Avionics News November 2012 - 59

investigating the role of management policies and procedures in aircraft accidents and incidents.” Reason also developed the fourstage model that works well in both the medical and aviation industries. This model starts with organizationallevel conditions, leading to shop-level error or violation-producing conditions, which lead to mistakes, slips or violations at level three. The imperfect defense layers are at level four, and the occasional mistake, slip or violation makes it possible to have an accident or incident. In addition, the SHELL model describes software, hardware and environment, along with two types of liveware. The SHELL model, developed by Hawkins & Orlady, works well to describe the interaction between people and their systems, environment and hardware. Bennett has an error-by-design model incorporating situational and systemic factors combining to increase risk to the point where a catastrophic event is nearly impossible to avoid. All of these models help teachers and students come to an understanding of the underlying causes of human error. In addition, these models can help students and mechanics develop measures to reduce human errors and prevent those made from causing incidents or accidents. Years ago, when I was one credit short of a Bachelor of Arts degree, I found a single-credit weekend

class taught by Professor Gregory Boothroyd. As I recall, the title of the course was eliminating self-defeating behavior. Dr. Boothroyd is a certified addictions counselor, licensed professional counselor, and now, professor emeritus of counseling at Western Michigan University. I found the two days to be interesting and enlightening. Boothroyd and his wife, Lori Gray Boothroyd, are the authors of Going

As a result, I’ve taken the inspiration and developed a similar model. As a fan of auto racing, and since aviation is a fast-paced industry, I’ve chosen a racetrack type model. With each job or task, the technician enters the track. Soon, he or she will reach a decision or action point. Beyond the decision point are two paths. The narrower path leads to error reduction. Unfortunately, the wider path leads to human errors. Although we attempt to barricade the

What motivates people and what problems do they have? In what work areas do they shine and struggle? These are just a few questions a human factors consultant may ask.

Home: A Positive Emotional Guide for Promoting Life-Generating Behaviors. When I took the course, Boothroyd used his book, Goin’ Home: A Therapeutic and Spiritual Guide Toward Eliminating Self-Defeating Behaviors. In the book was a model. The model was a circle with a decision point and one exit. Self-defeating behaviors kept one on the circle, going nowhere. One decision was all it would take to exit the circle of defeat. Ultimately, human error is defeating behavior, which is why we work so hard to prevent human error from causing aircraft crashes. I found Boothroyd’s model to be inspiring.

entrance to the error path, some of us will still get through. The infamous dirty dozen acts as a magnet drawing the technician toward error. The system in which the technician is working can also act as a draw toward the error path. Although the error path is wide, it leads to problems. The problem could be as minor as a few minutes of embarrassment, or as major as a loss of life. The problems could force the technician out of the aviation industry. Most of us get multiple chances and the opportunity to make the right deContinued on following page
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Avionics News November 2012

Table of Contents for the Digital Edition of Avionics News November 2012