CCFB 86

Cabin Crew & The Dirty Dozen: Spot It, Stop It

The “Dirty Dozen” are 12 common human factors that can lead to mistakes/errors. As cabin crew are often the first line of defence when it comes to safety, these factors are crucial for cabin crew to recognise.

The Dirty Dozen

  1. Pressure – Tight schedules or demanding passengers can lead to rushed decisions.
  2. Complacency – It won’t happen to me

  3. Communication – Misunderstandings or a lack of communication between crew can lead to errors.
  4. Distraction – Juggling multiple tasks.
  5. Knowledge – Keep up with training and procedures.
  6. Fatigue – Long duty days, flying through the WOCL, early starts, late finishes. Humans get tired, being aware of that can help prevent errors.
  7. Stress – Stressful situations can affect judgment.
  8. Assertiveness – Speak up when something feels off, even if it’s uncomfortable.
  9. Teamwork – Work together to ensure smooth operations.
  10. Awareness – Having completed the same task so many times e.g. door operation crew can develop a lack of awareness.
  11. Resources – A lack of resources can interfere with your ability to complete a task
  12. Deviation – Failure to follow procedures, skipping steps can be dangerous.

 

The human factors and aviation safety world recently lost one of its greats – Dr James Reason. A British psychologist, Dr. Reason revolutionised how we think about errors in aviation. Understanding human factors that contribute to errors is key to preventing accidents, and Dr. Reason was instrumental in shaping our approach to this.

 

“Human error is universal and inevitable – it is not a moral failing. While human fallibility can be moderated, it can never be entirely eliminated.”
Dr James Reason CBE, May 1938 – Feb 2025

 

His “Swiss Cheese Model” explains how multiple weaknesses in systems can line up to cause accidents. Instead of blaming individuals, he highlighted the role of systems, culture, and human behaviour.  The Swiss Cheese Model explains how accidents happen when multiple small errors align. Imagine layers of Swiss cheese, where each slice is a safety system (an SOP), and the holes represent weaknesses (eg. any of the the dirty dozen common human factors). Normally, the holes don’t line up, so the safety system works. But if they do align, a mistake/errror can slip through, causing a near miss/incident/accident.

As cabin crew, your understanding of these common human factors—and your ability to recognise, avoid, and mitigate them—can make all the difference. Several of the reports included in this edition show a breakdown in communication between the crew.  Safety is a shared responsibility; by staying vigilant, communicating well, and working as a team, you can help reduce the risk of errors.

Stay safe,

Jennifer Curran

 

  • CC6757

    Possible lightning strike
    Possible lightning strike

    Shortly after take-off, during the climb phase of flight, the crew were released from their seats. The seatbelt sign was still illuminated for passengers. There was a sudden strong acrid smell throughout entire aircraft (similar to an electrical fire). An interphone call was placed immediately to the flight crew who advised we were flying between lightning clouds and a “known phenomena were this can produce this smell”.

    A cabin crew member later reported seeing a flash through the forward cabin at the exact same moment of the smell and suspected a lightning strike. This was reported to the captain, who questioned the crew member on what exactly they had seen.

    Flight continued to {Airport} without further issue. On landing into {Airport} I heard the Captain verbally report to engineering possible lightning strike. The Engineer was furious. He was very vocal about – an ACARs (Aircraft Communications Addressing and Reporting System) message should have been sent. And the need to conduct lightning strike checks now that it has been reported, the length of time involved in completing those checks was approx. 6 hours,  and the fact that the aircraft now won’t be going out as scheduled.

    I don’t know why, but when I got home, I checked flight radar and saw that aircraft departed as scheduled for {Airport} 2.5hrs after it arrived from {Airport}. There is so much pressure on tight turns at the moment. My concern is that the lightning strike checks of the aircraft were not completed.

    Company Comment

    The Operational Safety team confirmed that a lightning strike inspection was carried out with nil damaged noted. The aircraft was inspected by Engineering with a walkaround completed by the next Flight Crew with no damaged reported.

    CAA Comment

    The cabin crew were correct in reporting what they experienced in the cabin in order to assist the flight crew in identifying the cause of the event and take appropriate action.  Operators have maintenance procedures for assessing the effects of lightning strikes and ensuring the airworthiness of an aircraft.

