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SAFE WINGS

This issue…

Overcoming Human Threats to Aviation Safety

Human Factors The Dirty Dozen

* For Internal Circulation Only

Flight Safety Magazine of Air India, Air India Express and Alliance Air Issue 48, MAY2016

F l i g h t S a f e t y M a g a z i n e o f A i r I n d i a , A i r I n d i a E x p r e s s a n d A l l i a n c e A i r

SAFE WINGS May Edition 48

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EDITORIAL

There is a lot of safety related information available on the Internet, but we mostly

ignore it. However when an occurrence happens closer home or is related to our

airline we pay more attention and follow it fairly regularly and meticulously. Similarly

when one of us writes about his/her own personal experiences or expresses their own

views it makes reading that much more interesting. We would therefore like more

contributions so that we can feature them in the magazine. You do not need to have a

flair for writing and all you have to do is send us your contribution in simple words or

describe an occurrence in your own words. This will be of interest to others and we

will all learn something. We will edit it to make it very presentable in consultation

with you and then publish it. So please go ahead and send us your contributions. We

are happy to inform you that this is our FOURTH ANNIVERSARY EDITION of this

magazine.

ACKNOWLEDGEMENTS

The posting of stories, reports and documents in this magazine does not in any way,

imply or necessarily express or suggest that all the information is correct. It is based

on details gathered from various sources and is for information purpose only. The

Flight Safety Department is making this material available in its efforts to advance the

understanding of safety. It is in no way responsible for any errors, omissions or

deletions in the reports.

May Edition 48 SAFE WINGS

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Overcoming Human

Threats to Aviation Safety

uman Error has been identified as the major cause in 70% of all

accidents in aviation and therefore human factor specialists have

identified the Error prevention management program which is being

implemented by all concerned over two decades. In spite of this, human

error still continues to dominate the aviation scenario and it has not

decreased considerably.

Analysis of such human error related accidents revealed that

mismanagement of THREATS is causing humans to commit such errors

which can be easily avoided. There are SIX “I” s which are causing human

threat and this needs to be addressed for reduction of human errors as a

Threat management program.

They are classified as follows:

Ineffective Supervision

Selection of People, Lack of Motivation , Lack of

Managerial Skills and Inadequate Manpower

Incompetence

Lack of Training, Lack of Skills, Lack of Resources and Poor Standard of Training

Indifference to Reporting

Reluctance to report, Lack of clarity, Lack of immediate action , No feedback to the

reports and Fear of punitive action

Indecisiveness

Lack of decision making ability, Lack of knowledge and Improper understanding

Improper Attitude

Egoistic, Aggressive ,Negative, Absence of coordination ,Lack of teamwork and Lack of

assertiveness

Indiscipline Deviation from SOP, Violation, Negligence and

Carelessness

H By :P.S.Ganapathy ( Aviation Consultant)



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The remedies to overcome the

SIX “I”s

• Selection of competent

personnel

• Regular Audit and timely

follow up actions

• Good Training

• Proactive reporting system

• Transparent and fair

investigating system

• Adequate Resources

• Excellent communication

flow

• Passionate supervision

• Inspiration process

No matter how interested top

management might be , or

what assistance a

manufacturer offers, or how

insistent a certificating agency

might be – None of these

factors will have a significant

effect on safety without the

passionate involvement and

support from the Individual

performing the task. Hence

empower the employees to

imbibe the safety culture at

every level in the organization.

Mr PS Ganapathy

Mr PS Ganapathy joined Air India in

August 1966 and retired as General

Manager Operations 33 years later in

1999. After his retirement he worked

for Oman Air for 10 years and then

for Directorate General of Police

Aviation( Royal Oman Police) for 3

years at Muscat. . Besides his

recognised work in the Aviation field,

he is actively involved in activities of

the Aeronautical Society of India and

the JRD Tata Memorial Trust at

Mumbai.

Mr Ganapathy has a passion for

Mathematics and uses Numbers and

Alphabets in interesting ways. His

article on Human Factors and Flight

Safety is a typical demonstration of

this unique skill to make learning

more interesting.


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Human Factors The Dirty Dozen - Safety through

Mathematics using

Numbers & Alphabets.

In this Article, i have taken twelve human factors, (Transport of Canada

identified) that degrade people's ability to perform effectively and safely, which

could lead to Human errors. The Dirty Dozen was a concept developed by

Gordon Dupont, in 1993, whilst he was working for Transport Canada,

The Dirty Dozen refers to twelve of the most common human error

preconditions, or conditions that can act as precursors, to accidents or

incidents. These twelve elements influence people to make mistakes which

should be avoided to prevent human error accidents / Incidents and they are

as follows:

1. Complacency

2. Distraction

3. Fatigue

4. Norms

5. Pressure

6. Stress

7. Lack of Assertiveness

8. Lack of Awareness

9. Lack of Communication

10. Lack of Knowledge

11. Lack of Resources

12. Lack of Teamwork

DIRTY DOZEN is the one which CAUSES FAILURE and it is an INCIDENT

SIGNAL as proved below arithmetically.

