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Error Error

ManagementManagement

Error Error

ManagementManagement

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Normal operations:• threats and errors• deviations• failures and successes

Accidents

Serious incidents

Minor incidents

Frequency of event, Quantity of data

Sev

erit

y of

eve

nt

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Frequency of event, Quantity of data

Sev

erit

y of

eve

nt

Normal operations:• threats and errors• deviations• failures and successes

Accidents

Serious incidents

Minor incidents

Normal operations:• threats and errors• deviations• failures and successes

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LOSA (Line Operations Safety Audit) results:

More than 70% of flights had at least one error or violation

About 30% of errors/violations were mismanaged or consequential

Leading to “undesired aircraft state” or another error/violation

Courtesy of University of Texas. Based on 3309 flights.

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This presentation is about coping with

errors in normal operations, typically detected

with flight operations monitoring tools,

It is not about incidents, usually subject to a detailed investigation.

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1. Why do we sometimes fail?

2. Consequences on flight safety

3. Managing errors and violations

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1. Why do we sometimes fail?

2. Consequences on flight safety

3. Managing errors and violations

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© Ismo Aaltonen

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Intention to achieve somethingGood planAction “on autopilot”Unintended deviation from plan

Several error mechanisms, for example:“Strong but wrong” habits

Inaccuracies

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The climb is getting bumpy…

Radar was off!

Predictive windshear had been set to “auto”

Radar remained off

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Intention to achieve something

Good plan

Something is skipped, omitted

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Mistake

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Intention to achieve something

The solution is…Deficient

Wrong

Dangerous

Clumsy

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Deliberate violation of a rule, procedure, policy or norm

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Completely newCompletely new

RoutineRoutine

Mistakes(capacity overflow)

Slips & Lapses

Mistakes(incorrect solutions)

Exceptionalviolations

Routineviolations

Optimizingviolations

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1. Why do we sometimes fail?

2. Consequences on flight safety

3. Managing errors and violations

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There is a very loose coupling between an error and negative consequences

Other factors shape the outcome

Especially true in aviation

Nevertheless…

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Flaps not set for takeoff (lapse)Aircraft type and performance?

Actual takeoff weight?

Runway length?

Obstructions ahead?

Takeoff configuration warning?

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1. Why do we sometimes fail?

2. Consequences on flight safety

3. Managing errors and violations

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ERROR PREVENTION

ERROR MANAGEMENT

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Error ReductionMinimizing the likelihood of error

Minimizing the consequences of error

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Error DetectionFacilitate easy and rapid detection of errors

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Error Management Strategies

Error RecoveryMake it easy to rapidly recover to a safe state

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Error ToleranceBuild the system to

tolerate errors

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Error PreventionWhere reasonable and where doing so does not

increase other risks, remove an error-prone task by (re)design of system, procedure or process.

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Mistakes(capacity overflow)

Slips & Lapses

Mistakes(incorrect solutions)

Exceptionalviolations

Routineviolations

Optimizingviolations

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Slips & Lapses

Mistakes(incorrect solutions)

Routineviolations

Optimizingviolations

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Slips & Lapses

Mistakes(incorrect solutions)

Routineviolations

Optimizingviolations

• Error Tolerance• Error Reduction• Error Detection

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Mistakes(incorrect solutions)

Routineviolations

Optimizingviolations

Key issues:• Situation Recognition and Diagnosis• Decision Making

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Violation Management

Routineviolations

Optimizingviolations

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Optimizingviolations

The “Lethal Cocktail”

Expectation that rules will have to be bent to get the job done

Feeling of Powerfulness: above-average people need not follow all procedures

Opportunities to “short cut”Inadequate Planning, forcing

people to improviseRoutine

violations

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Optimizingviolations

Remove the need to ViolateAdequate planning

Capability to adapt to new demands

Open communication

Safety Culture

Routineviolations

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Can’t we hold people responsible for their mistakes and violations?

Real safety enhancement usually comes from systemic solutions

Not from actions at the individual level

Situation where a person really has to be removed from operation is very rare

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Look BEHIND the error or violation

What type of error?

Find solutions

Real, systemic