Definition

Due to a spate of maintenance-related aviation accidents and incidents in the late 1980s and early 1990s, Transport Canada, together with the aviation industry, identified 12 human factors issues, known as the "Dirty Dozen." In its human factors training, Hawker Pacific Aerospace, a Lufthansa Technik company, expanded the "Dirty Dozen" to the "Filthy Fifteen" by introducing three more human performance issues:

• Not admitting limitations
• Lack of operational integrity
• Lack of professionalism

The three additions capture more common reasons why aircraft maintenance technicians make errors and deviate from company policies, processes, and procedures.

The Full List

• Lack of communication
• Distraction
• Lack of resources
• Stress
• Complacency
• Lack of teamwork
• Pressure
• Lack of awareness
• Lack of knowledge
• Fatigue
• Lack of assertiveness
• Norms
• Not admitting limitations
• Lack of operational integrity
• Lack of professionalism

A discussion of the three new additions follows below:

Not Admitting Limitations

This factor highlights that everyone has limits. To be precise, study and analysis of human performance limitations is a vital part of human factors training. We must understand and thus be honest, transparent, and assertive in admitting our limitations in order to perform tasks effectively and safely. Exceeding our limitations decreases performance, increases risk to the individual and to coworkers, and may lead to aircraft and equipment damage. The countermeasures to not admitting limitations include:

• Be aware of your physical, cognitive, and technical limitations.
• Listen to your body's warning signs.
• Get over your ego.
• Admit lack of knowledge.
• Always follow correct procedures.
• Seek answers and ask for help.
• Take breaks and live a healthy lifestyle.

Lack of Operational Integrity

Integrity refers to a firm adherence to a code of moral values and its application through observance to regulatory requirements and approved maintenance procedures. A lack of integrity can result in risk-taking behaviors, such as routine violations (ineffective workplace norms) and situational violations (cutting corners due to circumstances in the work environment, such as time pressure and unavailability of equipment or tools). "It was a little out of tolerance last time, and it worked. It's a little out again--what's the big deal?" Integrity means doing the right thing every time, no matter if others are watching or not.

Deviation from procedures may not result in immediate negative consequences for safety. As a result, people may become complacent and grow to believe deviations carry little risk. This makes lack of operational integrity particularly insidious. Safety nets for this human error precursor include:

• A clear commitment to integrity communicated by the organization to its work force.
• Knowing and applying the characteristics of integrity.
• Making your actions consistent with your words.
• Speaking up immediately if you know you have made an error.
• Always considering the safety of others.
• Always following correct procedures.

Lack of Professionalism

Doctors in many western countries take the Hippocratic Oath upon entering the profession, as a symbol of their commitment to upholding ethical and moral standards. In the aircraft maintenance world, technicians live by the technician's creed, originally written by one of Flight Safety Foundation's founders, Jerome Lederer, in 1941. The creed appeared on the back cover of the first issues of FSF's Aviation Technicians Bulletin in 1953. The text of the creeed follows:

Upon my honor I swear that I shall hold in sacred trust the rights and privileges conferred upon me as a certified mechanic. Knowing full well that the safety and lives of others are dependent on my skill and judgment, I shall never knowingly subject others to risks which I would not be willing to assume for myself, or for those dear to me.

In discharging this trust, I pledge myself never to undertake work or approve work which I feel to be beyond the limits of my knowledge; nor shall I allow any non-certificated superior to persuade me to approve aircraft or equipment as airworthy against my better judgment; nor shall I permit my judgment to be influenced by money or other personal gain; nor shall I pass as airworthy aircraft or equipment about which I am in doubt, either as a result of direct inspection or uncertainty regarding the ability of others who have worked on it to accomplish their work satisfactorily.

I realize the grave responsibility which is mine as a certified airman, to exercise my judgment on the airworthiness of aircraft and equipment. I, therefore, pledge unyielding adherence to these precepts for the advancement of aviation and for the dignity of my vocation.

Professionalism refers to the skill, judgment, and behavior expected from a person who is trained to do a job well. The term also describes the standards of education and training that prepare members of the profession with the necessary knowledge and skills. In aircraft maintenance, professionalism can be interpreted as willingness to take responsibility for placing the safety of the traveling public above individual self-interest. Professionalism can be further described through the following aspects:

• Discipline--following approved procedures to perform a given task.
• Communication--keeping team members informed of progress and developments.
• Teamwork--working together well to resolve problems and maintain control.
• Knowledge--having deep understanding of aircraft systems and their operation.
• Expertise--retaining and transferring knowledge and skills.
• Situational awareness--knowing what is happening around you.
• Experience--calling upon prior training and knowledge to assess new situations.
• Decision-making--taking correct decisive actions.
• Resource management--allocating resources to ensure control of the larger situation while specific problems are being addressed.
• Prioritization--setting safety above personal concerns.