Dirty Dozen #EASA11 B2

1.) Define Dirty Dozen

Dirty Dozen list the most frequent 12 Human Factor that affect aircraft maintenance and
inspection. It does give a quick and practical summary of those human factors causing incident.
The dirty dozen as follow:

K Lack of knowledge. Means lack of experience or training in the task handed.

C Complacency. Self-satisfaction accompanied by a loss of awareness of the dangers.

F Fatigue. Weariness from labor or exertion, nervous, exhaustion, temporary loss of

power to respond.

S Stress. Mental, emotional or physical tension, strains and distress.

R Lack of resources. Failure to use / acquire appropriate tools equipment, information and
procedure of the task handed.

P Pressure- Pushing for something in spite of opposing odds, creating a sense of urgency or
hesitate.

D Distraction. Diversion of one’s attention away for mental, emotional confusion or disturb.

A Lack of awareness. Failure to be alert or vigilant in observing the present situation and
identifying unsafe condition in the projected future.

C Lack of communication. Lack of clear, direct commands and effective, active listening skills.

A Lack of assertive. Lack of positive communication of one’s ideas, wants and needs.

T Lack of teamwork. Lack of working together to achieve common goal.

N Norms. The commonly accepted practice of working routine job without referring to manual.

2.) According to Dirty Dozen, how to get situational awareness (at least two methods).

There are three stages of Situational Awareness which are perception, comprehension and
projection. These are the stage to get situational awareness.

In the perception stage, we should interpret the information correctly.

When projection stage, a defect should be immediately rectified.

Task #EASA11 B1

1.) Relate to familiarity for the task, list 3 level of human performance.

Depending on how familiar the task to us, we tend to approach it differently from one to another.

Related to the familiarity of the task, the rule-based performance is performance that critically
dependent on rules and norm where produces and routines became the guide. It requires good
attention and mental effort to identify clues and signals. For example, visual inspection, system
and function test. Some processing information.

The skill-based performance is critically dependent on skill. If well practiced, very little mental
effort is needed to perform them. Performances are almost automatic and thus, divided attention is
possible to achieve without degrading the quality of performance. For example, driving and riding
a bike. Little process information.

The highest level of human performance is the knowledge- based performance. It depends on the
knowledge and training critically. This time, the experience and awareness becomes the guide.
During this performance, significant amount of mental effort is the key to identify problem, close
attention is needed to learn from the unfamiliar system. High information processing are presents
in this performance. For example, during system troubleshooting.

2.) According to the nature of task, list at least four type of task. Which kind of human error
typically to the repetitive task.

There are 4 types of task according to nature. Physical work, repetitive task, visual inspection and
complex system.

For physical work, the human body is a series of physical links (bones) connected to certain
points (joints) to allow various movements.

Repetitive task. Loss of interest and lack of awareness during some task like checking out
multiple systems and generally performing task several times during shift.

Visual inspection is affected by illumination level and visual acuity. Lack of attention may result
in unreliable inspection result.

Complex systems have wide variety of inputs and typically performing complex response. There
may be a single output, or many distributed output from system.

Typical human error towards repetitive task is complacency which is associated with over-
confidence. It can be corrected by reasonable high work levels and off-line training for difficult
and challenging problems.
Communication #EASA10, EASA13

1.) Define communication and its modes. Describe precondition for effective communication.

Communication is defined as a transmission of something from one person to another. The thing
that is transmitted can be a message, signal or other information. There are 4 types of modes for
communication.

Verbal / spoken is a single word, a phrase or sentence. A grunt.

Written / textual. Printed words or numbers on paper or screen, hand written notes.

Graphics. Example, picture, diagram, hand drawn sketches, indication on a cockpit instrument.

Body language. Examples, facial expression, touch such as a pat on the back and a posture.

The precondition for an effective communication is that the both transmitter and receiver must be
share a common code to communicate well with each other. There are 4 process of communication-
sender, encoding, decoding, receive. So that the meaning and information of the message can be
interpret without error.

2.) Describe the requirement for written communication.

General requirement for good written communication are:

Clear. It must be easy to understand, readable, and free from any emotional and hidden messages.

Correct. It must relate accurately to the problem at hand.

Complete. It must convey the complete message.

Concise. It must be direct to the point. Presenting irrelevant details does not improve the
efficiency of communication.

Good communication is very important in every industry. In aircraft maintenance engineering, it is

vital and there are various aspect of communication that affects the aircraft maintenance engineer.
Working environment #NEW

1.) Physical factors of working environment.

Noise. Noise is defined as unwanted sound. Noise can have impact on psychological condition
and may result in frustration and anxiety.

Fume is the presence of flammable, irritative, or toxic vapor in the workplace. It affects
performance, visibility, and perception.

Motion and vibration. Vibration is any oscillating motion that changes its magnitude periodically
with the reference of a point. Vibration can impair visual acuity and interfere neuromuscular control
which may lead to fatigue.

