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Knowledge-based thinking
A project supported by AIRBUS and the CAAC
June 2007
Human Errors
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
3. Automation and Human Errors
Advanced technology and automation can help
people doing a lot of jobs and avoid some errors
But advanced technology and automation can’t
avoid all basic errors
Even simple error may cause complex system to
failure.
To build a system to manage human errors
A project supported by AIRBUS and the CAAC
June 2007
A project supported by AIRBUS and the CAAC
June 2007
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
4. How to Do for Human Errors
PAST APPROACH
Name and blame
If pilot/crew or technician had followed training
and SOPs (standard operating procedures) he or
she would not have made the error
Pilot/crew or technician was not careful enough
Self-blame
How could this have happened to me?!
I was not paying enough attention
Self-denial
This would never happen to me (us)
This will never happen to me (us) again
A project supported by AIRBUS and the CAAC
June 2007
How to Do for Human Errors
PAST APPROACH
Why?
Easier to point the finger
Hindsight bias
Apparently isolated incidents
Emotionally (politically, sun 2005) satisfying
Lack of understanding of human cognitive
processes
Quick-fix approach
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
How to Do for Human Errors
SHIFT IN APPROACH
Shift focus from operator to system
Simply trying hard will not prevent errors
Error is a symptom
Accidents result from combination of
events/factors
Event Chain
A project supported by AIRBUS and the CAAC
June 2007
How to Do for Human Errors
SHIFT IN APPROACH
Active errors: whose effects are felt almost
immediately
performance of the “front-line” operators (sharp end)
Latent errors: whose effects may be hidden for
long, becoming evident only when they combine
with other factors
management leadership, philosophy, response
(Reason, 1990)
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
LATENT
ACTIVE
How to Do for Human Errors
SHIFT IN APPROACH
ACTIVE
A project supported by AIRBUS and the CAAC
June 2007
CURRENT APPROACH
Humans have cognitive limitations
To err is human
Cannot eliminate all human error
Error is not deterministic but probabilistic
Focus on making system less error prone and more
error tolerant
How to Do for Human Errors
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
CURRENT APPROACH
Activities directed at improving safety:(flight)
Technology: e.g., GPWS, TCAS, navigation aids, landing
aids
Research: basic and applied, databases
Operations: standardized, explicit procedures (flows,
checklists)
Training: standardized, recurring, incl. performance
evaluation
Regulation: inspection, enforcement
All above aspects: include human performance issues
(e.g., fatigue, etc.)
How to Do for Human Errors
A project supported by AIRBUS and the CAAC
June 2007
How do we make a robust, efficient, and safety system?
First, it is key to know all (or as more as possible) information or fact
(truth) about operating system, including operation and airworthiness of
aircraft.
How do we know these?
We knows these from accidents, yes.
from incident, yes!
from other investigation or oversight , yes!
But all of these are not enough for improving safety.
We should be aware of all unsafe precursors of
aviation system.
We should develop a system that should be
perfect and tolerable to errors
How to Do for Human Errors
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AIRWORTHINESS AND FLIGHT STANDARDS(16)
