Latest from James Reason
Joined: Aug 2007
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From: Hucking Fell
TC
perhaps we need to consider what is the model for success (of anything), before we consider a model for failure.
Would a model for success have a series of elements, all interacting in a linear sort of way, that lead to a successful conclusion ?
Would a failure model be the same, but with one component that is changed/modified for whatever reason, in whatever way,which then gives a different, less than expectation result.
I'd keep a wide open mind on this, and try not to be to aviation specific. Good question for us all to ponder. Worth starting a seperate thread on this ?
BS
perhaps we need to consider what is the model for success (of anything), before we consider a model for failure.
Would a model for success have a series of elements, all interacting in a linear sort of way, that lead to a successful conclusion ?
Would a failure model be the same, but with one component that is changed/modified for whatever reason, in whatever way,which then gives a different, less than expectation result.
I'd keep a wide open mind on this, and try not to be to aviation specific. Good question for us all to ponder. Worth starting a seperate thread on this ?
BS
Joined: May 2008
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From: Kettering
Model of Success
There does seem to be a desire to talk more about success rather than harp on about failure these days. I suppose the problem is that after an adverse event there is a need (desire) to make sense of why things went wrong and so we look at 'failure'.
A model of success, on the other hand, would need to identify opportunities for failure and then develop preventative measures. Hollnagels' barrier approach.
If we accept that everyone is trying to do a good job, then what we need to examine is the ways in which normal operations become exposed to hazards.
A model of success, on the other hand, would need to identify opportunities for failure and then develop preventative measures. Hollnagels' barrier approach.
If we accept that everyone is trying to do a good job, then what we need to examine is the ways in which normal operations become exposed to hazards.
Joined: Aug 2007
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From: Hucking Fell
I guess there can be a million reasons why a "something" might be successful, but it only takes one (sometimes completely unrelated) event to have a very significant adverse effect.
Agree with the human desire to order/model/make understanding of, adverse events, as that is probably the easier thing to do, and it will be very event specific.
Accidents still happen on a regular basis, and sometimes are almost identical in nature. They will also happen on opposite sides of the world, and be entirely unrelated. Doesn't stop them happening though.
There is no doubt the more complex a process, and the more technology that it involves, the likelihood of something going wrong will increase.
You don't see much in the papers about the Monks in the local monastry having a poor accident rate with regard to their ale making activities !
(P'raps we have something to learn from those guys)
I Don't have an answer to the success/failure model - perhaps there isn't one ?
BS
Agree with the human desire to order/model/make understanding of, adverse events, as that is probably the easier thing to do, and it will be very event specific.
Accidents still happen on a regular basis, and sometimes are almost identical in nature. They will also happen on opposite sides of the world, and be entirely unrelated. Doesn't stop them happening though.
There is no doubt the more complex a process, and the more technology that it involves, the likelihood of something going wrong will increase.
You don't see much in the papers about the Monks in the local monastry having a poor accident rate with regard to their ale making activities !
(P'raps we have something to learn from those guys)
I Don't have an answer to the success/failure model - perhaps there isn't one ?
BS
Fleet Manager
Joined: Apr 2001
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From: various places .....
So are you saying that Pilot/Maintenance/Human Error is a metaphor for NEGLIGENCE?
The legal folk probably would go down the black and white negligence path. However, Industry folk are more interested in the shades of grey. Current thinking is tending along the path of
(a) we have come a long way in tidying up the systemic problems
(b) the individual and his/her individual errors are becoming a significant part of the whole and we now need to skew our attention back, somewhat, toward the individual. Doesn't matter what discipline the individual is involved with .. pilots, maintainers, techo folk etc.
The legal folk probably would go down the black and white negligence path. However, Industry folk are more interested in the shades of grey. Current thinking is tending along the path of
(a) we have come a long way in tidying up the systemic problems
(b) the individual and his/her individual errors are becoming a significant part of the whole and we now need to skew our attention back, somewhat, toward the individual. Doesn't matter what discipline the individual is involved with .. pilots, maintainers, techo folk etc.
Joined: May 2008
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From: Kettering
Negligence and Human Error
Not sure how WL's comment is addressed to but, first, I thought it was now accepted that almost all adverse events are solely caused by human error. I can think of some aircraft destroyed by debris from buildings trashed by hurricanes (Homestead AFB a few years back for example) but the rest is down to us.
However, we need to be careful to distinguish between accidents that arise from operations exceeding a threshold of controllability and those arising from acts of negligence.
When I was talking about a model of success earlier I had in mind the sort of training needed to make pilots more sensitive to the cues that indicated that they were close to being in a state of 'uncontrol'. Elsewhere on this site there is a video of the ALPA safety conference closing address. The speaker is actually making this point. Current training and checking regimes have been trimmed to the extent that some pilots are unaware of the performance margins available to them ... and so they screw up. That's error but its not negligence.
