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Presented to:
By:
Date:
Federal Aviation
AdministrationThreat and ErrorManagement
and
Hazard Identification
on Airports
27th Great Lakes Airports Conference
Roger Motzko, FAA, ATO Safety
2 November 2011
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2
Definitions
Hazard:
Anything that will or has the potential to cause harm Risk:
The likelihood and severity of consequence of a
hazard
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Hazard:Anything that will or has the potential to cause harm
3
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Risk:
The likelihood and severity of consequence of a hazard
4
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Three Methods of Analysis
Historic
Study data over time, develop trends from accidents Diagnostic
Identify precursors by using collective safety
reporting systems Prognostic
An informed method that looks at future
development and eliminates potential hazardsbefore they are introduced
5
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Direct Cost (FY 98 08)
$5.14 Billion and 1113 Lives
Direct Cost (FY 98 08)
$5.14 Billion and 1113 Lives
Indirect Cost
Loss of Manpower
Delay in DoingBusiness
Corporate Reputation
Investigation Costs
Litigation
Indirect Cost
Loss of Manpower
Delay in DoingBusiness
Corporate Reputation
Investigation Costs
Litigation
COSTS OF NAVAL ACCIDENTSCOSTS OF NAVAL ACCIDENTS
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So where to begin?
Start with Reasons Swiss Cheese model
Base on Human Factors Analysis and Classification System(HFACS) by Doug Weigmann & Scott Shappell
Categorization of system failure in complex systems Latent Failures Active Failures
Bring together human factors, Operations, Human systems,Systems safety and Engineering Issues Man, Machine, Medium, Mission, Management
Adopt a philosophy of analysis that focuses on the systeminstead of the individual
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Failed or
Absent Defenses
OrganizationalFactors
Unsafe
Supervision
Preconditionsfor
Unsafe Acts
UnsafeActs
Accident & Injury
Reasons Swiss-cheese Model of Human ErrorReasons Swiss-cheese Model of Human Error
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Errors
ACTS
Errors
PerceptionErrors
Skill-BasedErrors
J udgment andDecision-MakingErrors
Violations
Inadequate
Supervision
PlannedInappropriate
Operations
Failed to CorrectKnown Problem
Supervisory
Violations
SUPERVISION
Resource/Acquisition
Management
Organizational
Climate
Organizational
Process
ORGANIZATIONALINFLUENCES
Condition ofIndividuals
CognitiveFactors
TechnologicalEnvironment
PhysicalEnvironment
Self-ImposedStress
Coordination/Communication/Plannin
g Factors
Personnel
Factors
Psycho-Behavioral
Factors
EnvironmentalFactors
PRECONDITIONS
PerceptualFactors
Physical Mental
Limitations
AdversePhysiological
States
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Think decision tree Analysis starts with end result
Traces back through the decisions and conditions
Layers of Swiss Cheese are conditions at each level
Some cheese has more holes (hazards) than others
Poor organizational climate, no rules enforcement
Personnel fatigued, or poorly trained
Some environments more challenging
Goal More solid cheese - or countermeasures to avoidthe holes
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Why bother?Why bother?
0
5
10
15
20
25
30
35
40
45
50
Errors in Skill DecisionErrors
Perception PolicyViolations
Material Factor+ Human error
MaterialFailure
NumberofEpisodes
To reduce mishap rate, efforts must be focused on identifyingthe primary causes, which in most cases is the human fittinginto the system.
Navy F/A-18 Class A Flight Mishaps
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ActsThe act is the end result. It answers the question of, whathappened?
Skill-based Errors: errors in regularly-
performed tasks Decision Errors: selection of an incorrect
course of action for a particular situation
Perception Errors: perception of an il lusionleads to an incorrect course of action
Violation: intentionally acting against
written policy or procedures.
