5. How safe is flying? Lives lost per year 100 000 10 000 1000 100 10 1 10 000 1 10 100 1000 1 million 10 million (Adapted after Amalberti, 2005) Numbers of events for each accident Climbing Mt Everest Health care (in USA) Chemical manufacturing 100 000 Chartered flights Road transport (in USA) Scheduled airlines Rail transport (Europe)
14. The Need for Resilience Resilience Ability of a system to recover from catastrophic failure Resilience engineering aims to strengthen the ability of organisations to create processes that are robust yet flexible
15. Reliability and Resilience Goal: Safety Yes! No! We can design a perfect safe system! We cannot design a perfect safe system! Accidents = Human Error Accidents = Weaknesses in system Avoiding accidents: Automation and SOPs Restrict the operator! Avoiding accidents: Provide “action space” Support the operator! Reliability Learning from failure Limited operator action Train for likely events Resilience Learning from success Competent operator action Train for unlikely events Human Factors and CRM The human operator keeps the system together
17. Human Factors and CRM Human Factors Learning Physiology Sociology Leadership Communication Technology Design Psychology And so on …
18. Human Factors and CRM CRM Human Factors Learning Physiology Sociology Leadership Communication Technology Design Psychology And so on …
19. Crew Resource Management CRM is the effective utilisation of all available resources (e.g. crew members, aeroplane,systems and supporting facilities) to achieve safe and efficient operation.
20. Threat Error Undesired Aircraft State (UAS) Threat and Error Management (TEM) (Merritt & Klinect, 2006)
21. Normal Operations Monitoring (NOM) Reality? SOPs NOM PPC Systematic collection of data from operations Gathering and Using Safety Data
22.
23. Going Wide or Deep Human Factors is necessary for effective identification, understanding and intervention Quantitative data: Flight data, auditing data, operations monitoring, questionnaires etc. Qualitative data: Accident/incident investigations, case analyses, interviews, observational studies Why? What?
24. Human Factors in Operations Alaska Airlines 261 Swissair 111 Turkish Airlines 1951
27. Drift to Failure Unsafe actions Safe actions according to procedures etc. Efforts to become more effective may lead to unsafe acts New norms, routines, procedures… Safe actions
28. Swissair 111 - In-flight Fire Nova Scotia, Canada September 2, 1998 (Transportation Board of Canada, 2003)
29. Swissair 111 - In-flight Fire Nova Scotia, Canada September 2, 1998 (Transportation Board of Canada, 2003) Reliability Resilience “ If smoke/fumes are not eliminated, land at nearest suitable airport.”
Introduction to Emirates CRM Initial CRM Revision date: 5 January 2009 Health care is wrestling with safety issues. So flying is indeed safe … however … (leads on to next slide).
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12-01-21 The process above simply states that a threat mismanaged or ignored, can lead to errors and eventually an undesired aircraft state (UAS), which if once again left alone can result in an accident. The next click shows that if one intervenes (using CRM and the TEM-model) the threat can be managed and a safe flight can be achieved. Even if the threat is not managed effectively and an error is made, pilots normally identify (80% - LOSA study) their own mistakes. If the error is identified, then it can be rectified and the aircraft returned to a safe flight. Good CRM practise (effective communication, task sharing, assertiveness, leadership, judgement and decision making) will normally result in an error being identified and rectified. Finally even if the aircraft ends in an UAS, there is again an opportunity to return the aircraft to a safe flight. Once again good CRM, the TEM model and basic ANC can be utilised. The overall intention of this slide is to show that in effect there are several opportunities during threat and error management to identify the threat, error or UAS and return the aircraft to a desired state (safe flight).
12-01-21 Detta är viktigt att kunna från detta avsnitt.
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12-01-21 Vi kan se fel som om de är interna eller externa. Med interna fel avser vi de som kan kopplas till människans funktion som människa. Det kan då handla om svagheter i vår faktiska uppfattning av den omgivande verkligheten. Det kan finnas ljud som indikerar fel som vi inte hör. Det kan finnas vibrationer vi inte känner eller överhettningar vi hade sett om vi kunnat uppfatta andra våglängder av ljus. Oavsett om vi mottar information om något så kan vi fortfarande misstolka informationen. Vår perception påverkas kraftigt av förväntningar och erfarenheter. T.ex. så kan ett ljud från en krånglande motor kan uppfattas som ett helt annat problem. På samma sätt så kan vår analys påverkas av saker som egentligen inte är relevanta i sammanhanget. En tid att passa kan påverka analysen så att risken med ett fel underskattas. Detta gäller för övrigt också vårt beslutsfattande. Även våra handlingar, i synnerhet vår motorik, kan ses som utsatt för risken av inre fel. Om vi inte är tillräckligt säkra på det vi ska utföra så kan en ovanligt hög stressnivå leda till att motoriska program inte kan utföras korrekt. Gränsdragningen kan vara svår i dessa sammanhang men att sätta stress som inre fel är inte korrekt eftersom det är effekten av stress på t.ex. analys- eller beslutsförmåga som är det som utlöser fel och inte stressen i sig. Under senare år har begreppet mental modell kommit i fokus med detta avses den modell av hur något fungerar som dess operatör har. Beroende på kunskap, erfarenhet, utbildning, träning o.s.v. kan den mentala modellen stödja korrekta operationer eller ligga bakom att fel inträffar.