However, we need to be careful to distinguish between accidents that arise from operations exceeding a threshold of controllability and those arising from acts of negligence.
When I was talking about a model of success earlier I had in mind the sort of training needed to make pilots more sensitive to the cues that indicated that they were close to being in a state of 'uncontrol'. Elsewhere on this site there is a video of the ALPA safety conference closing address. The speaker is actually making this point. Current training and checking regimes have been trimmed to the extent that some pilots are unaware of the performance margins available to them ... and so they screw up. That's error but its not negligence.
There are no limits
Joined: May 2002
Posts: 506
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From: Shrewsbury, England.
My comment is aimed at the forum in general.
What is an error? I believe it to be 'an undesired state'. How do we arrive at this.
If a person makes an error, why do they make it
Lack of knowledge
Lack of understanding
Lack of ability
Lack of process
For each of these examples (non-exhaustive) there is some degree of negligence on the part of the person or the system.
I hypothesise that system error counts for around 80% of all undesired states. These are the errors that need to be managed first because they are the easy ones to correct.
Changing human behaviour will take many generations although I personally do not support the position that rationalised training programmes or increasing automation in aviation will make a positive contribution to reducing errors.
What is an error? I believe it to be 'an undesired state'. How do we arrive at this.
If a person makes an error, why do they make it
Lack of knowledge
Lack of understanding
Lack of ability
Lack of process
For each of these examples (non-exhaustive) there is some degree of negligence on the part of the person or the system.
I hypothesise that system error counts for around 80% of all undesired states. These are the errors that need to be managed first because they are the easy ones to correct.
Changing human behaviour will take many generations although I personally do not support the position that rationalised training programmes or increasing automation in aviation will make a positive contribution to reducing errors.
Joined: Aug 2007
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From: Hucking Fell
Hi WL
Your post leads to something that I have been looking into this year and that is "Threat and Error Management" - TEM.
"TEM is a conceptual framework that assists in understanding from an operational perspective, the inter relationship between safety and human performance, in dynamic and challenging operational contexts"
The components of a TEM model are;
Threats (usually of the environment)
Errors (usually of people, or latent errors of the system)
Undesired aircraft state (Expensive clanging noises)
Countermeasures. (Happiness)
A threat and/or error can lead to an undesired aircraft state. An examination of threats and errors will lead to "Countermeasures", which are either "Hard" (SOPs, briefings training etc) or "Individual and Team" which covers Planning, execution, and review.
The model can be used in several ways;
1.Debrief of a specific incident, or
2. Reviewing a cluster or trend of incidents,or
3. Review of your safety database
I have used it in all three instances, and this summer ran a series of workshops to tackle some problems we were having in ground operations.
We found out so much that we just did not know about, basically because people don't have the time to make safety reports (in the ground ops/ramp environment)
We were able to come up with a range of contermeasures, suggested by the very people who we initially thought were part of the problem, they actually became part of the solution - how neat is that.
This stuff works in a real world environment.
Have a Google of "threat and Error management" and then put in Capt Dan Maurino.
He has written an excellent paper, which led me to other research, which led to the construction of my own model, which we have used in the company,which gave us answers (countermeasures), and as I look at the ground incident stats, they haven't quite collapsed on last year, but a big positive move in the right direction.
Don't get hung up philosophising about errors and blame, just go and "do the do"
BS
Your post leads to something that I have been looking into this year and that is "Threat and Error Management" - TEM.
"TEM is a conceptual framework that assists in understanding from an operational perspective, the inter relationship between safety and human performance, in dynamic and challenging operational contexts"
The components of a TEM model are;
Threats (usually of the environment)
Errors (usually of people, or latent errors of the system)
Undesired aircraft state (Expensive clanging noises)
Countermeasures. (Happiness)
A threat and/or error can lead to an undesired aircraft state. An examination of threats and errors will lead to "Countermeasures", which are either "Hard" (SOPs, briefings training etc) or "Individual and Team" which covers Planning, execution, and review.
The model can be used in several ways;
1.Debrief of a specific incident, or
2. Reviewing a cluster or trend of incidents,or
3. Review of your safety database
I have used it in all three instances, and this summer ran a series of workshops to tackle some problems we were having in ground operations.
We found out so much that we just did not know about, basically because people don't have the time to make safety reports (in the ground ops/ramp environment)
We were able to come up with a range of contermeasures, suggested by the very people who we initially thought were part of the problem, they actually became part of the solution - how neat is that.
This stuff works in a real world environment.
Have a Google of "threat and Error management" and then put in Capt Dan Maurino.
He has written an excellent paper, which led me to other research, which led to the construction of my own model, which we have used in the company,which gave us answers (countermeasures), and as I look at the ground incident stats, they haven't quite collapsed on last year, but a big positive move in the right direction.
