The Human Factors System
By OffRoadPilots
Human factors are an integral part of a safety management system (SMS)
Compression disk are integrated parts of a turbine engine, matching gears are
integrated into a manual transmission system, and a nylon line is a part of a fishing
system. When a compression disk, transmission, or fishing line fail, are
malfunctions of one system, and is not a failure of the entire system. A failure will
affect the overall transportation or recreational system, but a failure does not fail
the overall systems. A human error, or human failure does not fail the entire safety
management system.
Human errors are mistakes or
actions made by individuals
that result in unintended or
undesired outcomes. These
errors can occur in various
contexts, including everyday
life, work, healthcare,
aviation, and many others.
Skill-Based Errors: These
errors happen during routine
tasks that individuals have
mastered but can still make mistakes due to lapses in attention or distractions. For
example, a typist may hit the wrong key on a keyboard due to momentary
inattention.
Decision Errors: Decision errors occur when individuals make poor judgments or decisions. This can result from factors like incomplete or inaccurate information, cognitive biases, or a lack of experience. For instance, a manager may make a poor investment decision based on incomplete market data. An accountable executive may make poor decisions based on bias, or the use of invalid data.Perceptual Errors: Perceptual errors involve misinterpreting sensory information.
People may misread a label, misunderstand a signal, or misinterpret a visual cue.
For instance, a pilot might misinterpret an instrument reading. An SMS manager
may misinterpret a regulatory requirements, such as their perceived safety, or an
Airport Manager may misinterpret an airport standard, or how to apply the
standard.
Memory Lapses: These errors occur when individuals forget important information
or instructions. Forgetting a crucial step in a procedure or neglecting to set a
reminder can lead to memory lapses. Training isa crucial element of a successful
SMS to remain current and with knowledge of requirement.
Attentional Errors: Attentional errors happen when individuals are focusing on
other tasks than on the current task at hand. Distractions, multitasking, fatigue, or
stress can reduce attention and lead to errors. For example, a driver who is texting
while driving, or a pilot texting while taxiing may miss a stop sign or a taxilane
marking. Attention errors occurs when one of the five senses are affected by
outside interference (such as texting).
Procedural Errors: Procedural errors involve mistakes in following established
procedures or protocols. These can happen due to a lack of knowledge, confusion,
rushing through a process, or where skipping steps is an accepted organizational
work practice. For instance, a pilot could skip a part of the landing checklist while
focusing on other events on approach to an airport.
Complacency Errors: Complacency refers to a state of self-satisfaction and
contentment, often accompanied by a lack of motivation or willingness to make
necessary changes or improvements. When someone is complacent, they tend to
be overly comfortable with their current situation or achievements, and they may
not feel the need to strive for further progress or growth. This attitude can be
detrimental in various aspects of life, as it can lead to stagnation, missed
opportunities, and a failure to address potential problems or challenges. In many
contexts, such as personal development, business, and leadership, complacency isseen as a negative trait because it can hinder progress and innovation.
Encouraging a proactive and continuously improving mindset is often seen as a
way to counteract complacency.
Communication Errors: These
errors involve
misunderstandings or
miscommunications between
flight crew, or pilots and ATC.
Poor communication can
result in missed instructions,
misinterpreted messages, or
confusion among team members.
Contextual Errors: Contextual errors occur when individuals make decisions or take
actions based on the wrong context or assumptions. This can lead to unintended
consequences. For example, an aircraft mechanic may use the wrong settings for
an aircraft because they assume it is the same or similar to what they have used
before.
Intentional Errors: In some cases, individuals may deliberately engage in actions
they know are incorrect or unsafe. This can be due to various reasons, such as
pressure, a desire for shortcuts, or malicious intent. When errors are made
intentionally, they are not errors but unacceptable behaviors. Conventional
wisdom is to call unacceptable behaviors errors, but the root cause, or special
cause variation is when the human factors system deliberately behaves to produce
a hazard. On the other hand, intentional error may also be resilience to recover an
aircraft to safety after an unexpected event occurred. Example of a recovery error
is if a pilot experienced a 50KTS direct crosswind while landing, and intentionally
raise the flaps to climb out of the hazard.
It's important to note that human errors are a normal part of human behavior, and
they can occur in any field or activity. Efforts to reduce the impact of human errorsoften involve training, improving systems and procedures, and implementing
safeguards and redundancy to minimize the consequences of these errors.
The human factors system is affected by the five senses.
The five senses are the sensory mechanisms or faculties through which humans
and many animals perceive and interact with the world around them.
Sight (Vision): Sight is the sense of seeing, and it allows individuals to perceive and
interpret the world through visual stimuli. The eyes detect light, color, shapes, and
movement.
Events can affect sight in various ways, as they can introduce temporary or lasting
changes to the visual experience. Here are some ways in which events can impact
sight:
Lighting Changes: Events such as sudden changes in lighting conditions can have an
immediate impact on sight. For example, walking from a brightly lit area into a dark
room can temporarily impair vision until the eyes adjust to the new lighting.
