Quality Assurance in ATS, Human Factors and Aviation Safety Quality Assurance in ATS, Human Factors...

Quality Assurance in ATS,Quality Assurance in ATS, Human Factors and Human Factors and

Aviation SafetyAviation Safety

Captain Daniel MaurinoCaptain Daniel Maurino

Flight Safety and Human Factors, ICAOFlight Safety and Human Factors, ICAO NAR/CAR/SAM Air Traffic ServicesNAR/CAR/SAM Air Traffic Services

Quality Assurance SeminarQuality Assurance Seminar Ciudad de Méjico, 16-20 October 2000Ciudad de Méjico, 16-20 October 2000

QA & Aviation HF: Close RelativesQA & Aviation HF: Close Relatives

Human Factors and aviation safetyHuman Factors and aviation safety Differentiate Differentiate processesprocesses from from

outcomesoutcomes Emphasis on monitoring processesEmphasis on monitoring processes Relative importance of outcomes as Relative importance of outcomes as

driving forcesdriving forcesErrors do not cause accidentsErrors do not cause accidents

““Historical” SafetyHistorical” Safety ““Historical” SafetyHistorical” Safety

Design & manufactureDesign & manufacture

Management & supervisionManagement & supervision

Training & maintenanceTraining & maintenance

Stakeholders Stakeholders

OperationalOperationalpersonnelpersonnel

An Outcome-Oriented IndustryAn Outcome-Oriented Industry An Outcome-Oriented IndustryAn Outcome-Oriented Industry






The Need to Monitor ProcessesThe Need to Monitor ProcessesThe Need to Monitor ProcessesThe Need to Monitor Processes






The Fundamental QuestionThe Fundamental Question The Fundamental QuestionThe Fundamental Question

improve the improve the human condition?human condition?

improve the improve the processesprocesses underlying aviation underlying aviation operations?operations?

Errors and ConsequencesErrors and Consequences

CausesCauses and and consequencconsequenc

eses are not are not proportionalproportional

in their in their magnitudemagnitude

Operational Errors Reside in the ContextOperational Errors Reside in the Context

SafetySafety ProductionProduction

Operational behaviours:Operational behaviours: A compromiseA compromise

Training: Poor Learning GroundsTraining: Poor Learning Grounds

SafetySafety ProductionProduction

Training behaviours: “By the book”Training behaviours: “By the book”

Understanding Operational ErrorsUnderstanding Operational Errors

Threat to safetyThreat to safety

No significantNo significantconsequencesconsequences

Error life span

Error Error consequencesconsequences

ErrorError

Outcomes: Quite InfrequentlyOutcomes: Quite Infrequently

Error Error

FFlapslapsomittedomitted

DegradationDegradation//breakdownbreakdown

DeviationDeviation

ChecklistChecklistfailurefailure

AmplificatiAmplificationon

Unheeded Unheeded warningwarning

Processes: Quite FrequentlyProcesses: Quite Frequently

FlapsFlapsomittedomitted

ErrorError

AmplificationAmplification

EffectiveEffectivewarningwarning

NormalNormaloperationoperation

DeviationDeviation

ChecklistChecklist worksworks

Safety & QA: The Data We Must CollectSafety & QA: The Data We Must Collect Safety & QA: The Data We Must CollectSafety & QA: The Data We Must Collect






The Overriding Importance of CultureThe Overriding Importance of Culture

Anglo-Saxons design and supply; “the Rest of Anglo-Saxons design and supply; “the Rest of the World” usesthe World” uses

Anglo-SaxonAnglo-Saxon solutions are effective for Anglo-solutions are effective for Anglo-Saxon contextsSaxon contexts

Effectiveness in the “Rest-of-the-World”? Effectiveness in the “Rest-of-the-World”? World-wide accident rate: World-wide accident rate: failurefailure of of the the “dominant culture”“dominant culture” concept concept

Human Error & Process Control Human Error & Process Control

Aviation cannot be entirely specifiedAviation cannot be entirely specified Humans will inevitably make errorsHumans will inevitably make errors Normative prescription (music score)Normative prescription (music score) Real-time implementation of the scoreReal-time implementation of the score

Deviation(s) managementDeviation(s) managementDanger:Danger: loss of control of deviation loss of control of deviation management process management process rather rather that that deviations themslevesdeviations themsleves

Deviation ManagementDeviation Management

Rigid frameRigid frame

Normative Normative safetysafety

Flexible links Flexible links with damperswith dampersGenerative Generative

safetysafety

The End of the InnocenceThe End of the Innocence The End of the InnocenceThe End of the Innocence

ProductionProduction

Pro

tecti

on

Pro

tecti

on BankruptcyBankruptcy

CatastropheCatastropheComfort z

one

Comfort zone

Quality Assurance in ATS, Human Factors and Aviation Safety Quality Assurance in ATS, Human Factors...

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