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Operational Safety – Technical Safety. Welcome!. Operational Safety – Technical Safety. Operational Safety – Technical Safety. Operational Safety – Technical Safety. Operational Safety – Technical Safety. Operational Safety – Technical Safety. Human Factor. Intentional non - compliance

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  1. Operational Safety – Technical Safety • Welcome! SWISS Safety, 30 March 2006 SVFB

  2. Operational Safety – Technical Safety SWISS Safety, 30 March 2006 SVFB

  3. Operational Safety – Technical Safety SWISS Safety, 30 March 2006 SVFB

  4. Operational Safety – Technical Safety SWISS Safety, 30 March 2006 SVFB

  5. Operational Safety – Technical Safety SWISS Safety, 30 March 2006 SVFB

  6. Operational Safety – Technical Safety • Human Factor • Intentional non - compliance • Proficiency • Operational Decision • Communication • Procedural • Incapacitation SWISS Safety, 30 March 2006 SVFB

  7. LOSA results: Errors committed and consequences (per 100 flights) 0 10 20 30 40 50 60 Violation(intentional) Procedural(un-intentional) Note: Crews which committed violations where twice as likely to encounter an additional error! Communication Proficiency / Skill OperationalDecision-making Source: UT; Dr. R. Helmreich number of errors which became consequential number of flights with errors

  8. Operational Safety – Technical Safety Safety Culture Senior Management Commitment • Without the whole hearted commitment of management, any safety program will be ineffective • Safety is good for business Question: Who is producing Safety? SWISS Safety, 30 March 2006 SVFB

  9. Accidents Reactive Focus Incidents Accident Precursors Incident Precursors Exceedences Proactive Focus Normal Operations Operational Safety – Technical Safety SWISS Safety, 30 March 2006 SVFB

  10. Operational Safety – Technical Safety Data provided by Quick Access Recorder B - 747 - 500 Parameters MD - 11 - 1’500 Parameters A320 - 2’500 Parameters A330 - 4’000 Parameters out of 10’000 SWISS Safety, 30 March 2006 SVFB

  11. Operational Safety – Technical Safety “Stop shaking, man! Just tell me what happened?” SWISS Safety, 30 March 2006 SVFB

  12. Operational Safety – Technical Safety Flight Data Monitoring SWISS Safety, 19 May 2005 WANO 12 12

  13. Operational Safety – Technical Safety Contributing factors to maintenance errors SWISS Safety, 30 March 2006 SVFB

  14. Operational Safety – Technical Safety Managing maintenance errors • We must not aim to eliminate human error • Error is a useful mechanism to allow humans to learn • However, we must manage error where it can have a significant impact on: • Aircraft Safety • Health and Safety • Economics SWISS Safety, 30 March 2006 SVFB

  15. Operational Safety – Technical Safety Regulators approach • In Europe, EASA have identified maintenance human factor issues • Currently have plans to develop regulations governing all areas of the industry between 2005 and 2007: • Design organisations, (Part21-P-NPA) • Airframe manufacturers, (Part25- P- NPA 25-310) • Powerplant manufacturers (Part E- NPA-E-38) • Maintenance organisations: (Part 145 Amendment 5) SWISS Safety, 30 March 2006 SVFB

  16. Operational Safety – Technical Safety Regulators approach • Error reporting system • Efficient shift and task handover procedures • Organisation of shifts • Effective planning of maintenance tasks • HF training • etc EASA PART Part 145 Amendtment 5 requires SWISS Safety, 30 March 2006 SVFB

  17. Operational Safety – Technical Safety Managing maintenance errors • Maintenance organizations are faced with the practical questions of Human Factors, including: • Minimizing the number of errors and their consequences • Error detection (e.g. reporting) • Event analysis and improvement actions • Training • Dealing with violations • Understanding violations and removing the need to violate • Violation management SWISS Safety, 30 March 2006 SVFB

  18. Styles of Safety Culture Blame Just and Learning No Blame Operational Safety – Technical Safety Managing maintenance errors • The Challenge • The conflict of maintenance professionalism • Maintenance personnel in some organisations are unable to openly report for fear of disciplinary action • The Solution • These issues cannot be solved by one measure alone, but in the development of a “Just and Learning Safety Culture” SWISS Safety, 30 March 2006 SVFB

  19. Airbus maintenance error study Operational Safety – Technical Safety SWISS Safety, 30 March 2006 SVFB

  20. Operational Safety – Technical Safety Airbus maintenance error study • Top Six Error Types: • 13% Installation incomplete, component installed but not secured • 10% Installation incorrect, incorrect torque applied • 9% Installation incomplete, component/ fluid/ material missing • 8% Installation incomplete, access panel not closed/ secured • 6% Installation incorrect, system/ equipment incorrectly set or reset • 5% Installation incorrect, incorrect component/ part/ fluid/ gas/ material installed SWISS Safety, 30 March 2006 SVFB

  21. Goal Removal: 1 way A B C D E F G H A G D E H F C B Installation: 40,000 combinations - not including omissions [Adapted from Hall, Human Factors Training Module 1 SWISS Safety, 30 March 2006 SVFB

  22. Operational Safety – Technical Safety Conclusion • Reducing seemingly minor errors is only going to become more critical • As skies and airport get more crowded, mistakes can have more serious consequences • What is safe today is not going to be safe enough tomorrow “Reducing Errors to Make Flights Safer” The Wall Street Journal Europe SWISS Safety, 30 March 2006 SVFB

  23. Operational Safety – Technical Safety Thank you!Questions? and Answers! SWISS Safety, 30 March 2006 SVFB

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