HUMAN FACTOTS IN AVIATION

航空中的人为因素 (COURSE CODE: 0763001W)

Dr. Asif Raza

民航学院

南京航空航天大学
Topic: Human Error
Sub-topic 1: Introduction to Human Error
LECTURE TOPICS:

Introduction Error
to Human Errors. Management
Error. .
 OVERVIEW OF HUMAN FACTORS

SUB TOPIC 1: INTRODUCTION TO HUMAN ERROR

We’re all human.
We all make mistakes and forget things.
Our attention span is limited.
We overlook key information when making decisions.
We get distracted, bored, tired or preoccupied.
We mishear and misunderstand.
  Everyone makes mistakes and errors, regardless of how
well trained and motivated they are.
 However, in the workplace, the consequences of such
human failure can be severe.
 Analysis of accidents and incidents shows that human
failure contributes to almost all accidents,and exposures
INTRODUCTION
to substances hazardous to health.
 In order to avoid accidents and ill health, companies
need to manage human failure as robustly as the
technical and engineering measures they use for that
purpose.
  The challenge is to develop error-tolerant systems,
and to prevent errors from initiating.
 To manage human error proactively, it should be
addressed as part of the risk assessment process,
where significant potential human errors are
identified, such as, poor design, distraction, time
pressure, workload, competence, morale, noise
INTRODUCTION levels, communication systems and performance
influencing factors.
 Control measures are devised and implemented,
preferably by redesign of the task or equipment.
 This also involves identifying the human errors that
led to the accident, and those factors that made such
errors more likely
 It is important to be aware that human failure is
not random, although human error is a natural
part of life.

A key point to note with regards to human error

HUMAN ERROR is that although undesirable, it is nevertheless
both frequent and widespread.

Therefore, understanding why errors occur, and

the different factors which make them worse,
will help you develop more effective controls
 Human error is a generic term to encompass all
those occasions in which a planned sequence of
mental or physical activities fails to achieve its
intended outcome, and when these failures
cannot be attributed to the intervention of some
HUMAN ERROR chance agency (James reason, 1990).
----CONTINUE

Human error can be defined as the failure of

planned actions to achieve a desired goal.
 Data from a wide range of sources suggest
that some aspect of human error is
involved in about 80% or more of
accidents and incidents.
HUMAN ERROR
---CONTINUE When we look at what types of errors
people usually make, we soon realize that
they are not random. We all tend to make
the same kinds of mistakes in similar
situations.
TYPES OF HUMAN ERROR

Slips and Lapses: Mistakes: Violations:

• Actions that were not • Errors of judgment or • Intentional, but usually

as planned or decision-making, well-meaning failures
unintended actions, where the intended where the person
such as pressing the actions are wrong, deliberately does not
wrong button or often due to lack of carry out the
forgetting to carry out knowledge or training. procedure correctly.
a step in a procedure. People fall back on They often occur
These occur during a remembered rules where the equipment
familiar task. from similar or task has been poorly
situations, which may designed and/or
not be correct. maintained.
 Slips and Pressing the wrong button, forgetting a step in a
Lapses: procedure, etc.

EXAMPLES OF Doing the wrong thing believing it to be right due to

Mistakes: lack of knowledge or training.
HUMAN ERROR

Violations Non-compliance, circumventions, shortcuts, and

: workarounds.
 Mistakes resulting from poor
training are often mistaken for
violations.
MISCONCEPTIO
NS ABOUT
HUMAN ERROR Violations are rarely malicious and
usually result from an intention to
get the job done as efficiently as
possible.
An example of human error

 For example, a potential human error that can occur with a task as simple
as photocopying, highlights how mistakes can be made unconsciously,
especially when we are not paying careful attention in the task.
 Understanding the different types of human failure can help identify control
measures, but there is a need to be careful to not oversimplifying the situation.

Understanding In some cases, it can be difficult to place an error in a single category, as it

may result from a slip or a mistake.

human failure and

identifying control
For example, there may be a combination of underlying causes that requires a
measures combination of preventative measures.

It may also be useful to think about whether the failure is an error of omission,
that is, forgetting or missing out a key step, or an error of commission, for
instance, doing something out of sequence or using the wrong control, when
taking action to prevent that type of error.
 Typically, there are four consequences of human error

• This consequence occurs when human error does not result in any significant

Little or no effect:
CONSEQUENCES OF HUMAN ERROR
impact on the system or environment.
• For example, misplacing a pencil on a desk or misspelling a word in a non-
critical document.

Damage to equipment • This consequence occurs when human error leads to damage or destruction of
equipment or hardware.
and hardware: • For example, dropping a laptop or spilling a drink on a keyboard.

• This consequence occurs when human error leads to physical harm to an

Personal injury: individual.

• For example, slipping and falling on a wet floor or getting burned by hot
equipment.

• This consequence occurs when human error leads to major damage or loss of
Catastrophic damage: life.
• For example, a pilot making an incorrect decision leading to a plane crash
 If we make a wrong turn while driving, we can turn
back in the direction we intended and we can
usually find lost car keys after a few minutes of
searching (minor consequence).

CONSEQUENCES However, in aviation and other safety-critical

OF HUMAN industries, errors can have more serious
ERROR consequences and are not always caught and
corrected as easily.

The threat human error poses can be viewed in

the same light as other threats the industry must
manage.
 Human error can be seen as a natural threat that must be
managed in much the same way.

An understanding of the risk factors for human error can

CONSEQUENCES help us to reduce its frequency.
OF HUMAN
ERROR
We can also anticipate it and take precautions to limit its
effects (importance of hazard & risk management).

The one difference is that, unlike hazards in nature,

human error is a constantly evolving threat, as it stems
from human beings' infinite adaptability and
capabilities.
 Human error is a natural threat that needs to be managed
alongside other threats in the aviation industry.

Understanding the risk factors for human error can help

reduce its frequency and mitigate its impacts.

Hazard and risk management can help anticipate human

KEY POINTS error and take precautions to limit its effects.

Human error is a constantly evolving threat due to human

beings' infinite adaptability and capabilities.

Human error hazards and risks will require a more active

management program.