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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.
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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 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
“Historical” Safety Design & manufacture Management & supervision Training & maintenance Stakeholders Operational personnel
An Outcome-Oriented Industry Design & manufacture Management & supervision Training & maintenance Stakeholders Operational personnel
The Need to Monitor Processes Design & manufacture Management & supervision Training & maintenance Stakeholders Operational personnel
improve the human condition? improve the processesunderlying aviation operations? The Fundamental Question
Errors and Consequences Causesand consequencesare not proportionalin their magnitude
Operational Errors Reside in the Context Operational behaviours:A compromise Safety Production
Training: Poor Learning Grounds Training behaviours: “By the book” Safety Production
Understanding Operational Errors Error consequences Threat to safety No significant consequences Error Error life span
Checklist failure Unheeded warning Flaps omitted Degradation/ breakdown Error Deviation Amplification Outcomes: Quite Infrequently
Checklistworks Effective warning Normal operation Deviation Amplification Processes: Quite Frequently Flaps omitted Error
Safety & QA: The Data We Must Collect Design & manufacture Management & supervision Training & maintenance Stakeholders Operational personnel
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
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
Rigid frame Normative safety Flexible links with dampers Generative safety Deviation Management
The End of the Innocence Bankruptcy Protection Comfort zone Catastrophe Production