File Name: risk management and error reduction in aviation maintenance .zip
Like CRM, MRM training emphasizes a team approach to human error reduction using principles that seek to improve communications, situational awareness , problem solving, decision making, and teamwork. Unlike traditional coercive and hierarchical top-down safety programs, MRM advocates a decentralized, human-centric approach to safety. MRM encourages work teams to communicate vital operational risk and safety information directly and informally, regardless of rank or position, thus permitting rapid response to prevent impending crises. Some variation of human factors training, whether called MRM or not, is now standard at many commercial airlines, aircraft manufacturers, and aviation-related organizations.
Beta This is a new way of showing guidance - your feedback will help us improve it. Everyone can make errors no matter how well trained and motivated they are. However in the workplace, the consequences of such human failure can be severe. Analysis of accidents and incidents shows that human failure contributes to almost all accidents and exposures to substances hazardous to health. In order to avoid accidents and ill-health, companies need to manage human failure as robustly as the technical and engineering measures they use for that purpose.
The challenge is to develop error tolerant systems and to prevent errors from initiating; to manage human error proactively it should be addressed as part of the risk assessment process, where:. This Key Topic is also very relevant when trying to learn lessons following an incident or near miss. This also involves identifying the human errors that led to the accident and those factors that made such errors more likely — PIFs.
It is important to be aware that human failure is not random; understanding why errors occur and the different factors which make them worse will help you develop more effective controls.
There are two main types of human failure: errors and violations. A human error is an action or decision which was not intended. A violation is a deliberate deviation from a rule or procedure. HSG 48 provides a fuller description of types of error, but the following may be a helpful introduction. Some errors are slips or lapses, often "actions that were not as planned" or unintended actions. They occur during a familiar task and include slips eg pressing the wrong button or reading the wrong gauge and lapses eg forgetting to carry out a step in a procedure.
These types of error occur commonly in highly trained procedures where the person carrying them out does not need to concentrate on what they are doing. These cannot be eliminated by training, but improved design can reduce their likelihood and provide a more error tolerant system. Other errors are Mistakes or errors of judgement or decision-making where the "intended actions are wrong" ie where we do the wrong thing believing it to be right.
These tend to occur in situations where the person does not know the correct way of carrying out a task either because it is new and unexpected, or because they have not be properly trained or both. Often in such circumstances, people fall back on remembered rules from similar situations which may not be correct. Training based on good procedures is the key to avoiding mistakes.
Violations non-compliances, circumventions, shortcuts and work-arounds differ from the above in that they are intentional but usually well-meaning failures where the person deliberately does not carry out the procedure correctly.
They are rarely malicious sabotage and usually result from an intention to get the job done as efficiently as possible. Mistakes resulting from poor training ie people have not been properly trained in the safe working procedure are often mistaken for violations.
Understanding that violations are occurring and the reason for them is necessary if effective means for avoiding them are to be introduced. Peer pressure, unworkable rules and incomplete understanding can give rise to violations.
HSG48 provides further information. Involving the workforce in drawing up rules increases their acceptance. Getting to the root cause of any violation is the key to understanding and hence preventing the violation. This aide-memoire on Human Failure Types explains in more detail, along with examples and typical control measures. Understanding these different types of human failure can help identify control measures but you need to be careful you do not oversimplify the situation. In some cases it can be difficult to place an error in a single category — it may result from a slip or a mistake, for example.
There may be a combination of underlying causes requiring a combination of preventative measures. It may also be useful to think about whether the failure is an error of omission forgetting or missing out a key step or an error of commission eg doing something out of sequence or using the wrong control , and taking action to prevent that type of error. The likelihood of these human failures is determined by the condition of a finite number of ' performance influencing factors ' , such as design of interfaces, distraction, time pressure, workload, competence, morale, noise levels and communication systems.
There is more to managing human failure in complex systems than simply considering the actions of individual operators. However, there is obvious merit in managing the performance of the personnel who play an important role in preventing and controlling risks, as long as the context in which this behaviour occurs is also considered.
Companies should consider whether any of the above apply to how their organisation manages human factors. Is this page useful? Yes No.
Not a MyNAP member yet? Register for a free account to start saving and receiving special member only perks. Human factors issues, specifically human errors, contribute to more aircraft incidents and accidents than any other single factor. Human errors include errors by the flight crew, maintenance personnel, air traffic controllers, and others who have a direct impact on flight safety. What lies behind human error is very frequently inaccurate situational awareness: the failure for whatever reason to evaluate an operational or maintenance situation properly. Thus, whenever the term human error appears, the reader should keep in mind that situational awareness, or the lack thereof, is usually the dominant factor. This can be a critical problem.
Beta This is a new way of showing guidance - your feedback will help us improve it. Everyone can make errors no matter how well trained and motivated they are. However in the workplace, the consequences of such human failure can be severe. Analysis of accidents and incidents shows that human failure contributes to almost all accidents and exposures to substances hazardous to health. In order to avoid accidents and ill-health, companies need to manage human failure as robustly as the technical and engineering measures they use for that purpose. The challenge is to develop error tolerant systems and to prevent errors from initiating; to manage human error proactively it should be addressed as part of the risk assessment process, where:. This Key Topic is also very relevant when trying to learn lessons following an incident or near miss.
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Enter your mobile number or email address below and we'll send you a link to download the free Kindle App. Then you can start reading Kindle books on your smartphone, tablet, or computer - no Kindle device required. To get the free app, enter your mobile phone number. Although several U. The highly respected authors strongly believe in incorporating the human factors principles in aviation maintenance. This is the first of two volumes providing effective behavioural guidance on risk management in aviation maintenance for both the novice and the experienced maintenance personnel.
Aviation maintenance technicians AMTs often work extended hours and through the night. There is a growing realization that maintenance and engineering organizations should develop their own fatigue risk management systems FRMS to deal with these issues. By William L. Rankin, Ph.
Сорокадвухлетний португальский наемник был одним из лучших профессионалов, находящихся в его распоряжении. Он уже много лет работал на АНБ.
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