Management Science Letters

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1 Management Scence Letters (20) 2 28 Contents lsts avalable at GrowngScence Management Scence Letters homepage: A study on the crtcal factors of human error n cvl avaton: An early warnng management perspectve n Bangladesh Md. Salah Uddn Rajb a* and Luo Fan b a Assstant Professor, Faculty of Busness Admnstraton, Amercan Internatonal Unversty, Bangladesh (AIUB), Dhaka -2, Bangladesh b Professor, School of Management, Wuhan Unversty of Technology-40070, Wuhan, P.R Chna C H R O N I C L E A B S T R A C T Artcle hstory: Receved September 8, 204 Accepted December 204 Avalable onlne December Keywords: Crtcal Factors Human Error Developng Countres Fuzzy evaluaton Early Warnng Management Bangladesh The safety of cvl avaton wll be more secured f the errors n all the facets can be reduced. Lke the other ndustral sectors, human resource s one of the most complex and senstve resources for the cvl avaton. The error of human resources can cause fatal dsasters. In these days, a good volume of researches have been conducted on the dsaster of cvl avaton. The researchers have dentfed the causes of the cvl avaton dsasters from varous perspectves. They dentfed the areas where more concern s needed to reduce the dsastrous mpacts. Ths paper ams to fnd out the crtcal factors of human error n cvl avaton n a developng country (Bangladesh) as t s accepted that human error s one of man causes of cvl avaton dsasters. The paper revews the prevous research to fnd out the crtcal factors conceptually. Fuzzy analytcal herarchy process (FAHP) has been used to fnd out the crtcal factors systematcally. Analyses ndcate that the concentraton on precondton for unsafe acts (ncludng sub-factors) s requred to ensure the avaton safety. 20 Growng Scence Ltd. All rghts reserved.. Introducton Ar transport s growng rapdly and accordng to the nformaton of Internatonal Cvl Avaton Organzaton (ICAO), the expected growth rate s % to 6% over the next two decades. But, cvl avaton has to ensure the safety for ts customer. It s accepted that the accdent at arlne ndustry s more dsastrous than any other ndustry. Lke the other ndustral sector, sustanable growth s expected n that sector also. A combnaton of multple nter-related sequental events and falures are responsble for the cvl avaton ncdents and accdents, n whch human error plays a sgnfcant role (Hawkns, 99). Management of human error s a factor to reduce the accdent and to ensure the sustanable development of Arlnes. It s agreed that t s unrealstc to treat human and techncal factors as ndependent n ncdents and accdents (Isaac & Rutenberg 999). It s hardly possble to dentfy any factors responsblty to dsaster ndvdually, as dsaster s occurred by the combnaton of varous factors (human and techncal). Hence, proactve approach has been suggested n many studes *Correspondng author. Tel: E-mal addresses: rajb@aub.edu (Md. S. U. Rajb) 20 Growng Scence Ltd. All rghts reserved. do: 0.267/j.msl

