Resilience Engineering

Transcription

1 Gunnar Steinhardt UPL Safety Seminar 31st of January 2015 Luxembourg

2 Definition: Ability of a system to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions. Aim: maintain required operation.

3 Examples Resilient to foreseen disturbance

4 Example Loosing resilience

5 Error Management Resilience Engineering

6 Things that go wrong

7 Things that go wrong 90 Things that go right Z

8 Old Safety Programs try to decrease the things that go wrong tries to increase the things 75 that go right. 70 Z

9 Two views on human error The Old View of human error Human error is a cause of trouble Complex systems are basically safe You must find people s inaccurate assessements, wrong decisions, bad judgements The New View of human error Human error is a symptom of trouble deeper inside a system Complex systems are not basically safe Instead, find how people s assessments and actions made sense at the time, given the circumstances that surrounded them

10 Risk Profile

11 Risk Profile

12 Risk Profile

13 Risk Profile

14 Noticing triggers Action

15 System Variability in Performance Safety Limit Quality Margin Target Area Range Of Control Quality Margin Under pressure Safety Limit

16 System Failures: Loosing Resilience Decompensation Working at cross-purposes Getting stuck in outdated behaviours

17 Decompensation

18 Decompensation

19 Decompensation Autopilot

20 Decompensation Autopilot

21 Decompensation ATC Purser Pilot PA Descent Performance data

22 Decompensation Pilot

23 Decompensation Pilot

24 Decompensation - Compensation

25 Decompensation

26 Decompensation Premonitions 1. One part of the control system is working harder and harder.

27 Decompensation Remedy Change the operating level by injecting more resources into the control sequence.

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29 Communication & team behaviour

30 System Failures: Loosing Resilience Decompensation Working at cross-purposes Getting stuck in outdated behaviours

31 Working at cross-purposes

32 Working at cross-purposes

33 Working at cross-purposes

34 Working at cross-purposes

35 Working at cross-purposes Premonitions 1. Top to bottom communication is lost.

36 Working at cross-purposes Remedy Effective communication at a system level, but also at a team or crew level.

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38 Communication & team behaviour

39 System Failures: Loosing Resilience Decompensation Working at cross-purposes Getting stuck in outdated behaviours

40 Getting stuck in outdated behaviours Swissair 111

41 Getting stuck in outdated behaviours

42 Getting stuck in outdated behaviours Premonitions 1. A lot of small things go wrong, minor incidents happen 2. No common team understanding of the situation.

43 Getting stuck in outdated behaviours Remedy Pursue all signals, especially those which do not confirm your view of the world. Consult your team in order to have a common understanding of the situation. Allow learning from the current situation.

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45 Communication & team behaviour

46 Definition: Ability of a system to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions. How do we do that?

47 If things go right under difficult circumstances, it s mostly because of peoples adaptive capacity; their ability to recognize, adapt to and absorb changes and disruptions.

48 Noticing Triggers Action

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53 Recognize risk profile change

54 Recognize risk profile change

55 and Human Error The New View on human error: The point is not to see where people went wrong, but why what they did made sense to them. The aim is to help your organisation to learn something valuable from failure, instead of just saying human error.

56 and Learning

57 and Learning Definition: Ability of a system to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions.

58 and Learning prior to during following Learn to Recognize a situation before it appears Be prepared and deal with it Integrate successful strategies.

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60 Comments, remarks or questions?