Errors and Violations

 A working definition of “human error” (including violations) is “those occasions in which a planned sequence of mental or physical activities fails to achieve its intended outcome, and when these failures cannot be attributed to the intervention of some chance agency”.              It is useful to distinguish, right from the outset, the difference between "human error" and "system error". 

Whilst it is always a human being who commits the error, there are two approaches to looking at error: 

(i) from the point of view of the individual and 

(ii) from the point of view of the whole system, of which the individual technician is only one part. 

The concept of "maintenance error" is sometimes equated to "system error". Another useful way of looking at error (and violations) is in terms of system component failure, where human actions are part of the system and need to be engineered such that they are resistant to error and, in the case of failure, error detection and alerting mechanisms built into the system. People often think of "human error" as an erroneous action made by the last person to touch the aircraft before it went wrong! It may well be the case that there was an erroneous action on the part of a maintenance technician, but it is important to look at this in the context of the whole system and organisational factors which may have contributed to that error. The reader is encouraged to read CAP 715 which contains a succinct description of types of errors and violations, or to refer to Professor James Reason’s book “Human Error” for a more detailed description and discussion of the subject. A good understanding of the causes of errors and violations is necessary in order to address them. All too often, the ‘blame and train’ approach is used inappropriately to address error. It is important to understand the root causes behind errors and violations, and whether an error is a ‘one off’ or a more systemic problem which may re-occur, and whether it is a problem with an individual technician or with the system.

Human Factors training will help individuals recognise the factors which may lead to errors and violations and to avoid error provoking situations and behaviour as far as possible. However, this can only have limited effectiveness without the whole maintenance system being designed to be error resistant, e.g. well-written procedures, good planning, mechanisms for detecting and highlighting errors when they do occur, etc. Human error is inevitable and can never be totally eliminated. The emphasis within a maintenance organisation should be upon pro-active error management. The processes and mechanisms described within the CAP should help an organisation to better manage its errors, violations and error potential.

Popular posts from this blog

Human Factor Introduction

Human Factor -  A  Person working in a maintenance environment requires human factor knowledge as per his job requirement. Human Factor Training  - Aviation safety relies on maintenance. When it is not done correctly , it may cause an incident or an accident.  Mistakes of maintenance personnel is difficult to detect. They are subjected to work in changing working in variety of adverse conditon. Regulatory Requirement : CAR 66 Module 09 Human factor - for get AMEL Human Factor   - Study of human capabilities and limitations in the workplace.   It is about study of the interaction  of maintenance personnel, the equipment used, the written and verbal procedures and  rules followed by them, and the environmental conditions of any system.  Aim of human  factors is to optimise the relationship between maintenance personnel and systems to improve  safety, efficiency, and well-being. HF - Fitting the man to the job and the job to th...
Read more

SHEL(L) Model

Model are used to understand human factor  as a framework around which human factor issues can be structured. SHEL(L),PEAR, Dirty Dozen  S - Software H - Hardware L - Liveware E - Environment                                         Liveware  is at the center of the model, is   the most critical and flexible component in the working  Environment and subject to considerable variations in performance and suffer many limitations.                           Physical size and shape.  In the design of workplace and equipment, body measurements and movements is considerd , which may vary according to factors such as age, ethnicity and gender. Human Factors inputs is provided  in the design process, and data for these inputs are available from anthropometry, biomechanics and k...
Read more

Information Processing Limitation

Human information processing  have limitations.   AMT requires support such as reference  to written material (e.g. manuals). Attention and Perception -  A proportion of ‘sensed’ data may be lost without being                              ‘perceived’.   Failing to  perceive  something  which   someone  has said to you, when you are concentrating on something else, even  though the words would have been received at the ear without any problem.  Information processing system has  ability  to perceive   something (such as a picture,                       sentence, concept, etc.) even though some of the data  may be missing.  Danger - people can fill in the gaps with  information from their own store of knowledge or experience, and this may lead to  t...
Read more