The ‘dirty dozen’ is a term often used to describe the most common human factors precursors of incidents or accidents. We can all play a part in mitigating these accident generators by understanding them and taking responsibility for them.
Here’s a simplified explanation of each human factor, along with some tips and tricks from safety management system facilitator, human factors specialist and LifeFlight human performance manager, Tarryn Ryan.
Lack of communication
Communication works for those who work at it.
– John Powell
It’s not just our words that matter – speech intelligibility, interpretation, intonation, assumption, expectation, ambiguity and the use of non-standard phraseology or jargon, can affect good verbal communication. Poorly written manuals or instructions can be both ineffective and dangerous.
Ryan says good communication is the backbone of effective teamwork and situational awareness. ‘Active listening is one strategy to mitigate miscommunication,’ she says. ‘Active listening means listening attentively to what has been said to ensure you understand, reflect on the message and then respond. And don’t hesitate to ask questions to ensure your understanding.’
Distraction
There are always distractions. If you allow them.
– Tony La Russa
Piloting an aircraft demands our full focus (yes, even with autopilot!), but distractions can, and will, happen. Turbulence, visual illusions, unexpected noises, issues with onboard systems, radio calls, crew coordination or even passenger issues are examples of external distractions. Internal distractions, such as stress, fatigue, or illness can also impair a pilot’s judgement.
‘The sterile cockpit rule is one well-known tactic to avoid distraction, and task prioritisation is another,’ Ryan says. ‘If your attention has been diverted, such as a checklist interrupted because of a radio call, always go back 2 steps in the checklist to ensure you have not missed anything.’
Lack of resources
It’s best to have your tools with you. If you don’t, you’re apt to find something you didn’t expect.
– Stephen King
Resources can mean equipment, training, tools, human resources or even a lack of access to these things. In the same way you wouldn’t expect your LAME to repair your aircraft without proper tools, don’t expect yourself, your crew or your aircraft to perform well without the right resources.
‘For private or solo pilots, being adequately resourced means ensuring that you and your aircraft are suitably equipped and prepared for the flight,’ Ryan says. ‘In a commercial scenario, adequate resourcing is usually up to the operators, but pilots should be empowered to speak up if they feel they are not resourced adequately.’
Lack of awareness
Awareness precedes change.
– Robin Sharma
Lack of awareness is the inability to fully grasp what is going on around us. Not being aware of the effect of our attitude or actions on others is an example of lack of self-awareness. Not paying attention to traffic calls due to an over-reliance on automation is an example of lack of situational awareness.
Being vigilant about what is going on for us as pilots, on the ground or in the air, means we have the ability to adapt appropriately. ‘Building awareness begins with self-awareness,’ Ryan says. ‘For example, defining personal limits before a flight creates a mindset that assists in decision-making and situational awareness.’
Defining personal limits before a flight creates a mindset that assists in decision-making and situational awareness.
Complacency
Complacency is the forerunner of mediocrity. You can never work too hard on attitudes, effort and technique.
– Don Meyer
Complacency can manifest as over-confidence, laziness, a false sense of security, being prone to confirmation bias or expectation of normality. Reduced vigilance leads us to underestimate potential threats, over rely on automation or speed through checklists.
‘To avoid being complacent, start with self-awareness and surround yourself with people who say it like it is,’ Ryan says. ‘And always expect the unexpected. Aviation is a dynamic environment – conditions can change unexpectedly and rapidly. However, when we are adequately prepared for these conditions, such as by thoroughness in pre-flight planning, ‘we equip ourselves better to deal with them.’
Pressure
You can measure a man’s character by the choices he makes under pressure.
– Winston Churchill
Commercial pressures, pressure from colleagues, passengers or peers, or pressure from within can be actual or perceived. Examples of environmental pressures might be a faulty instrument or having to land before weather closes in. Pressure can reduce our situational awareness, cloud our decision-making, degrade communication and cause us to prioritise convenience or expediency over safety.
Assertiveness training and fostering a culture of safety over blame are key tactics to combat commercial pressures. ‘Get-home-itis is a classic example of self-induced pressure,’ Ryan says. ‘Corners can get cut and limits pushed, sometimes leading to disastrous outcomes. If you find yourself in this situation, pause, take a breath and evaluate your options. Better to get home a day late, than push it and potentially end up in a serious incident.’
