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A project supported by AIRBUS and the CAAC
June 2007
Substandard
Conditions of
Operators
PRECONDITIONS
FOR
UNSAFE ACTS
Errors
Perceptual
Errors
Skill-Based
Errors
UNSAFE
ACTS
Decision
Errors Routine Exceptional
Violations
Adverse
Physiological States
Physical/Mental
Limitations
Adverse Mental
States
Adverse
Mental States
Personal
Readiness
Crew Resource
Management
Substandard
Practices of
Operators
Inadequate
Supervision
Planned
Inappropriate
Operations
Failed to
Correct
Problem
Supervisory
Violations
UNSAFE
SUPERVISION
Resource
Management
Organizational
Climate
Organizational
Process
ORGANIZATIONAL
INFLUENCES
A project supported by AIRBUS and the CAAC
June 2007
Unsafe Acts of Operators
銄Shappell & Wiegmann, 2002
Unsafe
Acts
UNSAFE
ACTS
UNSAFE
ACTS
EErrrroorrss Violations
Perceptual Routine Exceptional
Errors
Decision
Errors
Skill-Based
Errors
Decision Errors
Improper Takeoff
Improper Approach/Landing
Improper Procedure
Misdiagnosed Emergency
Wrong Response to Emergency
Exceeded Ability
Inappropriate Maneuver
Poor Decision
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
Unsafe Acts of Operators
©Shappell & Wiegmann, 2002
Unsafe
Acts
UNSAFE
ACTS
UNSAFE
ACTS
EErrrroorrss Violations
Perceptual Routine Exceptional
Errors
Decision
Errors
Skill-Based
Errors
Breakdown in Visual Scan
Delayed Response
Failed to Prioritize Attention
Failed to Recognize Extremism
Improper Instrument Cross-Check
Inadvertent use of Flight Controls
Omitted Step in Procedure
Omitted Checklist Item
Poor Technique
A project supported by AIRBUS and the CAAC
June 2007
Unsafe Acts of Operators
©Shappell & Wiegmann, 2002
Unsafe
Acts
UNSAFE
ACTS
UNSAFE
ACTS
EErrrroorrss Violations
Perceptual Routine Exceptional
Errors
Decision
Errors
Skill-Based
Errors
Perceptual Errors
Misjudged Distance/Altitude/Airspeed
Spatial Disorientation
Visual Illusion
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
Unsafe Acts of Operators
©Shappell & Wiegmann, 2002
Unsafe
Acts
UNSAFE
ACTS
UNSAFE
ACTS
EErrrroorrss Violations
Perceptual Routine Exceptional
Errors
Decision
Errors
Skill-Based
Errors
Routine (Infractions)
Failed to Adhere to Brief
Violation of Regulations/SOP
- Flew an unauthorized approach
- Violated training rules
- Failed to adhere to departure procedures
- Flew overaggressive maneuver
- Failed to properly prepare for flight
A project supported by AIRBUS and the CAAC
June 2007
Unsafe Acts of Operators
©Shappell & Wiegmann, 2002
Unsafe
Acts
UNSAFE
ACTS
UNSAFE
ACTS
EErrrroorrss Violations
Perceptual Routine Exceptional
Errors
Decision
Errors
Skill-Based
Errors
Briefed Unauthorized Flight
Intentionally Exceeded the Limits of the Aircraft
Violation of Regulations/SOP
- Continued low-altitude flight in VMC
- Failed to ensure compliance with rules
- Unauthorized low-altitude canyon running
Briefed and flew unauthorized maneuver
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
Preconditions for Unsafe Acts
©Shappell & Wiegmann, 2002
Preconditions
for
Unsafe Acts
Unsafe
Acts
PRECONDITIONS
FOR
UNSAFE ACTS
Condition of
Operators
Physical/
Mental
Limitations
Adverse
Mental
States
Technological
Environment
Physical
Environment
Personal
Readiness
Crew Resource
Management
Personnel
Factors
Adverse
Physiological
States
Environmental
Factors
A project supported by AIRBUS and the CAAC
June 2007
Unsafe Supervision
©Shappell & Wiegmann, 2002
Unsafe
Supervision
Preconditions
for
　
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