the working environment. From
the key components that made up the Safety Management System and Safety
Culture, it is understandable that why without safety culture, a safety management
System will not be effective. The Safety culture elements refers to the work
environments, such as values, rules and understandings that influence the
employees perceptions and attitudes toward the importance of a safety of the
organization. On the other hand, the Safety Management System is the
arrangements made by the organization in order to promote a safety culture and
achieve good safety performance.
Without a Safety Culture the industry will not be able to minimize the risks of
accidents with just having a Safety Management System. It is the combine effects of
the 2 that create a balance of risk management. The safety culture works by
providing the proper analysis of risk faced by the industry and by using this
information, the Safety Management System can make arrangement to strengthen
the safety culture, for example, the attitude of employees when performing a task
can be strengthen if they have beneficial claims if they done the task with correct
procedure. Therefore, we can conclude that in order for a Safety Management

System to establish in the aviation industry, a safety culture must coexist with
Safety Management System.
Reprimanding Engineer
Reprimanding an engineer is a process where they are judge on their mistakes.
However, the chances of that engineer making the same mistakes in the future is
very low but if we are looking at a different type of mistakes, it is almost impossible
to say that by reprimanding an engineer can actually prevent them from making the
mistakes in the future. Even if we reprimand the engineer who is at fault it is
difficult to put the blame on him/her as we are well aware of human factors and
other factors that plays a role in such situation. Therefore, even if we were to
reprimand the engineers for the mistakes, it is not entirely possible to say that they
will not make other mistakes in the future. The only way to answer the question is
the type of mistakes which is either something that we cant control i.e. human
factors, and those that are caused by poor management in the organization. By
learning from mistakes, the management team will be able to adjust or improve the
working culture so that the same mistakes will not every happen again in the
organization.
The few aspects to that place the engineer in a position where he or she is at fault
of the mistakes but the fact reveals that they are not entirely at fault. They are:
Working Environment
Workload
Maintenance Team
Working Environment:
In the maintenance department of aviation industry, with the ever changing working
environment it is hard for engineers to cope with it. The maintenance department
will have aircraft going in and out of the hangar every day and it should be able to
accommodate the specific type and number of aircraft in the base to carry out the
maintenance. If the engineer have been working in a tight space area there are
bound to have human errors mistakes going on in the maintenance base.
When we talk about working environment, it also includes the environmental issues
such as temperature, lighting, noise and tools. In different countries the working
temperature can play a role in causing human errors which is can be prevented by
having proper ventilation in the working environment. Lighting on the other hand
plays an important role because a working environment with poor lighting can also
promote poor working environment and expose engineers to make mistakes. Noise
levels should be controlled to the point where it will not distract engineer when
carrying out tasks such as inspection if it is not practical to control the noise source,

engineers should be provided with the proper gear to stop the excessive noise that
cause distraction.
Working environment also includes the different types of tools that are used for
specific tasks. If a maintenance need to carry out a task that requires tools that the
maintenance department are not prepared with, engineers might be forced in a
situation where they need to improvise to get the job done which include using noncompatible tools to do a job.
Workload
An increased workload may also be considered to be associated as the cause of the
mistakes. Workload can affect engineers psychological and physical performance.
With increased workload, the amount of stress that builds up slowly can ultimately
cause an unwanted problem to happen. This is a common problem that can be
found in most aviation maintenance industry as engineers are constantly asked to
accomplish a task within a specific amount of time. If for some reason they are
unable to accomplish the task in time, their stress level will rise to a point where
they might complete the task without proper inspection of being done correctly.
Therefore, engineers are not the only reason that will link them to making mistakes
but originated from the maintenance department that schedule the amount of work
that needs to be done.
Maintenance Team
In the aviation maintenance industry, it is common to find that engineers work in a
team with a handful of technicians or other engineers to accomplish a certain job.
However, it is impossible to judge whos at fault when a problem appears in the task
that they performed. As a team, it is not justify putting the blame on 1 engineer that
performs the task as a team be it the correct way or not. The issues should be raise
up against the whole team in order to maintain a balance in the working culture so
that everyone in the maintenance department are well aware of such a problem and
will be more vigilance. After such an incident, the management team can set up a
system that need all team members to inspect that the task is done correctly and
without any problems and reducing the chances of repeating the same mistakes in
the future.
From the unintentional cause of mistakes, we now move on to discuss on the
violation of aircraft maintenance practice. Although most engineers stern from a
genuine desire to do a proper job but there are always some that chooses to be the
odd ones and decided to violate the practices intentionally and pose as a threat to
the aviation maintenance. There are 4 types of violation which can be classified:
Routine Violation

Routine violations is when engineers believe that procedures may be over

prescriptive and decided that they can be violated to simplify a task or commonly
known by us as cutting corners, to save time and efforts.
Situational Violations
Situational violation only occurs due to time pressure, high workload, unworkable
procedures, inadequate tooling, and poor working conditions. So in order to get the
job done, engineers consider that a procedure cannot be followed completely and
again skipped the full procedure.
Optimizing Violations
Optimizing violations involve breaking the rules for kicks or pleasure. These are
often quite unrelated to the actual task. The person just uses the opportunity to
show that he is very skillful in doing specific task.
Exceptional Violations
Exceptional Violations are when engineers have no other options to proceed with a
task without violating a few rules. Even if the engineers have no ill intention of
violating any procedure but circumstances persists.
When an error occurs in the maintenance department, the engineer who last
worked on the aircraft is usually consider to be at fault and may be reprimanded
and requires to go through some remedial training or simply told not to make the
same error again. However, by blaming the engineer who is at fault may not be a
positive ways of sending message across the maintenance department since other
engineers may be discourage to come clean about their mistakes and cover up
their mistakes. Ultimately, through reprimand it deny a safety culture to effectively
establish in the maintenance department. Without a safety culture, the engineer will
not be aware of the other mistakes and subsequently that engineer will make
another mistake.
All in all, it is not possible that the engineer will avoid making mistakes since there
is always a human limit. So, in order to reduce or prevent errors, the maintenance
organization needs to compromise between implementing measure to prevent or
reduce errors and making profits. Perhaps the most important of all is to achieve a
level of management where engineers have no means of intentionally violates the
proper procedure to accomplish tasks.
Conclusion
In conclusion, human factor is one of the most common factors that cause error or
accidents in the aviation maintenance industry. In order to prevent or reduce this
risk, organization implemented many new types of safety system and culture to
counter this problem. Human factor forces people to make mistakes and mistakes

leads to accident, be it a serious or minor ones but the end result will be
organization not making any profits. Having that said, since its not possible to avoid
human factors in the aviation industry, engineers making a mistakes unintentionally
can help the maintenance organization to learn from such an incident and
implement new system so that they can reduce or prevent such mistakes from
happening again in the future.