An integrated framework for understanding the relationship between human error and aviation safety

An Integrated Framework for
g
Understanding the Relationship
Between Human Error and
B t H E d
Aviation Safety (理解人为差错
与航空安全关系的整合框架)

Dr. Xidong Xu (徐锡东博士)
©2011 ASQ & Presentation Xu
Presented live on Sep 14th, 2011

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An Integrated Framework for Understanding the
Relationship between Human Error and Aviation Safety
(理解人为差错与航空安全关系的整合框架)

ASQ Reliability Chinese Webinar
September 13, 2011

Xidong Xu, Ph.D. (徐锡东博士）
Boeing Research & Technology （波音研究与技术）
Ad anced Air Traffic Management （先进空中交通管理）
Advanced
BOEING is a trademark of Boeing Management Company.
Copyright © 2011 Boeing. All rights reserved. 1

Disclaimer（免责声明）
Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management

Any opinions, findings, conclusions, and recommendations
y p , g , ,
expressed here are those of the author and do not necessarily
reflect the views of The Boeing Company.


Outline of Presentation（讲座提纲)

• Human error is a major contributing factor in aviation
accidents

• Human error viewed from individual perspective

• Human error viewed from group perspective
g pp p

• Human error viewed from organization/system
perspective

• Integration of three perspectives


What is Human Error? （人为差错是什么？）

GAP

I meant to …but I
do this… ended up
doing this
d i thi

• Did not intend it

Error is inevitable result • Did not do something
of natural limitations of according to some specified
human performance
h f set of rules or by some
external observer

• Did it but not correctly

Human Error Outpaces Machine Error as Leading Cause of
人为因素作为事故的要导致因素)
Accidents （人为因素作为事故的主要导致因素)
100%
~80% of accidents
90% are now
due to human
80% error

70%
~20% of accidents
60%
are now
due to machine
50%
causes
40%

30%

20%

10%

0%
1903
Copyright © 2011 Boeing. All rights reserved.
TIME Today 5

Must Continuously Improve Safety to Keep the Number of
Accidents in Decline （必须改进安全，减少事故的数量）

50
35,800
Airplanes
45 in service 19,000

40
Hull loss
2007 2027
35
accidents Business
Hull loss per year as usual
30 accidents
per million
25 departure
s
20

15
Our
10
Millions of Goal
5 departures
p

0
1960 1966 1972 1978 1984 1990 1996 2002 2008 2014 2020 2026
Accident,
Accident Airplanes in Service and Departure data are estimated through 31
31,
December 2007. Source: Boeing.


Accident Trend Implication: We Must Further Address Human Error to
Improve Safety（事故趋势意味着：我们必须进一步解决人为差错以改进安全）
事故趋势意味着：我们必须进步解决人为差错以改进安全）

Human error contributes to
most incidents/accidents

We investigate

We use what we learn and
know about human error to
improve safety


Individual Perspective（个人角度）


Group Perspective （小组角度）


Organization and System Perspective（组织和系统角度）
Environment
Economy
Terrain Aviation System
Weather
Airport Air Traffic
Air Traffic Regulatory
Control
Organization Authority
• Regulations
• Management
• Culture
• Policies


Human Error: Individual Perspective （人的差错：个人角度）

Wickens
Wickens’ Human Information Attention
Resources
Processing Model
(Wickens, 1992)

Short Term Perception Decision Response
Stimuli Sensory and Execution Responses
Storage Response
Selection

Working
Memory

Long-Term
Memory
Feedback
Adapted with permission of Pearson Education from Fig. 1.3 in “Engineering psychology and human performance”, 1992 by C.D. Wickens. For use in this presentation only.

Wickens’ Human Information Processing: Errors can Occur
Anywhere（威肯斯人类信息处理模型：任何环节都可能发生错误）
y 威肯斯人类信处模任何环节都可能发错误

Attention
Att ti
Resources

Stimuli Short Term
Sensory
Errors can and
Perception occur
Decision Response
Execution Responses
Storage
St anywhere i th
h R in the
Response
Selection
p ocess
process
Working
Memory

Long-Term
Memory

Feedback 12

Factors that Contribute to Errors （造成错误的因素）
• Lighting levels
• Temperature and humidity
• Vibration and noise Environment
• Smoke or air quality • Procedures
• Physical access to the job • Automation
• Controls
• Displays, etc.

