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民航发表于 2010-4-7 15:36:01

<?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">1.2.10</st1:chsdate> Therefore, behaviours under monitored<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
conditions, such as during training or line checks, may<o:p></o:p>
provide an approximation to the way operational personnel<o:p></o:p>
behave when unmonitored. These observations may<o:p></o:p>
contribute to flesh out major operational questions such as<o:p></o:p>
significant procedural problems. However, it would be<o:p></o:p>
incorrect and perhaps risky to assume that observing<o:p></o:p>
personnel during training would provide the key to<o:p></o:p>
understanding human error and decision making in<o:p></o:p>
unmonitored operational contexts.<o:p></o:p>

民航发表于 2010-4-7 15:36:13

Surveys<?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">1.2.11</st1:chsdate> Surveys completed by operational personnel<o:p></o:p>
can also provide important diagnostic information about<o:p></o:p>
daily operations and, therefore, human error. Surveys<o:p></o:p>
1-4 Line Operations Safety Audit (LOSA)<o:p></o:p>
provide an inexpensive mechanism to obtain significant<o:p></o:p>
information regarding many aspects of the organization,<o:p></o:p>
including the perceptions and opinions of operational<o:p></o:p>
personnel; the relevance of training to line operations; the<o:p></o:p>
level of teamwork and cooperation among various employee<o:p></o:p>
groups; problem areas or bottlenecks in daily operations;<o:p></o:p>
and eventual areas of dissatisfaction. Surveys can also probe<o:p></o:p>
the safety culture; for example, do personnel know the<o:p></o:p>
proper channels for reporting safety concerns and are they<o:p></o:p>
confident that the organization will act on expressed<o:p></o:p>
concerns? Finally, surveys can identify areas of dissent or<o:p></o:p>
confusion, for example, diversity in beliefs among particular<o:p></o:p>
groups from the same organization regarding the appropriate<o:p></o:p>
use of procedures or tools. On the minus side, surveys<o:p></o:p>
largely reflect perceptions. Surveys can be likened to<o:p></o:p>
incident reporting and are therefore subject to the<o:p></o:p>
shortcomings inherent to reporting systems in terms of<o:p></o:p>
understanding operational human performance and error.<o:p></o:p>

民航发表于 2010-4-7 15:36:26

民航发表于 2010-4-7 15:36:51

民航发表于 2010-4-7 15:37:09

Proactive strategies<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
Normal line operations monitoring<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">1.2.14</st1:chsdate> The approach proposed in this manual to<o:p></o:p>
identify the successful human performance mechanisms that<o:p></o:p>
contribute to aviation safety and, therefore, to the design of<o:p></o:p>
countermeasures against human error focuses on the<o:p></o:p>
monitoring of normal line operations.<o:p></o:p>
Figure 1-2. Training Behaviours — Accomplishing training goals<o:p></o:p>
Safety<o:p></o:p>
Production<o:p></o:p>
Chapter 1. Basic error management concepts 1-5<o:p></o:p>
<st1:chsdate w:st="on" Year="1899" Month="12" Day="30" IsLunarDate="False" IsROCDate="False">1.2.15 A</st1:chsdate>ny typical routine flight — a normal process<o:p></o:p>
— involves inevitable, yet mostly inconsequential errors<o:p></o:p>
(selecting wrong frequencies, dialling wrong altitudes,<o:p></o:p>
acknowledging incorrect read-backs, mishandling switches<o:p></o:p>
and levers, etc.) Some errors are due to flaws in human<o:p></o:p>
performance while others are fostered by systemic shortcomings;<o:p></o:p>
most are a combination of both. The majority of<o:p></o:p>
these errors have no negative consequences because operational<o:p></o:p>
personnel employ successful coping strategies and<o:p></o:p>
system defences act as a containment net. In order to design<o:p></o:p>
remedial strategies, the aviation industry must learn about<o:p></o:p>
these successful strategies and defences, rather than continue<o:p></o:p>
to focus on failures, as it has historically done.<o:p></o:p>

