From 1986 to 1993, Gordon Dupont worked as an accident investigator for the Canadian Aviation Safety Board (now the Transportation Safety Board). Over time, he began looking beyond the official accident causes, exploring the chain of events that led to them.
“After the hundreds of accidents I’d investigated over the years, I wanted to dig deeper to understand what the contributing factors were that made a pilot bet his life and lose,” Dupont told Vertical.
For instance, an accident’s official cause may have been inadvertent flight into instrument flight rules (IFR) conditions, leading to disorientation and impact with terrain. However, Dupont wanted to know what led the pilot to enter IFR in the first place. He examined hundreds of accidents and soon began to identify repeated human factors as clear contributors.
In 1993, Dupont distilled his observations into the “Dirty Dozen” — the 12 most common human factors contributing to aviation accidents.
“Fatigue was clearly the number one contributing factor I could pinpoint in all these accidents, but there were several other clear contributors,” Dupont said of the list. “It’s not just pilots, either. Several accidents that were once blamed on the pilot have since been looked at more closely and determined to be tied to maintenance.”
The Dirty Dozen and Their Safety Nets
Once Dupont had identified the Dirty Dozen, he developed an educational campaign built on changing people’s thinking as a part of risk mitigation.
“You have to train people to think they’re not as smart as they think they are,” Dupont explained. “As you become fatigued, for instance, you develop an attitude of ‘I don’t care’ because the body wants to sleep. You’re going to forget things. You’re going to miss things or miss what is right in front of you.”
When it comes to distraction, as another example, Dupont highlights a basic wiring in human brains that can set us up for failure: our brains are always thinking ahead.
“If you go for a coffee or answer a phone call, then go back to your task, you’re not thinking back, you’re thinking ahead,” he explained. “You could be thinking you were further along than you were and that is where things get missed.”
Each of the human factors in the Dirty Dozen have a similar story, identifying the unique human experiences driving behaviors that can lead to errors. Dupont feels if we are aware of these unconscious elements — like thinking you’re further along than you are — we can better avoid the pitfalls.
To help people reduce the risks of the Dirty Dozen, Dupont developed a list of mitigations, which he calls “safety nets” for each human factor. Overall, these include awareness of the threat as well as advice for how individuals and organizations can fortify themselves to avoid mistakes.
In the distraction example above, the original safety nets included developing and always using checklists, flagging incomplete work before stepping away, and developing the habit of going back three steps when restarting work.
The Dirty Dozen Today
Due to its ties to human behavior and performance, the Dirty Dozen continues to be as relevant 32 years after Dupont developed it, with the same 12 human factors remaining the largest offenders in aviation.
“The world and our industry may have evolved and changed, but the humans that are in it and their reasons for doing something that bets their lives haven’t changed at all,” Dupont said. “As long as humans are involved in aviation, there will be human factors.”
What’s more, several factors of aviation business that affect these human factors remain, such as the need to be profitable, he added. This one business demand can directly affect all 12 human factors.
The way the Dirty Dozen is approached, however, has changed. ACE Aviation Consulting CEO Willis Jacobs joined Dupont to give a Dirty Dozen presentation during the CHC Safety and Quality Summit in Vancouver, B.C., last year. During it, he highlighted Dupont’s emphasis that while humans aren’t changing, the way people approach these human factors must evolve to reduce their contribution to accidents. Instead of the former focus on eliminating these 12 offenders, the shift has moved to consciously and continuously managing them, he said.
Distraction, for instance, continues to be a deadly human factor in an age where there is so much more to distract people. Dupont said the internet, cellphones, and personal electronic devices (PEDs) have been a blessing and a curse. While these tools can help accomplish work more efficiently, they have also created a whole new level of distraction. Cellphones, for instance, with constant notifications, the ability to get a call or text at any time, and instant access to social media, create considerable distraction in the hangar and cockpit, he said.
Safety nets for distraction today include PED policies such as locking up cellphones while at work, in addition to checklists. However, Willis emphasized a need for a more holistic approach to managing distraction.
Taking away a cellphone doesn’t take away the underlying human tendency to be distracted, Willis explained. In fact, the younger generation has reported increased distraction worrying about potentially missing an important call or text from family if the cellphone is locked away during an entire shift.
“One solution is to work with employees to identify critical tasks during which the phones needed to be put away, allowing employees to police themselves,” Willis explained to conference attendees. “Talk to your employees, discuss the hazards, and develop solutions together.”
In fact, Willis highlighted how technology as a whole comes up quite a bit across many of the Dirty Dozen today. The ease of doing tasks thanks to technology can lead to complacency. Technology has also changed how we communicate, introducing new challenges to ensuring clear and effective communication.
Technology is also changing quickly, which can lead to a lack of awareness of all its potential risks and implications. What’s more, e-learning — another popular technological tool — can actually contribute to a lack of knowledge, Willis warned. In that case, he encouraged leaders to ask themselves if it’s really as effective as in-person learning in their organizations.
“Organizations need to continue to adapt safety measures to keep up with evolving technology and its impact on human factors,” Willis said.
Technology is only one example. Willis and Dupont emphasized the value of a holistic approach to continually reviewing, adapting, and revisiting mitigation strategies across all 12 human factors. Organizations that maintain awareness of the Dirty Dozen and continuously identify and evolve mitigations will be more successful at avoiding them, the duo emphasized during the presentation.
The Dirty Dozen also has the potential to reach far beyond flight operations and maintenance.
“It was always the thought that the Dirty Dozen was for the floor, and it rarely made its way into the C-suite,” Willis said. “If you think about a lot of the really difficult decisions that management makes today, you see how the Dirty Dozen is highly relevant to safety-critical decision making in the C-suite. Stress, for instance. What stress is pushing them in these decisions? Perhaps there are components of decision making tied to lack of communications, lack of teamwork, or complacency. If management teams were to take stock of the Dirty Dozen and apply it for that type of decision making, it would be equally important for the business.”
Dupont added: “The Dirty Dozen is here to stay and remains relevant. As we’ve seen in our thousands of workshops, those that take them seriously and work to develop and use the safety nets can help avoid the risk of accidents.”
Very useful information
Phones become addictive and people are more likely to be seeking anything that they can connect with or seeking attention. This could be due to family or emotional issues or work conditions and stress