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An Integrated Framework for                         g                Understanding the Relationship                   Betw...
ASQ Reliability Division                 ASQ Reliability Division                Chinese Webinar Series                Chi...
An Integrated Framework for Understanding the    Relationship between Human Error and Aviation Safety    (理解人为差错与航空安全关系的整合...
Disclaimer(免责声明)Engineering, Operations & Technology | Boeing Research & Technology   Advanced Air Traffic Management     ...
Outline of Presentation(讲座提纲)  Engineering, Operations & Technology | Boeing Research & Technology   Advanced Air Traffic ...
What is Human Error? (人为差错是什么?) Engineering, Operations & Technology | Boeing Research & Technology          Advanced Air ...
Human Error Outpaces Machine Error as Leading Cause of           人为因素作为事故的 要导致因素)Accidents (人为因素作为事故的主要导致因素)  Engineering,...
Must Continuously Improve Safety to Keep the Number ofAccidents in Decline (必须改进安全,减少事故的数量)Engineering, Operations & Techn...
Accident Trend Implication: We Must Further Address Human Error toImprove Safety(事故趋势意味着:我们必须进一步解决人为差错以改进安全)              ...
Individual Perspective(个人角度)Engineering, Operations & Technology | Boeing Research & Technology   Advanced Air Traffic Man...
Group Perspective (小组角度)Engineering, Operations & Technology | Boeing Research & Technology   Advanced Air Traffic Managem...
Organization and System Perspective(组织和系统角度)Engineering, Operations & Technology | Boeing Research & Technology           ...
Human Error: Individual Perspective (人的差错:个人角度)  Engineering, Operations & Technology | Boeing Research & Technology      ...
Wickens’ Human Information Processing: Errors can Occur  Anywhere(威肯斯人类信息处理模型:任何环节都可能发生错误)    y        威肯斯人类信 处 模         ...
Factors that Contribute to Errors (造成错误的因素)      Engineering, Operations & Technology | Boeing Research & Technology      ...
Error Prevention, Reduction, and Management:  Environment(预防 减少和管理错误:环境)                 预防、减少和管理错误:环境)  Engineering, Oper...
Error Prevention, Reduction, and Management:                 Aids(预防 减少和管理错误:设备/辅助)  Equipment/Job Aids(预防、减少和管理错误:设备/辅助) ...
Error Prevention, Reduction, and Management:                 Aids(预防 减少和管理错误:设备/辅助)  Equipment/Job Aids(预防、减少和管理错误:设备/辅助) ...
Error Prevention, Reduction, and Management:                 Aids(预防 减少和管理错误:设备/辅助)  Equipment/Job Aids(预防、减少和管理错误:设备/辅助) ...
Error Prevention, Reduction, and Management:                 Aids(预防 减少和管理错误:设备/辅助)  Equipment/Job Aids(预防、减少和管理错误:设备/辅助) ...
Error Prevention, Reduction, and Management:                 Aids(预防 减少和管理错误:设备/辅助)  Equipment/Job Aids(预防、减少和管理错误:设备/辅助) ...
Error Prevention, Reduction, and Management:                 Aids(预防 减少和管理错误:设备/辅助)  Equipment/Job Aids(预防、减少和管理错误:设备/辅助) ...
Error Prevention, Reduction, and Management:                 Aids(预防 减少和管理错误:设备/辅助)  Equipment/Job Aids(预防、减少和管理错误:设备/辅助) ...
Error Prevention, Reduction, and Management: Physical and  Physiological Factors(预防 减少和管理错误 身体和生理因素)                      ...
Human Error: Group Perspective (人的差错:小组角度)Engineering, Operations & Technology | Boeing Research & Technology     Advanced...
Flight Crew Performance Model (Helmreich & Foushee,         1993) (飞行机组表现模型)         Engineering, Operations & Technology ...