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ACTS
ViolationsErrors
MisperceptionErrors
J udgment and DecisionErrors
Skill-BasedErrors
Unsafe
Acts
UnsafeActs
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DECISION ERRORSRisk Assessment During Operation
Task Misprioritization
Necessary Action Rushed
Necessary Action Delayed
Caution/Warning Ignored
Wrong choice of action
ACTS
ViolationsErrors
MisperceptionErrors
J udgment and DecisionErrors
Skill-BasedErrors
Unsafe
Acts
UnsafeActs
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SKILL-BASED ERRORS
ACTS
ViolationsErrors
MisperceptionErrors
J udgment and DecisionErrors
Skill-BasedErrors
Inadvertent Operation
Checklist Error
Procedural Error
Overcontrol/Undercontrol
Breakdown in Visual Scan
Inadequately Trained Maneuver
Unsafe
Acts
UnsafeActs
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MISPERCEPTION ERRORS
(due to)
Misjudge Distance, Timing
Spatial Disorientation
Visual Illusions
ACTS
ViolationsErrors
Misperception
ErrorsJ udgment and Decision
ErrorsSkill-Based
Errors
Unsafe
Acts
UnsafeActs
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ACTS
ViolationsErrors
Misperception
Errors
J udgment and DecisionErrors
Skill-Based
ErrorsVIOLATIONS
(Willful disregard for rules and instructions!)
Violation Work-around
Violation Routine/Widespread
Violation ExtremeUnsafe
Acts
UnsafeActs
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Preconditions
Physical environment: the working environment.Rain, darkness, cold, hot, etc.
Technological Environment: the tools used in thetask. Vehicle design and usability of associatedsystems.
Self-imposed stress: things we do to ourselves alcohol, lack of sleep, fitness level.
Preconditions are the things that allow the unsafe acts tooccur, and they answer the question of, Why did ithappen? Broad categories are:
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Preconditions (cont.)
Coordination, communication, planning: teaminteraction, task planning (CRM).
Cognitive factors: situational awareness. Physical/mental limitations: operator size
incompatible with workspace, trouble retaining
information.
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Preconditions (cont.) Perceptual factors: visual or proprioceptive illusions
Psycho-behavioral factors: personality problems,overconfidence, aggressiveness, etc.
Adverse Physiological States: fatigue, effects of
medications, breathing difficulties. There may be more than one precondition for each
act!
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Condition ofIndividuals
CognitiveFactors
TechnologicalEnvironment
PhysicalEnvironment
Self-ImposedStress
Coordination/Communication/Planning Factors
Personnel
Factors
Psycho-Behavioral
Factors
EnvironmentalFactors
PRECONDITIONS
PerceptualFactors
Physical/
MentalLimitations
AdversePhysiological
States
CognitiveFactorsPreconditions
forUnsafe Acts
UnsafeActs
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Federal AviationAdminist rat ion
Threat and Error Management
2 November 2011
Condition ofIndividuals
TechnologicalEnvironment
PhysicalEnvironment
Self-ImposedStress
Coordination/Communication/Planning Factors
Personnel
Factors
Psycho-BehavioralFactors
EnvironmentalFactors
PRECONDITIONS
PerceptualFactorsPhysical/Mental
Limitations
AdversePhysiologicalStates
PHYSICAL ENVIRONMENT
Icing/Fog/Etc. on windows
Meteorological Conditions
Dust/Smoke/Etc. in Workspace
Brownout/Whiteout
Thermal Stress: Cold/Hot
Noise Interference
Preconditionsfor
Unsafe Acts
UnsafeActs
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Threat and Error Management
2 November 2011
CognitiveFactors
Psycho-BehavioralFactors
PerceptualFactors
Physical/
Mental
Limitations
AdversePhysiologicalStates
TechnologicalEnvironment
Self-ImposedStress
Coordination/Communication/Planning Factors
Personnel
Factors
EnvironmentalFactors
PRECONDITIONS
TECHNOLOGICALENVIRONMENT
Seating and Restraints
Instrument and Sensory Feedback
Visibility Restrictions
Controls and SwitchesAutomationPersonal Equipment Interference
Communications - Equipment
PhysicalEnvironment Condition of
Individuals
Preconditionsfor
Unsafe Acts
UnsafeActs
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Threat and Error Management
2 November 2011
CognitiveFactors
TechnologicalEnvironment
PhysicalEnvironment
Coordination/
Communication/
Planning Factors
Personnel
Factors
Psycho-Behavioral
Factors
EnvironmentalFactors
PRECONDITIONS
AdversePhysiological
States
Physical/
Mental
Limitations
