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民航发表于 2010-4-7 15:08:35

<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:chsdate w:st="on" Year="1899" Month="12" Day="30" IsLunarDate="False" IsROCDate="False">1.1.3</st1:chsdate> The compromise between production and safety<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
is a complex and delicate balance. Humans are generally<o:p></o:p>
very effective in applying the right mechanisms to<o:p></o:p>
successfully achieve this balance, hence the extraordinary<o:p></o:p>
safety record of aviation. Humans do, however, occasionally<o:p></o:p>
mismanage or incorrectly assess task and/or situational<o:p></o:p>
factors and fail in balancing the compromise, thus<o:p></o:p>
contributing to safety breakdowns. Successful compromises<o:p></o:p>
far outnumber failed ones; therefore, in order to understand<o:p></o:p>
human performance in context, the industry needs to<o:p></o:p>
systematically capture the mechanisms underlying successful<o:p></o:p>
compromises when operating at the limits of the<o:p></o:p>
system, rather than those that failed. It is suggested that<o:p></o:p>
understanding the human contribution to successes and<o:p></o:p>
failures in aviation can be better achieved by monitoring<o:p></o:p>
normal operations, rather than accidents and incidents. The<o:p></o:p>
Line Operations Safety Audit (LOSA) is the vehicle<o:p></o:p>
endorsed by ICAO to monitor normal operations.<o:p></o:p>

民航发表于 2010-4-7 15:15:58

民航发表于 2010-4-7 15:16:10

<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:chsdate w:st="on" Year="1899" Month="12" Day="30" IsLunarDate="False" IsROCDate="False">1.2.2</st1:chsdate> There are limitations to the lessons learned from<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
accidents that might be applied to remedial strategies vis-àvis<o:p></o:p>
human performance. For example, it might be possible<o:p></o:p>
to identify generic accident-inducing scenarios such as<o:p></o:p>
Controlled Flight Into Terrain (CFIT), Rejected Take-Off<o:p></o:p>
(RTO), runway incursions and approach-and-landing accidents.<o:p></o:p>
Also, it might be possible to identify the type and<o:p></o:p>
frequency of external manifestations of errors in these<o:p></o:p>
generic accident-inducing scenarios or discover specific<o:p></o:p>
training deficiencies that are particularly related to identified<o:p></o:p>
errors. This, however, provides only a tip-of-the-iceberg<o:p></o:p>
perspective. Accident investigation, by definition, concentrates<o:p></o:p>
on failures, and in following the rationale advocated<o:p></o:p>
by LOSA, it is necessary to better understand the success<o:p></o:p>
stories to see if they can be incorporated as part of remedial<o:p></o:p>
strategies.<o:p></o:p>

民航发表于 2010-4-7 15:16:22

<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:chsdate w:st="on" Year="1899" Month="12" Day="30" IsLunarDate="False" IsROCDate="False">1.2.3</st1:chsdate> This is not to say that there is no clear role for<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
accident investigation within the safety process. Accident<o:p></o:p>
investigation remains the vehicle to uncover unanticipated<o:p></o:p>
failures in technology or bizarre events, rare as they may be.<o:p></o:p>
Accident investigation also provides a framework: if only<o:p></o:p>
normal operations were monitored, defining unsafe<o:p></o:p>
behaviours would be a task without a frame of reference.<o:p></o:p>
Therefore, properly focused accident investigation can<o:p></o:p>
reveal how specific behaviours can combine with specific<o:p></o:p>
circumstances to generate unstable and likely catastrophic<o:p></o:p>
scenarios. This requires a contemporary approach to the<o:p></o:p>
investigation: should accident investigation be restricted to<o:p></o:p>
the retrospective analyses discussed earlier, its contribution<o:p></o:p>
in terms of human error would be to increase existing<o:p></o:p>
industry databases, but its usefulness in regard to safety<o:p></o:p>
would be dubious. In addition, the information could<o:p></o:p>
possibly provide the foundations for legal action and the<o:p></o:p>
allocation of blame and punishment.<o:p></o:p>

民航发表于 2010-4-7 15:16:38

Combined reactive/proactive strategies<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
Incident investigation<o:p></o:p>
<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:chsdate w:st="on" Year="1899" Month="12" Day="30" IsLunarDate="False" IsROCDate="False">1.<st1:chmetcnv w:st="on" TCSC="0" NumberType="1" Negative="False" HasSpace="True" SourceValue="2.4" UnitName="a">2.4 A</st1:chmetcnv></st1:chsdate> tool that the aviation industry has increasingly<o:p></o:p>
used to obtain information on operational human performance<o:p></o:p>
is incident reporting. Incidents tell a more complete<o:p></o:p>
story about system safety than accidents do because they<o:p></o:p>
signal weaknesses within the overall system before the<o:p></o:p>
system breaks down. In addition, it is accepted that incidents<o:p></o:p>
are precursors of accidents and that N-number of incidents<o:p></o:p>
of one kind take place before an accident of the same kind<o:p></o:p>
eventually occurs. The basis for this can be traced back<o:p></o:p>
almost 30 years to research on accidents from different<o:p></o:p>
industries, and there is ample practical evidence that<o:p></o:p>
supports this research. There are, nevertheless, limitations<o:p></o:p>
Chapter 1. Basic error management concepts 1-3<o:p></o:p>
on the value of the information on operational human<o:p></o:p>
performance obtained from incident reporting.<o:p></o:p>

