Post on 05-Jun-2018
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Human Factors investigation in KLM incident/accident investigation
Martin Nijhof,Flight Safety Investigator, KLM Flight Operations
Den Haag, 4 februari 2014
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Case study: Boeing 777 high speed RTO
Case study: Boeing 777 high speed RTO
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Rudder pedal adjustment control
Case study: Boeing 777 high speed RTO
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Investigation steps safety investigation
• Reconstruct what has happened
• Gather other factual data
• Data Analysis
• Draw conclusions (KLM reports do not include a probable cause statement)
• Produce recommendations
Human Factors definition
A Human factors Definition:
“Human factors” is an umbrella term for the study of the performance of a socialtechnical system
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Why KLM is currently not using a specificHF analyses model
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The current models do not explain why something happened.
Why KLM is currently not using a specificHF analyses model
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Cook & Dekker
The current models do not take complexity into account.
Emerging model
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FRAM from Eric Hollnagel takes complexity into account
How do we investigate HF?
• Investigation based on new view thinking
• Discussion between investigators
• Industry contacts / industry resources
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KLM Human Factors Resources
• One HF expert. Most investigators have been trained in the field of human factors (Human Factors Learning Labs in Lund)
• Maintaining / expanding HF knowledge by studying:
– HF Books
– Industry incident & accident reports
– Scientific publications
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Human Factors Knowledge ResourcesA few important books:
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RPDM
Loukpoulos / Dismukes /Barshi Gary Klein Eric Hollnagel
Human Factors Knowledge Resources
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Investigation reports:
• Transportation Safety Board of Canada(TSB)
• Australian Transportation Safety Bureau(ATSB)
Case study: Boeing 777 high speed RTO
Recommendation to Boeing Company:
It is recommended that the Boeing 777/787 rudder pedal adjustment system is modified such that the rudder pedal adjustment system cannot be left in an unlocked state after its operation.
Boeing action: amend the FCOM Normal Procedures section by adding a warning
WARNING: If the rudder pedal adjust crank is not stowed after use the rudder pedals may move out of the desired position.
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Resistance
• Manufacturer response often outcome driven ...
• Old view thinking
• Recommendations seen as action points
• Recommendations seen as interference
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