People or systems? To blame is human. The fix is to engineer

Person-centered safety theories that place the burden of causality on human traits and actions have been largely dismissed in favor of systems-centered theories. Students and practitioners are now taught that accidents are caused by multiple factors and occur due to the complex interactions of numerous work system elements, human and non-human. Nevertheless, person-centered approaches to safety management still prevail. This paper explores the notion that attributing causality and blame to people persists because it is both a fundamental psychological tendency as well as an industry norm that remains strong in aviation, health care, and other industries. Consequences of that possibility are discussed and a case is made for continuing to invest in whole-system design and engineering solutions.     

Why did the pilots shut down the wrong engine? Explaining errors in context using Schema Theory and the Perceptual Cycle Model

Although human error remains a dominant issue in aviation research, methods that predict human error have been criticised for not providing adequate causal explanations, rather they have focused on classification. The concept of Schemata has prevailed in the literature and has been shown to describe the contextual causes of human error. The purpose of this paper is to review the recent error literature and demonstrate that Schema Theory (as incorporated in the Perceptual Cycle framework) offers a compelling causal account of human error. Schema Theory offers a system perspective with a focus on human activity in context to explain why apparently erroneous actions occurred, even though they may have appeared to be appropriate at the time. This is exemplified in a case study of the pilots’ actions preceding the 1989 Kegworth accident. Schema Theory is presented as a promising avenue for further exploration into the context of human error in aviation.     

Reason模型在空中交通管制中的应用

指出了Reason模型及人的因素分析与分类系统的不足,提出对Reason模型进行修正的思路;结合中国民航业的实际情况,构建了空中交通管制不安全事件的分析框架;对防御系统失效、不安全行为、不安全行为的条件、管理失效4个层次的缺陷进行了论述,并给予详细的实证分析.研究有助于调查分析民航空管行业不安全事件中的原因以及为空管安全管理中的危险识别提供依据.     

基于知识地图的民用航空安全信息事件分析

安全信息的深入分析是数据驱动的安全管理基础。为深入挖掘民航安全信息的价值,分析不安全事件的发展和演化过程,预测事件可能引发的后果及可能性,以2011—2015年民航安全信息网收集的390起重着陆事件为样本,结合事件链因果关系分析,运用知识地图分析法,按照事件发展演化过程建立样本信息中包含知识信息及其因果关系、各事件链间的相关关系、不同后果事件演化的可能性的重着陆事件知识地图。结果表明,该知识地图能够获取重着陆事件在时间、地点、机型、运行阶段、原因、后果及可能的预防及管控重点,可以实现一起或多起重着陆事件信息的知识分析,发现可能存在的安全风险,预判引发严重后果事件的可能性,为有效实施风险管理提供依据。     

A modified accident analysis and investigation model for the general aviation industry: Emphasizing on human and organizational factors

IntroductionCurrently, there is a lack of specific analytical tools for general aviation accidents (GAAs). This has led to loopholes in the prevention of GAAs.MethodsA Swiss Cheese model for general aviation (SCM-GA) is proposed to identify the human and organizational factors involved in GAAs. In the proposed SCM-GA, 5 categories, 45 subcategories, a general aviation safety management system (GA-SMS) and safety culture were developed based on the classic accident causation models combined with the laws and regulations and safety management practices in the general aviation industry.ResultsOne GAA was analyzed using SCM-GA. The human and organizational causes revealed by SCM-GA were more complete than the causes revealed through the accident report. The identification results of the deficiencies in the subcategories of GA-SMS and the safety culture were more consistent with the requirements in the general aviation laws and regulations than the organizational factors in the accident report. Based on the subcategories of SCM-GA, 41 GAAs that occurred between 1996 and 2010 in China were statistically analyzed and χ² test analyses were performed to estimate the statistical strength of the association between two adjacent subcategories of SCM-GA. The results showed that two adjacent subcategories of SCM-GA were significantly associated. They helped to determine the hidden problems in the accident report based on the path of accident.ConclusionsSCM-GA is an accident analysis tool that can comprehensively analyze the human and organizational deficiencies involved in GAAs. The accident causes revealed by SCM-GA were more consistent with the general aviation safety management practices.Practical applicationsGeneral aviation companies should establish their own GA-SMS and safety culture based on the subcategories developed herein. Using SCM-GA for routine safety inspection and accident investigation will help the management and the staff make effective safety decisions to effectively prevent GAAs.     