Crew Resource Management (CRM) is a Major Solution forGroup (ICAO, 2005)(机组资源管理是小组的主要解决方案)      (ICAOEngineering, Operatio...
CRM Goals (ICAO, 2005)(机组资源管理的目标)Engineering, Operations & Technology | Boeing Research & Technology   Advanced Air Traffi...
Human Error: Organization and System Perspective(人为错误:组织和系统角度)Engineering, Operations & Technology | Boeing Research & Tec...
Reason’s Swiss Cheese Model (Reason, 1990)(里森的瑞士奶酪模型 )Engineering, Operations & Technology | Boeing Research & Technology ...
Organization/System Error Prevention, Reduction, and Management  (ICAO 1993)(组织/ 系统错误的预防 减少和管理)  (ICAO,             系统错误的预...
Organization/System Error Prevention, Reduction, and Management   (ICAO 1993)(组织/ 系统错误的预防 减少和管理)   (ICAO,             系统错误...
Organization/System Error Prevention, Reduction, and Management   (ICAO 1993)(组织/ 系统错误的预防 减少和管理)   (ICAO,             系统错误...
Organization/System Error Prevention, Reduction, and Management   (ICAO 1993)(组织/ 系统错误的预防 减少和管理)   (ICAO,             系统错误...
Organization/System Error Prevention, Reduction, and Management   (ICAO 1993)(组织/ 系统错误的预防 减少和管理)   (ICAO,             系统错误...
Organization/System Error Prevention, Reduction, and Management   (ICAO 1993)(组织/ 系统错误的预防 减少和管理)   (ICAO,             系统错误...
Organization/System Error Prevention, Reduction, and Management   (ICAO 2009)(组织/ 系统错误的预防 减少和管理)   (ICAO,             系统错误...
Organization/System Error Prevention, Reduction, and Management   (ICAO 2009)(组织/ 系统错误的预防 减少和管理)   (ICAO,             系统错误...
Organization/System Error Prevention, Reduction, and Management   (ICAO 2009)(组织/ 系统错误的预防 减少和管理)   (ICAO,             系统错误...
Integration of Three Perspectives and Conclusion(综合三种角度及结论)Engineering, Operations & Technology | Boeing Research & Techno...
Integration of Three Perspectives and Conclusion(综合三种角度及结论)Engineering, Operations & Technology | Boeing Research & Techno...
Integration of Three Perspectives and Conclusion(综合三种角度及结论)Engineering, Operations & Technology | Boeing Research & Techno...
Integration of Three Perspectives and Conclusion(综合三种角度及结论)Engineering, Operations & Technology | Boeing Research & Techno...
Integration of Three Perspectives and Conclusion(综合三种角度及结论)Engineering, Operations & Technology | Boeing Research & Techno...
References(参考资料)Engineering, Operations & Technology | Boeing Research & Technology         Advanced Air Traffic Managemen...
Acknowledgment(致谢)Engineering, Operations & Technology | Boeing Research & Technology   Advanced Air Traffic Management• T...
Engineering, Operations & Technology | Boeing Research & Technology   Advanced Air Traffic Management                     ...
Copyright © 2011 Boeing. All rights reserved.   46
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An integrated framework for understanding the relationship between human error and aviation safety

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The majority of aviation accidents are attributable to human error. Moreover, as machines (or mechanical systems) have become more reliable over the past decades, human error has outpaced machine problems as a major contributing factor in aviation accidents. It is therefore important to address human error for the improvement of aviation safety. Human error typically occurs as a result of poor interactions among operators, machines, and environment, and it is often influenced by group dynamics and organizational factors. This presentation introduces 1) what human error is, 2) the relationship between human error and aviation safety viewed from individual, group, and organizational perspectives, and 3) solutions to reduce human error.

