The Reason Model
ERROR AND VIOLATION
❑ Fundamental difference between operational errors
and violations lies in “INTENT” .
ERRORS are UNINTENTIONAL
❑ An error is an “honest mistake”
❑ People committing operational errors are trying to do the
right thing, but they fail to achieve their expectations
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The Reason Model
ERRORS FREQUENCIES ( SB >> RB >> KB )
Knowledge
-Based
Level
11% ❑ 61% of errors are at skilled-based (SB) level
❑ 27% of errors are at ruled-based (RB) level
Ruled- Skilled-
Based Based ❑ 11% of errors are at knowledge-based (KB) level
Level Level
27% 62%
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The Reason Model
“ VIOLATION ”
There are two general types of violations:
a. Situational violations
b. Routine violations.
According to a recent
US study , 63% of in
flight incidents originate
from rushing during
flight preparation.
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“ VIOLATION ”
(a) Situational Violations – time pressure or high workload.
The hurry up syndrome( time pressure )
(b) Routine Violations – “ The normal way of doing business” within
a work group
✓ Their objective is to get the job done.
✓ They aim at saving time and effort by
simplifying a task.
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Errors and Safety
Pilot Error Cited in Anchorage Accident
How
many
accidents
involve
human
Errors do cause accidents error ?
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The Reason Model (Latent Conditions)
➢ Latent Conditions may remain dormant for a long time.
➢ Individually, these latent conditions are usually not
perceived as harmful
➢ Latent Conditions become evident once the system’s
defenses have been breached.
Most latent conditions start with the decision-makers.
Typically, defenses in aviation can be grouped under
three large headings:
a. Technology
b. Training and
c. Regulations.
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Reason Model
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Reason Model
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2.5 The Organizational Factors
Organizational Processes
➢ Policy-making
Workplace Conditional Latent Conditions
➢ Planning
➢ Communication
➢ Allocation of Resources
➢ Supervision
Active Failures ➢ ….. Defenses
Activities over which any organizations has a reasonable degree of direct control
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2.5 The Organizational Factors
Organizational Processes
➢ Inadequate hazard
Workplace Conditional identification and Latent Conditions
risk management
➢ Condition of
equipment &
facilities
Active Failures Defenses
➢ Normalization of
deviance
Conditions present in the system before the accident, made evident by triggering factors
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2.5 The Organizational Factors
Organizational Processes
Workplace Conditional Latent Conditions
➢ Technology
➢ Training
Active Failures ➢ Regulations Defenses
Resources to protect against the risks that organizations involved in production activities
generate and must control.
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2.5 The Organizational Factors
Organizational Processes
➢ Workforce stability
Workplace Conditional ➢ Qualifications and Latent Conditions
experience
➢ Morale
➢ Credibility
Active Failures ➢ Ergonomics Defenses
➢ ….
Factors that directly influence the efficiency of people in aviation workplaces.
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2.5 The Organizational Factors
Organizational Processes
Workplace Conditional Latent Conditions
➢ Error
Active Failures ➢ Violations Defenses
Actions or inactions by people (pilot, controllers, maintenance, engineers,
aerodrome staff, ect.) that have an immediate adverse effect.
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Group Exercises
British Airways Flight 5390 was a flight from Birmingham Airport in England
for Málaga Airport in Spain. On 10 June 1990
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HF Module – N°3
SHELL Model
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The Shell Model
“AIRLINES”
▪ Airlines are service delivery companies
▪ To provide scheduled flights for passengers and cargo.
▪ The airline are as safe and its operations are economical
as possible.
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The Shell Model
“HR For Airline”
▪ The public is aware of pilots and flight attendants.
▪ Maintenance staff to ensure airplanes stay in as good a condition.
▪ Ground crews keep the cabin clean, provide supplies for the passenger
load cargo, luggage and refuel the airplane.
▪ Flight dispatchers compute airplane performance, plan flights, monitor
progress and provide support.
▪ Support staff sell tickets, market the airlines, liaise with the public, develop
schedules, manage the finances.
Each flight is the result of coordinated work by all employees of the airline.
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The Shell Model
▪ Aviation workplace are
- multi-component,
- Multi-feature,
- Complex operational contexts.
▪ To understand the human contribution of safety and to support the human
operational performance necessary to achieve the system’s production goals.
▪ It is necessary to understand how human operational performance may be
affected by the various components and features of the operational context
and the interrelationships between components, features and people.
This Model is a development of the MAN-MACHINE-ENVIROMENT-SYSTEM .
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The Shell Model (People and Safety)
In Figure,
▪ The caveman is representative of
operational personnel.
▪ The mission ( or production goal of the
system) is to deliver packages to the
other side of the mountains.
The different components and features of the
operational and their interaction with the caveman,
and among themselves, will impact the safety and
efficiency of the delivery of packages .
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The Shell Model (People and Safety)
▪ The interaction of the caveman with the lions, unless the caveman is properly equipped to
deal with the lions.
▪ The mountains on a probably thunderstorm and unpaved road without footgear and may
lead to injuries .
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