To Err is to be Human, this is true in aviation as in any other activity, however aviation is maybe less forgiving and we should understand the outcomes can be catastrophic.
In March 1977 a runway incursion in Tenerife became a disaster with the loss of 583 people. The various elements which were understood to be active in this disaster has been called on many times since and has helped to develop a baseline understanding from which has developed more mature process for accident investigation and prevention.
We accept that errors will occur regardless of training and motivation, consequences can be fatal. If we are going to be successful in managing and mitigating errors we need to develop organisational process which are designed specifically to manage the potential for human failure. (Human failure is normal and predictable. It can be identified and managed.)
The major challenge is to develop organisational systems which are error tolerant and have a tendency to preclude errors from occurring in the first place, together with risk assessment processes.
There are factors which make errors more likely, for example inferior design, individual distractions, pressure either created by the person or from the organisation (workload), other factors having a direct bearing are individual competence, and Organisational cultural issues.
We should understand that human failure is not a random event and it is possible to understanding why errors occur in so doing we can consider the different factors which make them worse in so doing to develop more effective controls.
We may consider that a human error resulted in an action or decision which was not intended, conversely a violation is a deliberate act which deviates from a rule or procedure.
Improved design of equipment and procedures can support a more error tolerant system, which cannot be eliminated by training. However training which is based on well thought out and designed procedures can provide a significant positive in avoiding mistakes.
Mistakes resulting from a lack of understanding of safe working procedures can in fact be mistaken for violations.
The best way to deal with Violations is to remove them from the process, by adding steps which encourage the detection of violations. It is important that people who are required to follow the rules are stakeholders. If we are creating rules they should make sense and add value to the process.
A thorough analysis of root casual factors following the disclosure of any perceived violations can contribute to developing effective mitigation’s.
Error reduction should be approached in a systematic and structured way, consider that by integrating activities within the environment of the Safety Manage and developing proactive data capture and reporting behaviours the organisation will be far better placed to manage Human Factor influences.
Comprehensive Risk Assessments should be undertaken where appropriate based on the understanding of the Safety System identified exposures or where related to safety critical tasks. Maintenance error management systems should seek to understand the role of all contributing factors to an event or occurrence.
Sofema Aviation Services offers Human Factors Training for Initial and Recurrent Requirements. In addition through our Training for Trainers Program we support organisations to develop their own in house capability.
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Tags:
Human Factors, Human Factors Training, Regulatory training, Train The Trainer, Errors, aviation mishap
