Regional Aviation Association of Australia National … · 8 fully loaded B737-800 aircraft per day...
Transcript of Regional Aviation Association of Australia National … · 8 fully loaded B737-800 aircraft per day...
Regional Aviation Association
of Australia
National ConventionHunter Valley 2016
The process of adapting well in the face of adversity, threats or significant stress.
American Psychological Association, 2016
The ability to recover from or adjust easily to change
Webster-Miriam Dictionary, 2016
The capacity to recover quickly from difficulties
Oxford Dictionary, 2016
The ability of a system to accommodate errors, normally unpredicted, and cope with new situations while keeping the system safe
IATA, 2009
The process of adapting well in the face of adversity, threats or significant stress.
American Psychological Association, 2016
The ability to recover from or adjust easily to change
Webster-Miriam Dictionary, 2016
The capacity to recover quickly from difficulties
Oxford Dictionary, 2016
Individual or organisational resilience ?
The ability of a system to accommodate errors, normally unpredicted, and cope with new situations while keeping the system safe
IATA, 2009
ERRORS AND TECHNOLOGY
Chernobyl (USSR) 1986
$12 billion US cost to the Soviet economy
HUMAN ERROR AND DISASTERS
Exxon Valdez, Alaska (USA) 1989
Oil Spill: 11 million US gallons
Flying Tigers, B747, (Malaysia) 1989
4 crew killed, aircraft destroyed
Costa Concordia, (USA) 2012
32 people drowned
Mars Climate Orbiter, Mars (Space) 1998 - 1999
$1 billion spacecraft lost
Union Carbide Plant, Bhopal, (India) 1984
Approx. 8000 dead
STS Challenger, Florida (USA) 1986
7 astronauts killed
HUMAN ERROR AND AVIATION
HUMAN ERROR AND AVIATION
HUMAN ERROR AND AVIATION
Human error not thought about too much until the 1970s
HUMAN ERROR AND AVIATION
1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
30
25
20
15
10
5
0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
OIL CRISIS
OIL CRISIS
GULF WAR
WTC ATTACK
SARS
Boeing ICAO
HULL LOSSES PER MILLION DEPARTURES GROWTH IN TRILLIONS OF RPK
Technical era Human era Organisational era
HUMAN ERROR AND AVIATION – AS A GRAPH
SOME NUMBERS (2015)
Airline Passenger Numbers: 3.5 billionWorld Bank/IATA, 2016
Airline Passenger Deaths: 136 (510 inc German Wings/Metrojet) IATA, 2016
1 accident per 3.1 million flights IATA, 2016
Global Road Fatalities: 1.25 millionWHO, 2015
Medical Error: 3.5 millionDonaldson, 2012
MEDICAL ERROR
Include diagnostic errors, omission errors, failure to follow SOPs
440,000
8 fully loaded B737-800 aircraft per day ……
ERRORS AND ACCIDENTS
‘Coal Face’ Staff
SUPERVISORS
MIDDLE MANAGEMENT
SENIOR MANAGEMENT
REGULATORY AUTHORITIES
LATENT CONDITIONS (resident pathogens)
AN ERROR IS…..
Unintentional deviation from organizational expectations or crew intentions
A VIOLATION (intentional non-compliance)…..
Intentional deviation from organizational expectations or crew intentions
Slips – attention failure (omission, commission, misordering, mistiming) eg flaps up instead of gear
Lapses – memory failure (omitting planned items, place-losing, forgetting intentions) No gear down
Mistakes
Rule based (misapplication of a good rule or application of a bad rule)
Knowledge based – inaccurate or incomplete mental model
TYPES OF ERRORS
Routine – habitual departures from rules and regulations
Situational – deviation from procedures needed to get the job done due to a mismatch between a work situation and available procedures
Optimising - individual satisfying other motives (excitement, impressing others, cutting corners…)
VIOLATIONS CAN BE…..
An external event or object that a person has to deal with that could become consequential to safety
THREATS
Unfamiliar airport,
similar callsign,
other traffic
Focuses on the errors and violations of individuals and ways to stop errors and violations from occurring.
“inattentive, forgetful, careless, negligent, reckless, incompetent”
Remedial action is directed at people at the ‘sharp end’.
Errors are isolated from their context.
Becoming less dominant in aviation, still dominant in medicine and other high risk industries
THE PERSONAL MODEL OF ERROR
Responsible professionals should not make errors (but they do).
Errors that result in bad consequences means the person was negligent or reckless and they deserve deterrent sanctions.
Being able to blame someone is legally convenient and psychologically satisfying.
