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* Isaac Newtons 3rd Law of Motion for every action there is an equal and opposite reaction
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Many of the concepts in this presentation are derived from publications by Erik Hollnagel, University of Linkping, Sweden and Sydney Dekker, Department of Aeronautical Engineering, Lund University, Sweden. Books I would recommend are: The Field Guide to Understanding Human Error, 2006, Dekker Just Culture, 2007, Dekker Barriers and Accident Prevention, 2004, Hollnagel The ETTO Principle: Efficiency-Thoroughness Trade-Off, 2009,
Hollnagel
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WYLFIWYF*
* What You Look For Is What You Find
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Caused by unsafe acts or conditions Prevented by fixing or eliminating the weak link or
inserting a barrier to interrupt the series of events
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Epidemiological Model
A complex, linear cause and effect model Accidents result from a series of active failures (unsafe
acts) and latent conditions (hazards)
Epidemiological, continued
Accidents result from deficiencies that lay dormant until
triggered by active failures
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Systemic Model
A complex, non-linear model Both accidents (and success) emerge from
subtle, unexpected interactions between relatively simple parts of a complex system
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Time
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Case Study Swedish Airlines MD-82 Overran End of Runway June 23, 1999
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Ground Spoilers
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Pilot arms spoilers before landing When the aircraft touches down, spoilers are
deployed:
when main gear wheels spin up, or front landing gear is compressed
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Spoiler Lever
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Facts
Brake disks cold after landing Per the flight recorders, spoilers did not deploy
and the ABS did not activate
No technical fault with braking system Arming spoilers is a pre-landing checklist item
Co-pilot reads the checklist Pilot arms the spoilers after lowering landing gear
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Accident Board Conclusion The cause was inadequate Crew Resource Management (i.e. pilot error) because
The pilot did not arm spoilers before landing, The co-pilot did not report lack of spoiler
deployment after landing
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To explain failure,
investigations must seek failure inaccurate assessments, wrong decisions and bad judgments
assessments and actions made sense at the time, given the circumstances that surrounded them.
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Pilot
49 years old 6,775 total flight hours 3,500 flight hours in type
Co-pilot
57 years old 17,000 total flight hours 7,000 flight hours in type
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If substitution is made during flight planning, the Per policy for short notice, the replacement pilot
assumed the duties of person (co-pilot) he replaced
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Lower Landing Gear (when glide slope active) Spoilers armed (when gear down and locked) Flaps FULL (when glide slope captured)
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At t = 0 At t = 10 At t = 16
Lower Landing Gear (when glide slope active) Spoilers armed (when gear down and locked) Flaps FULL (when glide slope captured)
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The problem is .
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Wind forces (180 knots) can compress landing gear as it is lowered Landing gear must be down and locked before spoilers armed
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Result
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On extremely slippery runways at high speeds, the pilot is confronted with a rather gradual deceleration and may interpret the lack of an abrupt sensation of deceleration as a total antiskid failure. The natural response might be to pump the brakes or turn off the anti-skid. Either action will degrade braking effectiveness.
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Time
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Seem ominous?
Modeling is difficult and time consuming Impact of subtle interactions is only apparent
after the event
Failure is not always predictable The A/I conclusion might be the accident was
not avoidable (except in hindsight)
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Work as Imagined
Work as Done
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Procedures are complete, correct and current People behave as they are expected to as
they are taught Therefore, humans are a liability and performance variability is a threat.
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S U C C E S S
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Work as Imagined
Work as Done
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Work as Imagined
Work as Done
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A question to ponder .
The basis for the Sequence of Events and
Epidemiological models is the assumption of cause and effect relationships
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Action A
Effect B
Observable
Observable
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Action ?
Effect B
Observable
Observable
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What is a cause?
The identification, after the fact, of a limited set of aspects of the situation that are seen as necessary and sufficient conditions for the observed effects to have occurred. The cause, in other words, is constructed rather than found.
- Hollnagel, Erik (2004) Barriers and Accident Prevention
The cause of an accident is not found in the rubble, it is constructed in the mind of the investigator.
- Dekker, Sydney (2002)The Field Guide to Human Error Investigations
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