1. Quality Assurance in ATS, Human Factors and Aviation Safety
Captain Daniel Maurino
Flight Safety and Human Factors, ICAO
NAR/CAR/SAM Air Traffic Services
Quality Assurance Seminar
Ciudad de Méjico, October 2000 1 1

2. QA & Aviation HF: Close Relatives
Human Factors and aviation safety
Differentiate processes from outcomes
Emphasis on monitoring processes
Relative importance of outcomes as driving forces
Errors do not cause accidents

3. “Historical” Safety Design & manufacture Management & supervision
Training & maintenance
Stakeholders
Operational
personnel

4. An Outcome-Oriented Industry
Design & manufacture
Management & supervision
Training & maintenance
Stakeholders
Operational
personnel

5. The Need to Monitor Processes
Design & manufacture
Management & supervision
Training & maintenance
Stakeholders
Operational
personnel

6. The Fundamental Question
improve the
human condition?
improve the processes underlying aviation operations?

7. Errors and Consequences
Causes and consequences are not proportional in their magnitude

8. Operational Errors Reside in the Context
Operational behaviours: A compromise
Safety
Production 3 3

9. Training: Poor Learning Grounds
Training behaviours: “By the book”
Safety
Production 3 3

10. Understanding Operational Errors
Error consequences
Threat to safety
No significant
consequences
Error
Error life span

11. Outcomes: Quite Infrequently
Error
Flaps
omitted
Deviation
Checklist
failure
Amplification
Unheeded warning
Degradation/
breakdown

12. Processes: Quite Frequently
Deviation
Checklist works
Amplification
Effective
warning
Flaps
omitted
Normal
operation
Error

13. Safety & QA: The Data We Must Collect
Design & manufacture
Management & supervision
Training & maintenance
Stakeholders
Operational
personnel

14. The Overriding Importance of Culture
Anglo-Saxons design and supply; “the Rest of the World” uses
Anglo-Saxon solutions are effective for Anglo-Saxon contexts
Effectiveness in the “Rest-of-the-World”?
World-wide accident rate: failure of the “dominant culture” concept 7

15. Human Error & Process Control
Aviation cannot be entirely specified
Humans will inevitably make errors
Normative prescription (music score)
Real-time implementation of the score
Deviation(s) management
Danger: loss of control of deviation management process rather that deviations themsleves

16. Flexible links with dampers
Deviation Management
Rigid frame
Normative safety
To bring all this to a conclusion, there are two main conditions to a safe operation of the system, very much like to a safe coupling of your car on the road.
The first one is that you need a rigid frame, namely a solid framework of procedures. This is the normative, and anticipative, in other words proactive, aspect of safety.
The second calls on flexible links to couple the system to the random aspects of reality, like holes and bumps on the road . This is the intelligent adaptation to unforseen situations, which R. Westrum named ‘generative’ , and which is a reactive process.
Flexible links with dampers
Generative safety

17. The End of the Innocence
Bankruptcy
Protection
Comfort zone
Catastrophe
Production