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Improving the mastery of human factors in a safety critical ATM organisation Academic dissertation to be publicly discussed, by due permission of the Faculty of Behavioural Sciences at the University
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Improving the mastery of human factors in a safety critical ATM organisation Academic dissertation to be publicly discussed, by due permission of the Faculty of Behavioural Sciences at the University of Helsinki in Auditorium XII, Main Building, Unioninkatu 34, Helsinki, on the 7th of June 2012, at 12 o clock. Supervisors: Professor Anneli Leppänen Finnish Institute of Occupational Health Work Organizations Finland Research Professor Leena Norros Technical Research Centre of Finland Automation and Human-Technology Interaction Finland Reviewers: Dr Christine Owen Faculty of Education University of Tasmania Project Leader: Organising for Effective Incident Management Bushfire CRC Australia Professor Matti Vartiainen Aalto University School of Science Work Psychology and Leadership Department of Industrial Engineering and Management Finland Opponent: Professor Pascale Carayon Department of Industrial and Systems Engineering University of Wisconsin-Madison USA ISBN (pbk.) ISBN (pdf) Layout and cover: Tarja Petrell, Studio Gemma Cover photo: Pietari Vanhala Publisher: Author Yliopistopaino Unigrafia, Helsinki 2012 Contents.. Abstract... 7 Tiivistelmä... 8 Acknowledgements List of original publications Abbreviations Figures used in this thesis Introduction The context the historical development of aviation Air traffic management as a system Global and European ATM Finnish Civil Aviation Administration Finnish ATM HF within the ATM Definition of and research related to HF HF in ATM guidelines and earlier research Learning at work and in an organisation Learning a new way of thinking and a method supporting it Value of a new way of thought and a tool (HF) for implementing it Organisational features that affect learning Environmental factors affecting learning in an organisation Approaches adopted in studies of complex sociotechnical systems Summary of the theoretical background of this thesis Applying HF in the target ATM organisation Aims of the study Materials and methods Participants Interviews Intervention material (development plans) Open questions (in two questionnaires) Safety culture questionnaire HF tool....45 3.7 Summary of the participants and methods of the thesis Validity Ethics Empirical studies From crisis to development analysis of air traffic control work processes (Study I) Methods Results Discussion Managers conceptions regarding human factors in air traffic management and in airport operations (Study II) Methods Results Discussion Learning in air navigation services after initial training (Study III) Methods Results Discussion Application of a new HF tool in an air traffic management organisation (Study IV) Methods Results Discussion General discussion Development phases of the target ATM organisation regarding the mastery of HF Factors supporting HF application Factors that hindered the HF application HF as a necessary tool for the target ATM organisation Evaluation of the HF application and this thesis How to proceed in the future References Tiivistelmä Inhimillisten tekijöiden (Human Factors, HF) hallinta turvallisuuskriittisissä järjestelmissä, kuten lennonvarmistuksessa ja lennonjohdossa on välttämätöntä, jotta varmistetaan toiminnan sujuvuus, turvallisuus ja hyvinvointi. Lennonjohdon tehtävä on ehkäistä lentokoneiden yhteentörmäykset ja huolehtia lentoliikenteen sujumisesta turvallisella ja taloudellisella tavalla. Lennonjohtotyö sisältää monimutkaisuutta, epävarmuutta ja muuttuvuutta, jotka lisäävät inhimillisten virheiden riskiä. Inhimillisten tekijöiden tieteenala soveltaa käyttäytymistieteellistä osaamista järjestelmien toiminnassa. Tässä väitöskirjassa inhimillisten tekijöiden tietämystä käytetään lennonvarmistuksen työn, työn hallinnan ja turvallisuuden kehittämisen työkaluna. Väitöskirja koostuu neljästä osatutkimuksesta, jotka kuvaavat inhimillisten tekijöiden soveltamista lennonvarmistusorganisaatiossa 10 vuoden aikana. Väitöskirjassa tarkastellaan sovellusprosessia heikentäviä ja tukevia tekijöitä, ja arvioidaan, miten uudenlainen ajattelu- ja toimintatapa omaksutaan organisaatiossa. Tutkimuksissa havaittiin, että lennonvarmistusorganisaatio edustaa teknis-autoritaarista ympäristöä, joka hallitsee infrastruktuurin kehittämisen ja jonka toimintaa vahvasti ohjaa kansainvälinen normisto. Ihmisen toimintaa koskevaa osaamista on lennonvarmistuksessa sovellettu heikosti (Tutkimus I). Organisaation esimiesten haastattelut toivat esille, että inhimillisten tekijöiden tietämyksen hyödyntämiselle organisaatiossa ei ollut olemassa yhtenäistä strategiaa (Tutkimus II). Organisaation oppimisjärjestelmässä oli puutteita, mm. poikkeamien tietoja ei analysoitu systemaattisesti toiminnan tai turvallisuuden kehittämiseksi (Tutkimus III). Operatiiviseen