Visual Distractions: Events that create visual distractions, such as flashing lights,
bright displays, or intense visual stimuli, can divert a person's attention and
momentarily affect their ability to focus on other objects or tasks.
Visual Fatigue: Prolonged exposure to events with intense visual stimuli, such as
watching a fast-paced action movie or playing video games for an extended period,
can lead to visual fatigue, eye strain, and temporary blurriness.
Emotional Events: Strong emotional events can influence sight through
physiological responses. For example, during highly emotional moments, the
body's stress response may affect the eyes, leading to changes in pupil size or
blurring of vision due to tears.Optical Illusions: Events or patterns that create optical illusions can distort one's perception of their surroundings. These illusions occur when the brain processes visual information in a way that differs from reality.
Psychological Effects:
Traumatic or emotionally
charged events can have
psychological effects that
indirectly impact sight. Post-
traumatic stress disorder
(PTSD), for instance, may lead
to flashbacks or hallucinations
that affect a person's visual
perception.
Environmental Changes:
Events related to environmental factors, such as natural disasters (e.g.,
earthquakes, hurricanes), can damage infrastructure and disrupt access to
essential services, including eye care. This can indirectly affect sight if individuals
are unable to receive necessary medical attention or access eyeglasses or contact lenses.
Accidents and Injuries: Events such as accidents, falls, or physical injuries can
directly impact sight by causing damage to the eyes or head trauma that affects
visual processing in the brain.
Medical Emergencies: Sudden medical events like strokes or migraines can lead to
visual disturbances or even temporary blindness in some cases.
Medication or Substance Use: Events involving the use of certain medications,
recreational drugs, or alcohol can affect vision. Some substances can cause visual
hallucinations, impaired perception, or blurred vision.It's important to recognize that the impact of events on sight can vary widely depending on the specific circumstances and individual factors.
While some events may result in temporary visual disturbances, others may lead to long-term
consequences. Addressing vision-related issues often involves consulting with
healthcare professionals, particularly if the events lead to sustained or severe
visual impairments. Regular eye exams and appropriate medical care can help
manage and improve visual health in response to various events that affect sight.
Hearing (Audition): Hearing is the sense of sound perception. It involves the
detection of vibrations (sound waves) in the air or other media by the ears.
Humans can hear a wide range of sounds and use hearing to communicate, detect
danger, and enjoy music, among other things.
Events can affect hearing in several ways, depending on the nature and intensity of
the event. Hearing is a complex physiological process, and exposure to various
Noise Exposure: Events with loud or sudden noises, such as concerts, fireworks,
gunfire, explosions, or industrial machinery, can lead to temporary or permanent
hearing damage. Prolonged exposure to high noise levels can damage the delicate
hair cells in the inner ear, leading to noise-induced hearing loss (NIHL).
Traumatic Events: Traumatic events like head injuries or accidents can damage the
auditory system, including the ear structures and the auditory nerve, potentially
resulting in hearing loss.
Acoustic Trauma: Exposure to extremely loud and sudden sounds, such as
gunshots or explosions, can cause immediate damage to the structures of the ear
and result in immediate hearing loss or tinnitus (ringing in the ears). Some aircraft,
such as the JetStream (nicknamed “JetScream”) is known for extreme high noise
exposure up to 120dB.Ear Infections: Events like ear infections can lead to temporary hearing loss,
especially in children. The infection can cause fluid buildup in the middle ear,
affecting sound transmission to the inner ear.
Barotrauma: Events that involve rapid changes in air pressure, like scuba diving or
flying in an airplane, can sometimes cause barotrauma to the ear, leading to ear
pain and temporary hearing problems.
Physical Injury: Events involving physical trauma to the head or ear can lead to
damage to the ear structures and potential hearing loss.
Psychological Stress: High-stress events and trauma can exacerbate existing
hearing conditions like tinnitus or hyperacusis (increased sensitivity to sounds).
It's important to protect the
hearing in noisy or potentially
harmful environments by
wearing earplugs or earmuffs,
maintaining a safe distance
from loud sources, and
seeking prompt medical
attention if sudden hearing
changes are experienced or
injuries related to events.
Hearing loss is often
irreversible, so prevention is
key to maintaining good
auditory health.
Taste (Gustation): Taste is the sense of detecting different flavors and chemicals
through the tongue and taste buds. The basic taste sensations are sweet, sour, bitter, salty, and umami (savory).The sense of taste does play a role in recognizing certain hazards or potentially harmful substances in the environment, particularly in the context of taste in the air from leaking hazardous materials in an aircraft, bodily exposure to toxic air after an aircraft accident or train derailments, or exposure and spill from leaking fuel or oil from an aircraft.
Smell (Olfaction): Smell is the sense of detecting odors and scents through the
nose. Olfactory receptors in the nasal passages help individuals perceive and
differentiate between various smells.
Smell plays a crucial role in recognizing hazards, as it is one of our primary senses
that can detect and alert us to potential dangers in our environment.
