ALIAS Conference 14-15 June 2012, EUI - Florence (Italy)Air disasters as organizational  errors: the case of Linate       ...
8.10.2001: The second most serious aircrash              ground accident                                   SAS MD87       ...
The accident dynamic  TWR                     MD87                  •• •                   •              •               ...
4
5
The sierra four …                                         (8.08.23)                MD87                                   ...
The accident dynamic                            (8.09.19)                    MD87                            (8.09.28)    ...
Accident Dynamic                   8
9
Why? Who is to blame?   Cessna pilots mistake   Ground controller error   Inadequate signals condition   Absence of a ...
The Error of Human Error…“... ‘human error’ is not a well defined category ofhuman performance. Attributing error to the a...
A multilevel model for the                    analysis of accidentsInter-organizational level - Integration - Coordination...
1. Individual Level• The Cessna and two pilots were not qualified and  certified to operate in low visibility conditions (...
2. Organizational FailuresFailures defences           No Surface Movement Radar (out of service since November 1999)     ...
3.The bigger picture—Linate                    ENAC              (airport authority)        ENAV                        SE...
Individual Failures                        Organizational and                                               Inter-organiza...
Failure Levels                          Inter-organizational level     •   Cost/safety trade-offs     •   Failures of inte...
Active versus Latent Failures               Inter-       Latent Conditions           Organizational    Coordination negle...
Conclusions• If we focus too closely upon the unsafe acts at  the sharp end, we are in danger of missing the  fact that th...
Two ways of looking at accidentsIndividual Blame Logic       Organizational Function Logic                     Errors and ...
Vicious Circle Individual                Organizational inertiaBlame Logic                 Defensive behavior             ...
Defensive Medicine?•   Defensive medicine takes place when healthcare    personnel prescribe unnecessary treatments, or av...
Defensive Medicine         Study         Year   Country       Result                                        (% of defensiv...
Positive DefensiveMedicineNegative DefensiveMedicine                     24
25
The side effects of defensive medicine• The threat of legal investigation does not make the  medical system more careful a...
Virtuous Circle  Organizational                         Removing latent factors  Function Logic                         Or...
Getting the balance right     Person model                              System model      Proximal                        ...
Blame free                   Just     Punitive culture                               cultureAll errors to system failure  ...
Just culture 10%             90%Blame          No Blame                          30
Establishing a Just Culture                   At-risk       Reckless         MaliciousHuman error                  behavio...
The Case of the    Italian Air Force•   20 flight divisions;    1000 pilots•   1990: The accident    of “Casalecchio di   ...
New risk and safety policy•    The promotion of a new vision of risk management and     safety•    The promotion of method...
Two different strategies        compliance vs. deterrentA deterrent strategy (blame culture)•   is backward-looking,•   im...
Just culture at ITAF(extracts from interviews) • For each event we look for the reason why it happens.   We do not talk ab...
Reporting of Incident and Flight Safety Occurrences          1991-2009 (rate for 10,000 hours of flying)220               ...
Major accidents                                1990 - 201026                    242422             21          20         ...
Number of accidents 1980-2010                               NUMBER       RATEO   DEADS      1980 – 89                     ...
Conclusion Either organizations manage human  errors, by learning from them                    Or… human errors will man...
Upcoming SlideShare
Loading in …5
×

Air disasters as organisational errors: the case of Linate by M. Catino

1,783 views

Published on

If you are interested in the topic please register to the ALIAS network:
http://network.aliasnetwork.eu/
to download other materials and get information about the ALIAS project (www.aliasnetwork.eu).

Published in: Technology, Business
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,783
On SlideShare
0
From Embeds
0
Number of Embeds
4
Actions
Shares
0
Downloads
92
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Air disasters as organisational errors: the case of Linate by M. Catino