toimintaan liittyviä inhimillisiä riskejä ja onnistumisia opittiin kuitenkin analysoimaan työn arkeen suunnitellulla työkalulla (Tutkimus IV). Tutkimusten tulokset osoittavat, että kulttuuriset ja rakenteelliset esteet, kuten hajanainen ja vanhakantainen ilmailuhallinnon historia hidastivat inhimillisten tekijöiden osaamisen juurruttamista. Aihealueen hyväksymistä organisaatiossa kuitenkin edistivät toimintaympäristön muutostarpeet, joihin käyttäytymistieteellisten työkalujen ja lähestymistapojen ajateltiin tarjoavan uusia ratkaisumalleja. Lennonvarmistusorganisaation kannattaa jatkaa inhimillisten tekijöiden tietämyksen hyödyntämistä, kuitenkin tunnistaen sen soveltamista heikentävät ja tukevat tekijät. Tulokset voivat tukea vastaavaa työtä myös muissa turvallisuuskriittisissä organisaatioissa. 8 Several colleagues have helped me to improve my own thinking of HF. Members of the Human Factors and Safety network, especially Marja-Leena Haavisto, Hannele Palukka, Inka Koskela, Maaria Nuutinen, Teemu Reiman and Pia Oedewald, offered me useful ideas during the process of HF application over the last 10 years. My heartfelt thanks go also to docent Kirsti Launis, who read the manuscript and offered me valuable comments before sending the manuscript to the pre-examiners. I also want to thank Essi Ryymin from City of Helsinki and Juhani Hyvärinen from Fennovoima at an essential moment you helped me to understand that I am near to finalising the whole work. There were also phases that I would not have coped with without the friendliness and professional support offered by Professor Esa Rantanen from the Rochester Institute of Technology, NY, USA. My current workplace, The Occupational Health Centre Unit of the City of Helsinki gave me unforeseen support by offering me 2.5-month leave in 2011 and, without hesitation, indicated real commitment to professional improvement within the organisation. I want to sincerely thank David Parland, Ritva Teerimäki and Tiina Pohjonen for this decision! I am extremely grateful to the pre-examiners of this thesis, Dr Christine Owen from the University of Tasmania and Prosessor Matti Vartiainen from the Aalto University, whose wise and intelligent comments gave me further insight into this topic and helped me to improve the whole text. The agents funding this thesis are the Finnish Academy and the Finnish Work Environment Fund. Without this support, the process of writing and concentrating would not have been possible or successful. I wish to thank Mr Jose Martinez-Abarca, BA Hons, for his flexible timetables and preparedness in editing the English of the studies on which this thesis was based and Georgianna Oja, ELS, for the language editing this thesis. Your help and support exceeded all my expectations. My beloved family, Pietari, Emma and Kaisa: you had real patience throughout the numerous years of my commitment to this project without having any choice. Unlike many other academic projects in general, this writing process gave us more time to spend time together. Still, I understand that my thoughts have been absorbed in this PhD activity, and you had to face the same joys, but also disappointments that were related with this academic effort. My precious husband, Pietari, you offered me practical, mental and intellectual support during the entire process. 10 Abbreviations ACC ATC ATCO AFIS ANS ATM ATS CAA COORS CRM DCU framework EASA Eurocontrol FAA FCAA HFACS HF HFE HRD HSE ICAO IEA IAEA JAA NTSB OD SES SHEL SMS UK US VOR Area control centre or area control Air traffic control Air traffic controller Aeronautical flight information services Air navigation services Air traffic management Air traffic service Civil Aviation Administration Confidential occurrence reporting system Crew resource management dynamicity (D), complexity (C) and uncertainty (U) European Aviation Safety Agency European Organization for the Safety of Air Navigation Federal Aviation Administration Finnish Civil Aviation Administration Human factors analysis and classification system Human factors Human factors ergonomics or human factors engineering Human resources development Health and Safety Executive in the United Kingdom International Civil Aviation Organization International Ergonomics Association International Atomic Energy Agency Joint Aviation Authority National Transportation Safety Board Organizational development Single European Sky A human factor model (including components Software, Safety Management System United Kingdom United States VHF omnidirectional radio range 12 The thesis begins with a presentation of ATM as a part of the aviation system, and Finnish ATM (including its historical phases) as the context of the studies on which this thesis is based. The theoretical background is then presented, including, at first, the definition and development phases of the field known as HF and the relevance of HF as a key safety factor in ATM systems. Frameworks of learning at work and in organisations are used, and their value as implications in this thesis is