The document discusses how the Royal Air Force (RAF) optimizes pilot performance through continuous feedback and self-improvement programs. It describes how RAF training incorporates lessons from fields like psychology and behavioral science to help pilots understand factors influencing performance like stress, arousal, and decision-making. The RAF aims to capture sources of error and underperformance to improve safety. Similarly, the document suggests financial firms could learn from the RAF's approach to better optimize investment decision-makers' performance.
Helicopters: My Type A is Better Than YoursIHSTFAA
This document outlines topics that were discussed in a meeting about safety issues in the helicopter industry. The meeting used a debate format to discuss controversial topics related to following rules and regulations. Some of the topics covered included the use of personal electronic devices in the cockpit, conducting flight risk assessments, implementing safety management systems, managing fatigue risk for maintenance workers, and adhering to standard operating procedures. Both sides of each issue were presented over a 4 minute time limit to generate discussion.
Analysis and Importance of Helicopter Accident ReportsIHSTFAA
This document provides an overview of loss of control accidents, which accounted for 41% of the 523 accidents studied. It examines specific loss of control occurrence categories like performance management, dynamic rollover, exceeding operating limits, emergency procedures, and loss of tail rotor effectiveness. Standard problem statements are given for the most common loss of control issues as well as intervention recommendations focused on training and safety management. Accident narratives are then presented to illustrate different loss of control scenarios. The goal is to use this analysis of real accidents to provide pilots with perspective on aeronautical knowledge and decision making beyond what is covered in typical flight manuals.
IHST Safety Resources for Helicopter Pilots and OperatorsIHSTFAA
The International Helicopter Safety Team (IHST) was created in 2006 with the goal of reducing worldwide civil helicopter accidents by 80% by 2016. With over 500 volunteers from 28 countries, IHST analyzes accident data to determine causes and develops safety tools like toolkits, bulletins, fact sheets and leaflets focused on improving safety culture and reducing accidents related to loss of control, visibility issues, and other frequent causes. IHST has helped reduce the average number of accidents per year since its inception and provides various products on its website and social media to promote safer helicopter operations worldwide.
Aeronautical Decision Making And Risk Management For PilotsMySkyMom
This presentation relies heavily on the FAA\'s Risk Management Handbook, which can be found at http://www.faa.gov It covers factors related to ADM, statistics, best practices, and related case studies.
This document discusses the concepts of Aeronautical Decision Making (ADM) and pilotage. It defines ADM as a systematic approach for pilots to determine the best course of action given a set of circumstances. The document outlines the basic steps of pilotage as navigating using landmarks on charts. It explains how ADM and pilotage are intertwined in flight planning by considering factors like the pilot, aircraft, environment and external pressures. Some operational pitfalls related to proper application of ADM during flight are also listed.
This document discusses the history and evolution of Crew Resource Management (CRM) training in the airline industry. It began in 1979 when NASA discovered many aviation accidents were caused by issues like poor communication and decision making among flight crews. United Airlines first adopted CRM in 1981, and it has since expanded to include other crew members. CRM training teaches skills like leadership, situation awareness, and decision making to improve safety. Studies found CRM has reduced errors and helped lower accident rates by around 70%. The crash of United Flight 232 in 1989 demonstrated how effective CRM can be when properly applied by a crew.
The document summarizes an analysis of the 2005 Helios Airways Flight 522 accident using the TRIPOD incident analysis methodology. It identifies five "tripods" or causal factors in the accident: 1) multiple warning systems on the Boeing 737 aircraft created challenges for the flight crew, 2) missing or failed barriers allowed the cabin altitude to exceed hypoxic thresholds, 3) organizational cultures where checklists are seen as ways to assign blame, 4) a lack of following checklists properly, and 5) latent failures remaining undiscovered prior to the accident. The analysis found nine missing barriers requiring changes and eight failed barriers that could be addressed more easily. It aims to shed light on organizational issues rather than blame individual pilots.
This document contains the text from a Federal Aviation Administration workshop on risk management for flight instructors. It discusses topics like defining risk, hazard, and risk assessment. It provides examples of accidents and the probable causes being related to pilot decision making. It emphasizes the importance of teaching pilots to identify risks, evaluate hazards, and make informed decisions using risk management processes and checklists. The document also contains several scenarios to help stimulate decision making skills in trainees.
Helicopters: My Type A is Better Than YoursIHSTFAA
This document outlines topics that were discussed in a meeting about safety issues in the helicopter industry. The meeting used a debate format to discuss controversial topics related to following rules and regulations. Some of the topics covered included the use of personal electronic devices in the cockpit, conducting flight risk assessments, implementing safety management systems, managing fatigue risk for maintenance workers, and adhering to standard operating procedures. Both sides of each issue were presented over a 4 minute time limit to generate discussion.
Analysis and Importance of Helicopter Accident ReportsIHSTFAA
This document provides an overview of loss of control accidents, which accounted for 41% of the 523 accidents studied. It examines specific loss of control occurrence categories like performance management, dynamic rollover, exceeding operating limits, emergency procedures, and loss of tail rotor effectiveness. Standard problem statements are given for the most common loss of control issues as well as intervention recommendations focused on training and safety management. Accident narratives are then presented to illustrate different loss of control scenarios. The goal is to use this analysis of real accidents to provide pilots with perspective on aeronautical knowledge and decision making beyond what is covered in typical flight manuals.
IHST Safety Resources for Helicopter Pilots and OperatorsIHSTFAA
The International Helicopter Safety Team (IHST) was created in 2006 with the goal of reducing worldwide civil helicopter accidents by 80% by 2016. With over 500 volunteers from 28 countries, IHST analyzes accident data to determine causes and develops safety tools like toolkits, bulletins, fact sheets and leaflets focused on improving safety culture and reducing accidents related to loss of control, visibility issues, and other frequent causes. IHST has helped reduce the average number of accidents per year since its inception and provides various products on its website and social media to promote safer helicopter operations worldwide.
Aeronautical Decision Making And Risk Management For PilotsMySkyMom
This presentation relies heavily on the FAA\'s Risk Management Handbook, which can be found at http://www.faa.gov It covers factors related to ADM, statistics, best practices, and related case studies.