Physical and
Equipment
Physiological Error and Job Aids
Factors

• Size, reach, strength
, , g
• Illness, incapacitation, injury
• Overall health and diet • Other crew members
Group and
• Alertness, circadian
Alertness circadian, fatigue • Management
Organizational
O i i l
• Drug effects • Larger operational organization
Factors
• Motivational influences: complacency, • High-level decision makers such as
confidence the regulator
• Mental health influences – anxiety, stress,
etc… © 2011 Boeing. All rights reserved.
Copyright 13

Error Prevention, Reduction, and Management:
Environment（预防减少和管理错误：环境）
预防、减少和管理错误：环境）

• Environment Environmental Improvements and Mitigation

• Lighting
• Temperature and humidity
• Vibration and noise


Aids（预防减少和管理错误：设备/辅助)
Equipment/Job Aids（预防、减少和管理错误：设备/辅助)

• Environment Human Factors Design Principles (Wickens,
Gordon-Becker, Li & Lee, 2003)
G d B k Liu, L
• Equipment and Job Aids
• Make displays legible
• Avoid b l t j d
A id absolute judgment limits
t li it
• Top-down processing
• Redundancy-gain
• Discriminality
• Principle of pictorial realism
• Principle of the moving part
p gp
• Minimizing information access costs
• Proximity compatibility principle
• Principle of multiple resources
• Knowledge in the world
• Principle of predicting aid
• Principle of consistency



• Environment


“Redundancy-gain”—the same
information is displayed more than once (Wickens, et al., 2003).



• Environment


Photo source: http://humansystems.arc.nasa.gov/groups/FDDRL/technologies/3dcdti.html
“Principle of pictorial realism”—a display
should look like what it represents (Wickens, et al., 2003).


• Environment


Photo source: https://www.faasafety.gov/gslac/alc/course_content.aspx?cID=49&sID=293&preview=true

“Knowledge in the world”—people should not be
required to retain important information solely in
f
memory (Wickens, et al., 2003).


• Environment


Conflict!

“Principle of predicting aid”—a display should help
predict future conditions (Wickens, et al., 2003).



• Environment Error Tolerant Systems

• Equipment and Job Aids • Errors will be inevitable (and error is often
necessary for learning to occur)

• Therefore, an error-tolerant system would
allow the user to recover from an error



• Environment Human-Centered Automation (Parasuraman,
Sheridan, & Wickens, 2000)
Sh id Wi k
• Equipment and Job Aids • Benefits of automation
• More accurate and more efficient than
manual operations
• Reduced operator workload under routine
conditions
• Costs of automation
• Increased operator workload under non-
routine or abnormal conditions
• Poor situation awareness and degraded
manual skills
• G
Guidelines for design of human-centered
f f
automation
• If automation does a job better than the
human, automate it; if the human does it
better, let the human do it
• What automation does should be
transparent to the human operator
• Human operator should have final authority

Error Prevention, Reduction, and Management: Physical and
Physiological Factors（预防减少和管理错误身体和生理因素）
预防、减少和管理错误：身体和生理因素）

• Environment Personnel Selection—Select personnel who:

• Equipment and Job Aids • Are motivated, and physically and mentally
fit for the job
• Physical and Physiological • Have good information processing
Factors capabilities
• Can perform well under stress

Stress Management

• Recognize stress, identify stressors, and
mitigate stressors
• E i
Environmental solutions
t l l ti
• Design solutions
g
• Training
• Improve interpersonal relationship


Human Error: Group Perspective （人的差错：小组角度）

Groups can safeguard against errors made by
individuals but
i di id l b t can i t d
introduce errors of th i own t
f their type

Captains have not Crew members Crew performance
heeded warnings of possess information breaks down.
down
crew members. but do not share it.

Flight Crew Performance Model (Helmreich & Foushee,
1993) （飞行机组表现模型）

Group outcomes are influenced by input factors and process factors
The diagram below is adapted with permission of Dr. Robert L. Helmreich from Fig. 1.2 in “Why crew resource management? Empirical and theoretical bases of human factors training in aviation,” 1993 by R. L. Helmreich,
& H. C. Foushee. In E. L. Wiener & B. G. Kanki, R. L. Helmreich (Eds.), Cockpit resource management (pp. 3-45), New York: Academic Press. For use in this presentation only.

