EASA’s DIRTY DOZEN applied to your SMS
AVIATION SAFETY cannot be captured in a poster or a t-shirt. The below excellent article by EASA’s John Franklin provides very useful points about embedding this critical culture in each of our organizations. He has synthesized the multitude of behaviors on which SAFETY DNA can be built. The list if called THE DIRTY DOZEN, a phrase that he attributes a 1993 Transport Canada paper. The DIRTY DOZEN’s etymology (see fn1) to the same number as calendars have months.
This Journal has touched on this topic a number of times and it is an SMS concept worthy of repetition:
- A human risk to which SMS participants may be oblivious
- Work Environment + TENSION = bad #safetyculture ; DIVERSITY and BIAS training may lower risk #faa
- #sms learns from known errors; Cognitive Outcome Bias points to future #aviationsafety problems- can this science be incorporated? #faa #icao
- #SMS is not enough #safetyculture requires EVERY EMPLOYEE’S ENGAGEMENT, starting at the top. Captain Perkins’s great insights into #HUMANFACTORS science: leadership, occupational bias, amygdala, psychological safety, collective #FAA #A4A #ALPA #IAM #RAA
- Kern’s Shoshin Lesson at BASS is OUTSTANDING
A safety leader asks how AWARENESS BE REINFORCED CONTINUOUSLY and EFFECTIVELY. Repetition can be a useful tool for adult education, but it should be used in moderation and in conjunction with other learning methods. One way to attenuate the impact is to present the message in different formats, media, anything that attracts attention in a creative way.
As these real-world examples show, one way to reinforce broad themes is to use specific application of the safety principle.
Another pedagogical tool for adult learning1 is labeled “retrieval practice.” In a classroom, a teacher then asks a student to recall “X” and explain it. “Quizzing” would not be appreciated on the shop floor or a ready room. Mr. Franklin suggests two opportunities to demonstrate the importance of retrieval—
- verbal encouragement on a real time basis when someone exhibits 1 or more of the 12 (awareness of fatigue, good communications, identifying a possible distraction, etc.).
- Written recognition of a significant action qualifying as one of Mr. Franklin’s dirties. The best example is an “attaboy” or orchid letter, ideally from someone senior in the company, expressing appreciation for submitting any SMS report (obviously only when the individual is not anonymous). Some companies have reward systems for a variety of achievements and recognition of the DIRTY DOZEN must be included in the criteria!!!
Probably the most important technique to solidify a safety culture is frequent recognition of any behavior among the Dirty Dozen.
Perhaps the most powerful method of building a safety foundation is personal action by the leaders to show their adherence to the Dirty Dozen. Imagine a CEO walking onto a hangar, recognizing the AMTs stress/fatigue and helping; obviously, the executive is not qualified to perform their work, but (s)he could collect and organize the work cards, sweep some of the detritus on the floor or just bring coffee and donuts. Another example could involve the SVP of marketing attending a technical lecture on safety for the pilots, sending a message that the subject matters to all. A Deputy Administrator once carried a broken printer down a spiral staircase at an ATCT to learn personally how hard that was; before return to DC, the FAA grapevine had picked up and communicated this event systemwide.
The lesson of the DIRTY DOZEN is whatever works in your company, do it!!!
John Franklin • 18 January 2024
in community Air Operations
In any organization, it’s not always easy to translate your safety and risk management discussions into practical information and actions that you can use to help your operational staff in their different jobs and roles. There is also a lot of talk about Organisational and Human Factors and it’s important that we bring this to life to help people understand their role in managing risk to ensure safe operations and prevent accidents.
A great way to do this is through something called the “DIRTY DOZEN.” You might have heard of them before2. They were initially put forward by Gordon Dupont in 1993 while working for Transport Canada and then adopted by the US Federal Aviation Administration (FAA) and other regulators as a framework for recognizing the psychological and environmental aspects of human error. The Dirty Dozen was first used in aircraft maintenance – they are a dozen because 12 things fitted nicely on the 12 months of a calendar.
THE DIRTY DOZEN AS A WAY TO HELP REDUCE THE RISK OF OUR TOP SAFETY ISSUES
The whole point of the Dirty Dozen is to use them as practical things to think about every day. Obviously, there are 12 of them – six of them are things you need to ensure successful and safe operations and the other six are things that could lead to an increase in risk.