2 22 (Maurno, 999). Consstng wth that, ths paper ams to fnd out the crtcal factors of human error n cvl avaton under the perspectve of a developng country whch s Bangladesh. Moreover, t hopes to represent the scenaro of most of the developng countres as well. It s natural that the entre system s nfrastructure ar ports and ar traffc control/management together can ensure the avaton safety and consequently can ensure the growth of cvl avaton effcently and effectvely. There are dfferent organzatons to assess the avaton safety of dfferent countres. The Federal Avaton Admnstraton of USA has categorzed the cvl avaton of Bangladesh n acceptable category (Knorr, 997). But, ths classfcaton becomes worthless when accdent takes place unpredctably. The researchers have also mentoned that the classfcaton contrbutes lttle to the mprovement of the avaton safety (e.g., Knorr, 997). Avaton Safety Network states that Bman Bangladesh Arlnes records accdents. Among accdents, two are fatal and remanng accdents are non-fatal. The man thng s that the consequences of any fatal accdent of cvl avaton are rretrevable. Hence, early warnng management can play a sgnfcant role n cvl avaton. 2. Lterature Revew Human error has been defned n varous ways. Swan and Guttman (98) defned human error as any member of a set of human actons that exceeds some lmt of acceptablty. Lorenzo (990) defnes human error as any human acton that exceeds the tolerances defned by the system wth whch the human nteracts. Reason (990) defnes human error as the falure to acheve an ntended outcome beyond the nfluence of random occurrence. Human error probabltes may assess from actual observaton or smulaton technques. Smulaton approach consders the dynamc model of the human operator, tasks, and external stuatonal factors (Woods et al., 987; Caccabue et al., 99). Rasmussen (982) s dentfcaton of multfaceted human error s a hghly cted research work. Rasmussen (982) dentfed the followng multfaceted human error; Table Multfaceted human error taxonomy (Adapted from Rasmussen, 982) Factors affectng performance Operator ncapactaton (sckness etc.) Internal human malfuncton Subjectve goals and ntentons Intrnsc human varablty Detecton Mental load, resources Mechansm of human malfuncton Identfcaton Affectve factors Dscrmnaton Decson Task characterstcs Input nformaton processng Acton Physcal envronment Recall External mode of malfuncton Work tme characterstcs Inference Specfed task not performed Causes of human malfuncton Physcal coordnaton Commsson of erroneous act External events (dstracton etc.) Personal task Commsson of extraneous act Excessve task demand (force, tme, Equpment/procedure desgn, Accdentally concdental events knowledge, etc.) nstallaton, nspecton, etc. (sneak path) The human error has been classfed n dfferent ways. Reason (990) classfed as Behavoral, Contextual and Conceptual. Behavoral error ncludes formal characterstcs (e.g., omsson, extraneous etc.), mmedate consequences (nature and extent of damage), observablty of consequences, degree of recoverablty, and responsble party. Casual error addresses the causalty by assocatng human errors wth characterstcs of the envronmental and task context. Conceptual error attempts to establsh causalty n terms of more fundamental, lkely predctable, characterstcs of human behavor (Reason, J., 990). Norman (98) classfes human error as; ) slps and 2) mstake. Slps are falures n executng the correct ntenton and mstakes result from mstaken ntentons. Prabhu et al. (992) organze error shapng factors from the three levels of cogntve control; ) Skll, 2) Rule and ) Knowledge. These human errors manly drve form effects of learnng, nterference among competng control structures, lack of resources, and stochastc varablty. The Human Factors Analyss and Classfcaton System (HFACS) s perhaps the most wdely used human factors accdent analyss framework. The framework s developed by Shappell and Wegmann (200, 200, 2004) through ther

3 Md. S. U. Rajb and Luo Fan / Management Scence Letters (20) 2 research work. There are 4 levels n that framework; Level : Unsafe acts of operators actve falures, Level 2: Precondtons for unsafe acts latent/actve falures, Level : Unsafe supervson latent falures and Level 4: Organzatonal nfluences latent falures (Shappell, S.A., 200, 200, 2004). Chang et al., (200) examnes human performance factors n ar traffc control on the bass of SHEL (Software, Hardware, Envronment and Lveware) model. L Wen-Chn et al. (2008) analyze 4 cvl avaton accdents occurred n Chna, between the years 999 to 2006 by usng the HFACS framework. Ther result fnds a sgnfcant relatonshp between errors at the operatonal level and organzatonal nadequaces at both the mmedately adjacent level (Precondton for unsafe acts) and hgher levels n the organzaton (Unsafe supervson and organzatonal nfluences). Shappell and Wegmann (200, 200, 2004) s model has been used n ths paper from the perspectves of proactve approaches to attan the objectve.. Methodology To attan the objectve of the paper Shappell and Wegmann (200, 200, 2004) s model has been used. One notable thng s that Shappell and Wegmann state that there s a herarchcal mpact n the model.e., upper levels are proposed to affect the lower levels. Ths noton has been kept unchanged cautously n the questonnare to ensure the qualty use of the model. Fg. s the model that has been used to formulate the questonnare. To cope wth the survey envronment, techncal computng method has been selected for the paper. Fuzzy logc has been used for the paper. Fuzzy logc s the codfcaton of common sense. It enables the approprate human reasonng capabltes. Fuzzy approach has been combned wth the Analytc Herarchy Process (AHP) developed by Thomas L. Saaty. MATLAB (Verson 6.) has been used to perform the techncal computng. The followngs are the basc of fuzzy logc that have been used n that research paper;. Fuzzy set If X s the unverse of dscourse and ts elements are denoted by x, then a fuzzy set A n X s defned as a set of ordered pars: A { x, A( x) x X}.2 Factor Selecton for the measurement Factors have been selected consstng wth the adapted model. In model, there are two levels. The frst herarchy factor s F F, (,2,. m), whch comes from the second herarchy factor and F j ( j,2,. n). Evaluaton Index ( ) for the Selected Factors Consstng wth the objectve of the paper, evaluaton Index has been formulated. Four dfferent classes have been used n the evaluaton scale to dentfy the crtcal factors of human error. They are; very hghly responsble ( V ), hghly responsble ( V 2 ), medum responsble ( V ), and normal responsble ( V 4 ). These classes have been formulated consderng the ntensty of factors to the human error..4 Weght ( A ) Assessment for the Selected Factors 9 rato scale has been used to formulate the decson matrx. Decson Matrx D has been formulated on the bass of the opnon of several experts consstng wth the rules of AHP (Analytc Herarchy Process). Two factors are compared on the same herarchy model as prescrbed by the factor herarchcal dvson model. Largest Egenvalue ( max ) has been used to calculate the Consstency Index ()