    As previously noted, cabin crew are an integral part of the safety chain, and their role in communicating with the flight crew is paramount. As the flight crew’s eyes, ears, and nose in the cabin, the cabin crew should always inform the flight crew of anything unusual or worrisome, as this reporter did.

    All large aircraft must be designed and certified to withstand lightning strikes without sustaining significant damage to their structure or effects on their systems that would adversely affect safety for the remainder of the flight. When lightning strikes an aircraft, a specific process must be applied to detect any damage caused by the strike, evaluate the damage, and perform the necessary repair before returning the aircraft back into service.

    There are several types of post lightning strike inspection depending on the severity and evidence of a lightning strike. This enables flexibility depending on airline operations, time constraints, human resources, availability of ground support equipment, etc. Two and a half hours may be sufficient to carry out the inspection, although even the preliminary inspections still would likely have required a “Cherry Picker”. For more information on lightning strikes and aircraft, click on this link Lightning Strikes | Safety First

    The reporter describes a ‘sudden strong acrid smell’ Ozone and nitrogen oxides created by ionized air produce a piercing odour. Lightning’s odour can be noticed immediately after a strike occurs and resembles the scent of burning electrical equipment. Lighting Has a Smell, And The Science Behind It Is Beautiful : ScienceAlert

    A similar report to this was received in 2022 and can be reviewed here CC5862 – CHIRP

  • CC6837

    Pressure from company risking safety checks
    Pressure from company risking safety checks

    At {airport} we have 5mins less on board to do our pre-departure duties than other flights, as a SCCM this is adding more pressure on me during my checks and we have the extra element of putting out service products onboard in the large business cabin which takes time. The company wants this done before boarding but has not given us any extra time to get this done.

    As a SSCM I feel stressed and anxious coming to work for this route and getting onboard can be stressful enough as I want to get my checks done as soon as possible to make myself available to help the other crew with setting these extra service items up pre-boarding.

    As we always have new crew onboard the checks take longer as they need support in their specific areas. I find myself running up and down, hanging over crew asking them if their checks are completed – when all they are doing is what is right, taking their time in finding their equipment and checking it thoroughly.

    What adds pressure is that as SCCMs we receive an email if the dispatcher reports the cabin has not been released within that 7 minutes to ask us why. The company states this does not go against us and it’s all about finding out causes etc, however it is kept on our personal files! Even if we can prove to the company via the Captain the delay in boarding was not down to cabin crew, they wipe this off their records, but it’s kept on our personal records as a personal fault of the SCCM.

    Company Comment

    Pre-flight safety and security checks are always the top priority. If delays or other circumstances prevent the timely completion of service-related tasks, these should be rescheduled for a more suitable time. Cabin crew are expected to inform the SCCM if they are unable to complete service-related tasks after finishing their safety and security checks. As the onboard manager, the SCCM is encouraged to address these situations proactively. If pre-flight service tasks cannot be completed, they should be carried out later (including post-take-off) when feasible, with any relevant reports submitted accordingly.

    Information regarding delays is held in the crew member’s electronic records, but it is not recorded as a ‘personal fault of the SCCM.’ Instead, it serves as a factual record of what happened from the perspective of both the station and the SCCM, including any conversations held with the relevant parties.

    We understand that having a delay allocated to an SCCM can be sensitive, and a lot of thought has been given to the wording of the emails. The purpose of the follow-up is to provide the SCCM with an opportunity to share their version of events and to help identify and share learnings with service partners such as overseas Airports, Flight Ops, and Dispatchers. The email clearly states that the follow-up is not about blaming anyone, and there is no intention to attribute fault.

    Delay contacts are not deleted from a crew members’ electronic file, as they help us understand how SCCMs respond to requests for further information regarding delays. This information supports operational improvements and is not viewed as a ‘personal fault.’

    CAA Comment

    As indicated in the operator’s response, completion of pre-flight checks following published standard operating procedures is a requirement to ensure a flight is operated in accordance with the operations manual and must take priority over service-related tasks.  Cabin crew are encouraged to proactively report via their company reporting scheme to identify scenarios where there is a potential detriment to the effective completion and required standard of pre-flight procedures.

