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1HUMAN FACTOR ITALIA

PRACTICAL INTEGRATION

OF HUMAN FACTOR

IN BOWTIE

BOWTIES AND RISK MANAGEMENT CROSS INDUSTRY EVENT - ROME 6 JUNE

F/O Luca Toncelli - CAPT Francesco Fanelli


Our GOAL??

PROPOSAL FOR A PRACTICAL

INTEGRATION OF HUMAN FACTOR

IN BOWTIE,

ANALYSING A CASE STUDY

- FLIGHT AF447 -


01

02

03

04

Human Factor Italia

Integration of HF

in BowTie

Conclusion

HF and Risk management

Our GOAL??


… BE PREPARED FOR THE UNPREPARED …

Who we are

HFI competence come from

experiences in more than10professional backgrounds:

Aviation, Healthcare, Defense,

Aerospace, Managerial

consultancy…..

HFI offers full immersion, interactive courses with non conventional

exercices .

Stimulates discussion and facilitates sharing of experience by partecipants.

Suggests new points of view and helps to think out of the box to

observe the working dynamics differently.

+

Experential formats where it is possible

to optimize the human performance by

improving competency and acting the non

technical skills, (soft skills).

Training and certification for Aviation,

Maritim, Diving, Construction segments

HFI Team counts more than

25+consultants, scientific members, trainers,

collaborators, experts of

High Reliability Organization

8

Human Factor Italia


HUMAN ELEMENT RATE IN CROSS-INDUSTRY INCIDENT

20%

80%

Nuclear Power

Equipment failures

Human error

20%

22%

24%

15%

9%

9%1%

U.S. Department of Energy’s root cause analysis

standard (DOENE-1004-92)

Equipment /Material Problem

Personnel/Human error

Procedural problem

Training deficiency

Management oversight

Design Problem

External Phenomenon

12%

68%

12%

Causes of collision at sea

Equipment failure

Human error

Other

HF and Risk management


Incident vs Flight Departures (millions)

59 62 65 68 71 74 77 80 83 86 89 92 95 98 01 04 07 10 13 16

10

20

30

50

40

0

Boeing, 2016. Statistical Summary of Commercial Jet Airplane Accidents Worldwide Operations 1959 – 2016

1 Incidenti con decessi e perdita totale del velivolo (commericiale)

Pilot Error

Flight Simulator

introduction

Human Factor

Safety Risk Management

Crew Resource Management

0.25

‘65: less than 2 million of

departures per year.

‘16: more than 20 million of

departures per year.

UOMO O MACCHINA? HF and Risk management

TECNHICAL

HUMAN:ERROR AND VIOLATION

ORGANIZATIONAL


SAFETY MANAGEMENT SYSTEM: INTEGRATION OF HUMAN ELEMENT IN BOWTIE

RISK MANAGEMENT

PROCESS

Three fundamental aspects:

• TECHNICAL

• ORGANISATIONAL

• HUMAN ELEMENT


SMS ICAO METHODOLOGY FOR INTEGRATION OF HUMAN ELEMENT IN BOWTIE

Task analysis is an analysis technique used in Human factors and Ergonomics,intended both to identify the tasks and activities or phases that must be carried out to achieve the objectives, understand the training needs and identify the potential for human error.

2TASK

ANALYSIS

CBT Competency Based Training is the innovative approach to training based simply on developing skills rather than repeating tasks until the result meets the prescribed standard. The development and continuous application of basic competencies allow operators to manage an infinite number of abnormal scenarios including the unexpected.

ICAO defines COMPETENCE as:a combination of skills, knowledge and attitudes (KSA) required to perform a task to the prescribed standard, resulting from job and task analysis.

Operational analytical tool,is a conceptual model based on threatanticipation, errormitigation and management of undesired states, using Core Competence as countermeasures (barriers).

3COMPETENCY

BASETRAINING

4CORE

COMPETENCIES

5TEM

Threat andError

Management

EBT: Within the SMS also the Training must be BASED ON RISK, for the mitigation of risks linked to the human element.RISKS to be mitigated must be those highlighted or set by the day-to-day activity, Incident Analysis and Audit

1EVIDENCE

BASETRAINING

PRATICAL INTEGRATION

OF HUMAN FACTOR IN

BowTieXP Software

CAUTIONThe scope of safety investigations is to prevent

further incidents.

Only a few of the findings of this Final Report havebeen utilized for the purpose of this presentation.

