{"id":3816,"date":"2024-07-06T09:29:04","date_gmt":"2024-07-06T09:29:04","guid":{"rendered":"https:\/\/crmknowledgehub.com\/?p=3816"},"modified":"2024-07-06T09:29:04","modified_gmt":"2024-07-06T09:29:04","slug":"understanding-human-error-in-naval-aviation-mishaps","status":"publish","type":"post","link":"https:\/\/crmknowledgehub.com\/index.php\/2024\/07\/06\/understanding-human-error-in-naval-aviation-mishaps\/","title":{"rendered":"Understanding human error in naval aviation mishaps"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\"><strong>Ben Hutchinson discusses a paper analysing 95 serious incidents in naval aviation using the HFACS model. Error types are viewed as symptoms of deeper trouble within an organisation.<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Source: <a href=\"https:\/\/www.linkedin.com\/pulse\/understanding-human-error-naval-aviation-mishaps-ben-hutchinson-algfc\">LinkedIn<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">This was interesting \u2013 it studied 95 severe naval aviation mishaps.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The incidents were evaluated using the DoD HFACS model, the applicability of HFACS was then evaluated , and then a sample of events thematically evaluated a sample of events.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">They drew on the delineation of errors into performance-based (PBE) and judgement\/decision-making (JDME), as per the DoD HFACS model.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">It\u2019s argued \u201cerror types are viewed as symptoms of deeper trouble within an organization \u2026That is, the term human error is often considered an unhelpful and reductive label used to identify the solitary person(s) as the weak component with a complex system\u201d.<\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img fetchpriority=\"high\" decoding=\"async\" width=\"542\" height=\"598\" src=\"https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-1-HFACS.png\" alt=\"\" class=\"wp-image-3817\" srcset=\"https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-1-HFACS.png 542w, https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-1-HFACS-272x300.png 272w, https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-1-HFACS-500x552.png 500w\" sizes=\"(min-width: 960px) 75vw, 100vw\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">Findings were:<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The first findings \u2013 the accidents mapped against HFACS, were largely uninteresting (see attached image)<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img decoding=\"async\" width=\"828\" height=\"1024\" src=\"https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-2-HFACS-828x1024.png\" alt=\"\" class=\"wp-image-3818\" srcset=\"https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-2-HFACS-828x1024.png 828w, https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-2-HFACS-242x300.png 242w, https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-2-HFACS-768x950.png 768w, https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-2-HFACS-500x619.png 500w, https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-2-HFACS.png 1012w\" sizes=\"(min-width: 960px) 75vw, 100vw\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The Bayes theorem analysis was a bit more interesting \u2013 they note that five total latent failures produced different levels of impact on the two types of errors<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Planned inappropriate operations and climate\/cultural influences were heavily influenced JDME<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Sensory misperception, technological environment and mental awareness more heavily influenced PBE<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Teamwork \u201cwas the only latent failure that provided equal substantial impact on both types of errors\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; They note that the technological environment connects with the overall workplace design, e.g cockpit and display designs, controls etc<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Although just 17 mishaps cited the technological environment \u201cthe current findings demonstrate the profound impact it plays in disrupting basic aviator skill principles\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Moreover, prior research highlights that factors of aviator awareness and perception \u201c<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; have emphasized the necessity of well-designed technology for effectively displaying information to the aviator for maintaining safe performance\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Also, the latent failure \u201cplanned inappropriate operations\u201d may suggest that \u201caviators are put into unfamiliar situations and therefore situations with increased risk\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Reflecting on the incident classification systems\/taxonomies, \u201cthey are not effective at being able to capture information relevant to the context and constraints workers faced when being involved in an accident,<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The systems are too reliant on hindsight bias, which \u201chinders a deeper understanding of why individuals did what they did and particularly why they considered that their actions (or inactions) would not have led to a mishap at the time\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Finally, such error systems can \u201cunintentionally direct accident investigations in such a way that provides an arbitrary stop-rule for the investigation<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">More interesting was their qualitative analysis of the events \u2013 seeking a way to overcome the inherent limitations of the taxonomic approach by exploring context and real-world constraints.