1100-Threat and Error Management and Hazard Identification

Threat and Error Management and Hazard Identification on Airports
Presented to: 27th Great Lakes Airports Conference By: Date: Roger Motzko, FAA, ATO Safety 2 November 2011
Federal Aviation Administration
Definitions
Hazard:
Anything that will or has the potential to cause harm
Risk:
The likelihood and severity of consequence of a hazard
Threat and Error Management 2 November 2011
Hazard:
Anything that will or has the potential to cause harm
Risk:
The likelihood and severity of consequence of a hazard
Three Methods of Analysis

Historic
Study data over time, develop trends from accidents
Diagnostic
Identify precursors by using collective safety reporting systems
Prognostic
An informed method that looks at future development and eliminates potential hazards before they are introduced
COSTS OF NAVAL ACCIDENTS

Direct Cost (FY 98 08)
$5.14 Billion and 1113 Lives
Indirect Cost
Loss of Manpower Delay in Doing
Business
Corporate Reputation Investigation Costs Litigation
Threat and Error Management 2 November 2011 Federal Aviation Administration
So where to begin?
Start with Reasons Swiss Cheese model Base on Human Factors Analysis and Classification System (HFACS) by Doug Weigmann & Scott Shappell Categorization of system failure in complex systems Latent Failures Active Failures Bring together human factors, Operations, Human systems, Systems safety and Engineering Issues Man, Machine, Medium, Mission, Management Adopt a philosophy of analysis that focuses on the system instead of the individual
Reasons Swiss-cheese Model of Human Error

Organizational Factors Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Failed or Absent Defenses Accident & Injury
ORGANIZATIONAL INFLUENCES Resource/Acquisition Management Organizational Climate Organizational Process
SUPERVISION
Inadequate Supervision
Planned Inappropriate Operations
Failed to Correct Known Problem
Supervisory Violations
PRECONDITIONS
Environmental Factors Physical Environment Technological Environment
Personnel Factors Condition of Individuals Coordination/Com munication/Plannin g Factors SelfImposed Stress
Cognitive Factors
PsychoBehavioral Factors
Adverse Physiological States
Physical Mental Limitations
Perceptual Factors
ACTS
Errors Errors Judgment and Threat and Error Management Decision-Making 2 November 2011Errors Skill-Based Errors Perception Errors
Violations
Think decision tree

Analysis starts with end result Traces back through the decisions and conditions Layers of Swiss Cheese are conditions at each level Some cheese has more holes (hazards) than others Poor organizational climate, no rules enforcement Personnel fatigued, or poorly trained Some environments more challenging Goal More solid cheese - or countermeasures to avoid the holes
Why bother?
To reduce mishap rate, efforts must be focused on identifying the primary causes, which in most cases is the human fitting into the system.
50 45 40
Number of Episodes
Navy F/A-18 Class A Flight Mishaps
35 30 25 20 15 10 5 0
Errors in Skill Decision Errors Perception Policy Violations Material Factor + Human error Material Failure
Acts
The act is the end result. It answers the question of, what happened?
Skill-based Errors: errors in regularlyperformed tasks Decision Errors: selection of an incorrect course of action for a particular situation Perception Errors: perception of an illusion leads to an incorrect course of action Violation: intentionally acting against written policy or procedures.
ACTS
Errors
Violations
Judgment and Decision Errors
Skill-Based Errors
Misperception Errors
Unsafe Unsaf Acts e Acts
ACTS
Errors
Violations
Skill-Based Errors
DECISION ERRORS
Risk Assessment During Operation Task Misprioritization Necessary Action Rushed Necessary Action Delayed Caution/Warning Ignored Wrong choice of action
15
ACTS
Errors
Violations
Skill-Based Errors
SKILL-BASED ERRORS
Inadvertent Operation Checklist Error Procedural Error Overcontrol/Undercontrol Breakdown in Visual Scan Inadequately Trained Maneuver
17
ACTS
Errors
Violations
Skill-Based Errors
MISPERCEPTION ERRORS (due to)

