Working with aerospace systems you very quickly come upon the terms ‘irreversible function’ or ‘irreversible command’ but what are they and why should we be concerned?
Archive for the ‘Human error’ Category
Pilots in the Loop? Airbus and the FBW Side Stick
Posted in Aerospace Safety, Cognitive psychology, Human error, The human machine interface, Violations, tagged AF 447, AirBus, ATSB, crew coordination, FBW, NTSB, side stick controller on 16/09/2011 | 2 Comments »
Airbuses side stick improves crew comfort and control, but is there a hidden cost? The Airbus FBW side stick flight control has vastly improved the comfort of aircrew flying the Airbus fleet, much as the original Airbus designers predicted (Corps, 188). But the implementation also expresses the Airbus approach to flight control laws and that [...]
The Phantom Menace, or the Crossing that Never Was…
Posted in Affordances, Cognitive psychology, Human error, Technology, Traffic safety, tagged Cultural cliche, false affordance, information hazard, NSW RTA, pedestrian crossings, pedestrian safety, road safety on 10/08/2011 | 2 Comments »
How the marking of a traffic speed hump provides a classic example of a false affordance and an unintentional hazard.
What the BEA didn’t say about Air France AF 447
Posted in Aerospace Safety, Errors, tagged AF 447, airbus aircraft, attensity, BEA Investigation, BEA report, crew resources, human factors, safety management system, safety thread, stall recovery on 05/08/2011 | Leave a Comment »
The BEA third interim report on the AF 447 accident raises questions So I’ve read the BEA report from one end to the other and overall it’s a solid and creditable effort. The report will probably disappoint those who are looking for a smoking gun, once again we see a system accident in which the [...]
Side Sticks and Shared Situational Awareness
Posted in Aerospace Safety, Human error, The human machine interface, tagged AF447, AirBus, centre stick controller, cockpit error management, crew resource management, Risk, Safety, side stick controller on 27/07/2011 | 3 Comments »
One of the less often considered aspects of situational awareness in the cockpit is the element of knowing what the ‘guy in the other seat is doing’. This is a particularly important part of cockpit error management because without a shared understanding of what someone is doing it’s supremely difficult to detect errors. The replacement of the central control stick with side stick ‘glass’ controllers eliminates a little acknowledged means of coordinating a common understanding of control inputs between aircrew with the potential for a hazardous loss of crew error management.
On the Brittleness of Software
Posted in Aerospace Safety, Human error, The human machine interface, tagged AF447, Air France, design assumptions, design paradigm, epistemic risk, James Reason, never give up design strategy, requirements incompleteness, Software latent fault, stall warning on 23/07/2011 | 3 Comments »
Reading through the BEA’s precis of the data contained on AF447′s Flight Data Recorder you find that during the final minutes of AF447 the aircrafts stall warning ceased, even though the aircraft was still stalled. This loss of stall warning removed a significant cue to the aircrew that they had flown the aircraft into a deep stall, undoubtedly adding to their confusion. SU4CF4KDVSWQ
Through a Mirror Darkly…
Posted in Human error, The human machine interface, tagged FFG 7, functional versus sequential grouping, human errors, MIL-STD-1472, mirrored controls, PCC, refractory on 13/07/2011 | Leave a Comment »
Good and bad in the design of an Oliver Hazard Perry class frigates ECS propulsion control console HMI.
Is this Human Error?
Posted in Aerospace Safety, Violations, tagged Bud Holland, Canberra bomber, Czar 52, James Reason, Procedural violation, RAAF on 30/06/2011 | Leave a Comment »
James Reason would classify this as a violation rather than error, that is a deliberate departure from an approved procedure. But this is where we get into the cultural and organisational aspects of such behaviour.
Let Slip the Wolves of Error
Posted in Aerospace Safety, Human error, tagged Cry Wolf effect, Unreliable air data on 26/06/2011 | Leave a Comment »
In a series of aircraft incidents air crew have consistently demonstrated difficulty in first identifying and then dealing with unreliable air data and warnings. To me figuring out why this difficulty occurs is essential to addressing a significant air safety problem.
A Thing Called Hindsight and AF447
Posted in Aerospace Safety, Human error, tagged AF447, error patterns, Hindsight bias, human error, just world hypothesis, NASA Ames on 23/06/2011 | Leave a Comment »
Knowing the outcome of an accident flight does not ‘explain’ the accident Hindsight bias and it’s mutually reinforcing cognitive cousin the just world hypothesis are traditional parts of public comment on a major air accident investigation when pilot error is revealed as a causal factor. The public comment in various forum after the release of the [...]
AF447… What We Now Know
Posted in Aerospace Safety, Human error, tagged accident sequence, AF 447, AF447, Air France, AirBus, BEA Investigation, epistemic risk, Fault tolerance, human machine interface, system architecture on 27/05/2011 | 12 Comments »
The BEA has released a precis of the data contained on AF447′s Flight Data Recorder and we can know look into the cockpit of AF447 in those last terrifying minutes.
Driving Tanks and Human Factors
Posted in Human error, The human machine interface, tagged human error types, M113 APC, operational context, physical skill on 06/05/2011 | 1 Comment »
How even apparently simple interfaces can contain subtle error traps Back in the day learner drivers of the then new M 113 were found to be repeatedly veering off the road or into oncoming traffic when trying to carry out an emergency stop. In some circumstances learner drivers would also accelerate while trying to perform [...]
Common Cause at Daiichi Fukushima
Posted in Cognitive psychology, Heuristics & Biases, Human error, Nuclear Power Safety, organisational safety cultures, tagged confirmatory bias, Cultural effects, Daiichi Fukushima, directed verdict, group cohesiveness, Groupthink, Irving Janis, Japanese tsunami, NISA, Risk, TEPCO, uncertainty avoidance on 28/04/2011 | Leave a Comment »
There are few purely technical problems… The Washington Post has discovered that concerns about the vulnerability of the Daiichi Fukushima plant to potential Tsunami events were brushed aside at a review of nuclear plant safety conducted in the aftermath of the Kobe earthquake. At other plants the Japanese National Institute of Advanced Industrial Science and [...]
Racing the Devil
Posted in Decision making, Human error, Humour, Uncertainty, tagged driver behaviour, epistemic uncertainty, rail crossings, Rail safety on 21/03/2011 | Leave a Comment »
This railway crossing near miss due to a driver ‘racing the devil’ is, on the face of it, a classic example of the perversity of human behaviour. But on closer examination it does illustrate the risk we introduce when transitioning from a regine of approved operational procedures to those that have been merely accepted or tolerated.
I tend towards the integrative rather than reductionist view of engineering and science. I'm interested in emergence, networks, relationships and interfaces as they apply to safety.what are the facts?
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