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An integrated framework for understanding the relationship between human error and aviation safety

  1. 1. An Integrated Framework for  g Understanding the Relationship  Between Human Error and  B t H E d Aviation Safety (理解人为差错 与航空安全关系的整合框架) Dr. Xidong Xu (徐锡东博士) ©2011 ASQ & Presentation Xu Presented live on Sep 14th, 2011http://reliabilitycalendar.org/The_Reliability_Calendar/Webinars_liability Calendar/Webinars ‐_Chinese/Webinars_‐_Chinese.html
  2. 2. ASQ Reliability Division  ASQ Reliability Division Chinese Webinar Series Chinese Webinar Series One of the monthly webinars  One of the monthly webinars on topics of interest to  reliability engineers. To view recorded webinar (available to ASQ Reliability  Division members only) visit asq.org/reliability ) / To sign up for the free and available to anyone live  webinars visit reliabilitycalendar.org and select English  Webinars to find links to register for upcoming eventshttp://reliabilitycalendar.org/The_Reliability_Calendar/Webinars_liability Calendar/Webinars ‐_Chinese/Webinars_‐_Chinese.html
  3. 3. An Integrated Framework for Understanding the Relationship between Human Error and Aviation Safety (理解人为差错与航空安全关系的整合框架) ASQ Reliability Chinese Webinar September 13, 2011 Xidong Xu, Ph.D. (徐锡东博士) Boeing Research & Technology (波音研究与技术) Ad anced Air Traffic Management (先进空中交通管理) AdvancedBOEING is a trademark of Boeing Management Company.Copyright © 2011 Boeing. All rights reserved. 1
  4. 4. Disclaimer(免责声明)Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management Any opinions, findings, conclusions, and recommendations y p , g , , expressed here are those of the author and do not necessarily reflect the views of The Boeing Company.Copyright © 2011 Boeing. All rights reserved. 2
  5. 5. Outline of Presentation(讲座提纲) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management • Human error is a major contributing factor in aviation accidents • Human error viewed from individual perspective • Human error viewed from group perspective g pp p • Human error viewed from organization/system perspective • Integration of three perspectives Copyright © 2011 Boeing. All rights reserved. 3
  6. 6. What is Human Error? (人为差错是什么?) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management GAP I meant to …but I do this… ended up doing this d i thi • Did not intend it Error is inevitable result • Did not do something of natural limitations of according to some specified human performance h f set of rules or by some external observer • Did it but not correctly Copyright © 2011 Boeing. All rights reserved. 4
  7. 7. Human Error Outpaces Machine Error as Leading Cause of 人为因素作为事故的 要导致因素)Accidents (人为因素作为事故的主要导致因素) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management 100% ~80% of accidents 90% are now due to human 80% error 70% ~20% of accidents 60% are now due to machine 50% causes 40% 30% 20% 10% 0% 1903 Copyright © 2011 Boeing. All rights reserved. TIME Today 5
  8. 8. Must Continuously Improve Safety to Keep the Number ofAccidents in Decline (必须改进安全,减少事故的数量)Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management 50 35,800 Airplanes 45 in service 19,000 40 Hull loss 2007 2027 35 accidents Business Hull loss per year as usual 30 accidents per million 25 departure s 20 15 Our 10 Millions of Goal 5 departures p 0 1960 1966 1972 1978 1984 1990 1996 2002 2008 2014 2020 2026 Accident, Accident Airplanes in Service and Departure data are estimated through 31 31, December 2007. Source: Boeing.Copyright © 2011 Boeing. All rights reserved. 6
  9. 9. Accident Trend Implication: We Must Further Address Human Error toImprove Safety(事故趋势意味着:我们必须进一步解决人为差错以改进安全) 事故趋势意味着:我们必须进 步解决人为差错以改进安全)Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management Human error contributes to most incidents/accidents We investigate We use what we learn and know about human error to improve safetyCopyright © 2011 Boeing. All rights reserved. 7
  10. 10. Individual Perspective(个人角度)Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic ManagementCopyright © 2011 Boeing. All rights reserved. 8
  11. 11. Group Perspective (小组角度)Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic ManagementCopyright © 2011 Boeing. All rights reserved. 9
