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4.6.10 Errors (which are a normal human activity) are quite distinct from violations. Both can lead to a
failure of the system. Both can result in a hazardous situation. The difference lies in the intent.
4.6.11 A violation is a deliberate act, while an error is unintentional. Take, for example, a situation in
which an ATCO allows an aircraft to descend through the level of a cruising aircraft when the DME distance
between them is 18 NM, and this occurs in circumstances where the correct separation minimum is 20 NM.
If the ATCO made a mistake in calculating the difference in the DME distances advised by the pilots, this
would be an error. If the ATCO calculated the distance correctly and allowed the descending aircraft to
continue through the level of the cruising aircraft knowing that the required separation minimum did not exist,
this would be a violation.
4.6.12 Some violations are the result of poor or unrealistic procedures where people have developed
“work arounds” to accomplish the task. In such cases, it is very important that they be reported as soon as
they are encountered in order that the procedures can be corrected. In any event, violations should not be
tolerated. There have been accidents where a corporate culture that tolerated or, in some cases,
encouraged the taking of short cuts rather than the following of published procedures was identified as a
contributory cause.
Control of human error
4.6.13 Fortunately, few errors lead to adverse consequences, let alone accidents. Typically, errors are
identified and corrected with no undesirable outcomes, for example, selecting an incorrect frequency or
setting the altitude bug to the wrong altitude. On the understanding that errors are normal in human
behaviour, the total elimination of human error would be an unrealistic goal. The challenge then is not
merely to prevent errors but to learn to safely manage the inevitable errors.
4-20 Safety Management Manual (SMM)
4.6.14 Three strategies for managing errors in aircraft maintenance are briefly discussed below:5
a) Error reduction strategies intervene directly at the source of the error by reducing or eliminating the
contributing factors to the error. Examples of error reduction strategies include improving the access
to an aircraft component for maintenance, improving the lighting in which the task is to be
performed, reducing environmental distractions and providing better training. Most error management
strategies used in aircraft maintenance fall into this category.
b) Error capturing assumes the error has already been made. The intent is to “capture” the error
before any adverse consequences of the error are felt. Error capturing is different from error
reduction in that it does not directly serve to reduce or eliminate the error. Examples of errorcapturing
strategies include cross-checking to verify correct task completion and functional test
flights.
c) Error tolerance refers to the ability of a system to accept an error without serious consequence.
Examples of measures to increase error tolerance are the incorporation of multiple hydraulic or
electrical systems on an aircraft to provide redundancy, and a structural inspection programme that
provides multiple opportunities to detect a fatigue crack — before it reaches critical length.
4.7 SAFETY CYCLE
4.7.1 Given the number and potential relationships of the factors that may affect safety, an effective
SMS is required. An example of the type of systematic process required is shown in Figure 4-6. A brief
description of the safety cycle follows.
4.7.2 Hazard identification is the critical first step in managing safety. Evidence of hazards is required
and may be obtained in a number of ways from a variety of sources, for example:
a) hazard and incident reporting systems;
b) investigation and follow-up of reported hazards and incidents;
c) trend analysis;
d) feedback from training;
e) flight data analysis;
f) safety surveys and operational oversight safety audits;
g) monitoring of normal operations;
h) State investigation of accidents and serious incidents; and
i) information exchange systems.
5. From the Human Factors Training Manual (Doc 9683).
Chapter 4. Understanding Safety 4-21
Figure 4-6. Safety cycle
4.7.3 Each hazard identified must be evaluated and prioritized. This evaluation requires the
compilation and analysis of all available data. The data is then assessed to determine the extent of the
hazard; is it a “one-of-a-kind” or is it systemic? A database may be required to facilitate the storage and
retrieval of the data. Appropriate tools are needed to analyse the data.
4.7.4 Having validated a safety deficiency, decisions must then be made as to the most appropriate
　
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