Identify Human Factors
Many years ago, probably in the 1994 version of the ISO standards organization would identify their root cause for complaints and non-conformances as human error. Then as the standards changed they would not allow human error to be identified as the root cause as on its own it would not identify the root cause.
As the systems have evolved over the years the human error has been brought back into play but badged as human factors and it is a perfectly acceptable part of root cause analysis if used in the correct way.
ISO 9001 refers to human factors within clause 7.1.4 which is often overlooked by organizations along with preventing human error within 8.5.1. The Aerospace standards (AS9100, AS9120, AS9110) have taken this a step further and require organizations to review non-conformances and identify human factors that have contributed to the non-conformances.
You can’t simply write your root cause as human error on your corrective actions on its own, you have to look into the reasons why the human error occurred or the potential risks of human error.
Why identify human factors
The quickest way to learn and improve is from failures. You can have the best mind in the world and not predict every eventuality and cover every corner.
We all make mistakes; it’s what makes us human and when we assess management systems and there have been no complaints or non-conformances for 3 years then there is a possibility that things aren’t being recorded. You do not get penalised for having issues, auditors are more interested in what you are doing to address the issues.
When you look at human errors you are not looking at blaming the person, you are looking at identifying why that person made the error. You can’t just say the human made a mistake, that’s not identifying the root cause and you will not resolve the issue.
A few years ago, the Aircraft Maintenance Industry identified what has been labelled the “Dirty Dozen”, they are 12 human factors that cause error and if you highlight the attributing factors within your corrective action system you can identify trends and address the root cause.
The Dirty Dozen - 12 human factors highlighted below:
LACK OF COMMUNICATION
Poor communication is probably the highest contributing factor and one of the most critical. The issues are not just about the lack of communication but also the receiver understanding what has been communicated. Was the communication clear and understood?
It has been proven that only 30% of all verbal communication is received and understood so as an organization you should refrain from using just verbal communication as a means of transferring information. It's ok to verbally communicate things but you need to follow this up with written confirmation or have the information written down in the first place and verbally communicate from there.
During aerospace assessments you might notice the auditors will always review the process for shift handovers, we are assessing whether the shift handover has been suitably communicated to the next set of operators. Issues and job information is usually communicated through a diary system but also a quick discussion is held to ensure the written information is understood.
Think about your management system, are there any weaknesses in the communication of information? A tell-tale sign is if operators are having to constantly ask questions. They should have the information to hand in front of them and not having to keep asking questions to get the job done as this can lead to errors.
COMPLACENCY
I think we have all done this from time to time, there is a task that you do time and time again and your brain switches off and you go into robot mode. Without realising you drift off course and lose focus on what you were doing, you become complacent.
Quite often procedures and processes are updated but because someone is in their routine they do not realise or remember they have bene updated and continue operating as they have for the last few years.
Complacency can also occur following a highly intense activity, your body will sometimes relax and you reduce your mental awareness. You don’t want to put stress on people but not enough stress can lead to boredom which in turn results in complacency, ensure you are keeping people stimulated and monitor the work completed for repetitive tasks.
LACK OF KNOWLEDGE
This is up there as one of the most common; people are not being trained effectively, especially when moving up the chain within an organization. Operators are made into managers but are never given the knowledge required to be a manager, it’s a different set of skills.
One of the weaknesses in knowledge is on the job experience and training. Systems and procedures can change but employees are not given the up to date knowledge or information. Some organizations will review each of the updated procedures with employees and have them sign receipt of the knowledge transfer but this is not very common.
Think about how you are communicating changes within your organization. Are people making mistakes purely because they lacked the knowledge? Did anyone ensure they had the knowledge required to perform their duties and tasks?
DISTRACTION
Psychologists say that distraction is the number one cause of forgetting things, hence why I keep notes in my phone as i am terrible. This is all due to distractions in everyday life that most of us have to deal with.
At the moment, whilst we are all working from home the errors made due to distractions has increased dramatically. Amazon deliveries, your dog barks to be let out, your children decide to paint your walls with their crayons! All these things are distracting us from doing our job in an effective manner at the moment so although productivity has likely gone up for some; the quality of the work has possibly reduced.
Distractions still occur whether we are all working from home or not, there could be loud bangs and noises, questions being asked or people asking for help or your phone could go. What happens after a distraction is when you get back to the task at hand you often think you have done something but haven’t. I have been trying to write this article for 2 days now but i keep getting distracted by phone calls, urgent emails or the kids screaming in the background.
Within the workplace you should try to avoid as many distractions as possible, when someone is performing a task try not to disturb them, turn off your emails and phone if you have an important task that requires your full attention. Try to create “do not disturb areas” so people can focus on critical tasks.
LACK OF TEAMWORK
Depending on your job function, a lot of the time you will be required to work within a team and if someone is not contributing to the team effort this can lead to errors. The team could consist of people outside of your organization such as suppliers or contractors.
To create an effective team it is necessary to have in place the right people with the correct skills and knowledge including communication and leadership but more importantly being able to work within a team.
It is important that all team members are aware of the goals and aims, each members roles and responsibilities, individual expectations and outcomes, communication methods and how often they will be working together.
