Quality Assurance in ATS, Human Factors and Aviation Safety Captain Daniel Maurino Flight Safety and Human Factors, ICAO NAR/CAR/SAM Air Traffic Services Quality Assurance Seminar Ciudad de Méjico, 16-20 October 2000 1 1

QA & Aviation HF: Close Relatives Human Factors and aviation safety Differentiate processes from outcomes Emphasis on monitoring processes Relative importance of outcomes as driving forces Errors do not cause accidents

“Historical” Safety Design & manufacture Management & supervision Training & maintenance Stakeholders Operational personnel

An Outcome-Oriented Industry Design & manufacture Management & supervision Training & maintenance Stakeholders Operational personnel

The Need to Monitor Processes Design & manufacture Management & supervision Training & maintenance Stakeholders Operational personnel

The Fundamental Question improve the human condition? improve the processes underlying aviation operations?

Errors and Consequences Causes and consequences are not proportional in their magnitude

Operational Errors Reside in the Context Operational behaviours: A compromise Safety Production 3 3

Training: Poor Learning Grounds Training behaviours: “By the book” Safety Production 3 3

Understanding Operational Errors Error consequences Threat to safety No significant consequences Error Error life span

Outcomes: Quite Infrequently Error Flaps omitted Deviation Checklist failure Amplification Unheeded warning Degradation/ breakdown

Processes: Quite Frequently Deviation Checklist works Amplification Effective warning Flaps omitted Normal operation Error

Safety & QA: The Data We Must Collect Design & manufacture Management & supervision Training & maintenance Stakeholders Operational personnel

The Overriding Importance of Culture Anglo-Saxons design and supply; “the Rest of the World” uses Anglo-Saxon solutions are effective for Anglo-Saxon contexts Effectiveness in the “Rest-of-the-World”? World-wide accident rate: failure of the “dominant culture” concept 7

Human Error & Process Control Aviation cannot be entirely specified Humans will inevitably make errors Normative prescription (music score) Real-time implementation of the score Deviation(s) management Danger: loss of control of deviation management process rather that deviations themsleves

Flexible links with dampers Deviation Management Rigid frame Normative safety To bring all this to a conclusion, there are two main conditions to a safe operation of the system, very much like to a safe coupling of your car on the road. The first one is that you need a rigid frame, namely a solid framework of procedures. This is the normative, and anticipative, in other words proactive, aspect of safety. The second calls on flexible links to couple the system to the random aspects of reality, like holes and bumps on the road . This is the intelligent adaptation to unforseen situations, which R. Westrum named ‘generative’ , and which is a reactive process. Flexible links with dampers Generative safety

The End of the Innocence Bankruptcy Protection Comfort zone Catastrophe Production