    Operators are continuously seeking ways to improve efficiency and improve the onboard product/service for their customers but please do not allow yourself to be pressurised into not completing your safety checks properly.

    The briefing is an opportunity to address expectations to crew, explain that although there are 5 minutes less on this route, continue to be thorough but expeditious with onboard checks and that safety must come first if there is not time to complete service elements.

    ‘Pressure’ is one of the most frequently reported key-issue safety concerns to CHIRP. Be it commercial pressure, time pressure and/or peer pressure whether the pressure is real or perceived, the results are frequently the same, in this reporter’s case it may have caused anxiety, a fear of something being missed and poor CRM.

    As part of a ‘Just Culture’ crew must feel empowered to  communicate back to their operator if something isn’t working without the fear of being penalised as reports play a vital role in highlighting challenges allowing changes to be made if required. The company must believe that this reduction in time is achievable, and without crew reporting back to their operator that it isn’t (or even that it is, positive reporting is also encouraged) then the operator will not have the data to conclude that in fact the reduction in time is not achievable.

  • CC6831

    Cabin Crew – Sales over Safety
    Cabin Crew – Sales over Safety

    Cabin Crew at {AIRPORT} have received a brief referring to inflight sales service, it details that the service must commence within 5 minutes of being released. It states gaps in sales should not exceed 15 mins between sales. It also says any bars should be closed at 15 mins before landing.

    The senior manager has posted that the first sale of any flight should be within 5 minutes after being released and that any service in the cabin should continue (without trollies) until 10 minutes to landing. At 15 minutes to landing, Cabin Crew are responsible for securing the cabin and any bar service being completed at this time, will result in Cabin Crew being distracted and focusing on payment and service and potential for PAX to move or result in Cabin Crew missing things during Cabin Secure. There is also a time element here which means less time is being spent on Cabin Secure.

    It appears this has concerned many Crew at {AIRPORT} as they believe our operator is breaching safety protocols and manual handling regulations as well as this it is prioritising sales over safety.

    Company Comment

    Inflight service requirements for crew are that the service should commence 5 minutes after take-off when safe to do so. It is up to crew to determine if they can safely remove the trolley before commencing the service e.g. turbulence, other safety concerns preventing them from beginning the service. All crew are trained on manual handling techniques so that they can safely carrying out inflight service requirements and these procedures are risk assessed. Our Operations Manual SEP requirements for cabin secure includes completing the checks of the toilet and galleys at 15 minutes to landing and the cabin from 10 minutes. If crew are in the middle of a sale e.g. a passenger requests a bottle of water, this means that the crew can complete the transaction where safe to do so, it does not mean that crew should be completing an inflight service at this time. With any flight, crew should ensure they focus on SOPs and ensure cabin secure is not rushed and completed as per procedure. We would encourage crew to file a report through the safety reporting system.

    CAA Comment

    As part of the pre-flight briefing process the flight time should be established from the flight crew together with any other factors that may influence cabin crew in-flight duties in order to enable the SCCM to plan and monitor service activities and make any adjustments that may be necessary to ensure these are completed prior to descent and pre-landing cabin secure duties.  This is particularly important where there are forecast adverse weather conditions that may result in turbulence during descent where securing of the cabin and the cabin crew themselves is the priority.

    It is for the SCCM and their crew to make their best efforts to meet sales targets however, if there is a safety reason that the SCCM has assessed on the day that means that these targets cannot be achieved regardless of service requirements, cabin crew must prioritise safety over service and ensure that any deviations from the operator’s service expectations are documented and reported back to the operator.

    All cabin crew should feel empowered to report to their operators, reporting is not just down to the SCCM. Reporting that a service element has not been achieved and explaining why helps the operator build a picture of what’s actually happening online.

    Manual handling techniques must be adhered to, they have been designed to minimise the risk of injury to crew.

  • CC6869

    Ground staff wanted aircraft door closed when passengers were in the way to mitigate delay
    Ground staff wanted aircraft door closed when passengers were in the way to mitigate delay

    I was on an {airport} there and back and we landed approximately 30mins late into {airport} with a full aircraft. We had a quick turn around and started boarding ASAP for our flight back to {airport} which was due to depart at HH:MM local.

