Analysing Human Error

1
Analysing Human Error in Incident
Investigation HERA-JANUS Dissemination in ECAC
Luxembourg 17-18 June 2003 Institute of Air
Navigation Service

HERA-JANUS
The Workshop
To know more about
2
Overview

• Who should attend?
• Agenda / Pre-programme
• Speakers
• When?
• Where?
• Registration and Hotel Reservation
• Hotel Information
• Enquiries
• Return to first page

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Who should attend?

• Safety Managers
• Incident Investigators
• Safety Regulators
• Operational Managers
• Human Factors Managers and Specialists
• Representatives International Organisation
  (aviation)

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Agenda / Pre-programme

• Session 1 The HERA-JANUS Technique
• EUROCONTROL / FAA Harmonisation Process
• HERA-JANUS Demonstration based on a real case
• Session 2 HERA-JANUS Benefits - The Users
  perspective
• Safety Managers
• Incident Investigators
• The Human Factor Specialists
• The US Experience
• Session 3 HERA-JANUS in the European Safety
  Management and Safety Regulation Framework
• Session 4 Implementing HERA-JANUS
• European Views
• FAA Views

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Speakers

• The speakers will be
• European Safety Managers and Incident
  Investigators who have been involved in the
  development, testing and validation of
  HERA-JANUS.
• European Safety Manager and Incident
  Investigators who are using HERA-JANUS
• EUROCONTROL Representatives from Human Factors,
  Safety Management, and Safety Regulation
• FAA Representatives who were involved in the
  EUROCONTROL/FAA harmonisation process and
  HERA-JANUS implementation.
• See the names of those who have already confirmed
  their participation in the next slide

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Speakers
Tzvetomir BLAJEV EUROCONTROL Safety Management
Unit Mick CAMPBELL Safety Manager - Irish
Aviation Authority (TBC) Keith CARTMALE Safety
Manager UAC Maastricht Paul ENGELEN Manager
Incident investigation LVNL The
Netherlands Anthony FERRANTE FAA Manager Air
Traffic Investigations Anne ISAAC Human Factors
Expert - EUROCONTROL Human Factors and Manpower
Unit. Paul KROIS FAA Manager ATC Human Factors
Research Program Jörg LEONHARDT Human
Factors/CISM -Corporate Safety and Quality
Management DFS Germany Antonio LICU EUROCONTROL
Safety Regulation Unit Philip MARIEN Incident
Investigator UAC Maastricht Martin POLMAN
Incident investigator LVNL The Netherlands Julia
POUNDS FAA/CAMI Research Psychologist Dominique
VAN DAMME Human Factors Expert EUROCONTROL HF and
Manpower Unit
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When?

• Starting on Tuesday 17 June at 1000
• Ending on Wednesday 18 June at 1300

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Where?

• EUROCONTROL - Institute of Air Navigation Service
• IANS
• 12, rue Antoine de Saint-Exupéry
• L- 1432 Luxembourg
• View IANS Website here

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Registration and Hotel Reservation

• Please fill-in the registration form and send it
  no later than 6th June to
• EUROCONTROL INSTITUTE of AIR NAVIGATION SERVICE
• COURSE RESERVATION OFFICE or email
  IANS.reservation_at_eurocontrol.int
• 12, Rue Antoine de Saint-Exupéry
• L-1432 Luxembourg
• FAX [phone]
• E-MAIL IANS.reservation_at_eurocontrol.int

Registration Form available online here or email
IANS.reservation_at_ eurocontrol.int
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Hotel Information

• If you need a Hotel Reservation please enter
  your request on the registration form.
• EUROCONTROL has special arrangements with the
  hotels, the special EUROCONTROL rates will only
  be applicable if the booking is done by IANS
  Reservations Office
• Hotel list available online here or email
  IANS.reservation_at_eurocontrol.int

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Enquiries

• For further information on Return to first
  page
• The Programme
• Mrs Dominique Van Damme or Mrs Anne Isaac
• EUROCONTROL HQ
• DAS/HUM
• Rue de la Fusée, 96
• 1130 Brussels
• Tel [phone] or 32.2.729.39.57
• E-mail dominique.van-damme_at_eurocontrol.int or
  or anne.isaac_at_eurocontrol.int
• Administration, registration, accommodation, etc
• EUROCONTROL INSTITUTE of AIR NAVIGATION
  SERVICE - COURSE RESERVATION OFFICE
• 12, Rue Antoine de Saint-Exupéry
• L-1432 Luxembourg
• FAX [phone]
• E-MAIL IANS.reservation_at_eurocontrol.int

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Overview

• What is HERA-JANUS?
• Why HERA-JANUS?
• HERA-JANUS objectives
• Target audience
• How was it developed?
• HERA-JANUS in the incident investigation process
• Benefits and added value of HERA-JANUS
• HERA-JANUS implementation
• External recognition
• Return to first page

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What is HERA-JANUS?

A technique to analyse, in depth, human error
within the incident investigation process A
EUROCONTROL/FAA harmonised technique
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Why HERA-JANUS?

• Human errors are involved in 70 to 90 of
  incidents
• Understanding what happened and why it happened
  is the best way to learn lessons
• Human errors were often poorly investigated
• There was previously no ATC specific human error
  taxonomy

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HERA-JANUS objectives

• To improve safety
• Supporting in depth analysis of human factors
  involved in incidents
• Supporting the identification of the contextual
  conditions
• Supporting refined remediation and
  recommendations

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Target audience

• Incident Investigators
• Safety Managers
• Human Factors specialists

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How developed?

• A theoretical and academic approach
• Literature review of more than 300 references
• Identification of the error models and
  methodologies used in other areas
• Adaptation of the chosen model to ATM - both
  present and future
• An extensive operational involvement
• ATCOs, Incident Investigators, Safety Managers
• Extensive development, testing, and validation
  processes
• With close co-operation between EUROCONTROL and
  FAA

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HERA-JANUS in Incident Investigation Process
Event
Data collection
Analysis
HERA JANUS
Report Recommendations
Follow-up Safety Management
Feedback Dissemination
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Benefits and added value of HERA-JANUS

• Safety Managers and Incident Investigators
• Support to the Investigation Process
• Structured approach
• Harmonisation of incident data analysis
• New views and new perspectives to incident
  investigation
• More focused recommendations
• Support to Safety Management
• Trend analysis
• No-blame safety culture

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Benefits and added value

• The Organisation
• Refinement of Safety Targets
• Increase of Safety Awareness within the whole
  organisation
• Promotion of a Safety Culture

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HERA-JANUS Implementation

• Management
• Active support and commitment
• Cost/Effort
• HERA-JANUS Training
• Incident investigators 5 days
• Safety managers 3 days
• HERA-JANUS Co-ordinator at National Level
• HERA-JANUS user group

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External recognition
Return to first page

• ANSP
• HERA-JANUS used as preferred method for incident
  analysis
• HERA-JANUS output used for Team Resource
  Management
• SRU (ESSAR 2)
• HERA-JANUS integrated in TOKAI
• HERA-JANUS taxonomy included in the HEIDI
  taxonomy
• FAA
• HERA-JANUS part of the FAA-EUROCONTROL Research
  and Development Programme - Action Plan 12