AE4001 Human Factors in Aviation Safety by mrbenugwe

VIEWS: 27 PAGES: 17

									                 AE4001 Environmental Aspects in Aviation



                                  Human Factors i
                                  H       F t     in
                                   Aviation Safety

                                              Dr. Ir.     M.
                                               Dr Ir HISAR M PASARIBU

        KK DESAIN, OPERASI DAN PERAWATAN PESAWAT TERBANG
               FAKULTAS TEKNIK MESIN DAN DIRGANTARA
                    INSTITUT TEKNOLOGI BANDUNG

AE4001 Environmental Aspects in Aviation                                Hisar M. Pasaribu/ITB




                                               Flight Safety is . . .


                                                  State of Mind

                                                that make people

                                           THINK, ACT and BEHAVE

                                               in such a way that

                              the FLIGHT could be done SAFELY



AE4001 Environmental Aspects in Aviation                                   Hisar M. Pasaribu / ITB




                                                                                                     1
                                 The History of Safety Measures


                                TECHNICAL
                                 FACTORS



                                            HUMAN FACTORS




                                                            ORGANIZATIONAL
                                                               FACTORS




AE4001 Environmental Aspects in Aviation                                     Hisar M. Pasaribu/ITB




                      Human Factors in Aviation Safety

          In this lecture, you will learn about:

                   An Overview of Human Factors

                   Human error

                   Management of human error




AE4001 Environmental Aspects in Aviation                                     Hisar M. Pasaribu/ITB




                                                                                                     2
            An Overview of Human Factors




AE4001 Environmental Aspects in Aviation                                  Hisar M. Pasaribu/ITB




     Human Element in Accidents and Incidents


                      UK Health and Safety Executive
                                     f    k l       id t in
                               80 % of workplace accidents i UK


                      International Civil Aviation Organization
                               75% of aviation accidents


                      UK Department of Transports
                             90 % of shipping collisions and groundings


AE4001 Environmental Aspects in Aviation                                  Hisar M. Pasaribu/ITB




                                                                                                  3
                                     What is Human Factors?
        Human factors is the multi-disciplinary science that applies
         knowledge about the capabilities and limitations of human
         performance to all aspects of the design, operation, and
         maintenance of products and systems.

        It considers the effects of physical, psychological, and
         environmental factors on human performance in different
         task environments, including the role of human operators in
                  system.
         complex system

        It attempts to optimize the interaction between people,
         machines, methods, and procedures that interface with one
         another within an environment in a defined system to
         achieve a set of system goals.
AE4001 Environmental Aspects in Aviation                                                Hisar M. Pasaribu/ITB




        Human Factors and Human Performance
    A key aspect of the definition of Human Factors is the phrase
     ‘capabilities and limitations of human performance.”
                                                           Physiology
                                           P h l
                                           Psychology                     Anthropometry



                                                            HUMAN
                           Engineering                                         Biomechanics
                                                           FACTORS


                                                                         Biology
                                                        Medicine
                                           What is required of the      What the human being
          MINIMIZE                          human in a system            is capable of doing
AE4001 Environmental Aspects in Aviation                                                Hisar M. Pasaribu/ITB




                                                                                                                4
        Human Factors and Human Performance
    Human performance is a measure of human activity that expresses
     how well a human has carried out an assigned, well-defined task
     or a portion of a task.

    Human performance = f ( speed, accuracy )

    If a task is not performed “accurately” in accordance with its
     requirements, an error has occurred.

    Accidents rarely involve a deliberate disregard of procedures, BUT
     are generally caused by situations in which a person’s capabilities
                                                   person s
     are inadequate OR are overwhelmed in an adverse situation.

    Therefore, considerations must be given NOT ONLY TO the human
     error (failure to perform as required) BUT ALSO TO why the error
     occurred.
AE4001 Environmental Aspects in Aviation                                                     Hisar M. Pasaribu/ITB




                                           Human Performance
                                                                                 Mental and emotional
           General health, mental                     Mental and emotional
                                                                                 states due to social
            and medical conditions                     states                     events
                Human conditions
                                                      Mental capacity to        Environmental stress
             brought on by lifestyle                   process information
                                                       p                         Interaction with
                   Physical stress
                                                      Personality                coworkers: peer
                          Fatigue                                                pressure and ego
                                                       Psychological
                                     Physiological        factors             Psychosocial
                                       factors                                   factors

                     Physical
                       y                                 Human
                     factors                           Performance

                                           Environmental                 Hardware
                                              factors       Task          factors
                                                           factors
AE4001 Environmental Aspects in Aviation                                                     Hisar M. Pasaribu/ITB




                                                                                                                     5
                                           Human Performance
    Some human personality traits that contribute to the psychological
     factors:
                                                    Memory
                                 Risk taking                           Attitude
                                                                       A i d



                    Perceptions                                            Motivation



               Self discipline                 PSYCHOLOGICAL FACTORS
                                                                         Attention


                            Judgment and                           Complacency
                           decision making
AE4001 Environmental Aspects in Aviation                                             Hisar M. Pasaribu/ITB




                                             SHELL Model


                       Software
                                                       H
                                                     S L E
                       Hardware
                       Environment
                       Liveware

                                                       L
        Liveware (the human) is at the center of the model.

