Analysis of Human Error and GEMS in Aviation Safety Management

This literature review examines human error in the aviation industry and the implementation of the Generic Error Modelling System (GEMS) to mitigate related issues. It explores the relationship between workload, stressors, and human error, referencing real-world accident cases. The review discusses human error measurement techniques, focusing on the theory and application of GEMS in aviation, while also addressing the challenges in error management and correction systems. The study concludes that, given the high-reliability nature of the aviation industry, careful consideration must be given to all potential triggers that could lead to error-driven accidents, emphasizing the importance of proactive error detection and correction systems.

Running head: HUMAN ERROR AND GENERIC ERROR MODELLING
Literature review on Human Error and Generic Error Modelling
Name of the Student
Name of the University
Author note

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Executive Summary
The purpose of this paper is to explore and examine the Human error in aviation industry and
the GEMS implementation for mitigate the issues. The paper has examined the relationship
of Workload and stressor with the human error while aligning with the real case of accidents.
The measurement techniques of human error have been also discussed through exploring the
theory and implementation of Generic Error Modeling System or GEMS in aviation industry.
The challenges in error management and correction systems have been discussed in this
paper. From the discussion it has been found that the being a high Reliability industry the
aviation industry has to take care of all the possible triggers behind any potential occurrence
of error driven accidents.

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Table of Content
Introduction................................................................................................................................3
Human errors in aviation............................................................................................................3
Examples of Human Errors in aviation operation:.....................................................................5
Role of Human factors and Generic Error Modelling in aviation operations............................6
The challenges in managing human errors in aviation operation..............................................8
Conclusion..................................................................................................................................9
References:...............................................................................................................................11

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Introduction
The aviation industry experiences a paradox of very low frequency of accidents and
very high impact on financial, physical, operational and human assets. Being a high
Reliability industry the aviation industry has to take care of all the possible triggers behind
any potential occurrence of error driven accidents (Shappell et al. 2017). In aviation
operation various errors can occur including the Instrumental error, External error, Human
error and many others. Among all the errors, the most significant and most controllable one
is human error. In this paper, the types of human errors will be discussed along with the error
correction methods. The measurement techniques of human error will be also discussed
through exploring the theory and implementation of Generic Error Modelling System or
GEMS in aviation industry. The error detection and correction systems will also be discussed.
The purpose of this paper is to discuss the Human error in aviation operation and the
significance of controlling errors through GEMS implementation.
Human errors in aviation
Human Error is term used in aviation industry that refers the mistake in planning and
executing a task that eventually causes disabilities to achieve the goals. The Human Error can
occur in three phases of aviation operation namely Aircraft maintenance, Flight operation and
manufacturing process. In 53% of overall incidents reported, the errors were occurred for
Pilot Error. On the other hand 21% errors were occurred Mechanical Failure because of
improper maintenance and manufacturing defects (Wiegmann and Shappell 2017). 11%
errors were occurred due to bad weather condition.

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53%
21%
11%
7%
7%
1%
Pilot error
Mechanical failure
Weather
Other human error
Sabotage
Other causes
Figure 1: Percentage of Human Errors in Aviation Industry Worldwide
Source: (Wiegmann and Shappell 2017)
In most circumstances when an accident occurs it is assumed that the commanding
pilot or captain has made the error because of internal dilemmas or external stimulations. In a
Visual Landing Procedure (VLP) the internal error can occur due to extreme weather
condition. The risk of landing error can increase up to 35% due to external or environmental
conditions. International Civil Aviation Organization (ICAO) states that after 2004 the
occurrence of pilot error increased by 78.6% from its previous risk coefficient. ATC
communication error is another common errors in the aviation operation. ATC
communication error can only be considered as a part of human error when it is not occurred
due to radio signal disconnection or other instrumental failure. The ATC or Air Traffic

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Control related error occurs due to incorrect instrumental reading such as fault in altimeter
setting, IRS (Inertial Reference System) heading correction, poor flight path navigation and
others.
Figure 5: Measurement of Accident Possibilities
Source: (Rungta et al. 2013)
Apart from ATC communication, chances of any Flight Path Navigation related error
increases by 46% because of over dependency on Automatic Flight Control or Autopilot.
Novice pilots often changes the pitch without neutralising the Altitude Hold status in
autopilot.
Examples of Human Errors in aviation operation:
In the history of aviation many accidents were occurred, where the human errors were
involved directly or indirectly. Some of the recent examples of human error are presented
below.
On July 17, 2007 the Airbus A320-233 crashed at Sao Paulo Airport in Brazilian
territory. It was a deadliest disaster that killed all 187 passengers aboard with 12 people on
the ground (Woods et al. 2017). After investigating the communication records of ATV and
the mechanical inspection it has been found that the after touching down the pilot left the