  12. 12. Organization and System Perspective(组织和系统角度)Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management Environment Economy Terrain Aviation System Weather Airport Air Traffic Air Traffic Regulatory Control Organization Authority • Regulations • Management • Culture • PoliciesCopyright © 2011 Boeing. All rights reserved. 10
  13. 13. Human Error: Individual Perspective (人的差错:个人角度) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management Wickens Wickens’ Human Information Attention Resources Processing Model (Wickens, 1992) Short Term Perception Decision Response Stimuli Sensory and Execution Responses Storage Response Selection Working Memory Long-Term Memory FeedbackAdapted with permission of Pearson Education from Fig. 1.3 in “Engineering psychology and human performance”, 1992 by C.D. Wickens. For use in this presentation only. Copyright © 2011 Boeing. All rights reserved. 11
  14. 14. Wickens’ Human Information Processing: Errors can Occur Anywhere(威肯斯人类信息处理模型:任何环节都可能发生错误) y 威肯斯人类信 处 模 任何环节都可能发 错误 Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management Attention Att ti ResourcesStimuli Short Term Sensory Errors can and Perception occur Decision Response Execution Responses Storage St anywhere i th h R in the Response Selection p ocess process Working Memory Long-Term Memory Copyright © 2011 Boeing. All rights reserved. Feedback 12
  15. 15. Factors that Contribute to Errors (造成错误的因素) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management• Lighting levels• Temperature and humidity• Vibration and noise Environment• Smoke or air quality • Procedures• Physical access to the job • Automation • Controls • Displays, etc. Physical and Equipment Physiological Error and Job Aids Factors• Size, reach, strength , , g• Illness, incapacitation, injury• Overall health and diet • Other crew members Group and• Alertness, circadian Alertness circadian, fatigue • Management Organizational O i i l• Drug effects • Larger operational organization Factors• Motivational influences: complacency, • High-level decision makers such as confidence the regulator• Mental health influences – anxiety, stress, etc… © 2011 Boeing. All rights reserved. Copyright 13
  16. 16. Error Prevention, Reduction, and Management: Environment(预防 减少和管理错误:环境) 预防、减少和管理错误:环境) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management• Environment Environmental Improvements and Mitigation • Lighting • Temperature and humidity • Vibration and noise Copyright © 2011 Boeing. All rights reserved. 14
  17. 17. Error Prevention, Reduction, and Management: Aids(预防 减少和管理错误:设备/辅助) Equipment/Job Aids(预防、减少和管理错误:设备/辅助) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management• Environment Human Factors Design Principles (Wickens, Gordon-Becker, Li & Lee, 2003) G d B k Liu, L• Equipment and Job Aids • Make displays legible • Avoid b l t j d A id absolute judgment limits t li it • Top-down processing • Redundancy-gain • Discriminality • Principle of pictorial realism • Principle of the moving part p gp • Minimizing information access costs • Proximity compatibility principle • Principle of multiple resources • Knowledge in the world • Principle of predicting aid • Principle of consistency Copyright © 2011 Boeing. All rights reserved. 15
  18. 18. Error Prevention, Reduction, and Management: Aids(预防 减少和管理错误:设备/辅助) Equipment/Job Aids(预防、减少和管理错误:设备/辅助) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management• Environment• Equipment and Job Aids “Redundancy-gain”—the same information is displayed more than once (Wickens, et al., 2003). Copyright © 2011 Boeing. All rights reserved. 16
  19. 19. Error Prevention, Reduction, and Management: Aids(预防 减少和管理错误:设备/辅助) Equipment/Job Aids(预防、减少和管理错误:设备/辅助) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management• Environment• Equipment and Job Aids Photo source: http://humansystems.arc.nasa.gov/groups/FDDRL/technologies/3dcdti.html “Principle of pictorial realism”—a display should look like what it represents (Wickens, et al., 2003). Copyright © 2011 Boeing. All rights reserved. 17