民航发表于 2010-4-7 15:37:30

<?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="2.16" UnitName="a">2.16 A</st1:chmetcnv></st1:chsdate> medical analogy may be helpful in<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
illustrating the rationale behind LOSA. Human error could<o:p></o:p>
be compared to a fever: an indication of an illness but not<o:p></o:p>
its cause. It marks the beginning rather than the end of the<o:p></o:p>
diagnostic process. Periodic monitoring of routine flights is<o:p></o:p>
therefore like an annual physical: proactively checking<o:p></o:p>
health status in an attempt to avoid getting sick. Periodic<o:p></o:p>
monitoring of routine flights indirectly involves measurement<o:p></o:p>
of all aspects of the system, allowing identification of<o:p></o:p>
areas of strength and areas of potential risk. On the other<o:p></o:p>
hand, incident investigation is like going to the doctor to fix<o:p></o:p>
symptoms of problems; possibly serious, possibly not. For<o:p></o:p>
example, a broken bone sends a person to the doctor; the<o:p></o:p>

民航发表于 2010-4-7 15:37:46

doctor sets the bone but may not consider the root cause(s)<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
— weak bones, poor diet, high-risk lifestyle, etc. Therefore,<o:p></o:p>
setting the bone is no guarantee that the person will not turn<o:p></o:p>
up again the following month with another symptom of the<o:p></o:p>
same root cause. Lastly, accident investigation is like a postmortem:<o:p></o:p>
the examination made after death to determine its<o:p></o:p>
cause. The autopsy reveals the nature of a particular<o:p></o:p>
pathology but does not provide an indication of the<o:p></o:p>
prevalence of the precipitating circumstances. Unfortunately,<o:p></o:p>
many accident investigations also look for a<o:p></o:p>
primary cause, most often “pilot error”, and fail to examine<o:p></o:p>
organizational and system factors that set the stage for the<o:p></o:p>
breakdown. Accident investigations are autopsies of the<o:p></o:p>
system, conducted after the point of no return of the system’s<o:p></o:p>
health has been passed.<o:p></o:p>

民航发表于 2010-4-7 15:38:02

<?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">1.2.17</st1:chsdate> There is emerging consensus within the aviation<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
industry about the need to adopt a positive stance and<o:p></o:p>
anticipate, rather than regret, the negative consequences of<o:p></o:p>
human error in system safety. This is a sensible objective.<o:p></o:p>
The way to achieve it is by pursuing innovative approaches<o:p></o:p>
rather than updating or optimizing methods from the past.<o:p></o:p>
After more than 50 years of investigating failures and<o:p></o:p>
monitoring accident statistics, the relentless prevalence of<o:p></o:p>
human error in aviation safety would seem to indicate a<o:p></o:p>
somewhat misplaced emphasis in regard to safety, human<o:p></o:p>
performance and human error, unless it is believed that the<o:p></o:p>
human condition is beyond hope.<o:p></o:p>

民航发表于 2010-4-7 15:38:27

<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /><st1:chmetcnv w:st="on" TCSC="0" NumberType="1" Negative="False" HasSpace="True" SourceValue="1.3" UnitName="a">1.3 A</st1:chmetcnv> CONTEMPORARY APPROACH TO<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
OPERATIONAL HUMAN PERFORMANCE<o:p></o:p>
AND ERROR<o:p></o:p>
<st1:chsdate w:st="on" Year="1899" Month="12" Day="30" IsLunarDate="False" IsROCDate="False">1.3.1</st1:chsdate> The implementation of normal operations<o:p></o:p>
monitoring requires an adjustment on prevailing views of<o:p></o:p>
human error. In the past, safety analyses in aviation have<o:p></o:p>
viewed human error as an undesirable and wrongful<o:p></o:p>
manifestation of human behaviour. More recently, a considerable<o:p></o:p>
amount of operationally oriented research, based<o:p></o:p>
on cognitive psychology, has provided a very different<o:p></o:p>
perspective on operational errors. This research has proven,<o:p></o:p>

民航发表于 2010-4-7 15:38:42

in practical terms, a fundamental concept of cognitive<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
psychology: error is a normal component of human behaviour.<o:p></o:p>
Regardless of the quantity and quality of regulations the<o:p></o:p>
industry might promulgate, the technology it might design,<o:p></o:p>
or the training people might receive, error will continue to<o:p></o:p>
be a factor in operational environments because it simply is<o:p></o:p>
the downside of human cognition. Error is the inevitable<o:p></o:p>
downside of human intelligence; it is the price human beings<o:p></o:p>
pay for being able to “think on our feet”. Practically speaking,<o:p></o:p>
making errors is a conservation mechanism afforded by<o:p></o:p>
human cognition to allow humans the flexibility to operate<o:p></o:p>
under demanding conditions for prolonged periods without<o:p></o:p>
draining their mental “batteries”.<o:p></o:p>

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