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Recurrent CRM 2010-2011 - Cognition and error 21/01/12 Version 1.0 07/07/2010 If we believe that the systems – again meaning people, technology and organisation – can be designed to be totally safe and that we have succeeded in this then the aftermath of an accident is quite simple. We only need to know who made the error and then act accordingly (punishment normally being the preferred option). If we on the other hand believe that it is impossible to design a complex system involving people, technology and a large organisation so that it is completely safe we would probably be more interested in why the error was made. Note that only the “why” provides an opportunity for learning, while the who will bring closure by establishing who made the error.
If the recent decades of change in the civil aviation industry have been evolutionary or revolutionary might be a matter of which perspective to choose. That the changes in areas like technological development, traffic growth, privatisation and government policies have been and will continue to be important is a widely held consensus. According to the International Air Transport Association, IATA, these areas are examples of how “Civil aviation is undergoing dramatic change.” It is reasonable to expect that this change should have an impact on all aspects of civil aviation, including basic civil aviation training. Accordingly, it is reasonable to expect that there would be a need of research projects in the field of basic civil aviation training to adapt to these changes.
Recurrent CRM 2010-2011 - Cognition and error 21/01/12 Version 1.0 07/07/2010 If we believe that the systems – again meaning people, technology and organisation – can be designed to be totally safe and that we have succeeded in this then the aftermath of an accident is quite simple. We only need to know who made the error and then act accordingly (punishment normally being the preferred option). If we on the other hand believe that it is impossible to design a complex system involving people, technology and a large organisation so that it is completely safe we would probably be more interested in why the error was made. Note that only the “why” provides an opportunity for learning, while the who will bring closure by establishing who made the error.
Recurrent CRM 2011-2012 – Introduction 21/01/12 Version 2.0 02/05/2011 Results of the flight management attitude questionnaire answered by 2096 EK pilots from May 2009-May2010. The above is the average answer by 20 countries (more than 20 pilots per country) and shows a very close range of answers. So national culture does not have much affect on flight deck interactions, although questions 12-17 were directly national culture based questions and here the responses do signify a high spread (standard deviation). The above graph therefore signifies that Pilot Professional Culture is fairly standard world wide.
12-01-21 Development in the area of civil aviation training, especially in recent years, is more difficult to encapsulate. According to Dekker & Johansson (2000), “Ab initio training has not changed in any fundamental sense since the fifties.” At the same time Orlady & Orlady (1999) claims “Airline pilot training programs have undergone important and largely evolutionary changes in the past two decades.” The different views on the development of civil aviation training could be due to that they refer to two fundamentally different types of training. One is basic civil aviation training and the other is the training that pilots and other crewmembers go through to maintain and develop their skill and competence. Basic civil aviation training provides future pilots with the initial training they need to achieve the licences required for employment in the civil aviation industry. (Training for Private Pilot License, PPL, is excluded in this paper.) Training for pilots includes initial company training, transition or conversion training on a specific aircraft, upgrade training and recurrent training.
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Changing the Safety Culture To understand how to affect change you must understand the evolution of the safety culture from past to present and how it needs to evolve in the future. Figure 1 illustrates this evolutionary process. Traditionally, when something broke, it was fixed; if there was an accident, a change was made to prevent the accident from reoccurring. This reactive approach depended on a “command and control” style of management in order to achieve a safe environment. Lack of Standard Operating Procedures (SOPs) required close supervision to ensure safety. With the advent of company safety programs in the 1980s the aviation industry moved to a more team driven approach to safety. This approach continued to reduce the accident rate by creating safety awareness through programs such as Crew Resource Management (CRM) and Human Factors training. Documented SOPs allowed the training of consistent, repeatable procedures with the emphasis on individuals acting as a team. However, safety programs were still mostly reactive in nature. The goal of a systems approach to safety is to further reduce the incident rate by making safety “behaviour driven”. In other words, if everyone is trained to do their job in a safe manner and proactively look for hazards, then a company can improve their defences and build an organization more resistant to human error.
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