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