My MPhil to PhD Transfer Presentation - 30 Jul 2013

In 1900, Wilbur wrote to his father,

“Carelessness & overconfidence,”

he said, “are usually more

dangerous than deliberately

accepted risks.”

We can design products and systems to eliminate or minimise human error but

addressing human reliability and particularly individuals’ attitudes towards risk

is much more challenging; therefore I believe risk takers pose more of a

significant threat to flight safety than professionals making genuine errors.

MANAGING HUMAN RISK IS THE KEY TO ENSURING FLIGHT SAFETY

ICAO (2013) ICAO Predicts Continued Traffic Growth Through 2015. Available at: http://www.icao.int/Newsroom/Pages/ICAO-predicts-continued-traffic-growth-through-2015.aspx [Accessed on 28 Jul 2013]

EASA (2013) EASA Annual Safety Review 2012. Available at: http://www.easa.europa.eu/communications/docs/annual-safety-review/2012/EASA-Annual-Safety-Review-2012.pdf [Accessed on 28 Jul 2013]

EASA (2012) European Aviation Safety Plan 2013 - 2016. Available at: http://www.easa.europa.eu/sms/docs/European%20Aviation%20Safety%20Plan%20%282013-2016%29%20-v1.0%20Final.pdf (Accessed on 31 Jul 2013]

CALCULATIVE We have systems in place to manage all

hazards

PROACTIVE Safety leadership and values drive

continuous improvement

REACTIVE Safety is important, we do a lot every time we

have an accident

PATHOLOGICAL Who cares as long as we’re not caught

GENERATIVE Safety is how we do business

around here

Managing the Risks of Organisational Accidents, 1997

Risk management is a balancing act. It involves balancing risks and rewards.

Risk Thermostat – Prof. John Adams Source: Risk, 1995

“Just Culture protects people’s honest mistakes from being seen as culpable. But what is an honest mistake, or rather when is a mistake no longer honest?”

“We’ve lost the practical differentiation between human error, at-risk, and reckless behaviours. In doing so, we’ve created only one standard: PERFECTION.......”

Unsafe Acts

Unintended Action

Intended Action

SLIP

LAPSE

MISTAKE

VIOLATION

Attentional Failures Omision Misordering Mistiming

Memory Failures Omiting planed item Place losing Forgetting intentions

Rule Based Mistakes Misapplication of good rule Application of bad rule Knowledge Based Mistakes

Many variable forms

Routine violations Exceptional violations

Acts of sabotage

• To evaluate the participating airlines’ and maintenance organisations’ risk management processes from human factors point of view.

• To investigate the factors driving today’s commercial air transport pilots and engineers to take risks in their operational environment.

• To develop a framework for assessing human reliability in commercial air transport, which will consider risk taking behaviour as well as genuine human errors.

• To make recommendations how this model can be used to improve the effectiveness of the risk management processes in airlines & AMO’s

“Research examining the impact of these individual differences on pilots’ risk-taking behaviour reveals attitude and risk perception to be key predictors. (Hunter, 2002, 2005)”