Misjudge Distance, Timing Spatial Disorientation Visual Illusions
ACTS
Errors
Violations
Skill-Based Errors
Misperception
VIOLATIONS
Errors (Willful disregard for rules and instructions!)
Violation Work-around Violation Routine/Widespread Unsafe Unsaf Acts e Acts Violation Extreme
Preconditions
Preconditions are the things that allow the unsafe acts to occur, and they answer the question of, Why did it happen? Broad categories are:
Physical environment: the working environment. Rain, darkness, cold, hot, etc. Technological Environment: the tools used in the task. Vehicle design and usability of associated systems. Self-imposed stress: things we do to ourselves alcohol, lack of sleep, fitness level.
Preconditions (cont.)
Coordination, communication, planning: team interaction, task planning (CRM). Cognitive factors: situational awareness. Physical/mental limitations: operator size incompatible with workspace, trouble retaining information.
Preconditions (cont.)
Perceptual factors: visual or proprioceptive illusions Psycho-behavioral factors: personality problems, overconfidence, aggressiveness, etc. Adverse Physiological States: fatigue, effects of medications, breathing difficulties. There may be more than one precondition for each act!
PRECONDITIONS
Environmental Factors
Personnel Factors Coordination/ Communication/ Planning Factors
Physical Environment
Technological Environment
Condition of Individuals
SelfImposed Stress
Cognitive Cognitive Factors Factors

Preconditions for Unsafe Acts Unsafe Acts
Physical/ Mental Limitations
Perceptual Factors
PRECONDITIONS
SelfImposed Stress
Perceptual Factors
PHYSICAL ENVIRONMENT
Icing/Fog/Etc. on windows Meteorological Conditions Dust/Smoke/Etc. in Workspace Brownout/Whiteout Thermal Stress: Cold/Hot Noise Interference
PRECONDITIONS
SelfImposed Stress
Cognitive Factors
Physical/ Mental
Perceptual Factors
Limitations TECHNOLOGICAL ENVIRONMENT
Seating and Restraints Instrument and Sensory Feedback Visibility Restrictions Controls and Switches Automation Personal Equipment Interference Communications - Equipment
PRECONDITIONS
Personnel Factors
Coordination/ Communication/ Planning Factors
SelfImposed Stress
Cognitive Factors
Perceptual Factors
COORD/COMM/PLAN
Crew/Team Leadership Cross-Monitoring Performance Task Delegation Rank/Position Authority Gradient Communicating Critical Info Standard/Proper Terminology Mission Planning/Briefing
Threat and Error Management Miscommunication 2 November 2011
PRECONDITIONS
SelfImposed Stress
Cognitive Factors
Perceptual Factors
SELF-IMPOSED STRESS
Alcohol Physical Fitness Drugs/Supplements/Self Medication Nutrition Inadequate Rest Unreported Disqualifying Medical Condition
PRECONDITIONS
SelfImposed Stress
Cognitive Factors
Perceptual Factors
COGNITIVE FACTORS
Inattention Channelized Attention Cognitive Task Oversaturation Confusion Negative Transfer Distraction Geographic Mis-orientation (Lost) Checklist Interference Federal Aviation Administration
PRECONDITIONS
SelfImposed Stress
Cognitive Factors
Perceptual Factors
PSYCHO-BEHAVIORAL
Personality Style Pre-Existing Personality Disorder Pre-Existing Psychological Disorder Emotional State Overconfidence Complacency Get-Home-Itis/Get-There-Itis Overaggressive Federal Aviation Administration
PRECONDITIONS
SelfImposed Stress
Cognitive Factors
Perceptual Factors
ADVERSE PHYSIOLOGICAL
Physical Fatigue (Overexertion) Fatigue Physiological/Mental Motion Sickness Circadian Rhythm Desynchrony Pre-Existing Physical Illness/Injury Prescribed Meds for Injury/Illness
PRECONDITIONS
SelfImposed Stress
Cognitive Factors
Perceptual Factors
PHYSICAL/MENTAL LIMITS
Learning Ability/Rate Memory Ability/Lapses Anthropometric/Biomechanical Limits Motor Skill/Coordination or Timing Deficiency Technical/Procedural Knowledge
PRECONDITIONS
SelfImposed Stress
Cognitive Factors
Perceptual Factors
PERCEPTUAL FACTORS
Illusions: Kinesthetic/Vestibular/Visual Misperception of Operational Conditions Misinterpreted/Misread Instrument Expectancy Auditory Cues Spatial Disorientation: 1, 2, & 3 Federal Aviation Administration Temporal Distortion
Supervision
Supervisors are ultimately responsible for the conduct of their units.
Inadequate supervision: lack of guidance, written policy, or training opportunities Failure to correct known problem: problems with personnel or operations Inappropriate Operations: lack of proper risk assessment or assigned inappropriate personnel to task Violations: unnecessarily allows operations outside of SOP
SUPERVISION
Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts
SUPERVISION
Unsafe Supervision
INADEQUATE SUPERVISION
Leadership/Supervision/Oversight Inadequate Supervision Modeling Local Training Issues/Programs Supervision Policy Supervision Personality Conflict Supervision Lack of Feedback
SUPERVISION
PLANNED INAPPROPRIATE OPERATIONS