Workplace layout is an access equipment provided should aim to make the user feel comfortable
during performing task. Make use of staging and mobile access platform to reach various parts of an
aircraft.

Illumination. An adequate illumination is the major consideration in determining the reliability of

inspection. Glare may produce discomfort and interfere with visual performance.

Climate and temperature. Human is comfortable only over narrow band of temperature. Extreme
temperature can cause environmental stressors.

Safety equipment protects and minimizes risks of an engineer when performing task. Safety
harness must be used when inspecting task at higher position from ground level.

2.) Line Maintenance

In line maintenance, engineer must know how to protect himself from the elements of extreme
climate, make sure that he is not distracted by temperature change.

1. Extreme cold. Under cold temperature, an engineer will lost the ability to perform precision
task due to loss of finger flexibility.

2. Extreme heat. An excessive heat will cause in decreasing of performance. An engineer will
suffer dehydration and delusion after long period under excessive heat condition.

3. During heavy rain. When engineer out working under raining days, he must wear suitable attire
or fluorescent clothing.

4. Strong wind situation. Working in strong winds can be distracting, especially if having to work
at height (e.g. on staging), safety harness must be used when inspecting task at higher position from
ground level.

5. During snowing condition. Ground crews should carry out ground de-icing operation to prevent
ice adhering on aircraft parts.
Factor Affecting Human Performance #EASA12

1.) Describe at least six factors that influence the human performance.

Fitness and health. Physical fitness may have a direct relationship to mental performance and
health. Improves fitness will reduce tension, anxiety and increase the self- esteem.

Stress. Stress relate to the state of tension of human reaction to some stimuli. Extreme cases of
stress over a long period will result in heart disease or Chronic Fatigue Syndrome (CFS).

Time Pressure. Time pressure can stimulate the task to be carried out. When excessive time
pressure occurs, it can lead to situational violation such as taking shortcuts and risks.

Sleep and fatigue. Sleep serves a restorative function and is essential for mental performance. The
purpose of sleep is to rest and recover from fatigue which is caused by daytime work.

Alcohol. Alcohol can dull the senses and cause judgment to be hindered.

Medication. It normally used to cure some disease. But it has to consider that each medicine will
have side effects that may impair engineer performance.

Workload. There are two type of workload which is overload and unload. Overloads often cause a
person to work faster to achieve goals, but indirectly more error will be made. For the unload or under
load, it can cause deterioration in performance and increase in error as personnel finds it boring or
lacks of tasks.

2.) List 4 types of stress and its related symptom.

4 types of stress
1. Cognitive Stressors. It refers to mental demands of the task itself.
2. Work stressors. This is like anxiety, incentives, and group pressure, medical and
proficiency checks.
3. Environmental stressors are such as temperature, humidity, noise, pressure, fumes,
vibration and illumination.
4. Domestic stressors. Normally caused by family separation or well- being of dependents.

Related Symptoms

Physiological symptoms - such as sweating, dryness of the mouth.

Health effects - such as headaches, sleep problems.

Behavioral symptoms - such as restlessness, shaking.

Subjective effects - such as anxiety, depression.

Situational Awareness #NEW

1.) Define Situational Awareness

Situational Awareness is the synthesis of an accurate and up to date ‘mental model’ of one’s
environment and state, and the ability to use this to make predictions of possible future states.

2.) List 3 stages of situational awareness.

An example is an engineer seeing blue streaks on the fuselage can reflect to the three stages in
Situational Awareness.

First, perception stage. An engineer saw the blue streaks on the fuselage near the lavatory service
panel.

Second, comprehension stage. He reasoned the lavatory cap could be missing or the drain line
leaking. Here, his training and experience including his mind set able to help him to make a good
technical judgment.

Third, projection stage. He could calculate that very soon the aircraft would return to flight, any
further leak could allow the blue water to freeze, leading to engine damage. He saw an unsafe
condition and determined that the leaking defect should be immediately rectified.

3.) Obstacles for maintaining good Situational Awareness.

Information is not available, information is hard to see or hear (signal-to-noise ratio is low).
Information is misperceived (see what you expect to see, hear what you expect to hear) and
information is present but missed.

Next, task sequences are forgotten, consequences are not properly understood and either a mental
model is in lack or wrongly used.
SHELL (GVI)

SHELL model is a conceptual model. It focuses on the problem on how human factor interface
with the world around them. There are 5 elements in the model.

During the GVI, the inspector should understand the SHELL model involved in task.

Liveware (individual). The L in the center represents the inspectors who carry out the task and he
must be familiar with the procedure clearly. He must keep his mental and physical fitness in optimum
condition to complete the task effectively. He should understand the basic human factor such as
fatigue, stress, skill limitation, boredom, complacency and motivation to do the visual inspection.

