2. SUBJECTS
- Objective SMS
- SMS Manual
- Safety Evolution in Aviation
- Threats to Safety and Quality
- Human Error Defined
- Human Error
- Human Factors
- Human Error Model
- Error Mechanism Categories
- Strategic Approach
- Safety/ Risk Management
- Safety Policy/ Just Culture
5. SAFETY EVOLUTION IN AVIATION
TODAY
Organizational Factors
Human Factors
Technical Factors
1950s 1970s 1990s 2000s
6. Threats to Safety
en Quality “ We have met
the enemy……and
he is us!”
Errors
happen!
7. HUMAN ERROR DEFINED
An inappropriate or undesirable human decision or
behavior that reduces or has the potential to reduce
effectiveness, safety, or system performance
A human action/decision that exceeds system tolerances
• “An action is taken that was ‘not intended by the actor
12. Loadmaster killed as he walks into prop.
Body and remains scattered over 100 feet.
13.
14. HUMAN ERROR MODEL
Basic Errors
Unsafe
Acts
Unintended
Action
Intended
Action
Slip
Lapse
Mistake
Violation
Skill-Based-
Attentional
Failures
Skill-Based-
Memory
Failures
Rule-based or
Knowledge-based
Mistakes
Routine violations
Exceptional violations
Sabotage
INCIDENT/ACCIDENT
15. Attention Failures
Memory Failures
Failures in Execution
Misapplication of a good rule
Application of a bad rule
DecisionErrors
Error Mechanism Categories
Skill Based:
Rule Based:
Knowledge Based:
Inaccurate knowledge of the system
Incomplete knowledge of the system
16. WHAT TO DO ABOUT IT?
Instead of trying to change the human condition –
change the conditions under which people work
Reduce the error-provoking nature of the task,
the team, the workplace and the organization
Strengthen and improve defenses to limit and
contain the bad effects of those errors that will
still occur
20. INTRODUCTION IN RISK MANAGEMNT
Een continue proces net als het
kwaliteits proces
Identificeren – Analyseren –
Mitigeren – Monitoren - ..........enz
We blijven rondgaan totdat het
risiko aanvaarbaar laag is
21. SAFETY POLICY
Belangrijke verklaring van de
Accontable Manager waarin hij
verklaart verantwordelijk te zijn
voor al onze operaties en services!
Dit betekent nogal wat!!
Dit kan alleen als wij er allemaal
aan mee doen!!!
Hij moedigt dan ook iedereen aan
potentiele gevaren en gevaarlijke
situaties te melden!!
22. JUST-CULTURE
Een Rechtvaardige Cultuur is hiervoor
een NOODZAAK
De melder van voorvallen mag NOOIT
gestraft worden
Dat mogen we verwachten van onze
Accountable Manager maar ook van de
Overheid!!
According to Wiener, "Complacency is caused by the very things that should prevent accidents, factors like experience, training and knowledge contribute to complacency. Complacency makes crews skip hurriedly through checklists, fail to monitor instruments closely or utilize all navigational aids. It can cause a crew to use shortcuts and poor judgment and to resort to other malpractices that mean the difference between hazardous performance and professional performance.
Wij doen hetzelfde als leerlingen solo gaan! Met draaiende motor uitstappen!?
Slips and Lapses
In a familiar and anticipated situation people perform a skill-based behaviour. At this level, they can commit skill-based errors (slips or lapses). In the case of slips and lapses, the person’s intentions were correct, but the execution of the action was flawed - done incorrectly, or not done at all. This distinction between being done incorrectly or not at all is another important distinction.
When the appropriate action is carried out incorrectly, the error is classified as a slip. When the action is simply omitted or not carried out, the error is termed a lapse. “Slips and lapses are errors which result from some failure in the execution and/or storage stage of an action sequence.” Reason refers to these errors as failures in the modality of action control: at this level, errors happen because we do not perform the appropriate attentional control over the action and therefore a wrong routine is activated.
Examples of slips and lapses in aviation
A classic example is an aircraft’s crew that becomes so fixated on trouble-shooting a burned out warning light that they do not notice their fatal descent into the terrain. In contrast to attention failures (slips), memory failures (lapses) often appear as omitted items in a checklist, place losing, or forgotten intentions. Likewise, it is not difficult to imagine that when under stress during in-flight emergencies, critical steps in emergency procedures can be missed. However, even when not particularly stressed, individuals have forgotten to set the flaps on approach or lower the landing gear. (Lapses -> balie dames schrijven to list of op de dagstaat)
Mistakes
Once a situation is recognised as unfamiliar, performance shifts from a skill-based to a rule-based level. First of all, the human tries to solve the problem by relying on a set of memorised rules and can commit rule-based mistakes. These kinds of error depend on the application of a good rule (a rule that has been successfully used in the past) to a wrong situation, or on the application of a wrong rule.
In the case of planning failures (mistakes), the person did what he/she intended to do, but it did not work. The goal or plan was wrong. This type of error is referred to as a mistake.
When we recognise that the current situation does not fit with any rule stored, we shift to knowledge-based behaviour. At the knowledge-based behaviour level we can commit planning errors (Knowledge based mistakes). They basically concern the difficulty we have in gathering information on all the aspects of a situation, in analysing all the data and in deriving the right decision. Planning is based on limited information, it is carried out with limited time resources (and cognitive resources) and it can result in a failure.
Carola/ joris roelofs/ Jacco Arensman en de kaart rondvlucht map
Decision making on basis of SB – RB - KB
James Reason
Foute Management beslissingen:
Onvoldoende of onvolledige procedures
Kosten besparingen
Geen trainingen
Onvoldoende Supervisie:
Niet corrigeren van bekende problemen
Workload/ stess
Onvoldoende training
Vermoeidheid (mentaal physiologisch)
Fouten
Verkeerde Perceptie
Foute Beslissingen