  1. 1. ALIAS Conference 14-15 June 2012, EUI - Florence (Italy)Air disasters as organizational errors: the case of Linate Prof. Maurizio Catino University of Milan - Bicocca (Italy) maurizio.catino@unimib.it 1
  2. 2. 8.10.2001: The second most serious aircrash ground accident SAS MD87 Cessna 2
  3. 3. The accident dynamic TWR MD87 •• • • • •• • Cessna R5 R6 3
  4. 4. 4
  5. 5. 5
  6. 6. The sierra four … (8.08.23) MD87 (8.08.28) (8.08.32) Cessna (8.08.36) • Roger, … D-VX hold position (8.08.40) 6
  7. 7. The accident dynamic (8.09.19) MD87 (8.09.28) (8.09.37) Cessna (8.09.38) 7
  8. 8. Accident Dynamic 8
  9. 9. 9
  10. 10. Why? Who is to blame? Cessna pilots mistake Ground controller error Inadequate signals condition Absence of a ground radar Airport management negligence Tragic fatality … 10
  11. 11. The Error of Human Error…“... ‘human error’ is not a well defined category ofhuman performance. Attributing error to the actionsof some person, team, or organisation isfundamentally a social and psychological processand not an objective, technical one.”(Woods et al., 1994)Assume that thesource of failure is“human error” Analyse events to find where a person is involved Stop analysis when one is found 11
  12. 12. A multilevel model for the analysis of accidentsInter-organizational level - Integration - Coordination Defences -… Individual-level (errors, violations, mistakes, decisions) Accident Organizational level - Defences - Managerial decisions - Error-inducing conditions -… (Catino 2010) 12
  13. 13. 1. Individual Level• The Cessna and two pilots were not qualified and certified to operate in low visibility conditions (land and take off) such as that day (violation)• The Cessna crew took the wrong taxiway (error) and entered the runway without specific clearance (violation)• There were communication failures between the tower and the Cessna pilots: the ground controller did not realize that the Cessna was on taxiway R6 (error), and he issued a clearance to taxi towards the main apron although he could not make sense of the report position S4 13
  14. 14. 2. Organizational FailuresFailures defences  No Surface Movement Radar (out of service since November 1999)  Installed equipment for prevention r.i. at R6 intersection deactivated  TWY Lights  Stop BarsError-inducing conditions  The ground markigs were not clearly visible (RWY Holding Position Markings)  Signs, signals and lights were inadequate and misleading (out standard ICAO)  Official documention failed to report the presence of unpublished marking (S4, S5, etc)Latent failures  No learning from near miss  Best practices not applied  No functional Safety Management System 14
  15. 15. 3.The bigger picture—Linate ENAC (airport authority) ENAV SEA(air traffic regulator) (Service Provider) 15
  16. 16. Individual Failures Organizational and Inter-organizational Failures Markings and signs were not in accordance with ICAO standards; Red bars and TWY lights non The Cessna crew took the wrong controllable by ATC; Deficiency in the state oftaxiway (error) and entered the runway implementation and maintenance of airport without specific clearance (violation) standard signage; Official documentation failed to report the presence of unpublished markings (S4); No equipment to prevent runway incursions No surface movement radar; Installed equipment There were communication failures for prevention r.i. at R6 intersection deactivated; between the tower and the Cessna Markings and signs were not in accordance with ICAO standards; Deficiency in the state of pilots implementation and maintenance of airport standard signage; Non-compliance with international standards on markings, lights and signs; High traffic volume; lack of visual aids The Cessna and two pilots were notqualified and certified to operate in low Lack of coordination among the airportvisibility conditions (land and take off) authorities; weaknesses in the control system such as that day (violation) 16
  17. 17. Failure Levels Inter-organizational level • Cost/safety trade-offs • Failures of integration and coordination • Bureaucratic safety culture • No Safety Management system • … Organizational - level • No ground radar Individual-level • No international safety standard• Errors • Weak defenses• Violations • Lack of visual aids• Communications • No learning from near miss misunderstandings • … 17
  18. 18. Active versus Latent Failures Inter- Latent Conditions Organizational  Coordination neglect Factors  Inadequate safety policies Organizational Latent Conditions Factors  No ground radar; no international standard  No learning from near miss; … Preconditions Latent Conditions for  Poor visibility of R5/R6 signs; Mental Fatigue; Unsafe Acts  S4 marking unknown to the controller; … Unsafe Active Conditions Acts • The Cessna crew took the wrong taxiway and entered the runway Failed or • Communication failures Absent Defenses Accident & Injury(Adapted from Reason, 1997) 18
  19. 19. Conclusions• If we focus too closely upon the unsafe acts at the sharp end, we are in danger of missing the fact that this was the result of an organizational error• It’s important to take a system perspective• Communication and organization problems of many kinds were crucial factors in this and other disasters 19
