Chirps
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Chirps
Forgive me if this is in the wrong place and feel free to move as deemed however I do wish to get as wide audience as possible so I guess R&N is the best place.
I am in the process of setting up a system to work in a similar way to CHIRP but centred on Threat and Error Management.
I am interested to hear what you line pilots (and management) would like to get from such a scheme. I have my own ideas (as a pilot), but this is not about me, it is about everyone who will use this (and it will be open to everyone).
Hope to get some good feedback!
RIX
I am in the process of setting up a system to work in a similar way to CHIRP but centred on Threat and Error Management.
I am interested to hear what you line pilots (and management) would like to get from such a scheme. I have my own ideas (as a pilot), but this is not about me, it is about everyone who will use this (and it will be open to everyone).
Hope to get some good feedback!
RIX
niknak
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I am sure that your intentions are honourable, but equally I am not sure what you are trying to achieve here.
CHIRP works very well and the people who run it will try and tackle any problem thrown at them. They all have extensive experience in aviation and usually achieve equitable solutions.
The only thing they haven't been able to sort out in the UK is the beligerence of the UK Airport Security authorities and their refusal to recognise common sense with regard to Aircrew, Engineers and other essential Airport Personnel going airside. Even that is no fault of CHIRP.
CHIRP is a well oiled machine which started from humble beginnings and now represents most sectors of the industry.
I am sure they'd welcome your opinion and whatever you have to offer, but I am equally sure that there's no reason to have a seperate organisation.
CHIRP works very well and the people who run it will try and tackle any problem thrown at them. They all have extensive experience in aviation and usually achieve equitable solutions.
The only thing they haven't been able to sort out in the UK is the beligerence of the UK Airport Security authorities and their refusal to recognise common sense with regard to Aircrew, Engineers and other essential Airport Personnel going airside. Even that is no fault of CHIRP.
CHIRP is a well oiled machine which started from humble beginnings and now represents most sectors of the industry.
I am sure they'd welcome your opinion and whatever you have to offer, but I am equally sure that there's no reason to have a seperate organisation.
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).
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).
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I was not clear in my original post because I wished to elicit ideas from as many people in as many locations as possible although now it seems it would be prudent to include the original information I left out.
This will be a project run in Latvia (a place currently lacking a CHIRP style system), but open to pilot reports from anywhere. It is certainly not an attempt to oust the UK CHIRP programme which is something of great value to which I have submitted reports myself on a number of occasions.
My current thinking is that this will be a mix of LOSA style obervational and pilot submitted reports (I am in a postition of currently setting up the LOSA style component here in LV). The idea behind the pilot submitted reports is that we are all continually facing the same threats and making the same errors. It is unlikely that you will be the first person to encounter any specific problem. By this means it would be possible to relay information about things that turned out to be a non-event but had the propensity to escalate into something greater. This is something that seems to be lacking (here and elsewhere).
My ultimate goal is to create something that can be used by crews everywhere any time and will be of value to all (including the GA pilot for whom airmanship is the closest definition he would otherwise get to TEM).
RIX
Most ‘HF’ accidents involve situational and behavioural components. First, the situational aspects can be likened to a systems approach to error (accidents), where the problems may be generic and up-stream of the operation, and second, the behavioural aspects more related to TEM and the complexities of human cognition.
Thus useful output from a TEM CHIRP should include both of these aspects; noting that the threats and opportunities for error (the situation) may be easier to obtain and, if solutions are implemented, more effective. (James Reason – “its difficult to change the human condition (error prone), but you can change the places where humans work.”
I wish you well with your worthy goal, … but when achieved you still have to get the pilots to read the information!
For inf, please see (and read) the three papers on Error Management Training.
Thus useful output from a TEM CHIRP should include both of these aspects; noting that the threats and opportunities for error (the situation) may be easier to obtain and, if solutions are implemented, more effective. (James Reason – “its difficult to change the human condition (error prone), but you can change the places where humans work.”
I wish you well with your worthy goal, … but when achieved you still have to get the pilots to read the information!
For inf, please see (and read) the three papers on Error Management Training.
