The Human Factors System
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.
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 is seen 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.
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 errors often 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.
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).
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 is crucial 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.
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.
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