ACCIDENT ANALYSIS AND PREVENTION. Gavin McKellar International Conference on Ergonomics. Sao Paulo August 2011
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1 ACCIDENT ANALYSIS AND PREVENTION Gavin McKellar International Conference on Ergonomics. Sao Paulo August 2011
2 Tips for the next World Cup Lessons Learned
3 Is Aviation Safe?
4 Fatalities
5
6 LEVELS OF RISK DRAWING THE LINE INTOLERABLE MANAGEABLE ACCEPTED
7 Situational Awareness
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9 Decision Making
10 DECISION MAKING
11 RESULTS OF FATIGUE Inability to assess risk and to action Inability to identify and react to stimuli Taking quicker decisions based on experience Inadequate response Reduced concentration Loss of Situational Awareness Poor Decision Making Inability to judge level of impairment
12 FATIGUE VS DRUNK? Drunk? Or Too Tired To Care? Longer than 18 hours awake could impair human functioning as severely as heavy drinking Greater than 23 hours awake is = blood alcohol content of 1.2 Driving limit is 0.05 Professional limit= years jail term-serious.
13 CLOSING THESAFETY LOOP Aviate Navigate Communicate Monitor- Ensure acceptable level of risk mantained Action Implement SAFETY LOOP Decision Makinguse CRM Collect-Identify. Verify Analyze-risk. Use Models Contain High Risk
14 Relationship Between Accidents & Lack of Effective Implementation
15 CAUSES OF ACCIDENTS Failures in the System Equipment Failures Human Performance/Limitations Pressures of the Environment Violations
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17 Accident prevention Accidents An accident is never due to a single cause but to a chain of events. Serious incidents Incidents Occurrences All of these events led to previous occurrences / incidents / serious incidents Proper analysis of Latent and Immediate Factors in occurrences / incidents / serious incidents can prevent reoccurrence of these events, and prevent accidents.
18 The Error Iceberg E 7 E 6 E 1 C 3 C 6 C 7 C 1 C 3 C 5 E 14 Accident E 20 E 1 E 22 E 21 E 16 E 22 E 2 E 11 E 3 E 14 E 21 E 9 E 8 Serious Incidents C 2 C 3 Other Events E 10 E 4 E 1 E 25 E 14 E 7 E 21 E 6 E 2 Error significance Contributing factors significance
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20 ERROR AVOIDANCE THREAT THREAT MANAGEMENT CREW ERROR ERROR MGNT U A S U A S MNGT INCIDENT EVENT
21 THREATSMANAGEMENT
22 Errors
23 Human Error
24 340 Toronto Threats, Errors UAS Combine
25 Reason s Swiss cheese model of the Organizational Accident Some holes due to active failures Hazards Losses Other holes due to latent conditions Successive layers of defences, barriers, & safeguards
26 Incident Investigation ATSB Investigation ATSB Investigation Process Process Litson and Associates
27 Incident Investigation ACCI Map Litson and Associates
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33 PILOTS OFTEN INHERIT DEFECTS IN THE SYSTEM
34 Safety Taken For Granted?
35
36
37 CULTURE NORMS AND VALUES THAT AFFECT BEHAVIOUR REACHES INTO ALL AREAS OF LIFE THE WAY WE DO IT AROUND HERE
38 CULTURE MISMATCHES AT THE (CULTURAL) INTERFACES = POSSIBLE BREEDING GROUNDS FOR HUMAN ERRORS CONFLICT AND MISUNDERSTANDINGS