D I R T Y D O Z E N Total

4 9 18 20 25 + 4 15 26 5 14 140

C A U S E S F A I L U R E Total

3 1 21 19 5 19 + 6 1 9 12 21 18 5 140

I N C I D E N T S I G N A L Total

9 14 3 9 4 5 14 20 + 19 9 7 14 1 12 140

Taking remedial measures to overcome the above listed 12 human

factors is a positive action for safety enhancement.

By :P.S.Ganapathy ( Aviation Consultant)



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1. COMPLACENCY is totally

UNDESIRABLE.

People tend to become

overconfident after becoming proficient in a certain task, which can mask the awareness of dangers. Such

overconfidence develops COMPLACENCY which is UNDESIRABLE as it will lead to skipping of required actions resulting in incidents. Therefore people should at

all times adhere to operating procedures even if the same task is performed several times successfully.

2. DISTRACTION is DANGEROUS as it disrupts the concentration and

step by step procedure leading to incidents. Hence protect against it.

Distraction is the act of drawing

away or diverting, an action that divides attention and it has been attributed as one of the causes

of accidents and hence DISTRACTION should be considered as a DANGEROUS act. When distracted during tasks it is always a good practice to go back three to four steps in the procedure.

D I S T R A C T I O N Total

4 9 19 20 18 1 3 20 9 15 14 132

I S D A N G E R O U S Total

9 19 + 4 1 14 7 5 18 15 21 19 132

C O M P L A C E N C Y Total

3 15 13 16 12 1 3 5 14 3 25 110

U N D E S I R A B L E Total

21 14 4 5 19 9 18 1 2 12 5 110

Remember success breeds complacency and Complacency breeds

failure. Complacency kills and hence be aware of its ill effect to avoid

it at all times.

Always use checklists and expect something will go wrong. Ensure

double check of critical tasks.


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Distraction will have huge impact particularly on Multi tasking activities

and hence FIGHT distraction.

Always use cross checking as one of the effective tools and strictly

adhere to the Sterile Cockpit philosophy. It is important to be aware that

Distraction has occurred.

3. The effect of HUMAN FATIGUE is CATASTROPHE. Hence manage

fatigue effectively.

Fatigue is a loss of alertness and a feeling of tiredness affecting performance HUMAN FATIGUE is a safety

threat leading to CATASTROPHE. Hence it is to be managed very

effectively . Knowing the symptoms and look for them in yourself and others is very important.

H U M A N F A T I G U E Total

8 21 13 1 14 6 1 20 9 7 21 5 126

C A T A S T R O P H E Total

3 1 20 1 19 20 18 15 16 8 5 126

Remember – I „M SAFE - Checklist

Illness - Do I have any symptoms ?

Medication – Have I been taking prescription or over the counter drugs

Stress - Am I under phychological pressure from the job ? Worried about

financial matters , health problems or family worries ?

Alcohol – Have I been drinking within 12 hours ? Within 24 hours ?

Fatigue - Am I tired and not adequately rested ?

Eating – Am I adequately nourished ?

Acute Fatigue :

Produced by sleep loss or

physical exertion.

Chronic Fatigue

Medical or psychological

problem.

Operational Fatigue

Most commonly seen after

3-4 days of heavy tasking.



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4. NORMS are HARMFUL as they are unwritten rules.

Norms is short for ‘Normal’ or the

way things are normally done. In

fact they are unwritten rules which

are followed and invariably they

have ambiguous solutions. Taking

short cuts, working from memory

or not following procedures are few examples of “NORMS” which will to lead

HARMFUL consequences as proved below. Remember that following

approved procedures is the safest practice to prevent errors.

N O R M S Total

14 15 18 13 19 79

H A R M F U L Total

8 1 18 13 6 21 12 79

Always comply with defined work procedures. Be aware that

"norms" don't make it right.

Particularly indentify the negative norms and ensure that they are

not followed.

5. Carrying out any safety task under PRESSURE is always an ACCIDENT

SIGNAL. Avoid working under pressure.

Pressure to get things done

quickly is always there in any

task. But be aware that

working under PRESSURE will

lead to hasty decisions and

skipping steps in the form of

ACCIDENT SIGNAL.

Communicate if you think you

will need more time to complete the task.

P R E S S U R E Total

16 18 5 19 19 21 18 5 121

A C C I D E N T S I G N A L Total

1 3 3 9 4 5 14 20 19 9 7 14 1 12 121

CHARACTER is who

you are under

PRESSURE, not who

you are when

everything is fine.


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6. STRESS is A WORRY which will have an impact on performance.

