Systematic Approach in Managing Human Error in Aviation

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Systematic Approach in Managing Human Error in
Aviation
Luftfartskonferansen 2007

• Vangelis Demosthenous
• Training Consultant
• Trinity College University of Dublin

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Presentation Outline

• Why many human factors efforts in aviation fail
• What could we learn from European research on
  Human Factors
• What could we learn from other organisations on
  Human Factors
• What are some basic steps for implementing a
  human factors program in aviation

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Trinity College, University of Dublin
A 16th Century university with 21st Century
knowledge

• Aerospace Psychology Research Group, founded 1992
• Research on human and organisational factors in
  aviation and other high reliability industries
• STAMINA training developing human factors
  expertise in the industry

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Our broader approach to HF Training
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Our Human Factors Courses - Trainees from various
Organisations including
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Human Factors Implementation- An example of an
Organisation
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What is our Company doing about Human Factors?

• We comply with all current regulations.
• A recent audit from the CAA did not resulted in
  any findings on Human Factors.

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What do people, management and workforce, think
about Human Factors and how do they handle it?

• Did not really believe in human factors?
• Not all incidents were reported
• People thought that human factors is only training

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How is the rest of the industry handle Human
Factors?Is there any research activity that we
could learn from?

• Benchmarking
• Internet
• Conference proceedings

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Benchmarking Flight Operations

• CRM in various effectiveness levels
• Performance monitoring systems (e.g. LOSA)
  applied by some operators
• Performance monitoring systems do not provide
  clear route to changing the operational system
  (findings from HILAS project)

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Benchmarking Maintenance

• Tendency to address problems on the sharp end
  only
• Quality of data from incidents and audit findings
  and proper management of this data
• There is a big gap between the proper and the
  actual way of doing things (e.g. violation of
  procedures)

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Is there any research activity that we could
learn from?

• Eurocontrol
• HILAS Supported by EU
• 4c4p Model

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The HILAS Research Project

• HILAS - learning from operational performance in
  flight operations maintenance to improve
  aviation systems and technologies
• Supported by the European Commission 6th
  framework programme.

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The HILAS Research Project

• Integrated project with 40 partners
• 13 European countries Israel, China
• Manufacturers
• Airlines
• Maintenance organisations
• Research institutes, universities
• RTD companies
• Initiated 1st. June 2005 to last 4 years

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Core management team

• Trinity College Dublin (co-ordinator)
• Smiths Aerospace
• Thales Avionics
• JRC
• Aircraft Management Technologies (AMT)
• Easyjet
• SAS Braathens AS
• NLR

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HILAS - 4 Strands of activity

• Knowledge Integration
• Flight Operations
• Flight Deck Technologies
• Maintenance

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4p4c Model A Model for Implementing and
Auditing Human Factors
By Trinity College, University of Dublin
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Functions of a Human Factors Programme
Continuous Improvement

• Occurrence Management
• Investigations
• Audits
• Implementing monitoring recommendations
• Risk analysis

By Trinity College, University of Dublin
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Functions of a Human Factors Programme
Competence

• Training Needs Analysis
• Initial and continuation training
• Developing trainers
• Training management records
• Assessment
• Training evaluation
• Ongoing competence review
• Management development to manage human factors

By Trinity College, University of Dublin
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Functions of a Human Factors Programme

• Rewarding reporting, safety, initiative,
  ownership
• Management communication
• Handling confidentiality
• HR procedures promotions, performance review,
  etc.
• Procedure for procedure deviation

Culture
By Trinity College, University of Dublin
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Functions of a Human Factors Programme

• HF principles in writing procedures
• Shift/task hand over procedures
• Human performance limitations in planning
• Duplicate inspections
• Planning procedures to ensure the availability of
  resources
• Signing off tasks performed by others

Comprehensive Integration
By Trinity College, University of Dublin
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Cascading evolution of human factors elements in
an organisation
By Trinity College, University of Dublin
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4ps- An example
Competence makes good business sense
Training Establishment
Identifying Competencies
Training Methods
By Trinity College, University of Dublin
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4p4c Model A Model for Implementing and
Auditing Human Factors (see Auditors Course
delivered by Trinity College)
By Trinity College, University of Dublin
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Implementation Plan for a Human Factors Program
Basic steps

• Verify Commitment from Management and Workforce
• Make a Gap-Analysis
• Select areas of implementation using
• Gap-Analysis outcomes
• Risk Management principles
• Use a System not a Band-aid approach
• Develop and implement a detailed plan

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Commitment from Management and Workforce

• Present experience from other organisations
• Identify benefits for the organisation
• Identify benefits for themselves

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Gap-Analysis
Where we are
Where do we want to go
Gap
What measures are cost effective and feasible
What measures can be appliedto correctthe gap
How important is the performance gap
Compare in order to determine the
performance gap
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Determining the Gap
Regulatory Requirements
Incident reports
Benchmarking
Audit reports
Safety Management System
Surveys
Where we are
Where we want to go
Gap
Corporate Goals
Observations
Interviews discussions
Audits Findings and incident Recommendations
Normal Operation Monitoring
Safety Culture Principles
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Risk Management Get Priorities Right
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System VS Band-aid Approach
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System VS Band-aid Approach

• Band-aid Approach
• just repair the damage
• System Approach - Find out
• Why did the damage happen?
• Whether this is a frequent event (including other
  aircraft?
• What defences in our system failed to prevent
  this from happening? why did they failed?
• How could we minimise the risk associated with
  this hazard?

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Develop Implement a detailed Plan

• Plan to be consistent with corporate goals,
  policies and procedures
• Specify managements role
• Appoint a senior person who believes in the topic
• Do not attempt to do everything at once the
  program should be evolution not revolution
• Start with simple tasks that produce results
• Appoint people responsible for each task
• Form working team(s) as required
• Set time schedules deadlines

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Human Factors ProgramTypical Reasons for Failure

• Insufficient support from the management
• Failure to set objectives other than meeting the
  requirements
• Establishing not a truly just culture
• Competencies of key people not addressed properly
• Marginalised application e.g. mainly training

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Human Factors and Safety Management System

• Human Factors provide methods for identifying and
  controlling many of the potential hazards
  (remember the 80)
• Human Factors should be an integral part of the
  SMS program.

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The success of Human Factors depends on other
System Conditions and other System Parts
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Human Factors and some of the other System
Conditions and Parts
Safety Culture
Safety Management System
Health Safety
Human Factors
Quality System
Work Incentives
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Measure Program Effectiveness

• Get peoples opinions, thoughts, sense their
  attitudes through
• Surveys
• Training feedback
• Monitor behaviour at work
• Use operational performance indicators (e.g.
  KPIs)
• Ensure that ROI (Return On Investment) is
  measured
• Measure performance before and after
  implementation

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Take measures to keep program alive

• Promote benefits including ROI - Share the
  success stories
• Recognize individuals or teams efforts
• Celebrate successes
• Conduct regular meetings with management and
  workforce to get feedback and share goals,
  lessons learned, progress acheived.

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So What did I learn?

• Go beyond regulations
• Get people involved
• Learn from others (benchmark, research etc)
• Know where we are, where we want to go and how to
  get there
• Systemic approach
• Measure effectiveness

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Thank you!