Detection of Noxious Odors: The human olfactory system is sensitive to a wide
range of odors, including those associated with hazardous substances such as
chemicals, gases, and spoiled food. When we encounter noxious or unusual smells,
our brain signals us to be cautious and investigate further.
Early Warning for Hazardous Material Leaks: Smell is often the first line of defense
against hazardous material leaks from the freight compartment. When there is
hazmat smell, signals an immediate danger and prompts flight crew to take action,
such as closing airducts to the cockpit and passenger cabin. An example of
identifying hazardous smell is the SwissAir 111 crash where the smell initially was
ignored as a hazardous smell.
Identifying Fire and Smoke: Smoke from fires produces a distinct and acrid smell.
Recognizing this odor is crucial in identifying a fire hazard. The smell of burning
materials alerts flight crew to a fire even before they see flames or smoke, allowing
for a faster response.
Detecting Spoiled Food: Smell helps us identify spoiled or rotten food, which can
be a hazard if consumed. The foul odor of spoiled food indicates the presence of
harmful bacteria or toxins, and avoiding it helps prevent foodborne illnesses. It iscrucial for flight crew to avoid spoiled food, and each flight crew may receive
different meals form different suppliers.
Recognizing Chemical Hazards: Many chemicals emit strong and potentially
harmful odors. Being able to detect these odors is essential in environments where
exposure to hazardous chemicals is a risk. Chemical leaks, spills, or improper
storage can release odorous chemicals that signal the need for immediate action
and evacuation.
Identifying Biological Hazards: Some biological hazards, such as the smell of mold,
mildew, or sewage, can be detected through smell. These odors may indicate the
presence of harmful microorganisms or unsanitary conditions.
Sensing Environmental Hazards: Smell can also help in recognizing environmental
hazards, such as the smell of smoke from a nearby wildfire or the odor of polluted
air or water. These smells can signal poor air quality or water contamination,
prompting pilots to take avoidance actions. When smoke from wildfires is extreme,
a pilot may not be capable of performing required tasks.
It's important to note that while smell is a valuable tool for hazard recognition, it
should not be relied upon exclusively. Other senses, such as sight and hearing,
along with various monitoring and detection devices, play critical roles in
identifying and mitigating hazards. In situations involving potential hazards, it is
essential to trust instincts and take appropriate safety measures, which may
include diverting from the area, notifying ATC, or seeking medical assistance after
the experience.
Touch (Tactile Perception): Touch is the sense of physical contact and pressure on
the skin and other body tissues. It allows individuals to feel textures, temperatures,
pain, and pressure. It also plays a crucial role in perceiving sensations such as
pleasure and pain.Touch is one of our primary senses that allows us to gather information about the physical world by making contact with objects and surfaces. While touch itself
doesn't "recognize" hazards in the way our brain does, it provides us with
important sensory input that our brain interprets to identify potential hazards.
Temperature Sensation: The skin has specialized receptors called thermoreceptors
that detect temperature changes. Touch can help us recognize hazards like
extreme heat (e.g., a hot stove or a burning surface) or extreme cold (e.g., freezing
water) by sensing temperature variations.
Pain Perception:
Nociceptors are sensory
receptors in the skin that
detect painful or harmful
stimuli. When you touch
something that is sharp,
pointy, or otherwise
dangerous, nociceptors can
send signals to the brain to
alert you to potential harm.
Texture and Surface
Recognition: Touch allows
us to perceive the texture and surface characteristics of objects. For example, a slippery or uneven surface might be recognized through touch, helping us avoid slips and falls.
Pressure Sensation: Mechanoreceptors in the skin detect pressure changes. When you touch something with too much pressure or force, the brain can interpret this input as a potential hazard, such as a heavy object that could fall or cause injury.Texture and Shape Recognition: Through touch, we can identify the shape, size, and texture of objects. This can help us recognize objects that may be sharp, jagged, or otherwise pose a threat if handled incorrectly.
Vibration Sensation: Vibrations can be detected through touch, and unusual
vibrations in an object or surface can indicate a malfunction or potential hazard,
like a malfunctioning machine or an unstable structure.
It is important to note that while touch plays a crucial role in identifying potential
hazards, our brain's interpretation of these sensory inputs is what ultimately allows
us to recognize and respond to hazards effectively. Touch is just one part of a
complex sensory system that works in conjunction with our other senses, such as
vision and hearing, to keep us safe and aware of our surroundings.
These five senses collectively provide individuals with a rich and complex
understanding of their environment, enabling them to navigate, communicate, and
experience the world around them.
The human factors system is a complex system and cannot be swept under the
carpet, ignored, or pushed away by deciding on pilot error or aircraft mechanic
error.
When a root cause is assigned to pilot error, the root cause excludes the human
factors system. Each one of the five sense are a part of human factors. When root
cause is assigned is that the pilot failed to complete a checklist task, it is assumed
that none of the five senses affected the pilot.
Pilot error, or failure to complete a task is not the cause, but a symptom allowed
by the system. Human factors and human behavior are integrated parts of a
system and needs to be included in the equation to assign a relevant root cause.
OffRoadPilots
