The document discusses safety in aviation. It notes that accidents are only a small part of safety issues, with many more errors and unreported occurrences. It discusses human factors in aviation accidents and how human error is usually one link in a chain of events involving tools, tasks and the operating environment. The document outlines three main factors that can lead to human error - overload, inappropriate response, and inappropriate activities. It discusses error prevention through better task design, equipment design, training, and error-tolerant systems. Finally, it discusses responsibilities and considerations for various groups including pilots, flight schools, the FAA, DPEs and CFIs to promote a culture of safety in aviation.

1. Presented to:
By:
Date:
Federal Aviation
AdministrationThe Other Things We
Must Know!
It’s All About TheIt’s All About The
Safety……!Safety……!
Fred Harms

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Safety is a balancing act
Cost vs. Benefits
Cost vs. Benefits

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•ACCIDENTS
•INCIDENTS
•ERRORS AND
UNREPORTED
OCCURRENCES
Accidents
are only the
tip of the
iceberg!
For every
accident there
are 600 errors
and/or
unreported
occurrences

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HUMAN FACTORS
• The term 'human error’
– is used in recognition of the fact that most
aviation accidents do involve human error at
some point in the chain of events.
– these errors (or unsafe acts) tend to be just
one link in a chain of events.

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Human error is a symptom of
trouble deeper inside the system.
• Safety is NOT inherent in systems. People
have to create safety.
• Human error is connected to our tools, tasks
and operating environment. Progress in
safety comes from understanding and
influencing these connections.

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Error, by any other name….
• Complacency — the failure to recognize the
gravity of a situation or to adhere to
standards of care or good practice.
• Non-compliance — the failure to follow rules
or procedures that would keep the job safe.
• Loss of situation awareness — the failure to
notice things that in hindsight turned out to
be critical.

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3 Factors Leading to Human Error
1. Overload:Overload: is the imbalance between a person’s
capacity (natural ability, training, state of mind), and
added burdens resulting from environmental factors
(noise), internal factors (stress) and situational factors
(unclear instructions).
2. Inappropriate Response:Inappropriate Response: If a person detects
a hazardous condition but does nothing to correct it,
or if a person removes or fails to use a safeguard, it is
an inappropriate response.
3. Inappropriate Activities:Inappropriate Activities: A person who
undertakes a task that he/she does not know how to
do or misjudges the degree of risk in a given task and
proceeds based on the misjudgment.

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You have read the accident
reports!
• VFR into IMC
• Equipment malfunction, but deferred
• “Let’s take a look and see”
• “If you can get it inside, it will fly”
• “Why check the weather, we’re going
anyway!”
• “Although the weather was deteriorating,
the pilot pressed on.”

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Three factors in Intentional Non
Compliance
1. Motivation (Reward)
2. High Probability of Success
3. Absence of Peer Pressure or Reaction
All three required, or intentional non-
compliance does not occur.

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1. Task Design – design tasks with working
memory capacity in mind
2. Equipment Design
a) Minimize perceptual confusions – ease of
discrimination
• Ex: airplane controls that feel like what they do (flaps, wheels)
a) Make consequences of action visible – immediate
feedback
• Ex: choice box in some software programs
a) Lockouts – design to prevent wrong actions
• Ex: car that will not let us lock door if the key is still in
a) Reminders – compensate for memory failures
• Ex: ATM reminds us to take our card
Error Prevention / Mitigation

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3. Training – provide opportunity for mistakes
in training, to learn from them
• Ex: Scenario-based training/evaluations
4. Assists and Rules – checklists to follow
• Ex: Pilot pre-flight checklist
4. Error-tolerant systems – system allows for
error correction or takes over when operator
makes serious error
• Ex: Undo button in computer program
Error Prevention / Mitigation

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–Failure?Failure?
–Mistake?Mistake?

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The Focus of Flight Training
• Assumption – risk assessment skills will
emerge as part of the training experience.
• Reality – we are trained within a specific
operational environment and our experience
is relatively selective.
We have difficulty in accurately appraising
our performance and anticipating hazards
that we are likely to experience.

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The Great Lie
• “When pilots fail to admit the risks, the
odds are they won’t do a good job of
managing those risks.”
• “The vast majority of fatal accidents are
caused by a failure in risk management, yet
flight training is focused almost exclusively
on skill.”
• “The answer is that instructors must teach,
and pilots must learn a practical, proactive
procedure to anticipate and manage risks.”
John King

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A CLOSED MIND TO
RISK LEADS TO
ACCEPTANCE OF
GREATER RISK.

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Pilot Responsibility
• Knowledge/skill maintenance
• Motivation
• Know and comply with the rules
and the standards
• Evaluate and support a Safety
Culture

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Prevention Strategies
Recognize that…
• Procedures are there for a reason
• You (and your aircraft) have limitations
• The situation may be worse than you
think
• Nothing is worth killing yourself for
• People want you home in one piece
• Self discipline is the key

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School/FBO Responsibility
• Viability – staying in business
• Training/education
• Operating policies
• Support a Safety Culture
• Comply with the rules and
uphold the standards

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• Rote learning over cognitive – pass the check
ride.
• Inner-generational blindness.
• Reactive day-to-day business management.
• Turn over rate high.
• Newness to the aviation System.
Flight Schools Face Unique Pressures

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The Social Environment
1. Human behavior is influenced by our social
environment
a) Social norms, mgmt practices, morale, training,
incentives
• e.g. construction workers will not wear safety gear if no one
else is

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FAA Responsibility
• Create and enforce rules and
standards
• Verify training and performance
• Properly select DPE’s, and
assign responsibilities
• Impart a safety culture

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ICAO Annex 6
• “From 1 January, 2009,
States shall require, as part of
their safety programme, that
an operator implement a
safety management system
acceptable to the State of the
Operator…”
• The U.S. has filed a
difference with ICAO
• Currently, there are no FAA
authorized procedures to
accept or approve Service
Providers’ SMS’s

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Development of a Safety Management System
The story-line may seem familiar!

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DPE Responsibility
• Knowledge
• Motivation
• Task design
• Support a Safety Culture
• Comply with the rules and
uphold the standards

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CFI Responsibility
• Teach and comply with the
rules and standards
• Training/education
• Motivation
• Task design
• Impart a Safety Culture

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When pilots leave the supervisionWhen pilots leave the supervision
of their instructor theof their instructor the
accident rate goes upaccident rate goes up
almost 50%!almost 50%!

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Most pilots learn riskMost pilots learn risk
management by trialmanagement by trial
and error.and error.
Flight instructors canFlight instructors can
teach pilots specificteach pilots specific
risk managementrisk management
skills withskills with scenariosscenarios
that require the pilotthat require the pilot
to use those skills.to use those skills.

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Considerations for Decision Making
• Pilots make improper decisions when they feel a
pressure to go or continue.
• The safety culture or value system of any
organization can influence how a pilot makes
decisions.
• Completing a flight safely requires that every pilot
develop a risk assessment and management plan,
with personal minimums that are not compromised.

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Final Thoughts!
• We can’t stop people from being human….so
let’s build an error tolerant system of checks
and balances.
• If something goes wrong, you can count on
second guessers who have the benefit of
hind sight….SO

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Let’s Ask Ourselves These
Questions….
Will my decisions and actions be:
• Prudent?
• Reasonable by company standards?
• Consistent with best practices?
Bias to the conservative!

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Other Things We Must Know
Thank You For Attending
The Central Region FAA Safety Team (FAASTeam) is
dedicated to Quality Customer Service and we would value
your feedback. Please provide your feedback at:
www.faa.gov/about/office_org/headquarters_offices/avs/offices/afs/qms

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