This document discusses the concepts of Aeronautical Decision Making (ADM) and pilotage. It defines ADM as a systematic approach for pilots to determine the best course of action given a set of circumstances. The document outlines the basic steps of pilotage as navigating using landmarks on charts. It explains how ADM and pilotage are intertwined in flight planning by considering factors like the pilot, aircraft, environment and external pressures. Some operational pitfalls related to proper application of ADM during flight are also listed.
This document discusses the history and evolution of Crew Resource Management (CRM) training in the airline industry. It began in 1979 when NASA discovered many aviation accidents were caused by issues like poor communication and decision making among flight crews. United Airlines first adopted CRM in 1981, and it has since expanded to include other crew members. CRM training teaches skills like leadership, situation awareness, and decision making to improve safety. Studies found CRM has reduced errors and helped lower accident rates by around 70%. The crash of United Flight 232 in 1989 demonstrated how effective CRM can be when properly applied by a crew.
The document summarizes an analysis of the 2005 Helios Airways Flight 522 accident using the TRIPOD incident analysis methodology. It identifies five "tripods" or causal factors in the accident: 1) multiple warning systems on the Boeing 737 aircraft created challenges for the flight crew, 2) missing or failed barriers allowed the cabin altitude to exceed hypoxic thresholds, 3) organizational cultures where checklists are seen as ways to assign blame, 4) a lack of following checklists properly, and 5) latent failures remaining undiscovered prior to the accident. The analysis found nine missing barriers requiring changes and eight failed barriers that could be addressed more easily. It aims to shed light on organizational issues rather than blame individual pilots.
This document contains the text from a Federal Aviation Administration workshop on risk management for flight instructors. It discusses topics like defining risk, hazard, and risk assessment. It provides examples of accidents and the probable causes being related to pilot decision making. It emphasizes the importance of teaching pilots to identify risks, evaluate hazards, and make informed decisions using risk management processes and checklists. The document also contains several scenarios to help stimulate decision making skills in trainees.
This document discusses human factors and crew resource management (CRM) training. It aims to (1) demonstrate human factors concepts, (2) increase safety awareness, (3) ability to detect hazards, (4) effective communication, (5) decision making, and (6) identify human error factors. Past aviation accidents are reviewed that revealed human errors including distraction, fatigue, and failure to communicate effectively. Threats, errors, and their management are defined to optimize human performance and safety.
Safety Management Systems (SMS) and Decision MakingIHSTFAA
The document summarizes some key limitations of traditional safety programs:
1. Traditional safety programs are limited in their understanding of exactly what risks and threats create accidents, relying instead on "educated guesses" based on personal experiences.
2. They have no method of tracking safety implementations to measure return on investment and effectiveness.
3. They take a reactive approach rather than conducting analysis of the nature and prioritization of risks to proactively address safety issues.
Accident investigations at Sea: Learning from Failure or Failure to Learn?Nippin Anand
This document discusses different perspectives on accident investigations and highlights issues with current investigation methods. It argues that investigations should look beyond direct causes like human error and examine underlying organizational, cultural, and motivational factors. Investigations often oversimplify situations and fail to understand why professionals took the actions they did. To be effective, investigations need to consider the context and "local rationality" of situations rather than just focusing on rule violations.
This presentation was given on the 14th of April 2016 during the EASA/OPTICS Conference in Cologne, Germany. It is almost the same presentation given previously at the CHC Safety & Quality Summit but includes a few additional slides about the initial results of the data collected.
Crew Resource Management For Ems FinishedJohn Halbrook
The document discusses crew resource management (CRM) principles and how they can be applied to emergency medical services (EMS) to improve patient safety and outcomes. It outlines several aviation accidents caused by failures in communication, leadership, situational awareness and decision making among flight crews. Corresponding issues in EMS are identified, such as overlooking a patient's condition. CRM strategies such as effective communication, shared leadership, situation awareness and collaborative decision making could help address common EMS problems. The goal is for all crew members to work together safely and efficiently like an integrated team rather than individuals.
1. The document discusses various human factors that can lead to accidents in aviation, such as distraction, time pressure, and misperceptions.
2. It analyzes data on 523 helicopter accidents between 2000 and 2006, finding that the majority occurred during the enroute phase of flight and most involved emergency medical services.
3. Maintaining situational awareness, effective crew resource management, and understanding human tendencies towards error are emphasized as important for safety.
This document discusses implementing safety management systems (SMS) for small fleet and private operators. It addresses some of the key challenges in doing so, such as scaling traditional SMS systems down to an administratively manage level and determining which elements to prioritize with limited resources. The biggest challenge identified is getting operators to see the need for an SMS in the first place. The presentation provides an overview of SMS and how it differs from traditional safety programs by taking a more proactive, data-driven approach. It offers practical advice on developing SMS policies for small operators, including establishing personal flight limits and duty time policies. Fatigue management is discussed as an important area requiring policy. A just culture policy example is also presented.
Uses and Risks of Commercial Drones in StadiumsNige Austin
The Stadiums industry will enjoy great commercial bene t from the use of drones. It is also open to the risks associated with the misuse of drones by third parties.
This article explores this question of managing liability in the current Australian legal framework.
This document is from a Federal Aviation Administration (FAA) workshop for Certified Flight Instructors (CFIs) that focuses on takeoffs and landings. It discusses how most fatal accidents occur during the maneuvering phase of flight, including takeoff and landing. It emphasizes the importance of practicing stall, slow flight and spin recovery, as these maneuvers are where pilots are most vulnerable. The document also covers factors that can lead to distractions in the traffic pattern, techniques to improve survivability in crashes, and the importance of go-arounds and avoiding risky maneuvers like low-level aerobatics near airports.
Crew Resource Management- An Inquiry in to the Differences Between F:A-18 C ...Raymond Scholl
This document is a thesis submitted by Raymond J. Scholl to the School of Business and Management of National University in partial fulfillment of the requirements for a Masters of Science in Organizational Leadership. The thesis examines whether there are differences between F/A-18C pilots and F/A-18D aircrew (pilots and WSOs) along the dimensions of authority, teamwork, leadership, and safety. Data collection and analysis are used to help readers understand leadership concepts and skills valued by aircrew operating in high-risk environments. The literature review discusses existing research on crew resource management and the key dimensions of authority, teamwork, and leadership within aircraft cockpits.
