Archives For human error

An interesting article in Forbes on human error in a very unforgiving environment, i.e. treating ebola patients, and an excellent use of basic statistics to prove that cumulative risk tends to do just that, accumulate. As the number of patients being treated in the west is pretty low at the moment it also gives a good indication of just how infectious Ebola is. One might also infer that the western medical establishment is not quite so smart as it thought it was, at least when it comes to treating the big E safely.

Of course the moment of international zen in the whole story had to be the comment by the head of the CDC Dr Friedan, that and I quote “clearly there was a breach in protocol”, a perfect example of affirming the consequent. As James Reason pointed out years ago there are two ways of dealing with human error, so I guess we know where the head of the CDC stands on that question. :)

sydney ferries

Seen on a Sydney Ferry, one wonders whether you truly need to explain the function of a door knob, or if you do why you’d use use a sign for a door handle… Perhaps this is just a wry nautical jape?

The “‘Oh #%*!”, moment captured above definitely qualifies for the vigorous application of the rule that when the fire’s too hot, the water’s too deep or the smoke’s too thick leave. :-)

But in fact in this incident the pilot actually had to convince the navigator that he needed to leave ‘right now!’. The navigator it turned out was so fixated on shutting down the aircrafts avionics system he didn’t realise how bad thing were, nor recognise that immediate evacuation was the correct response.

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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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Out of the Loop

14/08/2011 — 2 Comments

Out of the loop, aircrew and unreliable airspeed at high altitude

The BEA’s third interim report on AF 447 highlights the vulnerability of aircrew when their usually reliable automation fails in the challenging operational environment of high altitude flight.

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

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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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I attended the Australian Rail Safety Conference 2010 in Melbourne this week. The conference’s theme was safety leadership and as a result we had a broad spread of corporate executives present providing their views on the leadership aspect of safety.

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