How to manage Human errors
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How to manage Human errors
hello all,
Would anyone be able to tell me how to identify, manage and avoid errors on the flight deck. And also about what the best practice maybe in implementing such a plan. Emphasising of course things like staff interaction, accountability and motivation.
your thoughts are much appriciated.
Cheers!!
Would anyone be able to tell me how to identify, manage and avoid errors on the flight deck. And also about what the best practice maybe in implementing such a plan. Emphasising of course things like staff interaction, accountability and motivation.
your thoughts are much appriciated.
Cheers!!
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!”
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!”
Last edited by alf5071h; 10th Aug 2004 at 12:48.
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h1tman47
Several years ago I read an interesting article in the AFAP magazine. It had been reproduced from an American magazine and was a discussion on what made a good pilot.
As best I can remember, some of the salient points were:
So, while not direclty adressing your questions, being aware and having an ingrained process of review so that you quickly identify "errors", and being open to admiting that one mucked that up, is not too bad a start.
p.s. The AFAP might be able to provide the article.
Several years ago I read an interesting article in the AFAP magazine. It had been reproduced from an American magazine and was a discussion on what made a good pilot.
As best I can remember, some of the salient points were:
- A good pilot will maintain a high level of situational awareness.
- A good pilot will make mistakes but will usually be quick to recognise them.
- A good pilot, recognising and correcting a mistake, will usually ennunciate it to his/her co-pilot (no rank implied).
So, while not direclty adressing your questions, being aware and having an ingrained process of review so that you quickly identify "errors", and being open to admiting that one mucked that up, is not too bad a start.
p.s. The AFAP might be able to provide the article.
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Some key words that might help:
- Preparation
- Teamwork
- Vigilance
- Trust
Ask yourself the "what-if..." question all the time. (What do we do if this or that happens... NOW?)
Be prepared for that missed approach that one flies once (if at all) a year.
Use the "Next-step" philosophy.
Always be polite and smile at the ground crew when you arrive somewhere. That sets the mood for the turn-around of your A/C.
ANCM Aviate, Navigate, Communicate, Manage (review/monitor) in that order.
And then as grandma sez, fly high and fast.
- Preparation
- Teamwork
- Vigilance
- Trust
Ask yourself the "what-if..." question all the time. (What do we do if this or that happens... NOW?)
Be prepared for that missed approach that one flies once (if at all) a year.Use the "Next-step" philosophy.
Always be polite and smile at the ground crew when you arrive somewhere. That sets the mood for the turn-around of your A/C.
ANCM Aviate, Navigate, Communicate, Manage (review/monitor) in that order.
And then as grandma sez, fly high and fast.
Error can be managed at several levels.
Good system design should provide feedback for any action and information resulting from the action must be clearly displayed. Crew members must look for this information and understand it - situation awareness. E.g. an auto flight mode control panel should have annunciation at the point of operation and at the point of use i.e HDG is displayed next to the control knob and on the EFIS.
Well thought-out procedures, whether written or memorised, aid error detection. E.g. during takeoff instead of calling ‘power set’ a better procedure is to state the value of the power i.e. ”Power Set 91.4%” This reinforces the check of the power required and enables the non monitoring pilot to detect any gross error. It also builds experience of what power settings are normal for a range of situations and focuses mental attention on important parameters, thus avoiding a ‘habit’ call without actually checking the value.
Appropriate personal behaviours are essential, particularly in not rushing when taking action. Good knowledge of systems and aircraft performance will enable you to anticipate situations. Training for abnormal operation should provide experience of unusual situations, but remember there will always be a surprise factor and high stress levels; controlling stress also controls any tendency to rush. Think about the process of problem solving, not necessarily about the end solution, but the questions to ask in order to reach a solution. If you ask the right question, the solution is then obvious.
Be part of a team, they are the primary defence against your error.
Remember that everyone in a crew is equal, they all make errors; only the commander has the authority to make big errors.
Good system design should provide feedback for any action and information resulting from the action must be clearly displayed. Crew members must look for this information and understand it - situation awareness. E.g. an auto flight mode control panel should have annunciation at the point of operation and at the point of use i.e HDG is displayed next to the control knob and on the EFIS.
Well thought-out procedures, whether written or memorised, aid error detection. E.g. during takeoff instead of calling ‘power set’ a better procedure is to state the value of the power i.e. ”Power Set 91.4%” This reinforces the check of the power required and enables the non monitoring pilot to detect any gross error. It also builds experience of what power settings are normal for a range of situations and focuses mental attention on important parameters, thus avoiding a ‘habit’ call without actually checking the value.
Appropriate personal behaviours are essential, particularly in not rushing when taking action. Good knowledge of systems and aircraft performance will enable you to anticipate situations. Training for abnormal operation should provide experience of unusual situations, but remember there will always be a surprise factor and high stress levels; controlling stress also controls any tendency to rush. Think about the process of problem solving, not necessarily about the end solution, but the questions to ask in order to reach a solution. If you ask the right question, the solution is then obvious.
Be part of a team, they are the primary defence against your error.
Remember that everyone in a crew is equal, they all make errors; only the commander has the authority to make big errors.