航空安全文化的研究进展

结合国内外对航空安全文化定量和定性的研究结果,定义了航空安全文化,并阐述航空安全文化的内涵,介绍国内外航空安全文化研究的进展情况,指出了国内外航空安全文化研究的差距,进而给出我国航空安全文化的研究方向。目的在于使以后的研究越来越关注实证角度,为从人为因素角度加强航空安全提供可靠、可信的数据支持,提高飞行绩效,创造安全飞行周期新记录,最终提高航空公司的经济及社会效益。     

Human error risk analysis in offshore emergencies

Human factors play an important role in the completion of emergency procedures. Human factors analysis is rooted in the concept that humans make errors, and the frequency and consequences of these errors are related to work environment, work culture, and procedures. This can be accounted for in the design of equipment, structures, processes, and procedures. As stress increases, the likelihood of human error also increases. Offshore installations are among the harshest and most stressful work environments in the world. The consequences of human error in an offshore emergency can be severe.A method has been developed to evaluate the risk of human error during offshore emergency musters. Obtaining empirical data was a difficult process, and often little information could be drawn from it. This was especially an issue in determining the consequences of failure to complete muster steps. Based on consequences from past incidents in the offshore industry and probabilities of human error, the level of risk and its tolerability are determined. Using the ARAMIS (accidental risk assessment methodology for industries) approach to safety barrier analysis, a protocol for choosing and evaluating safety measures to reduce and re-assess the risk was developed. The method is assessed using a case study, the Ocean Odyssey incident, to determine its effectiveness. The results of the methodology agree with the analysis of survivor experiences of the Ocean Odyssey incident.     

管制员安全能力模型研究

为准确评价管制员安全能力,基于能力的定义和管制员工作职责,界定管制员安全能力的内涵;依据该内涵及其工作特性,建立由身体素质、业务素质和意识3个结构维度组成的管制员安全能力模型。其中,身体素质包括生理状况和心理状况;业务素质包括教育状况、培训状况、技能状况和经验状况;意识包括安全意识和工作意识。在各项指标性质差异较大情况下,利用功效系数法实现评价指标的标准化以减小误差,客观反映指标情况,同时采用G1-法和熵值法集成的主客观综合赋权法确定指标的权重,在一定程度上弥补主客观单一赋权的不足,最后通过逼近理想解排序法(TOPSIS)评价管制员安全能力。结果表明,按照从大到小排序对管制员安全能力的影响因素依次为意识、身体素质和业务素质。就对所论能力的影响而言,心理状况强于生理状况;技能状况强教育、培训和经验状况;安全意识对意识的影响大于工作意识。     

基于CREAM和贝叶斯网络的航空维修人为差错概率预测

航空维修差错不仅严重威胁着飞行安全,同时也会增加航空公司的维修成本。针对航空维修人员发生差错成因的复杂性以及历史事故数据缺乏的情况下,将人因可靠性与失误分析方法（CREAM）和贝叶斯网络（BN）相结合,提出一种改进的维修差错分析模型。根据维修任务构建相应的贝叶斯网络模型,为各子节点设置条件概率表（CPT）;基于维修基地的实际维修环境,对行为形成因子（PSFs）进行评估,得到共同绩效条件（CPCs）的水平;利用各CPC因子下各个行为功能失效模式的权重因子,对各认知活动进行失效概率的修正;将修正概率作为贝叶斯网络根节点的输入,利用推理机制,得到差错发生概率。通过案例分析和计算,验证了所述方法的可行性和有效性。     

