Threat And Error Management And Culture Flashcards
What is the role of human error in aviation accidents
- More than 75% of accidents = human error
- Half of global airline accidents are traced to pilot error
What is the degree to which human error can be eliminated?
Never completely
What are the main type of threats which could potentially affects a safe flight?
External - not caused by crew
- Expected: foreseeable e.g. terrain, forecast, wether, airport conditions
- Unexpected: unforeseeable e.g system malfunctions, operational pressures, unforeseen weather developments
Internal threats - the flight crew themselves e.g. stress, fatigue, distractions etc.
Latent threats - not obvious to crew and could lie dormant e.g. vague policies, poor culture
Overt/Active threat - these bite immediately and can include environmental factors, organisational or the crew themselves
Describe the threats management (a/b/c) recognising, avoiding and mitigating the effects of threats.
- Recognising: identify potential threats e.g. TCTWOS, ABRIEFS
- Avoiding: Identify current threats that are developing and avoid them - maintain S.A.
- Mitigating: Establish counter-measures to effectively diffuse the development of a risky situation
Identify examples of over/active threats.
Exists on the day of the flight, can be anticipated or unexpected, generally observable factors.
- Organisational e.g. scheduling changes, pressure from management.
- Environmental e.g. thunderstorms, icing conditions, ATC radar outages.
- Crew member e.g. unfamiliarity with aircraft type, non-native English proficiency.
- Individual - insufficient sleep, dehydration, recovering from an illness.
What are examples of aviation threats?
Latent threat = originate from higher up in aviation system and trickle down to the flight line. Develop behind the scenes.
E.g.
- Equipment design
- Visual illusions
- Aircraft malfunction
- Risk taking culture
Methods and means for detecting error in aviation system.
- Self detection
- Environmental signals
- Detection by another person
Pilot error types:
- Error of omission: left out crucial step or procedure
- Error of commission: performance an unnecessary or undesired action
- Sequential errors: performed steps in the incorrect order
- Time errors: did something too fast, too slow, too early, or too late.
Error avoidance techniques
- Briefings
- SOPs
- Checklists
How can incipient errors be trapped after they have been committed?
- Checklist usage
- Monitoring/situational awareness
- Operating procedures
- Check an verify
- Conform communications
- Clarify communications
- Question and communicate
How can the consequences of errors that are not trapped be mitigated?
- Crew must act quickly
- Don’t allow the aircraft to enter an undesired state
- Use CRM - teamwork, leadership, responsibility
How CRM countermeasures assist the management of threat and error.
- Crew/team countermeasures: open communication, teamwork, share the workload
- Planning and countermeasures: briefings, handovers, planning and mental simulation, contingency planning
- Execution countermeasures: monitoring, checklist discipline, cross/rechecks, maintaining SA, information management, task/workload management
- Review and modification of countermeasures: evaluating and modifying plans, inquiry and questioning.
What are the basic elements of the Reason model?
Swiss cheese model:
- Each slice of cheese has unique combination of holes which represents weakness within the system
If enough errors are made the holes will line up and an accident happens
Identify examples of a latent failure/error.
- Organisation influence: poor comms, not enough staff, shoestring training budgets, strenuous work schedules, turning a blind eye to certain regulations.
- Unsafe supervision: failure to effectively monitor/log employee performance, failure to identify risky behaviour, insufficient oversight of subordinates.
- Preconditions for unsafe acts: adverse weather, low IFR conditions, faulty equipments, crew fatigue, recent change in regulations or company operating procedures
Identify examples of an active failure/error.
AKA The Unsafe Acts
Primary cause = pilot error
E.g.
- Failure to maintain sufficient airspeed on final approach = stall
- Controlled flight into terrain
- Flying into severe weather due to lack of sufficient understanding of the aircraft’s radar system
- Fuel exhaustion and subsequent crash resulting from use of incorrect fuel-conversion units
Describe slips, lapses, mistakes and violations
- Slips = actions not carried out as intended
- Lapses = missed actions and omissions
- Mistakes = due to faulty plan and intention
- Violations = deliberate illegal actions
What are the elements in a safety culture?
- Commitment
- Behaviour
- Awareness
- Adaptability
- Information
- Justness
What are the reporting mechanisms to rectify safety problems?
Systematic and comprehensive reporting system made up of a confidential reporting system and a non-punitive environment.
- Feedback needs to be received of reports
What is the core concept of an organisational culture?
Ideally - Safety behaviour is fully integrated into everything the organisation does
- Starts from top, moving downwards
The principles of Safety Management System (SMS) in air operations
- Ensures that all employees feels responsible for and consider the impact of safety on everything they do.
- Must be generated ‘top-down’ and relies on a high degree of trust and respect between employees and management
What is meant by harassment, its effects on employees and how it should be dealt with should it arise in the workplace.
- Unwelcome comment, conduct or gesture that is insulting, intimidating, humiliating, malicious, degrading or offensive. It may be repeated or isolated incident.
- Raise awareness
- Become a role model
- Be aware of the atmosphere
- Open communication
What is meant by stereotypes and stereotypical behaviour within organisations and give examples of where such behaviour may have a negative impact on safety.
- Extension of social identity
- People don’t live up to their potential when you label and categorise them
- Makes it difficult to interact with others
- Safety culture can be compromised
Inertia of large organisation with respect to safety messages
- The enemy of most large companies is people who are afraid or unwilling to change
- safety message in a. Company will always become stagnant if change is not applied
Key reasons for safety reporting in aviation
- confidential means that reporters do not have to worry about any possible negative consequences of coming forward with safety problems
- Employees can identify hazard and notify management of potential organisational weaknesses
The rational for mandatory reporting of incidents as required by part 12.
Allows CAA to ensure the are informed so changes can be made to improve safety.
What is the relevance of internal hazard reporting?
- Contributes to the improvements of flight safety by ensuring that relevant information on safety is reported, stored, protected and disseminated.
Sole objective = prevention of accidents and incidents and not to attribute blame or liability
The key elements of the Just Culture approach to the management of errors, reporting and the use of disciplinary sanctions under this approach.
- People will not be punished if the error was unintentional
- Those who act recklessly or take deliberate or unjustifiable risks will however be subject to disciplinary action
Distinguish between normal error, at risk behaviour and high culpability behaviour.
Human error = person inadvertently Carrie out an error. Slip, Lapse, Mistake
At risk behaviour = a choice, risk not recognised or believed justified
High Culpability Behaviour = a conscious disregard of a substantial and unjustifiable risk
Distinguish between negligent and reckless behaviour.
Negligent = failing to take proper care. Not recognising the risks involved, believing risky actions are justified.
Reckless = knows the risk involved, but deliberately and knowingly choose to ignore
Attribute of at risk behaviour
- Where people behave in a manner that increases risk, they either fail to recognise the risks involved involved or they think the risk is justified.
- Some people are gamblers while others are not
- Age experience, attitudes of the pilots
Concepts of risk creep and risk tolerance and their application within an aviation organisation.
Risk creep = slow building up of risk until there is a sudden realisation, perhaps brought about by a serious incident or accident that things have gone too far
Risk tolerance = define as the extent to which a person or organisation choose to avoid or accept risk. What is acceptable vs what is not acceptable
What is the role of punitive sanction?
= disciplinary consequences imposed on someone who is in violation of a law or regulation. Such sanction could be a fin, but also imprisonment not.
- This is for serious wilful violations.
