1100-threat and error management and hazard identification

7/28/2019 1100-Threat and Error Management and Hazard Identification

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Presented to:

By:

Date:

Federal Aviation

AdministrationThreat and ErrorManagement

and

Hazard Identification

on Airports

27th Great Lakes Airports Conference

Roger Motzko, FAA, ATO Safety

2 November 2011


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Federal AviationAdminist rat ion

Threat and Error Management2 November 2011

2

Definitions

Hazard:

Anything that will or has the potential to cause harm Risk:

The likelihood and severity of consequence of a

hazard


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Hazard:Anything that will or has the potential to cause harm

3


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Risk:

The likelihood and severity of consequence of a hazard

4


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Three Methods of Analysis

Historic

Study data over time, develop trends from accidents Diagnostic

Identify precursors by using collective safety

reporting systems Prognostic

An informed method that looks at future

development and eliminates potential hazardsbefore they are introduced

5


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Direct Cost (FY 98 08)

$5.14 Billion and 1113 Lives

Direct Cost (FY 98 08)

$5.14 Billion and 1113 Lives

Indirect Cost

Loss of Manpower

Delay in DoingBusiness

Corporate Reputation

Investigation Costs

Litigation

Indirect Cost

Loss of Manpower

Delay in DoingBusiness

Corporate Reputation

Investigation Costs

Litigation

COSTS OF NAVAL ACCIDENTSCOSTS OF NAVAL ACCIDENTS


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So where to begin?

Start with Reasons Swiss Cheese model

Base on Human Factors Analysis and Classification System(HFACS) by Doug Weigmann & Scott Shappell

Categorization of system failure in complex systems Latent Failures Active Failures

Bring together human factors, Operations, Human systems,Systems safety and Engineering Issues Man, Machine, Medium, Mission, Management

Adopt a philosophy of analysis that focuses on the systeminstead of the individual


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Failed or

Absent Defenses

OrganizationalFactors

Unsafe

Supervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Accident & Injury

Reasons Swiss-cheese Model of Human ErrorReasons Swiss-cheese Model of Human Error


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Errors

ACTS

Errors

PerceptionErrors

Skill-BasedErrors

J udgment andDecision-MakingErrors

Violations

Inadequate

Supervision

PlannedInappropriate

Operations

Failed to CorrectKnown Problem

Supervisory

Violations

SUPERVISION

Resource/Acquisition

Management

Organizational

Climate

Organizational

Process

ORGANIZATIONALINFLUENCES

Condition ofIndividuals

CognitiveFactors

TechnologicalEnvironment

PhysicalEnvironment

Self-ImposedStress

Coordination/Communication/Plannin

g Factors

Personnel

Factors

Psycho-Behavioral

Factors

EnvironmentalFactors

PRECONDITIONS

PerceptualFactors

Physical Mental

Limitations

AdversePhysiological

States


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Think decision tree Analysis starts with end result

Traces back through the decisions and conditions

Layers of Swiss Cheese are conditions at each level

Some cheese has more holes (hazards) than others

Poor organizational climate, no rules enforcement

Personnel fatigued, or poorly trained

Some environments more challenging

Goal More solid cheese - or countermeasures to avoidthe holes


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Why bother?Why bother?

0

5

10

15

20

25

30

35

40

45

50

Errors in Skill DecisionErrors

Perception PolicyViolations

Material Factor+ Human error

MaterialFailure

NumberofEpisodes

To reduce mishap rate, efforts must be focused on identifyingthe primary causes, which in most cases is the human fittinginto the system.

Navy F/A-18 Class A Flight Mishaps


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ActsThe act is the end result. It answers the question of, whathappened?

Skill-based Errors: errors in regularly-

performed tasks Decision Errors: selection of an incorrect

course of action for a particular situation

Perception Errors: perception of an il lusionleads to an incorrect course of action

Violation: intentionally acting against

written policy or procedures.


