Advanced automated glass cockpit certification: Being wary of human factors

This paper presents some facets of the French experience with human factors in the process of certification of advanced automated cockpits. Three types of difficulties are described: first, the difficulties concerning the hotly debated concept of human error and its non-linear relationship to risk of accident; a typology of errors to be taken into account in the certification process is put forward to respond to this issue. Next, the difficulties connected to the basically gradual and evolving nature of pilot expertise on a given type of aircraft, which contrasts with the immediate and definitive style of certifying systems. The last difficulties to be considered are those related to the goals of certification itself on these new aircraft and the status of findings from human factor analyses (in particular, what should be done with disappointing results, how much can the changes induced by human factors investigation economically affect aircraft design, how many errors do we need to accumulate before we revise the system, what should be remedied when human factor problems are discovered at the certification stage: the machine? pilot training? the rules? or everything?). The growth of advanced-automated glass cockpits has forced the international aeronautical community to pay more attention to human factors during the design phase, the certification phase and pilot training. The recent creation of a human factor desk at the DGAC-SFACT (Official French services) is a direct consequence of this. The paper is divided into three parts. Part one debates human error and its relationship with system design and accident risk. Part two describes difficulties connected to the basically gradual and evolving nature of pilot expertise on a given type of aircraft, which contrasts with the immediate and definitive style of certifying systems. Part three focuses on concrete outcomes of human factors for certification purposes

Collasso Sferico e Strutture Cosmologiche

Nella trattazione che segue si discuterà il meccanismo di formazione delle strutture a grandi scale (galassie, ammassi di galassie, ecc.), problema della Cosmologia moderna ancora oggi non del tutto risolto. Nel Capitolo 1 ci introdurremo brevemente alla Cosmologia moderna. In particolare studieremo le equazioni che governano l’Universo (equazioni di Friedmann, del fluido, di accelerazione) e studieremo il comportamento delle loro soluzioni in funzione di diversi parametri. Vedremo così l’esistenza di differenti modelli e geometrie adatti alla descrizione del Cosmo e ne elencheremo le principali caratteristiche. Nel Capitolo 2 introdurremo la teoria dell’instabilità gravitazionale. Considereremo l’Universo come un fluido stazionario dotato di una propria equazione di stato e di un sistema di equazioni capace di descriverne il comportamento, per poi studiarne l’evoluzione in presenza di piccole perturbazioni delle quantità coinvolte (densità, pressione, velocità, entropia, potenziale). Estenderemo poi l’idea ad un fluido non stazionario, in particolare ad Universi piatti descritti dall’equazione di Friedmann. Trattando un Universo iniziale prevalentemente radiativo accenneremo all’effetto di stagnazione di una perturbazione. Nel Capitolo 3 tratteremo il modello di collasso sferico, adatto a descrivere l’evoluzione di una perturbazione di densità in regime non lineare. Stabiliremo condizioni di soglia per il collasso dell’oggetto sferico sovradenso e ne analizzeremo le diverse fasi di evoluzione. Infine assumeremo l’esistenza della Costante Cosmologica L e analizzeremo nuovamente il processo di collasso, evidenziandone somiglianze e differenze con le teorie precedenti.ope

Safety analysis over time: seven major changes to adverse event investigation

© 2017 The Author(s).BackgroundEvery safety-critical industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. The systematic analysis of incidents has greatly expanded our understanding of both the causes and prevention of harm. These methods have been widely employed in healthcare over the last 20 years but are now subject to critique and reassessment. In this paper, we reconsider the purpose and value of incident analysis and methods appropriate to the healthcare of today.Main textThe primary need for a revised vision of incident analysis is that healthcare itself is changing dramatically. People are living longer, often with multiple co-morbidities which are managed over very long timescales. Our vision of safety analysis needs to expand concomitantly to embrace much longer timescales. Rather than think only in terms of the prevention of specific incidents, we need to consider the balance of benefit, harm and risks over long time periods encompassing the social and psychological impact of healthcare as well as physical effects.We argued for major changes in our approach to the analysis of safety events: assume that patients and families will be partners in investigation and where possible engage them fully from the beginning, examine much longer time periods and assess contributory factors at different time points in the patient journey, be more proportionate and strategic in analysing safety issues, seek to understand success and recovery as well as failure, consider the workability of clinical processes as well as deviations from them and develop a much more structured and wide-ranging approach to recommendations.ConclusionsPrevious methods of incident analysis were simply adopted and disseminated with little research into the concepts, methods, reliability and outcomes of such analyses. There is a need for significant research and investment in the development of new methods. These changes are profound and will require major adjustments in both practical and cultural terms and research to explore and evaluate the most effective approaches

Problems and promises of innovation: why healthcare needs to rethink its love/hate relationship with the new

Innovation is often regarded as uniformly positive. This paper shows that the role of innovation in quality improvement is more complicated. The authors identify three known paradoxes of innovation in healthcare. First, some innovations diffuse rapidly, yet are of unproven value or limited value, or pose risks, while other innovations that could potentially deliver benefits to patients remain slow to achieve uptake. Second, participatory, cooperative approaches may be the best way of achieving sustainable, positive innovation, yet relying solely on such approaches may disrupt positive innovation. Third, improvement clearly depends upon change, but change always generates new challenges. Quality improvement systems may struggle to keep up with the pace of innovation, yet evaluation of innovation is often too narrowly focused for the system-wide effects of new practices or technologies to be understood. A new recognition of the problems of innovation is proposed and it is argued that new approaches to addressing them are needed

Problems and promises of innovation: why healthcare needs to rethink its love/hate relationship with the new

Innovation is often regarded as uniformly positive. This paper shows that the role of innovation in quality improvement is more complicated. The authors identify three known paradoxes of innovation in healthcare. First, some innovations diffuse rapidly, yet are of unproven value or limited value, or pose risks, while other innovations that could potentially deliver benefits to patients remain slow to achieve uptake. Second, participatory, cooperative approaches may be the best way of achieving sustainable, positive innovation, yet relying solely on such approaches may disrupt positive innovation. Third, improvement clearly depends upon change, but change always generates new challenges. Quality improvement systems may struggle to keep up with the pace of innovation, yet evaluation of innovation is often too narrowly focused for the system-wide effects of new practices or technologies to be understood. A new recognition of the problems of innovation is proposed and it is argued that new approaches to addressing them are needed

Dialogue control strategies in oral communication

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