Published by the TUC May 2010 and available here
This is a short document aimed at union representatives. It appears to me to give a pretty balanced warning that behavioural safety programs are not always implemented well, and can result in inappropriate interventions that aim to change worker behaviours' without addressing systems failures.
Friday, April 29, 2011
Human factors to blame for fatal crash of Air India Express flight from Dubai
Article from Arabian Aerospace published 26 April
An inquiry into the The Air India Express IX812 accident at Mangalore airport on May 22 2010 has identified a number of human factors causes. Only eight of the 166 people on board survived.
The Flight-data recorder shows the aircraft crossed the runway threshold at 200ft rather than at the prescribed 50 feet and much faster. As a result it didn’t touch down until 1600 metres along the runway leaving just 860 metres, which meant it overran the runway. The aircraft's right wing collided with an antenna and the aircraft dropped off the edge of a steep gorge.
Investigators say that cockpit voice recordings recorded typical breathing patterns of deep sleep from the Captain, lasting for 1h 28min, until just 21min before the accident. These recording indicated that the captain slept for at least 1h 40min.
During preparations for landing the co-pilot suggested three times that they should "go-around," which was ignored by the captain, and then erroneously confirmed the aircraft was on the correct approach following pressure by the captain to do so.
A contributing factor was that the airport radar was not working and so the landing was conducted on instruments only.
Report suggest that the captain and co-pilot had fallen out several weeks before the accident. This may be why co-pilot did not wake the captain earlier in the flight and contributed to poor communication between the pair. Also, that "prolonged sleep by the captain, particularly during the overnight circadian low period, could have led to sleep inertia and possibly impaired judgement over the approach shortly after he woke."
An inquiry into the The Air India Express IX812 accident at Mangalore airport on May 22 2010 has identified a number of human factors causes. Only eight of the 166 people on board survived.
The Flight-data recorder shows the aircraft crossed the runway threshold at 200ft rather than at the prescribed 50 feet and much faster. As a result it didn’t touch down until 1600 metres along the runway leaving just 860 metres, which meant it overran the runway. The aircraft's right wing collided with an antenna and the aircraft dropped off the edge of a steep gorge.
Investigators say that cockpit voice recordings recorded typical breathing patterns of deep sleep from the Captain, lasting for 1h 28min, until just 21min before the accident. These recording indicated that the captain slept for at least 1h 40min.
During preparations for landing the co-pilot suggested three times that they should "go-around," which was ignored by the captain, and then erroneously confirmed the aircraft was on the correct approach following pressure by the captain to do so.
A contributing factor was that the airport radar was not working and so the landing was conducted on instruments only.
Report suggest that the captain and co-pilot had fallen out several weeks before the accident. This may be why co-pilot did not wake the captain earlier in the flight and contributed to poor communication between the pair. Also, that "prolonged sleep by the captain, particularly during the overnight circadian low period, could have led to sleep inertia and possibly impaired judgement over the approach shortly after he woke."
Saturday, April 23, 2011
Why Air Traffic Controllers Fall Asleep on the Job
There have been a number of stories in the news recently about US air traffic controllers falling asleep on the job. There has been one example of an obvious violation of rules, but overall I wonder about the systemic failures that have caused the problems.
An article in The Wall Street Journal by Langhorne Bond and Robert W Poole Jr discuss the causes.
Apparently the Federal Aviation Authority (FAA) has known about Controller fatigue for decades but "has repeatedly swept it under the rug." One of the likely problems is the shift pattern. One of the most popular is called 2-2-1: Controllers work two swing shifts, two day shifts, and one midnight shift. The second day shifts ends at 2 p.m. and the subsequent midnight shift begins at 10 p.m., just eight hours later. Such a schedule disrupts circadian rhythms, creating fatigue on the midnight shift. Controllers and their union have fought to keep 2-2-1 because it gives them a three-day weekend afterwards.
The National Transportation Safety Board (NTSB) has called for abolishing 2-2-1 and the inspector general for the Department of Transportation has called for a 10-hour minimum between shifts in general, and 16 hours after a midnight shift.
