Professional Documents
Culture Documents
FAIDHI
ROHIT
SHOFIYAH
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Contents Page
• Problem Statement
• What are Human Factors?
• What is SHEL? Or SHELL?
• Elements of SHELL
• What is Error Chain?
• Murphy’s Law?
• Human factors that led to the Incident
• What the Investigators Found/ Conclusion
• The End
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Problem Statement
• Your task today is to investigate the human
factors issues that could have caused this
incident.
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Human Factors
In general, a human factor is a physical or cognitive property of an
individual or social behaviour which is specific to humans and
influences functioning of technological systems as well as human-
environment equilibriums.
Rohit- http://www.usernomics.com/human-factors.html
http://en.wikipedia.org/wiki/Human_factors
http://www.mtr.com.hk/eng/sustainability/sustainrpt/2005rpt/sia-hfs.html 4
What is SHEL? Or SHELL?
• This concept has originated from the ‘SHEL Model’ by
Edwards in 1972, which the name was derived from the
initials of its components:
(Software, Hardware, Environment, and Liveware).
http://wikiofscience.wikidot.com/science:s
(ZENG YANG)
hell-model-of-human-factors
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Hawkins(Central Liveware)
• The Liveware, which is in the centre of the SHELL
Model, can be defined as human elements such as
knowledge, attitudes, cultures and stress. This
Liveware is regarded as the core of the SHELL
Model and other components match with the
Liveware as the central figure .
http://wikiofscience.wikidot.com/science:s
hell-model-of-human-factors (ZENG YANG) 9
Chain of event or Error chain
• term referring to the concept that many contributing factors typically lead to an
accident, rather than one single event.
• contributing actions typically stem from human factor related mistakes and pilot
error, rather than mechanical failure.
• For today problem, if the SMM to the work by the book following the step and
not judging by himself which lead to the different size of bolt use for the
windscreen. And why the procedures not requiring a pressure check or
duplicated check. This lead to an accident waiting to occur.
• The SMM must ensure to perform each and every function safely and by the
book, no shortcuts.
• If we can break just one link in the chain, the accident will not happen.
• And also, A study conducted by Boeing found that 55% of airline accidents
between 1959 and 2005 were caused by such human related factors, while only
17% of accidents were caused by mechanical issues with the aircraft.
Faidhi
http://en.wikipedia.org/wiki/Chain_of_events_%28aviation%29
Murphy’s Law
• “Murphy’s Law” can be regarded as the notion: “If
something can go wrong, it will.”
• The investigation revealed that the previous windscreen had been fitted with
incorrect bolts, which had been replaced on a "like for like" basis by the Shift
Maintenance Manager without reference to the maintenance documentation.
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