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engine at full power. The most surprising fact was the pilot was experienced enough to
handle these situation. The pilot was executing the old and outdated landing procedure of
manual landing in the Wet and slippery condition.
In 2005, an accident occurred during the shipping of an amphibious airplane operated
by Chalk’s Ocean Airlines. The aircraft crashed on the shipping channel port of Miami,
Florida. After investigation NTSB found that the crash had been caused because of the
separation of right wing during flight due to fault in maintenance operation (dos Santos et al.
2017).
Another helicopter incidents occurred in March 2018. A tour helicopter crashed into
New York’s East River and killed all the passengers. It has been found that because of lack of
proper evacuation system in that rotorcraft the passengers were suffocated in the water to
death.
In 2015 the British Airways flight was scheduled to fly from Las Vegas to London.
Just after the initiation of the takeoff operation, the pilots reported engine fire. Because of
abrasion, while descending the evacuation slides 27 out of 170 passengers were injured
(Griffin, Young and Stanton 2017). The investigation and incident assessment team reported
that the outcomes of the accidents could be minimized with proper decision making.
Role of Human factors and Generic Error Modelling in aviation operations
Human Error is the most likely part of any aviation or other industrial operation as
well, because humans are fallible and therefore, errors are to be expected even after proper
training and expertise. Human Errors are two types namely Execution Failure and Planning
Failure. Mainly lack of attention, improper memory cause the execution failure

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(Skybrary.aero. 2016). On the other hand, misapplication, selectivity, lack of knowledge can
cause planning failure. The pressure of work in other words workload is the most common
cause of human error in aviation industry that changes the operational efficiency of the pilots,
Aircraft maintenance staffs, Air traffic system and other associated technical and non-
technical workforce. The risks associated with human error can often be reduced by
developing processes and systems that are human-friendly and error tolerant.
Generic Error Modeling System is a systematic approach of human error
measurement and correction. According to Generic Error Modeling theory the errors are
caused from three origins namely skill based, Rule based ad Knowledge based. Skill based
activities are the automatic activities that depends highly on developed reflex and muscle
memory. Visual landing procedure, Emergency awareness are some major examples of skill
based activities in aviation. The error occurred because of poor skill is called Intention. Slips
and Lapses are common types of skill-based errors. Slips occurs because of unintended
results of a intended action (Rungta et al. 2013). Such as overpowering the engine at takeoff
can cause engine failure and burring. Lapses refer missing the steps during an execution of
vital activity. Lapses occurs due to lack of working memory.
According to Bernardo, Kirby and Mavris (2015),Rule based error occurred when an
operator does not apply rules properly or even for complete unawareness. Misinterpretation
of any rule can also lead to this type of error. For Rule based errors, the operators are
considered as a subject of active violation. Because of abiding by a completely wrong landing
procedure or wrong emergency handling procedure can caused these errors. Some of the
errors are called mistakes because of the faulty plans. Applying wrong principles and lack of
appreciation can cause these errors. Knowledge based errors occur due to lack of knowledge
in a particular topic or procedure. As an example use of appropriate flaps angle can increase
the performance efficiency of any aircraft. It also reduce the resulted airspeed required to