FATIGUE
Fatigue is something we are all susceptible to after prolonged physical or mental stress. If we have been working long hours without breaks we will easily get fatigued and for some people it will require medical treatment.
The more fatigued we become the worse we are with concentration levels and decision making, we forget things and become easily distracted. And speaking from personal experience we become irrational and angry.
To reduce the risk of fatigue it is important to get regular sleep, have a healthy diet and also get exercise and rest. All of which are being impacted at the moment, especially if you are working for the NHS at the moment.
You should ensure that you are not over working employees, limit their hours and monitor their breaks to ensure they are being taken.
LACK OF RESOURCES
Resources consist of personnel, time, data, tools, skills, experience and knowledge. If any of these resources are lacking they can interfere with the ability to complete a task as required. It’s important to remember that you may have resources there but they may not be adequate such as poor IT.
It has been proven that having the correct resources available and they are suitable, tasks are completed more effectively.
To resolve the lack of resources you will need money and when something breaks down or you need something quick and it isn’t available this will have a negative impact. To help manage this issue you should plan ahead, have a resource replacement programme in place to ensure assets are replaced before they reach the end of their life.
You should also ensure that you have a maintenance programme for your equipment to ensure you maximise the life expectancy. Speak to your employees and ensure the equipment being used is suitable for use.
PRESSURE
We are all feeling a bit of pressure at the moment, especially as the covid situation changes on a daily basis. A little bit of pressure is good for you and to be expected nowadays but when there is too much pressure this has a negative impact and we do not meet deadlines or complete tasks correctly.
Pressure can be a result of some of the other human factors such as lack of resources and can come from any angle; boss, colleague, customer.
I know colleagues myself who never say no, they put themselves under pressure by not saying when enough is enough. If the workload is too great or you are under too much pressure you need to learn how to refuse additional tasks or get some extra time to complete current tasks. Organizations need to ensure they are managing workloads and ensuring employees are not under too much pressure.
LACK OF ASSERTIVENESS
This is not about being a bad boss or team leader who walks around shouting demands this is about allowing free speech amongst the team without fear of retribution. Are your team members allowed to express concerns and are they allowing each other to express freely?
Sometimes we go with the flow and follow the majority but in some cases this can be wrong. There are many studies on this and it can be known as Cognitive Dissonance, there are some great books on this if you want to learn more. A prime example of where this could be a problem is within the aerospace industry.
If a plane is being flown by a pilot and the co-pilot sees an issue which is being ignored by the pilot, the co-pilot may not say anything as they are respecting the pilot’s seniority. They may assume the pilot knows better even though their own judgement and training is telling them something else. People need to speak up and be heard, and team leaders need to provide that space and listen to other opinions.
STRESS
We can certainly tick this one off at the moment. The interesting thing about stress is it impacts everyone differently and sometimes its hidden. There are two key types of stress within the aerospace sector; acute and chronic.
Acute stress arises from real-time demands placed on us, our mental processing and physical body cannot cope, this can be lined to lack of resources. Chronic stress arises from the accumulation of long term pressures placed on us. Chronic stress can arise from life demands such as problems at home, illness, bereavement or just generally those general life issues we all come across from time to time.
If you notice someone snapping or being irritable they could be stressed, they could become complacent. You may notice people looking tired, stress can cause someone not to sleep and become ill. Many organizations are not training employees to identify stress, not just within themselves but also within each other.
LACK OF AWARENESS
“I didn’t know about that” is a common term heard within organizations who are lacking awareness. Not being aware of systems and procedures can be a factor in causing issues but awareness can also arise from some of the other human factors such as stress and fatigue. If someone is stressed they may not be aware of the surroundings or changes within the organization and be somewhat blinkered.
Stay vigilant within the workplace, if you notice someone is making mistakes think about what is causing that, do you need to monitor what they are doing for the time being until the matter has been resolved.
NORMS
An auditor loves this “we have always done it that way”. Although it is important to have experienced employees they can sometimes not like change and will continue to do something the way they have always done it even if others have moved on.
Norms also arise from the unwritten rules and tasks employees undertake. It’s not in the job description or written down but they know it’s something they need to do, also instructions could be limited but the operator knows what they are doing so you never write it down. When that person leaves the information is lost.
Ensure employees are working to defined procedures and not deviating away, maybe they have a better method of doing the same task but they need to communicate their feelings to get something changed or aligned.
Trend analysis
Within your management system you should be tracking the human factor issues and identifying trends and common themes. Maybe you are seeing many of the issues arising from the lack of awareness within the organization, once you know this you can start putting in actions to address the root cause.
If you’re not recording complaints and non-conformances you will have repeat issues and never resolve the problems fully. Employees could get disgruntled and leave due to the lack of concern for the employees wellbeing, are they stressed or under pressure? Without recording and reviewing you will never know.
In conclusion
Within the aerospace scheme you are forced to identify human factors as a result of non-conformances and i have witnessed organizations embrace this process and reap the rewards.
Think about your management system and the working environment, is there anything you can do as an organization to prevent some of these human factors from occurring in the first place? When you notice issues surrounding the human element of the management system put in some robust corrective actions.
A happy and healthy working environment will reduce errors and drive focus to ensuring customer requirements are being met.
Authored by: Michael Venner, NQA Aerospace and Automotive Director
