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Human Error Training Term Paper for Safety 401

Abstract

It is an industry-accepted fact that the most prevalent factor in aviation mishaps is the human factor. The most interesting point of this statement is that human factor has, in the history of aviation, always been present, and within the last 50 years, accounted for over 80 percent of why a mishap occurred. The subject has been so widely studied with programs and processes to prevent human factor mishaps, that within the United states Department of Defense alone, each service has their own staff of experts and resources allocated to study and develop the Holy Grail of mishap prevention. So why, with all these civil and military resources, can we not improve upon the already statistically low rate of human error causal factor in mishaps? It is the contention of this paper that while the primary reasons human factor mishaps occur cannot be eliminated, they can be controlled with a user level understanding of human factors provided by a through, formal, and integrated human error training process that is integrated with other risk prevention training and processes.

Human Error Training

Introduction

Today's industry has embraced ORM, CRM, and a myriad of other programs designed to reduce or eliminate risk factors that may lead to mishaps. Knowledge and cultural influences are keys to prevention. In 1997, the Defense Science Board, which is DOD's premier body of scientific advisers, found that ''leadership is the single most important factor affecting aviation safety.'' This suggests that it may be important to find new ways to let top leaders in DOD know that safety is a high priority and to hold these leaders accountable (H.A.S.C. No. 108-29, 180th Congress, 2nd Session, February 11, 2004). Making organizational changes may also help promote aviation safety. Supervisors, managers, executives, and leaders at all levels must learn the basics of human factors to enable self-assessment of the type of organizations they lead. They must familiarize themselves with the concepts and be better at administering and guiding their departments, planning operations and rooting out potential causes of mishaps.

Human Factors

The study of human factors in aviation attempts to deal with a great deal of research on the subject of human factors and the role of the human in a system comprised of himself, his machine, his environment and the operating rules. Today, human error is a significant causal factor in the majority of aviation incidents and accidents and is implicated in a variety of occupational accidents including 70-80% of those in civil and military aviation (O'Hare, Wiggins, Batt, & Morrison, 1994; Wiegmann & Shappell, 2001a; Yacavone, 1993).

In 2003, the Secretary of Defense challenged the military services to improve accident rates saying, "World-class organizations do not tolerate preventable accidents. Our accident rates have increased recently, and we need to turn this situation around. I challenge all of you to reduce the number of mishaps and accident rates by at least 50% in the next two years" (H.A.S.C. No. 108-29, 180th Congress, 2nd Session, February 11, 2004). Historically speaking, commercial, and military rate of aviation accidents has gone down dramatically over the years. For instance, in 1950 the Air Force and the Navy had rates of 36 and 50 mishaps per 100,000 flying hours respectively. By comparison, in 2001 the mishap rate for the entire DOD was roughly two. For the 10-year period between 1990 and 2000, overall mishaps rates declined from just over two to about 1.5. However, in 2002 and 2003, the department's overall mishap rate jumped back up about two mishaps per 100,000 flying hours (H.A.S.C. No. 108-29, 180th Congress, 2nd Session, February 11, 2004). This prompted congressional hearings to ask the question, why. An interesting but possibly unanswerable question given the fact that humans, by their very nature, make mistakes (Wiegmann & Shappell, 1997) and thus, it may be reasonable to accept that aircraft accidents will continue to occur in the near future.

Several aviation experimental psychologists have developed a model to sift through all of the human factors causes of naval aviation mishaps and known as the Human Factors Accident Classification System (HFACs) developed by Scott Shappell (Naval Safety Center, 1995). In figure 1, he distributes the levels of possible failures among four categories: Organizational Factors, Unsafe Supervision, Preconditions for Unsafe Acts, and the Unsafe Acts themselves. The first three categories are considered latent failures, because they do not directly cause mishaps, but they set the stage for those mishaps to occur. The final category of Unsafe Acts is active failures. These failures result in mishaps because of things that people did or did not do. They may be errors, where the individual did not intend to perform a hazardous act, or they may be violations, where the individual knowingly performs a hazardous act. The enlightening thing about HFACS is that it provides a methodology to allow units to see where their problems lay.

Figure 1. The "Swiss cheese" model of human error causation (adapted from Reason, 1990).

Missing aircrew coordination or Crew Resource Management (CRM) was identified in the early 90's as a common human factor across military (Yacavone, 1993) and commercial aviation (Kayton, 1993). Industry implementation of CRM training did have an initial dramatic and encouraging start in the reduction of aircrew mishaps (Alkov &Gaynor, 1991; Kayton, 1993). It was also soon obvious that such training was not the end all too human factor mishaps. The industry fears this concept has peaked in effective reduction to aircrew mishaps (Helmreich, Merritt, & Wilhelm, 1999). Other studies suggest that CRM continues to play a role in almost 30% of all aviation accidents (Wiegmann & Shappell, 2001). One could conclude intervention strategies aimed at reducing the occurrence or consequences of human error have not been as effective as were expected.

With a growing and universal concern that along with expected