Helios Airways Flight 522 crashed in 2005, killing all 121 people on board. The crew failed to properly set the pressurization system before takeoff, resulting in gradual cabin decompression and hypoxia. As the plane entered Greek airspace, the hypoxic crew did not contact air traffic control. Fighters were scrambled and saw the trainee pilot attempting to control the plane with portable oxygen. The plane crashed due to lack of fuel. The accident highlighted issues where the interfaces between the liveware (humans), software (procedures), hardware (plane systems), and environment (hypoxic conditions) were less than perfect.
HELIOS 522 - Mark Adrian Langtry - Crew Resource ManagementMark Adrian Langtry
The document discusses the International Civil Aviation Organisation's "SHEL" model for analyzing human factors in aviation. It uses the model to summarize the human factors that contributed to the crash of Helios Airways Flight 522. The flight crashed due to the crew's failure to properly set the pressurization system before takeoff, resulting in hypoxia. This was due to poor communication and decision making between the culturally diverse crew members as they attempted to operate the plane in a hypoxic state.
In 1994, the University of Texas Human Research Project and Delta Airline developed the Line Operations Safety Audit (LOSA) program. With time, the LOSA program evolved into what is now known as Threat and Error Management (TEM).
The TEM framework is an applied concept which emerged from the observations and surveys of actual flight operations. It considers the various issues that a flight crew may encounter as a result of internal and external factors.
This model explores the contributing factors of the threat to aviation safety and, in turn, allows for the unearthing of ways to mitigate them and maintain proper safety margins. Now recognized and adopted across continents, the TEM framework aims to educate flight personnel on managing threats and errors before they degenerate into serious incidents or accidents. It is important to note that TEM is also applicable to maintenance operations, cabin crew, and air traffic control.
This document outlines 12 common causes of human error in aircraft maintenance, called "The Dirty Dozen". It describes each of the 12 factors, including lack of communication, complacency, lack of knowledge, distraction, lack of teamwork, fatigue, lack of resources, pressure, lack of assertiveness, stress, lack of awareness, and norms. For each factor, examples of accidents are presented and recommendations are provided for how to reduce errors by improving safety nets like checklists, inspections, and communication between maintenance technicians. The goal is to raise awareness of the types of human errors that can occur and how following best practices in maintenance can help prevent accidents.
This document discusses aeronautical decision making (ADM) and provides an example of how poor decision making can lead to an accident. It begins by explaining that ADM is a systematic approach that helps pilots determine the best course of action given the circumstances through recognizing hazards. The document then provides more details on the history of ADM training and the steps involved in good decision making. It also discusses analytical decision making using the DECIDE model. Finally, it gives an example of how a pilot rushing to make a Thanksgiving dinner ignored weather hazards and crashed while attempting a landing with 100 foot ceilings and 1/4 mile visibility, illustrating how failing to follow proper decision making can have tragic consequences.
This document provides an overview of crew resource management (CRM) training, including its history and evolution. It discusses how CRM training was developed in response to accident analyses that found ineffective communication, inadequate leadership, and poor group decision making were factors in 70% of accidents. The first CRM programs in the 1980s focused on skills like leadership and interpersonal skills, while later generations integrated CRM into technical training and addressed issues like automation and human factors. Current CRM training is meant to be integrated into regular procedures. The document also lists common CRM training topics like communication, leadership, teamwork, decision making, error management, and stress/fatigue.
This 50 minute webinar presented by Prof. David Thirtyacre of Embry-Riddle Aeronautical University Worldwide, looks at UASs--Unmanned Aerial Systems, sometimes called drones, and provides an overview of the emerging field.
1. In 1999, a Global Hawk UAV successfully landed autonomously at Edwards Air Force Base after detecting abnormal temperatures during a test flight.
2. After landing, the UAV was commanded to taxi but a software error referenced the take-off speed of 155 knots instead of the 6 knot taxi speed.
3. As a result, the UAV accelerated down the runway at over 90 mph and crashed after failing to negotiate the turn at the end, causing $5.3 million in damage and halting the test program for three months.
Presentation by Dr Matthew Beck, of the Institute of Transport and Logistics Studies, University of Sydney. Delivered as a seminar on 11 July 2014 at the Choice Modelling Centre, University Leeds: www.cmc.leeds.ac.uk
The disappearance of Malaysian Air Flight MH370 on the 8th of March 2014 received worldwide media attention. Whilst air disasters resonant with the wider public more so than other transport disasters, the lack of information on why MH370 disappeared has the potential to make this incident particularly affective. With the exponential growth in international travel, along with a hyper-competitive marketplace for air service providers, understanding how travellers might react to such disasters will help inform the decisions of relevant policy makers, who are seeking to alleviate the concerns of the travelling public and minimise the potential for future issues. This study presents the preliminary results from a series of stated preference type experiments that examine the attitudes of potential travellers with regards to air travel and air travel safety.
Dr Matthew Beck is a Senior Lecturer and Program Director for Transport and Infrastructure Management at the Institute of Transport and Logistics Studies, University of Sydney. Matthew recently completed a PhD investigating the role of group decision making in the purchase of household motor vehicles. Prior to that he completed a Master of Philosophy in Marketing, also from University of Sydney, where he examined the transition of casual sporting fans to fanatical supporters. Matthew is also extremely active in consulting, working on diverse brand management, media relations, fast moving consumer goods and pharmaceutical projects. In the rare periods when not working, you might find him working on his real objective; becoming the number one golfer in transportation and logistics.
http://sydney.edu.au/business/staff/matthewb
The Unmanned Aerial System Can Also Loiter At A Different...Tara Hardin
Here are some key factors that can affect the National Transportation Safety Board's (NTSB) investigations:
- Weather conditions - Severe weather like thunderstorms, high winds, low visibility etc. at the time of an accident can impact evidence collection and delay investigations.
- Complexity of accident - Crashes involving new technologies, multiple aircraft or injuries/fatalities take more time and resources to investigate fully.
- Cooperation of parties involved - The willingness of operators, manufacturers, air traffic control to share data, records and personnel for interviews can expedite or slow down investigations.