pondered. The implementation of HF as a new way of thinking and acting (as an innovation) in the target ATM organisation is then presented. Then, a few essential frameworks concerning the safety critical and sociotechnical nature of ATM are presented. The overall theoretical background of this thesis is summarised with a figure. The background is followed by the specific aims of the studies (I IV) and the methods used in the thesis. Thereafter, each study is introduced and discussed. Finally the results are set in the more general context of the theoretical background of this thesis, and the factors that encouraged and hindered the mastery of HF are evaluated. Practices for improving HF mastery in the target ATM organisation (as well as in other safety critical domains) in the future are considered. 1.1 The context the historical development of aviation The role of HF in aviation has its roots in the earliest days of aviation. Already the first flights in the beginning of the 1900s indicated the paradox of aviation safety: the purpose of aviation was an adventure and discovery, but the flights had to be restricted in order to maintain safety (e.g. departure and destination locations had to be carefully selected). Instrumentation emerged for aircrafts during World War I and further improved in World War II (Koonce, 1999). The essence of the ergonomics was recognised especially by British aviation in its attempts to improve the ergonomics of the cockpits in military aircraft (Murrell, 1976). Aviation is still expanding. More people need or want to fly, the number and types of aircrafts are increasing, and technical innovations are constantly being introduced in the control of aircrafts and in the human roles and jobs in aviation. In addition, the domain of HF as a discipline is expanding, producing new applications and topics to be employed (Garland, Wise & Hopkin, 1999). 1.2 Air traffic management as a system Air navigation services (ANS) are provided for air traffic during all phases of operations. ANS include the following six categories of facilities and services: communication, navigation and surveillance services, meteorological services for air navigation, aeronautical information services, search and rescue, and ATM (ICAO, 2009). ATM is defined as the dynamic, integrated management of air traffic and airspace safely, economically and efficiently in collaboration with all parties (ICAO, 2005). Its components 16 In 1931, Finland acceded to the Paris Convention with respect to international aviation, and the government was able to participate in the planning of international transport. In Finland, the building of airports needed both state guidance and funds. In 1937, an assistant junior secretary for aviation (under the Ministry of Transport and Public Works) was appointed the task of acting as the country s proper aviation authority, responsible for all matters related to air safety (e.g. observing international flight regulations and granting operational licences). Ministry-appointed part-time inspectors, most of whom were engineers from the Armed Forces, carried out these activities. In 1943, an administrative unit called the Aviation Office was formed within the Ministry of Transport and Public Works. Earlier, the possibility of combining the air company Aero O/Y and the national civil aviation administration into a single private company had also been studied, but then cancelled 3. Air traffic growth in the 1950s centred around domestic flights, and in the 1960s the international arena became important. In 1963, the coordination between airspace use and air surveillance with the Air Force was clarified. By the 1960s, the fragmented nature of aviation administration was attracting increasing attention from politicians and within the industry itself. It was even reported that the approach of the aviation administration was unnecessarily slow and complicated in individual cases. This was probably the first time that organisational factors were raised and were of interest from the functional point of view. In 1972, a civil aviation board and an authority subordinate to it were established, and the National Board of Civil Aviation (NBA) began work. Three of its administrative functions were airport maintenance and ANS (by the Airports Department), air safety (by the Flight Safety Department) and general management (by the Administrative Department) (Hakola, 1997). These same functions can be found in the organisation structure even today (Finavia, 2010; see also Figure 3). The first signals of outer pressures and a need for change were seen in 1980 s and 1990 s. By 1987, air traffic congestion was putting international political pressure on aviation officials. The ANS Department was set up, which was comprised of ATC, communications, navigation and other ANS facilities (see Figure 1). By 1990, reform was needed to create business models for state-owned firms, and, in 1991, a new state enterprise, the Civil Aviation Administration (CAA), began operating. The privatisation