THE LEGAL MODEL OF ERROR
EVEN EXPERTS MAKE ERRORS
The best people can make the worst errors
The untrained/uneducated do not have a monopoly on error
Traces the error causal factors back into the system as a whole.
Remedial action is directed at situations and organisations.
Fallibility is accepted as part of being human.
Adverse events are the product of latent conditions within the system.
Views accidents as ‘organisational accidents’
THE SYSTEMS MODEL OF ERROR
HIGH RELIABILITY ORGANISATIONS
Have a ‘systems’ approach to safety and managing error.
Organisational culture is important (Just Culture).
Accept that errors will occur.
Learn from the rare adverse events they do have.
Use human variability to build individual and system resilience
Reason, 1997
HIGH RELIABILITY ORGANISATIONS
PILOT ERROR
Associated with crew actions pre-flight or in the cockpit
Can occur in single pilot or multi-crew operations
Generally, any consequences of the error are evident immediately or soon after the error has been made
Considerable training undertaken to minimise pilot error.
Phase of Flight
Cruise Descent Approach & Ldg
Taxi-in & parkClimbTake off
Pre-flight
& taxi
Workload
Brain Power Required
Max Cognitive Ability (Max Brain Power Available)
Excess Brain Power Available
(Ability to handle extra tasks)
PILOT ERROR – WHEN CAN IT HAPPEN
Phase of Flight
Cruise Descent Approach & Ldg
Taxi-in & park
ClimbTake off
Pre-flight
& taxi
Workload
Brain Power Required
Decreased Max Cognitive Ability
(Decreased Max Brain Power Available)
PILOT ERROR – WHEN CAN IT HAPPEN
AUTOMATION ERROR
AUTOMATION – BIG AIRCRAFT ONLY ?
Computers in the cockpit will eliminate human error !
• Lack of vigilance and monitoring
• Automation as “dumb and dutiful”
• Mode awareness, mode confusion, mode errors
• Commanding the system, or does it command you?
• Lack or loss of situational awareness
• Loss of manual and cognitive skills
• Automation complacency or mistrust
• Lack of design transparency
• Not having a ‘Plan B’ when things go wrong
COMMON AUTOMATION PROBLEMS
MAINTENANCE ERROR
Associated with aircraft maintenance actions.
Generally, any consequences of the error are NOT evident immediately after the error has been made. The consequences may not occur for several days, weeks, months or even years.
The most dangerous part of aircraft maintenance is shift changeover.
Very little training undertaken to minimise maintenance error.
►Incomplete installation (33%)
►Damage on installation (14.5%)
►Improper installation (11%)
►Equipment not installed/missing (11%)
►Foreign object damage (6.5%)
►Improper troubleshooting, inspecting or testing (6%)
►Equipment not activated or deactivated (4%)
Data from Boeing study of 276 in-flight engine shutdowns (2004)
MAINTENANCE ERROR
MAINTENANCE ERROR DC-10 CHICAGO 1979
Only one way
to disassemble
40,000+ ways
to incorrectly
reassemble
MAINTENANCE ERROR
Aviation maintenance environments are complex with a high chance of error possible.
ERRORS WILL ALWAYS HAPPEN
LATENT CONDITION PONDS
Train personnel to try and avoid making errors and
detect the errors that have been made then correct them and
limit the effects of errors that already been made.
Train personnel so well that they do not make errors (yeah right)
Install computers to prevent human error…….
Design systems to be error tolerant (system still functions after an error has
been made) – different from fault tolerant
Design systems to be error proof (design prevents an error being made at all
or makes it difficult for an error to be made) – guarded switches, two man rule
Use other safeguards and defences (checklists, SOPs)
WHAT TO DO ABOUT ERRORS
Human Factors training: aims to optimise the relationship between people, their activities and the systems with which they interact
Crew Resource Management training: aims to provide people with the cognitive and social skills required to achieve safe and efficient flight and maintenance operations
Non-Technical Skills: an amalgamation of human factors, crew resource management training and TEM designed to create individual and system resilience within an organisation and manage threats and errors.
WHAT TYPE OF TRAINING
Accident
Technical Skills Failure
Non-Technical Skills Failure
Timeline
75% of accidents are due to NTS failures
NON-TECHNICAL SKILLS
DECISION MAKING
SITUATIONAL AWARENESS
Information acquisition and processing
Workload management
Leadership and managerial skills
Threat and error management
Stress and stress management
Cultural factors
Communication
Fatigue and fatigue management
Automation
NON-TECHNICAL SKILLS CORE ELEMENTS
Regional Aviation Association
of Australia
National Convention