- Political/regulatory environment - Pressure from political entities or pending regulatory decisions relating to an accident can influence investigation timelines and findings
The document discusses automation in aviation. It notes that automation reduces the need for human intervention through the use of control systems and information technologies. In aviation specifically, automation is increasingly used in flight operations and air traffic control. While automation improves efficiency and job completion, it can negatively impact human operators by shifting their role from performer to observer, potentially leading to complacency issues. The document examines both the advantages of automation, like increased situational awareness and reduced costs, and the disadvantages, such as overdependence on automation systems and complacency.
This document discusses human factors and crew resource management (CRM) training. It aims to (1) demonstrate human factors concepts, (2) increase safety awareness, (3) ability to detect hazards, (4) effective communication, (5) decision making, and (6) identify human error factors. Past aviation accidents are reviewed that revealed human errors including distraction, fatigue, and failure to communicate effectively. Threats, errors, and their management are defined to optimize human performance and safety.
Safety Management Systems (SMS) and Decision MakingIHSTFAA
The document summarizes some key limitations of traditional safety programs:
1. Traditional safety programs are limited in their understanding of exactly what risks and threats create accidents, relying instead on "educated guesses" based on personal experiences.
2. They have no method of tracking safety implementations to measure return on investment and effectiveness.
3. They take a reactive approach rather than conducting analysis of the nature and prioritization of risks to proactively address safety issues.
Accident investigations at Sea: Learning from Failure or Failure to Learn?Nippin Anand
This document discusses different perspectives on accident investigations and highlights issues with current investigation methods. It argues that investigations should look beyond direct causes like human error and examine underlying organizational, cultural, and motivational factors. Investigations often oversimplify situations and fail to understand why professionals took the actions they did. To be effective, investigations need to consider the context and "local rationality" of situations rather than just focusing on rule violations.
This presentation was given on the 14th of April 2016 during the EASA/OPTICS Conference in Cologne, Germany. It is almost the same presentation given previously at the CHC Safety & Quality Summit but includes a few additional slides about the initial results of the data collected.
Crew Resource Management For Ems FinishedJohn Halbrook
The document discusses crew resource management (CRM) principles and how they can be applied to emergency medical services (EMS) to improve patient safety and outcomes. It outlines several aviation accidents caused by failures in communication, leadership, situational awareness and decision making among flight crews. Corresponding issues in EMS are identified, such as overlooking a patient's condition. CRM strategies such as effective communication, shared leadership, situation awareness and collaborative decision making could help address common EMS problems. The goal is for all crew members to work together safely and efficiently like an integrated team rather than individuals.
1. The document discusses various human factors that can lead to accidents in aviation, such as distraction, time pressure, and misperceptions.
2. It analyzes data on 523 helicopter accidents between 2000 and 2006, finding that the majority occurred during the enroute phase of flight and most involved emergency medical services.
3. Maintaining situational awareness, effective crew resource management, and understanding human tendencies towards error are emphasized as important for safety.
This document discusses implementing safety management systems (SMS) for small fleet and private operators. It addresses some of the key challenges in doing so, such as scaling traditional SMS systems down to an administratively manage level and determining which elements to prioritize with limited resources. The biggest challenge identified is getting operators to see the need for an SMS in the first place. The presentation provides an overview of SMS and how it differs from traditional safety programs by taking a more proactive, data-driven approach. It offers practical advice on developing SMS policies for small operators, including establishing personal flight limits and duty time policies. Fatigue management is discussed as an important area requiring policy. A just culture policy example is also presented.
Uses and Risks of Commercial Drones in StadiumsNige Austin
The Stadiums industry will enjoy great commercial bene t from the use of drones. It is also open to the risks associated with the misuse of drones by third parties.
This article explores this question of managing liability in the current Australian legal framework.
This document is from a Federal Aviation Administration (FAA) workshop for Certified Flight Instructors (CFIs) that focuses on takeoffs and landings. It discusses how most fatal accidents occur during the maneuvering phase of flight, including takeoff and landing. It emphasizes the importance of practicing stall, slow flight and spin recovery, as these maneuvers are where pilots are most vulnerable. The document also covers factors that can lead to distractions in the traffic pattern, techniques to improve survivability in crashes, and the importance of go-arounds and avoiding risky maneuvers like low-level aerobatics near airports.
Crew Resource Management- An Inquiry in to the Differences Between F:A-18 C ...Raymond Scholl
This document is a thesis submitted by Raymond J. Scholl to the School of Business and Management of National University in partial fulfillment of the requirements for a Masters of Science in Organizational Leadership. The thesis examines whether there are differences between F/A-18C pilots and F/A-18D aircrew (pilots and WSOs) along the dimensions of authority, teamwork, leadership, and safety. Data collection and analysis are used to help readers understand leadership concepts and skills valued by aircrew operating in high-risk environments. The literature review discusses existing research on crew resource management and the key dimensions of authority, teamwork, and leadership within aircraft cockpits.
Helios Airways Flight 522 crashed in 2005, killing all 121 people on board. The crew failed to properly set the pressurization system before takeoff, resulting in gradual cabin decompression and hypoxia. As the plane entered Greek airspace, the hypoxic crew did not contact air traffic control. Fighters were scrambled and saw the trainee pilot attempting to control the plane with portable oxygen. The plane crashed due to lack of fuel. The accident highlighted issues where the interfaces between the liveware (humans), software (procedures), hardware (plane systems), and environment (hypoxic conditions) were less than perfect.
HELIOS 522 - Mark Adrian Langtry - Crew Resource ManagementMark Adrian Langtry
The document discusses the International Civil Aviation Organisation's "SHEL" model for analyzing human factors in aviation. It uses the model to summarize the human factors that contributed to the crash of Helios Airways Flight 522. The flight crashed due to the crew's failure to properly set the pressurization system before takeoff, resulting in hypoxia. This was due to poor communication and decision making between the culturally diverse crew members as they attempted to operate the plane in a hypoxic state.
In 1994, the University of Texas Human Research Project and Delta Airline developed the Line Operations Safety Audit (LOSA) program. With time, the LOSA program evolved into what is now known as Threat and Error Management (TEM).
