Management of Human Factors Risk

in Safety-Critical Industries

11 May 2006

A Conference Presented by the Human Factors Group
of the Royal Aeronautical Society

Papers and Materials on Human Factors Risk

1. Presentations

Papers are posted as links to the programme titles below. In some cases, an audio stream may be provided where comprehensive notes are not available. Workshop reports are also posted where available. All papers reflect the views of their authors alone. We recommend that readers save PPTs to file by right-clicking since most are more than 3MB in size.

2. Programme

2. Programme

08.30 Registration and Coffee
09.00 Welcome
Carey Edwards MRAeS, Chairman, RAeS Human Factors Committee
09.05 Introduction to Lord Tunnicliffe (MP3),
Conference Chairman Capt. Jeremy Butler MRAeS, Non-executive Director National Patient Safety Agency.
09.15 Opening Address (MP3)Lord Tunnicliffe, Chairman, Rail Safety Standards Board
10.00 Human Factors Risk Culture (PPT) (PDF)James Reason CBE, Emeritus Professor, Manchester University
10.45 Coffee Break
11.00 ‘What if…’ Managing the risks that come with having to make decisions [DOC] [PDF]Group Captain Andy Ebdon, Harrier GR9 Upgrade Programme Manager, Defence Logistics Organisation (RAF)
11.40 Operational Assessment of HF Risk in Civil Aviation [PPT] [PDF] Capt. Steve Sheterline, General Manager Training (British Airways)
12.20 Luncheon
13.10 HF Practitioner Award Presentations 2004/2005Kevin Baines (Baines Simmons) – 2004

Captain Lucio Polo (Alitalia) – 2005

13.20 Managing HF Risk in Healthcare:
The Work of the National Patient Safety Agency [PPT] [PDF]Dr. Mike Rejman, National Patient Safety Agency
14.00 Fatigue Position Statement [PPT] [PDF]Capt. Nick Trowsdale, British Airlines Pilot Association
14.15 Focus Group MeetingsTopic 1 Team Leader Jill Toney (Training Standards Manager United Airlines)”Effective policies for HF training and procedural standards”

Topic 2 Team Leader Paul Traub (Director High Hazard Industries, CCD Ergonomics)

“HF benefit, risk and hazards including regulatory compliance and legal liability”

Topic 3 Team Leader Derek Brown (UK CAA)

Fatigue Management Issues – Regulatory Standards and Compliance” [PDF]

Topic 4 Team Leaders Kevin Baines and Capt. Dave Robinson

“What are Human Factors?” The term “Human Factors” is poorly understood and poorly explained, which contributes to a general impression that it is a black art. As a result, decision makers do not make human factors a priority because they do not see how it
already directly affects their organisations. The focus of this workshop is to give a clear understanding of what HF is and how to distinguish effective HF policy management from non-management or ineffective management.

15.00 Tea Break
15.20 Assessing HF Risk in Rail Transport [PPT] [PDF]Dr. Debbie Lucas, Principal Specialist Inspector, Human, Organisational and Risk National Expertise Team, HMRI, Office of Rail Regulation
Managing Fatigue-related risk
: a Defense-in-Depth approach [PPT] [PDF]Prof Drew Dawson, Director Centre for Sleep Research, University of Southern Australia
16.55 Feedback and ConclusionConference Chairman Capt. Jeremy Butler MRAeS, Non-executive Director NPSA
17.10 Close

Related Papers
The Evolution of Crew Resource Management Training in Commercial Aviation, R. Helmreich, A. Merritt, J. Wilhelm. In press, International Journal of Aviation Psychology

Redefining CRM [DOC] [PDF] – A discussion paper by J. Norman Komich, CRM Working Group

The aim of the conference was to enable senior managers to improve awareness of the risks and liabilities posed by human factors hazards, to review best practice to avoid and mitigate risks at the level of corporate policy, organisational psychology and specific management tools, and to examine the legal and regulatory framework as it applies to human factors.

Delegates included senior managers from aviation, health care, rail and related safety-critical industries.

The conference was for those intending to:

  • Lead an organisation to recognize, understand and take action to manage HF risk
  • Challenge the culture of denial: explain HF risk and how it arises and spreads in an organisation
  • Challenge the idea that HF risk management is always a net cost
  • Encourage managers to know the HF risk management tools and policies they can use, and to use them to lead significant shifts in corporate culture and resilience
  • Show how human error can be avoided, managed and mitigated, how to develop robust error-trapping risk, security and continuity policies, and how to make understanding human error work for you instead of creating latent disasters and fragile, error-prone systems
  • Explain how these concepts operate in practice by examining Fatigue as the central focus of a range of issues including safety management, performance degradation, productivity/profitability, regulatory compliance, evaluating HF risk, quantifying HF hazards, legal liability, policy-setting and corporate leadership


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