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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
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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
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