    I got told by the ground staff that ‘boarding was complete’ however there was still  a queue of passengers down the jetty waiting to board.

    At 3 minutes to the scheduled time of departure the last passenger stepped onboard however, they had to wait at the threshold of the boarding door as there was a queue of passengers in the galley and down the aisle. The ground staff manager then said to the close the aircraft door. I said we needed to wait as we couldn’t access the door due to passengers and their hand baggage being in the way of being able to close the door.

    Ground staff then said that in that case they would put the delay down cabin crew requests. This looked terrible in front of our customers and I find it unacceptable that I was ‘threatened’ with a delay code being attributed to me when I wasn’t able to access the door to close it, especially when I could be performance managed on delays.

    When I was able to access the door once the last passenger had moved into the galley and down the aisle. I reiterated to the ground staff that it was not ‘a cabin crew request’ but I physically couldn’t access the door to close it and that was why they needed to wait and be patient.

    Company Comment

    It is important for crew members to always follow Standard Operating Procedures (SOPs) to ensure their safety and the safety of others. In situations like this, maintaining clear and open communication with ground staff and the Captain is key, especially when there may be pressure to complete tasks that could affect safety.

    While ground staff may not always be fully familiar with our operating procedures or the specific tasks involved in safely closing the cabin door, this is an opportunity for respectful communication to help align expectations. Cabin crew should never feel pressured to rush safety procedures or cut corners.

    If the pressure becomes uncomfortable or feels unsafe, it’s important to inform the Captain and submit a report so that any concerns can be properly addressed. By submitting a Cabin Safety Report, we will be able to follow with the correct teams and share the feedback with them. The request to close the door before it was safe to was not ideal, and it’s essential that crew members continue to prioritise safety and stand firm when necessary to ensure a safe operation.

     

    CAA Comment

    As indicated in the operator’s response, cabin crew should not feel pressured to start passenger boarding or close the aircraft doors until they are satisfied all required safety activities have been achieved.  If the aircraft doors are closed before all passengers are seated and all cabin baggage stowed the cabin crew cannot confirm whether any items cannot be safely stowed and require loading in the aircraft hold and this requires the dispatcher/ground staff to be available and in communication with the cabin crew.

    If there is a delay to departure (pax/checks/baggage/PRM/catering etc) then it is important to document exactly why and ensure that effective communication is set up between the flight crew, cabin crew and the ground crew. Crew can feel under pressure especially at busy times such as boarding, but, as this reporter did, it is important to remember that safety must remain the number one priority.

    There are numerous issues that could have resulted as a consequence of the crew member closing the door when instructed to do so by the ground staff. Most staff have KPIs to meet and it’s not unusual that they too can feel pressurised on a busy flight.

    If you experience behaviours such as those reported here, please ensure that you report these concerns back to your operator, this will give your operator the oversight required to be able to follow up a concern and monitor whether this is a regular occurrence at a specific outstation or base.

  • FC5388 (c)

    Ground incident not reported to Captain by cabin crew
    Ground incident not reported to Captain by cabin crew

    I was the last passenger to board through the rear door on a delayed flight due to wind strength.  When the cabin crew member attempted to close the rear door they could not move the door and requested assistance from the ground crew.  The aircraft stairs had moved position in the wind and were resting against the bottom of the door (as reported by ground crew on the stairs).  The ground crew asked the cabin crew to stand clear while the stairs were lowered, however the direction selected was incorrect and the stairs lifted into the bottom of the door causing slight movement to the aircraft.

    I highlighted to the cabin crew member that as a Captain myself, this must be reported to the Captain.  He agreed and I believe spoke to a colleague on the interphone.  When seated and waiting for weather to allow departure I asked the SCCM if the Captain had been informed.  The SCCM was unaware of the incident.  I said the Captain must be informed before departure.  They spoke to a colleague and informed me that it was ‘fine’.

    After landing I spoke to the Captain about what I had witnessed.  Both the Captain and the First Officer were unaware and had not been informed by any member of the cabin crew.  The Captain requested that I explain what happened and also said that there had not been any pressurisation warnings during the flight.  The Captain said the door would be checked for damage.