When interfacing the outside world, the human factors involved are:

Liveware (software). Many inspectors face the problem of poor judgment and decision making.
The inspector must follow the maintenance instruction and standard practice according to relevant
manual and ensure that all the documents are approved and up to date.

Liveware (Hardware). The inspector should choose the correct tools and equipment to carry out
the task and ensure they are inspected and approved tools like borescope and magnifying glass can be
used out to carry the inspection. He needs some material to clean the inspection and safety harness
should be used when inspecting high position from ground level.

Liveware (environment). Environmental adequate illumination and suitable temperature are

essential. Vibration level, noise, fumes, distraction and interruption can cause omission existed.

Liveware (team). Supervisory and advice from senior are very important for each inspector. They
should keep effective communication within members during task. Communication in terms of
inspection record, work card, logbook and handover documents which provide feedback information.
The quality of communication relate to norms and assertiveness.

In conclusion, the individual liveware is the most important, critical, flexible and valuable. The
element must be adapted and matched with this individual liveware to accommodate human limitation
and avoid human error or team breakdown in aviation system.
SHELL (Engine)

SHELL model is a conceptual model. It focuses on the problem of how human factor interface
with the world around them. There are 5 elements in the model as shown below:

S- Software

H- Hardware

E - Environment

L - Liveware -individual

L - Liveware - team

During engine run, engineer should understand the SHELL model has involved in the task:

Liveware (individual). The L in the center represents the engineer who carries out the task and he
must be familiar with the procedure clearly. He must keep his mental and physical fitness in optimum
condition to complete the task effectively. He should understand the basic human factor such as
fatigue, stress, skill limitation, boredom, complacency and motivation to perform engine run.

When interfacing with the outside world, the human factors involved are:

Liveware (software). The engineer should take the advantage of engine guide book and relevant
maintenance manual and ensure all of the works carry out accordingly to the approved documentation.

Liveware (hardware). The engineer should ensure the tools and equipment used in the aircraft are
approved and ensure all landing gear lock pin have installed correctly.

Liveware (environment). The engineer should ensure the environment is suited for work. For
example, adequate illumination, enough space and suitable temperature. For safety, engineer should
keep tools and people away from the dangerous area.

Liveware (team). The engineer should allocate enough people for engine operation. Allocate some
crew to clean the operation area. They should keep active communication between each team
members to avoid mistake during the task.

In conclusion, the individual liveware is the most important, critical, flexible and valuable. The
element must be adapted and matched with this individual liveware to accommodate human limitation
and avoid human error and team breakdown in aviation system.
Violation

Violation is any deliberate deviation from the rules, procedure, instruction or regulation. Violation
can be divided into four groups which are Routine Violation, Situational Violation, Optimizing
Violation and Exceptional Violation.

Routine violations are things that have become normal way of doing something within person’s
work group. For example, an engineer thinks that he can exclude some procedure to simplify the task,
to save time and energy.

Situational violence occurs in particular task and certain circumstances. For example, unrealistic
deadline, unworkable procedure, inadequate tooling, high workload and working condition. These
often occur when the only way to get the job done is by breaking the rules.

Optimizing violation are breaking the rules and taking risks just for thrill. They are quite often
unrelated to the actual task and it is normally just to satisfy a personal needs. For example, a tug
driver who is asked to take his tug from A to B. But for thrill he chooses to drive fast and take risk.

Exceptional violent are violating the rules under the particular factor in the time. Exceptional
violent are inevitable no matter how well the person intentioned is. For example, a worker who has
late to work, he speed to work and thus, violating the traffic rules.

In conclusion, violation is forbidden in the aviation industry because it is the threat to the industry
airworthiness. The engineer must always keep in mind that safety is the main priority. He must not
violate the rules which might put others at risk.
Human Factor

Human factor refer to the study of human capabilities and limitations. Human factor researchers
studied system performance, which is the interaction of maintenance personnel the equipment they
used, the verbal and written procedures, the rules they follow and the environment condition of any
system.

The aim of human factor is to study the optimizing of relationship between maintenance personnel
and system with the view of improving safety, efficiency and well- being.

Swiss cheese model has highlighted the concept of ‘defenses’ against human error with an
organization and has coined the notion of ‘defenses in depth’. It is when these defenses are weaken
and breached, the human error can result in incident and accidents. These defenses have been
portrayed diagramically as several slices of Swiss cheese. Traditional defense system is multi- layered.

In the ideal world, all the layers are intact but each one has got gaps and holes in it. Although the
defenses are good, they are designed for procedure not peoples. When failures (gaps) line up, the
successive defense layer can be penetrated.

To prevent the task interrupted and mind lapse error, we should:

 Always go back 3 steps when get back to job after interruption.

 Make a check list and follow the checklist during the job.
 Labels the parts right away after removing.
 Have a work logbook or recording during shift handover.
 Set up parameter to show that the engineer doesn’t want to be interrupted.