1 / 18

Quality Assurance in ATS, Human Factors and Aviation Safety

Quality Assurance in ATS, Human Factors and Aviation Safety. Captain Daniel Maurino Flight Safety and Human Factors, ICAO NAR/CAR/SAM Air Traffic Services Quality Assurance Seminar Ciudad de Méjico, 16-20 October 2000. QA & Aviation HF: Close Relatives.

vladimir
Download Presentation

Quality Assurance in ATS, Human Factors and Aviation Safety

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Quality Assurance in ATS, Human Factors and Aviation Safety Captain Daniel Maurino Flight Safety and Human Factors, ICAO NAR/CAR/SAM Air Traffic Services Quality Assurance Seminar Ciudad de Méjico, 16-20 October 2000

  2. QA & Aviation HF: Close Relatives Human Factors and aviation safety • Differentiate processes from outcomes • Emphasis on monitoring processes • Relative importance of outcomes as driving forces • Errors do not cause accidents

  3. “Historical” Safety Design & manufacture Management & supervision Training & maintenance Stakeholders Operational personnel

  4. An Outcome-Oriented Industry Design & manufacture Management & supervision Training & maintenance Stakeholders Operational personnel

  5. The Need to Monitor Processes Design & manufacture Management & supervision Training & maintenance Stakeholders Operational personnel

  6. improve the human condition? improve the processesunderlying aviation operations? The Fundamental Question

  7. Errors and Consequences Causesand consequencesare not proportionalin their magnitude

  8. Operational Errors Reside in the Context Operational behaviours:A compromise Safety Production

  9. Training: Poor Learning Grounds Training behaviours: “By the book” Safety Production

  10. Understanding Operational Errors Error consequences Threat to safety No significant consequences Error Error life span

  11. Checklist failure Unheeded warning Flaps omitted Degradation/ breakdown Error Deviation Amplification Outcomes: Quite Infrequently

  12. Checklistworks Effective warning Normal operation Deviation Amplification Processes: Quite Frequently Flaps omitted Error

  13. Safety & QA: The Data We Must Collect Design & manufacture Management & supervision Training & maintenance Stakeholders Operational personnel

  14. The Overriding Importance of Culture • Anglo-Saxons design and supply; “the Rest of the World” uses • Anglo-Saxonsolutions are effective for Anglo-Saxon contexts • Effectiveness in the “Rest-of-the-World”? • World-wide accident rate: failure of the “dominant culture” concept

  15. Human Error & Process Control • Aviation cannot be entirely specified • Humans will inevitably make errors • Normative prescription (music score) • Real-time implementation of the score • Deviation(s) management • Danger: loss of control of deviation management process rather that deviations themsleves

  16. Rigid frame Normative safety Flexible links with dampers Generative safety Deviation Management

  17. The End of the Innocence Bankruptcy Protection Comfort zone Catastrophe Production

More Related