There are many concepts related to the science and practice of human factors. However, from a practical standpoint, it is most helpful to have a unified view, or a model of the things we should be concerned about when considering aviation maintenance human factors. For more than a decade, the term “PEAR” has been used as a memory jogger, or mnemonic, to characterize human factors in aviation maintenance. The PEAR mode prompts recall of the four important considerations for human factors programs, which are listed below.
- People who do the job.
- Environment in which they work.
- Actions they perform.
- Resources necessary to complete the job.
Aviation maintenance human factors programs focus on the people who perform the work and address physical, physiological, psychological, and psychosocial factors. [Figure 14-12]
The programs must focus on individuals, their physical capabilities, and the factors that affect them. They also should consider their mental state, cognitive capacity, and conditions that may affect their interaction with others. In most cases, human factors programs are designed around the people in the company’s existing workforce. You cannot apply identical strength, size, endurance, experience, motivation, and certification standards equally to all employees.
The company must match the physical characteristics of each person to the tasks each performs. The company must consider factors like each person’s size, strength, age, eyesight, and more to ensure each person is physically capable of performing all the tasks making up the job. A good human factors program considers the limitations of humans and designs the job accordingly. An important element when incorporating human factors into job design is planned rest breaks. People can suffer physical and mental fatigue under many work conditions. Adequate breaks and rest periods ensure the strain of the task does not overload their capabilities. Another “People” consideration, which also is related to “E” for “Environment,” is ensuring there is proper lighting for the task, especially for older workers. Annual vision testing and hearing exams are excellent proactive interventions to ensure optimal human physical performance.
Attention to the individual does not stop at physical abilities. A good human factors program must address physiological and psychological factors that affect performance. Companies should do their best to foster good physical and mental health. Offering educational programs on health and fitness is one way to encourage good health. Many companies have reduced sick leave and increased productivity by making healthy meals, snacks, and drinks available to their employees. Companies also should have programs to address issues associated with chemical dependence, including tobacco and alcohol. Another “People” issue involves teamwork and communication. Safe and efficient companies find ways to foster communication and cooperation among workers, managers, and owners. For example, workers should be rewarded for finding ways to improve the system, eliminate waste, and help ensure continuing safety.
There are at least two environments in aviation maintenance. There is the physical workplace on the ramp, in the hangar, or in the shop. In addition, there is the organizational environment that exists within the company. A human factors program must pay attention to both environments. [Figure 14-13]
The physical environment is obvious. It includes ranges of temperature, humidity, lighting, noise control, cleanliness, and workplace design. Companies must acknowledge these conditions and cooperate with the workforce to either accommodate or change the physical environment. It takes a corporate commitment to address the physical environment. This topic overlaps with the “Resources” component of PEAR when it comes to providing portable heaters, coolers, lighting, clothing, and good workplace and task design.
The second, less tangible, environment is the organizational one. The important factors in an organizational environment are typically related to cooperation, communication, shared values, mutual respect, and the culture of the company. An excellent organizational environment is promoted with leadership, communication, and shared goals associated with safety, profitability, and other key factors. The best companies guide and support their people and foster a culture of safety. A safe culture is one where there is a shared value and attitude toward safety. In a safe culture, each person understands their individual role is contributing to overall mission safety.
Successful human factors programs carefully analyze all the actions people must perform to complete a job efficiently and safely. Job task analysis (JTA) is the standard human factors approach to identify the knowledge, skills, and attitudes necessary to perform each task in a given job. The JTA helps identify what instructions, tools, and other resources are necessary. Adherence to the JTA helps ensure each worker is properly trained and each workplace has the necessary equipment and other resources to perform the job. Many regulatory authorities require that the JTA serve as the basis for the company’s general maintenance manual and training plan. Many human factors challenges associated with use of job cards and technical documentation fall under “Actions.” Clearly understandable documentation of actions ensures instructions and checklists are correct and useable. [Figure 14-14]
The final PEAR letter is “R” for “Resources.” [Figure 14-15]
It is sometimes difficult to separate resources from the other elements of PEAR. In general, the characteristics of the people, environment, and actions dictate the resources. Many resources are tangible, such as lifts, tools, test equipment, computers, technical manuals, and so forth. Other resources are less tangible. Examples include the number and qualifications of staff to complete a job, the amount of time allocated, and the level of communication among the crew, supervisors, vendors, and others. Resources should be viewed (and defined) from a broad perspective. A resource is anything a technician (or anyone else) needs to get the job done. For example, protective clothing is a resource. A mobile phone can be a resource. Rivets can be resources. What is important to the “Resource” element in PEAR is focusing on identifying the need for additional resources.
