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Communication Breakdowns That Lead to Disaster

Introduction: The Memo Nobody Read We’ve all experienced it: the important company memo about a new process, posted to a shared drive or tacked to a bulletin board, that goes completely ignored. The result is usually minor confusion or an annoying, preventable mistake. But what happens when that missed memo involves the O-ring seals on a jet engine? In high-stakes environments like aviation maintenance, the consequences of failed communication are catastrophic. The principles that prevent disasters in an aircraft hangar are the same ones that can make or break any team. Drawn from aviation safety reports, these are the critical, life-saving lessons on how communication truly works—and what happens when it doesn't. 1. The Illusion of Communication: Why Posting a Memo Isn't Enough The first critical failure is assuming that making information available is the same as communicating it. True communication only happens when a message is received and understood, and simply posting a...
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Human performance is at times imperfect

  The statement “It has long been acknowledged that human performance is at times imperfect” means that: Humans are not machines – even skilled, trained, and experienced people can make mistakes. Unlike automated systems, human behavior is influenced by fatigue, stress, workload, distractions, memory limits, and even emotional state. Errors are natural and expected – mistakes, lapses, and slips are part of human performance. They do not always indicate negligence or incompetence; rather, they are often the result of the limitations of human capability . History and experience support this fact – in industries like aviation, medicine, and nuclear operations, many accidents and incidents have shown that human error is a major contributing factor. This has led to the development of Human Factors as a discipline to understand and mitigate these limitations. Organizations must account for imperfection – instead of expecting flawless performance, systems, procedures, and safeguards...
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Good human factor principal

Good Human Factors principles are essential for designing maintenance procedures in aviation that are safe, efficient, and effective. Here are some key principles: Error Prevention and Recovery 1. *Clear instructions*: Provide step-by-step instructions for maintenance tasks. 2. *Visual aids*: Use diagrams, pictures, and videos to support instructions. 3. *Error-proofing*: Design procedures to prevent errors from occurring. 4. *Recovery procedures*: Establish procedures for recovering from errors or unexpected events. Decision Support 1. *Decision trees*: Provide decision trees to aid technicians in making informed decisions. 2. *Checklists*: Use checklists to ensure critical tasks are completed. 3. *Diagnostic tools*: Provide diagnostic tools to aid in troubleshooting. Workload Management 1. *Task segmentation*: Break down complex tasks into smaller, manageable segments. 2. *Workload allocation*: Allocate workload according to technician expertise and availability. 3. *Rest and break p...
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Need To Take HF Into Account

"Need to take HF into account" refers to the importance of considering Human Factors (HF) in various contexts, such as: 1. Aircraft maintenance: Considering the potential for human error, fatigue, and other factors that can impact maintenance tasks. 2. System design: Designing systems that account for human limitations, abilities, and behaviors to minimize errors and optimize performance. 3. Training: Developing training programs that address human factors, such as decision-making, communication, and teamwork. 4. Safety management: Identifying and mitigating potential safety risks related to human factors. 5. Error management: Understanding how human factors contribute to errors and developing strategies to prevent or mitigate them. Human Factors include aspects like: - Cognitive abilities (perception, attention, memory) - Physical abilities (strength, endurance, dexterity) - Emotional and social factors (stress, fatigue, teamwork) - Organizational and environmental factors (...
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Social Psychology

      Social Psychology  is the  scientific  study of how people's  thoughts ,  feelings ,and  behaviors  are influenced by the actual, imagined, or implied presence of others.                Social psychologists examine factors that cause behaviors to unfold in a given way in the presence of others.      Social psychologists  study conditions under which certain behavior, actions, and feelings occur. Social psychology is concerned with the way these feelings, thoughts, beliefs, intentions, and goals are cognitively constructed and how these mental representations, in turn, influence our interactions with others.       Social Environment -  AMEs work within a “system”.  There are various factors within this system that impinge on the AMEs , ranging from his knowledge, skills and abilities , the environment in which he works, to the culture  of ...
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Internal Occurrence Management Scheme

 Internal Occurrence Management Scheme (OMS).  An Occurrence Management Scheme should contain the following elements:   clearly identified aims and objectives;  demonstrable corporate commitment with responsibilities for the Occurrence Management Scheme clearly defined;   corporate encouragement of uninhibited reporting and participation by individuals;   disciplinary policies and boundaries identified and published;  an occurrence investigation process;   the events that will trigger error investigations identified and published;  investigators selected and trained;  OMS education for staff, and training where necessary;   appropriate action based on investigation findings• feedback of results to workforce;   analysis of the collective data showing contributing factor trends and frequencies.                        The aim of the scheme i...
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Occurrence Reporting

               A key element of a HFP is a system whereby problems, or potential problems, can be reported and dealt with.                                           Many organisations already have some form of reporting system for technical issues or discrepancies, but this may need to be expanded, or additional system(s) put in place, to allow for the reporting of human errors, ambiguities with procedures, mismatches between required and actual practice, etc.              The CAR145 requirement is for an organisation to have in place an internal occurrence reporting scheme to enable the collation of occurrence reports, including the assessment and extraction of relevant information in order to identify adverse trends or to address deficiencies in the interests of safety.         ...
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