Human Error
To this day the majority of aviation accidents are attributed in some way, to some form of human error. Surprising when you consider all the effort and expense put into management, research, training and the development of new technologies such as automation. Yes, safety has vastly improved over the last 50 years, making flying one of the safest methods of getting around our planet. But still human error related accidents occur.
What is human error?
Errare Humanum Est- To Err is Human
Definition
“Planned actions that fail to achieve their desired consequences without the intervention of some chance or unforeseeable agency” (Reason, 1990, p.17).
Types of human error
The simplest catergorisation of human error would be to split them into errors of omission or commission (Kern, 1998).
- Omission - Errors of omission occur when crew members fail to carryout a required task.
- Commision - Errors of commission occur when crew members carryout a task incorrectly or do something that is not required.
Later researchers further differentiated human error as (Strauch, 2004: Reason, 1990);
- Slips - Which occur as the result of minor errors of execution.
- Lapses - Which occur when a pilot becomes distracted and doesn’t complete a task or omits a step whilst performing it.
- Mistakes - Which occur when actions conform to an inadequate plan.
- Violations - Which occur where actions deviate from safe procedures standards or rules, be they deliberate or erroneous.
Antecedents to human error
Reason (1990) also affirmed the idea that the operators, those who commit errors, do not do so in a vacuum. For instance pilots may be consciously attempting to perform perfectly, but human errors can still coccur. This is because other factors, or antecedents, can influence the operator’s performance (Strauch, 2004). These antecedents can include;
- Other operators,
- The environment,
- The equipment being used,
- National cultures,
- Organisational cultures.
Errors in Aviation
There are three main areas in aviation, of interest to human factors professionals and managers who wish to understand and reduce human error.
- Pilot or Flightdeck error.
- Air traffic Control error.
- Maintenance Error
Managing Error in Aviation
Traditional ideas
Early psychological researchers regarded people who erred as being less effective due to unconscious drives. A theory that tainted early research on human error. Approaches to human error rectification and management tending to centre on blame, training and quite possibly punishment (McDonald, 2003).
Modern models and methods.
Based on the work by resesearches such as Reason, Helmreich, and many others, there are now a wide number of models and methods avialable for managing human error and performance in aviation. the following list details some of more significant ones and provides links for further reading.
- Crew Resource Management (CRM) - Focuses on interpersonal communication, leadership, and decision making in the cockpit.
- Single Pilot Resource Management (SPRM) - SPRM is similar to CRM but focuses more on situational awareness, time and workload management, aeronautical decision making and automation management.
- Line Operations Safety Audits (LOSA) - LOSA are designed to collect data on crew performance, and then analyse and understand the organisational factors behind any error events.
- Safety Management Systems (SMS) - SMS is a management process aimed at reducing human error by identifying and managing risk in the workplace.
- Threat and Error Management (TEM) - A model developed to help understand, and explain, the interaction between safety and human performance, within an operational context.
- Maintenance Error Decision Aid (MEDA) - A program developed by Boeing to increase the value of findings from any investigations into erroneous maintenance procedures.
- Safety Cultures - The attitudes, beliefs, perceptions and values that employees share with regard to workplace safety.
Want to know more?
- Pilot Error
- An external link to examples of aircraft accidents attributable to pilot errors
- 'The Dirty Dozen'
- A Transport Canada campaign aimed at highlighting 12 elements which may produce maintenance errors.
- Maintenance Error Decision Aid; Boeing Site
- An external link to an article about the MEDA investigation process.
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Authors / Editors
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