CALLBACK 504 presents reports in which altitude deviations are triggered by mistakes or misperceptions shaped by Human Factors as opposed to deviations stemming from equipment or system failures.
Frequently, Human Factors play the significant role in the sequence of an altitude deviation incident. Mistakes mainly occur in automation management, instrument interpretation, altimeter settings, and communication with controllers and crewmembers...
Hello Michel - from a Safety I perspective this comes as no surprise. Taking a Safety II view on this, however, poses questions such as: How many potential altitude deviations were prevented by human intervention (pilots, controllers)? - What were some of the factors surrounding the instances and were the automation (mis)management, instrument (mis)interpretations, altimeter (mis)settings and (mis)communications perhaps due to sub-optimal design of the system and/or procedures? I firmly believe that a combined analysis - both, Safety I and II - promises the next quantum leap in safety management. Simply looking at what went wrong short-changes us...
Hi Max, good to read from you in this other context!
You are right and combining Safety 1 and Safety 2 is suggested by many and appears mostly promising.
Interestingly, we knew well before Safety 2 the positive role of pilots and other human operators in socio-technical systems and the importance of surrounding factors in poor, as well as good, performance.
Refer for instance to James Reason.
