How to manage Human errors

[alf5071h]

h1tman47 If I knew the answer to your question then I would not be posting to Pprune – sunny climes, big mansion, etc.

However, aviation goes on and human error remains a problem to be contained – threat and error management. The basis of TEM is awareness (identification) of errors or error provoking situations. Then selection and implementation of an appropriate defence or series of defences (to avoid or mitigate the error), finally there should be a feed back mechanism. That’s the theory (and industry is awash with high-level theories), but in practice as your question poses, there is little if any practical material.

I like to use the ‘Kearn’ model of airmanship; discipline, skill & proficiency, knowledge, situation awareness, and judgement. The NZ CAA covers some of these points in their Focus magazine Nov-Dec 2002 onwards.

A more universal approach to TEM is to use SOPs, but these are not foolproof. First the need for an SOP has to be identified (threat or error provoking situation) and second the procedure has to be prepared. Procedures are normally written down, but this does not always have to be the case; culture – commonly held views can be an SOP, so too a picture (worth a thousand words). One of the most important aspects of an SOP is in the preparation; the problem has to be clearly understood, then the assumptions made in the proposed use of the SOP should be stated. The actual SOP can, and should be very simple, the supporting documentation (assumptions) and methods of training (the reasons why) should be extensive and well documented.

A problem with SOPs is that they are not always used, quite often due to human error. Thus, training adding knowledge of situations and systems, how to gain and maintain situation awareness, and how to control human attitudes is required (Airmanship, CRM, etc). For SOPs where the end user has had greater involvement in their preparation then there is more likelihood that the SOP will be understood and used.

See “The benign face of the human factor” by James Reason, Dan Maurino and Bob Helmreich, Flight Safety Australia Jan-Feb 2001, also Nov–Dec 2003 “Only Human” by Patrick Hudson.

There are many other references that scratch the surface of this problem, each with merit and often with bias. I suggest that you review the extensive material in your part of the world first (NZ & OZ), this will eliminate some of the more extreme cultural issues and focus on the problem at a simple level – just what the industry requires.

“You don't have to be an outstanding human being to make a mistake but you have to be a damn good one to rectify it!”