ČLOVEŠKE ZMOGLJIVOSTI IN OMEJITVE

Transkripcija

1 ČLOVEŠKE ZMOGLJIVOSTI IN OMEJITVE Nina Lokovšek Maj 2013

2 ZAKAJ SE MORAMO O TEM POGOVARJATI?

3 Ker je to potrebno za varnejše letenje Še vedno je več kot 70% nesreč v letalstvu zaradi človeškega dejavnika Boljše poznavanje človeških sposobnosti in omejitev lahko zmanjša delež nesreč

4 Izpit iz letalske medicine (Human performance in limitation) UK Civil Aviation Authority od 1992 Joint Aviation Authority od 1996 JAR - FCL 1 podpoglavje J vprašanja iz letalske medicine

5 STATISTIKA NESREČ Raziskava 1994 Velika Britanija: tveganje 1: , da pride do nesreče s smrtnim izidom ali težje poškodbe zahteva: 5 ur letenja 30 min vožnje z avtomobilom 30 min pešačenja 5 min vožnje s kolesom Letni procent nesreč za načrtovane lete Pred 1960: čez 60/ odhodov Po 1960: 1-2/ odhodov SPREMLJANJE STATISTIKE JE POTREBNO ZARADI REGULACIJE ZAHTEV IN SPREMEMB V ŠOLANJU

6 Človeški dejavnik

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8 Medicina Struktura telesa Biomehanika Tvorba, izguba toplote Utrujenost 8

9 Antropometrija Študij velikosti telesnih delov Lahko uporabnik doseže kontrole? Načrtovanje za ekstremno velike ali majhne ljudi Povprečna osebnost ne obstaja 9

10 Kognitivna znanost Mentalni procesi zaznavanja Sposobnost reševanja problemov Stvari, ki prizadenejo zaznavanje Učinki stresa na mentalne procese 10

11 Klinična psihologija Tipi osebnosti Medsebojni odnosi Spoprijemanje s stresom Obvladovalni mehanizmi Samopodoba Sprejemanje kritike 11

12 Organizacijska psihologija Organizacijska struktura Nagrade in kompenzacije Motivacija Delovne skupine Upravljanje/vzdrževanje odnosov Pravična obravnava 12

13 Pedagoška psihologija Načini učenja Načini, naučiti ljudi, da si lažje zapomnijo Način pouka 13

14 Raziskovalna psihologija Krepitev želenega vedenja Raziskave na delovnem mestu Statistične analize Učinki stresa na obnašanje Nadzorovane študije o vplivu delovnih politik in postopkov 14

15 Računalniška znanost Povezava računalnik-človek Način uporabniških vmesnikov Analiza zahtev za orodja programske opreme, ki temeljijo na poskusni opremi Učenje računalniške pismenosti 15

16 Varnostno načrtovanje Industrijska varnost Spodrsljaji, napake Ravnanje z materiali Uporaba in skladiščenje škodljivih snovi Opozorila 16

17 Industrijsko načrtovanje Organiziran pristop k študiju dela Določitev ustreznih delovnih standardov Izdelavo delovne naloge učinkovito Statistična analiza delovne uspešnosti Učinkovita postavitev objekta 17

18 A Reminder to Apply Human Factors Principles 24 x 7 18

19 Why Use Models? Models make it easier to understand complex things Easy to remember Models can be 2-D, 3D, or mental 19

20 SHELL

21 Edwards: letalski sistem SHELL S-software (procedure in pravila, ki jim moraš slediti) H-hardware (letalo, sistemi in oprema) E-environment (letalo in zračni prostor) L-liveware (posadka) LL-liveware/liveware (posadka/kontrolorji/mehaniki/ meteorologi...)

22 The PEAR Model PEAR is easy to remember It works for maintenance It is matched with the SHELL model 22

23 PEAR People - ljudje, ki opravljajo delo Environment - organizacijsko in delovno okolje Actions - akcije(naloge) Tools - orodja, procedure in drugi viri 23

24 People Fizično Velikost spol starost čutila Fiziološko zdravje prehrana življenski stil budnost/utrujenost kemične odvisnosti Psihološko izkušnje znanje trening odnosi čustva Psihosocialno medosebni odnosi komunikacija empatija vodenje 24

25 Ljudje-utrujenost Psihološko Fizično Velikost spol starost čutila Fiziološko zdravje Izberimo enega prehrana življenski stil budnost/utrujenost kemične odvisnosti izkušnje znanje trening odnosi čustva Psihosocialno medosebni odnosi komunikacija empatija vodenje 25

26 What Does This Mean? Živimo 24x7x365 Letalstvo ne počiva Človek potrebuje počitek! 26

27 Časovno načrtovanje? Čas predstavitve!! Najbolje je da so slušatelji budni! MLST-mean sleep latency time 27

28 Types of Fatigue Acute Fatigue Acute Fatigue Intense Short duration Cured with a good night s sleep Chronic Fatigue (harder to fix) Frequent recurrence Long duration Slow recovery Often a physical sickness or mental stress causing chronic fatigue 28

29 Types of Fatigue Chronic Fatigue Acute Fatigue Intense Short duration Cured with a good night s sleep Chronic Fatigue (harder to fix) Frequent recurrence Long duration Slow recovery Often a physical sickness or mental stress causing chronic fatigue 29

