ERGONOMICS FORUM. Gavin McKellar 4

Transcription

1 ERGONOMICS FORUM Gavin McKellar 4

2 Counting

3

4 Human Factors Human Factors Litson and Associates

5 Human Factors What is Human Factors? Human factors involves the study of all aspects of the way humans relate to the world around them, with the aim of improving operational performance and safety The recognition and study of human factors is important for safety, because they can be the cause of serious human errors on the levels of physical behaviour and socio -cognitive decisionmaking Litson and Associates

6 PILOT SLIPS

7 PILOT SAVES Souix City Azores 330 LH Bagdad Air Transat Pilots every day

8

9 Human Factors is the study of: Physical Physiological Psychological Psychosocial variables that affect a human s performance.

10 Human Factors SHEL(L) Model Understanding the relationship between people and operational contexts S Software Hardware H L LL E Environment Liveware Liveware, other persons

11 S = Software Transfer of information between the human and supporting systems checklists manuals publications procedures regulatory requirements maps and charts

12

13 BE SAFE OUT THERE!!

14 The common photostat error?

15 H = Hardware Physical and mental interactions between the person and machine or equipment (ergonomics) design limitations instrument/control design and location instrument colors/readability seat design eye reference position

16

17

18 GETTING THE JOB DONE

19 E = Environment Internal Factors personal comfort and physical working conditions temperature illumination/glare air quality External Factors Weather conditions Airport surroundings Airport conditions Oversight Politics Pressure Culture Foreign

20

21

22 L = Liveware The nature of interactions between humans voice communications phraseology speech content/rate language barriers readback/hearback crew briefings crew interactions labor relations non-verbal cues

23

24 Humans Equipment Policies procedures practices Other People Influences

25 Policies procedures practices Influences Humans Other People Equipment

26 Human Factors Decision making Factors contributing to decision errors The situations were not recognized as ones that should trigger a change of course of action, due to the ambiguity of the cues Risk was under-estimated Goals conflicted (safety vs. productivity, mission completion or social factors) Consequences were not anticipated or evaluated

27 Human Factors Decision making Despite efforts to design systems and procedures to support 'correct' and safe operations, errors in human judgment still occur and contribute to accidents

28

29

30 PERCEPTIONS

31

32

33 Human Factors Visual Illusions Litson and Associates

34 Aoccdrnig to a rscheearch at an Elingsh Uinervtisy, it deosn t mttaer in what oredr the ltteers in a word are, the olny iprmoetnt tihng is that frist and lsat ltteer is at the rghit pclae.the rset can be a toatl mses and you can still raed it wouthit porblrm. This is bcuseae we do not raed ervey lteter by it slef but the word as a wlohe.

35 We ve made it, Warren! The moon!

36 ERROR CATAGORIES cannot eliminate error, manage it PROFICIENCY PROCEDURAL COMMUNICATION DECISION MAKING WILLFULL NON- COMPLIANCE

37

38 Cockpit Resource Management Crew resource Mngt. Corporate Resource management H.F. Comms. DM Behavior, Culture, Leadership. Teams, Delegation, Monitored Approach, ANC, etc Threat & Error Mngt CRM

39 Error management: What do you aim for? Person Task and Team Workplace Organisation

40 Most organizations go for the person Blame and train Write another procedure Search for missing piece

41 But it s better to aim for... Task + Workplace + Organization System+Limitations+Envoroment

42 Errors are like mosquitoes

43 You can swat them and spray them But they still keep coming

44 The only effective measures are To drain the swamps in which they breed. And to use various proven defences: mosquito netting mosquito repellent quinine-based pills, etc. Use Threat and Error Management Model to determine what threats are leading to the errors and ensure you are managing errors as well as latent and overt threats

45 Focusing on individual errors is like...

46 Human Factors Error Producing Rates Unfamiliarity with the task (X17) Time Shortage (X11) Poor Signal to Noise Ratio (X10) Poor Man / Machine Interface (X 8) Designer / User Mismatch (X 8) Irreversibility of Errors (X 8) Information Overload (X 6) Negative Transfer Between Tasks (X 5) Misperception of Risk (X 5) Poor Feedback from Machine / System (X 4) Inexperience (Not lack of training) (X 3) Poor Instructions or Procedures (X 3) Inadequate Cross Checking (X 3) Educational Mismatch of Person Task (X 2) Disturbed Sleep Patterns (X1.6) Hostile Environment (X1.2)

47

48 Human Factors Fatigue Impairment due to Prolonged physical or mental work Long periods without sleep Disruption of sleep patterns Litson and Associates

49 Human Factors Tiredness & Fatigue We cannot live without sleep We need about 7-8 hours of sleep every day Not enough sleep leads to: attention difficulties slower reaction times slower, muddled thinking erratic behaviour FALLING ASLEEP uncontrollably Effects of sleep loss build up Recovery usually takes 2 full nights of sleep Litson and Associates

50 RESULTS OF FATIGUE Inability to assess risk and to action Inability to identify and react to stimuli Taking quicker decisions based on experience Inadequate response Reduced concentration

51

52 FATIGUE VS DRUNK? Drunk? Or Too Tired To Care? Longer than 18 hours awake could impair human functioning as severely as heavy drinking Greater than 23 hours awake is = blood alcohol content of 1.2 Driving limit is 0.05 Professional limit= years jail term-serious.

53

54 Foto: cortesía, Cap. RAUL ESTRELLA

55

56 FAA MR J. Goode Claims to have found positive correlation between length of duty time and error. There is a discernable pattern of increased probability of an accident the greater the hours of duty time for commercial pilots in the USA

57

58 C 5 GALAXY ACCIDENT Errors in-- A/c handling Non-briefings Using shut throttle and not live Flap selection Flap retraction

59 C5 GALAXY ACCIDENT USAF board remarked crew had less than 4.5 hours sleep before reporting at 01h00 Crew could have been in low arousal state and less likely to pick up errors. Impaired decision making

60 MK 747-F HALIFAX Errors in working out performance Failure in procedural defences to detect error in perf. data Error in not trapping Crew failure to recognise abnormal t/o perf. Once t/o started Always consider latent factors, threats and errors

61 Incident Investigation Little Rock - Exercise Litson and Associates

62 CRM Survival Exercise

63 Human Performance issues need understanding Legislation for accident prevention is required Continual management of risk is required Conclusions

64 Conclusions 2 Accidents are complex Working together for success is needed Share lessons Develop a safety culture Implement!

65 Any Questions????