These twelve elements influence people to make mistakes. The Dirty Dozen is a concept developed by Gordon Dupont, in 1993, whilst he was working for Transport Canada, and formed part of an elementary training program for Human Performance in pilot training. They are:
Lack of communication
Poor communication often appears
at the top of contributing and causal factors in accident reports, and is
therefore one of the most critical human factor elements. Communication refers
to the transmitter and the receiver, as well as the method of transmission.
Transmitted instructions may be unclear or inaccessible. The receiver may make
assumptions about the meaning of these instructions, and the transmitter may
assume that the message has been received and understood. With verbal
communication it is common that only 30% of a message is received and
understood.
DETAILED information must be
passed before, during and after any task, and especially across the handover of
shifts. Therefore, when messages are complex they should be written down, and
organisations should encourage full use of logbooks, worksheets, and checklists
etc. Verbal messages can be kept short, with the most critical elements
emphasised at the beginning and repeated at the end. Assumptions should be
avoided and opportunities for asking questions both given and taken.
Complacency
Complacency can be described as a
feeling of self-satisfaction accompanied by a loss of awareness of potential
dangers. Such a feeling often arises when conducting routine activities that
have become habitual and which may be “considered”, by an individual (sometimes
by the whole organisation), as easy and safe. A general relaxation of vigilance
results and important signals will be missed, with the individual only seeing
what he, or she, expects to see. Complacency can also occur following a highly
intense activity such as recovering from a possible disaster; the relief felt
at the time can result in physical relaxation and reduced mental vigilance and
awareness. This particular psychological experience is referred to as a Lacuna.
Whilst too much pressure and demand causes over-stress and reduced human performance, too little results in under-stress, boredom, complacency and reduced human performance. It is therefore important, when conducting simple, routine and habitual tasks, and when fatigued, to maintain an adequate, or optimum, level of stress through different stimulation. Always expect to find a fault! Following written instructions, and adhering to procedures that increase vigilance, such as inspection routines, can provide suitable stimulus. It is important to avoid: working from memory; assuming that something is ok when you haven’t checked it; and, signing off work that you are unsure has been completed. Teamwork and mutual cross-checking will provide adequate stimulus when fatigued.
Lack of knowledge
The regulatory requirements for
training and qualification can be comprehensive, and organisations are forced
to strictly enforce these requirements. However, lack of on-the-job experience
and specific knowledge can lead workers into misjudging situations and making
unsafe decisions. Aircraft systems are so complex and integrated that it is
nearly impossible to perform many tasks without substantial technical training,
current relevant experience and adequate reference documents. Furthermore,
systems and procedures can change substantially and employees’ knowledge can
quickly become out-of-date.
It is important for employees to
undertake continuing professional development and for the most experienced
workers to share their knowledge with colleagues. Part of this learning process
should include the latest knowledge on human error and performance. It should
not be a taken as a sign of weakness to ask someone for help or for
information; in fact this should be encouraged. Checklists and publications
should always be referred to and followed, and never make assumptions or work
from memory.
Distraction
Distraction could be anything
that draws a person’s attention away from the task on which they are employed.
Some distractions in the workplace are unavoidable, such as loud noises,
requests for assistance or advice, and day-to-day safety problems that require
immediate solving. Other distractions can be avoided, or delayed until more
appropriate times, such as messages from home, management decisions concerning
non-immediate work (e.g. shift patterns, leave entitlement, meeting dates,
administrative tasks etc), and social conversations.
Psychologists say that
distraction is the number one cause of forgetting things: hence the need to
avoid becoming distracted and to avoid distracting others. Humans tend to think
ahead. Thus, when returning to a task, following a distraction, we have a
tendency to think we are further ahead than we actually are.