30 Fatigue and Proper Rest Get your 8 hours of sleep Proper sleep conditions Nutrition Exercise Hydration Moderate caffeine 30

31 An Excellent Website About Sleep 31

32 Avoiding Error When Fatigued Fatigue is a human condition When you are very tired you will not admit it (like a tired child) Acknowledge fatigue and tell coworkers Try to remain active Talk to others Use caffeine in moderation 32

33 Promoting Alertness at Work Arrive fit for duty (rested) Move around, take breaks Alert co-workers if fatigued Have some caffeine Do boring tasks early, if possible 33

34 People Size Anthropometrics Physical Size Let s review one Gender Age Strength The five senses Physiological Health Psychological Experience Knowledge Training Attitude Emotional state Psychosocial Interpersonal relations Nutrition Ability to communicate Lifestyle Empathy Alertness/fatigue Leadership Chemical dependency 34

35 Anthropometry The Study of Body Measurement User populations Why it s important Male/female split Individual variation Use of percentiles The myth of the 50th percentile person 5th through 95th percentile 35

36 Anthropometry Percentiles 36

37 People Vision and Hearing Physical Size The Five Senses Gender Age Strength The five senses Physiological Health Psychological Experience Knowledge Training Attitude Emotional state Psychosocial Interpersonal relations Nutrition Ability to communicate Lifestyle Empathy Alertness/fatigue Leadership Chemical dependency 37

38 People Vision and Hearing European Aviation Safety Agency (EASA) requires an understanding of the eye, the ear, and the nose FAA places more emphasis on protection The following slides show EASA-level details 38

39 People Vision This animation reviews the parts of the eye and how they function Wear your safety glasses Have a regular eye exam 39

40 People Hearing This animation reviews the parts of the ear and how they function Wear hearing protection Have an audio check-up 40

41 People Taste / Touch / Smell Sensors in the skin perceive temperature, pressure, and other tactile information 41

42 How to Remember the Five Senses When you toast you: See Smell Taste Feel Hear 42

43 Sensing Versus Perception Human Senses Human Factors Human Factors Human Factors 43

44 What is This? 44

45 What is This Now? Both the letter B and the number 13 are the same figure. However, the context determines how you perceive it. (Coren, et al, (1994), Sensation and Perception, Harcourt Brace College Publishers) 45

46 Environment Physical Organizational Personnel Weather Supervision extremes Location Labor - management Size of company (in/out) Workspace Profitability Lighting Job security Sound levels Morale Housekeeping Corporate culture Safety issues Safety culture 46

47 Organizational Factors Safety Culture Safety is everyone s responsibility Management rewards safe actions Everyone is empowered to stop work for safety concerns Employees will enforce safety practices Reporting unsafe acts or conditions will be rewarded Employees work as a team Formal safety management systems are due in 2009 (ICAO) 47

48 Actions What do you need to know? What skills are necessary? Steps to perform a task Sequence of actions Communication requirements Information requirements Inspection requirements Certification requirements 48

49 Actions What Can You Do Today? How do you communicate error events? Are there enough people to do the job? Do personnel understand the cost of aircraft damage? How can you motivate one another to care more? Are you responsible for the things that others do? 49

50 Task Analysis It s How We Do It Identify the steps required to complete a task For each step, identify the information, tools, communication links, procedures, and so forth, necessary to complete the step 50

51 Communication Lack of communication is a major cause of errors Verbal and non-verbal Positive listening Communication protocols Affirm reception of information (readback) Never assume the information you transmitted is the same information received 51

52 Resources Technical documentation systems Test equipment Enough time Enough people Lifts, ladders, stands, seats Materials Portable lighting, heating, cooling Training 52

53 Procedures Everything in aviation maintenance is proceduralized FAA regulations (part 43) require aviation maintenance technicians to follow approved procedures Some procedures don t work as written Most common violation is failure to follow procedures 53

54 5 Human Error 54

55 Human Error Definition of human error Types of errors The dirty dozen Examples of errors Event investigations Maintenance Error Decision Aid (MEDA) 55

56 The Greatest Hazard to Aircraft is? Gravity Humans 56

57 80% of Events are Caused by Human Error 57

58 The Odds are Against Doing it Right! Only one way to disassemble 40,000+ ways to incorrectly reassemble! 58

59 Definition of Human Error A human action with unintended consequences 59

60 Types of Human Error 60

61 Active and Latent Errors 61

62 Why Things Go Wrong Incomplete installation (33%) Damage on installation (14.5%) Improper installation (11%) Equipment not installed or missing (11%) Foreign object damage (6.5%) Improper troubleshooting, inspection, test (6%) Equipment not activated or deactivated (4%) Data from Boeing study of 276 in-flight engine shutdowns (1994) 62

63 The 12 Most Common Causes for Human Errors Eliminate these causes and you have conquered most human errors Talk about each of these What are the causes in your company? What are the corrective actions? 63

64 Pomanjkanje komunikacije 65

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66 Slabo timsko delo 67

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68 Norme 69

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70 Pritisk 71

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72 Samozadovoljstvo 73

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74 Pomanjkanje znanja 75

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76 Pomanjkljiva ozaveščenost/pazljivost 78

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78 Pomanjkanje virov 80

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80 Pomanjkanje odločnosti 82

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82 Utrujenost 84

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84 Stres 86

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86 odvračanje

87 Iceberg Model 89

88 FAA Human Factors Resources: 90