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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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