meant increased financial independence and the responsibility for the new organisation. Rapid reforms, such as modernisation and rebuilding, were started, especially regarding terminals, and the focus was on satisfying customer requirements. The Flight Safety Authority was established to carry out official civil aviation duties. It was independent of CAA s business operations, even though it was still a part of CAA. In the 2000s, rapid changes occurred in the outer functional environment of the whole organisation. Finland joined the European Union in 1995, and a more open flow of people and products became possible. The aviation markets also became more open because of 3 This kind of solution for organising aviation administration was made in the USSR in 1.3 HF within the ATM Definition of and research related to HF According to the International Ergonomics Association (Wilson, 2000), HF (or synonymously ergonomics, sometimes also abbreviated as HFE) is the scientific discipline concerned with understanding interactions among humans and other elements of a system. The profession, human factors engineering, applies theory, principles, data, and other methods to design in order to optimise human well being and overall system performance. The Health and Safety Executive (HSE) in the United Kingdom (UK) has defined HF as the environmental, organisational and job factors combined with the human and individual characteristics that influence behaviour at work in a way that can affect health and safety (HSE, 1999). Within the Federal Aviation Administration (FAA) in the United States (US), HF is defined as a multidisciplinary effort to generate and compile information about human capabilities and limitations, as well as to apply that information to equipment, systems, facilities, procedures, jobs, environments, training, staffing, and personnel management for safe, comfortable, and effective human performance (FAA, 2005). A core principle of HF is systems thinking: HF professionals consider the network of interactions between individuals and various elements of their environment (or work system) (Wilson, 2000). The knowledge required to design, implement and disseminate HF is diverse. It relies on knowledge of basic scientific disciplines, such as physiology, sociology and psychology, as well as on knowledge of such applied sciences as industrial engineering, business and management (Carayon, 2010). Several approaches and phases (or ages) of the analysis of HF and safety have been identified (Hale & Hovden, 1998; Sheridan, 2008; Reiman & Oedewald, 2009). However, they are not so clear and straightforward, as some views that have been hailed as modern have been around for some time in aviation (e.g. Wiener, 1977; 1980). The first age of the scientific study of safety (from the 19th century to World War II) concerned technical measures and represented traditional error/risk analysis. The person was usually considered the weakest component of the safety system (Heinrich et al., 1980). During this period, personnel training and selection were developed as preventive measures. The second age of safety (from World War II to the 1970s) focused more on human error and human recovery, for example, as according to Rasmussen (1982). The limits of technical risk assessment and preventive measures were realised in the 1980s. The third age of safety (in the 1990s) focused on safety management systems and organisational factor research, as well as on their development, with more pro-active aspects. The model of human error and organisational accidents developed by James Reason became widely accepted. This classification of unsafe acts distinguished between active and latent failures, the effects of which may lie dormant until triggered later by other mitigating factors. Different layers of the system infrastructure (defences or safeguards) ensure system safety and prevent the effects of failures (Reason, 1990; 1997). The Reason model has been criticised for making complex reality too linear and for remaining too abstract (Hollnagel, 2004). 24 Several ATC accident investigations concerning individual controllers have highlighted such individual limitations as attention slips and errors in judgement as causes of accidents (Danaher, 1980; Billings & Reynard, 1984). This approach is nowadays considered too simplistic for the analysis of work in complex sociotechnical systems (e.g. Dekker, 2002; 2007), but it still sometimes emerges. For example, the final accident report on the air crash in which the Polish president was killed (Final Report, 2011) placed most of the blame for the accident on the pilots. Focusing on individual features creates the risk of stating criminal responsibility in such cases (Dekker, 2007). Another concept that has been used to explain controller performance (usually limitations) is vigilance (the ability of an observer to maintain attention over long, uninterrupted periods). The ability to detect critical s
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