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

An Integrated Framework for gUnderstanding the Relationship B t H E dBetween Human Error and

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 XuPresented live on Sep 14th, 2011

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An Integrated Framework for Understanding the Relationship between Human Error and Aviation SafetyRelationship 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 WebinarSeptember 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）

1BOEING is a trademark of Boeing Management Company.Copyright © 2011 Boeing. All rights reserved.

Advanced Air Traffic Management （先进空中交通管理）

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.

2Copyright © 2011 Boeing. All rights reserved.

Outline of Presentation（讲座提纲)Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management

• Human error is a major contributing factor in aviationHuman error is a major contributing factor in aviation accidents

• Human error viewed from individual perspective

• Human error viewed from group perspectiveg p p p

• Human error viewed from organization/system• Human error viewed from organization/system perspective

• Integration of three perspectives


What is Human Error? （人为差错是什么？）

Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management

GAPGAP

I meant to do this…

…but I ended up d i thidoing this

• Did not intend it

• Did not do something according to some specified

Error is inevitable result of natural limitations of h f set of rules or by some

external observerhuman performance


• Did it but not correctly

Human Error Outpaces Machine Error as Leading Cause of Accidents （人为因素作为事故的主要导致因素)

Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management100%100%

~80% of accidents

人为因素作为事故的要导致因素)

90%90%

80%80%

are now due to human

error80%80%

70%70%

60%60%

50%50%

~20% of accidents are now

due to machine 50%50%

40%40%

causes

30%30%

20%20%20%20%

10%10%


0%0%19031903 TodayTodayTIMETIME

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）Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic ManagementAccidents in Decline （必须改进安全，减少事故的数量）

45

50

Airplanes in service 19,000

35,800

35

40 Hull loss accidentsper year

Business 2007 2027

25

30Hull loss accidents per million departure

per year as usual

15

20

departures

5

10Millions of departures

Our Goal

0

5

1960 1966 1972 1978 1984 1990 1996 2002 2008 2014 2020 2026

p

Accident Airplanes in Service and Departure data are estimated through 31


Accident, Airplanes in Service and Departure data are estimated through 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）Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic ManagementImprove Safety（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 investigateWe investigate

We use what we learn and know about human error toknow 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）

Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic ManagementEnvironment

TerrainWeather

EconomyAviation SystemAir TrafficAirport

Air Traffic Control

Regulatory AuthorityOrganization

• Regulations• Management• Management • Culture• Policies


Human Error: Individual Perspective （人的差错：个人角度）Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management

Attention Wickens’ Human InformationResources

Wickens Human InformationProcessing Model(Wickens, 1992)

SShort Term Sensory Storage

Perception Decision and

Response

Response Execution ResponsesStimuli

Selection

WorkingMemory

Long-Term Memory

Feedback


FeedbackAdapted 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）Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management

y 威肯斯人类信处模任何环节都可能发错误

Att tiAttention Resources

Short Term Sensory St

Stimuli Perception Decision and

R

Response Execution ResponsesErrors can occur

h i thStorage Response Selection

anywhere in the process

WorkingMemory

p ocess

Long-Term Memory

Memory

12Copyright © 2011 Boeing. All rights reserved. Feedback

Memory

Factors that Contribute to Errors （造成错误的因素）Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management

• Lighting levels• Temperature and humidity

Environment• Temperature and humidity• Vibration and noise• Smoke or air quality• Physical access to the job

• Procedures• Automation• Physical access to the job Automation• Controls• Displays, etc.

ErrorPhysical and Physiological

Factors

Equipment and Job AidsFactors

• Size, reach, strength, , g• Illness, incapacitation, injury• Overall health and diet• Alertness circadian fatigue

Group and O i i l

• Other crew members• ManagementAlertness, circadian, fatigue

• Drug effects• Motivational influences: complacency,

confidence

Organizational Factors

• Management• Larger operational organization• High-level decision makers such as

the regulator


confidence• Mental health influences – anxiety, stress,

etc…

the regulator

Error Prevention, Reduction, and Management: Environment（预防减少和管理错误：环境）Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic ManagementEnvironment（预防、减少和管理错误：环境）