Mission and Crew
Performance
Outcomes
• Safety
• Efficiency
Crew Crew and
Crew Process
Performance Mission Process
Factors
F
Input Factors Factors
• Attitudes
• Individual Aptitudes • Crew formation • Morale
• Physical Condition and Management
• Crew Composition • Aircraft Flight Control Individual and
• Organizational Factors • Communications Skills Organizational
• Cultures • Decision Processes Outcomes
• Regulatory Environment • Situational Awareness
• Operating Environment
• Operating Procedures
24

Crew Resource Management (CRM) is a Major Solution for
Group (ICAO, 2005)（机组资源管理是小组的主要解决方案）
(ICAO

• CRM is defined as using all resources available to crew ( g equipment,
g (e.g., q p
procedures, and people) to manage human error.

• CRM training are required by airlines in 185 countries and by International
Civil Aviation Organization (ICAO), which is a regulatory component of the
United Nations.

• Roots can be traced to a NASA-sponsored workshop in 1979, called
Resource Management on the Flight Deck which identified failures of
Deck,
interpersonal communications, decision making, and leadership as
contributing factors in the majority of air crashes.

• CRM was also instigated by the 1978 DC-8 crash outside Portland, Oregon,
where all the needed information was available but not shared or used
available,
among the crew members to prevent the accident.


CRM Goals (ICAO, 2005)（机组资源管理的目标）

• Enhance the crew performance in
p
• Coordination
• Communication skills
• Situational awareness
• Decision making
• Leadership

• Among others create an environment of trust and support where crew
others, support,
members (including cabin crew members) are confident to pass on
concerns to each other without fear of intimidation.

• Support crew responses to threats and errors.

• Contribute to the prevention of incidents and accidents.


Human Error: Organization and System Perspective（人为错误：
组织和系统角度）
Environment
Economy
Weather
Airport Air Traffic
Control
• Regulations
• Management
• Culture
• Policies


Reason’s Swiss Cheese Model (Reason, 1990)（里森的瑞士奶
酪模型）

Design Hazard
& Manufacturing
Defenses in Depth Standards
Procedures
Decision-
makers
Managers

Front-line
F t li
Personnel

Accident

Adapted from Figure 3.1 in FAA (2008, p. 15)

Organization/System Error Prevention, Reduction, and Management
(ICAO 1993)（组织/ 系统错误的预防减少和管理）
(ICAO, 系统错误的预防、减少和管理）

• Enhance organizational safety
g y Elements of a good safety culture:
culture
• Informed Culture
• Reporting Culture
• Learning Culture
• Just Culture
• Flexible Culture



g y Decision-makers should consider the
following h d fi i th t
f ll i when defining the structure of
t f
culture organizations:
• Improve structure of
• Complexity
organizations
• Standardization
• Formal decision-making process
• Adaptability to the environment



g y Organizations in socio-technical systems
must allocate resources to production and
t ll t t d ti d
culture safety in a balanced way.
organizations

• Improve allocation of resources



• Focus on flight operations, maintenance,
g y and ramp safety and so on
safety, on.
culture
• Administer safety programs by independent
• Improve structure of company safety officer who reports to
organizations highest l
hi h t level of corporate management.
l f t t


• Improve safety programs



Procedures that are standard, logical, and
g y efficient are error-resistant and thus
culture contribute to safety.

organizations



• Improve standard operating
p p g
procedures



g y • Feedback from accidents and incidents to
culture decision makers.

• Improve structure of • Feedback from unsafe acts to decision
organizations makers.

• Improve allocation of resources • Feedback from line management
deficiencies to decision makers.
makers

p p g
procedures

• Improve feedback and trend
monitoring systems



g y An SMS is “a systematic approach to
a
culture managing safety, including the necessary
• Improve structure of organizational structures, accountabilities,
organizations policies and procedures” (ICAO, 2009, p. 6-9).

