Aviation Human Factors Considerations related to Root Cause Analysis (RCA)

When we perform RCA it is not unusual to come up against causal factors which show a specific relationship between the event and one or more human factors.

Please consider that in general we can say that ALL Human Factors can potentially be managed in a way that either precludes or mitigates potential negative outcomes.

Unfortunately, competent trained persons continue to make HF related errors even when accomplishing relatively straightforward tasks. Whilst we are able when fully cognizant to recognize our errors, the potential exists for missed errors to compound into fully realised outcomes.

Types of Human Factor Errors typically identified during RCA activities

Violations

Violations may be either organisationally optimising or personally optimising, moreover they may be routine exceptional or flagrant.

Work Place Attitudes

Attitude within the workplace can directly impact events occurring in combination with other factors or can impact the effectiveness of the climate related to the development or otherwise of positive Safety Culture.

Organisational System Constraints

Typically related to limitations which may be in place within the workplace as well issues caused by the organisational structural considerations.

Management & Supervisory Failures

This type of failure can be found to relate to insufficient availability related to elapsed time or other time related constraints, Insufficient manpower or resources. Policy and Procedure Related, or Finally a lack of Competence related to a training shortfall.

Environmental Factors

A number of environmental related issues may impact an event or serve as contributing factors for example related to weather Heat or Cold (Ice / Snow) issues associated with poor lighting.

Personal Factors

These can directly either affect the individual or be caused by the individual for example – Fatigue – Stress (Possibly caused by work related pressure) several types of Illness can cause human deterioration which can also contribute to events.

Simple Human Error could also be a factor related to attention / memory, judgment, knowledge competence or skill
Dealing with Root Cause Analysis

The development of an understanding of the various Human factors (HF) interactions allows for the potential of a balanced approach during RCA related to the understanding of non-technical errors.

Factors such as Fatigue, Stress, Workload, Communications, Distractions, Focus, and Situation Awareness all have the potential to impact an event and lead to a negative outcome.

Applying the knowledge

Recreating and understanding the specific environment within which the incident occurred or may occur is a significant element in understanding the HF interaction.

Re occurring HF events raise concern for example Failure to Follow Procedures, Complacency, Distraction and even Boredom.

Human sciences which support an understanding of Human Factors include psychology, (the scientific study of the human mind and its functions, especially those affecting behaviour in a given context.) anthropology (the study of human societies and cultures and their development), physiology (the branch of biology that deals with the normal functions of living organisms and their parts) and medicine.

Delivering Change

Knowledge related to Human Factor is gathered and analysed to support changes to the design, operation, construction or maintenance of a product, or process.

To support effective analysis post event we should look into the “why” of the event digging into the root cause & employing the various techniques available through our knowledge of human science related to both the psycho-social environment as well as the systems engineering background. Insights into hazards, causes and consequences can be gained from analyses of accidents and incidents. Not only pointing to the existence of complex and unexpected human actions that might not be readily identified using other methods.

Going forward the modern application of human factors has to focus on a deeper understanding related to the interaction of the various elements and actors within the environment including Flight & Cabin Crew, Maintenance Staff and Air Traffic Control (ATC) Personnel.

For additional information regarding training provided by Sofema Aviation Services please see https://sassofia.com/regulatory-training-courses/ or email office@sassofia.com