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…
7) Lack of Resources
Sometimes defined as failure to use or acquire the appropriate tools, equipment, information and procedures for the task at hand. If all the parts are not available to complete a task, then there may be pressure to complete that task somehow either by an inappropriate alternative, taking a shortcut or by using old, or incorrect parts.
Regardless of the task, resources also include personnel, time, data, tools, skill, experience and knowledge etc. A lack of any of these resources can interfere with one’s ability to complete a task. It may also be the case that the resources available, including support, are of a low quality or inadequate for the task.
When the proper resources are available, and to hand, there is a greater chance that we will complete a task more effectively, correctly and efficiently. Therefore, forward planning to acquire, store and locate resources is essential. It will also be necessary to properly maintain the resources that are available; this includes the humans in the organisation as well.
Sometimes the pressure to “just get the job done” results in human nature finding a solution – but is it safe? Does it follow a procedure? What would happen if the solution went wrong? How many times in the last week have you done something that does not follow a procedure, is unsafe or breaks the rules? How often in the past week have you broken a driving speed limit?”
Pressure comes from many sources, just like distraction, and is often caused by pushing for something despite opposing odds, creating a sense of urgency or hassle. Pressure is to be expected when working in the dynamic environment of aviation.
However, when the pressure to meet a deadline interferes with our ability to complete tasks correctly, then it has become too much. It is the old argument of Quantity versus Quality; and in aviation we should never knowingly reduce the quality of our work.
Pressure can be created by lack of resources, especially time, and from our own inability to cope with a situation. We may come under direct, or indirect pressure from a job requirement, from clients and even from colleagues.
However, one of the most common sources of pressure is us.
We put pressure on ourselves by taking on more work than we can handle, especially other people’s problems, by trying to save face, and by positively promoting super powers that we do not possess. These poor judgements are often the result of making assumptions about what is expected of us.
Learning assertiveness skills will allow a worker to say ‘No’, ‘Stop!’, and communicate concerns with colleagues, customers or themselves. These skills are essential, and when deadlines are critical, extra resources and help should always be obtained to ensure the task is completed to the required level of quality.
9) Lack of Assertiveness
Following on from the above, this factor links well. If we did want to react to the requirement of pressure, then being assertive is often the skill required to counteract it. A lack of assertiveness is a lack of positive communication of one’s ideas, wants and needs. Being both unable to express our concerns and not allowing others to express their concerns creates ineffective communications and damages teamwork. Unassertive team members can be forced to go with a majority decision, even when they believe it is wrong and dangerous to do so.
Assertiveness is a communication and a behavioral style that allows us to express feelings, opinions, concerns, beliefs and needs in a positive and productive manner.
When we are assertive, we also invite and allow others to assert themselves without feeling threatened, undermined or that we’ve lost face. Speaking one’s mind assertively is not to be confused with aggression. It is about communicating directly, but honestly and appropriately; giving respect to the opinions and needs of others, but not compromising our own standards.
Assertiveness techniques can be learnt and they focus on keeping calm, being rational, using specific examples rather than generalisations, as well as inviting feedback. Most importantly, any criticisms should be directed at actions and their consequences rather than people and their personalities; this allows others to maintain their dignity, and a productive conclusion to be reached.
Stress can be a silent killer. It can build and build and build to breaking point, then suddenly we're overwhelmed to the point we can no longer function or inflict harm on ourselves, friends or family. Just like pressure, know how to recognize the signs and know where to turn for help are vital. It's not a sign of weakness.
There are many types of stress. Typically, in the aviation environment there are two distinct types - acute and chronic. Acute stress arises from real-time demands placed on our senses, mental processing and physical body; such as dealing with an emergency or working under time pressure with inadequate resources.
Chronic stress is accumulated and results from long-term demands placed on the physiology by life’s demands, such as family relations, finances, illness, bereavement, divorce, or even winning the lottery. When we suffer stress from these persistent and long-term life events, it can mean our threshold of reaction to demands and pressure at work can be lowered. Thus, at work, we may overreact inappropriately, too often and too easily.
The situation of stress arising from lack of stimulation at work has been covered above under Complacency.
