ČLOVEŠKE ZMOGLJIVOSTI IN OMEJITVE Nina Lokovšek Maj 2013
ZAKAJ SE MORAMO O TEM POGOVARJATI?
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
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
STATISTIKA NESREČ Raziskava 1994 Velika Britanija: tveganje 1: 1000000, 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/ 1000000 odhodov Po 1960: 1-2/ 1000000 odhodov SPREMLJANJE STATISTIKE JE POTREBNO ZARADI REGULACIJE ZAHTEV IN SPREMEMB V ŠOLANJU
Človeški dejavnik
Medicina Struktura telesa Biomehanika Tvorba, izguba toplote Utrujenost 8
Antropometrija Študij velikosti telesnih delov Lahko uporabnik doseže kontrole? Načrtovanje za ekstremno velike ali majhne ljudi Povprečna osebnost ne obstaja 9
Kognitivna znanost Mentalni procesi zaznavanja Sposobnost reševanja problemov Stvari, ki prizadenejo zaznavanje Učinki stresa na mentalne procese 10
Klinična psihologija Tipi osebnosti Medsebojni odnosi Spoprijemanje s stresom Obvladovalni mehanizmi Samopodoba Sprejemanje kritike 11
Organizacijska psihologija Organizacijska struktura Nagrade in kompenzacije Motivacija Delovne skupine Upravljanje/vzdrževanje odnosov Pravična obravnava 12
Pedagoška psihologija Načini učenja Načini, naučiti ljudi, da si lažje zapomnijo Način pouka 13
Raziskovalna psihologija Krepitev želenega vedenja Raziskave na delovnem mestu Statistične analize Učinki stresa na obnašanje Nadzorovane študije o vplivu delovnih politik in postopkov 14
Računalniška znanost Povezava računalnik-človek Način uporabniških vmesnikov Analiza zahtev za orodja programske opreme, ki temeljijo na poskusni opremi Učenje računalniške pismenosti 15
Varnostno načrtovanje Industrijska varnost Spodrsljaji, napake Ravnanje z materiali Uporaba in skladiščenje škodljivih snovi Opozorila 16
Industrijsko načrtovanje Organiziran pristop k študiju dela Določitev ustreznih delovnih standardov Izdelavo delovne naloge učinkovito Statistična analiza delovne uspešnosti Učinkovita postavitev objekta 17
A Reminder to Apply Human Factors Principles 24 x 7 18
Why Use Models? Models make it easier to understand complex things Easy to remember Models can be 2-D, 3D, or mental 19
SHELL
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...)
The PEAR Model PEAR is easy to remember It works for maintenance It is matched with the SHELL model 22
PEAR People - ljudje, ki opravljajo delo Environment - organizacijsko in delovno okolje Actions - akcije(naloge) Tools - orodja, procedure in drugi viri 23
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
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
What Does This Mean? Živimo 24x7x365 Letalstvo ne počiva Človek potrebuje počitek! 26
Časovno načrtovanje? Čas predstavitve!! Najbolje je da so slušatelji budni! MLST-mean sleep latency time 27
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
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
Fatigue and Proper Rest Get your 8 hours of sleep Proper sleep conditions Nutrition Exercise Hydration Moderate caffeine 30
An Excellent Website About Sleep 31
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
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
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
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
Anthropometry Percentiles 36
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
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
People Vision This animation reviews the parts of the eye and how they function Wear your safety glasses Have a regular eye exam 39
People Hearing This animation reviews the parts of the ear and how they function Wear hearing protection Have an audio check-up 40
People Taste / Touch / Smell Sensors in the skin perceive temperature, pressure, and other tactile information 41
How to Remember the Five Senses When you toast you: See Smell Taste Feel Hear 42
Sensing Versus Perception Human Senses Human Factors Human Factors Human Factors 43
What is This? 44
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
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
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
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
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
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
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
Resources Technical documentation systems Test equipment Enough time Enough people Lifts, ladders, stands, seats Materials Portable lighting, heating, cooling Training 52
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
5 Human Error 54
Human Error Definition of human error Types of errors The dirty dozen Examples of errors Event investigations Maintenance Error Decision Aid (MEDA) 55
The Greatest Hazard to Aircraft is? Gravity Humans 56
80% of Events are Caused by Human Error 57
The Odds are Against Doing it Right! Only one way to disassemble 40,000+ ways to incorrectly reassemble! 58
Definition of Human Error A human action with unintended consequences 59
Types of Human Error 60
Active and Latent Errors 61
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
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
Pomanjkanje komunikacije 65
Slabo timsko delo 67
Norme 69
Pritisk 71
Samozadovoljstvo 73
Pomanjkanje znanja 75
Pomanjkljiva ozaveščenost/pazljivost 78
Pomanjkanje virov 80
Pomanjkanje odločnosti 82
Utrujenost 84
Stres 86
odvračanje
Iceberg Model 89
FAA Human Factors Resources: www.hfskyway.com 90