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HERA

HERA. HERA is the Human error in ATM project HERA includes several activities within the area of Human Error - its identification its analysis its management its mitigation There have been 2 phases in the project. HERA 1. HERA phase 1

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HERA

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  1. HERA • HERA is the Human error in ATM project • HERA includes several activities within the area of Human Error - its identification • its analysis • its management • its mitigation • There have been 2 phases in the project

  2. HERA 1 • HERA phase 1 • Identify the error models and methodologies used in other areas • Adapt the chosen model to ATM - both present and future • Create a technique of error identification and analyses based on the chosen model

  3. HERA 2 • HERA phase 2 • Using the HERA technique, identify errors; their detection and recovery, made in the ‘real ATM ‘ environment • Using the HERA technique, try and identify and predict the errors which will emerge from new ATM systems • Using the HERA technique, support the efforts in the Safety domain by assisting in the development of a safety management system • Implement the HERA incident investigation technique into the ECAC States

  4. JANUS • HERA phase 3 • HERA was then assessed by the FAA and they found it to be better than their own system and after much discussion, debate and analysis • - the JANUS approach was developed

  5. Incident Investigation Follow-up Feedback Post Incident Process

  6. Human Error - Data collection and Analysis Two different but related activities

  7. What do you do to collect data about Human Factors aspects?

  8. Event Incident Investigation Data collection Analysis Report HERA

  9. Objectives of the Training • the HERA-JANUS technique • its place within the incident investigation • Human Factors background • How to use the technique • What it is not! • This is not an incident investigation course

  10. Human Information Processing

  11. Human Error and Violation

  12. What is a Human Error? Define what a Human Error is

  13. Human Error Definition : Any action (or inaction) that potentially or actually results in negative system effects, where more than one possible course of action is available

  14. What is a violation? Define what a violation is

  15. Violation Definition : Actions that contravene a rule, procedure or operating instruction

  16. JANUS Overview The Individual Act Outside Factors Information Processing: Which Error Detail (ED) was involved? IP Level Memory Task Perception EM Decisions Information/ Equipment Which mechanism lies behind the failure? Response CC’s Contextual Conditions Error Mechanism: Which function failed?

  17. What the person (or persons) does? Describe the error(s) Error Type - Section 1

  18. How they do it? Human Information Processing Error Detail- Section 2 Error Mechanism - Section 3 Information Processing level - Section 3

  19. Why they do it? The Context and Environment Sections - 4, 5 and 6

  20. Putting It All Together • Identify each error - in turn : • Identify the Error • Identify the Error Detail • Identify the Error Mechanism followed by the Information Processing level • List the Task, Information & Equipment • Identify all the Contextual Conditions

  21. STOP RULES • If you find yourself (or others) saying - • they should have….. • they could have…… • they would have…... STOP • If you can’t find the facts you are looking forSTOP • If you find yourself (or others) saying - • I /we would have assumed….STOP

  22. Land Short of Fuel Case What are the Human Errors?

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