    CAA Comment

    Contact between ground servicing equipment and any part of an aircraft has the potential to cause damage and, if observed or suspected, should be reported immediately to the flight crew in order to enable an inspection of the aircraft exterior and establish whether any further inspection is required before departure.

    CHIRP Cabin Crew Comment

    Good communication between cabin crew and flight crew isn’t just a nice-to-have — it’s a safety essential. Cabin crew are an integral part of the safety chain, and their role in communicating with the flight crew is paramount. Whether it’s a passenger who has drunk too much, ice on the wing or as in this situation, a problem with the rear steps, anything that happens out of the norm, no matter how small, must be communicated to the flight crew as soon as possible. The flight crew expect the cabin crew to communicate any concerns to them.

    Unfortunately, the incident described in this report highlights a significant lapse in that communication and despite the potential for structural damage (any impact to the aircraft structure needs immediate attention), the initial cabin crew member didn’t escalate the issue to the SSCM or the flight crew. What’s further alarming is that the SCCM when advised by the passenger also didn’t report these concerns to the flight crew which should have happened immediately. Assuming “it’s fine” is a risk no one should take.

     

    CHIRP Flight Crew Comment

    It’s really disappointing that an important safety message didn’t reach the flight crew until after the flight, especially when it was communicated clearly by someone who identified themselves as a credible witness. The reporter identifies the importance of effective communication between all crew, including ground handlers. The captain and first officer are unlikely to know directly of such incidents owing to the location of the rear steps and the busy cockpit work activities that are needed before push back and departure. Therefore, it is at times like these that teamwork is vital, and it is the eyes and ears of the cabin crew and ground handling teams that the flight deck relies upon. In a situation like this, cabin crew are also strongly encouraged to tell ground handlers and their supervisors, as well as communicating with the flight deck.

    As Lieutenant General David Lindsay Morrison, AO, who served as Chief of Army in the Australian Army famously said: “the standard you walk past is the standard you accept”. In other words, if you allow something unacceptable to occur, you’re essentially setting a precedent for it to happen again. All credit to the reporter who was ‘off duty’ but still took the time to raise a valid safety concern, repeatedly and tenaciously, and then report it afterwards for the benefit of all.

    For this incident, it was an observant passenger, who happened to be an aviation professional, that raised the alarm. The ground handling team in this circumstance were ultimately responsible for the safe positioning of the steps and consequently duty bound to report the incident to the captain as soon as it occurred. There is some doubt as to whether it had been wind that had caused the steps to contact the door, as commented by the reporter, but it may also have been a result of the aircraft settling after being loaded with fuel, passengers and bags. Irrespective of cause, the incident should have been reported immediately to the captain so that they could arrange for a qualified engineer’s inspection to be carried out.

    The reporter suggests that the ground handling team witnessed the incident, but they don’t appear to have reported it to cabin crew or flight deck. The ground handlers are a critical part of the safety team and they have a vital responsibility. It is never acceptable to just ‘assume it will be ok’, whatever the pressure to get the aircraft off on time.

    The cabin crew were also made aware of the incident, but did not pass on the information provided by the concerned passenger to the flight deck. The reason for this isn’t apparent on this occasion. It is appreciated that if every safety concern made by every passenger was passed unfiltered to the flight deck, then not many flights would take off on time. However, cabin crew are encouraged not to dismiss passengers concerns out of hand, rather to use best judgement in deciding what information to onwards transmit, based on what happened and the qualification and understanding of the person making the raising the alarm. It’s always worth putting yourselves in the shoes of the captain and considering ‘given the source, would I want to know this information?’; if there’s doubt, there’s no doubt and the information can always be discounted if necessary. Potentially it was a lack of confidence or sense of perceived pressure to achieve an on-time departure by cabin crew or ground handlers; this is covered by our CHIRP Comment above.

    Finally, on learning of the incident after the flight, as well as arranging for the door to be checked for damage, it is hoped that the captain of the aircraft submitted an internal ASR highlighting the breaks in the chain on this occasion that led to safety critical information not being onwards communicated.