The TEM framework is an applied concept which emerged from the observations and surveys of actual flight operations. It considers the various issues that a flight crew may encounter as a result of internal and external factors.
This model explores the contributing factors of the threat to aviation safety and, in turn, allows for the unearthing of ways to mitigate them and maintain proper safety margins. Now recognized and adopted across continents, the TEM framework aims to educate flight personnel on managing threats and errors before they degenerate into serious incidents or accidents. It is important to note that TEM is also applicable to maintenance operations, cabin crew, and air traffic control.
This document outlines 12 common causes of human error in aircraft maintenance, called "The Dirty Dozen". It describes each of the 12 factors, including lack of communication, complacency, lack of knowledge, distraction, lack of teamwork, fatigue, lack of resources, pressure, lack of assertiveness, stress, lack of awareness, and norms. For each factor, examples of accidents are presented and recommendations are provided for how to reduce errors by improving safety nets like checklists, inspections, and communication between maintenance technicians. The goal is to raise awareness of the types of human errors that can occur and how following best practices in maintenance can help prevent accidents.
This document discusses aeronautical decision making (ADM) and provides an example of how poor decision making can lead to an accident. It begins by explaining that ADM is a systematic approach that helps pilots determine the best course of action given the circumstances through recognizing hazards. The document then provides more details on the history of ADM training and the steps involved in good decision making. It also discusses analytical decision making using the DECIDE model. Finally, it gives an example of how a pilot rushing to make a Thanksgiving dinner ignored weather hazards and crashed while attempting a landing with 100 foot ceilings and 1/4 mile visibility, illustrating how failing to follow proper decision making can have tragic consequences.
This document provides an overview of crew resource management (CRM) training, including its history and evolution. It discusses how CRM training was developed in response to accident analyses that found ineffective communication, inadequate leadership, and poor group decision making were factors in 70% of accidents. The first CRM programs in the 1980s focused on skills like leadership and interpersonal skills, while later generations integrated CRM into technical training and addressed issues like automation and human factors. Current CRM training is meant to be integrated into regular procedures. The document also lists common CRM training topics like communication, leadership, teamwork, decision making, error management, and stress/fatigue.
This 50 minute webinar presented by Prof. David Thirtyacre of Embry-Riddle Aeronautical University Worldwide, looks at UASs--Unmanned Aerial Systems, sometimes called drones, and provides an overview of the emerging field.
1. In 1999, a Global Hawk UAV successfully landed autonomously at Edwards Air Force Base after detecting abnormal temperatures during a test flight.
2. After landing, the UAV was commanded to taxi but a software error referenced the take-off speed of 155 knots instead of the 6 knot taxi speed.
3. As a result, the UAV accelerated down the runway at over 90 mph and crashed after failing to negotiate the turn at the end, causing $5.3 million in damage and halting the test program for three months.
Presentation by Dr Matthew Beck, of the Institute of Transport and Logistics Studies, University of Sydney. Delivered as a seminar on 11 July 2014 at the Choice Modelling Centre, University Leeds: www.cmc.leeds.ac.uk
The disappearance of Malaysian Air Flight MH370 on the 8th of March 2014 received worldwide media attention. Whilst air disasters resonant with the wider public more so than other transport disasters, the lack of information on why MH370 disappeared has the potential to make this incident particularly affective. With the exponential growth in international travel, along with a hyper-competitive marketplace for air service providers, understanding how travellers might react to such disasters will help inform the decisions of relevant policy makers, who are seeking to alleviate the concerns of the travelling public and minimise the potential for future issues. This study presents the preliminary results from a series of stated preference type experiments that examine the attitudes of potential travellers with regards to air travel and air travel safety.
Dr Matthew Beck is a Senior Lecturer and Program Director for Transport and Infrastructure Management at the Institute of Transport and Logistics Studies, University of Sydney. Matthew recently completed a PhD investigating the role of group decision making in the purchase of household motor vehicles. Prior to that he completed a Master of Philosophy in Marketing, also from University of Sydney, where he examined the transition of casual sporting fans to fanatical supporters. Matthew is also extremely active in consulting, working on diverse brand management, media relations, fast moving consumer goods and pharmaceutical projects. In the rare periods when not working, you might find him working on his real objective; becoming the number one golfer in transportation and logistics.
http://sydney.edu.au/business/staff/matthewb
The Unmanned Aerial System Can Also Loiter At A Different...Tara Hardin
Here are some key factors that can affect the National Transportation Safety Board's (NTSB) investigations:
- Weather conditions - Severe weather like thunderstorms, high winds, low visibility etc. at the time of an accident can impact evidence collection and delay investigations.
- Complexity of accident - Crashes involving new technologies, multiple aircraft or injuries/fatalities take more time and resources to investigate fully.
- Cooperation of parties involved - The willingness of operators, manufacturers, air traffic control to share data, records and personnel for interviews can expedite or slow down investigations.
- Political/regulatory environment - Pressure from political entities or pending regulatory decisions relating to an accident can influence investigation timelines and findings
The document discusses automation in aviation. It notes that automation reduces the need for human intervention through the use of control systems and information technologies. In aviation specifically, automation is increasingly used in flight operations and air traffic control. While automation improves efficiency and job completion, it can negatively impact human operators by shifting their role from performer to observer, potentially leading to complacency issues. The document examines both the advantages of automation, like increased situational awareness and reduced costs, and the disadvantages, such as overdependence on automation systems and complacency.
The document discusses security issues in cyber-physical systems and proposes enforcing sensor network theory, information flow-based theory, and control theory to develop security policies and mechanisms for cyber-physical systems. It categorizes different types of attacks based on these three approaches and discusses mitigations to improve cyber-physical system security and allow their continued growth. The document defines cyber-physical systems as integrated computational and physical processes that sense, interact with, and control physical entities using communication, computation, and feedback control.
