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Uncovering human factors risks Gaining visibility of opera2onal human factors issues through the Safety Management System
Overview of the presentation
Presentation topics
• Gaining visibility of Human Factors risks – Safety reporting systems, investigations – Safety audits – Risk Management Systems – Fatigue Risk Management Systems – Flight Data Monitoring – Safety Climate Survey
• Managing human factors risks – Non-Technical Skills (NTS) training – Safety promotion activities – Changing policies, processes and systems
• Future directions
Virgin Australia’s Safety Management System model
Gaining visibility of human factors risks
Ways of gaining visibility and managing human factors risks
Sources of data to gain visibility of HF risks
Ways to manage HF risks
Safety reporting and investigations
Our goal: to ascertain the error-producing conditions in our daily operations, by encouraging reporting of
the following;
Flight OperationsNumber of Operational Safety Occurrences by Risk
0
30
60
90
120
150
180
Very
Low
Low
Mod
erat
e
Hig
h
Extr
eme
Very
Low
Low
Mod
erat
e
Hig
h
Extr
eme
Very
Low
Low
Mod
erat
e
Hig
h
Extr
eme
Aug-11 Sep-11 Oct-11
Num
ber o
f Occ
urre
nces Accountable Indirect
Safety reporting and investigations
Safety reporting and investigations
Safety audits
• More proactive way to reveal day-to-day issues (particularly undetected errors and conditions)
Some examples – Flight safety: data entry errors due to task
saturation – Cabin safety: fatigue-related errors in door
procedures – Ground safety: slight deviations from SOPs
due to low familiarity with the operation
Risk Management Systems
• Identifying HF-related risks associated with operational changes
• Distribution and escalation of risk management tools (i.e. risk registers)
Example: SOP change during the takeoff phase
– Risk of behavioural reversion – Risk of miscommunication between
Captain and First Officer – Risk of reducing reaction times, etc.
Fatigue Risk Management Systems (FRMS)
• The FRMS reporting processes & communications systems are a significant part of data collection on crew wellbeing.
• Example: alteration of the Australia-LAX pairings for a longer layover.
Flight Data Monitoring
• Provides objective, detailed technical data
• Allows for verification of crew’s recollections
• Examples: – Rejected takeoff actions – Rates of descent on
approach – Breaches that are unknown
to the crew
Safety Climate Survey
• Allows for a collation of feedback from crew
• Will be conducted
organisation-wide in 2012.
Gaining visibility: Bringing together all information sources
‘Gaining visibility’
The key is having all levels of management having an appropriate level of knowledge
about the human factors-related risks
Managing human factors risks
Sources of data to gain visibility of HF risks
Ways to manage HF risks
NTS courses and other safety training
• Providing skills and knowledge to crew and other ‘safety critical’ staff
• Can incorporate ‘lessons learned’ from investigations, audits, reports
• Allows for a consistency in approaching human factors issues
Technical training enhancements
Safety promotion activities
• Promoting greater safety awareness and knowledge through targeted messaging.
• Examples –
– Management ‘road shows’ – Monthly publications – Safety campaigns
Changes to policies, process and procedures
• Making organisation-wide changes should be the goal, in addition to training.
• Examples: – Flight: Pre-descent briefing checklist
improvements – Cabin: changing crew rest policies to allow for
more effective in-flight sleep. – Ground: developing Local Operating
Procedures to accommodate unique port procedures
Where to from here?
• Further improving visibility of human factors risks by; – Improving investigators’ analytical skills – Moving towards performance-based auditing – Flight Data Monitoring trend data
effectiveness • Further improving the management of human
factors risks by; – Expanding human factors education and
‘skilling’
Any questions?
Thank you!
Heather Fitzpatrick Safety and Quality Advisor
Virgin Australia Phone: +61 434 602 983
Email: heather.fitzpatrick@virginaustralia.com.au
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