Human Failures in Accidents New Zealand Helicopter Association

A FEW ACCIDENTS… Chernobyl (USSR) 1986 $12 billion US cost to the Soviet economy

Exxon Valdez, Alaska (USA) 1989 Oil Spill: 11 million US gallons

Flying Tigers, B747, (Malaysia) crew killed, aircraft destroyed

Deepwater Horizon, Gulf of Mexico (USA) million barrels of oil spilt

Costa Concordia, Guam (USA) people drowned

Hindenburg, New Jersey (USA) people killed

Mars Climate Orbiter, Mars (Space) $1 billion spacecraft lost

Union Carbide Plant, Bhopal, (India) 1984 Approx dead

STS Challenger, Florida (USA) astronauts killed

ZK-HJN, Lake Manapouri, (New Zealand) dead

ZK-SML, Mount Duppa, (New Zealand) dead

RMS Titanic, Atlantic Ocean, dead

What do these accidents/incidents/disasters have in common ? Human Failures Human Errors

HUMAN ERROR

EVEN EXPERTS CAN MAKE ERRORS

An Error Unintentional deviation from organizational expectations or crew intentions (the best people can make the worst errors) A Violation (Intentional Non-compliance)? Intentional deviation from organizational expectations or crew intentions ERRORS AND VIOLATIONS

TYPES OF ERORS Slips – attention failure (omission, reversal, mis- ordering, mistiming) Lapses – memory failure (omitting planned items, place-losing, forgetting intentions) Mistakes Rule based (misapplication of a good rule or application of a bad rule) Knowledge based – inaccurate or incomplete system mental model

TYPES OF ERRORS Slips – attention failure (omission, reversal, mis- ordering, mistiming) Lapses – memory failure (omitting planned items, place-losing, forgetting intentions) Mistakes Rule based (misapplication of a good rule or application of a bad rule) Knowledge based – inaccurate or incomplete system mental model

WHAT ABOUT VIOLATIONS ? Routine – habitual departures from rules and regulations Situational – deviation from procedures or rules needed to get the job done due to a mismatch between a work situation and available procedures or rules Optimising - individual satisfying other motives (excitement, impressing others, cutting corners…)

WHAT ABOUT THREATS …. An external event or object that a crew has to deal with that could become consequential to safety

WHAT TO DO ? Design systems to be error tolerant (system still functions after an error has been made) Design systems to be error proof (design prevents an error being made at all or makes it difficult for an error to be made)

Train personnel to try and avoid making errors and/or detect the errors that have been made and correct them and/or limit the effects of errors that already been made. WHAT TO DO ABOUT ERRORS ? Train personnel so well that they do not make errors Install computers to prevent human error Design systems to be error tolerant (system still functions after an error has been made) Design systems to be error proof (design prevents an error being made at all or makes it difficult for an error to be made) Use other safeguards and defences (checklists)

What do these accidents/incidents/disasters have in common ? Human Failures Human Errors Non-technical Skill Failures

N.T.S. – OUR SKILL BASE Technical Skills Company Personnel Non Technical Skills

Accident Technical Skills Failure Non-Technical Skills Failure Timeline  FAILURES AND ACCIDENTS 70% of accidents due to NTS failures

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 N.T.S. CORE ELEMENTS Automation Issues: Mode Confusion Mode Error such as… Selecting incorrect mode, Misreading a display, Missing mode transitions, Assuming it is turned on, Not understanding logic Training ? Basic Skills ?

IN THE BEGINNING…

THEN…

A QUANTUM LEAP ? …

NOW… LOTS OF AUTOMATION

THEN…

NOW…

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 N.T.S. CORE ELEMENTS

NZ Helicopter Occurrences

ACCIDENTS AND PAX NUMBERS Boeing ICAO HULL LOSSES PER MILLION DEPARTURESGROWTH IN TRILLIONS OF RPK

TECHNICAL FAILURES v NON-TECHNICAL SKILL FAILURES TECHNILOGICAL FAILURES HUMAN PERFORMANCE Hollnagel TRENDS IN ATTRIBUTED ACCIDENT CAUSES NON-TECHNICAL SKILL FAILURES

Landmark Accidents

LANDMARK ACCIDENTS: TENERIFE 1977

LANDMARK ACCIDENTS: Kegworth 1989

LANDMARK ACCIDENTS: Valujet 1996

LANDMARK ACCIDENTS: Chicago 1979

Who should undergo NTS training ? Flight Crew Cabin Crew Maintenance Engineers Other Operational Safety Critical Personnel Management Link your NTS training program to your SMS

Understand personal limitations Improve awareness, knowledge and skills Change attitudes, modify behaviours Improve cross-functional collaboration Develop adaptive capacity (personally and organisationally) Improve SAFETY and efficiency NTS TRAINING BENEFITS

Source: Ascend /Aviation Safety Network/Flight Safety Foundation SOME SOBERING NUMBERS (2013) Airline Fatalities: accidents Road Fatalities: 1.24 million USD $580 billion Passenger Numbers: 3.1 billion 32,500,000 flights Medical Fatalities: 3.5 million 223,000,000 procedures

Thanks for your time New Zealand Helicopter Association Contact: Glen Eastlake, Queenstown, New Zealand