Ordered/Led Task Beyond Capability Crew/Team Makeup/Composition Limited Recent Experience Proficiency Risk Assessment Formal Authorized Unnecessary Hazard
SUPERVISION
FAILED TO CORRECT KNOWN PROBLEM

Personnel Management Operations Management
SUPERVISION
SUPERVISORY VIOLATIONS
Supervision Discipline Enforcement Supervision Unwritten Policy Directed Violation Assigned Unqualified Individuals
39
Organizational Factors
The Organization is responsible for overall policy, doctrine, and allocation of resources to the subordinate units and personnel
Resource/Acquisition Management: the ways in which equipment is allocated Organizational Climate: affects morale in a unit Process: policies and procedures that drive the concept of operations
ORGANIZATIONAL INFLUENCES
Resource/Acquisition Management
Organizational Influences Unsafe Supervision
Organizational Climate
Organizational Process
RESOURCE/ACQUISITION MANAGEMENT
Air Traffic Control Resources Airfield Resources
Unsafe Acts
Preconditions for Unsafe Acts
Operator Support Acquisition Policies/Design Processes Personnel Resources Information Resources/Support Financial Resources/Support
ORGANIZATIONAL ORGANIZATIONAL INFLUENCES INFLUENCES Resource/Acquisition Management

Organizational Process
ORGANIZATIONAL CLIMATE
Organizational Values/Culture
Evaluation/Promotion/Upgrade Perceptions of Equipment Mission/Economic Climate Organizational Structure
ORGANIZATIONAL ORGANIZATIONAL INFLUENCES INFLUENCES Resource/Acquisition Management

Organizational Operational Process Process
ORGANIZATIONAL PROCESS
Ops Tempo/Workload Program and Policy Risk Assessment Procedural Guidance/Publications
Unsafe Acts
Preconditions for Unsafe Acts
Organizational Training Issues/Programs Program Oversight/Program Management
Questions?

1100-Threat and Error Management and Hazard Identification

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

1100-Threat and Error Management and Hazard Identification

Uploaded by

Copyright:

Available Formats

Threat and Error Management and Hazard Identification on Airports

Federal Aviation Administration

Threat and Error Management 2 November 2011

Federal Aviation Administration

Threat and Error Management 2 November 2011

Federal Aviation Administration

Threat and Error Management 2 November 2011

Federal Aviation Administration

Three Methods of Analysis

Threat and Error Management 2 November 2011

Federal Aviation Administration

COSTS OF NAVAL ACCIDENTS

Threat and Error Management 2 November 2011

Federal Aviation Administration

Reasons Swiss-cheese Model of Human Error

Threat and Error Management 2 November 2011

Federal Aviation Administration

ORGANIZATIONAL INFLUENCES Resource/Acquisition Management Organizational Climate Organizational Process

Planned Inappropriate Operations

Failed to Correct Known Problem

Environmental Factors Physical Environment Technological Environment

Personnel Factors Condition of Individuals Coordination/Com munication/Plannin g Factors SelfImposed Stress

Adverse Physiological States

Physical Mental Limitations

Federal Aviation Administration

Think decision tree

Navy F/A-18 Class A Flight Mishaps

Threat and Error Management 2 November 2011

Federal Aviation Administration

Threat and Error Management 2 November 2011

Federal Aviation Administration

Judgment and Decision Errors

Unsafe Unsaf Acts e Acts

Threat and Error Management 2 November 2011

Federal Aviation Administration

Judgment and Decision Errors

Unsafe Unsaf Acts e Acts

Threat and Error Management 2 November 2011

Federal Aviation Administration

Threat and Error Management 2 November 2011

Federal Aviation Administration

Judgment and Decision Errors

Unsafe Unsaf Acts e Acts

Threat and Error Management 2 November 2011

Threat and Error Management 2 November 2011

Federal Aviation Administration

Judgment and Decision Errors

Unsafe Unsaf Acts e Acts

MISPERCEPTION ERRORS (due to)

Threat and Error Management 2 November 2011

Federal Aviation Administration

Judgment and Decision Errors

Errors (Willful disregard for rules and instructions!)

Threat and Error Management 2 November 2011

Federal Aviation Administration

Federal Aviation Administration

Threat and Error Management 2 November 2011

Federal Aviation Administration

Threat and Error Management 2 November 2011

Federal Aviation Administration

Personnel Factors Coordination/ Communication/ Planning Factors

Cognitive Cognitive Factors Factors

Adverse Physiological States

Physical/ Mental Limitations