  20. 20. Error Prevention, Reduction, and Management: Aids(预防 减少和管理错误:设备/辅助) Equipment/Job Aids(预防、减少和管理错误:设备/辅助) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management• Environment• Equipment and Job Aids Photo source: https://www.faasafety.gov/gslac/alc/course_content.aspx?cID=49&sID=293&preview=true “Knowledge in the world”—people should not be required to retain important information solely in f memory (Wickens, et al., 2003). Copyright © 2011 Boeing. All rights reserved. 18
  21. 21. Error Prevention, Reduction, and Management: Aids(预防 减少和管理错误:设备/辅助) Equipment/Job Aids(预防、减少和管理错误:设备/辅助) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management• Environment• Equipment and Job Aids Conflict! “Principle of predicting aid”—a display should help predict future conditions (Wickens, et al., 2003). Copyright © 2011 Boeing. All rights reserved. 19
  22. 22. Error Prevention, Reduction, and Management: Aids(预防 减少和管理错误:设备/辅助) Equipment/Job Aids(预防、减少和管理错误:设备/辅助) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management• Environment Error Tolerant Systems• Equipment and Job Aids • Errors will be inevitable (and error is often necessary for learning to occur) • Therefore, an error-tolerant system would allow the user to recover from an error Copyright © 2011 Boeing. All rights reserved. 20
  23. 23. Error Prevention, Reduction, and Management: Aids(预防 减少和管理错误:设备/辅助) Equipment/Job Aids(预防、减少和管理错误:设备/辅助) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management• Environment Human-Centered Automation (Parasuraman, Sheridan, & Wickens, 2000) Sh id Wi k• Equipment and Job Aids • Benefits of automation • More accurate and more efficient than manual operations • Reduced operator workload under routine conditions • Costs of automation • Increased operator workload under non- routine or abnormal conditions • Poor situation awareness and degraded manual skills • G Guidelines for design of human-centered f f automation • If automation does a job better than the human, automate it; if the human does it better, let the human do it • What automation does should be transparent to the human operator • Human operator should have final authority Copyright © 2011 Boeing. All rights reserved. 21
  24. 24. Error Prevention, Reduction, and Management: Physical and Physiological Factors(预防 减少和管理错误 身体和生理因素) 预防、减少和管理错误:身体和生理因素) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management• Environment Personnel Selection—Select personnel who:• Equipment and Job Aids • Are motivated, and physically and mentally fit for the job• Physical and Physiological • Have good information processing Factors capabilities • Can perform well under stress Stress Management • Recognize stress, identify stressors, and mitigate stressors • E i Environmental solutions t l l ti • Design solutions g • Training • Improve interpersonal relationship Copyright © 2011 Boeing. All rights reserved. 22
  25. 25. Human Error: Group Perspective (人的差错:小组角度)Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management Groups can safeguard against errors made by individuals but i di id l b t can i t d introduce errors of th i own t f their type Captains have not Crew members Crew performance heeded warnings of possess information breaks down. down crew members. but do not share it.Copyright © 2011 Boeing. All rights reserved. 23
  26. 26. Flight Crew Performance Model (Helmreich & Foushee, 1993) (飞行机组表现模型) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management Group outcomes are influenced by input factors and process factorsThe diagram below is adapted with permission of Dr. Robert L. Helmreich from Fig. 1.2 in “Why crew resource management? Empirical and theoretical bases of human factors training in aviation,” 1993 by R. L. Helmreich,& H. C. Foushee. In E. L. Wiener & B. G. Kanki, R. L. Helmreich (Eds.), Cockpit resource management (pp. 3-45), New York: Academic Press. For use in this presentation only. Mission and Crew Performance Outcomes • Safety • Efficiency Crew Crew and Crew Process Performance Mission Process Factors F Input Factors Factors • Attitudes • Individual Aptitudes • Crew formation • Morale • Physical Condition and Management • Crew Composition • Aircraft Flight Control Individual and • Organizational Factors • Communications Skills Organizational • Cultures • Decision Processes Outcomes • Regulatory Environment • Situational Awareness • Operating Environment Copyright © 2011 Boeing. All rights reserved. • Operating Procedures 24
