unit 4 human error presentation

7/24/2019 Unit 4 Human Error Presentation

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Human Error

AVIA 4000, Special Projects: Human

Factors in AviationRaymond E. Cain, Jr., Ph.D., Instructor

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Unit objectives

After completion of this unit of instruction, the

student will be able to demonstrate the following:

Define the term human error

Explain the tenets of human error

Describe the TransCockpit Gradient Authority

Explain 10 ways to classify human error

Explain and implement the twopronged attack onreducing human error

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Background in human error

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AIRCRAFT ACCIDENTS AREDOMINATED BY HUMAN ERROR

Because

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Humans are well human!!

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Now lets take a look at some

accident statistics


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Worldwide commercial jet operations

19592009

16 Original Manufacturers (37 significant types)

993.5 million flight hours (since 1959)

563.5 million departures (since 1959)

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20002009, 393 accidents

301 during passenger operations

81 during all cargo operations

11 during maintenance test, ferry, positioning,training and demonstration

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20002009, 89 fatal accidents

72 during passenger operations

14 during all cargo operations

3 during maintenance test, ferry, positioning,training and demonstration

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20002009 fatalities

89 fatal accidents

Passengers = 4,942

(*171)

Cargo = 42 (*73)

Missile test, etc. = 17

Total = 5,001 (*244)

*External Fatalitiesthose on ground and in

other aircraft involved

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Fatal Accidents by Phase of Flight

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Accidents by Injury and Damage

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Fatalities by Common Taxonomy Team

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General Aviation Accidents

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General Aviation Nall Report

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General Aviation Nall Report

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Ciceros Theorems

It is the nature of man to

err

Only a fool perseveres in

error

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Human error

Rigby (1972)any set of human actions that

exceeds some limit of acceptability

Wigglesworth (1975)a missing or

inappropriate response to a stimulus

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For example

Poorly designed equipment and/or procedures

may induce a human error because a person actsor reacts to a scenario presented in a what

appears to be a perfectly normal situation

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Characteristics of errors induced bypoorly designed equipment and/or

procedures (a) are likely to berepeated, (b) are largely predictable,and (c) must be corrected bydesignersnot operators.


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ThreeMile Island, Chernobyl, &

Tenerife

Human error occurred in a working

environment deficient in HF

Powersthatbe were warned of inadequate

HF and the possibility of devastating

consequences

Warnings to take effective, curative measures

were not heeded

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Tenets of human error

Origins of error can be fundamentally

different

Anyone can and will make errors

The consequences of similar error can be

quite different

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Value of the human operator

The human is a flexible system component

If ergonomics have been properly applied, the

human can increase system reliability

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Accident proneness

What is it?

Chronic personality trait

Chance

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Sources of error: TransCockpit

Gradient Authority

Too Steep

Dominate Captain

Passive F.O.

NO COMMUNICATION

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Gradient Authority

Too Flat Passive Captain

Aggressive F.O.

WHOS IN CHARGE?

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Gradient Authority

Optimum

Leading Captain

Assertive F.O.

FUNCTIONAL TEAM

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Ways to classify human error

Designinduced and operatorinduced

Random, systematic, sporadic

Omission, commission, substitution

Reversible and irreversible

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DesignInduced error

Usually occurs at the Liveware ~Hardware or

Liveware ~ Software interface

Failure to design hardware or softwareproperly (does not take into account normal

characteristics of Liveware)

Example??

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OperatorInduced error

Inadequate performance on part of individual

Reflecting possible deficient skills, motivation,

or vision

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Random error

No discernible pattern

Many factors may influence range of variability

Variety of Origins (all play a role) Personnel selection

Training

supervision

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Systematic error

Characterized by a small dispersion which is offset from the desired point

Often caused by one or two factors

Normally easier to correct once a proper analysis has been made

Good operator feedback system will help

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Sporadic error

Errors occur after routinely good performance

Extremely difficult to predict

Are usually resistant to correction through training or

indoctrination

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Error of omission

Failing to do something which ought to be

done

Missing an item on a checklist

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Error of commission

Doing something which ought not to be done

Silencing gear warning horn during configuration

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Error of substitution

Taking action when required, but wrong action

Shutting down the wrong engine with an engine

fire

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Reversible versus irreversible error

Reversible

Allows for correction

Examples?

Computer screen

Parachute

Safety screen

Irreversible Examples

Dumping too much fuel

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Two pronged attack

Aimed at reducing human error

Firstminimize occurrence of errors (or the

probability)

Secondreduce the consequences of errors (orthe severity)

How do we do this?

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First prong for reducing human error

Recognize that errors are part of our normal

behavior

Dispel the illusion that it is possible to achieve

error free operation

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Minimize occurrence of error

Ensure high level of staff competence through

optimizing selection, training, and control

(checks)

Personality, attitudes, and motivation will play a

major role

Tolerance to fatigue and other stresses are

important Must work with others as they are and not how

we wish them to be

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unit 4 human error presentation

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