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Captain Steve Pelecanos, Australasian Marine Pilots Institute: Black Swan Events - New developments in maritime safety

Captain Steve Pelecanos, Australasian Marine Pilots Institute: Black Swan Events - New developments in maritime safety



Captain Steve Pelecanos, Chairman, Australasian Marine Pilots Institutedelivered this presentation at Rail Safety 2013. For more information on the annual conference, please visit ...

Captain Steve Pelecanos, Chairman, Australasian Marine Pilots Institutedelivered this presentation at Rail Safety 2013. For more information on the annual conference, please visit http://www.railsafetyconference.com.au.



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    Captain Steve Pelecanos, Australasian Marine Pilots Institute: Black Swan Events - New developments in maritime safety Captain Steve Pelecanos, Australasian Marine Pilots Institute: Black Swan Events - New developments in maritime safety Presentation Transcript

    • Steve Pelecanos
    • What is a black swan?
    • Confirmed by empirical evidence It illustrates: • The severe limitations to our learning from observations or experience • The fragility of our knowledge • A single observation can invalidate general knowledge derived from (millennia of) confirmatory sightings
    • Examples of recent Black Swan Events • • • • • • • • • The 1987 stock market crash The recovery The demise of the Soviet Bloc The rise of Islamic Fundamentalism The effect of the spread of the internet 9/11 SE Asian Tsunami Japanese Tsunami/Earthquake/Nuclear PP meltdown GFC
    • How good are we at predicting the future? In 1943, the chairman of IBM, Thomas Watson, declared that, “there is a world market for maybe five computers.” In 1962, Decca recording company said of the Beatles, “we don’t like their sound, and guitar music is on the way out.” In 1974, Margaret Thatcher proclaimed that, “it will be years — not in my time — before a woman will become Prime Minister.”
    • 1001 days in the life of a Xmas turkey 24th December The Turkey’s well-being 250 200 150 Surprise 100 50 1 101 201 301 401 501 Days 601 701 801 901 1001
    • Predicting the evolution of the modern maritime pilot 80’s 70’s 60’s 50’s 90’s 00’s 10’s ?
    • Black Swan theory suggests it would be naïve to make predictions on the basis of what’s happened in (or projecting) the past.
    • The nervous system Command and Control Messages from sense receptors and to muscles and glands
    • Neuron dendrites soma axon synaptic knobs
    • Part 3
    • Generic skills learning continuum Competence
    • knowledge baseline knowledge refresher training α β γ α<β<γ<δ time δ
    • Unlearning • Unlearning is just as important as learning • It is the weakening of connections between neurons Bad Habits • If we only strengthened connections our neuronal networks would get saturated • It is essential when moving from one developmental stage to the next Neuromodulators • Enhance or diminish overall performance of synaptic connections • Bring about enduring change • Release oxytocin to effect change
    • Part 4
    • AF447 Rio to Paris
    • Response to Interim BEA Report Professor Mishkati – University of Southern California, Adviser to US Secretary of State Technology may be masking a deterioration and deskilling in basic flying ability. Lessons learned from a generation of pilots may be lost to the new breed of pilots. Bill Voss – Flight Safety Foundation President Skills are being lost. We must go back and look at our training for it is not consistent with what the real world circumstances are. David Evans – A380 Check Captain Qantas Two young pilots were at the controls and were confronted by alarms and false warnings that took all their attention. They missed other cues – simple things like aircraft attitude and throttle settings. Jean-Paul Troadec – Chairman, BEA The situation was salvageable NASA Research Centre Pilots are becoming complacent and relying too much on automation but that’s because airline SOP’s mandate reliance on automation. Automation lends to a false sense of security, especially with inexperienced pilots who reported a higher sense of “insecurity” during automation failure and tended to ignore raw data.
    • QF32 • No 2 engine failure • Loss of control of No. 1 engine • damage to the nacelle, wing, fuel system, landing gear and flight controls • 53 ECAM messages
    • Captain David Evans – Senior A380 Check Captain, QANTAS • Reintroducing some basic aerobatics to the training would go a long way • Because many pilots learn on flight simulators, they are focused only on what’s in front of them. Peripheral skills are lacking and they don’t look out the window • When I’m training younger pilots, they are often transfixed on the primary flight display and do not scan other instruments such as the engine. They just don’t look around. • Standard recurrent training set by the regulator is changing to take account of Black Swan events • Modern technology is inherently very reliable, however, its very reliable nature can lure an unsuspecting aviator into a false sense of security. Adding blind faith to this information stream, especially if you are a GEN X or GEN Y “technology native” can have catastrophic results • Pilots need a healthy scepticism of the information and an ability to see through the instrumentation and take in other prominent cues to enhance the big picture.
    • INTERNATIONAL CIVIL AVIATION ORGANISATION Training and Qualification Initiative (TQI) Focus on: • Flight Operations • Evidence based training • Instructor qualifications • Selection criteria Randy Babbitt – FAA Administrator, on the new Rules: • Pilots will need to show they can apply skills, not just master them • There will be a more robust evaluation of pilots • There is a shift to comprehensive competence rather than mastery of individual skills Roger Weeks – CASA’s representative on TQI • CASA and the Australian airlines have been working on training for more Black Swan events
    • Part 5 modernising the AMPI training regime Black Swans neural pathways AMPI Training Standard learning and unlearning Aviation initiatives
    • modernising the AMPI training regime Black Swans 1. 2. 3. 4. Number of pilot positions will double in the next 8 years There are not sufficient MC1’s to satisfy demand The pilotage task is changing Operational Emergencies and Failures Response 1. Regain control of Alternate pathway (Ab initio) training 2. Arrest insidious deskilling process (first principles competence) 3. Incorporate “black swan” training in AMPI Training Standard
    • modernising the AMPI training regime Neural Pathways 1. Systems approach creates strong neural pathways which are appropriate for a normal operational environment but difficult to abandon during “black swan” events. 2. Use of technology and instrumentation is, in many cases, vital however, it shrinks the sensory (pilotage) brain map whose use in an emergency is degraded. Response 1. Develop a training regime that strikes a balance between a systems approach using technology and a systems approach using first principles (seamanship) to ensure that technological and sensory brain maps remain active.
    • modernising the AMPI training regime Learning and Unlearning 1. Minimum no. of observation trips is an ineffective training model 2. Training pilots are probably not qualified for the task 3. CPI – the law of diminishing returns? 4. We are probably unlearning the wrong stuff Response 1. Develop programs to maximise learning environment 2. Bias learning towards practical and multi-sensory experiences 3. Focus on unlearning techniques
    • modernising the AMPI training regime Aviation Initiatives 1. Technology is masking deskilling 2. Pilots are becoming complacent and relying too much on automation, ignoring raw data 3. Lessons learned from a generation of pilots are being lost 4. Reintroduction of basic airmanship to training 5. ICAO TQI – including training for “black swan” events Response 1. 2. 3. 4. Training Standard to include basic seamanship Training Standard to include training for “black swan” events Training should be founded on evidence-based learning Instructors should be qualified and approved by AMPI
    • Training… Something to think about Continuous Learning Alvin Toffler wrote that “the illiterate of the 21st century will not be those who cannot read or write, but those who cannot learn, unlearn, and relearn.” We learn constantly; we do not distinguish between “working” and “learning”; we strive to convert every experience into a learning event. 
Simplicity Hans Hofmann observed that “the ability to simplify means to eliminate the unnecessary so that the necessary may speak.” In everything we do, we should strive to keep things simple and easily comprehensible. Quality The highest quality, consistently delivered, is the only acceptable way forward.