• Environment Environmental Improvements and Mitigation

• Lighting• Temperature and humidity• Vibration and noise


Error Prevention, Reduction, and Management: Equipment/Job Aids（预防减少和管理错误：设备/辅助)Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management

• Environment Human Factors Design Principles (Wickens, G d B k Li & L 2003)

Equipment/Job Aids（预防、减少和管理错误：设备/辅助)

• Equipment and Job AidsGordon-Becker, Liu, & Lee, 2003)

• Make displays legibleA id b l t j d t li it• Avoid absolute judgment limits

• Top-down processing• Redundancy-gain• Discriminality• Principle of pictorial realism• Principle of the moving partp g p• Minimizing information access costs• Proximity compatibility principle• Principle of multiple resourcesPrinciple of multiple resources• Knowledge in the world• Principle of predicting aid

Principle of consistency• Principle of consistency



• Environment


• Equipment and Job Aids

“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



“Knowledge in the world”—people should not be f

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


required to retain important information solely in memory (Wickens, et al., 2003).


• Environment



Conflict!

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



Error Tolerant Systems• Environment


• 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



Human-Centered Automation (Parasuraman, Sh id & Wi k 2000)

• Environment


Sheridan, & Wickens, 2000)• Benefits of automation

• More accurate and more efficient than • Equipment and Job Aids

manual operations• Reduced operator workload under routine

conditions• Costs of automation

• Increased operator workload under non-routine or abnormal conditionsroutine or abnormal conditions

• Poor situation awareness and degraded manual skills

G f f• Guidelines for design of human-centered 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）Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic ManagementPhysiological Factors（预防、减少和管理错误：身体和生理因素）

• Environment Personnel Selection—Select personnel who:


• Physical and Physiological

• Are motivated, and physically and mentally fit for the job

• Physical and Physiological Factors

• Have good information processing capabilities

• Can perform well under stress

Stress Management

• Recognize stress, identify stressors, and mitigate stressorsE i t l l ti• Environmental solutions

• Design solutions• Trainingg• Improve interpersonal relationship


Human Error: Group Perspective （人的差错：小组角度）Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management

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

Captains have not heeded warnings of

Crew members possess information

Crew performance breaks down


heeded warnings of crew members.

possess information but do not share it.

breaks down.

Flight Crew Performance Model (Helmreich & Foushee, 1993) （飞行机组表现模型）Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management1993) （飞行机组表现模型）

Group outcomes are influenced by input factors and process factorsThe 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,

Mission and Crew Performance

Mission and Crew Performance

& 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.

Performance Outcomes

Performance Outcomes

• Safety

Crew Performance

Crew and Mission ProcessCrew Process

F

• Safety• EfficiencyCrew

PerformancePerformance Input Factors

Mission Process FactorsFactorsPerformance

Input Factors

• Attitudes

Individual and

• Crew formation and Management

• Aircraft Flight Control

• Individual Aptitudes• Physical Condition• Crew Composition Individual and

• Attitudes• Morale

Individual and Organizational

Outcomes

• Aircraft Flight Control• Communications Skills• Decision Processes

• Crew Composition• Organizational Factors• Cultures

Individual and Organizational

Outcomes


• Situational Awareness• Operating Procedures

• Regulatory Environment• Operating Environment

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）Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic ManagementGroup (ICAO, 2005)（机组资源管理是小组的主要解决方案）

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

• CRM training are required by airlines in 185 countries and by International• 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 ofResource Management on the Flight Deck, which identified failures of 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 usedwhere all the needed information was available, but not shared or used 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• Among others, create an environment of trust and support, where crew 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）Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic ManagementEnvironment组织和系统角度）

TerrainWeather


Air Traffic Control




Reason’s Swiss Cheese Model (Reason, 1990)（里森的瑞士奶酪模型）Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management酪模型）

Hazard

Standards

Hazard

Defenses in Depth

Design & Manufacturing

StandardsProcedures

Decision-

Defenses in Depth

makersManagers

F t liFront-line 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）Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management(ICAO, 1993)（组织/ 系统错误的预防、减少和管理）

• Enhance organizational safety Elements of a good safety culture:g yculture

• Informed Culture• Reporting Culture• Learning Culture• Just Culture• Flexible Culture



• Enhance organizational safety Decision-makers should consider the f ll i h d fi i th t t f

g yculture

• Improve structure of

following when defining the structure of organizations:

• Complexityorganizations • Complexity• Standardization• Formal decision-making process

Adaptability to the environment• Adaptability to the environment



• Enhance organizational safety Organizations in socio-technical systems t ll t t d ti d

g yculture


must allocate resources to production and safety in a balanced way.

organizations

• Improve allocation of resources



• Enhance organizational safety • Focus on flight operations, maintenance, and ramp safety and so ong y

culture


and ramp safety, and so on.