The other cause of fatigue on midnight shifts is black backgrounds on controller display screens, which require dark rooms for best visibility. But dark rooms tend to induce drowsiness, especially on a midnight shift. It is now common international practice to have light gray background screen displays that can be used in high-light environments, but in the U.S. this has been ignored.
An article in The Wall Street Journal by Langhorne Bond and Robert W Poole Jr discuss the causes.
Apparently the Federal Aviation Authority (FAA) has known about Controller fatigue for decades but "has repeatedly swept it under the rug." One of the likely problems is the shift pattern. One of the most popular is called 2-2-1: Controllers work two swing shifts, two day shifts, and one midnight shift. The second day shifts ends at 2 p.m. and the subsequent midnight shift begins at 10 p.m., just eight hours later. Such a schedule disrupts circadian rhythms, creating fatigue on the midnight shift. Controllers and their union have fought to keep 2-2-1 because it gives them a three-day weekend afterwards.
The National Transportation Safety Board (NTSB) has called for abolishing 2-2-1 and the inspector general for the Department of Transportation has called for a 10-hour minimum between shifts in general, and 16 hours after a midnight shift.
The other cause of fatigue on midnight shifts is black backgrounds on controller display screens, which require dark rooms for best visibility. But dark rooms tend to induce drowsiness, especially on a midnight shift. It is now common international practice to have light gray background screen displays that can be used in high-light environments, but in the U.S. this has been ignored.
Thursday, April 14, 2011
EI launches poster pack to encourage continuous workforce involvement in safety
Available from the Institute website
Good practice in safety across all sectors of the energy industry is of paramount importance. It is generally accepted that engagement with the workforce can lead to safer workplaces as staff become more aware of and involved in mitigating health and safety issues.
With good workforce involvement (WFI), staff, including contractors, are encouraged to take part in the decision making process about managing health and safety in the workplace, however, achieving good WFI requires planned and sustained effort. To support safety managers and leaders in their efforts to implement effective WFI programmes, the Energy Institute (EI) has developed a series of posters to encourage colleagues to contribute to safety in the workplace.
This new poster pack can be used as part of a wider WFI campaign and these resources are supported by Guidance on running a WFI campaign and using the WFI poster pack to help in proactive health and safety management. The posters tackle a number of themes, such as: What stops you from communicating safety issues? What if you are the only person in your team who sees the risk? and What ideas do you have to improve safety? The posters are designed to challenge general perceptions and provoke discussion amongst workers. To support the sharing of ideas, the series also includes space to capture comments to contribute to WFI schemes.
Good practice in safety across all sectors of the energy industry is of paramount importance. It is generally accepted that engagement with the workforce can lead to safer workplaces as staff become more aware of and involved in mitigating health and safety issues.
With good workforce involvement (WFI), staff, including contractors, are encouraged to take part in the decision making process about managing health and safety in the workplace, however, achieving good WFI requires planned and sustained effort. To support safety managers and leaders in their efforts to implement effective WFI programmes, the Energy Institute (EI) has developed a series of posters to encourage colleagues to contribute to safety in the workplace.
This new poster pack can be used as part of a wider WFI campaign and these resources are supported by Guidance on running a WFI campaign and using the WFI poster pack to help in proactive health and safety management. The posters tackle a number of themes, such as: What stops you from communicating safety issues? What if you are the only person in your team who sees the risk? and What ideas do you have to improve safety? The posters are designed to challenge general perceptions and provoke discussion amongst workers. To support the sharing of ideas, the series also includes space to capture comments to contribute to WFI schemes.
Wednesday, April 13, 2011
Introduction to Higher Reliability Organizations
Article from Fire Engineering website by Dane Carley and Craig Nelson published 11 March 2011.
The number of fatalities experienced by US fire service has not changed much in the last 20 years. "We have good, inspiring leaders who recognize the problem and provide solutions. We have good firefighters and company officers who know their jobs inside and out. They follow the rules, use solid safety practices, and train more often than ever before. Leaders, firefighters, and company officers alike are well trained, well educated, and experienced. Therefore, we believe the problem lies within the number of rules, current safety practices, and our approach to safety."
"Other industries operating in a similar environment where there are severe consequences for a single mistake do not see similar accident statistics."
The article discusses the application of the principles of Higher Reliability Organisations (HRO).