Integration of HF

in BowTie


- FOCUS ON -

SOCIO-TECHNICAL, BEHAVIORAL

BARRIERS

AND

ESCALATION FACTORS RELATED

TO HUMAN-PERFORMANCE

AIR FRANCE FLIGHT 447 Integration of HF

in BowTie

LOSS OF

CONTROL

STALL

STALL

Inadeguate

weather

assessment

Unable

to assess and

execute

emergency

procedure

Plan, assess and

avoid weather

threats along the

route


CORECOMPETENCIES

BARRIERS AGAINST ESCALATION

FACTORS RELATED TO HUMAN-

ERROR


in BowTie

LOSS OF

CONTROL

STALL

STALL RECOVERY

UP SET

RECOVERY

Emer-procedure

not performed

Incorrect

procedure

procedure not

correctly

executed



in BowTie

STALL

LOSS OF

CONTROL

STALL RECOVERY

UP SET

RECOVERY

procedure not

correctly

executed

Incorrect

procedure

Emer-procedure

not performed


.

WHEN BARRIER’S EFFICIENCY DEPENDS ON HUMAN PERFORMANCES

IT NECESSARY TO CONSIDER L’ERRORE UMANO AS AN ESCALATION FACTOR

BARRIERS MUST CONSIDER AND ASSESS CAREFULLY

ON ONE SIDE THE ORGANISATIONAL FACTORS

WHO DEFINE THE CIRCUMSTANCES, THE OPERATIONAL CONTEXT

«THE SITUATIONS»

AND ON THE OTHER SIDE THE COMPETENCY

NEEDED TO CARRY OUT THE TASKS

IN THESE SPECIFIC CIRCUMSTANCES

BARRIER

FAILURE

BARRIER EFFICIENCY

ORGANISATIONAL

FACTOR

SITUATION

CIRCUMSTANCES

HUMAN

ERROR

COMPETENCY

Integration of HF

in BowTie

BOWTIE for HUMAN AND ORGANISATIONAL FACTOR


CORE COMPETENCIES AS BARRIERS IN BOWTIE

Integration of HF

in BowTie


STALL RECOVERY


Integration of HF

in BowTie


CORE COMPETENCIES AS BARRIERS IN BOWTIE

STALL RECOVERY


HUMAN AND ORGANISATIONAL ELEMENTS ARE

70% OF INCIDENT ROOT CAUSES

ORGANISATIONAL FACTORS

AS THREATS:

THE ELEMENTS, THAT DEFINE

THE CONTEXT, THE

SITUATION AND THE

CIRCUMSTACES, AFFECT THE

EXECUTION OF TASKS WITH

RESPECT TO THE EXPECTED

PERFORMANCE STANDARD

- FOCUS ON -

ORGANISATIONAL BARRIERS.

BOWTIE for HUMAN AND ORGANISATIONAL FACTOR Integration of HF

in BowTie

CORE COMPETENCIES

AS BARRIERS TO HUMAN ERROR.


.

WHEN BARRIER’S EFFICIENCY DEPENDS ON HUMAN PERFORMANCES

IT NECESSARY TO CONSIDER L’ERRORE UMANO AS AN ESCALATION FACTOR

BARRIERS MUST CONSIDER AND ASSESS CAREFULLY

ON ONE HAND THE ORGANISATIONAL FACTORS

WHO DEFINE THE CIRCUMSTANCES, THE OPERATIONAL CONTEXT

«THE SITUATIONS»

AND ON THE OTHER HAND THE COMPETENCY

NEEDED TO CARRY OUT THE TASKS

IN THESE SPECIFIC CIRCUMSTANCES

ConclusionsEFFICIENCY OF BARRIER MANAGEMENT SYSTEM

BARRIER

FAILURE

BARRIER EFFICIENCY

ORGANISATIONAL

FACTOR

SITUATION

CIRCUMSTANCES

HUMAN

ERROR

COMPETENCY


• MANUAL EBT - ICAO DOC 9995 –

• HUMAN FACTOR IN BARRIER MANAGEMENT – CHARTERD INSTITUTE OF ERGNOMICS & HUMAN FACTOR

• BOEING STATSUM 1958 – 2014 – BOEING

• COLLISION, WHY THEY OCCUR? - GUARD NEWS EDITOR

• HUMAN FACTORS ENGINEERING: NEXT FRONTIER INRELIABILITY – DREW TROYER

• BOWTIE METHODOLOGY MANUAL – CGE

• BOWTIEXP SOFTWARE MANUAL

• SMM – ICAO DOC 9859

• EVIDENCE BASE TRAINING IMPEMENTATION GUIDE - IATA

REFERENCES

GRAZIE EBUON LAVORO

HUMAN FACTOR [email protected]@[email protected]

mailto:[email protected]



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