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􀂃 Knowledge-based thinking
A project supported by AIRBUS and the CAAC
June 2007
Human Errors
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
3. Automation and Human Errors
􀀴 Advanced technology and automation can help
people doing a lot of jobs and avoid some errors
􀀴 But advanced technology and automation can’t
avoid all basic errors
􀀴 Even simple error may cause complex system to
failure.
􀀴 To build a system to manage human errors
A project supported by AIRBUS and the CAAC
June 2007
A project supported by AIRBUS and the CAAC
June 2007
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
4. How to Do for Human Errors
PAST APPROACH
􀀴 Name and blame
􀂃 If pilot/crew or technician had followed training
and SOPs (standard operating procedures) he or
she would not have made the error
􀂃 Pilot/crew or technician was not careful enough
􀀴 Self-blame
􀂃 How could this have happened to me?!
􀂃 I was not paying enough attention
􀀴 Self-denial
􀂃 This would never happen to me (us)
􀂃 This will never happen to me (us) again
A project supported by AIRBUS and the CAAC
June 2007
How to Do for Human Errors
PAST APPROACH
􀀴 Why?
􀂃 Easier to point the finger
􀂃 Hindsight bias
􀂃 Apparently isolated incidents
􀂃 Emotionally (politically, sun 2005) satisfying
􀂃 Lack of understanding of human cognitive
processes
􀀴 Quick-fix approach
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
How to Do for Human Errors
SHIFT IN APPROACH
􀀴 Shift focus from operator to system
􀀴 Simply trying hard will not prevent errors
􀀴 Error is a symptom
􀀴 Accidents result from combination of
events/factors
􀀴 Event Chain
A project supported by AIRBUS and the CAAC
June 2007
How to Do for Human Errors
SHIFT IN APPROACH
􀀴 Active errors: whose effects are felt almost
immediately
􀂃 performance of the “front-line” operators (sharp end)
􀀴 Latent errors: whose effects may be hidden for
long, becoming evident only when they combine
with other factors
􀂃 management leadership, philosophy, response
(Reason, 1990)
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
LATENT
ACTIVE
How to Do for Human Errors
SHIFT IN APPROACH
ACTIVE
A project supported by AIRBUS and the CAAC
June 2007
CURRENT APPROACH
􀀴 Humans have cognitive limitations
􀀴 To err is human
􀀴 Cannot eliminate all human error
􀀴 Error is not deterministic but probabilistic
􀀴 Focus on making system less error prone and more
error tolerant
How to Do for Human Errors
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
CURRENT APPROACH
􀀴 Activities directed at improving safety:(flight)
􀂃 Technology: e.g., GPWS, TCAS, navigation aids, landing
aids
􀂃 Research: basic and applied, databases
􀂃 Operations: standardized, explicit procedures (flows,
checklists)
􀂃 Training: standardized, recurring, incl. performance
evaluation
􀂃 Regulation: inspection, enforcement
􀂃 All above aspects: include human performance issues
(e.g., fatigue, etc.)
How to Do for Human Errors
A project supported by AIRBUS and the CAAC
June 2007
􀀴 How do we make a robust, efficient, and safety system?
􀀴 First, it is key to know all (or as more as possible) information or fact
(truth) about operating system, including operation and airworthiness of
aircraft.
􀀴 How do we know these?
􀀴 We knows these from accidents, yes.
from incident, yes!
from other investigation or oversight , yes!
􀀴 But all of these are not enough for improving safety.
􀀴We should be aware of all unsafe precursors of
aviation system.
􀀴We should develop a system that should be
perfect and tolerable to errors
How to Do for Human Errors
　
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