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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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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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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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• 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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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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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
The decision of an entire airline to no longer accept NDB approaches (Non-Directional Beacon approaches to a runway, in which the aircraft has no vertical guidance and rather imprecise lateral guidance) (Collins, 2001) is one example; the reluctance of airlines and/or pilots to agree on LASHO—Land And Hold Short Operations—which put them at risk of traveling across an intersecting runway that is in use, is another.
In resource-constrained systems, however, safety does not always prevail. RVSM (Reduced Vertical Separation Minima) for example, which will make aircraft fly closer together vertically, will be introduced and adhered to, mostly on the back of promises from isolated technical fixes that would make aircraft altitude holding and reporting more reliable. But at a systems level RVSM tightens coupling and reduces slack, contributing to the risk of interactive trouble, rapid deterioration and difficult recovery (Perrow, 1984).
ICAO is a United Nations Organization that issues international standards related to civil aviation. It bases its authority on the Chicago Convention, an international treaty. As administrators of the treaty, ICAO’s standards have the weight of the treaty itself. Member states have agreed to abide by the ICAO Annexes, which deliver the standards as specific to the various components of the air transportation system (e.g. manufacturing, air traffic, airports, operations, licensing, etc.).
Review slide in the context of:
There is a lot of energy around the deadline for Member States to be complaint with Annex 6, and what that means for the US aviation industry. Recall that the ICAO requirement applies to “Member States,” not individual service providers. Here is the extract….notice the golden words…..
Although the FAA does not have a regulation in place (to meet the Jan 1, 2009 deadline), the FAA has chartered an Aviation Rule-Making Committee (ARC), and the FAA is following its formal rulemaking process to consider an SMS rule. The FAA intends to comply with the ICAO requirement, but is unwilling to rush a formal process to produce a meaningless rule that doesn’t function for the Industry or the FAA. In the interim, Flight Standards is conducting SMS Voluntary Implementation Pilot Projects to develop experience for both the Industry and FAA.