So what is single-pilot resource management? The FAA Risk Management Handbook notes that SRM is defined as the art of managing all the resources (both onboard the aircraft and from outside sources) available to a pilot prior to and during flight to ensure a successful flight
This document provides information about the "Air Surveillance & Reconnaissance 2011" conference to be held March 22-23, 2011 in London. The conference will bring together decision makers from over 10 countries to discuss current and future air ISR priorities, platforms, and technologies. It will feature presentations from leaders in the US, Canada, Germany, France, India, and other nations. Panel discussions led by NATO will examine platform integration and the future of UAVs. The goal is to provide timely intelligence from air assets to commanders on the ground. Sponsors and exhibitors will have opportunities for branding and thought leadership.
CHC Safety & Quality Summit 2016 - Risk Culture in Commercial Air TransportCranfield University
This presentation was given at the 2016 CHC Safety & Quality Summit in Vancouver. The aim was to present an argument to introduce 'Risk Culture' as a new component of 'Safety Culture. This is an academic research which aims to explore what/how operational risk decisions are made by pilots and engineers and if such decisions are also acceptable at different levels including senior management.
Human Centered Automation: a philosophy for automation in aviationPaula Azevedo Macedo
1) Human-centered automation is a philosophy where automation is designed to work cooperatively with human operators to achieve objectives, with the human retaining ultimate responsibility. It focuses on assisting and augmenting human capabilities.
2) Key principles of human-centered automation include keeping the human operator informed and in command of automated systems through predictability and mutual monitoring between human and automation.
3) The purpose of automation should be to make aviation systems more error-resistant and tolerant by fostering the best aspects of human-machine interaction.
This document discusses how unmanned systems can extend operational reach by providing intelligence, surveillance, and reconnaissance over greater areas for longer periods of time. It argues that unmanned vehicles allow operational commanders to influence battles from a greater distance in terms of space, time, and available forces. When deployed in networks, unmanned systems can monitor enemy activities across broad regions continuously and engage targets rapidly as situations develop. This persistence enhances situational awareness and allows a faster operational tempo that keeps adversaries unbalanced.
FAA Advanced Qualification Program (AQP) and CRM for Military & .docxlmelaine
FAA Advanced Qualification Program (AQP) and CRM for Military & Single Seat Pilots: Applications in CRM
ASCI 516 Applications in CRM
Module 8 Presentation
Military History of CRM
Military interest in CRM to prevent errors increased when training suggested an enhancement of mission effectiveness was also shown
In the Air Force, CRM was first considered as a way to take advantage of developments in training to update existing training for aircrew coordination
1980’s training programs in the Air Force, Army and Navy were generally referred to as Aircrew Coordination Training (ACT)
2
CRM in the Military
In 1970, civil aviation took the lead in CRM, and the military began implementing this type of training in the early 1980’s
3
Air Carrier and Military Aviation
Commonalities
Navigation
Weather
Controlling aircraft in flight
4
Differences
Purpose of organization
Qualifications of crews
Rank distinctions
Responsibilities of the crews
Labor relations
Miscellaneous factors (ie. Training)
5
Differences - Task
Task environment
Mission tasks
Decision goals
Time elements
Mission Alterations
Equipment
6
Differences - People
Entry level experience of military vs. civilian pilots
Promotion in military often means accepting jobs not related to flying
Motivation
Study of pilots who were both commercial airline and military reserve pilots showed military offers more of the “fun flying” and camaraderie
7
Differences - Organization
Rank and position
Officer/enlisted relations possible inhibitor of assertiveness
Rank reversals considered likely to add tension to cockpit relations
Formality that exits in military cockpit (based on recognition of rank differences) may act as barrier to effective communications
8
Military aircrew are often given duties that may interfere with their flying
safety officer
logistics officer
legal officer
maintenance officer
EEO program oversight
Scheduling
ordering A/C parts
train
investigate accidents
lecture
hold inspections
sit on promotion boards
fill out fitness reports
keep records
counsel subordinates
report to superiors
9
Training
Airlines are in business of transporting people safely – training is make that possible
Military trains for accomplishment of mission
virtually all peacetime flying is training activity
10
Military ACT/CRM Programs
By 1989 the Air Force/Navy/Army had at least one CRM-type program
Most programs are generally stand-alone lecture/discussion sessions, lasting 1-3 days
Videotapes developed for the airlines are often incorporated directly into programs
11
CRM For General Aviation
The Single Pilot
CRM For General Aviation
“No man is an island” and no pilot flies in a protective bubble.
How we interact with every person we come into contact with before and during a flight can significantly affect the outcome of that flight
Learning how to handle yourself and those around you is one of the keys to being a safer pilot
Crew Resourc ...
FAA Advanced Qualification Program (AQP) and CRM for Military & .docxnealwaters20034
FAA Advanced Qualification Program (AQP) and CRM for Military & Single Seat Pilots: Applications in CRM
ASCI 516 Applications in CRM
Module 8 Presentation
Military History of CRM
Military interest in CRM to prevent errors increased when training suggested an enhancement of mission effectiveness was also shown
In the Air Force, CRM was first considered as a way to take advantage of developments in training to update existing training for aircrew coordination
1980’s training programs in the Air Force, Army and Navy were generally referred to as Aircrew Coordination Training (ACT)
2
CRM in the Military
In 1970, civil aviation took the lead in CRM, and the military began implementing this type of training in the early 1980’s
3
Air Carrier and Military Aviation
Commonalities
Navigation
Weather
Controlling aircraft in flight
4
Differences
Purpose of organization
Qualifications of crews
Rank distinctions
Responsibilities of the crews
Labor relations
Miscellaneous factors (ie. Training)
5
Differences - Task
Task environment
Mission tasks
Decision goals
Time elements
Mission Alterations
Equipment
6
Differences - People
Entry level experience of military vs. civilian pilots
Promotion in military often means accepting jobs not related to flying
Motivation
Study of pilots who were both commercial airline and military reserve pilots showed military offers more of the “fun flying” and camaraderie
7
Differences - Organization
Rank and position
Officer/enlisted relations possible inhibitor of assertiveness
Rank reversals considered likely to add tension to cockpit relations
Formality that exits in military cockpit (based on recognition of rank differences) may act as barrier to effective communications
8
Military aircrew are often given duties that may interfere with their flying
safety officer
logistics officer
legal officer
maintenance officer
EEO program oversight
Scheduling
ordering A/C parts
train
investigate accidents
lecture
hold inspections
sit on promotion boards
fill out fitness reports
keep records
counsel subordinates
report to superiors
9
Training
Airlines are in business of transporting people safely – training is make that possible
Military trains for accomplishment of mission
virtually all peacetime flying is training activity
10
Military ACT/CRM Programs
By 1989 the Air Force/Navy/Army had at least one CRM-type program
Most programs are generally stand-alone lecture/discussion sessions, lasting 1-3 days
Videotapes developed for the airlines are often incorporated directly into programs
11
CRM For General Aviation
The Single Pilot
CRM For General Aviation
“No man is an island” and no pilot flies in a protective bubble.
