Human Failures in Accidents

1. New Zealand Helicopter Association Human Failures in Accidents

2. A FEW ACCIDENTS… Chernobyl (USSR) 1986 $12 billion US cost to the Soviet economy

3. Exxon Valdez, Alaska (USA) 1989 Oil Spill: 11 million US gallons

4. Flying Tigers, B747, (Malaysia) 1989 4 crew killed, aircraft destroyed

5. Deepwater Horizon, Gulf of Mexico (USA) 2010 4.9 million barrels of oil spilt

6. Costa Concordia, Guam (USA) 2012 32 people drowned

7. Hindenburg, New Jersey (USA) 1937 35 people killed

8. Mars Climate Orbiter, Mars (Space) 1998 - 1999 $1 billion spacecraft lost

9. Union Carbide Plant, Bhopal, (India) 1984 Approx. 8000 dead

10. STS Challenger, Florida (USA) 1986 7 astronauts killed

11. ZK-HJN, Lake Manapouri, (New Zealand) 2000 5 dead

12. ZK-SML, Mount Duppa, (New Zealand) 2011 1 dead

13. RMS Titanic, Atlantic Ocean, 1912 1500 dead

14. What do these accidents/incidents/disasters have in common ? Human Failures Human Errors

15. HUMAN ERROR

16. EVEN EXPERTS CAN MAKE ERRORS

17. ERRORS AND VIOLATIONS An Error Unintentional deviation from organizational expectations or crew intentions (the best people can make the worst errors) A Violation (Intentional Non-compliance)? Intentional deviation from organizational expectations or crew intentions

18. TYPES OF ERORS Slips – attention failure (omission, reversal, mis-ordering, mistiming) Lapses – memory failure (omitting planned items, place-losing, forgetting intentions) Mistakes Rule based (misapplication of a good rule or application of a bad rule) Knowledge based – inaccurate or incomplete system mental model

19. TYPES OF ERRORS Slips – attention failure (omission, reversal, mis-ordering, mistiming) Lapses – memory failure (omitting planned items, place-losing, forgetting intentions) Mistakes Rule based (misapplication of a good rule or application of a bad rule) Knowledge based – inaccurate or incomplete system mental model

20. WHAT ABOUT VIOLATIONS ? Routine – habitual departures from rules and regulations Situational – deviation from procedures or rules needed to get the job done due to a mismatch between a work situation and available procedures or rules Optimising - individual satisfying other motives (excitement, impressing others, cutting corners…)

21. WHAT ABOUT THREATS …. An external event or object that a crew has to deal with that could become consequential to safety

22. WHAT TO DO ? Design systems to be error tolerant (system still functions after an error has been made) Design systems to be error proof (design prevents an error being made at all or makes it difficult for an error to be made)

23. WHAT TO DO ABOUT ERRORS ? Design systems to be error tolerant (system still functions after an error has been made) Design systems to be error proof (design prevents an error being made at all or makes it difficult for an error to be made) Use other safeguards and defences(checklists) Install computers to prevent human error Train personnel so well that they do not make errors Train personnel to try and avoid making errors and/or detect the errors that have been made and correct them and/or limit the effects of errors that already been made.

24. What do these accidents/incidents/disasters have in common ? Human Failures Human Errors Non-technical Skill Failures

25. N.T.S. – OUR SKILL BASE Company Personnel Non Technical Skills Technical Skills

26. FAILURES AND ACCIDENTS Non-Technical Skills Failure Technical Skills Failure Accident Timeline  70% of accidents due to NTS failures

27. N.T.S. CORE ELEMENTS DECISION MAKING SITUATIONAL AWARENESS Information acquisition and processing Workload management Leadership and managerial skills Threat and error management Stress and stress management Cultural factors Communication Fatigue and fatigue management Automation Automation Issues: Mode Confusion Mode Error such as… Selecting incorrect mode, Misreading a display, Missing mode transitions, Assuming it is turned on, Not understanding logic Training ? Basic Skills ?

28. IN THE BEGINNING…

29. THEN…

30. A QUANTUM LEAP ? …

31. NOW… LOTS OF AUTOMATION

32. THEN…

33. NOW…

34. N.T.S. CORE ELEMENTS DECISION MAKING SITUATIONAL AWARENESS Information acquisition and processing Workload management Leadership and managerial skills Threat and error management Stress and stress management Cultural factors Communication Fatigue and fatigue management Automation

35. NZ Helicopter Occurrences 2000 - 2013

36. ACCIDENTS AND PAX NUMBERS 30 25 20 15 10 5 0 HULL LOSSES PER MILLION DEPARTURES GROWTH IN TRILLIONS OF RPK 3.5 3.0 2.5 2.0 1.5 1.0 0.5 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 Boeing ICAO

37. TECHNICAL FAILURES v NON-TECHNICAL SKILL FAILURES 100 80 60 40 20 0 TRENDS IN ATTRIBUTED ACCIDENT CAUSES NON-TECHNICAL SKILL FAILURES HUMAN PERFORMANCE TECHNILOGICAL FAILURES 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 Hollnagel

38. Landmark Accidents

39. LANDMARK ACCIDENTS: TENERIFE 1977

40. LANDMARK ACCIDENTS: Kegworth 1989

41. LANDMARK ACCIDENTS: Valujet 1996

42. LANDMARK ACCIDENTS: Chicago 1979

43. Who should undergo NTS training ? Flight Crew Cabin Crew Maintenance Engineers Other Operational Safety Critical Personnel Management Link your NTS training program to your SMS

44. NTS TRAINING BENEFITS Understand personal limitations Improve awareness, knowledge and skills Change attitudes, modify behaviours Improve cross-functional collaboration Develop adaptive capacity (personally and organisationally) Improve SAFETY and efficiency

45. SOME SOBERING NUMBERS (2013) Passenger Numbers: 3.1 billion 32,500,000 flights Airline Fatalities: 265 29 accidents Road Fatalities: 1.24 million USD $580 billion Medical Fatalities: 3.5 million 223,000,000 procedures Source: Ascend/Aviation Safety Network/Flight Safety Foundation

46. New Zealand Helicopter Association Thanks for your time Contact: Glen Eastlake, Queenstown, New Zealand 0274 963 141 glen.eastlake@safeware.com.au