        The match or mismatch of the elements of the model is just as
         important as the characteristics of the elements themselves.

        A mismatch between elements can be a source of human error.

AE4001 Environmental Aspects in Aviation                                             Hisar M. Pasaribu/ITB




                                                                                                             6
                                           SHELL Model

                                                 H
                                           Workstation, seats,
                                           Workstation seats
                                            displays, controls



              S                                   L                     E
                                                        Temperature,
                               Procedures,
                                                      noise, vibration,
                                manuals,
                                                         air quality,
                                checklists
                                                           weather
                                        y      g
                                      Physiological condition,,
                                         knowledge/skills
                            Personalities, relationships, communication styles



AE4001 Environmental Aspects in Aviation
                                                  L                          Hisar M. Pasaribu/ITB




AE4001 Environmental Aspects in Aviation




                                                                                                     7
                                           Human Error




AE4001 Environmental Aspects in Aviation                                   Hisar M. Pasaribu/ITB




                                            Human Error
        Human Error can be defined as ‘the failure of planned
         actions to achieved a desired goal.’

        Human Error is an event that occurs whenever a task or a
         task element is not performed in accordance with its
         specifications.

        An error occurs when a task element is:
                      Not performed when required – the error of omission
                      Performed when not required – the error of commission
                      Performed incorrectly – the error of substitution
                      Performed out of sequence
                      Performed late
AE4001 Environmental Aspects in Aviation                                   Hisar M. Pasaribu/ITB




                                                                                                   8
                       Some Myths About Human Error


               Myth:
                                  randomly.
               Human error occurs randomly




               Fact:
               Human error is not random.
               It is systematically connected to features of operator’s
               tools, tasks, and operating environment.

AE4001 Environmental Aspects in Aviation                             Hisar M. Pasaribu/ITB




                       Some Myths About Human Error


               Myth:
               A highly experienced and motivated operator could not
               have made an error during a familiar task.



               Fact:
               The best people can make the worst mistakes.




AE4001 Environmental Aspects in Aviation                             Hisar M. Pasaribu/ITB




                                                                                             9
                       Some Myths About Human Error


               Myth:
                                                 easily,
               If an operator can perform a task easily they will never
               make an error doing the task.



               Fact:
               Operators will periodically make errors as a consequence
               of variations in task, environment, and individual factors.



AE4001 Environmental Aspects in Aviation                             Hisar M. Pasaribu/ITB




                       Some Myths About Human Error


               Myth:
               The types of human error that lead to serious accidents
               are different to the types of human error that we see in
               everyday life.


                Fact:
               The types of human error can be the same. Whether the
               consequences are minor or disastrous depends on the
               situation.


AE4001 Environmental Aspects in Aviation                             Hisar M. Pasaribu/ITB




                                                                                             10
                         Human Error in Aviation Safety

    Human errors are normally system-related.

    Safety attention at present is heavily focused on trying to
     understand :

                  the human decision-making process, and

                  how humans react to operational situations and interact
                   with the new technology in aircraft and ground systems.

    Mismanagement by the flight crew is the dominant causal
     factor, since the pilots are the last link in the chain to
     identify and correct errors that result in accidents and
     incidents.
AE4001 Environmental Aspects in Aviation                             Hisar M. Pasaribu/ITB




                         Human Error in Aviation Safety

    Determining the precise reason for human errors is a
     daunting task.

    It requires an understanding of human behavior factors in the
     operation of a system.

    While technical decisions for aircraft design, production and
     operation are based on “HARD” sciences, data on human
     performance and reliability are regarded as “SOFT” and
     p                          y       g
     receives little attention.

    Human capabilities are not readily based on consistent and
     precise measurements.

AE4001 Environmental Aspects in Aviation                             Hisar M. Pasaribu/ITB




                                                                                             11
                         Human Error in Aviation Safety

    Essentially, three reasons explain why people make poor
     decisions:
            1. Incomplete information                                  These are not mutually
                                                                        exclusive categories,
            2. Inaccurate information                                  nor are they limited to
            3. Poor information processing                              inexperience pilots.

