1. Quality Assurance in ATS, Human Factors and Aviation Safety Quality Assurance in ATS, Human Factors and Aviation Safety Captain Daniel Maurino Captain Daniel Maurino Flight Safety and Human Factors, ICAO NAR/CAR/SAM Air Traffic Services NAR/CAR/SAM Air Traffic Services Quality Assurance Seminar Ciudad de Méjico, 16-20 October 2000 Ciudad de Méjico, 16-20 October 2000

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

3. Historical Safety Historical Safety Design & manufacture Management & supervision Training & maintenance Stakeholders Operationalpersonnel

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

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

6. The Fundamental Question 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 SafetyProduction Operational behaviours:A compromise Operational behaviours: A compromise

9. Training: Poor Learning Grounds SafetyProduction Training behaviours: By the book Training behaviours: By the book

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

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

12. Processes: Quite Frequently Flapsomitted Error AmplificationEffectivewarning Normaloperation Deviation Checklist works

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

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

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

16. Deviation Management Deviation Management Rigid frame Normative safety Flexible links with dampers Generative safety

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