  27. 27. Crew Resource Management (CRM) is a Major Solution forGroup (ICAO, 2005)(机组资源管理是小组的主要解决方案) (ICAOEngineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management • CRM is defined as using all resources available to crew ( g equipment, g (e.g., q p procedures, and people) to manage human error. • CRM training are required by airlines in 185 countries and by International Civil Aviation Organization (ICAO), which is a regulatory component of the United Nations. • Roots can be traced to a NASA-sponsored workshop in 1979, called Resource Management on the Flight Deck which identified failures of Deck, interpersonal communications, decision making, and leadership as contributing factors in the majority of air crashes. • CRM was also instigated by the 1978 DC-8 crash outside Portland, Oregon, where all the needed information was available but not shared or used available, among the crew members to prevent the accident.Copyright © 2011 Boeing. All rights reserved. 25
  28. 28. CRM Goals (ICAO, 2005)(机组资源管理的目标)Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management • Enhance the crew performance in p • Coordination • Communication skills • Situational awareness • Decision making • Leadership • Among others create an environment of trust and support where crew others, support, members (including cabin crew members) are confident to pass on concerns to each other without fear of intimidation. • Support crew responses to threats and errors. • Contribute to the prevention of incidents and accidents.Copyright © 2011 Boeing. All rights reserved. 26
  29. 29. Human Error: Organization and System Perspective(人为错误:组织和系统角度)Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management Environment Economy Terrain Aviation System Weather Airport Air Traffic Air Traffic Regulatory Control Organization Authority • Regulations • Management • Culture • PoliciesCopyright © 2011 Boeing. All rights reserved. 27
  30. 30. Reason’s Swiss Cheese Model (Reason, 1990)(里森的瑞士奶酪模型 )Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management Design Hazard & Manufacturing Defenses in Depth Standards Procedures Decision- makers Managers Front-line F t li Personnel Accident Adapted from Figure 3.1 in FAA (2008, p. 15)Copyright © 2011 Boeing. All rights reserved. 28
  31. 31. Organization/System Error Prevention, Reduction, and Management (ICAO 1993)(组织/ 系统错误的预防 减少和管理) (ICAO, 系统错误的预防、减少和管理) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management• Enhance organizational safety g y Elements of a good safety culture: culture • Informed Culture • Reporting Culture • Learning Culture • Just Culture • Flexible Culture Copyright © 2011 Boeing. All rights reserved. 29
  32. 32. Organization/System Error Prevention, Reduction, and Management (ICAO 1993)(组织/ 系统错误的预防 减少和管理) (ICAO, 系统错误的预防、减少和管理) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management• Enhance organizational safety g y Decision-makers should consider the following h d fi i th t f ll i when defining the structure of t f culture organizations:• Improve structure of • Complexity organizations • Standardization • Formal decision-making process • Adaptability to the environment Copyright © 2011 Boeing. All rights reserved. 30
  33. 33. Organization/System Error Prevention, Reduction, and Management (ICAO 1993)(组织/ 系统错误的预防 减少和管理) (ICAO, 系统错误的预防、减少和管理) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management• Enhance organizational safety g y Organizations in socio-technical systems must allocate resources to production and t ll t t d ti d culture safety in a balanced way.• Improve structure of organizations• Improve allocation of resources Copyright © 2011 Boeing. All rights reserved. 31
  34. 34. Organization/System Error Prevention, Reduction, and Management (ICAO 1993)(组织/ 系统错误的预防 减少和管理) (ICAO, 系统错误的预防、减少和管理) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management • Focus on flight operations, maintenance,• Enhance organizational safety g y and ramp safety and so on safety, on. culture • Administer safety programs by independent• Improve structure of company safety officer who reports to organizations highest l hi h t level of corporate management. l f t t• Improve allocation of resources• Improve safety programs Copyright © 2011 Boeing. All rights reserved. 32
