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Actions or inactions by people (pilots, controllers, maintenance
engineers, aerodrome staff, etc.) that have an immediate adverse effect.
Errors
Violations
A project supported by AIRBUS and the CAAC
June 2007
The perspective of the organizational accident
Improve Identify
Monitor
Contain
Reinforce
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
People and safety
Aviation workplaces
involve complex
interrelationships among
its many components.
To understand
operational
performance, we must
understand how it may
be affected by the
interrelationships among
the various components
of the aviation work
places. Source: Dedale
A project supported by AIRBUS and the CAAC
June 2007
B
A
Understand
human performance
within the
operational context
where it takes place
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
Processes and outcomes
Causes and
consequences
of operational
errors are not
linear in their
magnitude
Source: Dedale
A project supported by AIRBUS and the CAAC
June 2007
The SHEL(L) model
S
H L L
E
Software
Hardware
Environment
Liveware
Liveware, other
persons
Understanding the relationship between people and operational
contexts
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
Operational performance and technology
In production-intensive
industries like
contemporary aviation,
technology is essential.
As a result of the
massive introduction of
technology, the
operational
consequences of the
interactions between
people and technology
are often overlooked,
leading to human error.
A project supported by AIRBUS and the CAAC
June 2007
Understanding operational errors
Human error is
considered contributing
factor in most aviation
occurrences.
Even competent
personnel commit
errors.
Errors must be accepted
as a normal component
of any system where
humans and technology
interact.
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
Errors and safety – A non linear relationship
Statistically, millions of
operational errors are made
before a major safety
breakdown occurs
Source: Dedale
A project supported by AIRBUS and the CAAC
June 2007
Accident investigation – Once in a million flights
Flaps omitted
Checklist failure
Unheeded warning
Error Deviation Amplification Degradation /
breakdown
Incident /
accident
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
Safety management – On almost every flight
Flaps omitted
Checklist works
Effective warning
Error Deviation Amplification Normal flight
A project supported by AIRBUS and the CAAC
June 2007
Three strategies for the control of human error
Error reduction strategies
intervene at the source
of the error by reducing
or eliminating the
contributing factors.
Human-centred design
Ergonomic factors
Training
…
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
Three strategies for the control of human error
Error capturing strategies
intervene once the error
has already been made,
capturing the error
before it generates
adverse consequences.
Checklists
Task cards
Flight strips
…
A project supported by AIRBUS and the CAAC
June 2007
Three strategies for the control of human error
Error tolerance strategies
intervene to increase the
ability of a system to
accept errors without
serious consequence.
System redundancies
Structural inspections
…
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
Understanding violations – Are we ready?
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AIRWORTHINESS AND FLIGHT STANDARDS(7)