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Federal AviationAdminist rat ionThreat and Error Management2 November 2011

ACTS

ViolationsErrors

MisperceptionErrors

J udgment and DecisionErrors

Skill-BasedErrors

Unsafe

Acts

UnsafeActs


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DECISION ERRORSRisk Assessment During Operation

Task Misprioritization

Necessary Action Rushed

Necessary Action Delayed

Caution/Warning Ignored

Wrong choice of action

ACTS

ViolationsErrors

MisperceptionErrors


Skill-BasedErrors

Unsafe

Acts

UnsafeActs


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SKILL-BASED ERRORS

ACTS

ViolationsErrors

MisperceptionErrors


Skill-BasedErrors

Inadvertent Operation

Checklist Error

Procedural Error

Overcontrol/Undercontrol

Breakdown in Visual Scan

Inadequately Trained Maneuver

Unsafe

Acts

UnsafeActs


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MISPERCEPTION ERRORS

(due to)

Misjudge Distance, Timing

Spatial Disorientation

Visual Illusions

ACTS

ViolationsErrors

Misperception

ErrorsJ udgment and Decision

ErrorsSkill-Based

Errors

Unsafe

Acts

UnsafeActs


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ACTS

ViolationsErrors

Misperception

Errors


Skill-Based

ErrorsVIOLATIONS

(Willful disregard for rules and instructions!)

Violation Work-around

Violation Routine/Widespread

Violation ExtremeUnsafe

Acts

UnsafeActs


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Preconditions

Physical environment: the working environment.Rain, darkness, cold, hot, etc.

Technological Environment: the tools used in thetask. Vehicle design and usability of associatedsystems.

Self-imposed stress: things we do to ourselves alcohol, lack of sleep, fitness level.

Preconditions are the things that allow the unsafe acts tooccur, and they answer the question of, Why did ithappen? Broad categories are:


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Threat and Error Management

2 November 2011

Preconditions (cont.)

Coordination, communication, planning: teaminteraction, task planning (CRM).

Cognitive factors: situational awareness. Physical/mental limitations: operator size

incompatible with workspace, trouble retaining

information.


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2 November 2011

Preconditions (cont.) Perceptual factors: visual or proprioceptive illusions

Psycho-behavioral factors: personality problems,overconfidence, aggressiveness, etc.

Adverse Physiological States: fatigue, effects of

medications, breathing difficulties. There may be more than one precondition for each

act!