  35. 35. Organization/System Error Prevention, Reduction, and Management (ICAO 1993)(组织/ 系统错误的预防 减少和管理) (ICAO, 系统错误的预防、减少和管理) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management Procedures that are standard, logical, and• Enhance organizational safety g y efficient are error-resistant and thus culture contribute to safety.• Improve structure of organizations• Improve allocation of resources• Improve safety programs• Improve standard operating p p g procedures Copyright © 2011 Boeing. All rights reserved. 33
  36. 36. Organization/System Error Prevention, Reduction, and Management (ICAO 1993)(组织/ 系统错误的预防 减少和管理) (ICAO, 系统错误的预防、减少和管理) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management• Enhance organizational safety g y • Feedback from accidents and incidents to culture decision makers.• Improve structure of • Feedback from unsafe acts to decision organizations makers.• Improve allocation of resources • Feedback from line management deficiencies to decision makers. makers• Improve safety programs• Improve standard operating p p g procedures• Improve feedback and trend monitoring systems Copyright © 2011 Boeing. All rights reserved. 34
  37. 37. Organization/System Error Prevention, Reduction, and Management (ICAO 2009)(组织/ 系统错误的预防 减少和管理) (ICAO, 系统错误的预防、减少和管理) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management• Enhance organizational safety g y An SMS is “a systematic approach to a culture managing safety, including the necessary• Improve structure of organizational structures, accountabilities, organizations policies and procedures” (ICAO, 2009, p. 6-9).• Improve allocation of resources Human factors—and preventing, reducing,• Improve safety programs and managing human error—are an integral part of SMS.• Improve standard operating p p g procedures• Improve feedback and trend monitoring systems• Currently, implement Safety Management System (SMS) Copyright © 2011 Boeing. All rights reserved. 35
  38. 38. Organization/System Error Prevention, Reduction, and Management (ICAO 2009)(组织/ 系统错误的预防 减少和管理) (ICAO, 系统错误的预防、减少和管理) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management• Enhance organizational safety g y Several ICAO Annexes to the Chicago culture Convention have required Safety Management System (SMS) implementation in:• Improve structure of organizations • Air navigation services providers • Certified airport operators• Improve allocation of resources • Aircraft operators • Approved maintenance organizations• Improve safety programs • Certain other organizations• Improve standard operating p p g procedures• Improve feedback and trend monitoring systems• Currently, implement Safety Management System (SMS) Copyright © 2011 Boeing. All rights reserved. 36
  39. 39. Organization/System Error Prevention, Reduction, and Management (ICAO 2009)(组织/ 系统错误的预防 减少和管理) (ICAO, 系统错误的预防、减少和管理) Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management• Enhance organizational safety g y SMS Components culture • Safety policy and objectives• Improve structure of • Safety risk management organizations • Safety assurance • Safety promotion• Improve allocation of resources SMS Characteristics• Improve safety programs • Corporate management ownership• Improve standard operating p p g • A risk-based approach risk based procedures • Integrated into the business system• Improve feedback and trend monitoring systems• Currently, implement Safety Management System (SMS) Copyright © 2011 Boeing. All rights reserved. 37
  40. 40. Integration of Three Perspectives and Conclusion(综合三种角度及结论)Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management• Human error contributes to the majority of aviation accidents. j y • We must further address human error to improve safety.• We started to examine human error using a human information processing model.• Many factors influence human error: • H Human error t i ll occurs as a result of poor i t typically lt f interactions among operators, ti t machines/equipment, and environment. • Human error is often influenced by group and organizational factors and dynamics.• The relationship between human error and aviation safety can be viewed from different perspectives: • Individual • Group • Organization and SystemCopyright © 2011 Boeing. All rights reserved. 38