EVERYONE HAS A PART TO PLAY – INCLUDING THE ORGANISATION
Obviously, everyone has their own part to play in ensuring safety in everyday operations. Whether you are a pilot, cabin crew, engineer, ground staff or anything else – you are our first line of defence against the operational risks that we face. You are the ones continually identifying and mitigating risks to keep our passengers and all our staff safe. But there is only so much that you can do alone. Your success relies on the wider organisation providing everything you need to do your job. This is why our reporting system is so important. When you identify challenges in doing your job, report it to our MANAGEMENT SYSTEM through the button on the Intranet to tell the safety and learning team about it. The problem will then be investigated and will hopefully lead to a new safety action to improve things. You will always get feedback on any reports you submit.
INTRODUCING THE DIRTY DOZEN – REBOOTED
The Dirty Dozen covers a wide spectrum of human factors, each link closely together as part of the landscape our day-to-day operations. Here’s a comprehensive rundown:
1. COMPLACENCY: Familiarity can lull us into a false sense of security. If we have a sense of overconfidence or routine this can lead us to act the way we think we should and not specifically in the right way for the situation.
2. FATIGUE: Human performance reduces considerably when we are fatigued. Managing work schedules and ensuring adequate rest is vital for our safety and those of our passengers.
3. KNOWLEDGE: The absence of essential knowledge is a direct path to errors. Continuous learning and training are vital to ensuring safe operations.
4. PRESSURE: Unrealistic deadlines and expectations can put people under pressure that can lead to errors. Balancing efficiency with doing things in the right way is key. We should always try to factor in the time to do everything that needs to be done.
5. TEAMWORK: Safe and effective operations require many different people to work together in perfect harmony. It is easier to manage operational risks and hazards when everyone plays their different roles as part of a team and not as an individual.
6. COMMUNICATION: Safe operations require everyone to know what is going on. This requires continually communication and sharing of information, between colleagues and with people from other organisation.
7. NORMS: Deviating from established standards and practices can introduce risk. Upholding and reinforcing norms is critical for safety but we should also avoid group think that could lead to safety issues. If you see a process or practice that doesn’t fit the situation, report it.
8. RESOURCES: It is important that we have enough competent people who are operationally ready and fit for duty and that we have the right tools, equipment and infrastructure in place.
9. ASSERTIVENESS: Failing to question or voice concerns can mean risks are not identified by everyone or might lead to errors. It is important that we have a mindset in every team that encourages assertiveness so that everyone in the team can speak up.
10. DISTRACTION: A momentary lapse of attention can have lasting repercussions. Ensuring a distraction-free environment is crucial – this is particularly important at key parts of a flight or other tasks where focus is important for success.
11. STRESS: Excessive stress also impacts our ability to performance to our best and impairs judgment, especially when coupled with some of the other parts of the Dirty Dozen. We should identify and mitigate stressors so please use the reporting system to help us minimise stress for everyone.
12. AWARENESS: Good decision making requires everyone to have a complete picture of the situation. This part of the Dirty Dozen is particularly linked to Communication, which is how we build the full picture and situational awareness can be impacted by pressure and stress especially.
What you can do
- THINK ABOUT THE DIRTY DOZEN AS YOU GO ABOUT YOUR DAY: When you think about the different parts of the Dirty Dozen, it makes it easier to identify situations where error inducing situations might build up. Many of our training programs now integrate human factors education to help set things specifically in the context of the day-to-day jobs that you all perform. This helps you to be aware of common pitfalls and are equipped to avoid them.
- REPORT, REPORT, REPORT: There is only so much that you can do yourself as an individual or within your operational. This is why safety reporting is so important. If you identify a situation involving any of the Dirty Dozen, please report it through the internet so that others can learn from it and particularly so that the Safety and Learning Team can help put in place mitigations at an organisational level.
Conclusion
The Dirty Dozen has emerged as a vital tool in recognizing and mitigating human error in aviation. By continuously addressing these human factors, aviation authorities and organisations like ours are making strides in enhancing the safety and reliability of aviation operations. Our commitment to understanding and improving human performance in aviation is an ongoing journey, one that requires the collective effort of the entire industry. As aviation continues to evolve, the principles embodied in the Dirty Dozen remain a guiding beacon, illuminating the path toward a safer aviation future.
