presentación ifalpa barcelona

IFALPA BARCELONA 2008IFALPA BARCELONA 2008

José Sánchez-AlarcosJosé Sánchez-Alarcos““Improving Air Safety through Organizational Learning”Improving Air Safety through Organizational Learning”

The future is notanymore as it was



How is the future now?How is the future now?

Every few years the available knowledge is Every few years the available knowledge is multiplied by two.multiplied by two.

It is not anymore feasible having It is not anymore feasible having encyclopedic men (No human head has encyclopedic men (No human head has enough room for the whole human enough room for the whole human knowledge).knowledge).

Knowledge is fragmented and shared.Knowledge is fragmented and shared. Men are not anymore the only support for Men are not anymore the only support for

knowledge.knowledge. The problem is not in the amount of The problem is not in the amount of

knowledge but in its links and who is knowledge but in its links and who is qualified to see them. qualified to see them.



But…Is this the IFALPA meeting But…Is this the IFALPA meeting or a session about epistemology?or a session about epistemology?

Let’s seeLet’s see



The flight as it was…The flight as it was…

• Hard to control.• Designers had to rely on pilots’ ability.



The flight as it became…The flight as it became…

• Once air activity became common:

•Designs were made for more common people.

•Emphasis moves from physical abilities to knowledge:

•Systems of the plane.•Navigation.•Fuel management.•SOPs.•…how and why the plane flies.

•Aviation was not still for common people.



What happened when air travelling What happened when air travelling started to be common?started to be common?

The first low-cost carrier in the world



What happened when air travelling What happened when air travelling started to be common-II?started to be common-II?

…and the last one till the moment



Problems in the new environmentProblems in the new environment

Hard competition on prices…driving to…Hard competition on prices…driving to…

Hard competition on costs…driving to:Hard competition on costs…driving to:• Fuel-efficient planes:Fuel-efficient planes:

Unstable and hard-to-fly…Unstable and hard-to-fly… But flown by average people…But flown by average people… With the help of automation.With the help of automation.

• Cheaper to operate and maintain:Cheaper to operate and maintain: Automation.Automation. From 4 technical people to 2. Could it be less?From 4 technical people to 2. Could it be less? Cross-crew ratings.Cross-crew ratings. Less time required to train a pilot.Less time required to train a pilot.



Put them together…Put them together…Complex automation:• Pilots know inputs and outputs in normal situations.• It can be confusing under abnormal situations.• Pilots can be losing abilities to handle manually the plane.• Hard to get and average workload: High or low.

From 4 to 2 and counting:• They came after the radio…• After that, they came after the flight engineer…• After that, it seems they go after the first officer…• Later, they will come after me and it will be too late (Bertolt Brecht).

Cross-crew ratings:• Source of specific mistakes.

Less time required to train a pilot:• So the pilot is more easily expendable.



So…what’s the problem?So…what’s the problem?



Let’s see two environmentsLet’s see two environments



The game of the 5 differencesThe game of the 5 differences

1.1. If there is a safety problem in the NPP, the If there is a safety problem in the NPP, the reactor stops…the plane, not.reactor stops…the plane, not.

2.2. In the NPP, there are always people who know In the NPP, there are always people who know better. Inside a plane, not.better. Inside a plane, not.

3.3. In the NPP, all the documents about the design In the NPP, all the documents about the design are always available (with the reactor stopped). are always available (with the reactor stopped). In the plane, not.In the plane, not.

4.4. In the NPP, the operator is required to behave In the NPP, the operator is required to behave always following the SOPs and, if the system always following the SOPs and, if the system does not work as expected, to ask. In the does not work as expected, to ask. In the plane, there is not someone to ask getting an plane, there is not someone to ask getting an answer fast enough.answer fast enough.

5.5. The NPP has always redundant people for an The NPP has always redundant people for an emergency, the plane not. emergency, the plane not.



CONCLUSIONSCONCLUSIONS

Pilots can be considered as safety critical systems:Pilots can be considered as safety critical systems:• There are not alternative resources.There are not alternative resources.• Redundancy is required.Redundancy is required.• They are not operators. Under unforeseen situations, it is They are not operators. Under unforeseen situations, it is

expected more from them than from any operator.expected more from them than from any operator. To act as safety critical systems:To act as safety critical systems:

• Designs have to allow workloads as near as possible to average Designs have to allow workloads as near as possible to average under any situation.under any situation.

• Designs have to be human-centered.Designs have to be human-centered. Since human are more pliable than computers, it can be easier to Since human are more pliable than computers, it can be easier to

make a human fit the computer’s limitations than to design the make a human fit the computer’s limitations than to design the computer to fit the human needs. When that happens, the human computer to fit the human needs. When that happens, the human becomes a prisoner trapped by the computer rather than liberated becomes a prisoner trapped by the computer rather than liberated by it (Karla Jennings).by it (Karla Jennings).

• They require training beyond operative issues.They require training beyond operative issues. Rassmussen rule: The operator has to be able to run cognitively the

program that the system is running.



TWO POSSIBILITIESTWO POSSIBILITIES

EMPHASIZE THERASSMUSSEN RULE:

In critical safety systems,The operator has to be able

To run cognitivelyThe program

That the system is executing.

IN OTHER WORDS:

Know-how is not enough.Know-why is required.

EMPHASIZE THEMORIN RULE:

The machine-machineIs always superiorTo the man-machine.



Where is the next stop?Where is the next stop?

The world could not gobeyond the capacityof a human head

The world cannot gobeyond the capacityof the systems that supposedlyserve the human.



The decision, at least partially, The decision, at least partially, is yoursis yours

Thank you very muchThank you very much

presentación ifalpa barcelona

Documents

human knowledge

common people

human fit

plane flies

human head

available knowledge

human needs

reactor stopsthe plane