Doc9803航线运行安全审计

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ffice:smarttags" />1.2.10 Therefore, behaviours under monitoredfficeffice" />

conditions, such as during training or line checks, may

provide an approximation to the way operational personnel

behave when unmonitored. These observations may

contribute to flesh out major operational questions such as

significant procedural problems. However, it would be

incorrect and perhaps risky to assume that observing

personnel during training would provide the key to

understanding human error and decision making in

unmonitored operational contexts.

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Surveysfficeffice" />

ffice:smarttags" />1.2.11 Surveys completed by operational personnel

can also provide important diagnostic information about

daily operations and, therefore, human error. Surveys

1-4 Line Operations Safety Audit (LOSA)

provide an inexpensive mechanism to obtain significant

information regarding many aspects of the organization,

including the perceptions and opinions of operational

personnel; the relevance of training to line operations; the

level of teamwork and cooperation among various employee

groups; problem areas or bottlenecks in daily operations;

and eventual areas of dissatisfaction. Surveys can also probe

the safety culture; for example, do personnel know the

proper channels for reporting safety concerns and are they

confident that the organization will act on expressed

concerns? Finally, surveys can identify areas of dissent or

confusion, for example, diversity in beliefs among particular

groups from the same organization regarding the appropriate

use of procedures or tools. On the minus side, surveys

largely reflect perceptions. Surveys can be likened to

incident reporting and are therefore subject to the

shortcomings inherent to reporting systems in terms of

understanding operational human performance and error.

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Flight data recordingfficeffice" />

ffice:smarttags" />1.2.12 Digital Flight Data Recorder (DFDR) and

Quick Access Recorder (QAR) information from normal

flights is also a valuable diagnostic tool. There are, however,

some limitations about the data acquired through these

systems. DFDR/QAR readouts provide information on the

frequency of exceedences and the locations where they

occur, but the readouts do not provide information on the

human behaviours that were precursors of the events. While

DFDR/QAR data track potential systemic problems, pilot

reports are still necessary to provide the context within

which the problems can be fully diagnosed.

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ffice:smarttags" />1.2.13 Nevertheless, DFDR/QAR data hold highfficeffice" />

cost/efficiency ratio potential. Although probably underutilized

because of cost considerations as well as cultural

and legal reasons, DFDR/QAR data can assist in identifying

operational contexts within which migration of behaviours

towards the limits of the system takes place.

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Proactive strategiesfficeffice" />

Normal line operations monitoring

ffice:smarttags" />1.2.14 The approach proposed in this manual to

identify the successful human performance mechanisms that

contribute to aviation safety and, therefore, to the design of

countermeasures against human error focuses on the

monitoring of normal line operations.

Figure 1-2. Training Behaviours — Accomplishing training goals

Safety

Production

Chapter 1. Basic error management concepts 1-5

1.2.15 Any typical routine flight — a normal process

— involves inevitable, yet mostly inconsequential errors

(selecting wrong frequencies, dialling wrong altitudes,

acknowledging incorrect read-backs, mishandling switches

and levers, etc.) Some errors are due to flaws in human

performance while others are fostered by systemic shortcomings;

most are a combination of both. The majority of

these errors have no negative consequences because operational

personnel employ successful coping strategies and

system defences act as a containment net. In order to design

remedial strategies, the aviation industry must learn about

these successful strategies and defences, rather than continue

to focus on failures, as it has historically done.

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ffice:smarttags" />1.2.16 A medical analogy may be helpful infficeffice" />

illustrating the rationale behind LOSA. Human error could

be compared to a fever: an indication of an illness but not

its cause. It marks the beginning rather than the end of the

diagnostic process. Periodic monitoring of routine flights is

therefore like an annual physical: proactively checking

health status in an attempt to avoid getting sick. Periodic

monitoring of routine flights indirectly involves measurement

of all aspects of the system, allowing identification of

areas of strength and areas of potential risk. On the other

hand, incident investigation is like going to the doctor to fix

symptoms of problems; possibly serious, possibly not. For

example, a broken bone sends a person to the doctor; the

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doctor sets the bone but may not consider the root cause(s)fficeffice" />

— weak bones, poor diet, high-risk lifestyle, etc. Therefore,

setting the bone is no guarantee that the person will not turn

up again the following month with another symptom of the

same root cause. Lastly, accident investigation is like a postmortem:

the examination made after death to determine its

cause. The autopsy reveals the nature of a particular

pathology but does not provide an indication of the

prevalence of the precipitating circumstances. Unfortunately,

many accident investigations also look for a

primary cause, most often “pilot error”, and fail to examine

organizational and system factors that set the stage for the

breakdown. Accident investigations are autopsies of the

system, conducted after the point of no return of the system’s

health has been passed.

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ffice:smarttags" />1.2.17 There is emerging consensus within the aviationfficeffice" />

industry about the need to adopt a positive stance and

anticipate, rather than regret, the negative consequences of

human error in system safety. This is a sensible objective.

The way to achieve it is by pursuing innovative approaches

rather than updating or optimizing methods from the past.

After more than 50 years of investigating failures and

monitoring accident statistics, the relentless prevalence of

human error in aviation safety would seem to indicate a

somewhat misplaced emphasis in regard to safety, human

performance and human error, unless it is believed that the

human condition is beyond hope.

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ffice:smarttags" />1.3 A CONTEMPORARY APPROACH TOfficeffice" />

OPERATIONAL HUMAN PERFORMANCE

AND ERROR

1.3.1 The implementation of normal operations

monitoring requires an adjustment on prevailing views of

human error. In the past, safety analyses in aviation have

viewed human error as an undesirable and wrongful

manifestation of human behaviour. More recently, a considerable

amount of operationally oriented research, based

on cognitive psychology, has provided a very different

perspective on operational errors. This research has proven,

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in practical terms, a fundamental concept of cognitivefficeffice" />

psychology: error is a normal component of human behaviour.

Regardless of the quantity and quality of regulations the

industry might promulgate, the technology it might design,

or the training people might receive, error will continue to

be a factor in operational environments because it simply is

the downside of human cognition. Error is the inevitable

downside of human intelligence; it is the price human beings

pay for being able to “think on our feet”. Practically speaking,

making errors is a conservation mechanism afforded by

human cognition to allow humans the flexibility to operate

under demanding conditions for prolonged periods without

draining their mental “batteries”.