HUMAN ERROR

HUMAN FACTORS AND CREW RESOURCE MANAGEMENT

WHAT IS HUMAN
ERROR?
BRAIN? WHAT’S WRONG WITH YOU?
ERROR

• It is defined as ―an action or inaction by an operational person

that leads to deviations from organizational or the operational
person’s intentions or expectations.
ERROR
“Two things are
infinite: the universe
and human stupidity;
and I'm not sure about
the universe.”
― Albert Einstein
 TYPES OF ERROR
• Slips and Lapses
• Slips are actions that do not
go as planned, while lapses
are memory failures.

• Mistakes
• Failures in the plan of
action.

Of all unwelcome houseguests, mold and fungus are

the least welcome.
SLIPS
Attempting a DIY
Haircut. Seriously?
Why?
LAPSES
Maintaining a polite
acquaintanceship
with someone
whose name you
can’t remember.
MISTAKES
Making screen names and
email addresses that truly
capture your emotional
maturity.
HFACS
• Developed by Dr. Douglas Wiegmann and Dr. Scott Shappell for the U.S. Navy
• Validated through comprehensive research of 1,020 NTSB accident
investigations
• Uses a systems approach whereby human error is not the cause but rather
the result of a larger problem in the organization.
HFACS
• provides a structure to review and analyze historical accident and safety data.
• enables the analyst to identify the underlying factors that are associated with
an unsafe act.
HFACs Framework Four Barrier Levels
UNSAFE ACTS

• Errors
• Perceptual error
• Skill-Based Errors
• Decision Errors
UNSAFE ACTS

• Violations
• Routine Violations
• Exceptional Violations
HFACs Framework Four Barrier Levels
PRECONDITIONS FOR UNSAFE ACTS

• Environmental Factors
• Condition of Operators
• Personnel Factors
ENVIRONMENTAL
FACTORS

• Physical Environment
• Technological Environment
CONDITION OF OPERATORS
• Adverse Mental State
• Adverse Physiological State
• Physical/Mental Limitations
PERSONNEL FACTORS

• Crew Resource Management

• Personal Readiness
HFACs Framework Four Barrier Levels
UNSAFE
SUPERVISION
• Inadequate Supervision
• Plan Inappropriate Operation
• Failure to Correct known
Problem
• Supervisory Violation
HFACs Framework Four Barrier Levels
ORGANIZATIONAL INFLUENCES

• Resource Management
• Organizational Climate
• Operational Process
BY USING HFACS

• organizations are able to identify the breakdowns within the entire system
that allowed an accident to occur.
• can also be used proactively by analyzing historical events to identify
reoccurring trends in human performance and system deficiencies.
• an organization can identify where hazards have arisen historically and
implement procedures to prevent these hazards
EFFECTIVE SAFETY REPORTING
MANAGING ERRORS
CREW RESOURCE MANAGEMENT(CRM)
• After a series of accidents in the 1970s which identified human error as the cause of major air
crashed, in 1979 NASA convened a workshop for the aviation industry entitled “Resource
Management on the Flightdech” which began the modern CRM movement in the United States.
As pointed out in in their article, “The Evolution of Crew Resource Management Training in
Commercial Aviation” (Helmreich, Meritt, & Wilhelm, 1999), United Airlines led the way with the
first comprehensive CRM training program in 1981, followed quickly by Delta Airlines and most
U.S. FAR part 121 carriers. The most vivid example of successful CRM concepts being used to good
effect was the landing of United Airlines Flight 232 in Sioux City, Iowa, In 1989, following the total
loss of all hydraulics systems aboard the DC-10. The captain of the DC-10 effectively used all
available resources including crew, ATC, and ground assets to achieve the miraculous landing of
United 232, saving 185 lives in the process.
• The CRM movement picked up speed in 1991 when the FAA issued an advisory circular to initiate
the Advanced Qualification Program(AQP), a voluntary program to allow airlines to develop
innovative human factors training to meet the needs of each specific airline organization. From
this, airline began to institutionalize CRM concepts by adding specific procedures in their
checklists, including Line Oriented Flight Training (LOFT) for all flight crews, which considered the
cultural perspectives of different regions of the world.
 Modern CRM theory accepts that human errors are indeed inevitable; therefore, CRM
practices should serve as a set of counter-measures with three distinct lines of defence:

• Finally - Mitigating the consequences of those

human errors which occur and are not trapped

• Second - Trapping incipient errors before they

are committed

• First - Error avoidance if possible

LINE OPERATION SAFETY AUDIT (LOSA)

• Closely linked to CRM, LOSA was endorsed by ICAO in 1999 as a

primary tool to develop countermeasures to human error. The LOSA
process uses an airline observer (usually a pilot) to collect data about
flight crew behaviour by riding on the “jump seat” during routine
flights and observing crew strategy for managing treats, errors and
undesirable aircraft states. These observations are conducted under a
guarantee of confidentiality with no organizational action taken
against the crew for its performance during the flight. Today, LOSA is
endorsed by FAA (Advisory circular 120-90) and ICAO (LOSA manual
9803) as an industry best practice to defend against human error in
the cockpit.
THREAT AND ERROR MANAGEMENT (TEM)
• A natural follow-on to LOSA is the concept of Threat and
Error management which focuses on the normal working
environment (Merritt & Klinect, 2006). First we will define
the terms threat, error, and undesired aircraft state; then
discuss some control strategies to manage those situations
which unfortunately become “undesirable aircraft states.”

