Error Management OGHFA 1_HP_06_VIS_Error Management 1

Frequency of event, Quantity of data Severity of event Normal operations: threats and errors deviations failures and successes Accidents Serious incidents Minor incidents Frequency of event, Quantity of data

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 Frequency of event, Quantity of data

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 How often the machine is played…the wheels are spinning all the time Errors/violation are COMMON. They do not always have consequences! Courtesy of University of Texas. Based on 3309 flights.

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.

Why do we sometimes fail? Consequences on flight safety Managing errors and violations

Why do we sometimes fail? Consequences on flight safety Managing errors and violations

Gear down, flaps 3 Gear down, flaps 3 Gear down, flaps 3 OVERSPEED! © Ismo Aaltonen

Intention to achieve something Good plan Action “on autopilot” Unintended deviation from plan Several error mechanisms, for example: “Strong but wrong” habits Inaccuracies

The climb is getting bumpy… Radar was off! Predictive windshear had been set to “auto” Radar remained off Again, several mechanisms

Intention to achieve something Good plan Something is skipped, omitted Again, several mechanisms

Mistake

Intention to achieve something The solution is… Deficient Wrong Dangerous Clumsy

Deliberate violation of a rule, procedure, policy or norm Still landing!

(incorrect solutions) Full attentional focus Exceptional violations Completely new Routine Mistakes (capacity overflow) Situation Mistakes (incorrect solutions) Optimizing violations Automatic routine Slips & Lapses Routine violations

Why do we sometimes fail? Consequences on flight safety Managing errors and violations

There is a very loose coupling between an error and negative consequences Other factors shape the outcome Especially true in aviation Nevertheless…

Flaps not set for takeoff (lapse) Aircraft type and performance? Actual takeoff weight? Runway length? Obstructions ahead? Takeoff configuration warning?

Why do we sometimes fail? Consequences on flight safety Managing errors and violations

How can YOU manage them in YOUR operation?

ERROR PREVENTION ERROR MANAGEMENT People will always make errors... …and they have the right to do so! High-risk systems have to be built to tolerate potential human errors

Error Reduction Minimizing the likelihood of error Minimizing the consequences of error Examples: Cockpit controls: clearly indicated, logically placed Protections on pushbuttons Clear manuals and procedures

Error Detection Facilitate easy and rapid detection of errors Red flags at ground lock pins Autopilot disconnect warning Cross-checking

Error Management Strategies Error Recovery Make it easy to rapidly recover to a safe state

Error Tolerance Build the system to tolerate errors Conservative margins

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.

(incorrect solutions) Mistakes (capacity overflow) Slips & Lapses (incorrect solutions) Exceptional violations Routine Optimizing The whole aviation system is designed to keep you out of there. Procedures, training, …

(incorrect solutions) Mistakes (incorrect solutions) Optimizing violations Slips & Lapses Routine violations

(incorrect solutions) Mistakes (incorrect solutions) Optimizing violations Error Tolerance Error Reduction Error Detection Routine violations Slips & Lapses

(incorrect solutions) Mistakes (incorrect solutions) Optimizing violations Key issues: Situation Recognition and Diagnosis Decision Making Most interesting and important: the everyday professional performance is here! The human mind is not particularly good at making diagnoses This is to a large extent due to biases and heuristics: Expectations Availability heuristic Confirmation bias Fixation Etc. Example: Crew getting fixated on an early impartial analysis of a problem situation Can lead to an incident or worsen the outcomes Routine violations

Violation Management Optimizing violations Routine violations Reasons for violations must be understood Violations are not always punishable Apply violation management strategies Routine violations

Expectation that rules will have to be bent to get the job done Optimizing violations 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 Reasons for violations must be understood Violations are not always punishable Apply violation management strategies It is tempting to violate Most violations are non-consequential Can-do attitude, often praised by management Violations are forbidden, so violators don’t tell anyone what they are doing A violator cannot know who else is violating or making a mistake at the same time Errors and mistakes are independent of intention… Routine violations The “Lethal Cocktail”

Remove the need to Violate Optimizing violations Remove the need to Violate Adequate planning Capability to adapt to new demands Open communication Safety Culture Reasons for violations must be understood Violations are not always punishable Apply violation management strategies It is tempting to violate Most violations are non-consequential Can-do attitude, often praised by management Violations are forbidden, so violators don’t tell anyone what they are doing A violator cannot know who else is violating or making a mistake at the same time Errors and mistakes are independent of intention… Routine violations

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 You may wonder why we do not talk about that Response is, of course, still valid, these are not excuses. Sometimes you MUST take action against someone. But: Focus on prevention. Does not help to say he was responsible…or should have done better, or you are responsible for this… You need TRUE solutions. …bridge to what does NOT work: :::

Look BEHIND the error or violation What type of error? Find solutions Real, systemic