The definition of a HRO is "an organization operating in a complex, high-risk environment in which a single error has the potential for disastrous consequences, yet the organization routinely performs with a low number of errors due to various organizational characteristics intentionally engineered to prevent human error."
"An HRO accomplishes this by consciously implementing a comprehensive plan that hinges on developing a learning culture within an organization using methods such as near-miss reporting and root-cause analysis."
"An HRO recognizes that organizations are comprised of humans who, no matter how diligent they are, make mistakes. In organizations like the fire service, we must first accept that we all make mistakes, no matter how smart, educated, or talented we are. An HRO builds systems on five basic principles to prevent a mistake, compensate when a mistake does occur, and then learn from the mistake to prevent it from occurring again. Weick and Sutcliffe (2007) list the principles of an HRO as:
Preoccupation with failure
Reluctance to simplify
Sensitivity to operations
Commitment to resilience
Deference to expertise"
The number of fatalities experienced by US fire service has not changed much in the last 20 years. "We have good, inspiring leaders who recognize the problem and provide solutions. We have good firefighters and company officers who know their jobs inside and out. They follow the rules, use solid safety practices, and train more often than ever before. Leaders, firefighters, and company officers alike are well trained, well educated, and experienced. Therefore, we believe the problem lies within the number of rules, current safety practices, and our approach to safety."
"Other industries operating in a similar environment where there are severe consequences for a single mistake do not see similar accident statistics."
The article discusses the application of the principles of Higher Reliability Organisations (HRO).
The definition of a HRO is "an organization operating in a complex, high-risk environment in which a single error has the potential for disastrous consequences, yet the organization routinely performs with a low number of errors due to various organizational characteristics intentionally engineered to prevent human error."
"An HRO accomplishes this by consciously implementing a comprehensive plan that hinges on developing a learning culture within an organization using methods such as near-miss reporting and root-cause analysis."
"An HRO recognizes that organizations are comprised of humans who, no matter how diligent they are, make mistakes. In organizations like the fire service, we must first accept that we all make mistakes, no matter how smart, educated, or talented we are. An HRO builds systems on five basic principles to prevent a mistake, compensate when a mistake does occur, and then learn from the mistake to prevent it from occurring again. Weick and Sutcliffe (2007) list the principles of an HRO as:
Preoccupation with failure
Reluctance to simplify
Sensitivity to operations
Commitment to resilience
Deference to expertise"
US Fire service
I happened to come across the Fire Engineering website. It seems to contains some very valuable information.
I found this a paper Learning from Firefighter Fatalities very interesting. It is a discussion dating from 2004. I think it will be interesting to anyone working in a hazardous industry. Firefighters have to deal with emergencies far more often than most organisations. They have plenty of experience of what can go wrong.
The site includes a continually updating section notifying of Line of Duty Deaths. A very sobering read.
Firefighters drills is another section that looks interesting. You don't need to be a full time firefighter to be involved in emergency response.
I found this a paper Learning from Firefighter Fatalities very interesting. It is a discussion dating from 2004. I think it will be interesting to anyone working in a hazardous industry. Firefighters have to deal with emergencies far more often than most organisations. They have plenty of experience of what can go wrong.
The site includes a continually updating section notifying of Line of Duty Deaths. A very sobering read.
Firefighters drills is another section that looks interesting. You don't need to be a full time firefighter to be involved in emergency response.
Friday, April 01, 2011
Asda sold 12.9p petrol by mistake
BBC Website 1 April 2011
Drivers paid just 12.9p a litre for petrol after staff put a decimal point in the wrong place.
About 50 motorists stocked up on unleaded fuel at the petrol station in Rooley Lane, Bradford, West Yorkshire.
Drivers queued up to use the automatic card-payment pumps for about two hours until the mistake was spotted.
Some motorists also filled up petrol cans with the bargain fuel after word spread around the city.
Drivers paid just 12.9p a litre for petrol after staff put a decimal point in the wrong place.
About 50 motorists stocked up on unleaded fuel at the petrol station in Rooley Lane, Bradford, West Yorkshire.
Drivers queued up to use the automatic card-payment pumps for about two hours until the mistake was spotted.
Some motorists also filled up petrol cans with the bargain fuel after word spread around the city.
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