Pilot Error: Getting to Know the ‘Dirty Dozen’ (Part 2)

Gordon Dupont established his ‘Dirty Dozen’ list to increase awareness of how human factors can contribute towards accidents and incidents. Simon Newbold continues his series with a look at the first six issues as they might apply to pilots.

Guest Posts  |  Simon Newbold  |  22nd March 2019
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Simon Newbold
Simon Newbold

Simon Newbold, an airfield operations consultant, began his career at then BAA Heathrow in September...

Dirty Dozen Pilot Safety Concerns

Gordon Dupont established his ‘Dirty Dozen’ list to increase awareness of how human factors can contribute towards accidents and incidents. Simon Newbold continues his series with a commentary of the first six issues as they might apply to pilots…
1) Lack of communication

The lack of clear direct statements and good, active listening skills. Poor communication often appears at the top of contributing and causal factors in accident reports, and is therefore one of the most critical human factor elements.
 Communication refers to the transmitter and the receiver, as well as the method of transmission. Transmitted instructions may be unclear or inaccessible. The receiver may make assumptions about the meaning of these instructions, and the transmitter may assume that the message has been received and understood. With verbal communication it is common that only 30% of a message is received and understood.
Detailed information must be passed before, during and after any task, and especially across the handover of shifts. Therefore, when messages are complex, they should be written down, and organisations should encourage full use of logbooks, worksheets, and checklists etc. 
Verbal messages can be kept short, with the most critical elements emphasised at the beginning and repeated at the end. Assumptions should be avoided and opportunities for asking questions both given and taken.
It is important to remember that communication is carried out through words, by using a tone and is often transmitted with body language. The choice and use of words should take into consideration that the text may be spoken, written and read too. Next is how we say those words, how loud or clear is the voice, what variety is there in the content, how are intonation, expression, phrasing and pauses used to make the message clearer? 
Finally, body language is important as what is being said is sometimes being observed.
2) Complacency

Complacency can occur for several reasons, including over-confidence, lack of understanding, lack of training, lack of experience and many others. Training or learning should always be practiced like it's the real thing. We must never stop training and we must never stop learning. Everyone can still learn something, especially with changing technology, changing structural features, and lack of putting into practice what we have been taught.
Complacency can be described as a feeling of self-satisfaction accompanied by a loss of awareness of potential dangers. Such a feeling often arises when conducting routine activities that have become habitual and which may be “considered”, by an individual or indeed by an organisation, as easy and safe. 
A general relaxation of vigilance results, and important signals are missed, with the individual only seeing what he, or she, expects to see. 
Complacency can also occur following a highly intense activity such as recovering from a possible disaster; the relief felt at the time can result in physical relaxation and reduced mental vigilance and awareness. This psychological experience is referred to as a lacuna.
Whilst too much pressure and demand cause over-stress and reduced human performance, too little results in under-stress, boredom, complacency and reduced human performance. It is therefore important, when conducting simple, routine and habitual tasks, and when fatigued, to maintain an adequate, or optimum, level of stress through different stimulation. 
Always expect to find a fault, always look for something that may have been missed. Following written instructions, and adhering to procedures that increase vigilance, such as inspection routines, can provide suitable stimulus. It is important to avoid:
  • Working from memory;
  • Assuming that something is ok when you haven’t checked it;
  • Signing off work that you are unsure has been completed.
Teamwork and mutual cross-checking will provide adequate stimulus when fatigued.
3) Lack of knowledge

From the experienced, to the new recruit, knowledge is everything. For that new starter, absorb it, act like a sponge and soak it up. For the one that has been there and done it, share it and never assume you know everything - it's impossible!
The regulatory requirements for training and qualification can be comprehensive, and organisations are forced to strictly enforce these requirements. 
However, lack of on-the-job experience and specific knowledge can lead workers into misjudging situations and making unsafe decisions. Aircraft systems are so complex and integrated that it is nearly impossible to perform many tasks without substantial technical training, current relevant experience and adequate reference documents. Furthermore, systems and procedures can change substantially, and employees’ knowledge can quickly become out-of-date.
It is important for all employed in the industry to undertake continuing professional development and for the most experienced workers to share their knowledge with colleagues. 
Part of this learning process should include the latest knowledge on human error and performance. It should not be taken as a sign of weakness to ask someone for help or for information; in fact, this should be encouraged. 
Checklists and publications should always be referred to and followed, and never make assumptions or work from memory. Across the world there are numerous case studies or examples of incidents or accidents that we all can learn from.
4) Distraction

