Table of "Dirty Dozen" Human Factors
Table of
"Dirty Dozen" Human Factors
The table below provides a comprehensive
description of the 12 Dirty Dozen Factors through the posters as well as
providing the relevant safety nets that should be subscribed to.
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Explanation
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Safety nets
available
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Caption says "I guess day shift can finish screwing on the panel." Lack of communication is depicted as the
worker is going to leave the panel of an aircraft unfinished without
communicating this to the next worker in any written or verbal form, assuming
that the next worker knows which part of the aircraft is left unfinished.
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Use logbooks to communicate, to
remove doubt. Discuss work to be done and what has been completed to the one
taking over from you. Never assume anything, always check.
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Caption says "I've looked back there 1,000 times and never found
anything wrong." Complacency is depicted whereby
a maintenance personnel has finished signing an inspection sheet whilst
telling himself that he has checked at the aircraft part a thousand times
without ever finding anything wrong; This is despite the fact that a
component of the aircraft has a spoilt cable. Hence, by performing a routine
task over and over again, overconfidence due to increasing proficiency could
lead lead to complacency setting in and errors in judgment can appear.
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Train yourself to expect to find a
fault and to consistently look out for these faults or hazards. Never sign
for anything you didn't do. Never assume anything, always check.
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Caption says "This is the third one to bend! What's going on?" Lack
of knowledge is depicted in which a maintenance personnel
cannot fathom how a helicopter part could be bent for a third time even
though he has kept working on it, demonstrating that there is a possibility
there is a lack of certain type of knowledge in how he is remedying the
helicopter part. This could be also due the rapid pace at which technology is
evolving and hence increased knowledge is needed when performing the task.
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Don't rely on memory and consult the
relevant up to date manuals. Always ask if you are in doubt. Get training on
type.
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Caption says "Hey, Your wife is on the phone." Distraction is depicted as the
personnel is informed of an urgent call from his wife, hence taking him away
from focusing on his job which could potentially lead to errors later as his
concentration has been affected.
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Always finish the job or unfasten the
connection. Document and handover the uncompleted work. When you return to
the job, re-inspect by another or always go back three steps by yourself. Use
a detailed check sheet.
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Caption says "I thought you wanted him to turn left right here!" Lack
of teamwork in which two marshallers are trying to guide an
aircraft in opposite directions shows a fundamental lack of cooperation and
communication which are essential in performing certain difficult tasks especially
when more people are involved.
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Discuss what, who and how a job is to
be done. Be sure that everyone understands and agrees through good
communications and co-ordination with team members. Look out for one another.
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Caption says "I'm glad this double shift is over." Fatigue is depicted with a
maintenance personnel blissfully unaware that he is reaching the end of the
horizontal stabilizer as he has become fatigued after working a double shift.
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Be aware of the symptoms and look for
them in yourself and others. Plan to avoid complex tasks when you are
physically exhausted. Sleep and exercise regularly. Ask others to check your
work. If you are fatigued, take a break.
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Caption says "We have nil stock of left skids so I guess this will
have to do."Lack of resources is depicted with a
maintenance personnel standing in front of a helicopter with two different
components; a float on the left and a skid on the right; obviously one of the
essential parts is insufficient and he has fixed a totally different part on
and still wants the helicopter to continue to fly. Hence, there are times
when there a lack of resources, a decision must be made not to fly for
safety’s sake.
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Check suspect areas at the beginning
of the inspection. Order and stock anticipated parts before they are
required. Know all available parts sources and arrange for pooling or
loaning. Maintain a standard and if in doubt ground the aircraft. Preserve
all equipment through proper maintenance.
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Caption says "Hurry up or we're going to be late again!" Pressure is depicted with an aircraft captain
who is averse to being late, rushing a maintenance personnel to finish
closing up a panel and whilst doing so, he misses seeing a component jutting
out.
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Be sure the pressure isn't
self-induced. Communicate your concerns. Request for assistance. Just say No.
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Caption says "Listen, I own the aircraft and I say it's not a bad
leak!" Lack of assertiveness is shown with the
maintenance personnel being badgered by the owner of the aircraft and not
asserting himself and backing down by telling him that the plane is indeed
suffering from a bad oil leak. Hence by allowing himself to be intimidated
and not speaking up, it could potentially lead to an accident.
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Be assertive and provide clear
feedback when danger is perceived. If it's not critical, record it in the
journey log book and only sign for what is serviceable. Refuse to compromise
your standards. Allow team members to give their opinions and accept
criticisms positively
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Caption says "We lost our best aircraft! How are they going to pay my
wages? What if I'm sued?" Stress is depicted with a
maintenance personnel pulling his cart of tools towards the moving propeller
and his overstressed at having lost his best aircraft and the fact that he
might be sued. Hence, the stress build up has exceeded his limits and he
can’t think rationally and perform his task right.
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Be wary of the effects of stress on
your performance. Stop and look rationally at the problem. Determine a
rational course of action and follow it. Take time off or at least have a
short break. Discuss it with someone. Ask fellow workers to monitor your
work. Exercise your body. Ensure sufficient rest at all times
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Caption says "All the regulation said was, 'Install Where it is
Easily Accessible."Lack of awareness is depicted as an
aftermath in this incident whereby a passenger has hit his head against a
fire extinguisher during an emergency as the maintenance personnel who had
installed the fire extinguisher there showed a lack of awareness by not using
common sense and vigilance by putting it at a place that though easily
accessible could potentially hurt someone.
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Think of what may occur in the event
of an accident. Check to see if your work will conflict with an existing
modification or repair. Ask others if they can see any problem with the work
done by checking periodically to ensure correct work procedures.
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Caption says "Never mind the Maintenance Manual. Its quicker the way
we do it here." Norms are depicted with a
forklift used to install a jet engine demonstrating how this procedure was
conducted at this maintenance facility, that even though it is a flawed
manner has become a norm as the majority performs in this way.
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Always comply with defined work
procedures. Be aware that "norms" don't make it right.
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Accidents in which
Dirty Dozen have contributed
This page provides a
synopsis of the crash of Alaska Airlines Flight 261 and how dirty dozen factors
have contributed to it.
This page provides a
synopsis of the crash of Air Midwest Flight 5481 and how dirty dozen factors
have contributed to it.
Overview
The dirty dozen factors have long since been
identified but yet has can be seen from the examples of accidents it has
contributed above, it has still not been fully eradicated in the realm of
aviation maintenance. It is imperative that maintenance organizations inculcate
a working environment that reiterates these factors holistically so that they
are ingrained in the maintenance personnel; this can be done through human
factors training workshops by reiterating these factors and showing the
aviation accidents they have caused.
It is by creating a culture in which all personnel
are aware of these factors and the safety nets involved, this would help
decrease the high percentage of human factors involved in maintenance issues.
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