The document discusses error management in aviation operations. It notes that over 70% of flights observed had at least one error or violation, with about 30% being mismanaged or leading to additional errors. It covers reasons for errors like habits, inaccuracies and omissions. While errors do not always lead to incidents, they can impact flight safety depending on other factors. The document recommends strategies for error management, including prevention, reduction, detection, recovery and tolerance. It suggests different approaches are needed for slips, lapses, mistakes, routine violations and optimizing violations. The goal is to implement systemic solutions rather than punishing individuals.

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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

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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