Human Error in the Aviation Industry - Research Paper Example

21 February Human Error in the Aviation Industry Introduction In the United s, at any given time of the day, there are approximately 5,000 aircraft flying. This equals roughly 87,000 flights every day. Of these 87,000 flights, 28,537 are commercial flights, 27,178 are private planes, 24, 548 are planes for hire, 5, 260 are military flights and 2,148 are aircraft carrying air cargo (http://1lawflying.wordpress.com). Statistically, flying is very safe. An average American has a 1 in 11 million chance of being killed in a plane crash in comparison to a 1 in 5,000 chance of being killed in an automobile accident (http://www.pbs.org/wgbh/nova/space/how-risky-is-flying.html). Nevertheless, aviation accidents do occur. Between 1999 and 2008 there were 370 aviation accidents, resulting in 4,970 fatalities. Commercial passenger airlines are the least likely of all flights to be involved in an accident (www.1001crash.com). The causes for aviation accidents are varied, but can be categorized into three groups: the physical environment, mechanical failure and human error. Specific issues within each of these three groups are the root cause for all aviation-related accidents. Accidents caused by the physical environment occur from Mother Nature herself. Things such as lightening, wind, ice, rain, etc. are all physical causes. In these cases, it is important for accident investigators to rule out any human error when reacting to physical causes. An airplane sliding off of an icy runway would be one example of an accident caused purely by the physical environment. There is nothing a flight crew could do in this situation to avoid it. Mechanical failure is the next category of accidents. Examples of mechanical failure include complete engine shut down, rudder failure, wheel structure malfunction, etc. Again, there has to be care taken to ensure that human error is not at play in mechanical failure. Investigators have to research carefully to make certain that the failure was completely related to the physical part of the equipment and not the maintenance or lack of. Over the past 20 years, accidents relating to mechanical failures have been steadily declining when compared to other accident causes. Accidents caused by mechanical issues are easier to determine and fix as compared to human errors and the physical environment. When there is a mechanical error, it can be analyzed and improvements can be made in the mechanical structure to avoid the same problem happening again. This isn’t the case for human error (Wiegmann & Shappell, 1997). The remainder of this paper will focus on the last category of accident causes, human error. It is estimated that anywhere from 60% to 80% of all aviation accidents include an element of human error (Shappell, et. al., 2007). Human error includes people working in all areas of aviation from those that direct planes on the ground and refuel planes, to those in the air traffic control tower, to those working on the planes mechanical systems, to those in the cockpit. All can be prone to making a mistake. 2. Human Error In their 2007 study, Shappell, et. al, classified human error, within the field of aviation, into three types: decision errors, skill-based errors and perceptual errors. They also discussed the ideas of errors by supervisors and errors by the organization. Decision errors are basically bad decisions. In these situations the person makes a conscious decision. It is not reactive, but thought through before coming to a conclusion about what to do. The errors occur when the decision made is not the proper choice for the situation at hand or there are procedures that are not carried out properly (Shappell, et. al., 2007). An example of a decision error would be if a pilot without an instrument rating decided to fly through a large cloud. The second type of errors is skill-based errors. These types of errors involve no conscious thought, but are automatic behaviors. There errors typically occur while performing skills that are highly practiced. They involve the accidental activation of incorrect switches, leaving out items that are usually routine or simply performing a typical task incorrectly (Shappell, et. al., 2007). The last type of error is perceptual errors. These errors can be in conjunction with other physical factors, but the error itself is due to a mistake made by a person. Examples would be having degraded sensory input when flying in challenging weather or making decisions to act with when there is incomplete information (Shappell, et. al., 2007). Along with the categories of errors listed above, Reason, has developed an additional approach to looking at human error. In his book, Human Error, he discusses the notion of intentional and unintentional actions. These terms are not meant to imply that people set out to intentionally make mistakes, but rather the terms are based on the decision making process that people use (Reason, 1990). Unintentional errors occur when there is a lapse in memory or a lack of adequate attention paid to the task. Intentional errors can be considered violations. These are when a person does not follow the rules and procedures that have been established. It could be out of habit, incorrect training or just a willful disregard thinking that their way is better or more efficient. It could be that a person develops their own habit of doing something incorrectly, which eventually leads to a costly mistake (Reason, 1990). The aviation industry is careful to recognize the difference between willful violations