  41. 41. Integration of Three Perspectives and Conclusion(综合三种角度及结论)Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management Environment Economy Terrain Aviation System Weather Airport Air Traffic Air Traffic Regulatory Control Organization Authority • Regulations • Management • Culture • PoliciesCopyright © 2011 Boeing. All rights reserved. 39
  42. 42. Integration of Three Perspectives and Conclusion(综合三种角度及结论)Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management A network of interactions and influences among individuals individuals, groups, organizations, equipment, and environment means human error perform in areduction, humans prevention, large complex system with many p byg andpmanagement must occur y yg y pulling influences and is not the result of integrating solutions across any one action in isolation. individual, group, and organizational levels levels.Copyright © 2011 Boeing. All rights reserved. 40
  43. 43. Integration of Three Perspectives and Conclusion(综合三种角度及结论)Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management Strategies to prevent , reduce, and manage error: g p , g • Personnel selection • Training including Crew Resource Management (CRM) • Environment improvement • Human-machine interface design improvement • Organizational measures including Safety Management System (SMS)Copyright © 2011 Boeing. All rights reserved. 41
  44. 44. Integration of Three Perspectives and Conclusion(综合三种角度及结论)Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management Studying, preventing, reducing, Studying preventing reducing and managing human error is an effort among many people working together Pilots Air Traffic Controllers Dispatchers g Regulators Flight Attendants Designers D i Managers E i Engineers S i ti t Scientists Mechanics Accident InvestigatorsCopyright © 2011 Boeing. All rights reserved. 42
  45. 45. References(参考资料)Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management• FAA (Federal Aviation Administration). (2008). Air traffic organization safety management system manual ( l (version 2.1). W hi t i 2 1) Washington, DC: FAA. DC FAA• Helmreich, R. L. & Foushee H. C. (1993). Why crew resource management? Empirical and theoretical bases of human factors training in aviation. In E. L. Wiener & B. G. Kanki, R. L. Helmreich (Eds.), Cockpit resource management (pp. 3-45). New York: Academic Press.• ICAO (International Civil Aviation Organization). (1993). Human factors digest No. 10: Human factors, management and organization (Circular 247-AN/148). Montreal: ICAO.• ICAO. (2005). Human factors training manual (Doc 9863-AN/950). Montreal: ICAO.• ICAO (2009). Safety management manual (Doc 9859) (2nd ed ) Montreal: ICAO. ICAO. (2009) ed.). ICAO• Parasuraman, R., Sheridan, T. B., & Wickens, C. D. (2000). A Model for types and levels of human interaction with automation. IEEE Transactions on Systems, Man, and Cybernetics—Part A: Systems and Humans, 30(3), 286 297 Humans 30(3) 286-297.• Reason, J. (1990). Human error. Cambridge, UK: Cambridge University Press.• Wi k Wickens, C. D. (1992) E i C D (1992). Engineering psychology and human performance (2 d ed.). New Y k i h l dh f (2nd d ) N York: HarperCollins Publishers Inc.• Wickens, C. D., Gorden-Becker, S. E., Liu, Y., & Lee, J. D. (2003). Introduction to human factors engineering (2nd ed.). Upper Saddle River, NJ: Prentice Hall.Copyright © 2011 Boeing. All rights reserved. 43
  46. 46. Acknowledgment(致谢)Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management• This presentation used or benefitted from some used, from, materials from the following Boeing colleagues: Mr. Robert E. Johnson, Dr. Randall J. Mumaw, and Dr. William L. Rankin. L RankinCopyright © 2011 Boeing. All rights reserved. 44
  47. 47. Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management Thank you!(谢谢!) 有问题吗 Questions?(有问题吗?)Copyright © 2011 Boeing. All rights reserved. 45
  48. 48. Copyright © 2011 Boeing. All rights reserved. 46

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