Stress
There cannot be a stressful crisis next week. My schedule is already full.
– Henry Kissinger
Stress might be a part of modern life, but too much stress affects mood, memory and sleep, and raises blood sugar levels, heart rate and blood pressure. It can make us reach for stimulants or depressants. Acute stress might be due to real-time events or demands, whereas chronic stress can be cumulative and might be due to personal relationships or work pressures.
‘Stress can cause our brain to enter fight, flight or freeze mode or upregulation, hampering effective decision-making,’ Ryan says. ‘It’s important to develop strategies to return to a clearer state of mind. Pausing – if the situation permits – and taking a few deep breaths – or a physiological sigh – both assist in deregulating this state.’
Lack of knowledge
There is no substitute for knowledge.
– W Edwards Deming
Inadequate training or lack of experience for the job we are doing or the aircraft we are flying, poor retention, the complexity of aviation technology and fast-paced industry changes can all leave us with knowledge gaps. Procedural shortcomings, misinterpreting data and decision-making errors can all be signs of lack of knowledge, leaving us ill-equipped to handle a situation.
‘Knowledge, skills and attitude are the foundation of airmanship,’ Ryan says. ‘These days, “hands and feet” are still relevant, but so is the knowledge and professionalism you display.’
Fatigue
Fatigue roughens up the edges of your nerves; it exposes fears and weaknesses.
– June Havoc
Fatigue is a major human factor and can be caused by sleep deprivation, circadian rhythm disruptions or workload. It can also be due to illness, stress, depression or pressure. It is characterised by diminished vision, motor skills or reaction times. It can cause reduced awareness, hyper-fixation, distraction, error-making and, if left unchecked, mental health deterioration and reduced cognitive performance.
‘Fatigue is insidious and its causes are often unclear,’ Ryan says. ‘We are really bad at recognising fatigue in ourselves until it is almost too late. The best remedy for fatigue is sleep! But good quality sleep, that is, 7-9 hours undisturbed.’
Norms
Sooner or later deviating from good practice will lead to a bad outcome.
– Rick Hoffman
Norms are unwritten rules, expectations and behaviours that guide us. Good examples of positive norms are following standard operating procedures, exhibiting good airmanship and fostering a strong safety culture. Bad examples of norms include normalisation of deviance and groupthink, which can pose a significant threat. Minor rule-bending can lead to major-rule bending becoming the norm.
‘Culture binds everything together and is often the driving force behind pilot behaviour, especially when we say, ‘but we’ve always done it this way’,’ Ryan says. ‘Rules and procedures are generated for a reason – hence the saying ‘written in blood’. If someone tells you to do something that is contrary to procedure, make sure you speak up about it.’
Lack of assertiveness
Being assertive does not mean that you always get what you want.
– Dr Joseph Russo
A lack of assertiveness can manifest as hesitating to speak up and can be the difference between having time to fix something, being safe or unsafe. A pilot lacking assertiveness might avoid questioning Air Traffic Control instructions, even if following them could compromise safe operations.
Positive assertiveness can be understood as a graded approach from least to most direct. Ryan says assertiveness is a skill that can be practised. ‘A simple P-A-C-E acronym helps with this: prompt, alert, challenge, emergency. A firm knowledge base also really helps in being more assertive in tricky situations.’
Lack of teamwork
Teamwork, plus a positive safety culture is what gets everyone home.
Whether solo or crewed, pilots can experience lack of teamwork. Air traffic and ground control, other pilots, maintenance personnel, the regulators, and crew, all form part of our aviation team. Teamwork is about shared responsibilities, mitigation of risk, and joint decision making, however, when the team fails to work cohesively, the consequences can be dire.
‘Clear communication and defined roles and responsibilities are the best foundation for effective teamwork,’ Ryan says. ‘It is also important for the team to back each other up and create an environment where anyone can speak up and ask for assistance.’ We would all recognise some of our own, or others’ behaviours in one or more of the ‘dirty dozen’ on occasion.