4 24 ( CI ) and consequently t (largest egenvalue) has been used n the calculaton of Consstency Rato ( CR ). Resource Management Organzatonal Organzatonal Clmate Resource Organzatonal Process Inadequate Supervson Unsafe Supervson Planned Inapproprate Operatons Faled to correct a known Problem Supervsory Volatons Human Error Physcal Envronment Technologcal Envronment Precondton for unsafe Acts Physcal/mental Lmtatons Adverse Mental Status Adverse Psychologcal Status Crew Resource Management Personal Management Decson Errors Unsafe Acts of Operators Skll-Based Error Perceptual Errors Fg.. HFACS, Upper level s proposed to affect the lower levels (Wegmann & Shappell, 200). Factor Evaluaton Matrx R Evaluaton matrx ( professonal. rjk R ) has been formulated after collectng the opnon of a group of executves and s a membershp grade that ultmately ndcates the degree of evaluaton grade. Evaluators opnon F j belongs to V k ( k,2,,4 ).,2, n n R ndcates the number of basc factors.,2, m ndcates the evaluaton factors.e., evaluaton sets V. R r r 2 rn r 2 r 22 r n2 rrm r 2m r nm Volatons (,2,,4 ) (2).6 Fuzzy Comprehensve Evaluaton Fuzzy comprehensve evaluaton method s started from the lower level to the hgher level n a multherarchy evaluaton problem. Fuzzy evaluaton set n the second herarchy:

5 Md. S. U. Rajb and Luo Fan / Management Scence Letters (20) 2 B A R ( b, b, b, b ) () 2 4 where b ( a r ) k n j jk (,2,,4 ; k,2,, 4) B has been used to ndcate the membershp grade of evaluaton object F to evaluaton element V k wth comprehensve evaluaton to each factor F j. After the second level of herarchy, st level of fuzzy evaluaton comes n the herarchy. R B A R B 2 A2 R 2 R j B 44 A R B A R Fuzzy comprehensve evaluaton of second herarchy; B A R b, b, b, ) In whch, b k n ( a j r jk.7 Handlng the Evaluaton Results ) ( 2 b4 ( k,2,, 4) () Grade weghted vector has been used to handle the fuzzy evaluaton that comes through the AHP approach. The used grade weghted vector s µv=(, 0.7, 0.0, 0.2). The comprehensve value can be dvded nto several ntervals as [, 0.7], [0.7, 0.0], [0.0, 0.2], [0.2, 0] correspondng to very hghly responsble, hghly responsble, medum responsble and normal responsble. Calculated comprehensve value nto the mentoned ntervals represents the vsually state of the human error factor. The parameter s a product of weghted vector µ v and B k. T N B ( b b.. b ) (6) T v k v, 2 k 4. Cvl Avaton n Bangladesh The Cvl Avaton Authorty of Bangladesh (CAAB) functons as the regulatory body for all avaton related actvtes n Bangladesh. CAAB s Responsble for safe, expedtous and effcent flow of the ar traffc wthn the Flght Informaton Regon (FIR). CAAB ssues the ar operator certfcate to the qualfed arlnes n Bangladesh. Apart from the government owned arlnes, there are prvate arlnes n Bangladesh certfed by CAAB. Bman Bangladesh Arlnes s the government owned arlnes n Bangladesh. Prvately owned arlnes of Bangladesh are Unted Arways, Regent Arways, NovoAr and US-Bangla Arlnes. There are nternatonal and domestc arports n Bangladesh. About 7 ar lnes are operatng n and out of the country. Bangladesh has blateral agreements wth about 4 states (CAAB, 202). Prevous nformaton ndcates that a huge amount s expensed at the reparng and reconstructon of the cvl avaton s nfrastructures whch are damaged by dfferent dsasters (Nehal Karm, 99). Bangladesh experenced only two fatal cvl avaton accdents. But the lves of human bengs that have been lost are rrecoverable. 4. Survey n Bangladesh To dentfy the crtcal factors of human error n cvl avaton of Bangladesh under the FAHP approach, a questonnare has been formulated consstng wth the Fg.. The data has been collected from the CAAB certfed arlnes personnel (executve level) of Bangladesh. For the basc factor decson, twenty executve opnons have been collected on bnary mood. Table 2 represents the statstcs of (4)