To reduce errors from distraction
it is best to complete a task before responding. If the task cannot be
completed without hurrying, then we can prominently mark (or, “lock off”) the
incomplete work as a reminder to ourselves and anyone else who may complete the
work. When returning to work, after being distracted, it is a good idea to
commence at least three steps back, so that we re-trace some steps before
picking up the task again. If necessary, having someone else double-check our
work using a checklist may be appropriate and useful.
Management have a role to play in
reducing the distractions placed on their employees. This may involve good
workspace design, management of the environment, and procedures that create
“safety zones”, “circles of safety” or “do not disturb areas” around workers
engaged in critical tasks.
Lack of teamwork
In aviation many tasks and
operations are team affairs; no single person (or organisation) can be
responsible for the safe outcomes of all tasks. However, if someone is not
contributing to the team effort, this can lead to unsafe outcomes. This means
that workers must rely on colleagues and other outside agencies, as well as
give others their support. Teamwork consists of many skills that each team
member will need to prove their competence.
Some of the key teamwork skills
include: leadership, followership, effective communication, trust building,
motivation of self and others, and praise giving.
A team’s effectiveness can also
be improved through the selection of team members to reflect a broad range of
experience and skill sets, and also through practice and rehearsal.
Fatigue
Fatigue is a natural
physiological reaction to prolonged physical and/or mental stress. We can
become fatigued following long periods of work and also following periods of
hard work. When fatigue becomes a chronic condition it may require medical
attention but, workers should never self-medicate! As we become more fatigued
our ability to concentrate, remember and make decisions reduces. Therefore, we
are more easily distracted and we lose situational awareness. Fatigue will also
affect a person’s mood, often making them more withdrawn, but sometimes more
irrational and angry.
It is a human problem that we
tend to underestimate our level of fatigue and overestimate our ability to cope
with it. Therefore, it is important that workers are aware of the signs and
symptoms of fatigue – in themselves and others. Fatigue self-management
involves a three-sided programme of regular sleep, healthy diet (including
reduced use of alcohol and other drugs), and exercise. Work of a critical and
complex nature should not be programmed during the low point on the body’s
circadian rhythm (usually 03:00 – 05:00am); and, when fatigued always get
someone else to check your work.
Lack of resources
If all the parts are not
available to complete a maintenance task, then there may be pressure on a
technician to complete the task using old, or inappropriate parts. Regardless
of the task, resources also include personnel, time, data, tools, skill,
experience and knowledge etc. A lack of any of these resources can interfere
with one’s ability to complete a task. It may also be the case that the
resources available, including support, are of a low quality or inadequate for
the task.
When the proper resources are
available, and to hand, there is a greater chance that we will complete a task
more effectively, correctly and efficiently. Therefore, forward planning to
acquire, store and locate resources is essential. It will also be necessary to
properly maintain the resources that are available; this includes the humans in
the organisation as well.
Pressure
Pressure is to be expected when
working in a dynamic environment. However, when the pressure to meet a deadline
interferes with our ability to complete tasks correctly, then it has become too
much. It is the old argument of Quantity versus Quality; and in aviation we
should never knowingly reduce the quality of our work. Pressure can be created
by lack of resources, especially time; and also from our own inability to cope
with a situation. We may come under direct, or indirect, pressure from the
Company, from clients and even our colleagues. However, one of the most common
sources of pressure is ourselves. We put pressure on ourselves by taking on
more work than we can handle, especially other people’s problems, by trying to
save face, and by positively promoting super powers that we do not possess.
These poor judgements are often the result of making assumptions about what is
expected of us.
Learning assertiveness skills
will allow a worker to say ‘No’, ‘Stop!’, and communicate concerns with
colleagues, customers and the Company. These skills are essential, and when
deadlines are critical, then extra resources and help should always be obtained
to ensure the task is completed to the required level of quality.
Lack of Assertiveness
Being both unable to express our
concerns and not allowing other to express their concerns creates ineffective
communications and damages teamwork. Unassertive team members can be forced to
go with a majority decision, even when they believe it is wrong and dangerous
to do so.