航空公司安全评估理论与实践

分析了民航安全的特性;基于“人、机、环境”系统工程理论,研究了民航安全评估的理论和方法;结合中国民航实际,发展了重视人的因素和管理因素的航空公司安全评估系统,该评估系统具有客观评估安全形势、发现薄弱环节和引导航空公司安全行为的功能;最后给出了航空公司安全评估实例。     

航空维修差错模式及差错成因的灰色关联分析

提出一种基于HFACS-ME框架和灰色关联分析法的航空维修差错模式和差错成因之间关系的分析方法。利用该方法分别从"模式—成因"和"成因—模式"2个方向,以"技能差错"和"身体状态差"为例,对差错模式和差错成因之间的关系进行分析,得到影响"技能差错"的主要差错成因依次为空间狭窄、培训不足、工具损坏、身体状态差、精神状态差、空间阻碍,以及"身体状态差"主要影响的差错模式为记忆差错、决策差错、技能差错。结果表明,灰色关联分析法对航空维修差错模式和差错成因之间关系的分析是有效的、可行的。     

我国通用航空安全监管问题研究

通用航空与运输航空是民航发展的两翼,民用航空的持续安全也包含通用航空的安全。随着低空空域的进一步开放,越来越多企事业进入通用航空市场领域,通用航空面临安全监管压力越来越大。论文在分析当前我国通用航空发展的趋势及面临的安全压力基础上,分析总结我国通用航空安全监管存在的问题,重点从监管机构、模式以及方式三层面深入探讨我国通用航空安全监管体系,指出完善通航安全监管法规体系和专业监管队伍建设,加强通用航空初始与持续安全监管,改善监管传统模式的通用航空安全监管思路。     

Arabian,Asian, western: a cross-cultural comparison of aircraft accidents from human factor perspectives

Introduction. Rates of aviation accident differ in different regions; and national culture has been implicated as a factor. This invites a discussion about the role of national culture in aviation accidents. This study makes a cross-cultural comparison between Oman, Taiwan and the USA. Method. A cross-cultural comparison was acquired using data from three studies, including this study, by applying the Human Factors Analysis and Classification System (HFACS) framework. The Taiwan study presented 523 mishaps with 1762 occurrences of human error obtained from the Republic of China Air Force. The study from the USA carried out for commercial aviation had 119 accidents with 245 instances of human error. This study carried out in Oman had a total of 40 aircraft accidents with 129 incidences. Results. Variations were found between Oman, Taiwan and the USA at the levels of organisational influence and unsafe supervision. Seven HFACS categories showed significant differences between the three countries (p?<?0.05). Conclusion. Although not given much consideration, national culture can have an impact on aviation safety. This study revealed that national culture plays a role in aircraft accidents related to human factors that cannot be disregarded.     

航空事故调查中人的因素安全建议框架研究

对航空事故中人的不安全行为进行了系统分析,将失误划分为感知失误、记忆失误、决策失误、技能失误4个类别,将违章划分为习惯性违章和偶然性违章。将人的因素干预维度确定为组织管理、人/团队、技术、任务和环境。针对不安全行为制定相应的初步改进措施后,还需从措施的可行性、可接受性、经济性和有效性4个方面进行综合评估和取舍。实证研究表明,人的因素干预矩阵是制定安全建议的有效工具,该框架具备良好的适用性。     

民航从业者工作负荷研究

回顾民航业特殊行业中从业者(飞行员、管制员和机务维修人员)特定的工作负荷及其测量方法,工作负荷引起压力的心理机制,以及过高的工作负荷可能对从业者生理反应和身体健康造成的负面影响,并提出了改善从业者过高工作负荷的措施和方法。与此同时,指出应该进一步研究民航从业者的工作负荷与某些组织变量(如人误、离职意向、工作满意感)的关系,这不仅可以帮助保障飞行安全、提高从业者的工作满意度,而且具有理论意义。     

