Error Management in Aviation

•Error Management: Achievements and Challenges
(Have we made a difference?)

•James Reason

•Once upon a time . . .

•Now: A complex system

•Cascading influences

•Errors need to be managed at all levels of the system

•Reaching ever higher for the fruit

•Milestones

•From 1917: Psychometric testing

•1940s: Cambridge Cockpit; Applied Psychology Unit; centres at Ohio State & University of Illinois; ERS (UK)

•1950s: HFS (US); ‘Human Factors in Air Transportation’ (Ross McFarland)

•1960s: Manned space flight; cockpit ergonomics; command instruments

•1970s: ALPA accident investigation course; IATA human factors committee; SHEL(L)

•1980s: CRM; ASRS; cognitive and systemic factors; interaction of many causal factors

•1990s: Organizational and cultural factors

•Sentinel events

•Tenerife runway collision

•Mt Erebus and the Mahon Report

•Manchester runway fire

•Dryden and the Moshansky Report

•BASI reports on the Monarch and Seaview accidents

•NTSB Report on Embraer 120 accident at Eagle Lake, Texas (Lauber dissent)

•Challenger (Vaughan) and Columbia Accident Investigation Board Report

•Individual factors

•Pilot aptitude measures

•Psychomotor performance

•Sensory and perceptual factors

•Fatigue and stress

•Vigilance decrement

•Cockpit ergonomics

•‘Ironies of automation’

•Cognitive issues

•Predictive value of WW2 AAF test battery
(from Ross McFarland, 1953)

•Social and team factors

•Crew resource management

•LOFT and behavioural markers

•Cabin evacuation studies

•Maintenance teams

•Air traffic controllers

•Ramp workers

•Naturalistic decision making

•Procedural non-compliance

•The high-hanging fruit

•Targeting error traps and recurrent accidents (e.g. CFIT, maintenance omissions, etc.)

•Resolving goal conflicts: production vs protection

•Combating the ‘normalization of deviance’

•Striving for system resilience (high reliability)

•Engineering a safe culture

•ICAO Annex 13 (8th Ed., 1994)

•Ever-widening search for
the ‘upstream’ factors

•Echoed in many hazardous domains

•CAIB Report (August, 2003)

•But has the pendulum swung
 too far?

•Mr Justice Moshansky on
the Dryden F-28 crash

•Academician Valeri Legasov
on the Chernobyl disaster

•CAIB Report (Ch. 5)

•Remote factors: some concerns

•They have little causal specificity.

•They are outside the control of system managers, and mostly intractable.

•Their impact is shared by many systems.

•The more exhaustive the inquiry, the more likely it is to identify remote factors.

•Their presence does not discriminate between normal states and accidents; only more proximal factors do that.

•

•Revisiting Poisson

•Poisson counted number of kicks received by cavalrymen over a given period.

•Developed a model for determining the chance probability of a low frequency/high opportunity event among people sharing equal exposure to hazard.

•How many people would one expect to have 0, 1, 2, 3, 4, 5, etc. events over a given period when there is no known reason why one person should have more than any other?

•Unequal liability: common finding

•Interpreting pilot-related data

•Repeated events are associated with particular conditions. Suggests the need for specific retraining.

•Repeated events are not associated with particular conditions:

§Bunched in a given time period. Suggests influence of local life events. Counselling?

§Scattered over time. Suggests some enduring problem. Promote to management?

•End-of-century grades

•Conclusions

•Widening the search for error-shaping factors has brought great benefits in understanding accidents.

•But maybe we are reaching the point of diminishing returns with regard to prevention.

•Perhaps we should revisit the individual (the heroic as well as the hazardous acts).

•History shows we did that rather well.

•