Some early visible signs of stress include changes in personality and moods, errors of judgement, lack of concentration and poor memory. Individuals may notice difficulty in sleeping and an increase in fatigue, as well as digestive problems. Longer-term signs of stress include susceptibility to infections, increased use of stimulants and self-medication, absence from work, illness and depression.
It is important to recognise the early signs of stress and to determine whether it is acute or chronic. Coping with daily demands at work can be achieved with simple breathing and relaxation techniques. However, perhaps more effective is having channels of communication readily available through which to discuss the issue and help to rationalize perceptions.
It is entirely appropriate that some of these channels involve social interaction with peers. As with fatigue, sleep, diet and exercise are all important factors in helping to reduce stress and build resilience to stressors. If the stress is chronic, then definite lifestyle changes will be required; this must be achieved with support from an employer. Companies therefore should offer employee assistance or wellbeing policies that include stress reduction programmes.
11) Lack of Awareness
Situational awareness is so important when working in all manners of the aviation environment. Simply knowing what's going on around you all the time is a skill but also a requirement. Lack of awareness occurs when there is a lack of alertness and vigilance in observing.
This usually occurs with very experienced persons who fail to reason out possible consequences to what may normally be a good practice. One of the safety nets for lack of awareness is to ask more “what ifs” if there is conflicting information or things don’t quite seem right.
Working in isolation and only considering one’s own responsibilities can lead to tunnel vision; a partial view, and a lack of awareness of the affect our actions can have on others and the wider task. Such lack of awareness may also result from other human factors, such as stress, fatigue, pressure and distraction.
It is important to build experience throughout our careers, especially concerning the roles and responsibilities of those we work with, and our own place in the wider Team.
Developing our foresight is essential in pre-empting the affects our actions may have on others. This is an attitude of professionalism and involves constant questioning “what if …?”
Asking others to check our work and challenge our decisions is useful in gaining the relevant experience and expanding our awareness. Vigilance is closely related to situational awareness, and workplace procedures, such as scanning, two-way communication and use of checklists will help to maintain vigilance.
Situational awareness is vital when driving on an airfield. Understanding where you are and what you need to do safely is vital. It is so easy it to become distracted and to become too focused on one thing meaning that you then forget or cannot see what else you need to be doing. It is easy to lose the ability to carry out a task safely and successfully because you are trying to do, or have been given too many things to do at once Lack of situational awareness and be summarised with:
• Focused Attention
• Task Saturation
Commonly accepted practices where assumptions are made that the course of action or procedure is correct based on history without re- validating or verifying the current procedures is known as “Norms”.
Be aware of the norms or the normal or the way things are routinely done. Be particularly vigilant for negative normal that detract from what we consider acceptable safety standards and practices. With changing technology and structures, we must no longer be sucked into the whole, "That's how we've always done it".
Workplace practices develop over time, through experience, and often under the influence of a specific workplace culture. These practices can be both, good and bad, safe and unsafe; they are referred to as “the way we do things round here”. Unfortunately, such practices follow unwritten rules or behaviors, which deviate from the required rules, procedures and instructions.
These Norms can then be enforced through peer pressure and force of habit. It is important to understand that most Norms have not been designed to meet all circumstances, and therefore are not adequately tested against potential threats.
Rules and procedures should have been designed and tested, and therefore ought to be enforced and followed rigorously.
Where workers feel pressure to deviate from a procedure, or work around it, then this information should be fed back so that the procedure can be reviewed and amended, if necessary.
That concludes the list of 12 but as mentioned earlier it is not exhaustive and the description I’ve commented on beneath the headings is only a view and can be expanded on. Just try and think of when an error occurred was it solely the action of the brain, or which, or which combination of the above can the situation be attributed to and is there is anything that could have been done differently.
Finally, and as I alluded to at the start, the whole situation of the mistake or error may have been triggered by a poor design, something or a process that was not fit for purpose or could have been planned better. Quite often the reason for a human to undertake a task that is unsafe or requires us to adapt is because the process or equipment is wrong, and we must be prepared to report and suggest improvement. There are also many studies on this topic, but I’ll conclude and leave space for further articles in the future.
Common human behaviour is to look for the easier way of doing something. A way that is quicker, is more straightforward despite the impact of that action maybe. Is it the design or the human?
Read the rest of Simon Newbold's excellent Pilot Error series here:
- 26 Feb 2018
- Mario Pierobon