Assertiveness is a communication
and behavioral style that allows us to express feelings, opinions, concerns,
beliefs and needs in a positive and productive manner. When we are assertive we
also invite and allow others to assert themselves without feeling threatened,
undermined or that we’ve lost face. Speaking one’s mind assertively is not to
be confused with aggression. It is about communicating directly, but honestly
and appropriately; giving respect to the opinions and needs of others, but not
compromising our own standards.
Assertiveness techniques can be
learnt and they focus on keeping calm, being rational, using specific examples
rather than generalizations, and inviting feedback. Most importantly, any
criticisms should be directed at actions and their consequences rather than
people and their personalities; this allows others to maintain their dignity,
and a productive conclusion to be reached.
Stress
There are many types of stress.
Typically in the aviation environment there are two distinct types - acute and
chronic. Acute stress arises from real-time demands placed on our senses,
mental processing and physical body; such as dealing with an emergency, or
working under time pressure with inadequate resources. Chronic stress is
accumulated and results from long-term demands placed on the physiology by
life’s demands, such as family relations, finances, illness, bereavement,
divorce, or even winning the lottery. When we suffer stress from these
persistent and long-term life events, it can mean our threshold of reaction to
demands and pressure at work can be lowered. Thus at work, we may overreact
inappropriately, too often and too easily.
The situation of stress arising
from lack of stimulation at work has been covered above under Complacency
above.
Some early visible signs of
stress include changes in personality and moods, errors of judgment, lack of
concentration and poor memory. Individuals may notice difficulty in sleeping
and an increase in fatigue, as well as digestive problems. Longer-term signs of
stress include susceptibility to infections, increased use of stimulants and
self-medication, absence from work, illness and depression.
It is important to recognize the
early signs of stress and to determine whether it is acute or chronic. Coping
with daily demands at work can be achieved with simple breathing and relaxation
techniques. However, perhaps more effective is having channels of communication
readily available through which to discuss the issue and help to rationalise
perceptions. It is entirely appropriate that some of these channels involve
social interaction with peers. As with fatigue, sleep, diet and exercise are
all important factors in helping to reduce stress and build resilience to
stressors. If the stress is chronic, then definite lifestyle changes will be
required; this must be achieved with support from the Company. Companies ought
therefore, to have employee assistance (or wellbeing) policies that include
stress reduction programs.
Lack of awareness
Working in isolation and only
considering one’s own responsibilities can lead to tunnel vision; a partial
view, and a lack of awareness of the effect our actions can have on others and
the wider task. Such lack of awareness may also result from other human
factors, such as stress, fatigue, pressure and distraction.
It is important to build
experience throughout our careers, especially concerning the roles and
responsibilities of those we work with, and our own place in the wider Team.
Developing our foresight is essential in pre-empting the effects our actions
may have on others. This is an attitude of professionalism and involves
constant questioning “what if …?” Asking others to check our work and challenge
our decisions is useful in gaining the relevant experience and expanding our
awareness. Vigilance is closely related to situational awareness, and workplace
procedures, such as scanning, two-way communication and use of checklists will
help to maintain vigilance.
Norms
Workplace practices develop over time,
through experience, and often under the influence of a specific workplace
culture. These practices can be both, good and bad, safe and unsafe; they are
referred to as “the way we do things round here” and become Norms.
Unfortunately such practices follow unwritten rules or behaviors, which
deviate from the required rules, procedures and instructions. These Norms can
then be enforced through peer pressure and force of habit. It is important to
understand that most Norms have not been designed to meet all circumstances,
and therefore are not adequately tested against potential threats.
Rules and procedures should have been designed and tested, and therefore ought to be enforced and followed rigorously. Where workers feel pressure to deviate from a procedure, or work around it, then this information should be fed back so that the procedure can be reviewed and amended, if necessary. Developing assertiveness can allow workers to express their concerns about unsafe Norms, despite peer pressure.
Credit: skylibary
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