If it takes your mind off the job, then it's a dangerous distraction. It is also fatal to become so tunnel-visioned that you could lose sight of something. Distraction could be anything that draws a person’s attention away from the task on which they are employed. 
Some distractions in the workplace are unavoidable, such as loud noises, requests for assistance or advice, and day-to-day safety problems that require immediate solving. Other distractions can be avoided, or delayed until more appropriate times, such as messages from home, or administration tasks.
Psychologists say that distraction is the number one cause of forgetting things, hence the need to avoid becoming distracted and to avoid distracting others. Humans tend to think ahead. Thus, when returning to a task, following a distraction, we tend to think we are further ahead than we actually are.
To reduce errors from distraction it is best to complete a task before responding. 
If the task cannot be completed without hurrying, then we can prominently mark (or “lock off”) the incomplete work as a reminder to ourselves and anyone else who may complete the work. When returning to work, after being distracted, it is a good idea to commence at least three steps back, so that we re-trace some steps before picking up the task again. 
If necessary, having someone else double-check our work using a checklist may be appropriate and useful. Another opportunity is to consider good workspace design, management of the environment, and procedures that create “safety zones”, “circles of safety” or “do not disturb areas” around workers engaged in critical tasks.
5) Lack of Teamwork

In aviation many tasks and operations are team affairs; no single person or organisation can be responsible for the safe outcomes of all tasks. However, if someone is not contributing to the team effort, this can lead to unsafe outcomes. This means that workers must rely on colleagues and other outside agencies, as well as giving others their support. Teamwork consists of many skills that each team member will need to prove their competence.
Some of the key teamwork skills include: leadership, followership, effective communication, trust-building, motivation of self and others, and praise giving. To create an effective team, it is necessary that the following issues, as appropriate, are discussed, clarified, agreed, and understood by all team members:
  • A clearly defined and maintained aim, or goal(s)
  • Each team member’s roles and responsibilities
  • Communication messages and methods
  • Limitations and boundaries
  • Emergency procedures
  • Individual expectations and concerns
  • What defines a successful outcome?
  • Debriefing arrangements
  • Opportunities for questions and clarification
A team’s effectiveness can also be improved through the selection of team members to reflect a broad range of experience and skill sets. All of this is then further enhanced through practice and rehearsal.
6) Fatigue

Fatigue is weariness from labour or exertion, nervous exhaustion or the temporary loss of power to respond. It is a natural physiological reaction to prolonged physical and/or mental stress. We can become fatigued following long periods of work and also following periods of hard work. 
When fatigue becomes a chronic condition, it may require medical attention. As we become more fatigued our ability to concentrate, remember and make decisions reduces. Therefore, we are more easily distracted and we lose situational awareness. Fatigue will also affect a person’s mood, often making them more withdrawn, but sometimes more irrational and angry.
It is a human problem that we tend to underestimate our level of fatigue and overestimate our ability to cope with it. 
Therefore, it is important that when we are doing something, we are aware of the signs and symptoms in ourselves and others.
Fatigue self-management involves a three-sided programme of regular sleep, a healthy diet, and exercise. Work of a critical and complex nature should not be programmed during the low point on the body’s circadian rhythm, usually 03:00–05:00am; and, when fatigued, always get someone else to check your work.
Fatigue or tiredness is a big factor in human factors that has or has nearly caused many an incident. How many times have you driven when tired? How many times have you lost concentration and then used the excuse that you are tired?

Stay tuned – next month we’ll cover the other six items covered on the ‘Dirty Dozen’ watch-list!

Read the rest of Simon Newbold's excellent Pilot Error series here:

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Simon Newbold

Simon Newbold

Guest Post

Simon Newbold, an airfield operations consultant, began his career at then BAA Heathrow in September 1990.  He worked in a variety of front line operational and managerial roles before spending four years as an Airfield Planning Manager, before returning to the front-line operation as a supervisor. Simon’s passion and knowledge for all things in the operation and the airports’ history has seen him train over 100 staff. After 27 and a half years Simon left Heathrow in February 2018 to take on a new challenge working for the high-profile Airport Management Consultancy firm APMC.



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