How we interact with every person we come into contact with before and during a flight can significantly affect the outcome of that flight
Learning how to handle yourself and those around you is one of the keys to being a safer pilot
Crew Resourc.
This document summarizes key aspects of winter operations for airports, air traffic control, and pilots. It discusses how changing weather conditions increase risks of runway excursions and the importance of collaboration and communication between stakeholders. Specifically, it emphasizes the importance of disseminating timely information on field conditions to pilots, avoiding unstable approaches, understanding operational limitations during winter, and evaluating winter plans before the season begins to enhance safety. It also discusses challenges with complacency around standard phraseology and procedures over time.
This document discusses Crew Resource Management (CRM). It explains that CRM aims to reduce errors and incidents through sharing knowledge and best practices. It was developed based on findings that some aviation accidents were caused by issues like poor communication, decision making, and leadership skills. CRM training focuses on cognitive and interpersonal skills for managing resources rather than technical skills. It has been used successfully in commercial aviation since the 1980s.
Risk management involves weighing the costs and benefits of risks. Hazard recognition is critical to risk management. A hazard is a present condition that could lead to an unplanned event, like an accident. Four common aviation hazards are a nick in a propeller blade, improper refueling, pilot fatigue, and use of unapproved parts. Personality, education, experience, and regulations all influence a pilot's ability to recognize hazards. Experience provides knowledge over time but can also provide a false sense of security that causes pilots to ignore or fail to recognize potential hazards.
Ultimate Designer Guide Handbook for Aviation, Spacecraft, Marine and Defence...Aristotle A
A result of my four years of extensive research
& studies on Aerospace, Spacecraft, Marine &
Defense Sectors cockpit MFD software UX &
UI design guidelines.
The document discusses the Air Traffic Control Communication Working Group of the Flight Safety Foundation's Approach-and-Landing Accident Reduction (ALAR) Task Force. The ALAR Task Force aims to reduce approach-and-landing accidents by 50% within 5 years by identifying equipment, operational, regulatory and training improvements. The Working Group focuses on improving communication between pilots and air traffic controllers to enhance approach-and-landing safety. Several airlines and airports have implemented successful joint pilot-controller training programs to foster shared understanding.
10 Most Promising Aerospace Tech Solution Providers January 2022InsightsSuccess4
This edition features a handful of Aerospace Tech Solution sectors that are at the forefront of leading us into a digital future
Read More: https://www.insightssuccess.com/10-most-promising-aerospace-tech-solution-providers-january2022/
This document provides industry best practices for helicopter flight data monitoring (HFDM) programs. It discusses the key components of an HFDM program, including hardware and software, organizational structure, and processes. The hardware should be capable of reliably recording and transferring relevant flight data. The organizational structure should include a program manager, data analysts, and a review group. The core processes involve collecting, validating, analyzing and trending flight data to identify safety issues and improve performance. Maintaining a good relationship between the HFDM program and the operator's safety management system is also emphasized.
AVSS & The Institute for Drone Technology™ joint report government regulation...Paul New
Drones will fail. Drones will crash. Drones will hit humans. Drones will “fly-away”. Birds will interfere
with drones. Drones will be lost. Pilots and software will make errors.
This is the drone reality.
However, regardless of the potential risk factors involved with their operation, drones do provide
citizens, businesses, industries, and governments with tremendous value.
Furthermore, in many cases, drones provide a safer alternative to traditional manned aircraft
applications or civilian labour such as in oil and gas and mining inspection services.
Therefore, AVSS and The Institute for Drone Technology believe the challenge of the emerging drone
technologies is not to detect, exclude, or avoid the use of drones, but to determine how we can
safely utilize this growing and beneficial technology.
2. Page 2 | The Human in the Loop
ESSENTIA
WHITE PAPERS
About Essentia
Essentia Analytics is a cloud-based software solution that uses behavioral
data analytics to help professional investors to make more skilled investment
decisions.
Essentia’s platform enables both hedge and traditional active fund managers
to capture richer data about their own behavior and its context, to understand
where their individual skills and weaknesses lie, identify patterns, and apply that
enhanced self-awareness to achieve improved performance.
Investment excellence demands a feedback loop. Essentia supplies one.
Learn more about us, request a demo and subscribe to our white paper series
at www.essentia-analytics.com.
The author, David Taudevin, is founder
of WingPro, a UK-based technology and
consultancy start-up. With clients in corporate
aviation, the military and air display teams,
WingPro works to enhance human performance
and operational risk management in critical
environments.
He originally trained as a fast jet pilot in the
Royal Air Force where he was the receipient of
several accreditations, including the Queen’s
Medal in 2009 and the Sword of Honour as
top graduate of his course at the RAF College,
Cranwell. On leaving the RAF he joined and led
the commercial team at a financial technology
firm producing accounting and risk management
software for hedge funds.
Email: david@wingpro.io
LinkedIn: uk.linkedin.com/in/davidtaudevin
Twitter: @davidtaudevin
3. The Human in the Loop | Page 3
Foreword
At Essentia, we’re very interested in how behavioral science is being applied to
improving performance and reducing losses in industries outside of finance.
As you read this paper about how military organizations like the UK’s Royal Air
Force (RAF) have embraced the practice of optimizing “the human in the loop”,
I suspect you’ll note many parallels between fighter pilots and investment
decision-makers.
You might consider, therefore, if your own organization can take a leaf from the
RAF’s book:
• Do you have processes in place to recognize and mitigate behavioral risk?
Does this form part of the formal training being offered to new traders,
analysts and portfolio managers?
• To what extent is your pre-trade investment process captured through data,
and analyzed for behavioral patterns?