<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img decoding=\"async\" width=\"369\" height=\"1024\" src=\"https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-3-HFACS-369x1024.png\" alt=\"\" class=\"wp-image-3819\" srcset=\"https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-3-HFACS-369x1024.png 369w, https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-3-HFACS-108x300.png 108w, https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-3-HFACS-500x1389.png 500w, https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-3-HFACS.png 540w\" sizes=\"(min-width: 960px) 75vw, 100vw\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">They found:<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Plan continuation was found in the data, being \u201c human operators do not notice that a situation is gradually deteriorating from safe to unsafe\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; People instead first notice clear and unambiguous cues and not necessarily ambiguous and \u201cseemingly harmless\u201d issues<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; This issue is exacerbated by \u201cthe social dynamics of diffusion of responsibility\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; This is exemplified with the bystander effect, being the social tendency for an onlooker intervention during an emergency to be suppressed by the \u201cmere presence of other onlookers\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; And, \u201cAs an unsafe situation is unfolding, an onlooker will observe other onlookers not intervening, thus confirming that this situation must not be an emergency\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 18 of 22 mishaps revealed teamwork breakdowns, such that the beginning of a mult-crew event appeared at first to be benign and manageable, but progressed to an unstable and unsafe state but \u201cnot obvious enough to signal to the aircrew that they should stop\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; These factors \u201cevoked conditions that allowed small, subtle changes and threats to go unnoticed, eventually making it more difficult to recover from error\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 13 of 23 mishaps \u201crevealed that squadron commanders were given unreasonable expectations to algorithmically identify the exhaustive collection of hazards and risks\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Said differently, commanders are held to \u201cunreasonably high expectation of accurately foreseeing all potential hazards when hazards have been seen to go unnoticed or underemphasized due to their subjective nature\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; These expectations \u201care incompatible with human judgment in general, including the ability to assess or anticipate risk\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Moreover, there was an \u201cexpectation that the risk management document and program was expected to identify unusual risks unique to the current event\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; \u201cLike plan continuation previously mentioned, only hindsight would reveal that cues would have been subtle and gone unnoticed by risk assessors\u201d<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; They also observed that there was limited opportunities for pilots to undertake deliberate practice of challenging tasks; aggravated by resource limitations<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; They talk about how departures from rules are seen to be exceptional, when pilots may not routinely strictly following all rules during normal operations<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u00b7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; And \u201cUnderstanding how the front-line pilots, aviators, or human operators within any complex system improvise to get the job done as safely as possible is essential\u201d<\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"558\" height=\"914\" src=\"https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-4-HFACS.png\" alt=\"\" class=\"wp-image-3820\" srcset=\"https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-4-HFACS.png 558w, https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-4-HFACS-183x300.png 183w, https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-4-HFACS-500x819.png 500w\" sizes=\"(min-width: 960px) 75vw, 100vw\" \/><\/figure>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"429\" height=\"1024\" src=\"https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-5-HFACS-429x1024.png\" alt=\"\" class=\"wp-image-3821\" srcset=\"https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-5-HFACS-429x1024.png 429w, https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-5-HFACS-126x300.png 126w, https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-5-HFACS-500x1194.png 500w, https:\/\/crmknowledgehub.com\/wp-content\/uploads\/2024\/07\/image-5-HFACS.png 628w\" sizes=\"(min-width: 960px) 75vw, 100vw\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">Ref: Miranda, A. T. (2018). Understanding human error in naval aviation mishaps.&nbsp;<em>Human factors<\/em>,&nbsp;<em>60<\/em>(6), 763-777.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Ben Hutchinson discusses a paper analysing 95 serious incidents in naval aviation using the HFACS model. Error types are viewed as symptoms of deeper trouble within an organisation. Source: LinkedIn This was interesting \u2013 it studied 95 severe naval aviation mishaps. The incidents were evaluated using the DoD HFACS model, the applicability of HFACS was [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[125,118],"tags":[141,142,140],"class_list":["post-3816","post","type-post","status-publish","format-standard","hentry","category-scientific-papers","category-threat-and-error-management","tag-error-management","tag-tem","tag-understanding-human-error"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.2 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Understanding human error in naval aviation mishaps - The CRM Knowledge Hub<\/title>\n<meta name=\"description\" content=\"Ben Hutchinson discusses a paper analysing 95 serious incidents in naval aviation using the HFACS model. 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