PerceptualFactors
COORD/COMM/PLANCrew/Team Leadership
Cross-Monitoring Performance
Task Delegation
Rank/Position Authority Gradient
Communicating Critical Info
Standard/Proper Terminology
Mission Planning/Briefing
Miscommunication
Condition ofIndividuals
Self-ImposedStress
Preconditionsfor
Unsafe Acts
UnsafeActs
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Threat and Error Management
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CognitiveFactors
TechnologicalEnvironment
PhysicalEnvironment
Self-ImposedStress
Coordination/Communication/Planning Factors
Personnel
Factors
Psycho-
BehavioralFactors
EnvironmentalFactors
PRECONDITIONS
AdversePhysiological
States
Physical/
Mental
Limitations
PerceptualFactors
SELF-IMPOSED STRESS
Alcohol
Physical Fitness
Drugs/Supplements/Self Medication
Nutrition
Inadequate Rest
Unreported Disqualifying Medical Condition
Condition ofIndividuals
Preconditionsfor
Unsafe Acts
UnsafeActs
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COGNITIVE FACTORSInattention
Channelized AttentionCognitive Task Oversaturation
Confusion
Negative Transfer
Distraction
Geographic Mis-orientation (Lost)
Checklist Interference
Condition ofIndividuals
CognitiveFactors
TechnologicalEnvironment
PhysicalEnvironment
Self-ImposedStress
Coordination/Communication/Planning Factors
Personnel
Factors
Psycho-Behavioral
Factors
EnvironmentalFactors
PRECONDITIONS
PerceptualFactors
Physical/
MentalLimitations
AdversePhysiological
StatesPreconditions
forUnsafe Acts
UnsafeActs
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PSYCHO-BEHAVIORAL
Personality Style
Pre-Existing Personality Disorder Pre-Existing Psychological Disorder Emotional State Overconfidence Complacency Get-Home-Itis/Get-There-Itis Overaggressive
Condition ofIndividuals
CognitiveFactors
TechnologicalEnvironment
PhysicalEnvironment
Self-ImposedStress
Coordination/Communication/Planning Factors
Personnel
Factors
Psycho-Behavioral
Factors
EnvironmentalFactors
PRECONDITIONS
PerceptualFactors
Physical/
MentalLimitations
AdversePhysiological
StatesPreconditions
forUnsafe Acts
UnsafeActs
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ADVERSE PHYSIOLOGICAL
Physical Fatigue (Overexertion) Fatigue Physiological/Mental
Motion Sickness Circadian Rhythm Desynchrony Pre-Existing Physical Illness/Injury
Prescribed Meds for Injury/Illness
Condition ofIndividuals
CognitiveFactors
TechnologicalEnvironment
PhysicalEnvironment
Self-ImposedStress
Coordination/Communication/Planning Factors
Personnel
Factors
EnvironmentalFactors
PRECONDITIONS
PerceptualFactors
Physical/
MentalLimitations
AdversePhysiological
States
Psycho-Behavioral
Factors
Preconditionsfor
Unsafe Acts
UnsafeActs
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Federal AviationAdminist rat ion
Threat and Error Management
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Condition ofIndividuals
CognitiveFactors
TechnologicalEnvironment
PhysicalEnvironment
Self-ImposedStress
Coordination/Communication/Planning Factors
Personnel
Factors
Psycho-Behavioral
Factors
EnvironmentalFactors
PRECONDITIONS
PerceptualFactors
Physical/
MentalLimitations
AdversePhysiological
States
PHYSICAL/MENTAL LIMITS
Learning Ability/Rate
Memory Ability/Lapses
Anthropometric/Biomechanical Limits
Motor Skill/Coordination or Timing Deficiency
Technical/Procedural Knowledge
Preconditionsfor
Unsafe Acts
UnsafeActs
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Federal AviationAdminist rat ion
Threat and Error Management
2 November 2011
Condition ofIndividuals
CognitiveFactors
TechnologicalEnvironment
PhysicalEnvironment
Self-ImposedStress
Coordination/Communication/Planning Factors
Personnel
Factors
Psycho-
BehavioralFactors
EnvironmentalFactors
PRECONDITIONS
PerceptualFactors
Adverse
PhysiologicalStates
PERCEPTUAL FACTORSIllusions: Kinesthetic/Vestibular/Visual
Misperception of Operational Conditions
Misinterpreted/Misread Instrument
Expectancy
Auditory Cues
Spatial Disorientation: 1, 2, & 3
Temporal Distortion
Physical/
MentalLimitations
Preconditionsfor
Unsafe Acts
UnsafeActs
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Supervision
Inadequate supervision: lack of guidance,written policy, or training opportunities
Failure to correct known problem: problems withpersonnel or operations
Inappropriate Operations: lack of proper riskassessment or assigned inappropriate personnelto task
Violations: unnecessarily allows operationsoutside of SOP
Supervisors are ultimately responsible for the conductof their units.