Don't get hung up philosophising about errors and blame, just go and "do the do"
BS
Joined: Jun 2008
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From: Behind a dusty desk, and in some really hot, dusty, wet and cold places subject to who is paying the bill. But mostly Gods own land.
"So are you saying that Pilot/Maintenance/Human Error is a metaphor for NEGLIGENCE?
Can anyone recall an aircraft accident solely caused by human error?"
Human error pilot:
Emirates EK407 - wrong data entered into computer
The Airbus at the Paris airshow - pilot switched off the safety computers
Human Error engineer:
BA 5390 - engineer fitted wring screws to window, 2nd engineer did the same
JAL 123 - engineers incorrectly repaired the pressure bulk head
Human error pilot & engineer:
Olympic - classic train of errors, engineers left valve open, pilots ignored the warning.
Tuniair - Sicily 2005 - pilot prayed in stead of doing emergency drills, engineers didn't fit a bit correctly
And as for "Human Error is a metaphor for NEGLIGENCE" no it's not and with an attitude like that I feel sorry for anyone who works with you or for you. An error, (one of many) is just one part of a chain of events leading to an event. Negligence is acting in a manner that is likely, or you know could lead to an event in it's own right.
Or you could just wiki negligence and read what it says...
Can anyone recall an aircraft accident solely caused by human error?"
Human error pilot:
Emirates EK407 - wrong data entered into computer
The Airbus at the Paris airshow - pilot switched off the safety computers
Human Error engineer:
BA 5390 - engineer fitted wring screws to window, 2nd engineer did the same
JAL 123 - engineers incorrectly repaired the pressure bulk head
Human error pilot & engineer:
Olympic - classic train of errors, engineers left valve open, pilots ignored the warning.
Tuniair - Sicily 2005 - pilot prayed in stead of doing emergency drills, engineers didn't fit a bit correctly
And as for "Human Error is a metaphor for NEGLIGENCE" no it's not and with an attitude like that I feel sorry for anyone who works with you or for you. An error, (one of many) is just one part of a chain of events leading to an event. Negligence is acting in a manner that is likely, or you know could lead to an event in it's own right.
Or you could just wiki negligence and read what it says...
Thread Starter
Moderator
Joined: Feb 2000
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From: UK
I'm working on a report on a light aircraft accident at the moment - four separate errors I can identify that led up to the accident, all ultimately by human beings (or organisations run by human beings), and the good old Swiss Cheese model covers it very well since I can show how any of them, handled differently, could have prevented the accident (well, three out of the four anyhow).
The only thing that doesn't quite accord in this particular case with the standard Swiss Cheese diagram is that it didn't finish with an obvious operator error - simply that too many opportunities had been missed to trap a structural fault.
MG:
Thank you, that just made my (agnostic!) day.
G
The only thing that doesn't quite accord in this particular case with the standard Swiss Cheese diagram is that it didn't finish with an obvious operator error - simply that too many opportunities had been missed to trap a structural fault.
MG:
pilot prayed in stead of doing emergency drills
G
Joined: Feb 2005
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From: Correr es mi destino por no llevar papel
Sorry Gengish, but our Miles Gustaph is pretty unreliable here. Good text on Tuninter ditching was written by Mark Lacagnina and can be found in July edition of Aviation Safety World. It nicely shows how train of small undetected typing errors lead to wrong type of FQI installed and lax attitude towards expected vs. actual fuel uplift sealed the flight's fate. F/O's prayer is not mentioned but yes, he said a brief prayer but it didn't affect the outcome much. I guess that it was just well mannered man's reaction to extreme stress. If I found myself in the same situation, CVR transcript would be full of #s.
Where I fly, procedure is for each pilot to calculate the takeoff speeds independently and they get compared before getting them set. Chances of both pilots making exactly the same mistake and shorting the check circuit are pretty small, especially as more often than not speeds do match. If this or similar procedure was in place at EK but pilots didn't follow it, then it is pilot error. If not, it still is pilot error but enabled by organizational error. I need help on resolving this, as I didn't follow the EK thread closely.
It wasn't Paris show, it was Habsheim! It was the case of poorly planned flypast with even worse execution and PIC of the flight did prepare the rope to hang himself. Switching the alpha floor off was nowhere near the top of causal factors. However, three dead people were result of some AF genius authorizing carriage of passengers on airshow flight.
It was Helios and Tuninter!
Human error pilot:
Emirates EK407 - wrong data entered into computer
The Airbus at the Paris airshow - pilot switched off the safety computers
Emirates EK407 - wrong data entered into computer
The Airbus at the Paris airshow - pilot switched off the safety computers
It wasn't Paris show, it was Habsheim! It was the case of poorly planned flypast with even worse execution and PIC of the flight did prepare the rope to hang himself. Switching the alpha floor off was nowhere near the top of causal factors. However, three dead people were result of some AF genius authorizing carriage of passengers on airshow flight.
Olympic (...) Tuniair
