ISIGsection 6.docx

ISIGsection 6.docx

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ISIGsection6

6.ReviewingandAnalysingInformation

6.1IntroductiontoHumanError

6.1.1HumanFactors

HumanFactorsisanumbrellatermforthestudyofpeople'sperformanceintheirworkandnonworkenvironments.Humanfactorsisaboutunderstandinghowpeopleinteractwithsystemsandinterfaces,useequipment,interpretpolicies,workwithproceduresandmanuals,andoperatewithintheirworkingenvironment.Itisalsoabouttheirrelationshipwithotherworkcolleagues.

SomepeoplerefertoHumanFactorsandHumanErrorasiftheyaresynonymous,buttheyarenotthesame.

HumanFactorsisfieldofscientificknowledgedrawingfromestablisheddisciplinessuchasergonomics,physiology,psychologyandengineering.HumanErrorisreallytheoutcomeorconsequenceofourhumanfactorslimitations.

Thefollowingtopics,areusuallyconsideredtoencompassthefieldofhumanfactors.

6.1.2HumanFactorstopics

TheprincipalobjectiveofhumanfactorseffortsacrosstheairlinesGroupistocontinuallyimprovesafetyandefficiency,viathereductionandmanagementofhumanerroratthepersonalandorganisationallevel.Thisobjectiveisbasedontheunderstandingthathumanerrorcanneverbeeliminated,onlymanaged.Oneofthebestwaystomanageerroracrosstheorganisationisthroughcompanywidehumanfactorstrainingprograms,suchasCrewResourceManagement（CRM）.CRMissimplytheapplicationofhumanfactorstrainingtoaircrew.

Thistrainingnowshallsquarelyfocusonprovidingaircrewwiththeskillstomanagetheconsequencesofhumanerror.Thisimpliesthaterrorisanormalandexpectedcondition,ofwhichtheconsequencesarejustasimportantasthecause.Inotherwords,itiswhatoperatorschoosetodoabouttheconsequencesoferrorthatisimportant,ratherthantheactofcommittingtheerroritself.

CurrentlyflightandcabincrewreceivethefollowingtraininginCRMandhumanfactors:

∙FlightandcabincrewnewhireCRMinductioncourse（2hours）.

∙SecondOfficerCRMcourse（2days）.

∙Cabincrewconversion（eg,longhaultoshorthaul）course（1.5hours）.

∙FlightandcabincrewannualrefresherCRMcourseinconjunctionwithemergencyprocedurestraining（23hours）.

∙Humanfactorsforcabincrewonboardmanagersandflightcrewcommandtrainees（2days）.

OtherbusinessdivisionssuchasEngineeringTechnicalandMaintenanceServices（ETOMS）providehumanfactorstrainingfornewhireapprentices.ItisexpectedthatsimilartrainingcourseswillbeexpandedtootheroperationalareassuchasAirports,Freight,OperationsResourcesandCateringinthenearfuture.

6.1.3HumanError

Humanerrorisagenerictermthatinvolvesallthoseinstanceswhereaplannedactivityfailstoachieveitsintendedoutcome.Outcomesaregenerallythoughtofastheundesirableconsequencesthatareproducedorthepotentialforundesirableconsequences.Inthemoreforgivingcircumstancesofeverydaylife,learningfromone'smistakesisusuallyabeneficialprocess.However,inthecontroltower,theflightdeckortheaircraftcabin,sucheducativeexperiencescanhaveunacceptableconsequences.

Regardlessofindustrytype,accidentstatisticsappeartobedominatedbythecontributionofhumanerror.Withintheaviationdomain,humanerrorhasreportedlybeenthecauseofbetween7085%ofallaccidents.StatisticsfromtheNationalTransportationSafetyBoard（NTSB）alsoconsistentlyindicatethattheprimarycauseof80%ofailgeneralaviationaccidentsinvolvesthepilot,andinmanycasespilotfactorislistedastheonlycause.AccordingtofiguresfromtheInternationalCivilAviationOrganisation（ICAO）outlinedbelow,flightcrewerrorsareresponsibleforbetween6070%ofallaircraftaccidents.

6.1.4Primarycausefactorsofaircraftaccidents

PrimaryFactor

Numberofaccidents

Percentageoftotalaccidentswithknowncauses

Total

Last10yrs

Flightcrew

Aircraft

Maintenance

Weather

Airport/ATC

Miscellaneous

569

138

31

41

43

62

136

32

13

9

11

33

However,theabovestatisticsaremisleadinginthattheyarebasedontheprimarycause.Sinceflightcrewarepresentwhenmostaircraftaccidentsoccuritisnotsurprisingthattheflightcrewcontributiontoaccidentsandincidentsmaybeoverinflated.Asaresult,thereexistscontrastingviewsaboutthecontributionofhumanerrortoaccidentoccurrence.Themethodemployed,thetendencyforvictimblaming,andtheextenttowhichtheerror'soriginistraced,willeachinfluencethefinaldecision.Itmaybeunproductivetoaskwhatproportionofaccidentsareduetohumanerror,butmoreusefultoask,"howmuchdoeshumanerrorcontributetoaccidentsrelativetoothercontributingfactors"?

