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Lecture 13 Human Errors & Error Management

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Alishba Ilyas Sheikh
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41 views25 pages

Lecture 13 Human Errors & Error Management

Uploaded by

Alishba Ilyas Sheikh
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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Human Errors & Work Ethics in

Aviation Maintenance
Human Errors in Aviation Accidents

 Airline safety has improved over the past 40 years


because of:-
 Better aircraft

 Better air traffic control

 Better weather prediction

 But the Human Error has increased from 20% to


80%

History of Human Factor in Aviation


Human Element

 The human element includes


 Pilots
 Engineers
 Technicians
 Senior management
 Quality inspectors
 All others in the aviation community
 Human element is the most flexible, adaptable and
valuable part of the aviation system, but it is also the
most vulnerable to influences

What is Human Factor?


Accident Pyramid
(Heinrich Ratio)

Serious Accident
1

Minor Accident with


Damage and Injury 10 well documented

Incidents and
Near Misses
102

Observed What? When? Where? Why?


Work Errors 10 3
>Standard Operating Procedures<

Human Error & Types


Human Error

 Human Error can be defined as:-

“Action or inaction that leads to deviation from


intentions or situational requirements such as
Policies, Regulations, and Standard Operation
Procedures.”

Human Error & Types


Active and Latent Errors

 Human Errors classification into two basic kinds


 Active Error – An action that has an immediate effect

 Latent Error – An action that has a delayed effect

 Because of the time delay between error and


consequence, latent errors and their causes are
much more difficult to trace than are active errors

Human Error & Types


Aircraft Accident Example No 1

Effects of Human Error in Aviation


Aircraft Accident Example No 2

Effects of Human Error in Aviation


Errors in Aviation Maintenance

• Study of 120 cases by Australian Bureau of Air


Safety investigation

Human Error & Types


…Errors in Aviation Maintenance
 Memory Lapse: 24%
 Caused due to interruption / multiple tasks
 Work-arrounds: 23%
 Caused due to lack of required equipment / procedures
 Situational Awareness:18%
 Due to lack of communication / documentation
 Expertise:10%
 Caused due to lack of knowledge / training
 Action Slip: 9%
 Due to unintentional wrong actions

Human Error & Types


Errors and Consequences

Errors and
consequences
are not
proportional in
their magnitude
Data of Fatal Aviation Accidents
Causal Factors (10 years Stats) No. of Onboard
Accidents Fatalities
Controlled Flight into Terrain (CFIT) 36 2169
Maintenance and Inspection 47 1481
Loss of Control/Uncontrolled 9 1387
Air Traffic Control 39 1000
Approach and Landing (NO CFIT) 133 910
In-flight smoke and fire 6 610
Ground Deicing/Anti-icing 9 384
Wind shear 10 381
Un-contained Engine Fire 11 199
TOTAL 394 9639
Effects of Human Error in Aviation
Cost of Human Error in Maintenance
 The average cost of an in-flight engine shutdown is
$500,000
 The average cost of a flight cancellation is $50,000
 The average cost of a return to gate is $15,000
 The Airline Transport Association estimates that ground
damage costs $850 million/year
 The average ground damage incident costs $70,000
 One Airline estimates $75-$100 million / year wasted on
error

Effects of Human Error in Aviation


Example of Cost Effect

Effects of Human Error in Aviation


Example: Resulting Damage

 Left-hand horizontal stabilizer

 Rudder

 Rear dock stands

 Hangar wall

Effects of Human Error in Aviation


Example: Cost Factors
 Material
 Regular and overtime labor
 Repair to dock stands and hangar wall
 Loss of bay during extra repair duration
 Delayed or third party maintenance for other aircraft
 Operational complications due to aircraft availability
 Investigation and remediation
Estimated total cost = $900,000.

Effects of Human Error in Aviation


Why Do We Make Errors?
Mental Limits

Why do we Make Errors


…Mental Limits

Why do we Make Errors


Causes of Human Errors

Human Errors

Events
70% due to
80% Human Error Organization 30%
Weaknesses Individual
Mistakes

20% Equipment
Failures
…Causes of Human Errors
 Lack of Communication
 Complacency
 Lack of Knowledge
 Distraction
 Lack of Teamwork
 Fatigue
 Lack of Resources
 Pressure
 Lack of Assertiveness
 Stress
 Lack of Awareness
 Norms

Why do we Make Errors


A System Approach

Events

The Worker

Task Factors – the job

Local Conditions – at the worksite

Organizational Factors – the system as a whole

Why do we Make Errors


Error Prevention Strategies

 Three error prevention strategies


 Error Reduction. Error reduction strategies are intended
to intervene directly at the source of the error itself

 Error Capturing. Error capturing assumes the error is


made. It attempts to “capture” the error before the aircraft
departs

 Error Tolerance. Error tolerance refers to the ability of a


system to accept an error without catastrophic (or even
serious) consequences
Conclusion

 Humans are fallible

 Human error is a major contributor to events and


occurrences
 Effects of human error in aviation are very devastating
Aim = Zero Human Error
 Advances in aviation technology have not been matched
by improvements in human performance
 The greatest cause of human error is weaknesses in the
system, not lack of skill or knowledge
The End

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