Pilot Error
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I blame democracy
Public expressions like that waste bandwidth. Electrons died in the name of free speech. Shame the same logic was not applied to the the unfortunate Colgan crew.
George is absolutely correct –
George is absolutely correct – Human error occurs at all levels, and rarely alone.”
With this conclusion he might fare better to consider the examples of error in the article - hindsight bias in accident assessment and that of stereotyping pilots – “sublime to ridiculous” without providing supporting evidence.
This is an important subject, but not well served by an article on a web site which appears to promote commercial objectives over safety improvement.
I recommend that George reads Perspectives on Human Error.
I have read and heeded the paper, lest I be accused of error as in Case 1.
With this conclusion he might fare better to consider the examples of error in the article - hindsight bias in accident assessment and that of stereotyping pilots – “sublime to ridiculous” without providing supporting evidence.
This is an important subject, but not well served by an article on a web site which appears to promote commercial objectives over safety improvement.
I recommend that George reads Perspectives on Human Error.
I have read and heeded the paper, lest I be accused of error as in Case 1.
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Do we manage error?
Giben that an error is the public recognition of some upstream cognitive failure, it raises the question of whether the current fad for TEM is actually plausible.
'Preventing' error presumes I can see it coming and do something about it. If I am acting in some more resilient manner (more skilled, more aware) then would the error now still occur?
After I have made an error my future actions do not manage the error, they serve to sustain safe flight and restore things to normal. I'm actually creating a new path to my intended goal, not attempting to patch up past actions.
'Preventing' error presumes I can see it coming and do something about it. If I am acting in some more resilient manner (more skilled, more aware) then would the error now still occur?
After I have made an error my future actions do not manage the error, they serve to sustain safe flight and restore things to normal. I'm actually creating a new path to my intended goal, not attempting to patch up past actions.
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Automation error?
Here's a great book on a study with regards to human factors and advanced aircraft. Similar to what Hatcher refers to in AF447....
Amazon.com: Airline Pilots' Perceptions of Advanced Flight Deck Automation: Aviation Human Factors Analysis (9783838339955): Preven Naidoo: Books
Amazon.com: Airline Pilots' Perceptions of Advanced Flight Deck Automation: Aviation Human Factors Analysis (9783838339955): Preven Naidoo: Books
A web search suggests that the book is based on a limited study and has little ‘error’ content. The author appears to be a First Officer flying the A319.
The study could be based on his Masters dissertation. Here a conclusion indicates that pilots have to take control of their learning environment and use self-study as the basis for understanding the aircraft. This might leave open to error how a student will gain contextual understanding of the manufacturer’s automation philosophy and gain tacit knowledge – the know how of using automation.
Although of interest, the study may be a low-weight contribution on automation in comparison with the references below, which consider some aspects of human error.
Humans and Automation, Use, Misuse, and Abuse.
A Model for Types and Levels of Human Interaction with Automation.
For a good introduction to human error, see Human Error, models and management (J Reason).
Turbo, re TEM – J Reason provides an insight to some of the problems which confront TEM.
Limiting the unsafe act is akin to avoidance of error (the act) or error promoting situations (awareness) which might be strategic activities such as in improved planning, decision making.
Another aspect is the elimination of error promoting situations through the use of good design, procedures, etc.
The more forward thinking aspects include acceptance that humans suffer error and thus it is important to detect and recover from the result, and then learn from the experience.
The study could be based on his Masters dissertation. Here a conclusion indicates that pilots have to take control of their learning environment and use self-study as the basis for understanding the aircraft. This might leave open to error how a student will gain contextual understanding of the manufacturer’s automation philosophy and gain tacit knowledge – the know how of using automation.
Although of interest, the study may be a low-weight contribution on automation in comparison with the references below, which consider some aspects of human error.
Humans and Automation, Use, Misuse, and Abuse.
A Model for Types and Levels of Human Interaction with Automation.
For a good introduction to human error, see Human Error, models and management (J Reason).
Turbo, re TEM – J Reason provides an insight to some of the problems which confront TEM.
Limiting the unsafe act is akin to avoidance of error (the act) or error promoting situations (awareness) which might be strategic activities such as in improved planning, decision making.
Another aspect is the elimination of error promoting situations through the use of good design, procedures, etc.
The more forward thinking aspects include acceptance that humans suffer error and thus it is important to detect and recover from the result, and then learn from the experience.
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alf
"Limiting the unsafe act is akin to avoidance of error (the act) or error promoting situations (awareness) which might be strategic activities such as in improved planning, decision making.
Another aspect is the elimination of error promoting situations through the use of good design, procedures, etc.
The more forward thinking aspects include acceptance that humans suffer error and thus it is important to detect and recover from the result, and then learn from the experience".
Problem is that by making 'error' the object and making the goal 'to avoid error' we miss the point that an error is actually a symptom of flawed action. The failure has already occurred by the time the error is noticed. So, the real goal is to make performance more reliable such that action remains within acceptable bounds. In a similar vein, the idea is not to 'recover' but to continue action towards a goal but now from a different starting point. TEM places 'error' outside of the human: it is something to be avoided, trapped and managed. But in reality, 'error' is an organic part of action and what we really need to do is shape the process of work to accommodate error while remaining within safe bounds.
"Limiting the unsafe act is akin to avoidance of error (the act) or error promoting situations (awareness) which might be strategic activities such as in improved planning, decision making.