Hence manage stress effectively.

STRESS is A WORRY which affects performance and alertness in executing

the task. Relaxation, Meditation and Exercises will help to reduce the stress.

Convert the negative stress into positive.

S T R E S S Total

19 20 18 5 19 19 100

A W O R R Y Total

1 + 23 15 18 18 25 100

It is not stress that kills us, it is our reaction to it. Take it positively and

relax to overcome the effect of stress. Delegate responsibilities and

recognize the stressors of self and others.

When under pressure seek help from the available resources and cross

check the task execution thoroughly. Putting pressure is to be avoided.

Be assertive to say No and STOP when required to ensure safety which is

number one priority.

What is STRESS?

It is the gap between

Expectation & Reality. More

the gap, more the stress so

expect nothing and accept

everything and MANAGE it

well.

Symptom of Stress

Physiological Medical deficiency, Sleep disturbance,

Psychological Anxiety, temper , loss of interest , poor self

esteem

Intellectual Difficulties in concentration, omissions, errors,

poor memory, reduced vigilance

Behavioural Loss of concentration, look for short cuts, Easily

distracted



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7. LACK OF ASSERTIVENESS will leadto OCCURRENCE OF INCIDENTS

which is a BARRIER TO PROGRESS of the organization. BE ASSERTIVE.

LACK OF ASSERTIVENESS has been one of the human factor causes in the OCCURRENCE OF INCIDENTS which is a BARRIER TO PROGRESS. Particularly the subordinates must speak up if they find deviations from procedures by the seniors. Respectively and honestly voice your concerns.

L A C K O F A S S E R T I V E N E S S Total

12 1 3 11 15 6 1 19 19 5 18 20 9 22 5 14 5 19 19 223

O C C U R R E N C E O F I N C I D E N T S Total

15 3 3 21 18 18 5 14 3 5 15 6 9 14 3 9 4 5 14 20 19 223

8. LACK OF AWARENESS is an ACCIDENT PATHWAY and hence always be alert and

vigilant.

LACK OF AWARENESS is

defined as a failure to recognize all the consequences of an action or lack of

foresight Thus it is the failure to be alert

B A R R I E R T O P R O G R E S S Total

2 1 18 18 9 5 18 + 20 15 + 16 18 15 7 18 5 19 19 223

Being Assertive is always considered as a Safety tool.

Never be a silent spectator when you observe that things are not going in the

right way.

Say a FIRM NO with respect when safety is compromised.

SELF AWARENESS is

key to CHANGE.

Be aware of your

duties and

responsibilities.

The basic difference between

being ASSERTIVE and being

Aggressive is our words and

behavior affect the rights and

wellbeing of others.

ASSERTIVENESS is enjoying

your rights and expressing

your feelings and sharing

your views with INTEGRITY

and RESPECT.


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or vigilant leading an ACCIDENT PATHWAY as proved below. Therefore each

time a task is performed it must be treated as if it were the first time.

L A C K O F A W A R E N E S S Total

12 1 3 11 + 15 6 + 1 23 1 18 5 14 5 19 19 153

A C C I D E N T P A T H W A Y Total

1 3 3 9 4 5 14 20 + 16 1 20 8 23 1 25 153

Awareness is a key ingredient to success. If you have it, teach it, if you

lack it, seek it. Asking others to check our work and challenge our

decisions is useful in gaining the relevant experience and expanding our

awareness.

9. LACK OF COMMUNICATION has been cited as a CAUSE FOR HUMAN

LAPSE leading to several HUMAN FACTORS ACCIDENT. Be effective in

communication.

Communication is vital

to establish

relationship which

leads to synergy for

sound decision

making. LACK OF

COMMUNICATION

leads to

misunderstandings

and that will be a

CAUSE FOR HUMAN LAPSE creating HUMAN FACTORS ACCIDENT. Remove

all barriers to communication to make it effective as they can distort or prevent

communication.

L A C K O F C O M M U N I C A T I O N Total

12 1 3 11 15 6 3 15 13 13 21 14 9 3 1 20 9 15 14 198

C A U S E F O R H U M A N L A P S E Total

3 1 21 19 5 + 6 15 18 8 21 13 1 14 12 1 16 19 5 198

Barriers to

Communication.

Uncommunicative

attitude, Culture , Stress ,

High workload, Body

language conflicting with

words, Different mother

tongue, Hierarchy .

GOOD

COMMUNICATION

is

Vital for sound

DECISION MAKING



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The key for effective communication lies in opening lines of

communication and expressing a willingness to listen. That is why God

has given two ears to listen more & one mouth to speak less. Never

assume anything and check log books for work done or deferred.

10. LACK OF KNOWLEDGE will result in MAKING AN ERROR which is a

SIGN OF AN ACCIDENT. Hence invest in training to acquire sound knowledge.

