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Mitigating Culture: Human Error in the Operational ATC World

Anthony Smoker RAeS Human Factors Group Mitigating Human Error Conference 15 th October 2003. Mitigating Culture: Human Error in the Operational ATC World. Human Error in the Operational ATC World. “Give me a fruitful error any time, bursting with its own correction” Pareto on Kepler 1870.

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Mitigating Culture: Human Error in the Operational ATC World

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  1. Anthony Smoker RAeS Human Factors Group Mitigating Human Error Conference 15th October 2003 Mitigating Culture: Human Error in the Operational ATC World

  2. Human Error in the Operational ATC World “Give me a fruitful error any time, bursting with its own correction” Pareto on Kepler 1870

  3. Attributes of the Operational World – focusing on en-route operations • Reporting of Incidents • Training and Mitigation • Organisational Culture • AGAS • Conclusions

  4. Attributes of the operational world

  5. The ATC Watch (team) • ATC watches or teams can be large groups of controllers and assistants • ATC Engineers – deliver “safe systems”

  6. ATC Technology • “Controllers don’t just use the technology – they are the technology” • Nature of errors? • System development: ATC-ATM

  7. Attributes of the operational world • Closed World: organisational isolation? • Operational community expect immediate change • Cascading information - communication

  8. Reporting of Incidents and Events

  9. Reporting • Critical to understanding errors • Mandatory reporting – MOR • Incident reporting and observations – in-house • Confidential systems (CHIRP)

  10. Specific Operational Problems • Systematic failures or errors found from investigation • Focused on one specific error type • altitude busts – procedure changes • Prolonged Loss of Communication (PLOC)

  11. Investigation • Local investigation at unit • Tools – Separation Monitoring Function, ASMT(EUROCONTROL) • Culture and operational acceptance • Techniques – TRACER, HERA/JANUS • Controllers trained as investigators

  12. Communicating the message • How to engage with controllers? • What is the right format? • Effectiveness of the message • Transparency • Feedback

  13. Training for Mitigation

  14. Training for Mitigation • Poor system design often mitigated by training • Operational environment is unforgiving, time critical and highly adaptable • System behaviours variable (akin to FMS modes)

  15. Maintenance of Mitigation • Competence schemes where available • Updating of safety cases with system changes • Frequency of changes

  16. Culture

  17. Operational Culture • ATC is a good example of a High Reliability organisation • Sustains high performance across a range of conditions • Perceptions of the operational community –barrier to culture change?

  18. Safety Culture • Organisational Culture(s) dictates safety culture: conflict between cultures? • “Organisational climate” • Trust • External influences on organisational culture – resource limitations

  19. Structures • ATC involvement – Watch Safety Officer etc • Incident & Investigation sections • Unit management • Headquarters functions • Regulators • How does this structure interface with the operational controller?

  20. Human Factors

  21. Role of Human Factors • Applied to understanding human error in control task • Handovers • Separation in provision of Radar Advisory Service • Can provide a direct input into procedures and training

  22. Applying Human Factors • Increasingly important to make ATC staff aware of factors that affect human performance

  23. Human Performance • Incorporated into Training from ab- initio and beyond • Defences against perceptual errors • Team Resource Management: ATC-TRM is not CRM

  24. AGAS

  25. AGAS - Action Group for ATM Safety Established by EUROCONTROL Provisional Council as a result of Uberlingen mid-air collision

  26. AGAS - Action Group for ATM Safety • “Areas for Immediate Focus • Safety related human resources • Incident reporting and data sharing • ACAS - Additional actions • Runway Safety • Enforcement of ESARRs and monitoring implementation

  27. Conclusions • Considerable progress has led to changes in approaches to human error in ATC/ATM • “A long game” • New challenges with new systems and changing organisations • Communication remains a problem

  28. Mitigating Culture: Human Error in the Operational ATC World • Anthony Smoker • RAeS Human Factors Group

  29. Mitigating Culture: Human Error in the Operational ATC World • Anthony Smoker • RAeS Human Factors Group

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