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Error Management: OGHFA 1 - HP - 06 - VIS - Error Management OGHFA 1 - HP - 06 - VIS - Error Management

The document discusses error management in aviation operations. It notes that over 70% of flights observed had at least one error or violation, and about 30% of errors were mismanaged in a way that led to additional errors. The presentation covers why errors occur, the consequences for flight safety, and strategies for managing errors, including error prevention, error reduction, error detection, error recovery, and error tolerance. It distinguishes between mistakes, slips and lapses, optimizing violations, and routine violations, and stresses the importance of systemic solutions over actions targeting individuals.

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41 views40 pages

Error Management: OGHFA 1 - HP - 06 - VIS - Error Management OGHFA 1 - HP - 06 - VIS - Error Management

The document discusses error management in aviation operations. It notes that over 70% of flights observed had at least one error or violation, and about 30% of errors were mismanaged in a way that led to additional errors. The presentation covers why errors occur, the consequences for flight safety, and strategies for managing errors, including error prevention, error reduction, error detection, error recovery, and error tolerance. It distinguishes between mistakes, slips and lapses, optimizing violations, and routine violations, and stresses the importance of systemic solutions over actions targeting individuals.

Uploaded by

bipinup
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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Error

Management

OGHFA 1_HP_06_VIS_Error Management 1


Accidents

Serious incidents
Severity of event

Minor incidents

Normal operations:
• threats and errors
• deviations
• failures and successes

Frequency of event, Quantity of data

OGHFA 1_HP_06_VIS_Error Management 2


Accidents

Serious incidents
Severity of event

Minor incidents

Normal operations:
• threats and errors
• deviations
• failures and successes

Frequency of event, Quantity of data

OGHFA 1_HP_06_VIS_Error Management 3


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.


OGHFA 1_HP_06_VIS_Error Management 4
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.

OGHFA 1_HP_06_VIS_Error Management 5


1. Why do we sometimes fail?

2. Consequences on flight safety

3. Managing errors and violations

OGHFA 1_HP_06_VIS_Error Management 6


1. Why do we sometimes fail?

2. Consequences on flight safety

3. Managing errors and violations

OGHFA 1_HP_06_VIS_Error Management 7


OGHFA 1_HP_06_VIS_Error Management 8
 Intention to achieve something
 Good plan
 Action “on autopilot”
 Unintended deviation from plan

 Several error mechanisms, for example:


“Strong but wrong” habits
Inaccuracies

OGHFA 1_HP_06_VIS_Error Management 9


 The climb is getting bumpy…

 Radar was off!

 Predictive windshear had been set to “auto”

 Radar remained off

OGHFA 1_HP_06_VIS_Error Management 10


 Intention to achieve something

 Good plan

 Something is skipped, omitted

OGHFA 1_HP_06_VIS_Error Management 11


Mistake

OGHFA 1_HP_06_VIS_Error Management 12


 Intention to achieve something

 The solution is…


Deficient

Wrong

Dangerous

Clumsy

OGHFA 1_HP_06_VIS_Error Management 13


OGHFA 1_HP_06_VIS_Error Management 14
 Deliberate violation of a rule, procedure, policy or norm

OGHFA 1_HP_06_VIS_Error Management 15


Completely new
Mistakes Exceptional
(capacity overflow) violations

Mistakes
(incorrect solutions) Optimizing
violations

Slips & Lapses Routine


violations

Routine
OGHFA 1_HP_06_VIS_Error Management 16
1. Why do we sometimes fail?

2. Consequences on flight safety

3. Managing errors and violations

OGHFA 1_HP_06_VIS_Error Management 17


OGHFA 1_HP_06_VIS_Error Management 18
 Thereis a very loose coupling between an error and
negative consequences
Other factors shape the outcome
Especially true in aviation

 Nevertheless…

OGHFA 1_HP_06_VIS_Error Management 19


 Flaps not set for takeoff (lapse)
Aircraft type and performance?
Actual takeoff weight?
Runway length?
Obstructions ahead?
Takeoff
configuration
warning?

OGHFA 1_HP_06_VIS_Error Management 20


1. Why do we sometimes fail?

2. Consequences on flight safety

3. Managing errors and violations

OGHFA 1_HP_06_VIS_Error Management 21


OGHFA 1_HP_06_VIS_Error Management 22
ERROR PREVENTION

ERROR MANAGEMENT

OGHFA 1_HP_06_VIS_Error Management 23


OGHFA 1_HP_06_VIS_Error Management 24
 Error Reduction
Minimizing the likelihood of error
Minimizing the consequences of error

OGHFA 1_HP_06_VIS_Error Management 25


 Error Detection
Facilitate easy and rapid detection of errors

OGHFA 1_HP_06_VIS_Error Management 26


Error Management Strategies

 Error Recovery
Make it easy to rapidly recover to a safe state

OGHFA 1_HP_06_VIS_Error Management 27


 Error Tolerance
Build the system to
tolerate errors

OGHFA 1_HP_06_VIS_Error Management 28


 Error Prevention
Where reasonable and where doing so does not
increase other risks, remove an error-prone task
by (re)design of system, procedure or process.

OGHFA 1_HP_06_VIS_Error Management 29


Mistakes Exceptional
(capacity overflow) violations

Mistakes
(incorrect solutions) Optimizing
violations

Routine
Slips & Lapses
violations

OGHFA 1_HP_06_VIS_Error Management 30


Mistakes
(incorrect solutions) Optimizing
violations

Routine
Slips & Lapses
violations

OGHFA 1_HP_06_VIS_Error Management 31


Mistakes
Optimizing
(incorrect solutions)
violations

• Error Tolerance
• Error Reduction
• Error Detection

Routine
Slips & Lapses violations

OGHFA 1_HP_06_VIS_Error Management 32


Mistakes
Optimizing
(incorrect solutions)
violations

Key issues:
• Situation Recognition and
Diagnosis
• Decision Making
Routine
violations

OGHFA 1_HP_06_VIS_Error Management 33


Optimizing
violations

Violation
Management

Routine
violations

OGHFA 1_HP_06_VIS_Error Management 34


 Expectation that rules will
have to be bent to get the job Optimizing
violations
done
 Feeling of Powerfulness:
above-average people need
not follow all procedures
 Opportunities to “short cut”
 Inadequate Planning, forcing
people to improvise
The “Lethal Routine
Cocktail” violations

OGHFA 1_HP_06_VIS_Error Management 35


 Remove the need to Violate
Optimizing
Adequate planning violations
Capability to adapt to new
demands
Open communication

 Safety Culture

Routine
violations

OGHFA 1_HP_06_VIS_Error Management 36


 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

OGHFA 1_HP_06_VIS_Error Management 37


OGHFA 1_HP_06_VIS_Error Management 38
OGHFA 1_HP_06_VIS_Error Management 39
Look BEHIND the error or violation
What type of error?

Find solutions
Real, systemic

OGHFA 1_HP_06_VIS_Error Management 40

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