Threats - Pilots must manage threats that come at them in the

normal operating environment. Threats are defined as
events or errors that:
• Occur outside the influence of the flight crew(i.E., not caused
by the crew);
• Increase the operational complexity of a flight; and
• Require crew attention and management if safety margins
are to be maintained.
Errors - Human error comes from the crew and may be innocent or intentional.
Errors are defined as flight crew actions or inactions that:
• Lead to a deviation from crew organizational intentions or expectations;
• Reduce safety margins; and
• Increase the probability of adverse operational events on the ground or during
flight.

Undesired Aircraft State - an error not well managed which may lead to an event
which compromises safety. An undesired aircraft state(UAS) is defined as a
position, speed, altitude, or configuration of an aircraft that:
• Results from flight crew error, actions, or inaction; and
• Clearly reduces safety margins.
CONTROL STRATEGIES TO MANAGE
THREATS AND ERRORS
• Effective control strategies may be engineering-based tools associated with
the aircraft such as cockpit automation, instrument displays, or warning
devices.

Types of CONTROL STRATEGIES

• Hard - defense mechanism installed to the aircraft

• Soft – more administrative in nature

GROUND PROXIMITY WARNING SYSTEM (GPWS)

• prevent controlled
flight into terrain with
visual and audio
warnings to “pull up.”
YOKE “STICK SHAKER” AND WARNING HORN

• Warns the pilots of

low air speed and
possible stall
situation.
CHECKLIST, RULES AND REGULATIONS, STANDARD
OPERATING PROCEDURES

• Using CRM, LOSA and TEM training

concepts, modern airline crews are now
taught the newest techniques and
communication skills to either avoid, trap or
mitigate the consequences of errors.
AIRBUS AND BOEING DESIGN STRATEGIES

• In the past 3 decades, with the rapid growth in microprocessor technology,

there has been a temptation on the part of some designer to build very
complex systems based on rationale that the systems could operate
automatically.

• In the event of the failure of automation it falls to the human to operate the
system.
• The Airbus general approach has been to remove the pilot from the loop and
turn certain functions over to sophisticated automation. Compensation is
automatic---- the system do not ask the crew’s approval.

• Boeing’s approach is to never bypass the crew: Sophisticated devices inform

the crew of a need and, in some cases, a step-by-step procedure: but in the
end, it is the crew who must authorize and conduct the procedure.
COCKPIT STANDARDIZATION

• BETWEEN FLEET STANDARDIZATION

• WITHIN FLEET STANDARDIZATION

BETWEEN FLEET STANDARDIZATION
This standardization of hardware is considered desirable to reduce training and maintenance costs as well
as to prevent human error that may occur as a result of the pilots moving from one aircraft to another.

• Certain cockpit hardware could be common to most or all the models operated by a carrier;
(radios, flight directors, certain displays , area navigation equipment, and weather radar)

• Some are devices added after the original manufacturer (TCAS, ACARS)
TRAFFIC COLLISION
AVOIDANCE SYSTEM
(TCAS)

AIRCRAFT
COMMUNICATIONS
ADDRESSING AND
REPORTING SYSTEM
(ACARS)
WITHIN FLEET STANDARDIZATION

This standardization is far more critical. It

deals with various greatly with respect to
cockpit configuration (different models of
flight directors, controls in different
locations, various directions of movement
of switches, and various operating
limitations). Like the configuration of DC-9,
B-727 and B-737
COMMUNICATION
FORMS OF COMMUNICATION

• WRITTEN COMMUNICATION

• VERBAL COMMUNICATION

• DIGITAL COMMUNICATION
COMMUNICATION ISSUES

• More than 70% of the reports to the Aviation Safety Reporting System involve
some type of oral communication problem related to the operation of an
aircraft.
• Technologies, such as airport traffic lights or data link, have been available for
years to circumvent some of the problems inherent sin ATC stemming from
verbal information transfer.
 TENERIFE AIRPORT DISASTER
583 FATALITIES DEADLIEST ACCIDENT IN AVIATION HISTORY

The ground collision between 2 Boeing 747 in Tenerife in 1977,

resulting I the greatest loss of life in an aviation accident,
occurred because of a communication error.

CAUSE:
The sudden fog greatly limited visibility. The control tower and the
crews of both planes were unable to see one another.
• Usually includes all facets of information transfer
• It is an essential part of Teamwork, and language clarity is central to the
communication process.
• “Party Line” effect – (hearing the communication to other pilots)

 Clear
 Simple
 Concise
 Intelligence compliance with direction and instructions requires knowledge of why
these are necessary in the first place.

• Transcockpit Authority Gradient (TAG)

• An expression of the relative strength and forcefulness of the
personalities invovlved.
• BE READY FOR THE LONG QUIZ NEXT
MEETING