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Inadequate
Supervision
PlannedInappropriateOperations
Failed toCorrect Known
Problem
Supervisory
Violations
SUPERVISION
Unsafe
Supervision
Preconditions
forUnsafe Acts
Unsafe
Acts
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InadequateSupervision
PlannedInappropriateOperations
Failed toCorrect Known
Problem
SupervisoryViolations
SUPERVISION
INADEQUATE SUPERVISION
Leadership/Supervision/Oversight InadequateSupervision Modeling
Local Training Issues/Programs
Supervision Policy
Supervision Personality Conflict
Supervision Lack of Feedback
Unsafe
Supervision
Preconditions
forUnsafe Acts
Unsafe
Acts
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PLANNED INAPPROPRIATEOPERATIONS
Ordered/Led Task Beyond Capability
Crew/Team Makeup/Composition
Limited Recent Experience
Proficiency
Risk Assessment Formal
Authorized Unnecessary Hazard
InadequateSupervision
PlannedInappropriateOperations
Failed toCorrect Known
Problem
SupervisoryViolations
SUPERVISION
Unsafe
Supervision
Preconditions
forUnsafe Acts
Unsafe
Acts
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FAILED TO CORRECTKNOWN PROBLEM
Personnel Management
Operations Management
InadequateSupervision
PlannedInappropriateOperations
Failed toCorrect Known
Problem
SupervisoryViolations
SUPERVISION
Unsafe
Supervision
Preconditions
forUnsafe Acts
Unsafe
Acts
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SUPERVISORY VIOLATIONSSupervision Discipline Enforcement
Supervision Unwritten Policy
Directed Violation
Assigned Unqualified Individuals
Inadequate
Supervision
PlannedInappropriateOperations
Failed toCorrect Known
Problem
Supervisory
Violations
SUPERVISION
Unsafe
Supervision
Preconditions
forUnsafe Acts
Unsafe
Acts
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Organizational Factors
Resource/Acquisition Management: the ways inwhich equipment is allocated
Organizational Climate: affects morale in a unit Process: policies and procedures that drive the
concept of operations
The Organization is responsible for overall policy,doctrine, and allocation of resources to the subordinateunits and personnel
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Administ rat ion
Threat and Error Management
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Organizational
Climate
Resource/Acquisition
Management
Organizational
Process
ORGANIZATIONAL
INFLUENCES
RESOURCE/ACQUISITION
MANAGEMENTAir Traffic Control Resources
Airfield Resources
Operator Support
Acquisition Policies/Design Processes
Personnel Resources
Information Resources/Support
Financial Resources/Support
OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
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Administ rat ion
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Organizational
Climate
ORGANIZATIONAL
INFLUENCES
ORGANIZATIONAL
INFLUENCES
ORGANIZATIONAL CLIMATE
Organizational Values/Culture
Evaluation/Promotion/UpgradePerceptions of Equipment
Mission/Economic Climate
Organizational Structure
Resource/Acquisition
Management
Organizational
Process
Organizational
Influences
Unsafe
Supervision
Preconditionsfor
Unsafe Acts
Unsafe
Acts
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Administ rat ion
Threat and Error Management
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Organizational
Climate
Operational
Process
ORGANIZATIONAL
INFLUENCES
ORGANIZATIONAL
INFLUENCES
Organizational
Process
ORGANIZATIONAL PROCESS
Ops Tempo/Workload
Program and Policy Risk Assessment
Procedural Guidance/Publications
Organizational Training Issues/Programs
Program Oversight/Program Management
Resource/Acquisition
Management
Organizational
Influences
Unsafe
Supervision
Preconditionsfor
Unsafe Acts
Unsafe
Acts
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Administ rat ion
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Questions?
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