DTU Inst. for Planlægning, Innovation og Ledelese Sektionen for Sikkerhed, Pålidelighed og Menneskelige Faktorer

Transkript

1 Team response under tids- og sikkerhedskritiske situationer, principper og erfaringer fra træning,øvelser og ulykker indenfor luft- og søfart, procesindustri m.m. DTU Inst. for Planlægning, Innovation og Ledelese Sektionen for Sikkerhed, Pålidelighed og Menneskelige Faktorer DTU Management Engineering Dept Safety, Reliability and Human Factors Group 30. oktober 2008

2 Response teams erfaringer fra forskning og ulykkesudredninger Systemperspektivet Den menneskelige faktor Crew Resource Management - træningskoncept Situation Awareness High Reliability Organisations Resilience theory

3 Factors largely beyond organizational control Factors largely within organizational control Authorities: Laws & regulations - international - national/ local Society at large: the press public perceptions Nature of production: tasks resources Safety Culture Managment & staff - norms & attitudes involving: Leadership & motivation Mutual trust /communic. Risks & safety prioritisation Perf. shaping factors Learning / reporting / feedbk Safety Mgm t Structure Frontline staff actions: Team & individual factors adsfasdf Incident / Accident Labour market Unions Professional societies Operator/owner req s Competition Insurers / market State of knowl. of target processes Technical maturity of control options Procedures / guidelines Risk identification Quality control Learning: mechanisms for reporting, analysis, review, feedback & dissemination Technology integration Human Machine Interaction Automation & ergonomics Training Recruitment / selection Manninng / shif rotation Resource allocation Environmental / process factors asdfafd

4 Butterfly-modellen: the Bowtie Model

5 Crew Resource Management baggrund Opstod i 1970 erne som reaktion på alvorlige flyulykker med fællestræk: Piloter samarbejdede ikke optimalt Trivielle pilotfejl begået af erfarne piloter dvs. teknisk erfaring/øget træning næppe en udvej Hierarkiet i cockpit forhindrede 1.piloten i at rejse tvivl Piloter og flyveledere samarbejdede ikke optimalt Trivielle mekaniske eller trafikmæssige småafvigelser ledte til unødvendige katastrofer Ruffel-Smiths exp.: fatigue vs. colleague familiarity

6 Crew Resource Management - indhold Interpersonal skills Communication Leadership Teamwork Briefing / planning /preparation Ressource management Seeking advice and feedback Coping with stress/pressure/fatigue Cognitive skills Situation awareness Mental readiness Assessing risks Anticipating problems Decision making Adaptive strategies/flexibility Workload distribution * (efter Yule & Flin, Surgery, 2001)

7 Crew Resource Management - evidens Evidens for virkning af CRM er blandet et paradoks (jf. patientsikkerhed / virkning på mortalitet og morbiditet) General Accounting Office (GAO) studie 169 accidents, 30% caused in part by pilot error 10% pilots did not apply CRM-principles CRM deficiencies contributed to 50% of serious accident

8 Situation Awareness Samlebegreb: en operatørs dynamiske, mentale model af en skiftende arbejdssituationen Team situation awareness: for hver operatør: den mentale model af arbejdssituationen og af hvad de andre ved og ikke ved Tre slags svigt i SA 1. fejlopfatter enkelte signaler 2. fejlopfatter situationen (forkert skabelon) 3. fejlagtig forudsigelse af næste systemtilstande

9 High Reliability Organisations Resilience engineering HRO samlet betegnelse for konsistent vellykket indsats i sikkerhedskritiske områder eksempler: Nukleare anlæg, hangarskibe, ATC Fælles kendetegn Risikobevidst kultur (sikkerhedskultur) Arbejdsfordeling og kommandofordeling følger kompetencer og resourcer, ikke hierarki Man opmuntrer evne til fleksibelt, improviseret respons Resilience engineering: fokus på organisationers / teams evne til at klare uforudsete, kritiske situationer

10 Endnu en socio-teknisk ulykke: Flykollissionen i 2002 over Überlingen i Sydtyskland Yet another socio-technical accident: The mid-air collission in 2002 over Überlingen

11 DTU Management: Safety, Reliability & Human Factors Group - Henning Boje Andersen 11

12 Bashkirian Airlines Flight DHL Flight 611 Bashkirian Airlines Flight 2937 Tupolev Tu-15 Bashkirian Airlines Origin: Domodedovo Int'l Airport, Mosc Destination: Barcelona Int l Airport 60 passengers 9 crew DHL Flight 611 Boeing Origin: Bahrain Int'l Airport, Bahrain Orio al Serio Airport, Bergamo, Destination: Brussels Airport 2 Crew DTU Management: Safety, Reliability & Human Factors Group - Henning Boje Andersen 12

