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Error Management OGHFA 1_HP_06_VIS_Error Management 1
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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
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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
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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.
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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.
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Why do we sometimes fail?
Consequences on flight safety Managing errors and violations
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Why do we sometimes fail?
Consequences on flight safety Managing errors and violations
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Gear down, flaps 3 Gear down, flaps 3 Gear down, flaps 3
OVERSPEED! © Ismo Aaltonen
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Intention to achieve something Good plan Action “on autopilot”
Unintended deviation from plan Several error mechanisms, for example: “Strong but wrong” habits Inaccuracies
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The climb is getting bumpy… Radar was off!
Predictive windshear had been set to “auto” Radar remained off Again, several mechanisms
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Intention to achieve something Good plan
Something is skipped, omitted Again, several mechanisms
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Mistake
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Intention to achieve something
The solution is… Deficient Wrong Dangerous Clumsy
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Deliberate violation of a rule, procedure, policy or norm
Still landing!
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(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
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Why do we sometimes fail?
Consequences on flight safety Managing errors and violations
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There is a very loose coupling between an error and negative consequences
Other factors shape the outcome Especially true in aviation Nevertheless…
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Flaps not set for takeoff (lapse)
Aircraft type and performance? Actual takeoff weight? Runway length? Obstructions ahead? Takeoff configuration warning?
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Why do we sometimes fail?
Consequences on flight safety Managing errors and violations
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How can YOU manage them in YOUR operation?
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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
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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
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Error Detection Facilitate easy and rapid detection of errors
Red flags at ground lock pins Autopilot disconnect warning Cross-checking
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Error Management Strategies
Error Recovery Make it easy to rapidly recover to a safe state
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Error Tolerance Build the system to tolerate errors
Conservative margins
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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.
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(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, …
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(incorrect solutions)
Mistakes (incorrect solutions) Optimizing violations Slips & Lapses Routine violations
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(incorrect solutions)
Mistakes (incorrect solutions) Optimizing violations Error Tolerance Error Reduction Error Detection Routine violations Slips & Lapses
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(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
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Violation Management Optimizing violations Routine violations
Reasons for violations must be understood Violations are not always punishable Apply violation management strategies Routine violations
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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”
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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
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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: :::
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Look BEHIND the error or violation
What type of error? Find solutions Real, systemic
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