Mitigating Culture: Human Error in the Operational ATC World Anthony Smoker RAeS Human Factors Group...
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![Page 1: Mitigating Culture: Human Error in the Operational ATC World Anthony Smoker RAeS Human Factors Group Mitigating Human Error Conference 15 th October 2003.](https://reader030.fdocuments.in/reader030/viewer/2022032612/56649efa5503460f94c0b8c5/html5/thumbnails/1.jpg)
Mitigating Culture: Human Error in the
Operational ATC World
Anthony SmokerRAeS Human Factors Group
Mitigating Human Error Conference15th October 2003
![Page 2: Mitigating Culture: Human Error in the Operational ATC World Anthony Smoker RAeS Human Factors Group Mitigating Human Error Conference 15 th October 2003.](https://reader030.fdocuments.in/reader030/viewer/2022032612/56649efa5503460f94c0b8c5/html5/thumbnails/2.jpg)
Human Error in the Operational ATC World
“Give me a fruitful error any time, bursting with its own correction”
Pareto on Kepler 1870
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Attributes of the Operational World – focusing on en-route operations
Reporting of IncidentsTraining and MitigationOrganisational CultureAGASConclusions
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Attributes of the operational world
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The ATC Watch (team)
ATC watches or teams can be large groups of controllers and assistants
ATC Engineers – deliver “safe systems”
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ATC Technology
“Controllers don’t just use the technology – they are the technology”
Nature of errors?System
development: ATC-ATM
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Attributes of the operational world
Closed World: organisational isolation?
Operational community expect immediate change
Cascading information - communication
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Reporting of Incidents and Events
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Reporting
Critical to understanding errorsMandatory reporting – MORIncident reporting and
observations – in-houseConfidential systems (CHIRP)
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Specific Operational Problems
Systematic failures or errors found from investigation
Focused on one specific error type altitude busts – procedure changesProlonged Loss of Communication
(PLOC)
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Investigation
Local investigation at unitTools – Separation Monitoring
Function, ASMT(EUROCONTROL)Culture and operational acceptance
Techniques – TRACER, HERA/JANUSControllers trained as investigators
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Communicating the message
How to engage with controllers?What is the right format?Effectiveness of the messageTransparencyFeedback
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Training for Mitigation
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Training for Mitigation
Poor system design often mitigated by training
Operational environment is unforgiving, time critical and highly adaptable
System behaviours variable (akin to FMS modes)
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Maintenance of Mitigation
Competence schemes where available
Updating of safety cases with system changes
Frequency of changes
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Culture
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Operational Culture
ATC is a good example of a High Reliability organisation
Sustains high performance across a range of conditions
Perceptions of the operational community –barrier to culture change?
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Safety Culture
Organisational Culture(s) dictates safety culture: conflict between cultures?
“Organisational climate”TrustExternal influences on
organisational culture – resource limitations
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Structures
ATC involvement – Watch Safety Officer etc
Incident & Investigation sectionsUnit management Headquarters functionsRegulators
How does this structure interface with the operational controller?
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Human Factors
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Role of Human Factors
Applied to understanding human error in control taskHandoversSeparation in provision of Radar
Advisory ServiceCan provide a direct input into
procedures and training
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Applying Human Factors
Increasingly important to make ATC staff aware of factors that affect human performance
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Human Performance
Incorporated into Training from ab- initio and beyond
Defences against perceptual errorsTeam Resource Management:
ATC-TRM is not CRM
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AGAS
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AGAS - AAction GGroup for AATM SSafety
Established by EUROCONTROL Provisional Council as a result of Uberlingen mid-air collision
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AGAS - AAction GGroup for AATM SSafety
“Areas for Immediate FocusSafety related human resourcesIncident reporting and data sharingACAS - Additional actionsRunway SafetyEnforcement of ESARRs and
monitoring implementation
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Conclusions
Considerable progress has led to changes in approaches to human error in ATC/ATM
“A long game”New challenges with new systems
and changing organisationsCommunication remains a problem
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Mitigating Culture: Human Error in the
Operational ATC WorldAnthony SmokerRAeS Human Factors Group
![Page 29: Mitigating Culture: Human Error in the Operational ATC World Anthony Smoker RAeS Human Factors Group Mitigating Human Error Conference 15 th October 2003.](https://reader030.fdocuments.in/reader030/viewer/2022032612/56649efa5503460f94c0b8c5/html5/thumbnails/29.jpg)
Mitigating Culture: Human Error in the
Operational ATC WorldAnthony SmokerRAeS Human Factors Group