13 Timeline DTU Management: Safety, Reliability & Human Factors Group - Henning Boje Andersen 13

14 TCAS II - Traffic Collision Avoidance System First a TA / traffic advisory a voice warning: Traffic, Traffic Next an RA/resolution advisory urgent: Descend, Descend or Climb, Climb, possibly followed by Expedite climb or Expedite descent or maintain vertical speed etc. etc. DTU Management: Safety, Reliability & Human Factors Group - Henning Boje Andersen 14

15 DTU Management: Safety, Reliability & Human Factors Group - Henning Boje Andersen 15

16 DTU Management: Safety, Reliability & Human Factors Group - Henning Boje Andersen 16

17 DHL Boeing crew members Bashkirian Tupolev 5 crew members, PF=commander supervised for approach to Barcelona DTU Management: Safety, Reliability & Human Factors Group - Henning Boje Andersen 17

18 Timeline (1) Tupolev Tu154M Departure: Moscow-Domodedowo, 18:48 hrs Destination: Barcelona Boeing B Departure: Bergamo, 21:06 hrs Destination: Brussels 21:21:50 B757 enters Controlarea Zurich Flight Level 260 ( ft) Clearance to climb to FL320 21:26:36 Request to climb to FL360 21:29:50 B757 FL 360 reached 21:30:11 Tu154 enters Controlarea Zurich at Flight Level 360 and appears on Zurich s radar Distance 27NM 21.30:24 TU154 crew notices on TCAS display a/c from left DTU Management: Safety, Reliability & Human Factors Group - Henning Boje Andersen 18

19 21:34:30 Karlsruhe ACC makes first of 11 vain attempts to call Zuric 21:34:42 TCAS: TA [ traffic, traffic ] generated in both a/c 21:34:49 Zurich to Tu154: descend flight level 3-5-0, expedite, I have crossing traffic 21:34:56 Tu154 Instructor commands descend, descends begins 21:34:56 TCAS RA: B757: descend, descend ; Tu154: climb, climb 21:34:58 B757 descends 21:34:59 Discussion within Tu154 crew 21:35:03 Controller: descend level 3-5-0, expedite descend 21:35:03+ Tu154 PIC aknowledges 21:35:13 Controller to Tu154: ja.., we have traffic at your 2 o clock position now at He thinks he has solved the conflict and turns to the other position to help approach of A320 TU154M: PIC to copilot: "Where is it?" Copilot: "Here on the left side!" Navigator: "It is going to pass beneath us!" 21:35:10 B757 TCAS RA: increase descend 21:35:24 Tu154 TCAS RA: increase climb 21:35:32 Collision near Überlingen DTU Management: Safety, Reliability & Human Factors Group - Henning Boje Andersen 19

20 Causal factors Direct causes: Late detection of conflict, ATCO ordering TU to descend; Tupolev pilot complying with ATCO instruction Contributing factors: 1) Single man operations allowed 2) Downgraded radar (no STCA and radar images not correlated automatically with the airplanes' flight plans) 3) Dual monitor and dual frequencies duties 4) Primary telephone system to neighboring centers disconnected, leaving only the bypass telephone line, which system failed, too, despite the controller's frantic attempts 5) TCAS unclarity about authority: follow air traffic controller or follow automation DTU Management: Safety, Reliability & Human Factors Group - Henning Boje Andersen 20

21 Aftermath The Zurich ACC controller Peter Nielsen was stabbed to death in front of his home in Kloten near Zürich, on February 24, 2004 by Vitaly Kaloyev, who lost his close family in the disaster, his two young children and his wife After 610 days of custody, in 2005 Kaloyev was sentenced to eight years in prison. In Nov 2007 he was released from prison, because his mental condition was not sufficiently considered in the initial sentence. He returned home to Ossetia where he was received as a hero by some and where he was appointed deputy minister of housing DTU Management: Safety, Reliability & Human Factors Group - Henning Boje Andersen 21

22 Aftermath On August 7, 2006, a Swiss prosecutor filed manslaughter charges against eight employees of Skyguide. The prosecutor called for jail terms of six to 15 months, alleging "homicide by negligence". Three of the four managers were convicted and given suspended prison terms and the fourth was ordered to pay a fine. Another four employees of the Skyguide firm were cleared of any wrongdoing. DTU Management: Safety, Reliability & Human Factors Group - Henning Boje Andersen 22