                           The crews consistently used a
                            process that would assist in
                              better decision making
                                                                                      There would be
         IF                                   WHILE                    THEN            fewer errors
                               Simultaneously providing
                                  a constant level of
                                monitoring and backup
AE4001 Environmental Aspects in Aviation                                                       Hisar M. Pasaribu/ITB




               Typical Human Error in Maintenance


                                              Memory failure                                18%

          Non-compliance with procedure                                               15%

                                           Technical mistakes               10%

                                           False assumptions               8%

                                           Perceptual failures        6%
                                                                 0%   5%        10%      15%        20%




AE4001 Environmental Aspects in Aviation                                                       Hisar M. Pasaribu/ITB




                                                                                                                       12
                               Increasing The Risk of Error
      0                                     5                      10                       15    Risk of Error


          LACK OF FAMILIARITY WITH THE TASK                                                       x 17


          TIME SHORTAGE                                            x 11


          POOR HUMAN‐SYTEM INTERFACE x 8


          POOR FEEDBACK 
          FROM SYSTEM
          FROM SYSTEM
                                           x4

          INEXPERIENCE 
          (NOT LACK OF           x3
          TRAINING)

          POOR 
          INSTRUCTIONS           x3
          OR PROCEDURES
AE4001 Environmental Aspects in Aviation                                                                 Hisar M. Pasaribu/ITB




                           Error-Producing Conditions in
                                    Maintenance

                     Time Pressure                                                                  23.5%
                            Equipment                                           14.4%
                                                                                14 4%
                                  Training                               12.3%
                                    Fatigue                              12.2%
                       Coordination                                      12.2%
                           Procedures                                   11.4%
                           Supervision                             10.4%
                                                                   10 4%
                        Environment                       5.4%
                    Previous Error                      4.5%

                                                0.0%        5.0%        10.0%       15.0%        20.0%        25.0%
                                                       Percent of Errors With Contributing Factors
AE4001 Environmental Aspects in Aviation                                                                 Hisar M. Pasaribu/ITB




                                                                                                                                 13
               Management of Human Error




AE4001 Environmental Aspects in Aviation                    Hisar M. Pasaribu/ITB




                     Human Error Should Be Managed

        Human Error is a natural part of life.

                Error,        undesirable,
        Human Error although undesirable is nevertheless both
         frequent and widespread.

        Management of human error can only be possible if errors
         are identified and recognized.




AE4001 Environmental Aspects in Aviation                    Hisar M. Pasaribu/ITB




                                                                                    14
                                           Learning From Errors


        If errors are not reported, possibly because staff think
         that they will be punished, then the organization will
         lose a valuable source of safety information.



        Therefore, we need to foster a Just Culture in which
         people
         p p are encouraged, even rewarded, for reporting
                           g ,                 ,       p    g
         unsafe acts.




AE4001 Environmental Aspects in Aviation                                         Hisar M. Pasaribu/ITB




                                           Person vs System Error


        The Person Approach

                                                               individuals.
                        Focuses on the errors and violations of individuals
                       Remedial efforts directed at people at the ‘sharp
                        end’.

        The System Approach
                       Traces the casual factors back into the system as a
                        whole.
                       Remedial efforts            directed   at   situations   and
                        organizations.

AE4001 Environmental Aspects in Aviation                                         Hisar M. Pasaribu/ITB




                                                                                                         15
                                                                      Error Responses


                  WORST                                                  Blame & fire

                                           INC
                                             CREASING EFFECT              Blame & penalize
                                                                         Bl          li

                                                                         Blame & train

                                                                         Emphasize safety – be careful
                                                           TIVENESS




                                                                         Emphasize procedure

                                                                         Rewrite procedures

                       BEST                                              Identify system weakness
AE4001 Environmental Aspects in Aviation                                                                  Hisar M. Pasaribu/ITB




                            Management of Human Error

                                      We can’t change human nature,
                                     but we can change the conditions
                                         d     hi h     l      t
                                       under which people operate.

                                                                          FOCUS ON


                    Error Reduction:                                                Error Containment:
                   what systemic factors                                             Detection and recovery
                     provokes errors.                                              (greater system tolerance)


AE4001 Environmental Aspects in Aviation                                                                  Hisar M. Pasaribu/ITB




                                                                                                                                  16
                     Human Error Reduction Program




AE4001 Environmental Aspects in Aviation                     Hisar M. Pasaribu/ITB




                                     Human Error - Summary




       Human error cannot be entirely eliminated.



       We need to understand WHY errors happen.



       Many errors reflect organizational problems.



AE4001 Environmental Aspects in Aviation                     Hisar M. Pasaribu/ITB




                                                                                     17

								
To top