Archives For Human error

I guess we’re all aware of the wave of texting while driving legislation, as well as recent moves in a number of jurisdictions to make the penalties more draconian. And it seems like a reasonable supposition that such legislation would reduce the incidence of accidents doesn’t it?

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BMW HUD concept (Image source: BMW) Those who cannot remember the past of human factors are doomed to repeat it…

With apologies to the philosopher George Santayana, I’ll make the point that the BMW Head Up Display technology is in fact not the unalloyed blessing premised by BMW in their marketing material.

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Occasional readers of this blog might have noticed my preoccupation with unreliable airspeed and the human factors and system design issues that attend it. So it was with some interest that I read the recent paper by Sathy Silva of MIT and Roger Nicholson of Boeing on aviation accidents involving unreliable airspeed.

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Buncefield Tank on Fire (Image Source: Royal Chiltern Air Support Unit)

Why sometimes simpler is better in safety engineering.

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I’ve just finished up the working week with a day long Safety Conversations and Observations course conducted by Dr Robert Long of Human Dymensions. A good, actually very good, course with an excellent balance between the theory of risk psychology and the practicalities of successfully carrying out safety conversations. I’d recommend it to any organisation that’s seeking to take their safety culture beyond systems and paperwork. Although he’s not a great fan of engineers. :)

In a recent NRCOHSR white paper on the Deeepwater Horizon explosion Professor Andrew Hopkins of the Australian National University argued that the Transocean and BP management teams that were visiting the rig on the day of the accident failed to detect the unsafe well condition because of biases in their audit practices.

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Stage Separation – A Classic Irreversible Command

The concept of irreversible commands is one that has been around for a long time in the safety and aerospace communities, but why are they significant from a safety perspective?

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Airbuses side stick improves crew comfort and control, but is there a hidden cost?

The Airbus FBW side stick flight control has vastly improved the comfort of aircrew flying the Airbus fleet, much as the original Airbus designers predicted (Corps, 188). But the implementation also expresses the Airbus approach to flight control laws and that companies implicit assumption about the way in which humans interact with automation and each other. Here the record is more problematic.

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How the marking of a traffic speed hump provides a classic example of a false affordance and an unintentional hazard.

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The BEA third interim report on the AF 447 accident raises questions

So I’ve read the BEA report from one end to the other and overall it’s a solid and creditable effort. The report will probably disappoint those who are looking for a smoking gun, once again we see a system accident in which the outcome is derived from a complex interaction of system, environment, circumstance and human behavior.

However I do consider that the conclusions, and therefore recommendations, are hasty and incomplete.

This post is part of the Airbus aircraft family and system safety thread.

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Why something as simple as control stick design can break an aircrew’s situational awareness

One of the less often considered aspects of situational awareness in the cockpit is the element of knowing what the ‘guy in the other seat is doing’. This is a particularly important part of cockpit error management because without a shared understanding of what someone is doing it’s kind of difficult to detect errors.

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Air France Tail plane (Image Source: Agencia Brasil CCLA 2.5)

Requirements completeness and the AF447 stall warning

Reading through the BEA’s precis of the data contained on Air France’s AF447 Flight Data Recorder you find that during the final minutes of AF447 the aircrafts stall warning ceased, even though the aircraft was still stalled, thereby removed a significant cue to the aircrew that they had flown the aircraft into a deep stall.

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Good and bad in the design of an Oliver Hazard Perry class frigates ECS propulsion control console HMI.

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James Reason would classify this as a violation rather than error

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What the Cry Wolf effect tells us about pilot’s problems with unreliable air data

In a recurring series of incidents air crew have consistently demonstrated difficulty in firstly identifying and then subsequently dealing with unreliable air data and warnings. To me figuring out why this difficulty occurs is essential to addressing what has become a significant issue in air safety.
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AF A330-200 F-GZCP (Image Source: P. Kierzkowski)

Knowing the outcome of an accident flight does not ‘explain’ the accident

Hindsight bias and it’s mutually reinforcing cognitive cousin the just world hypothesis are traditional parts of public comment on a major air accident investigation when pilot error is revealed as a causal factor. The public comment in various forum after the release of the BEA’s precis on AF447 is no exception.

This post is part of the Airbus aircraft family and system safety thread.

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The BEA has released a precis of the data contained on AF447′s Flight Data Recorder and we can know look into the cockpit of AF447 in those last terrifying minutes.

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How driver training problems for the M113 Armoured Personnel Carrier provide and insight into the ecology of interface design.

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Fukushima NPP March 17 (Image Source: )

There are few purely technical problems…

The Washington Post has discovered that concerns about the vulnerability of the Daiichi Fukushima plant to potential Tsunami events were brushed aside at a review of nuclear plant safety conducted in the aftermath of the Kobe earthquake. Yet at other plants the Japanese National Institute of Advanced Industrial Science and Technology (NISA) had directed the panel of engineers and geologists to consider tsunami events.

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This railway crossing near miss due to a driver ‘racing the devil’ is, on the face of it, a classic example of the perversity of human behaviour. But on closer examination it does illustrate the risk we introduce when transitioning from a regine of approved operational procedures to those that have been merely accepted or tolerated.

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