Knowledge is absolutely

necessary to perform any task safely and efficiently. LACK OF KNOWLEDGE leads to a situation of MAKING AN ERROR which is a sure

SIGN OF ACCIDENT. Good training is the only way to acquire knowledge which will help to sharpen the skills.

L A C K O F K N O W L E D G E Total

12 1 3 11 + 15 6 + 11 14 15 23 12 5 4 7 5 144

M A K I N G A N E R R O R Total

13 1 11 9 14 7 + 1 14 + 5 18 18 15 18 144

S I G N O F A N A C C I D E N T Total

19 9 7 14 + 15 6 + 1 14 + 1 3 3 9 4 5 14 20 144

Beware of false knowledge. It is more dangerous than ignorance.

Continuous update of skills and knowledge is fundamental to safety.

When in doubt –Find out and Study the manuals and update it with the

amendments.

H U M A N F A C T O R S A C C I D E N T Total

8 21 13 1 14 6 1 3 20 15 18 19 1 3 3 9 4 5 14 20 198


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11. LACK OF RESOURCES will lead to LACK OF PROFICIENCY which will

result in poor performance. Availability of proper resources is vital for

safety.

Sharpening and

updating of skills are

mandatory for safe

and efficient

performance of any task and good training ensures such proficiency. Adequate

resources in the form of equipments, manpower etcare required for providing

good training. Any LACK OF RESOURCES will lead to LACK OF

PROFICIENCY and therefore it is management’s responsibility to ensure the

availability of adequate resources.

L A C K O F R E S O U R C E S Total

12 1 3 11 + 15 6 + 18 5 19 15 21 18 3 5 19 171

L A C K O F P R O F I C I E N C Y Total

12 1 3 11 15 6 16 18 15 6 9 3 9 5 14 3 25 171

If correct resources are not available, arrangements must be made

to procure the same. The end result saves time, money and enables

organization to complete the task safely and efficiently.

Always ensure that all resources are available for the safe

completion of task

12. LACK OF TEAMWORK in any safety related task will create misunderstanding that LEADS TO ACCIDENTS. Teamwork promotes

understanding. Be a team player!

Equipment

and facilities PEOPLE Management

Systems



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LACK OF TEAMWORK results not only in misunderstanding but also overload of task which LEADS TO ACCIDENTS. Good team work ensures open communication and creates synergy resulting in safe and efficient completion

of tasks through good workload management.

L A C K O F T E A M W O R K Total

12 1 3 11 + 15 6 + 20 5 1 13 23 15 18 11 154

Remember “Alone we can do so little; together we can do so much.Talent

wins games, but teamwork wins championships.”

Value the suggestions of others and appreciate success.

CONCLUSION:

As Human Factors have tremendous impact on the behaviour and performance

of people in the system, it is very essential for all concerned in Aviation to have

a thorough understanding and knowledge on HUMAN FACTORS.

Since the DIRTY DOZEN has the potential to cause

accidents and incidents, it MUST BE AVOIDED as proved

below arithmetically.

D I R T Y D O Z E N Total

4 9 18 20 25 + 4 15 26 5 14 140

M U S T B E A V O I D E D Total

13 21 19 20 + 2 5 + 1 22 15 9 4 5 4 140

Safety is a continuous journey and it is a SHARED RESPONSIBILITY. It is

not an accident; but it is the result of intelligent and committed efforts.

L E A D S T O A C C I D E N T S Total

12 5 1 4 19 20 15 1 3 3 9 4 5 14 20 19 154


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Successful accomplishment of this responsibility requires everyone in the

organization to imbibe SAFETY CULTURE and practice it honestly from top to

bottom.

SAFETY CULTURE

Statutory rules‟/ procedures‟ compliance

Audit of performance

Fair investigation

Encouraging voluntary reporting

Training & Re-training of human resources

Yearning for excellence (zero accident)

Cultivating positive attitude

Utter no violation

Learning from mistakes

Teamwork

Uncompromising discipline

Respecting all resources

Embracing SAFETY as a way of life.

Imbibing SAFETY CULTURE requires GREAT COMMITMENT as demonstrated

below in the equation. A,B,C----Z are respectively assigned numerical

values 1,2,3---------26 and the sum total of both the words are same.

S A F E T Y C U L T U R E Total

19 1 6 5 20 25 + 3 21 12 20 21 18 5 176

G R E A T C O M M I T M E N T Total

7 18 5 1 20 + 3 15 13 13 9 20 13 5 14 20 176

PROMISING A SAFER SKY, AIR INDIA, AIR INDIA EXPRESS & ALLIANCE AIR

We give utmost importance to your valuable comments and feedback. Please do mail us at

[email protected] or

[email protected]

Editorial: Capt V Kulkarni, Bhavish B S Designed by Bhavish BS

mailto:[email protected]

mailto:[email protected]

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