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2 November 2011


CognitiveFactors


PhysicalEnvironment

Self-ImposedStress

Coordination/Communication/Planning Factors

Personnel

Factors

Psycho-Behavioral

Factors


PRECONDITIONS

PerceptualFactors

Physical/

MentalLimitations


States

CognitiveFactorsPreconditions

forUnsafe Acts

UnsafeActs


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2 November 2011



PhysicalEnvironment

Self-ImposedStress


Personnel

Factors

Psycho-BehavioralFactors


PRECONDITIONS

PerceptualFactorsPhysical/Mental

Limitations

AdversePhysiologicalStates

PHYSICAL ENVIRONMENT

Icing/Fog/Etc. on windows

Meteorological Conditions

Dust/Smoke/Etc. in Workspace

Brownout/Whiteout

Thermal Stress: Cold/Hot

Noise Interference

Preconditionsfor

Unsafe Acts

UnsafeActs


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2 November 2011

CognitiveFactors

Psycho-BehavioralFactors

PerceptualFactors

Physical/

Mental

Limitations

AdversePhysiologicalStates


Self-ImposedStress


Personnel

Factors


PRECONDITIONS

TECHNOLOGICALENVIRONMENT

Seating and Restraints

Instrument and Sensory Feedback

Visibility Restrictions

Controls and SwitchesAutomationPersonal Equipment Interference

Communications - Equipment

PhysicalEnvironment Condition of

Individuals

Preconditionsfor

Unsafe Acts

UnsafeActs


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2 November 2011

CognitiveFactors


PhysicalEnvironment

Coordination/

Communication/

Planning Factors

Personnel

Factors

Psycho-Behavioral

Factors


PRECONDITIONS


States

Physical/

Mental

Limitations

PerceptualFactors

COORD/COMM/PLANCrew/Team Leadership

Cross-Monitoring Performance

Task Delegation

Rank/Position Authority Gradient

Communicating Critical Info

Standard/Proper Terminology

Mission Planning/Briefing

Miscommunication


Self-ImposedStress

Preconditionsfor

Unsafe Acts

UnsafeActs


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2 November 2011

CognitiveFactors


PhysicalEnvironment

Self-ImposedStress


Personnel

Factors

Psycho-

BehavioralFactors


PRECONDITIONS


States

Physical/

Mental

Limitations

PerceptualFactors

SELF-IMPOSED STRESS

Alcohol

Physical Fitness

Drugs/Supplements/Self Medication

Nutrition

Inadequate Rest

Unreported Disqualifying Medical Condition


Preconditionsfor

Unsafe Acts

UnsafeActs


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2 November 2011

COGNITIVE FACTORSInattention

Channelized AttentionCognitive Task Oversaturation

Confusion

Negative Transfer

Distraction

Geographic Mis-orientation (Lost)

Checklist Interference


CognitiveFactors


PhysicalEnvironment

Self-ImposedStress


Personnel

Factors

Psycho-Behavioral

Factors


PRECONDITIONS

PerceptualFactors

Physical/

MentalLimitations


StatesPreconditions

forUnsafe Acts

UnsafeActs


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2 November 2011

PSYCHO-BEHAVIORAL

Personality Style

Pre-Existing Personality Disorder Pre-Existing Psychological Disorder Emotional State Overconfidence Complacency Get-Home-Itis/Get-There-Itis Overaggressive


CognitiveFactors


PhysicalEnvironment

Self-ImposedStress


Personnel

Factors

Psycho-Behavioral

Factors


PRECONDITIONS

PerceptualFactors

Physical/

MentalLimitations


StatesPreconditions

forUnsafe Acts

UnsafeActs


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2 November 2011

ADVERSE PHYSIOLOGICAL

Physical Fatigue (Overexertion) Fatigue Physiological/Mental

Motion Sickness Circadian Rhythm Desynchrony Pre-Existing Physical Illness/Injury

Prescribed Meds for Injury/Illness


CognitiveFactors


PhysicalEnvironment

Self-ImposedStress


Personnel

Factors


PRECONDITIONS

PerceptualFactors

Physical/

MentalLimitations


States

Psycho-Behavioral

Factors

Preconditionsfor

Unsafe Acts

UnsafeActs


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2 November 2011


CognitiveFactors


PhysicalEnvironment

Self-ImposedStress


Personnel

Factors

Psycho-Behavioral

Factors


PRECONDITIONS

PerceptualFactors

Physical/

MentalLimitations


States

PHYSICAL/MENTAL LIMITS

Learning Ability/Rate

Memory Ability/Lapses

Anthropometric/Biomechanical Limits

Motor Skill/Coordination or Timing Deficiency

Technical/Procedural Knowledge

Preconditionsfor

Unsafe Acts

UnsafeActs


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2 November 2011


CognitiveFactors


PhysicalEnvironment

Self-ImposedStress


Personnel

Factors

Psycho-

BehavioralFactors


PRECONDITIONS

PerceptualFactors

Adverse

PhysiologicalStates

PERCEPTUAL FACTORSIllusions: Kinesthetic/Vestibular/Visual

Misperception of Operational Conditions

Misinterpreted/Misread Instrument

Expectancy

Auditory Cues

Spatial Disorientation: 1, 2, & 3

Temporal Distortion

Physical/

MentalLimitations

Preconditionsfor

Unsafe Acts

UnsafeActs


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2 November 2011

Supervision

Inadequate supervision: lack of guidance,written policy, or training opportunities

Failure to correct known problem: problems withpersonnel or operations

Inappropriate Operations: lack of proper riskassessment or assigned inappropriate personnelto task

Violations: unnecessarily allows operationsoutside of SOP

Supervisors are ultimately responsible for the conductof their units.


