oghfa 1_hp_06_vis_error management 1 error management oghfa 1_hp_06_vis_error management 1
Post on 27-Dec-2015
215 Views
Preview:
TRANSCRIPT
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 1
Error Error
ManagementManagement
Error Error
ManagementManagement
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 1
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 2
Normal operations:• threats and errors• deviations• failures and successes
Accidents
Serious incidents
Minor incidents
Frequency of event, Quantity of data
Sev
erit
y of
eve
nt
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 3
Frequency of event, Quantity of data
Sev
erit
y of
eve
nt
Normal operations:• threats and errors• deviations• failures and successes
Accidents
Serious incidents
Minor incidents
Normal operations:• threats and errors• deviations• failures and successes
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 4
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
Courtesy of University of Texas. Based on 3309 flights.
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 5
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.
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 6
1. Why do we sometimes fail?
2. Consequences on flight safety
3. Managing errors and violations
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 7
1. Why do we sometimes fail?
2. Consequences on flight safety
3. Managing errors and violations
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 8
© Ismo Aaltonen
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 9
Intention to achieve somethingGood planAction “on autopilot”Unintended deviation from plan
Several error mechanisms, for example:“Strong but wrong” habits
Inaccuracies
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 10
The climb is getting bumpy…
Radar was off!
Predictive windshear had been set to “auto”
Radar remained off
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 11
Intention to achieve something
Good plan
Something is skipped, omitted
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 12
Mistake
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 13
Intention to achieve something
The solution is…Deficient
Wrong
Dangerous
Clumsy
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 14
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 15
Deliberate violation of a rule, procedure, policy or norm
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 16
Completely newCompletely new
RoutineRoutine
Mistakes(capacity overflow)
Slips & Lapses
Mistakes(incorrect solutions)
Exceptionalviolations
Routineviolations
Optimizingviolations
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 17
1. Why do we sometimes fail?
2. Consequences on flight safety
3. Managing errors and violations
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 18
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 19
There is a very loose coupling between an error and negative consequences
Other factors shape the outcome
Especially true in aviation
Nevertheless…
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 20
Flaps not set for takeoff (lapse)Aircraft type and performance?
Actual takeoff weight?
Runway length?
Obstructions ahead?
Takeoff configuration warning?
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 21
1. Why do we sometimes fail?
2. Consequences on flight safety
3. Managing errors and violations
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 22
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 23
ERROR PREVENTION
ERROR MANAGEMENT
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 24
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 25
Error ReductionMinimizing the likelihood of error
Minimizing the consequences of error
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 26
Error DetectionFacilitate easy and rapid detection of errors
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 27
Error Management Strategies
Error RecoveryMake it easy to rapidly recover to a safe state
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 28
Error ToleranceBuild the system to
tolerate errors
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 29
Error PreventionWhere reasonable and where doing so does not
increase other risks, remove an error-prone task by (re)design of system, procedure or process.
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 30
Mistakes(capacity overflow)
Slips & Lapses
Mistakes(incorrect solutions)
Exceptionalviolations
Routineviolations
Optimizingviolations
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 31
Slips & Lapses
Mistakes(incorrect solutions)
Routineviolations
Optimizingviolations
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 32
Slips & Lapses
Mistakes(incorrect solutions)
Routineviolations
Optimizingviolations
• Error Tolerance• Error Reduction• Error Detection
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 33
Mistakes(incorrect solutions)
Routineviolations
Optimizingviolations
Key issues:• Situation Recognition and Diagnosis• Decision Making
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 34
Violation Management
Routineviolations
Optimizingviolations
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 35
Optimizingviolations
The “Lethal Cocktail”
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 improviseRoutine
violations
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 36
Optimizingviolations
Remove the need to ViolateAdequate planning
Capability to adapt to new demands
Open communication
Safety Culture
Routineviolations
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 37
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
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 38
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 39
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 40
Look BEHIND the error or violation
What type of error?
Find solutions
Real, systemic
top related