Another aspect is the elimination of error promoting situations through the use of good design, procedures, etc.
The more forward thinking aspects include acceptance that humans suffer error and thus it is important to detect and recover from the result, and then learn from the experience".
Problem is that by making 'error' the object and making the goal 'to avoid error' we miss the point that an error is actually a symptom of flawed action. The failure has already occurred by the time the error is noticed. So, the real goal is to make performance more reliable such that action remains within acceptable bounds. In a similar vein, the idea is not to 'recover' but to continue action towards a goal but now from a different starting point. TEM places 'error' outside of the human: it is something to be avoided, trapped and managed. But in reality, 'error' is an organic part of action and what we really need to do is shape the process of work to accommodate error while remaining within safe bounds.
Turbo, I follow your argument which in some ways is similar to the views in – Why "Human Error" Is A Meaningless Concept .
However, in reality, the industry is ‘stuck’ with TEM and thus there is a need to explain what and/or how this activity (TEM) is to be implemented.
The problem is akin to using the DECIDE model for decision making (a good representation of the process), but apparently not at all how humans make decisions. Here, one solution is to generate the knowledge and experience required for situation based (naturalistic) decision making.
Similarly, we have a TEM model which depicts a process, but does little to help manage whatever our notion of threat or error is.
I like your ideas where after an action, if the outcome is not as required (towards the goal), then the assessed situation is used as a new starting point. Is this management or mitigation?
In some ways, this turns the TEM process into an iteration of situation assessment and decision making, which appears to be the basis of most activities.
But if you wish to stretch you mind then back to Woods & Cook in #3 or try PRIME (about page 136).
However, in reality, the industry is ‘stuck’ with TEM and thus there is a need to explain what and/or how this activity (TEM) is to be implemented.
The problem is akin to using the DECIDE model for decision making (a good representation of the process), but apparently not at all how humans make decisions. Here, one solution is to generate the knowledge and experience required for situation based (naturalistic) decision making.
Similarly, we have a TEM model which depicts a process, but does little to help manage whatever our notion of threat or error is.
I like your ideas where after an action, if the outcome is not as required (towards the goal), then the assessed situation is used as a new starting point. Is this management or mitigation?
In some ways, this turns the TEM process into an iteration of situation assessment and decision making, which appears to be the basis of most activities.
But if you wish to stretch you mind then back to Woods & Cook in #3 or try PRIME (about page 136).
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alf,
'human error' is clearly a useful concept but we just need people to understand the difference between cause and effect. We tend to focus on developing taxonomies of effect rather than addressing cause (for example, through better and more effective initial and recurrent training).
TEM is the biggest bit of flip flam foisted on an ignorant industry I have ever seen. First, it isn't a 'process'. Never forget, this all came out a consulting project which then became the meat in a PhD thesis. LOSA - an audit schedule - came first and then TEM came along on the second iteration as a graphical representation of the audit. It shows how the audit points hang together. The problem is that it has been endorsed by ICAO and no one has the wits to challenge a very weak concept.
The real problem with TEM is that it is isn't a model of anything; it is a roadmap of the audit process. For each block on the map, you then need a model to explain how things work at that stage. These components have not been formulated.
You mention DECIDE (and you could substitute DODAR, FOR-DEC etc). These are all reformulations of classic problem solving strategies. If, for example, I want to relocate my head office of select which car to buy next, then the process works. By because we are very sloppy in the use of language in aviation, we confuse dynamic real-world decision-making with problem solving.
I'd agree with you that the task of the pilot (or any actor in the workplace) is to makes sense of the present circumstances and choose a course of action that will meet operational goals safely. Now, to force this process into 2 boxes called 'situation awareness' (although you were careful to use 'assessment') and 'decision making' simply because these are topics listed in the syllabus is to miss the point. Maybe it's time to cast off some of these labels and get CRM back to some position where it is actually useful.
'human error' is clearly a useful concept but we just need people to understand the difference between cause and effect. We tend to focus on developing taxonomies of effect rather than addressing cause (for example, through better and more effective initial and recurrent training).
TEM is the biggest bit of flip flam foisted on an ignorant industry I have ever seen. First, it isn't a 'process'. Never forget, this all came out a consulting project which then became the meat in a PhD thesis. LOSA - an audit schedule - came first and then TEM came along on the second iteration as a graphical representation of the audit. It shows how the audit points hang together. The problem is that it has been endorsed by ICAO and no one has the wits to challenge a very weak concept.
The real problem with TEM is that it is isn't a model of anything; it is a roadmap of the audit process. For each block on the map, you then need a model to explain how things work at that stage. These components have not been formulated.
You mention DECIDE (and you could substitute DODAR, FOR-DEC etc). These are all reformulations of classic problem solving strategies. If, for example, I want to relocate my head office of select which car to buy next, then the process works. By because we are very sloppy in the use of language in aviation, we confuse dynamic real-world decision-making with problem solving.
I'd agree with you that the task of the pilot (or any actor in the workplace) is to makes sense of the present circumstances and choose a course of action that will meet operational goals safely. Now, to force this process into 2 boxes called 'situation awareness' (although you were careful to use 'assessment') and 'decision making' simply because these are topics listed in the syllabus is to miss the point. Maybe it's time to cast off some of these labels and get CRM back to some position where it is actually useful.
Last edited by turbocharged; 16th Mar 2010 at 06:45.
