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

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

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    bipinup
    28 views40 pages
    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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    aeronautics

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    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.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    28 views40 pages

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

    Uploaded by

    bipinup
    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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    © All Rights Reserved
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    Download as ppt, pdf, or txt
    of 40

    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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