民航发表于 2010-4-7 15:33:06

<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:chsdate w:st="on" Year="1899" Month="12" Day="30" IsLunarDate="False" IsROCDate="False">1.2.5</st1:chsdate> First, reports of incidents are submitted in the<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
jargon of aviation and, therefore, capture only the external<o:p></o:p>
manifestations of errors (for example, “misunderstood a<o:p></o:p>
frequency”, “busted an altitude”, and “misinterpreted a<o:p></o:p>
clearance”). Furthermore, incidents are reported by the<o:p></o:p>
individuals involved, and because of biases, the reported<o:p></o:p>
processes or mechanisms underlying errors may or may not<o:p></o:p>
reflect reality. This means that incident-reporting systems<o:p></o:p>
take human error at face value, and, therefore, analysts are<o:p></o:p>
left with two tasks. First, they must examine the reported<o:p></o:p>
processes or mechanisms leading up to the errors and<o:p></o:p>
establish whether such processes or mechanisms did indeed<o:p></o:p>
underlie the manifested errors. Then, based on this relatively<o:p></o:p>
weak basis, they must evaluate whether the error management<o:p></o:p>
techniques reportedly used by operational personnel<o:p></o:p>
did indeed prevent the escalation of errors into a system<o:p></o:p>
breakdown.<o:p></o:p>

民航发表于 2010-4-7 15:33:22

<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:chsdate w:st="on" Year="1899" Month="12" Day="30" IsLunarDate="False" IsROCDate="False">1.2.6</st1:chsdate> Second, and most important, incident reporting is<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
vulnerable to what has been called “normalization of<o:p></o:p>
deviance”. Over time, operational personnel develop informal<o:p></o:p>
and spontaneous group practices and shortcuts to<o:p></o:p>
circumvent deficiencies in equipment design, clumsy procedures<o:p></o:p>
or policies that are incompatible with the realities<o:p></o:p>
of daily operations, all of which complicate operational<o:p></o:p>
tasks. These informal practices are the product of the<o:p></o:p>
collective know-how and hands-on expertise of a group, and<o:p></o:p>
they eventually become normal practices. This does not,<o:p></o:p>
however, negate the fact that they are deviations from<o:p></o:p>
procedures that are established and sanctioned by the<o:p></o:p>
organization, hence the term “normalization of deviance”. In<o:p></o:p>
most cases normalized deviance is effective, at least<o:p></o:p>
temporarily. However, it runs counter to the practices upon<o:p></o:p>
which system operation is predicated. In this sense, like any<o:p></o:p>
shortcut to standard procedures, normalized deviance carries<o:p></o:p>
the potential for unanticipated “downsides” that might<o:p></o:p>
unexpectedly trigger unsafe situations. However, since they<o:p></o:p>
are “normal”, it stands to reason that neither these practices<o:p></o:p>
nor their downsides will be recorded in incident reports.<o:p></o:p>

民航发表于 2010-4-7 15:33:58

民航发表于 2010-4-7 15:35:27

<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:chsdate w:st="on" Year="1899" Month="12" Day="30" IsLunarDate="False" IsROCDate="False">1.2.8</st1:chsdate> Thus, incident reporting cannot completely<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
reveal the human contribution to successes or failures in<o:p></o:p>
aviation and how remedial strategies can be improved to<o:p></o:p>
enhance human performance. Incident reporting systems are<o:p></o:p>
certainly better than accident investigations in understanding<o:p></o:p>
system performance, but the real challenge lies in taking the<o:p></o:p>
next step — understanding the processes underlying human<o:p></o:p>
error rather than taking errors at face value. It is essential<o:p></o:p>
to move beyond the visible manifestations of error when<o:p></o:p>
designing remedial strategies. If the aviation industry is to<o:p></o:p>
be successful in modifying system and individual performance,<o:p></o:p>
errors must be considered as symptoms that<o:p></o:p>
suggest where to look further. In order to understand the<o:p></o:p>
mechanisms underlying errors in operational environments,<o:p></o:p>
flaws in system performance captured through incident<o:p></o:p>
reporting should be considered as symptoms of mismatches<o:p></o:p>
at deeper layers of the system. These mismatches might be<o:p></o:p>
deficiencies in training systems, flawed person/technology<o:p></o:p>
interfaces, poorly designed procedures, corporate pressures,<o:p></o:p>
poor safety culture, etc. The value of the data generated by<o:p></o:p>
incident reporting systems lies in the early warning about<o:p></o:p>
areas of concern, but such data do not capture the concerns<o:p></o:p>
themselves.<o:p></o:p>

民航发表于 2010-4-7 15:35:43

Training<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:chsdate w:st="on" Year="1899" Month="12" Day="30" IsLunarDate="False" IsROCDate="False">1.2.9</st1:chsdate> The observation of training behaviours (during<o:p></o:p>
flight crew simulator training, for example) is another tool<o:p></o:p>
that is highly valued by the aviation industry to understand<o:p></o:p>
operational human performance. However, the “production”<o:p></o:p>
component of operational decision making does not exist<o:p></o:p>
under training conditions. While operational behaviours<o:p></o:p>
during line operations are a compromise between production<o:p></o:p>
and safety objectives, training behaviours are absolutely<o:p></o:p>
biased towards safety. In simpler terms, the compromise<o:p></o:p>
between production and safety is not a factor in decision<o:p></o:p>
making during training (see Figure 1-2). Training<o:p></o:p>
behaviours are “by the book”.<o:p></o:p>

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