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2 November 2011

Inadequate

Supervision

PlannedInappropriateOperations

Failed toCorrect Known

Problem

Supervisory

Violations

SUPERVISION

Unsafe

Supervision

Preconditions

forUnsafe Acts

Unsafe

Acts


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2 November 2011

InadequateSupervision



Problem

SupervisoryViolations

SUPERVISION

INADEQUATE SUPERVISION

Leadership/Supervision/Oversight InadequateSupervision Modeling

Local Training Issues/Programs

Supervision Policy

Supervision Personality Conflict

Supervision Lack of Feedback

Unsafe

Supervision

Preconditions

forUnsafe Acts

Unsafe

Acts


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2 November 2011

PLANNED INAPPROPRIATEOPERATIONS

Ordered/Led Task Beyond Capability

Crew/Team Makeup/Composition

Limited Recent Experience

Proficiency

Risk Assessment Formal

Authorized Unnecessary Hazard




Problem


SUPERVISION

Unsafe

Supervision

Preconditions

forUnsafe Acts

Unsafe

Acts


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2 November 2011

FAILED TO CORRECTKNOWN PROBLEM

Personnel Management

Operations Management




Problem


SUPERVISION

Unsafe

Supervision

Preconditions

forUnsafe Acts

Unsafe

Acts


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2 November 2011

SUPERVISORY VIOLATIONSSupervision Discipline Enforcement

Supervision Unwritten Policy

Directed Violation

Assigned Unqualified Individuals

Inadequate

Supervision



Problem

Supervisory

Violations

SUPERVISION

Unsafe

Supervision

Preconditions

forUnsafe Acts

Unsafe

Acts


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2 November 201139


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2 November 2011

Organizational Factors

Resource/Acquisition Management: the ways inwhich equipment is allocated

Organizational Climate: affects morale in a unit Process: policies and procedures that drive the

concept of operations

The Organization is responsible for overall policy,doctrine, and allocation of resources to the subordinateunits and personnel


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Federal Aviation

Administ rat ion


2 November 2011

Organizational

Climate


Management

Organizational

Process

ORGANIZATIONAL

INFLUENCES

RESOURCE/ACQUISITION

MANAGEMENTAir Traffic Control Resources

Airfield Resources

Operator Support

Acquisition Policies/Design Processes

Personnel Resources

Information Resources/Support

Financial Resources/Support

OrganizationalInfluences

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs


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Federal Aviation

Administ rat ion


2 November 2011

Organizational

Climate

ORGANIZATIONAL

INFLUENCES

ORGANIZATIONAL

INFLUENCES

ORGANIZATIONAL CLIMATE

Organizational Values/Culture

Evaluation/Promotion/UpgradePerceptions of Equipment

Mission/Economic Climate

Organizational Structure


Management

Organizational

Process

Organizational

Influences

Unsafe

Supervision

Preconditionsfor

Unsafe Acts

Unsafe

Acts


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Federal Aviation

Administ rat ion


2 November 2011

Organizational

Climate

Operational

Process

ORGANIZATIONAL

INFLUENCES

ORGANIZATIONAL

INFLUENCES

Organizational

Process

ORGANIZATIONAL PROCESS

Ops Tempo/Workload

Program and Policy Risk Assessment

Procedural Guidance/Publications

Organizational Training Issues/Programs

Program Oversight/Program Management


Management

Organizational

Influences

Unsafe

Supervision

Preconditionsfor

Unsafe Acts

Unsafe

Acts


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Federal Aviation

Administ rat ion


2 November 2011

Questions?

1100-threat and error management and hazard identification

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