Aviation Human Error Modelled as a Production Process

Abstract

As technology systems have become more complex, so it is increasingly difficult for human operators to comprehend how the system is behaving. There is a need to better understand the causes of human-error in the context of the situational variables. The specific case under examination is the process of landing an aircraft. This paper applies a production engineering perspective. By production-process, we refer to the set of actions that are necessary to move a system from one state to a desired new state. Such processes involve mechanisms for taking inputs and converting them to the desired outputs, under certain controls and constraints. Human error is thus treated as a constraint on the processes. A novel process methodology is developed to represent how technical systems, situational variables, external factors, and human error evolve over time in a process. The applicability is demonstrated with a dataset of case studies. In parallel, a new categorization of human errors is derived for this situation. The method permits cases to be examined individually, and also collectively for patterns. The results show that the initial landing approach is often the point of error initiation. For the specific case of landing accidents the methodology identifies that the failure causality was the lack of attention to establish procedure at the very start of descent, followed by persistent disregard of disconfirmatory evidence at the initial landing approach, especially under conditions of poor visibility. The paper makes a methodological contribution as well as suggesting new insights for how human error occurs at landing.

Causes and Impact of Human Error in Maintenance of Mechanical Systems

“…Based on the study by Myszewski [6], human errors are viewed as examples of the ineffectiveness of the organization. Human errors can be classified into, slips, lapses, and violations [4]. This classification is in agreement with the one put forward by Reason [7] and Siu [8].…”

“…There is a frequent occurrence of inadvertent human errors in the maintenance of mechanical systems. Due to the complexity of technology, it is progressively becoming hard for human operators to properly cognize the system's behaviour [4]. Hence, there is a recurrent of human errors.…”

“…This paper aims to unearth the various causal factors of human error in maintenance leading to mechanical system's substandard performance, hence become a source of incidents and catastrophic accidents. It is approximated by NOPSEMA [3]; Dumitru and Boşcoianu [9]; Drury [10]; Begur and Babu [11]; Wiegmann and Shappell [12] and Pons and Dey [4] that human error is a major causal factor of between 70-80% of most equipment failures, incidents and accidents. It is about 15% -20% of failures, incidents and accidents that are due to maintenance error [10,11].…”

Preventing human error at an approved training organization using Dirty Dozen

“…Evolution and modernization have taken aircraft systems to newer and greater heights, which correlates with the notion that identification of technical or system failure can be done with more accessibility and convenience, especially when the technology becomes a great assistance for the people involved. However, being imperfect also means humans can still have a chance to make errors and this includes the ones responsible for aircraft maintenance worldwide [1]. Researchers have found out that in the 1990s, man-made mistakes have been responsible for 20% of flight accidents in the early years and the number has increased to 80% not long after.…”