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avoid the chances of stalling. Lack of training can cause these errors. The knowledge based
errors are completely conscious errors occurred because either lack of proper training or
negligence on learning materials.
The challenges in managing human errors in aviation operation
To measure the challenges in managing the Human Errors, it has to considered
initially that the external changes within which operators work cannot be altered, where only
the human made conditions can be changed. According to the proposed structure of human
error detection of Hollnggel (1998), three basic challenges that the human error management
faces are Criterion, Performance Shortfall and Violation (Said and Mokhtar 2014). Lack of
training and development often causes poor knowledge base. Even after the implementation
of error modeling and detection system errors sill occur due to the lack of problem based
knowledge. International Civil Aviation Organization (ICAO) states that during the
simulation training novice pilots does not get enough practice in emergency situation
handling like engine failure or hydraulic failure (Griffin, Young and Stanton 2017). It has
been found that the procedure f initiation of ignition bleeding can regulate the potential
drivers of overheating.
As per the evidences presented by Chiu and Hsieh (2016), the performance shortfall is
the mistaken action that leads to measureable performance dilemma. In many cases, the
experience pilots forget to follow the updated flight procedures. For pilot and other
crewmembers, the physical and environmental factors are Persistent radio communication
noise, Sudden alarms or warning horns, Uncomfortable temperature, Engine and system
noise, Vibration, Cramped workspace, Air quality and Lighting conditions. Aircraft
manufacturers always try to reduce these stressors through innovative design and technology.
Akyuz and Celik (2014) opined, the reading system of classic instrument guided navigation is

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highly distinguishable from the advanced MFD or multipurpose flight display. Lack of
proficiency in advanced instrumentation often causes errors in landing procedure. These are
the major limitation or loophole in current human error management system. At the same
time the act of violation cannot be control. The Violation refers the act of neglecting or
breaching a particular operational rules and regulations.
According to Bernardo, Kirby and Mavris (2015), Managing human errors in highly
related to error detection and correction system. Detecting the error and correcting the errors
are two major part of the aviation operation. Error detection and correction can segregated
into three main phases, namely investigating the incident, analyzing the errors, developing
proper control plan. The consistent perception and lack of changes in traditional emergency
handling as well as aircraft maintenance system are causing the ineffectiveness of Detection
and Control Cycle for Human Error. For implementing the contingency plan, additional
emergency handling system and evacuation system can be incorporated (Rashid, Place and
Braithwaite 2013). At the same time, the flight planning, flight rout can be changed according
to the requirement.
Conclusion
From the above discussion it has been found that the being a high Reliability industry
the aviation industry has to take care of all the possible triggers behind any potential
occurrence of error driven accidents. Aviation industry requires a huge number of precise
tasks with appropriate measures and procedures in a complex situation. Among all types of
errors, the most significant and most controllable one is human error. It has been found
through this discussion, managing human errors in highly related to error detection and
correction system. Detecting the error and correcting the errors are two major part of the
aviation operation. From the records and critical discussion it has been found that ATC

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communication error, Poor landing procedures, over dependency on autopilot are the
common examples of human errors. Human error in aviation occurs due to the operational
efficiency of the pilots, Aircraft maintenance staffs, Air traffic system and other associated
technical and non-technical workforce. From the critical evaluation of driving factors and
outcomes, it can be clearly seen that the risks associated with human error can often be
reduced by developing processes and systems that are human-friendly and error tolerant.

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References:
Akyuz, E. and Celik, M., 2014. Utilisation of cognitive map in modelling human error in
marine accident analysis and prevention. Safety science, 70, pp.19-28.
Bao, M. and Ding, S., 2014. Individual-related factors and Management-related factors in
Aviation Maintenance. Procedia Engineering, 80, pp.293-302.
Bernardo, J.E., Kirby, M. and Mavris, D., 2015. Development of generic airport categories
for rapid fleet-level noise modeling. Journal of Aerospace Operations, 3(2), pp.91-119.
Bove, T. and Andersen, H.B., 2017. 20 Types of error recovery in Air Traffic
Management. Engineering Psychology and Cognitive Ergonomics: Volume 5: Aerospace and
Transportation Systems, p.171.
Chiu, M.C. and Hsieh, M.C., 2016. Latent human error analysis and efficient improvement
strategies by fuzzy TOPSIS in aviation maintenance tasks. Applied ergonomics, 54, pp.136-
147.
Davies, D.R., Matthews, G., Stammers, R.B. and Westerman, S.J., 2013. Human
performance: Cognition, stress and individual differences. Psychology Press.
Dekker, S., 2017. The field guide to understanding'human error'. CRC press.
dos Santos, C.R.P., Granville, L.Z., Shwartz, L., Anerousis, N. and Loewenstern, D., 2013,
May. Quality improvement and quantitative modeling—Using mashups for human error
prevention. In Integrated Network Management (IM 2013), 2013 IFIP/IEEE International
Symposium on (pp. 143-150). IEEE.
Driskell, J.E. and Salas, E., 2013. Stress and human performance. Psychology Press.