Inordertoanalysethevarietyofhumanerrors,manyattemptshavebeenmadetocategorisethem.However,thereisnouniversallyagreedclassificationofhumanerror.Asaresult,adiverserangeoferrortypesareused.Someofthesearehighlytaskspecificandonlyuseableinspecificsettings,whileothersaresobroadtheyhavelittleutility.

Whiletherearedifferenterrorcategorisationsystems,thereisgeneralagreementthathumanerrorcanbedividedintoeitherintendedorunintendedactions.

∙Intendedactionsarethosethatproceedasplannedbutfailtoachievetheirintendedoutcome.Theseactionsarelargelyduetojudgementormotivationalprocesses.

∙Unintendedactionsarethoseinwhichtherightintentionorplanisincorrectlycarriedoutorwherethereisafailuretocarryoutanaction.Theseactionstypicallyoccurduetoattentionalormemoryfailures.

Onesimpleclassificationschemebasedonintendedandunintendedactionshasbeendevelopedasaresultofextensiveflightdeckobservationsofcrewbehaviour.Thiserrorclassificationsystemhasbeenadoptedbyairlinestoassistinthecategorisationofunsafeacts.Behaviourisclassifiedintofiveerrortypes,whichareshownbelowandexpandedoninmoredetailinthenextsection:

ErrorTypes

Action

CommunicationsError

Unintended

ProficiencyError

Unintended

OperationalDecisionError

Unintended

ProceduralError

Unintended

IntentionalNoncompliance/Violation

Intended

Insummary,itispossibletodistinguishbetweentwomainapproachestohumanerror.Firstly,itmaybeagreedthatindividualsareresponsiblefortheirownactionsandthereforefortheerrorstheymake.Secondly,analternativeviewisthaterrorsareaninherentcomponentinallhumanperformance.Subsequentlyerrorsshouldbeplannedforandwhentheydooccur,thefaultshouldbetracedtothesystemdesignerratherthantheoperator.Thislatterviewisknownasthesystemororganisationalapproachtoaccidentsandisdiscussedinmoredetailbelow.

6.2TheOrganisationalAccident

Historically,therehavebeentwoapproachestoanalysingaccidents;thepersonandsystemapproaches.Thepersonapproachtendstofocusonactivefailures,whichareindividualerrorsandviolationsthathaveanimmediateadverseeffect.Atypicalinvestigationmayhaveexaminedsuchfactorsaspersonality,attitudes,skill,knowledge,aswellasthephysicalandemotionalstateoftheindividual.However,thepersonapproachdoesnottakeintoaccounttheorganisationalinfluencesontheindividual.

Theorganisationalapproachtoanalysingaccidentsassumesthaterroristheresultoflimitedrationality,thatis,peoplehavegoodintentionsbutareconstrainedbytheirknowledge,pointofviewandtheorganisationalenvironmentinwhichtheywork.Theorganisationalapproachhighlightstheinfluenceoftraining,experience,interfacesystems,andsupportsystemsonhumanerror,whichissimplyasymptomofunderlyingflawsinthesystem.Thisviewisillustratedinthediagrambelow,whichindicatesthatindividualsdonotoperateinavacuum,butrathertheirbehaviourisinfluencedbyavarietyoforganisationalconditions.

Operatorsarenotautonomous

OneofthemorewidelyknownorganisationalapproachestohumanerroristhatofProfessorJamesReason.AccordingtoReasonthehumancausesofmajoraccidentsarewidelydistributed,notjustwithinthesystem,butoftenoverseveralpreceedingyearstothefinalevent.Reason（1992）callsthesecumulativefactorslatentfailureswhich:

Arethosedecisionsoractions,thedamagingconsequencesofwhichmayliedormantforalongtime,onlybecomingevidentwhentheycombinewithlocaltriggeringfactors（thatis,activefailures,technicalfaults,atypicalsystemconditions,etc.）tobreachthesystem'sdefences.（p.476）

Whileactivefailuresaretypicallyoperatorerrors,latentfailuresmayresultfromerrorsinhighleveldecisionmaking,equipmentdesign,installation,planningandmaintenance.Thisapproachdoesnotsuggestthatindividualpsychologicalfactorshavenoparttoplayinaccidents,butarguesthatresearchandhistoryhaverepeatedlyshownthatfrontlineoperators（e.g.pilotsanddrivers）aremerelytheinheritorsofsystemdefectscreatedhigherupwithinasystem.

TheprinciplesunderlyingReason'sapproacharediscussedindetailinthenextsection.

6.3TheReasonModel

Fromananalysisoflargescaleaccidentsacrossvarioushighriskindustriessuchastransportormining,itisgenerallyagreedthattherearetwotypesoffailuresinvolvedinmostaccidentsandincidents:

1.ActiveFailurestheseareerrorsinwhichtheconsequencesareimmediate.Theyareusuallycommittedbypeoplewhohavedirectcontactwithequipment,eg.aircrew,andmayinclude:

•Failuretolowerthelandinggear.

•Failuretocorrectlyopenadoorinanemergency.

•Directingpassengerstothewrongexitdoor.

2.LatentFailuresthesearefactorswhichmayliedormantwithinasystemuntiltheyareactivatedbyas