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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