and human error. Positively, few accidents occur due to willful violations. Violations are those acts which are based on a complete disregard for the policies and procedures that are vital to safe flights. Violations have been categorized into two types (Wiegmann, et. al, 2005). The first type, routine violations, is a result of habit. Often times, these are the violations that are overlooked. Wiegmann compares it to driving 5-10 miles over the speed limit, but not getting pulled over by police until you exceed that. It is still in violation of the law, but is overlooked. In these cases, it is important for supervisors to enforce all the rules, so human error can go up the chain of command in accidents. Accident investigation does not stop with the flight and air traffic control crews (2005). The second type of violations is referred to as exceptional violations. These are errors that are out of the norm for a particular person. These violations are not tolerated by those with authority. The example that Wiegmann give is that of a person who always drives the speed limit and then one time decides to drive 100 mph instead. That is exceptional behavior for that person (2005). When evaluating accidents that were determined to be caused by human error, 79.2% of them were attributed to skill based errors, 29.7% were categorized as decision errors, 13.7% were due to violations and 5.7% were caused by perceptual errors (Wiegmann, 2005). When looking specifically at the data for fatal accidents, skill based decisions, perceptual errors and decision errors, were equal in terms of causing a fatal accident. However, violations were four times more likely to be the cause of a fatal aviation accident (Wiegmann, 2005). 3. Specific Errors and Prevention The most prevalent type of error is skill based mistakes. For flight crews these include not appropriately adjusting for wind, not maintaining correct airspeed, allowing a stall or spin to take place or just the general mishandling of the aircraft either in the air or on the ground (Wiegmann, 2005). Funk, attributes these errors to the pilots failure to properly monitor all aspects of the flight (1991). This could be due to distraction which sidetracks the pilot, lack of experience, boredom or work fatigue. For other aviation-related jobs such as maintenance, design and air traffic control, errors can be attributed to the same type of issues (Dhillon & Liu, 2006). An aircraft mechanic can have a lack of knowledge in terms of repairing a specific problem or can get distracted while conducting a safety inspection. An air traffic controller can get bored and distracted or experience fatigue. There have even been known cases of air traffic controllers falling asleep on the job. Solutions to these type of mistakes include more training. It is imperative that all involved know their jobs inside and out. It is also advisable that those in management be cautious when scheduling flight crews, air traffic controllers and maintenance crews. In order to reduce fatigue, there must be the opportunity for enough rest before being expected to perform their best at work. It is suggested by Dhillon and Liu that accurate records by kept in terms of human error and to use those records to create training, policies and procedures to eliminate similar mistakes in the future (2006). Wiegmann, also suggest adding automated reminders in aircraft to ensure that flight crews don’t get complacent about monitoring essential tasks and data (2005). Many decision errors involve all aspects of planning, including evaluation of the weather. In 2000, Burian, Orasanu and Hitt conducted a study and found that pilots with little experience would second guess themselves when it came to the weather and would chose to fly in unsafe circumstances. In a study by Wiegmann, Goh and O’Hare, it was discovered the there were often errors when it came to using visual flight rules or instrument controls. These type of decisions require a thorough assessment of the situation and there can be poor choices made (2002). Improving decisions can be made through more specific training. Wiegmann, et. al, suggest employing more scenario-based training which as been proven to improve decision making for multiple areas (2005). Scenario training also applies to air traffic controllers and maintenance crews. Latorella and Prabhu recognized that the organizational structure can be a problem for aircraft maintenance. There are operational pressures to have inspections and repairs done quickly, there are communication concerns, there are policies and practices regarding the oversight of work and there are the issues of having the correct equipment for the job. These are all challenges which need to be refined to reduce human error in this aspect of aviation (1997). In terms of causing accidents, perceptual errors are the least likely to cause an accident. Perceptual errors are more common in military aviation accidents due to the type of flights being performed (Wiegmann, 2005). Most commonly these error types involve misjudging speed, distance, descent, altitude, etc. These errors are physiological and result in disorientation (Wiegmann, 2005). Having more than one pilot in the cockpit can help eliminate this error, when noticed by the co-pilot. In addition, additional training and practice, enhanced displays and new types of indicators and warnings will help alleviate these types of error (Wiegmann, 2005). The numbers are also lower for perceptual errors in that not all aspects of aviation personnel can make perceptual errors. It is difficult for mechanics