Human Failures Human Failures inin

Accidents Accidents

New Zealand Helicopter Association

A FEW ACCIDENTS… Chernobyl (USSR) 1986

$12 billion US cost to the Soviet economy

Exxon Valdez, Alaska (USA) 1989

Oil Spill: 11 million US gallons

Flying Tigers, B747, (Malaysia) 1989

4 crew killed, aircraft destroyed

Deepwater Horizon, Gulf of Mexico (USA) 2010

4.9 million barrels of oil spilt

Costa Concordia, Guam (USA) 2012

32 people drowned

Hindenburg, New Jersey (USA) 1937

35 people killed

Mars Climate Orbiter, Mars (Space) 1998 - 1999

$1 billion spacecraft lost

Union Carbide Plant, Bhopal, (India) 1984

Approx. 8000 dead

STS Challenger, Florida (USA) 1986

7 astronauts killed

ZK-HJN, Lake Manapouri, (New Zealand) 2000

5 dead

ZK-SML, Mount Duppa, (New Zealand) 2011

1 dead

RMS Titanic, Atlantic Ocean, 1912

1500 dead

What do these accidents/incidents/disasters have in common ?

Human Human FailuresFailuresHuman Human ErrorsErrors

HUMAN ERROR

EVEN EXPERTS CAN MAKE ERRORS

An ErrorUnintentional deviation from organizational expectations or crew intentions (the best people can make the worst errors)

A Violation (Intentional Non-compliance)?Intentional deviation from organizational expectations or crew intentions

ERRORS AND VIOLATIONS

TYPES OF ERORS

Slips – attention failure (omission, reversal, mis-ordering, mistiming)

Lapses – memory failure (omitting planned items, place-losing, forgetting intentions)

Mistakes

Rule based (misapplication of a good rule or application of a bad rule)

Knowledge based – inaccurate or incomplete system mental model

TYPES OF ERRORS

Slips – attention failure (omission, reversal, mis-ordering, mistiming)

Lapses – memory failure (omitting planned items, place-losing, forgetting intentions)

Mistakes

Rule based (misapplication of a good rule or application of a bad rule)

Knowledge based – inaccurate or incomplete system mental model

WHAT ABOUT VIOLATIONS ?

Routine – habitual departures from rules and regulations

Situational – deviation from procedures or rules needed to get the job done due to a mismatch between a work situation and available procedures or rules

Optimising - individual satisfying other motives (excitement, impressing others, cutting corners…)

WHAT ABOUT THREATS ….

An external event or object that a crew has to deal with that could become consequential to safety

WHAT TO DO ?Design systems to be error tolerant (system still functions after an error has been made)

Design systems to be error proof (design prevents an error being made at all or makes it difficult for an error to be made)

Train personnel to try and avoid making errors and/or

detect the errors that have been made and correct them

and/or limit the effects of errors that

already been made.

WHAT TO DO ABOUT ERRORS ?

Train personnel so well that they do not make errors

Install computers to prevent human error

Design systems to be error tolerant (system still functions after an error has been made)

Design systems to be error proof (design prevents an error being made at all or makes it difficult for an error to be made)

Use other safeguards and defences (checklists)

What do these accidents/incidents/disasters have in common ?

Human Human FailuresFailuresHuman Human ErrorsErrors

Non-technical Skill Non-technical Skill FailuresFailures

N.T.S. – OUR SKILL BASE

Technical Skills

Company Personnel

Non Technical Skills

Accident

Technical Skills Failure

Non-Technical Skills Failure

Timeline

FAILURES AND ACCIDENTS

70% of accidents due to NTS failures

DECISION MAKING

SITUATIONAL AWARENESS

Information acquisition and processing

Workload management

Leadership and managerial skills

Threat and error management

Stress and stress management

Cultural factors

Communication

Fatigue and fatigue management

Automation

N.T.S. CORE ELEMENTSAutomation Issues:

Mode Confusion

Mode Error such as…

Selecting incorrect mode,

Misreading a display,

Missing mode transitions,

Assuming it is turned on,

Not understanding logic

Training ?

Basic Skills ?

IN THE BEGINNING…

THEN…

A QUANTUM LEAP ? …

NOW… LOTS OF AUTOMATION

THEN…

NOW…

DECISION MAKING

SITUATIONAL AWARENESS

Information acquisition and processing

Workload management

Leadership and managerial skills

Threat and error management

Stress and stress management

Cultural factors

Communication

Fatigue and fatigue management

Automation

N.T.S. CORE ELEMENTS

NZ Helicopter Occurrences 2000 - 2013

ACCIDENTS AND PAX NUMBERS

1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

30

25

20

15

10

5

0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

Boeing ICAO

HULL LOSSES PER MILLION DEPARTURES GROWTH IN TRILLIONS OF RPK

TECHNICAL FAILURES v NON-TECHNICAL SKILL FAILURES

1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

100

80

60

40

20

0

TECHNILOGICAL FAILURES

HUMAN PERFORMANCE

Hollnagel

TRENDS IN ATTRIBUTED ACCIDENT CAUSES

NON-TECHNICAL SKILL FAILURES

Landmark Accidents

Tenerife 1977

LANDMARK ACCIDENTS: TENERIFE 1977

LANDMARK ACCIDENTS: Kegworth 1989

LANDMARK ACCIDENTS: Valujet 1996

LANDMARK ACCIDENTS: Chicago 1979

Who should undergo NTS training ?

Flight Crew

Cabin Crew

Maintenance Engineers

Other Operational Safety Critical Personnel

Management

Link your NTS training program to your SMSLink your NTS training program to your SMS

Understand personal limitations

Improve awareness, knowledge and skills

Change attitudes, modify behaviours

Improve cross-functional collaboration

Develop adaptive capacity (personally and organisationally)

Improve SAFETY and efficiency

NTS TRAINING BENEFITS

Source: Ascend /Aviation Safety Network/Flight Safety Foundation

SOME SOBERING NUMBERS (2013)

Airline Fatalities: 265 29 accidents

Road Fatalities: 1.24 million USD $580 billion

Passenger Numbers: 3.1 billion 32,500,000 flights

Medical Fatalities: 3.5 million 223,000,000 procedures

Thanks forThanks for your time your time

New Zealand Helicopter Association

Contact:Glen Eastlake, Queenstown, New Zealand0274 963 141glen.eastlake@safeware.com.au