• Improve allocation of resources Human factors—and preventing, reducing,
• Improve safety programs and managing human error—are an integral
part of SMS.
p p g
procedures

monitoring systems

• Currently, implement Safety
Management System (SMS)



g y Several ICAO Annexes to the Chicago
culture Convention have required Safety Management
System (SMS) implementation in:
organizations • Air navigation services providers
• Certified airport operators
• Improve allocation of resources • Aircraft operators
• Approved maintenance organizations
• Certain other organizations
p p g
procedures

monitoring systems




g y SMS Components
culture
• Safety policy and objectives
• Improve structure of • Safety risk management
organizations • Safety assurance
• Safety promotion
SMS Characteristics
• Corporate management ownership
p p g • A risk-based approach
risk based
procedures • Integrated into the business system

monitoring systems



Integration of Three Perspectives and Conclusion（综合三种角度及
结论）

• Human error contributes to the majority of aviation accidents.
j y

• We must further address human error to improve safety.

• We started to examine human error using a human information processing
model.

• Many factors influence human error:

• H
Human error t i ll occurs as a result of poor i t
typically lt f interactions among operators,
ti t
machines/equipment, and environment.
• Human error is often influenced by group and organizational factors and dynamics.

• The relationship between human error and aviation safety can be viewed
from different perspectives:

• Individual
• Group
• Organization and System


结论）
Environment
Economy
Weather
Airport Air Traffic
Control
• Regulations
• Management
• Culture
• Policies


结论）

A network of interactions and
influences among individuals
individuals,
groups, organizations, equipment,
and environment
means
human error perform in areduction,
humans prevention, large
complex system with many p byg
andpmanagement must occur y
yg y pulling
influences and is not the result of
integrating solutions across
any one action in isolation.
individual, group, and
organizational levels
levels.


结论）

Strategies to prevent , reduce, and manage error:
g p , g

• Personnel selection
• Training including Crew Resource Management (CRM)
• Environment improvement
• Human-machine interface design improvement
• Organizational measures including Safety Management System (SMS)


结论）

Studying, preventing, reducing,
Studying preventing reducing and managing human error
is an effort among many people working together

Pilots
Air Traffic Controllers Dispatchers

g
Regulators Flight Attendants

Designers
D i Managers

E i
Engineers S i ti t
Scientists

Mechanics Accident Investigators

References（参考资料）

• FAA (Federal Aviation Administration). (2008). Air traffic organization safety management system
manual (
l (version 2.1). W hi t
i 2 1) Washington, DC: FAA.
DC FAA

• Helmreich, R. L. & Foushee H. C. (1993). Why crew resource management? Empirical and theoretical
bases of human factors training in aviation. In E. L. Wiener & B. G. Kanki, R. L. Helmreich (Eds.),
Cockpit resource management (pp. 3-45). New York: Academic Press.

• ICAO (International Civil Aviation Organization). (1993). Human factors digest No. 10: Human factors,
management and organization (Circular 247-AN/148). Montreal: ICAO.

• ICAO. (2005). Human factors training manual (Doc 9863-AN/950). Montreal: ICAO.

• ICAO (2009). Safety management manual (Doc 9859) (2nd ed ) Montreal: ICAO.
ICAO. (2009) ed.). ICAO

• Parasuraman, R., Sheridan, T. B., & Wickens, C. D. (2000). A Model for types and levels of human
interaction with automation. IEEE Transactions on Systems, Man, and Cybernetics—Part A: Systems
and Humans, 30(3), 286 297
Humans 30(3) 286-297.

• Reason, J. (1990). Human error. Cambridge, UK: Cambridge University Press.

• Wi k
Wickens, C. D. (1992) E i
C D (1992). Engineering psychology and human performance (2 d ed.). New Y k
i h l dh f (2nd d ) N York:
HarperCollins Publishers Inc.

• Wickens, C. D., Gorden-Becker, S. E., Liu, Y., & Lee, J. D. (2003). Introduction to human factors
engineering (2nd ed.). Upper Saddle River, NJ: Prentice Hall.


Acknowledgment（致谢）

• This presentation used or benefitted from some
used, from,
materials from the following Boeing colleagues:

Mr. Robert E. Johnson, Dr. Randall J. Mumaw, and Dr.
William L. Rankin.
L Rankin



Thank you!（谢谢！）
有问题吗
Questions?（有问题吗？）


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An integrated framework for understanding the relationship between human error and aviation safety