to make a perceptual error. Air traffic controllers could make a perceptual error, but it is more likely to be attributed to a pool decision since information is interpreted from a screen as opposed to having any disorientation in “real” situations. It is much more difficult to reduce the number of violations that occur within the aviation industry. In fact, there has been no reduction in this type of violation over the past few years (Wiegmann, 2005). Improved monitoring and better, stricter enforcement of all the rules is the best method for reducing violations. It also takes consistency of enforcement. This area is one example of how those indirectly involved through inspection, scheduling and policy making can affect the safety of passengers and flight crews. In 2006, Li and Harris, did a research study focusing on just this aspect of aviation. They looked at the organization of the aviation industry and how that structure impacts all areas and could potentially lead to accidents. Their study suggested that the organizational structure does have an impact on all areas of the industry. The results said that the organization has little effect on decision errors, skill based errors and perceptual errors, but employee fatigue can be reduced by proper scheduling. However, organizations can greatly improve in the areas of planning, correcting problems, inspections, supervision and resource management. 4. Conclusion Overall, it is important to remember that it is not just pilots who are responsible for aviation accidents. Everyone involved in the aviation industry can have an effect on passenger safety and can make mistakes and poor decisions either intentional or unintentional. Although extremely safe statistically, the aviation industry has a large human connection and people are not perfect. The aviation industry does a good job of trying to reduce human error through training, government enforced rules and regulations, safety inspection procedures and continual improvements in technology, but alas, there is still that human factor that just can’t be avoided. The research has proven that it is valuable to be aware of the decision making process. Making conscious decisions as opposed to going through a learned routine can reduce human error. It is also important to have enough training to make quick, yet accurate decisions in moments of challenge, both on the job training and scenario-based training are effective. In addition, persons working in management within the aviation industry need to keep in mind the end goal of passenger and flight crew safety. The scheduling of flight crews, maintenance and air traffic controllers needs to be done purposefully as to avoid work fatigue and boredom. Although not discussed above, it is also important to have supervisors schedule teams of people who work well together and to provide opportunities for team building. Employees need to trust in their supervisors and respect the opinions of those inspecting their work. Flight crews need to trust the air traffic controllers and maintenance crew. Traffic controllers and maintenance employees need to trust the equipment. All aspects of the aviation industry are interrelated and all are prone to human error. Knowing the various types of decisions is helpful in that when an accident can be attributed to a specific cause and type of decision, the industry can then get to work to ensure similar accidents don’t occur. The aviation industry needs to continue to look at the physiological aspects of being human when it comes to reducing human error. Evaluating how people perform in various situations can help to hire the best people and can assist in scheduling. This information can also be helpful in developing training programs and professional development for those who are more experienced. The industry need to ensure that workers do not become too complacent in their role as decisions need to be made consciously. In general, the aviation industry will always have some level of human error. That cannot be avoided. The industry needs to ensure that the mistakes that are made can be corrected quickly and accurately. There have been vast improvements in the reduction of aviation related accidents and with continued research and implementation the industry is sure to remain one of the safest modes of travel. Works Cited Reason, J. Human Error. New York: Cambridge University Press, 1990. Print. Dhillon, B. and Liu, Y. “Human Error in Maintenance: A Review.” Journal of Quality in Maintenance Engineering. 12.1(2006): 21-36. Print. Latorella, K. and Prabhu, Prasad. “A Review of Human Error in Aviation Maintenance and Inspection.” International Journal of Industrial Ergonomics. 26. (2000): 133-61. Print. Shappell, S., Detwiler, C., Holcomb, K., Hackworth, C., Boquet, A. and Wiegmann, D. “Human Error and Commercial Aviation Accidents: An Analysis Using the Human Factors Analysis and Classification System.” Human Factors. 49.2. (2007): 227-42. Print. “Statistic Analysis of Airplane Accidents.” 1001crash.com. n.d. Web. 22 Feb. 2012. Wiegmann, D., Faaborg, T., Boquet, A., Detwiler, C., Holcomb, K. and Shappell, S. “Human Error and General Aviation Accidents: A Comprehensive, Fine- Grained Analysis Using HFACS.” Final Report Civil Aerospace Medical Institute Federal Aviation Administration. December 2005. Print. Wiegmann, D. and Shappell, S. “Human Factors Analysis of Postaccident Data: Applying Theoretical Taxonomies of Human Error.” The International Journal of Aviation Psychology. 7.1: (1997): 67-81. Print. 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