• Administer safety programs by independent company safety officer who reports to hi h t l l f t torganizations


highest level of corporate management.

• Improve safety programs



• Enhance organizational safety Procedures that are standard, logical, and efficient are error-resistant and thusg y

culture


efficient are error-resistant and thus contribute to safety.

organizations



• Improve standard operating p p gprocedures



• Enhance organizational safety • Feedback from accidents and incidents tog yculture


Feedback from accidents and incidents to decision makers.

• Feedback from unsafe acts to decision organizations


makers.

• Feedback from line management deficiencies to decision makers


• Improve standard operating

deficiencies to decision makers.

p p gprocedures

• Improve feedback and trend monitoring systems


Organization/System Error Prevention, Reduction, and Management (ICAO 2009)（组织/ 系统错误的预防减少和管理）Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management

• Enhance organizational safety An SMS is “a systematic approach to

(ICAO, 2009)（组织/ 系统错误的预防、减少和管理）

g yculture


An SMS is a systematic approach to managing safety, including the necessary organizational structures, accountabilities,

organizations


policies and procedures” (ICAO, 2009, p. 6-9).

Human factors—and preventing, reducing,



and managing human error—are an integral part of SMS.

p p gprocedures


• Currently, implement Safety Management System (SMS)Management System (SMS)



• Enhance organizational safety Several ICAO Annexes to the Chicagog yculture


Several ICAO Annexes to the Chicago Convention have required Safety Management System (SMS) implementation in:

organizations


• Air navigation services providers• Certified airport operators• Aircraft operators



• Approved maintenance organizations• Certain other organizations

p p gprocedures





• Enhance organizational safety SMS Componentsg yculture


SMS Components

• Safety policy and objectives• Safety risk management

organizations


• Safety assurance• Safety promotion

SMS Characteristics• Improve safety programs


SMS Characteristics

• Corporate management ownership• A risk-based approachp p g

procedures

• Improve feedback and trend

A risk based approach• Integrated into the business system

monitoring systems



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

结论）Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management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 t i ll lt f i t ti t• Human error typically occurs as a result of poor interactions among operators, 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


• Organization and System


结论）Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic ManagementEnvironment结论）

TerrainWeather


Air Traffic Control






A network of interactions and influences among individualsA network of interactions and influences among individualsinfluences among individuals,

groups, organizations, equipment, and environment

influences among individuals, groups, organizations, equipment,

and environmentmeans

humans perform in a large complex system with many pulling

meanshuman error prevention, reduction, and management must occur by p y y p ginfluences and is not the result of

any one action in isolation.

g yintegrating solutions across

individual, group, and organizational levelsorganizational levels.




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

• Personnel selectionPersonnel selection

• Training including Crew Resource Management (CRM)

• Environment improvement• Environment improvement

• Human-machine interface design improvement

• Organizational measures including Safety Management System (SMS)• Organizational measures including Safety Management System (SMS)




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

Air Traffic ControllersPilots

Dispatchers

Regulators Flight Attendants

D i

g

ManagersDesigners

S i ti t

Managers

E i ScientistsEngineers


Mechanics Accident Investigators

References（参考资料）Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management

• FAA (Federal Aviation Administration). (2008). Air traffic organization safety management system l ( i 2 1) W hi t DC FAAmanual (version 2.1). Washington, 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: ICAOICAO. (2009). Safety management manual (Doc 9859) (2nd ed.). Montreal: 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 297and Humans, 30(3), 286-297.

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

Wi k C D (1992) E i i h l d h f (2 d d ) N Y k• Wickens, C. D. (1992). Engineering psychology and human performance (2nd ed.). New 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）Engineering, Operations & Technology | Boeing Research & Technology Advanced Air Traffic Management

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

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



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