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operationalization of the principle - the principle of combating errors in aviation

operationalization of the principle - the principle of combating errors in aviation

Thus, the experimental study of the phenomena of accomplishments, failures and indistinction enables us to formulate the following conclusions:

  • 1. The demonstrated reproducibility of the phenomena in the experiment and the ability to control them indicate that the mechanisms in the hypothetical scheme are described correctly.

  • 2. The implementation of the procedure at the level of operations is a necessary condition for the occurrence of phenomena. Eliminating this condition is a radical way of dealing with the corresponding errors.

General principles of struggle with mistakes

Since the mistakes we have examined are the result of the operational nature of the procedure and the inclusion of an erroneous procedure in the structure of the pseudo-action experienced as a full-fledged action, the cardinal way to deal with errors of this type is to change the status of the procedure as a structural element of the activity, namely: translating it from the level of operations to the level Actions - operationalization of the procedure. Therefore, we can talk about the principle of operationalization as a general principle of combating mistakes, accompanied by inadequate experience (awareness), since awareness provides an adequate awareness of the behavioral external plan of activity.

Depending on whether the error is reversible or irreversible, i.e. Depending on the point in time from the point of view of the system, it is necessary for the operator to realize their inadequate experiences when performing the wrong procedures, the means of operationalization can be used differently. delay, because the flight mechanic has time to correct the error, i.e. awareness may be retrospective. And in the case of cleaning the chassis on the run, it is no longer possible to correct the mistake made, therefore the realization of the erroneousness of the procedure should be relevant. Accordingly, in the first case (if the error is reversible), the method of operationalization is called retrospective rationalization, and in the second case, the actual rationalization.

Aoperatsionalizatsiya can be done by organizing both internal (mental) and external funding activities. However aoperatsionalizatsiya, assuming only internal funds is less reliable, because the operator can not take advantage of it. Therefore, we consider aoperatsionalizatsiyu solely through external means of activity.

Ways to prevent incidents such as'landing with landing gear"

Since the error is that the mechanic does not use a control, then aoperatsionalizatsiya in this case can only wear retrospective.

As we have said, operationalization can in principle be carried out using controls and display elements. In the first case, the solution of the problem could be achieved, for example, by blocking (from the chassis control element) some other control element, which the flight mechanic should activate after the chassis release procedure. Then an unsuccessful attempt to use this element (in the case of not releasing the chassis) would be an artificial obstacle, which should lead to an awareness of the error. In the second case, the solution of the problem is achieved using a special (emergency) alarm.

In order that the signal was received and interpreted unambiguously, alarm must meet two requirements: Eye-catching effect and ensure the timely understanding of the meaning of the operator or the causes of the incident.

However, these requirements are not always met. Thus, in some cases one of the functions is generally neglected; For example, active (attention-getting) signaling of the chassis position on one type of civil aircraft in the recent past did not exist at all. Sometimes surplus funds are created. For example, right after the passage of the long-distance radio station, you must switch the radio compass to the nearer radio station - from the moment of a long-distance flight, a siren begins to sound and a special light will shine with a flashing light. In this case, the designers proceeded, apparently, from the desire to duplicate the sources of signaling for reliability, and in this case, each modality, both of the sound and light alarms, was given the function and activity.

The current light, the signaling of the chassis position is unambiguous, but it does not provide an attractive effect. Such an effect, according to the plan of the designers, should create an audible alarm, but the electric siren is a multifunctional, ambiguous signal. Such a distribution of functions can cause inadequate behavior of the pilot, as evidenced by the following example. During the landing, just at the moment when the mechanic operated the engines, the electric siren sounded. As already noted, it can be included in two situations: indicating that the chassis is not released, and the engine failure. In this case, the electric siren signal had the value "chassis not released". The flight mechanic took it as a signal about engine failure. This caused intensive orientation activity of the flight mechanic in relation to the emergency signaling devices of the engines and to the instruments of the propulsion group. And only after the flight mechanic had several times ascertained in the proper operation of the engines, he switched to other signaling devices and found the reason for switching on the electric siren.

But beyond that, elektrosirena has one disadvantage: it can be deactivated by the crew, and because of this signaling of the chassis property loses activity, i.e. attracting effect.

All this means that the current signaling mode is unsatisfactory.

It is obvious that the principle of operationalization can be considered consistently implemented only if the alarm is compulsory, ie, will attract attention, regardless of whether or not the pilot's intention to apply to it, and at the same time be unambiguous and clearly distinct from other emergency and especially non-emergency alarms, that specialized, in other words, if the principle is adhered to the specialized-coercive alarm.

To prevent the occurrence of landing with landing gear as the specific recommendations arising from the principle of specialized-coercive alarm, given the nature of the current system alarm in the cockpit could be invited to the next.

The signal that the chassis is not released for flight and landing annunciator located directly in front of flight engineer should make the flash. Such a signal, in this case provide a forced switching of attention. Specialized will also be achieved by using flight and landing of the alarm - a special landing gear position indicator, which is characterized by the specific form of the signal.

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