Another major human factors tool for use in investigation of maintenance problems is the Boeing developed Maintenance Error Decision Aid (MEDA). This is based on the idea that errors result from a series of factors or incidents. The goal of using MEDA is to investigate errors, understand root causes, and prevent accidents, instead of simply placing blame on the maintenance personnel for the errors. Traditional efforts to investigate errors are often designed to identify the employee who made the error. In this situation, the actual factors that contributed to the errors or accident remain unchanged, and the mistake is likely to recur. In an effort to break this “blame and train” cycle, MEDA investigators learn to look for the factors that contributed to the error, instead of the employee who made the error. The MEDA concept is based on the following three principles:
- Positive employee intent (In other words, maintenance technicians want to do the best job possible and do not make intentional errors.)
- Contribution of multiple factors (There is often a series of factors that contribute to an error.)
- Manageability of errors (Most of the factors that contribute to an error can be managed.)
When a company is willing to adopt these principles, then the MEDA process can be implemented to help the maintenance organization achieve the dual goals of identifying those factors that contribute to existing errors, and avoiding future errors. In creating this five-step process, Boeing initially worked with British Airways, Continental Airlines, United Airlines, a maintenance worker labor union, and the FAA. The five steps are:
- Event: the maintenance organization must select which error that caused events will be investigated.
- Decision: was the event maintenance related? If the answer is yes, then the MEDA investigation continues.
- Investigation: using the MEDA results form, the operator conducts an investigation to record general information about the airplane—when the maintenance and the event occurred, what event initiated the investigation, the error that caused the event, the factors contributing to the error, and a list of possible presentation strategies.
- Prevention strategies: the operator reviews, prioritizes, implements, and then tracks the process improvements (prevention strategies) in order to avoid or reduce the likelihood of similar errors in the future.
- Feedback: the operator provides feedback to the maintenance workplace so technicians know that changes have been made to the maintenance system as a result of this MEDA process.
The implantation and continuous use of MEDA is a longterm commitment and not a “quick fix.” However, airline operators and maintenance facilities frequently decide to use the MEDA approach to investigate serious, high visibility events which have caused significant cost to the company. The desire to do this is based upon the potential “payback” of such an investigation.
This may ultimately be counterproductive because a highly visible event may not really be the best opportunity to investigate errors. Those involved in the process may be intimidated by the attention coming from upper management and various regulatory authorities.
By using the MEDA process properly, the organization can investigate the factors that contributed to an error, discover exactly what led to that error, and fix those factors. Successful implementation of MEDA will allow the organization to avoid rework, lost revenue, and potentially dangerous situations related to events caused by maintenance errors.
The “SHEL” model is another concept for investigating and evaluating maintenance errors. [Figure 14-16]
As with other human factors tools, its goal is to determine not only what the problem is, but where and why it exists. SHEL was initiated by Professor Elwyn Edwards (Professor Emeritus, Aston University, Birmingham, U.K.) in 1972. It was later modified slightly by the late Capt. Frank Hawkins, a Human Factors consultant to KLM, in 1975. The acronym SHEL represents:
The model examines interaction with each of the four SHEL components, and does not consider interactions not involving human factors. The term “software” is not referring to the common use of the term as applied to computer programs. Instead it includes a broader view of manual layout, checklist layout, symbology, language (both technical and nontechnical), and computer programs. Hardware includes such things as the location of components, the accessibility of components and tooling. Environment takes temperature, humidity, sound, light, and time of day factors into account. Liveware relates technician interaction with other people, both on the job and off. These include managers, peers, family, friends, and self.
No discussion of human factors is complete without reference to James Reasons’ Model of Accident Causation. This diagram, which was introduced in 1990, and revised by Dr. Reason in 1993, is often referred to as the Swiss cheese model and shows how various “holes” in different systems must be aligned in order for an error to occur. Only when the holes are all aligned can the incident take place.
There are two types of failure which can occur—active and latent. An active failure is one in which the effects are immediate. An example of this type would be an aircraft slipping off one of the lifting jacks due to improper placement by the technician. In this example, the aircraft jack is the approved item of ground support equipment, and it has been properly maintained.
A latent failure occurs as a result of a decision or action made long before the incident or accident actually occurs. The consequences of such a decision may remain dormant for a long time. An example of a latent failure could also involve the aircraft slipping off a joint, but in this case, it could be an unapproved jack being used because funding had not been approved to purchase the correct ground support equipment (GSE).
The field of human factors, especially in aviation maintenance, is a growing field of study. This section of this chapter has presented only a small segment of the numerous observations and presentations about the topic. If the technician desires to learn more, numerous books exist and a review of Internet data will provide an abundant supply of information.
A good place to start researching would be the FAA’s own website at http://hfskyway.faa.gov/. This site, titled “Human Factors on Aviation Maintenance and Inspection (HFAMI)” provides access to products of the Federal Aviation Administration Flight Standards Service Human Factors in Aviation Maintenance and Inspection Program. Many aviation maintenance industry trade magazines include a section or at least a page devoted to human factors. “The Human Factors and Ergonomics Society” is a national organization composed of 22 technical groups, including one devoted to aerospace systems, which address both civilian and military issues of safety and performance.