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Bureau of Meteorology Human Factors

Meteorological service providers around the world provide industries and entities with critical meteorological information. These include;

  • Aviation
  • Maritime
  • Antarctic  operations
  • Media
  • Public
  • Government agencies

The Australian Bureau of Meteorology is a globally respected agency

Aviation more than any other industry has included Meteorological service providers as an integral part of the management of safety and the reason BoM personnel are undergoing Human Factors training

 

International Civil Aviation Organisation (ICAO)

ICAO consists 192 member states and was formed in Chicago in 1944

Agreement on a set of standardised practices for international air travel, supported by Annexes which defined the different components.

Annex 1 - Personnel Licensing

Annex 2 - Rules of the Air

Annex 3 - Meteorological Services

Annex 4 - Aeronautical Charts

Annex 5 - Units of Measurement

Annex 6 - Operation of Aircraft

Annex 7 - Aircraft Nationality and Registration Marks

Annex 8 - Airworthiness of Aircraft

Annex 9 - Facilitation

Annex 10 - Aeronautical Telecommunications

Annex 11 - Air Traffic Services

Annex 12 - Search and Rescue

Annex 13 - Aircraft Accident and Incident Investigation

Annex 14 - Aerodromes

Annex 15 - Aeronautical Information Services

Annex 16 - Environmental Protection

Annex 17 - Security

Annex 18 - The Safe Transportation of Dangerous Goods by Air

Annex 19 - Safety management

Chapter 2 of Annex 3

2.1.2 This objective shall be achieved by supplying the following users: operators, flight crew members, air traffic

services units, search and rescue services units, airport managements and others concerned with the conduct or development

of international air navigation, with the meteorological information necessary for the performance of their respective

functions.

Meteorological information. Meteorological report, analysis, forecast, and any other statement relating to existing or

expected meteorological conditions.

2.2.9 The meteorological information supplied to the users listed in 2.1.2 shall be consistent with Human Factors

principles and shall be in forms which require a minimum of interpretation by these users, as specified in the following

chapters.

Note.— Guidance material on the application of Human Factors principles can be found in the Human Factors Training

Manual (Doc 9683).

 

The concept of organisational safety

Organisational safety and ICAO adaptation of it have been evolving since the early 1990s. It came as a recognition that both human and organisational factors contribute to an accident, incident or significant event.  The Piper Alpha disaster in 1988 and the subsequent Lord Cullen inquiry into it had a significant impact on the evolution of Integrated Safety and Safety Management Systems.

ICAO utilised the work of Professors James Reason and Patrick Hudson (among others), that brought organisational failures and safety culture as foremost consideration in accident causation.

 

The basics of modern SMS were derived from the outcomes of the Cullen inquiry and were based of the failings that resulted from Piper Alpha

The elements in the management of safety were;

  • Management commitment and responsibility
  • Appointment of key safety personnel
  • Management accountability
  • Third party interface
  • Emergency response planning
  • Safety documentation
  • Hazard identification
  • Safety risk assessment and mitigation
  • Safety performance monitoring
  • Safety investigations
  • Management of change
  • Continuous improvement
  • Safety education and training
  • Safety communication

High Reliability Industries

High reliability industries repeatedly deliver successful, predictable results in a dynamic, technologically complex, time-constrained, and high-hazard environment.  Examples of HRIs include;

  • Aviation
  • Maritime
  • off-shore Oil and Gas,
  • nuclear industry,
  • space exploration,
  • heavy mining
  • Medical

Hallmarks of High Reliability Industries are;

  • Look for low frequency/High consequence events
  • carry out deliberate actions to achieve predictable results
  • maintain a sense of 'chronic unease' (sometimes called 'respectful distrust')
  • HROs learn how to 'fail in a safe way', and then ask 'how did we contribute to this failure?"

Consider how much weather has in influence on HROs

  • Sydney Hobart Yacht Race
  • Mildura Virgin and Qantas diversion flights
  • Kenn Borek Twin Otter Antarctica

The Australian Bureau of Meteorology is often inexorably linked to low frequency, high consequence events 

WHS vs QMS vs SMS

Safety CultureEdit Entry

Every organisation has a safety culture. The question is how good is it?
The courage for safety https://youtu.be/venO7Jd-978
 Without a safety culture, you don’t have a SMS – it’s that simple.  If people don’t feel empowered to contribute to it, they won’t feel inclined to be engaged with it, and therefore not be protected by it.
The safety culture in an organisation is integral to the Human Factors influence, both positive and negative.

Safety culture needs to be resilient. It must be able to be felt despite breaches of confidence, lapses by individuals and inevitable mistakes.  However it will never survive management indifference.

Preservation of the safety culture comes with Management commitment. When management ‘walks the walk’ all workers feel empowered to contribute to a positive safety culture. Damage to safety culture comes with management inflexibility, inconsistency or hypocrisy of safety standards.

