PPRuNe Forums - View Single Post - Chirps
Thread: Chirps
View Single Post
Old 7th Nov 2008, 01:17
  #3 (permalink)  
alf5071h
 
Join Date: Jul 2003
Location: An Island Province
Posts: 1,257
Likes: 0
Received 1 Like on 1 Post
Romeo India Xray I am intrigued, yet puzzled by your interest in setting up a ‘CHIRP’ for TEM.
CHIRP is a confidential reporting system, primarily aimed at human factors, however their results suggest that only a few HF aspects have tenuous relevance to the industry’s safety problems and generally relate to the ‘factors’ around the central ‘Liveware’ in the SHELL model, i.e. the reports rarely look at the individual.

If your plans are to rectify this with greater focus on the individual, by identifying threats, errors, actions (inaction), or mitigation, then this is an excellent idea.
The primary principle of TEM is that humans make errors, from which we learn. We are unlikely to prevent all errors, but by minimizing their occurrence and/or consequences we will improve safety. An open and frank exchange of the threats and errors in daily operation will be valuable, as will be the descriptions of threat and error avoidance, error detection, and recovery activities.

A major problem might be that a large proportion of errors in operation are not detected, or they are not considered as having any significant consequence (cf LOSA data). Perhaps it is these errors which would be of greater value to the industry. However, in order to gain this information, the above suggests that the processes in TEM themselves will have to improve – a good safety objective, and thus something which should be shared.

I hold a skeptical view of reporting systems. First, there is reluctance by individuals to report, particularly where it concerns error (the blame culture / workload). Second it is essential to investigate reports; who will do this for TEM, how will they be able to judge the more esoteric HF aspects such as what a person was thinking, what was the mental model of a situation, what rational (or biases) affected a decision.

Thus, I would fear that a ‘CHIRP’ TEM system might only seek to achieve what LOSA attempts to do, but lacking the external observation (which might mitigate some of the concerns above). I have similar reservations about the value of LOSA.
On balance, I would encourage a system of self-LOSA, where individuals are taught TEM fundamentals stressing the need for self questioning, self analysis, and debriefing.
Well considered debriefing could generate some to the reports that you seek; there could be good aspects (positive), not so good (negative), and the interesting aspects. IMHO the interesting aspects are the important HF issues … but then who is taught to debrief these, and if required, report them …?

What Can You Learn from Accident Reports?


Why System Safety Professionals Should Read Accident Reports.


A Review of Selected Aviation Human Factors Taxonomies. Accident/Incident Reporting Systems, and Data Collection Tools.


Investigation and Reporting of Incidents and Accidents (IRIA 2002).
alf5071h is offline