Download - OGHFA 1_HP_06_VIS_Error Management 1 Error Management OGHFA 1_HP_06_VIS_Error Management 1
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Error Error
ManagementManagement
Error Error
ManagementManagement
OGHFA 1_HP_06_VIS_Error ManagementOGHFA 1_HP_06_VIS_Error Management 1
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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
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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
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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
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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1. Why do we sometimes fail?
2. Consequences on flight safety
3. Managing errors and violations
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1. Why do we sometimes fail?
2. Consequences on flight safety
3. Managing errors and violations
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© Ismo Aaltonen
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Intention to achieve somethingGood planAction “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
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Intention to achieve something
Good plan
Something is skipped, omitted
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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
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Completely newCompletely new
RoutineRoutine
Mistakes(capacity overflow)
Slips & Lapses
Mistakes(incorrect solutions)
Exceptionalviolations
Routineviolations
Optimizingviolations
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1. Why do we sometimes fail?
2. Consequences on flight safety
3. 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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1. Why do we sometimes fail?
2. Consequences on flight safety
3. Managing errors and violations
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ERROR PREVENTION
ERROR MANAGEMENT
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Error ReductionMinimizing the likelihood of error
Minimizing the consequences of error
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Error DetectionFacilitate easy and rapid detection of errors
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Error Management Strategies
Error RecoveryMake it easy to rapidly recover to a safe state
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Error ToleranceBuild the system to
tolerate errors
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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.
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Mistakes(capacity overflow)
Slips & Lapses
Mistakes(incorrect solutions)
Exceptionalviolations
Routineviolations
Optimizingviolations
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Slips & Lapses
Mistakes(incorrect solutions)
Routineviolations
Optimizingviolations
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Slips & Lapses
Mistakes(incorrect solutions)
Routineviolations
Optimizingviolations
• Error Tolerance• Error Reduction• Error Detection
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Mistakes(incorrect solutions)
Routineviolations
Optimizingviolations
Key issues:• Situation Recognition and Diagnosis• Decision Making
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Violation Management
Routineviolations
Optimizingviolations
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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
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Optimizingviolations
Remove the need to ViolateAdequate planning
Capability to adapt to new demands
Open communication
Safety Culture
Routineviolations
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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
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Look BEHIND the error or violation
What type of error?
Find solutions
Real, systemic