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c) ensuring the provision of required services;
d) investigation of accidents and incidents; and
e) provision of operational safety oversight.
4.5.7 From a pilot’s perspective, supporting infrastructure includes such matters as:
a) airworthy aircraft suitable for the type of operation;
b) adequate and reliable communications, navigation and surveillance (CNS) services;
c) adequate and reliable aerodrome, ground handling and flight planning services; and
d) effective support from the parent organization with respect to initial and recurrent training,
scheduling, flight dispatch or flight following, etc.
4.5.8 An ATCO is concerned with such matters as:
a) availability of operable CNS equipment suitable for the operational task;
b) effective procedures for the safe and expeditious handling of aircraft; and
c) effective support from the parent organization with respect to initial and recurrent training, rostering
and general working conditions.
Human Factors1, 2
4.5.9 In a high-technology industry such as aviation, the focus of problem solving is often on
technology. However, the accident record repeatedly demonstrates that at least three out of four accidents
involve performance errors made by apparently healthy and appropriately qualified individuals. In the rush to
embrace new technologies, the people who must interface with and use this equipment are often
overlooked.
4.5.10 The sources of some of the problems causing or contributing to these accidents may be traced
to poor equipment or procedure design, or to inadequate training or operating instructions. Whatever the
1. Adapted from the Human Factors Guidelines for Safety Audits Manual (Doc 9806), Chapter 2.
2. Refer to the Human Factors Training Manual (Doc 9683) for a more comprehensive coverage of the theoretical and practical
aspects of Human Factors.
Chapter 4. Understanding Safety 4-9
origin, understanding normal human performance capabilities, limitations and behaviour in the operational
context is central to understanding safety management. An intuitive approach to Human Factors is no longer
appropriate.
4.5.11 The human element is the most flexible and adaptable part of the aviation system, but it is also
the most vulnerable to influences that can adversely affect its performance. With the majority of accidents
resulting from less than optimum human performance, there has been a tendency to merely attribute them to
human error. However, the term “human error” is of little help in safety management. Although it may
indicate where in the system the breakdown occurred, it provides no guidance as to why it occurred.
4.5.12 An error attributed to humans may have been design-induced or stimulated by inadequate
equipment or training, badly designed procedures, or a poor layout of checklists or manuals. Furthermore,
the term “human error” allows concealment of the underlying factors that must be brought to the fore if
accidents are to be prevented. In modern safety thinking, human error is the starting point rather than the
stopping point. Safety management initiatives seek ways of preventing human errors that might jeopardize
safety, and ways of minimizing the adverse safety consequences of the errors that will inevitably occur. This
requires an understanding of the operating context in which humans err (i.e. an understanding of the factors
and conditions affecting human performance in the workplace).
SHEL model
4.5.13 The workplace typically involves a complex set of interrelated factors and conditions, which
may affect human performance. The SHEL model (sometimes referred to as the SHELL model) can be used
to help visualize the interrelationships among the various components of the aviation system. This model is
a development of the traditional “man-machine-environment” system. It places emphasis on the human
being and the human’s interfaces with the other components of the aviation system. The SHEL model’s
name is derived from the initial letters of its four components:
a) Liveware (L) (humans in the workplace);
b) Hardware (H) (machine and equipment);
c) Software (S) (procedures, training, support, etc.); and
d) Environment (E) (the operating circumstances in which the rest of the L-H-S system must function).
4.5.14 Figure 4-4 depicts the SHEL model. This building block diagram is intended to provide a basic
understanding of the relationship of the human to other factors in the workplace.
4.5.15 Liveware. In the centre of the SHEL model are those persons at the front line of operations.
Although people are remarkably adaptable, they are subject to considerable variations in performance.
Humans are not standardized to the same degree as hardware, so the edges of this block are not simple
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Safety Management Manual (SMM) 安全管理手册(28)
