Error

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Error
Management
OGHFA 1_HP_06_VIS_Error Management 1

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Normal operations:
• threats and errors
• deviations
• failures and successes
Accidents
Serious incidents
Minor incidents
Frequency of event, Quantity of data
Severity
of
event

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Frequency of event, Quantity of data
Severity
of
event
Normal operations:
• threats and errors
• deviations
• failures and successes
Accidents
Serious incidents
Minor incidents
Normal operations:
• threats and errors
• deviations
• failures and successes

4. OGHFA 1_HP_06_VIS_Error Management 4
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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 Intention to achieve something
 Good plan
 Action “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 new
Routine
Mistakes
(capacity overflow)
Slips & Lapses
Mistakes
(incorrect solutions)
Exceptional
violations
Routine
violations
Optimizing
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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 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 Reduction
Minimizing the likelihood of error
Minimizing the consequences of error

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Error Detection
Facilitate easy and rapid detection of errors

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Error Management Strategies
Error Recovery
Make it easy to rapidly recover to a safe state

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Error Tolerance
Build the system to
tolerate errors

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Error Prevention
Where 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)
Exceptional
violations
Routine
violations
Optimizing
violations

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Slips & Lapses
Mistakes
(incorrect solutions)
Routine
violations
Optimizing
violations

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Slips & Lapses
Mistakes
(incorrect solutions)
Routine
violations
Optimizing
violations
• Error Tolerance
• Error Reduction
• Error Detection

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Mistakes
(incorrect solutions)
Routine
violations
Optimizing
violations
Key issues:
• Situation Recognition and
Diagnosis
• Decision Making

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Violation
Management
Routine
violations
Optimizing
violations

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Optimizing
violations
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 improvise
Routine
violations

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Optimizing
violations
 Remove the need to Violate
Adequate planning
Capability to adapt to new
demands
Open communication
 Safety Culture
Routine
violations

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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