民航运行中的威胁与差错管理

在民航运行中的威胁与差错管理的理论基础上,指出威胁与差错管理的目标并非消除威胁与差错,而是把其危害控制在一个可以接受的范围以内。分别界定了威胁、差错、非期望状况的概念,优化了威胁与差错管理的模型,并给予详细的实证分析。进一步丰富了威胁与差错管理的框架形式,提出了系统完善策略。该研究取得的成果有助于民航业从主动控制的角度提升安全效能。     

Occupational and public health and safety in a changing work environment: An integrated approach for risk assessment and prevention

During recent years the work environment has undergone significant changes regarding working time, years of employment, work organization, type of employment contracts and working conditions. In this paper, consequences of these changes on occupational and public health and safety are examined. These include the disruption of human biological rhythms, the increase of workers fatigue due to changes in patterns of working hours and years of employment, job insecurity and occupational stress, which have a serious impact on workers’ health and may result in an increase in occupational accidents. Unsafe work practices related to workload and time pressure, the impact of work changes on public safety and the deterioration of workers’ living conditions with respect to income, social-family life, health and insurance benefits, are also described. In this context, difficulties that occur due to the changing work environment in conducting effective occupational risk assessments and implementing OSH measures are discussed (for example, frequent changes between tasks and workplaces, underreporting of occupational accidents and diseases, lack of methodological tools, etc.). A fundamental criterion used while studying consequences on health and safety and the relative preventive measures is that health and safety must be approached as ‘the promotion and maintenance at the highest degree of the physical, mental and social well-being of workers’ and not only as retention of their work ability. Limits in combining “flexibility” at work and overall protection of occupational and public safety and health in a competitive market are put forward for discussion.     

事故前人因失误研究

在安全评价中，人因失误特别是事故后人因失误越来越受到重视；但相对而言，事故前人因失误没有引起足够的重视。本通过对大量核电厂安全分析报告和运行事件报告的考察，系统地阐述了事故前人因失误对系统安全的显影响，并在此基础上，归纳出在核电站开展事故前人因(失误)分析的程序。该程序主要包括系统熟悉，定性分析，筛选，定量计算，与故障树的集成，敏感性分析与不确定性分析，形成分析档等几个步骤。     

Occupational Health and Social Resources

There is a relationship between the changes in work-related diseases and the following factors: the transformation of the organization of work, organizational development, as well as human and social changes in the work environment. These factors also influence the maintenance of industrial health and safety standards at work. Safety technology will continue to be important, but will be reduced in significance compared to the so-called soft factors, that is, all dimensions and parameters affecting people’s health and social environment at the work place.

It seems that in the future the relationship between the social resource development and work protection will become more relevant. Social resource development influences the quality of work performance and motivation, the quality of work and work protection, the likelihood of accidents and breakdowns, and the level of self-control and capacity of change.

The consequences of work protection research will be discussed in this article with a focus on the contribution of social sciences.     

Occupational Cognitive Failures and Safety Performance in the Workplace

Introduction. The majority of industrial accidents occur because of human errors. Human error has different causes, however, in all cases cognitive abilities and limitations of human play an important role. Occupational cognitive failures are cognitively-based human errors that occur at work. The aim of this study was to examine the relationship between occupational cognitive failures and safety consequences. Method. Personnel of a large industrial company in Iran filled out an occupational cognitive failure questionnaire (OCFQ) and answered questions on accidents. Univariate and multiple logistic regression analysis were used to determine the relationship between cognitive failures and safety consequences. Results. According to developed regression models, personnel with a high rate of cognitive failure, in comparison to low rate, have a high risk of minor injury involvement (OR 5.1, 95% CI [2.62, 10.3]); similar results were for major injury and near miss. Discussion. The results of this study revealed usefulness of the OCFQ as a tool of predicting safety-related consequences and planning preventive actions.