6 26 decson to dentfy the crtcal factors of human error from precondtons for unsafe acts. Statstcs of organzatonal resources, unsafe supervson and unsafe acts of operaton has not been presented at there. Table 2 has been presented as an example of mathematcal calculaton. Table 2 Crtcal factors of human error nvestgaton table for Precondton of Unsafe Acts Grade Element V (VHR) V 2 (HR) V (MR) V 4 (NR) Physcal Envronment Technologcal Envronment Physcal/Mental Lmtatons Adverse Mental States 6 9 Adverse Physologcal States Crew Resource Management Personal Readness The Evaluaton Matrx ( R ) has been formulated from the basc matrx (table 2), R The weghts ( A ) has been determned by several experts n terms of -9 rato scale value n decsons matrx D. Decson matrx for precondton of unsafe acts are gven as follows, D / / / / 7 / / / / / 7 /9 / / / / / / 7 The prorty vector has been calculated after the normalzaton of weght matrx. A A A A 4 A The calculated consstency rato s 0.0, 0.0, 0.04, 0.02 and 0.02 respectvely whch are below than / / 7 / 7 9 7

7 Md. S. U. Rajb and Luo Fan / Management Scence Letters (20) (C.R <0.). Hence consstency s acceptable. The fuzzy evaluaton of Eq. () yelds, B A R ( a r ) j B B B B Now, T B A* B, B2, B, B4 = (0.2, 0., 0.27, 0.8) Fuzzy evaluaton has been corresponds wth the dfferent sub-factors systematcally. That means B, B 2, B, B and 4 B has been corresponds wth F, F2, F, F 4 and F.. Results/Defuzzfcaton Fuzzy comprehensve value has been determned by parametrc representaton method: T N B (, 0.7, 0.0, 0.2) (0.0, 0.2, 0.4, 0.4) T = 0.0 T N2 B2 (, 0.7, 0.0, 0.2) (0.0, 0.2, 0.6, 0.) T =0.49 T N B (, 0.7, 0.0, 0.2) (0.40, 0.40, 0.6, 0.0) T =0.79 T N4 B4 (, 0.7, 0.0, 0.2) (0.02, 0.20, 0.44, 0.) T =0.47 T N B (, 0.7, 0.0, 0.2) (0.2, 0., 0.27, 0.8) T =0.64 The defuzzfcaon shows that the factors of precondtons for unsafe acts are more responsble for human error than the other factors n cvl avaton under the perspectve of organzatonal personal nformaton. Organzatonal resources, unsafe supervson and unsafe acts of operators are n the second, thrd and n fourth postons respectvely. 6. Conclusons The paper has amed to make the sense about the crtcal factors of human error n cvl avaton n a developng country. The FAHP approach has been used as t s agreed that fuzzy logc helps to code the sense of human bengs. The techncal computng ndcates that takng care s requred more for precondton for unsafe acts ncludng strong physcal envronment, technologcal envronment, handle physcal/mental lmtatons, adverse mental status, adverse psychologcal status, crew resource management and for personal management to ensure the safety of the cvl avaton n Bangladesh, a developng country. Therefore, the analyses urge concentraton should be more on the mentoned factors from the concerned authortes. Ths paper s nvolved wth the determnaton of crtcal factors of human error on the bass of nformaton obtaned from the organzatonal personal. In future, alternatve sources of nformaton can be used and combned together. It s agreed that the human and techncal factors are not ndependent n any ncdents and accdents of cvl avaton. Therefore, the contrbuton from the techncal to the human error can be measured n future more keenly. Acknowledgement Ths paper has been developed at the tme of workng at the project Study on Rsks Couplng Mechansm of Ar Traffc Safety and the Early Warnng Decson Support System supported by Natonal Natural Scence Foundaton of Chna (NSFC).

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