6838632.ppt
- 1. OGHFA 1_HP_06_VIS_Error Management 1 Error Management OGHFA 1_HP_06_VIS_Error Management 1
- 2. OGHFA 1_HP_06_VIS_Error Management 2 Normal operations: • threats and errors • deviations • failures and successes Accidents Serious incidents Minor incidents Frequency of event, Quantity of data Severity of event
- 3. OGHFA 1_HP_06_VIS_Error Management 3 Frequency of event, Quantity of data Severity of event Normal operations: • threats and errors • deviations • failures and successes Accidents Serious incidents Minor incidents Normal operations: • threats and errors • deviations • failures and successes
- 4. OGHFA 1_HP_06_VIS_Error Management 4 LOSA (Line Operations Safety Audit) results: More than 70% of flights had at least one error or violation About 30% of errors/violations were mismanaged or consequential Leading to “undesired aircraft state” or another error/violation Courtesy of University of Texas. Based on 3309 flights.
- 5. OGHFA 1_HP_06_VIS_Error Management 5 This presentation is about coping with errors in normal operations, typically detected with flight operations monitoring tools, It is not about incidents, usually subject to a detailed investigation.
- 6. OGHFA 1_HP_06_VIS_Error Management 6 1. Why do we sometimes fail? 2. Consequences on flight safety 3. Managing errors and violations
- 7. OGHFA 1_HP_06_VIS_Error Management 7 1. Why do we sometimes fail? 2. Consequences on flight safety 3. Managing errors and violations
- 9. OGHFA 1_HP_06_VIS_Error Management 9 Intention to achieve something Good plan Action “on autopilot” Unintended deviation from plan Several error mechanisms, for example: “Strong but wrong” habits Inaccuracies
- 10. OGHFA 1_HP_06_VIS_Error Management 10 The climb is getting bumpy… Radar was off! Predictive windshear had been set to “auto” Radar remained off
- 11. OGHFA 1_HP_06_VIS_Error Management 11 Intention to achieve something Good plan Something is skipped, omitted
- 12. OGHFA 1_HP_06_VIS_Error Management 12 Mistake
- 13. OGHFA 1_HP_06_VIS_Error Management 13 Intention to achieve something The solution is… Deficient Wrong Dangerous Clumsy
- 15. OGHFA 1_HP_06_VIS_Error Management 15 Deliberate violation of a rule, procedure, policy or norm
- 16. OGHFA 1_HP_06_VIS_Error Management 16 Completely new Routine Mistakes (capacity overflow) Slips & Lapses Mistakes (incorrect solutions) Exceptional violations Routine violations Optimizing violations
- 17. OGHFA 1_HP_06_VIS_Error Management 17 1. Why do we sometimes fail? 2. Consequences on flight safety 3. Managing errors and violations
- 19. OGHFA 1_HP_06_VIS_Error Management 19 There is a very loose coupling between an error and negative consequences Other factors shape the outcome Especially true in aviation Nevertheless…
- 20. OGHFA 1_HP_06_VIS_Error Management 20 Flaps not set for takeoff (lapse) Aircraft type and performance? Actual takeoff weight? Runway length? Obstructions ahead? Takeoff configuration warning?
- 21. OGHFA 1_HP_06_VIS_Error Management 21 1. Why do we sometimes fail? 2. Consequences on flight safety 3. Managing errors and violations
- 23. OGHFA 1_HP_06_VIS_Error Management 23 ERROR PREVENTION ERROR MANAGEMENT
- 25. OGHFA 1_HP_06_VIS_Error Management 25 Error Reduction Minimizing the likelihood of error Minimizing the consequences of error
- 26. OGHFA 1_HP_06_VIS_Error Management 26 Error Detection Facilitate easy and rapid detection of errors
- 27. OGHFA 1_HP_06_VIS_Error Management 27 Error Management Strategies Error Recovery Make it easy to rapidly recover to a safe state
- 28. OGHFA 1_HP_06_VIS_Error Management 28 Error Tolerance Build the system to tolerate errors
- 29. OGHFA 1_HP_06_VIS_Error Management 29 Error Prevention Where reasonable and where doing so does not increase other risks, remove an error-prone task by (re)design of system, procedure or process.
- 30. OGHFA 1_HP_06_VIS_Error Management 30 Mistakes (capacity overflow) Slips & Lapses Mistakes (incorrect solutions) Exceptional violations Routine violations Optimizing violations
- 31. OGHFA 1_HP_06_VIS_Error Management 31 Slips & Lapses Mistakes (incorrect solutions) Routine violations Optimizing violations
- 32. OGHFA 1_HP_06_VIS_Error Management 32 Slips & Lapses Mistakes (incorrect solutions) Routine violations Optimizing violations • Error Tolerance • Error Reduction • Error Detection
- 33. OGHFA 1_HP_06_VIS_Error Management 33 Mistakes (incorrect solutions) Routine violations Optimizing violations Key issues: • Situation Recognition and Diagnosis • Decision Making
- 34. OGHFA 1_HP_06_VIS_Error Management 34 Violation Management Routine violations Optimizing violations
- 35. OGHFA 1_HP_06_VIS_Error Management 35 Optimizing violations The “Lethal Cocktail” Expectation that rules will have to be bent to get the job done Feeling of Powerfulness: above-average people need not follow all procedures Opportunities to “short cut” Inadequate Planning, forcing people to improvise Routine violations
- 36. OGHFA 1_HP_06_VIS_Error Management 36 Optimizing violations Remove the need to Violate Adequate planning Capability to adapt to new demands Open communication Safety Culture Routine violations
- 37. OGHFA 1_HP_06_VIS_Error Management 37 Can’t we hold people responsible for their mistakes and violations? Real safety enhancement usually comes from systemic solutions Not from actions at the individual level Situation where a person really has to be removed from operation is very rare
- 40. OGHFA 1_HP_06_VIS_Error Management 40 Look BEHIND the error or violation What type of error? Find solutions Real, systemic