Uncovering human factors risks - Home - - Heather  · Ways of gaining visibility and

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  • Uncovering human factors risks Gaining visibility of opera2onal human factors issues through the Safety Management System

  • Overview of the presentation

  • Presentation topics

    Gaining visibility of Human Factors risks Safety reporting systems, investigations Safety audits Risk Management Systems Fatigue Risk Management Systems Flight Data Monitoring Safety Climate Survey

    Managing human factors risks Non-Technical Skills (NTS) training Safety promotion activities Changing policies, processes and systems

    Future directions

  • Virgin Australias Safety Management System model

  • Gaining visibility of human factors risks

  • Ways of gaining visibility and managing human factors risks

    Sources of data to gain visibility of HF risks

    Ways to manage HF risks

  • Safety reporting and investigations

    Our goal: to ascertain the error-producing conditions in our daily operations, by encouraging reporting of

    the following;

  • Flight OperationsNumber of Operational Safety Occurrences by Risk

    0

    30

    60

    90

    120

    150

    180

    Very

    Low

    Low

    Mod

    erat

    e

    Hig

    h

    Extr

    eme

    Very

    Low

    Low

    Mod

    erat

    e

    Hig

    h

    Extr

    eme

    Very

    Low

    Low

    Mod

    erat

    e

    Hig

    h

    Extr

    eme

    Aug-11 Sep-11 Oct-11

    Num

    ber o

    f Occ

    urre

    nces Accountable Indirect

    Safety reporting and investigations

  • Safety reporting and investigations

  • Safety audits

    More proactive way to reveal day-to-day issues (particularly undetected errors and conditions)

    Some examples Flight safety: data entry errors due to task

    saturation Cabin safety: fatigue-related errors in door

    procedures Ground safety: slight deviations from SOPs

    due to low familiarity with the operation

  • Risk Management Systems

    Identifying HF-related risks associated with operational changes

    Distribution and escalation of risk management tools (i.e. risk registers)

    Example: SOP change during the takeoff phase

    Risk of behavioural reversion Risk of miscommunication between

    Captain and First Officer Risk of reducing reaction times, etc.

  • Fatigue Risk Management Systems (FRMS)

    The FRMS reporting processes & communications systems are a significant part of data collection on crew wellbeing.

    Example: alteration of the Australia-LAX pairings for a longer layover.

  • Flight Data Monitoring

    Provides objective, detailed technical data

    Allows for verification of crews recollections

    Examples: Rejected takeoff actions Rates of descent on

    approach Breaches that are unknown

    to the crew

  • Safety Climate Survey

    Allows for a collation of feedback from crew

    Will be conducted

    organisation-wide in 2012.

  • Gaining visibility: Bringing together all information sources

  • Gaining visibility

    The key is having all levels of management having an appropriate level of knowledge

    about the human factors-related risks

  • Managing human factors risks

  • Sources of data to gain visibility of HF risks

    Ways to manage HF risks

  • NTS courses and other safety training

    Providing skills and knowledge to crew and other safety critical staff

    Can incorporate lessons learned from investigations, audits, reports

    Allows for a consistency in approaching human factors issues

  • Technical training enhancements

  • Safety promotion activities

    Promoting greater safety awareness and knowledge through targeted messaging.

    Examples

    Management road shows Monthly publications Safety campaigns

  • Changes to policies, process and procedures

    Making organisation-wide changes should be the goal, in addition to training.

    Examples: Flight: Pre-descent briefing checklist

    improvements Cabin: changing crew rest policies to allow for

    more effective in-flight sleep. Ground: developing Local Operating

    Procedures to accommodate unique port procedures

  • Where to from here?

    Further improving visibility of human factors risks by; Improving investigators analytical skills Moving towards performance-based auditing Flight Data Monitoring trend data

    effectiveness Further improving the management of human

    factors risks by; Expanding human factors education and

    skilling

  • Any questions?

    Thank you!

    Heather Fitzpatrick Safety and Quality Advisor

    Virgin Australia Phone: +61 434 602 983

    Email: heather.fitzpatrick@virginaustralia.com.au