39
40 RSA ROAD SAFETY????
41 NATIONAL CULTURE The Hardest to Change
42 CORPORATE CULTURE Workers Behave the way Mangers Manage- Positively of Negatively
43 PROFESSIONAL CULTURE Pilot Invulnerability
44 Safety Culture Informed Culture SAFETY CULTURE Just Culture Reporting Culture Flexible Culture Learning Culture (Reason, 1997) & Wary Culture (added by Hudson, 2001)
45 To Err is Human -Error is normal part of human behavior People can and do make mistakes - Most errors are inadvertent People do not intend to commit errors Human error is a symptom, not a cause of accidents
46 Management Also Makes Errors - They make few ACTIVE errors - Mostly LATENT (hidden) errors -Latent errors can lie dormant for long periods Latent and Active errors combine to create an accident
47 PRO-ACTIVE SAFETY Needs to Know Risk Levels Risk Levels Unknown-Why? Because- Lack of data-why? Because- No reporting. Why? Because- No Trust. Why? Because- Fear of Prosecution. Why? Because-Blame Culture / Experience Solution-Just Safety Culture
48 IT WAS PILOT ERROR OK NOW WHAT? IT S S ABOUT THE UNDESTANDING OF ERROR AND PREVENTION
49 ERROR Almost ALL identifiable accidents and incidents have a crew error component Most commonly quoted figure is 70% but in reality human error is close to 100 % Aviation is a fallible system operated by humans so this allegation should not be a surprise
50
51 OBJECTIVE Constantly adjust the system Error proof all aspects of the operation Account for humans acting as humans Fault / Error tolerant system
52 POINT What is an error? An act, assertion, or belief that UNINTENTIONALLY deviates from what is correct, right or true American Heritage Dictionary
53 Counting
54 TREAT CAUSE NOT EFFECT Drain the swamp where the mosquitoes breed. Workers do not operate in a vacuum. Workers behave as managers managepositively or negatively.
55 ISASI 2001-Dick Wood Making a mistake whilst trying to comply with the law is not a crime, and punishing that mistake isn t going to prevent anyone from making the same mistake in the future
56 POINT An Intentional [bad] act is NOT an error It is an intentionalact
57 Accident or Crime? English Common Law: Mens rea-intentionto commit an unlawful act Actus reus-committingthe act 'Crime' requires both
58 Accident or Crime? The damage done to aviation safety by prosecution undertaken when there is no clear intention to commit a crime does not justify the marginal benefit that might result from such prosecutions. Journal of Air Law and Commerce op cit. pg 923
59 Different Legal Systems Common Law Napoleonic Law Tribal Law International Law
60 POINT Punishment can deter an Intentional act. The actor must consider the consequences of the action to be taken
61 POINT Punishment cannot deter an unintentional deviation (an error) The actor believes the action is correct and so without adverse consequences
62 POINT The Just Culture is NOT an attempt to put any group / profession above the Law The Just Safety Culture looks to balance improving safety for the public and the need for justice. A safety culture needs to identify risk, to understand threat and error management as well as learn lessons and be aware
63 Focus of Safety Investigation is Different (no Blame/ Liability)
64 JUST SAFETY CULTURE A culture with norms and values in which front line operators are not punished for actions or errors. Information leads to safety management and continual improvement of the system.
65 Just Safety Culture Punishment may be appropriate when there is evidence that the occurrence was caused by an act considered, in accordance with the law, to be conduct with intent to cause damage, or conducted with knowledge that damage would probably result, equivelent to reckless conduct, gross negligence or wilful misconduct.
66 BAD ACTS ICAO has defined acts for which discipline or punishment is appropriate Annex 13, Attachment E:
67 INTENTIONAL ACTS The International pilot community DEMANDS that intentional bad acts related to aviation be punished with zero tolerance
68 HUMAN NATURE Errors will not be prevented by threat of prosecution Errors can only be prevented by knowledge, training or system redesign Error prevention requires data
69 HUMAN NATURE BUT. (here it comes) The threat of prosecution dramatically impedes the acquisition of data on causal factors leading to an error
70 PUNISHMENT Public sentiment will continue to demand punishment. States cannot allow this sentiment to override the fundamental principle that punishment does not improve safety.
71 BISHOP TUTU TRUTH AND RECONCILIATION -Find a Balance between Justice and Reconsiliation (mercy/forgiveness) -Create this Culture from the Top. -Pass Legislation, then win the Hearts and Minds -Workers help define the Limits -Communicate acceptable behaviour and Rules
72 Passenger Survey
73 Barriers to Acceptable Behaviour Define the grey areas Use workers to define the limits Make sure all understand Put Legislation in place to protect the issues around a Just Culture
74 JUST CULTURE CONCLUSION Punishment in error cases is contrary to air safety principles Use Annex 13, Attachment E Criminalization of Error is counterproductive for public safety Blame for certain acts as defined, is encouraged.
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