  20. 20. Two ways of looking at accidentsIndividual Blame Logic Organizational Function Logic Errors and Accidents 20
  21. 21. Vicious Circle Individual Organizational inertiaBlame Logic Defensive behavior Blame culture Search for the guilty Hidden errors 21
  22. 22. Defensive Medicine?• Defensive medicine takes place when healthcare personnel prescribe unnecessary treatments, or avoid high-risk procedures, with the goal of reducing their exposure to malpractice litigation• Doctors in particular may: • prescribe unnecessary tests, procedures or specialist visits (positive defensive medicine), • or, alternatively, avoid high-risk patients or procedures (negative defensive medicine). 22
  23. 23. Defensive Medicine Study Year Country Result (% of defensive behaviours)Tancredi 1978 US 70%Studdert et al. 1995 US 93%Summerton 2000 UK 90%Hymaia 2006 Japan 98%Jackson Healthcare 2008 US 72%Massachusetts 2009 US 83%Medical Society 23
  24. 24. Positive DefensiveMedicineNegative DefensiveMedicine 24
  25. 25. 25
  26. 26. The side effects of defensive medicine• The threat of legal investigation does not make the medical system more careful and attentive toward the patient• Individual blame logic does not improve patient safety• Develop the capacity to learn from errors and system failures to become more resilient and reliable• To achieve this, a profound cultural and juridical transformation is required• Promote a different culture to reduce defensive medicine and to promote a process of learning from error 26
  27. 27. Virtuous Circle Organizational Removing latent factors Function Logic Organizational learning Just culture Search for Reporting close calls,organizational criticality errors 27
  28. 28. Getting the balance right Person model System model Proximal Remote factors factors Individual Collective responsibility responsibility Both extremes have their pitfalls(Reason, 1997) 28
  29. 29. Blame free Just Punitive culture cultureAll errors to system failure Individuals areNo individual is to be held blamed for all accountable mistakes 29
  30. 30. Just culture 10% 90%Blame No Blame 30
  31. 31. Establishing a Just Culture At-risk Reckless MaliciousHuman error behavior behavior behaviorInadvertent A choice: Conscious Violationsaction: slips, risk not disregard of Gross lapses, recognized unreasonable negligence mistakes or believed risk Criminal justified offences Reassure Coach Punish Unintentional Deliberate No blame Culpable 31
  32. 32. The Case of the Italian Air Force• 20 flight divisions; 1000 pilots• 1990: The accident of “Casalecchio di Reno”: 12 people died• New organization, new culture 32
  33. 33. New risk and safety policy• The promotion of a new vision of risk management and safety• The promotion of methods for the identification, analysis and prevention of risks (critical latent factors)• Database for incident reporting (voluntary and anonymous for the centre)• Ongoing training and education about safety and perception of errors in order to learn from them• The implementation of a just culture 33
  34. 34. Two different strategies compliance vs. deterrentA deterrent strategy (blame culture)• is backward-looking,• implemented after the accident happens• punitive, sanctions directed towards the individuals or organizations responsible for an error or accidentA compliance strategy (ITAF - just culture)• is forward-looking and preventive• early identification of errors and latent factors 34
  35. 35. Just culture at ITAF(extracts from interviews) • For each event we look for the reason why it happens. We do not talk about blame and responsibility. We do not want to know who the guilty person was but why the event happened and what we can do to avoid it in the future. • Error is a mechanism for learning (… there are some ) errors that if analyzed can help prevent future errors. • The more people I inform about my error, the less they risk repeating the error • The organization does not put pressure on people committing an error. Nobody is afraid of being punished. The debriefings are a training activity to talk and improve our work. The exchange among experts and newcomers is a good occasion for both people as it helps to see things from different points of view. 35
  36. 36. Reporting of Incident and Flight Safety Occurrences 1991-2009 (rate for 10,000 hours of flying)220 1922200 1745 1575180 1650 1773 1732160 1514 1472 1539140120 1130 1073100 1180 1064 650 1143 989 92180 645 574 550 600 694 729 681 865 5726040 391 410 434 340 274 266 240 272 24520 143 22 29 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 (Source: ITAF Flight Safety Inspectorate) Human Factors Total 36
  37. 37. Major accidents 1990 - 201026 242422 21 20 2020 1918 1616141210 9 8 8 8 88 6 6 6 66 5 5 4 44 3 320 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10(Source: ITAF Flight Safety Inspectorate) 37
  38. 38. Number of accidents 1980-2010 NUMBER RATEO DEADS 1980 – 89 87 0,59 61 1990 - 99 51 0,38 43 2000 - 10 33 0,32 22(Source: ITAF Flight Safety Inspectorate) 38
  39. 39. Conclusion Either organizations manage human errors, by learning from them Or… human errors will manage organizations To achieve the first one, is fundamental to develop a just culture 39

×