It can also be damaged by management losing sight or focus on what the safety aims and objectives are.

…The rig has an effective SMS and a sound safety culture.  As management are aware, safety culture is essential for the running of an SMS and must be ‘fair and just’.  If rig personnel trust in ‘fair and just’ they will report without inhibition.  Issues arise when breaches of say,  Life Saving Rules are seen as inflexible in outcome (ie – run off the lease) when the context of the human error is not considered.  Should a breach be deliberate, willful or flagrant, there is no question that consequences should be punitive.  However should the error be a result of Human Factors, it needs to considered in context, and the outcome be a learning experience as part of a fair and just safety culture.  The real danger when breaches of directives such as the Life Saving Rules are seen as the ‘Sword of Damocles’, personnel will simply stop reporting breaches to protect their jobs, and the safety culture will be lost…’

Extract from internal safety review to management for a Bass Strait exploration drilling rig

 

The Evolution of Safety Culture

 

Human Factors Exercise

Time: 30 minutes to disassemble and create instructions. 30 minutes to reassemble. 60 minutes to repeats with reverse roles. 30 minute class discussion.

This in an exercise in creating a product that needs to be passed to another group.

The first group will disassemble the puzzle with instructions on how to reassemble

There will be a handover brief

The second group with use the instructions to reassemble the puzzle.

The outcome will be discussed.

The exercise will be repeated with the groups reversed in the role.

No pictures or cameras

When disassembled the puzzle is to be stacked as one pile

Discuss as a class:

  • What worked?
  • What didn't?
  • What are the lessons learnt?
  • What improvements can be made?
  • What are the takeaway observations from the exercise?

 

Human Behaviour

Human Factors is about human performance, behaviour, error, and an understanding of how humans interact with procedures, technology, environment and other humans.

Ultimately it is unsafe behaviours and actions that lead to accidents.

Behaviours are influenced by multiple inputs, commencing in the formative years when our personalities are being formed.

 

The SHELL Model

The SHELL The model is used by ICAO to identify where HF breakdowns might occur.

Adaptation of the SHELL model

The encompassing culture needs to be considered to expand the scope and the and understand the full spectrum of HF influence, both positive and negative.

Breakdowns between the human – the Liveware component in the middle – and any of the surrounding components, can lead to HF consideration and possible error.

Any interaction must include the central liveware.  Human Factors breakdown do not include Hardware-Environment failures.  An example of this might be a lightning strike at an airfield leading to failure of ground based navigational equipment.  Clearly this could affect the safety of flight but it is not a human failure.

The Reason Model

The Reason model of accident causation describes how the breach of multiple system defences could result in an accident.   Professor James Reason also argued that single point failures in complex systems like aviation should not be consequential.  The defence failures (breaches) could be both active or latent failures.

.An Active failure could be described as something that a conscious decision (regardless of the motivation), resulted in a defence layer being breached.

Example; maintenance crews using work-a-rounds to achieve operational efficiency when they know a procedure might be contrary to SOPs.

A Latent failure is more insidious, it lies in wait  and  unknown until discovered.

Example; An organisational manual that details company procedure, that happens to be contradictory to OEM manual perhaps prohibiting such action.  The OEM manual was not thought to be checked on the assumption that the SOP writer had already done so.

Reason Model adaptation

Exercise - SHELL, Active and Latent failures, cultural influences

Time: watch video 10 minutes. Group work 30 minutes. Class discussion 20 minutes

Watch the following short video.

In groups write down the active and latent failures, the SHELL model breakdowns and the cultural influences

Active Failures

Latent Failures

Cultural influences

Shell

 

Antarctic Station Role play exercise

Time: 30 minute role play meeting. 30 minute class discussion

You are part of a leadership group at an Antarctica Station.  There is a meeting to discuss a critical scientific operation involving Aircraft, Inflatable Rubber Boats and associated personnel. The operations will be over the next three days including personnel living in the field overnight.

It has been a long and difficult season and many scientific projects have not achieved their aim due to weather and other operational reasons.

The meeting consists of;

  • The Station Leader - has overall responsibility for operations.
  • The BoM representative - provides the forecasts and weather information for Antarctic operations
  • Senior Pilot - responsibility for all aviation activity
  • Boat Master - responsibility for all boating operations
  • Senior Field Training Officer - responsible for all personnel operating in the deep field

Casey Station is the Antarctic station on the continent where all local operations are coordinated

Kingston is the Australian Antarctic Division Headquarters in Hobart who manage the whole Antarctic program and science projects

The meeting is chaired by the Station Leader and the aim is to determine the operational activity over the next three days.

The Meteorological briefing was highly technical in presentation.  There are significant discrepancies in what the models are predicting.

The aim of the meeting is to determine the operational activity for the next three days.

You will role play one of the people in this meeting.  Act to the role described and not what you may do in your real role.