• How is error treated within your organization? Are there cultural or personal
factors which make it difficult for people to put their hand up and admit to
errors or perceived weakness?
• What self-improvement loops do your investment decision-makers have in
place?
• To what extent are data and feedback brought back into the risk
management program, so that it can be improved and updated to better
reflect the real drivers of error or underperformance ?
We hope you enjoy this whitepaper and look forward to discussing it with you.
Clare Flynn Levy
Founder and CEO
Essentia Analytics
4. VIDEO: Demonstration of the Eurofighter Typhoon’s extreme
agility. www.youtube.com/watch?v=QoVGz9xai1M
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The Human in the Loop
Fast jet flying is an inherently complex and
demanding activity that remains dependent
on the mindset and decision-making ability of
the pilot. Recognizing the need to optimize
this human performance in order to achieve its
operational goals, the RAF has initiated a culture
of self-improvement with dynamic feedback loops
that seek out and capture the real sources of
underperformance for consistently better outcomes.
Man and machine
Aviation technology and design has seen unprecedented advances in recent
years and few aircraft represent this so well as the Eurofighter Typhoon.
First launched by a consortium of European manufacturers in 2011 and now
being adopted by airforces around the world, the single-seater Typhoon is
generally recognized as one of the most innovative fighter jets on the planet.
Built from advanced composite materials with a surface that is only 15% metal,
the jet has a radar-resistant airframe that is light but also strong enough to
support highly agile maneuvering at speeds of up to MACH2.
5. The Striker Helmet - visor and movement-tracking diodes.
Photo: BAE Systems
The Human in the Loop | Page 5
Inside, gone are the numerous levers, dials, analogue gauges that used to
populate a cockpit. Instead, the Typhoon boasts technology that would be at
home in Google’s test labs with four powerful onboard computers powering a
range of performance and flight management functions.
Height, speed and tracking data are displayed directly onto the visor of the
pilot’s “Striker” helmet. Each helmet, individually tailored to the pilot’s head,
also displays live views from cameras positioned around the outside of the
aircraft.
Much like an alternative reality simulator, when the pilot turns his head,
movement in the diodes on the back of the helmet is captured by sensors
within the cockpit so the aircraft always know where the pilot is looking in and
which camera view to display. If the pilot looks down, he sees not his lap and
feet but the sky and passing fields below the aircraft.
Control of the £90m ($130m) jet is through voice command and an ergonomic
24-function fingertip control throttle. To determine the coordinates of anything
he sees, the pilot simply nudges the throttle and aligns the dynamic crosshairs
seen on his visor with the object. Pulling the trigger then directs intelligent
weaponry to the target without any need for the pilot to orient the aircraft
towards it.
Onboard technology also supports the jet’s Flight Control System. ‘Carefree
Handling’ constantly monitors the aircraft’s limits, optimizing aeronautical
performance and even stabilizing the aircraft at the touch of a button should the
pilot become disorientated or start to blackout.
Such advances throw an obvious spotlight on the role played by the individual
sitting at the heart of all this. Indeed, if aviation technology and automation can
now do so much, why do we even still need a pilot?
The Typhoon
boasts
technology
that would be
at home in
Google’s test
labs.
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In considering this question, the military has been at the forefront of the trend
towards an increased use of unmanned aerial vehicles.
Controlled from the ground or autonomously following a pre-programmed
mission, devices such as drones can be effective for surveillance or operations
where the repetitive or prolonged nature of the sortie would be compromised
by human fatigue issues. They are also attractive for military planners seeking to
reduce cost and casualty rates.
Such unmanned operations, however, remain only a small part of military
aviation’s total range of activities. This is because when it comes to highly
dynamic environments involving complexity or combat, there remains
consensus that a human pilot is still the most effective form of flight
intelligence; no other resource is so effective at analyzing a changing situation
and translating this into tactical (and ethical) decisions.
The flipside to this human involvement is that even the most experienced
pilots can be prone to underperformance or poor decision-making; some
70% of aviation accidents have been found to result from human error – a risk
exacerbated by the increased operational tempo seen since 9/11 and the
pressure on resources caused by defense budget cuts.
In managing this human risk (and thus leveraging more effectively the
investment made in hardware like the Typhoon jet), the RAF’s leadership has
been forced to consider how to best optimize this highly capable, though error-
prone, resource, namely ‘the human in the loop’.
Old and bold?
Based on experience and understanding that has evolved since the First World
War, the RAF now adopts a broad, multi-disciplinary approach to understanding
the drivers of pilot performance.
2007 saw the opening of the RAF’s Human Factors Centre where aviation
psychologists carry out human performance research on how humans interact,
reason and respond in order to reduce performance variability and improve
safety. No subject is off-limits if it helps explain pilot behavior and Human
Factors analysis, more broadly, now spans areas as diverse as psychology,
behavioral science, communications and ergonomics.
The lessons learned from these disciplines are then fed into a continuous
and embedded self-improvement loop that is supported by the RAF’s strong
performance ethos and a willingness to embrace error or failure as an indicator
of where change may be needed.
The organizational and individual self-awareness demanded by these initiatives
is far from the bravado and swagger of Top Gun’s Maverick and Goose. But as
Even the most
experienced
pilots can
be prone to
poor decision-
making.
7. The Human in the Loop | Page 7
Major General G R Coward OBE has shrewdly noted, “The old adage recalls
that there are old pilots and bold pilots but very few old and bold pilots. If it is
the bold that take risks, I would suggest that it is the old who have considered
these risks and taken measures to minimize them.”
1
Game face
Research into the psychology of fast jet flying has shown that the single seat
fighter cockpit is an acute laboratory for exploring human performance and the
principles of decision-making behavior.
Despite advances in technology, fast jet pilots are regularly pushed to the limits
of their ability to cope as they engage in high levels of tasking and tactical
thinking where the smallest decision error can end in disaster.
They do this an unforgiving environment in which their senses are bombarded
by multiple information streams and physiological stresses. (G-force, for
example, ranging from -3G to 9G in a Typhoon, can impact sight and
consciousness to the point of momentary black out).
Not surprisingly, the UK’s fast jet training program is famously rigorous. Only the
best RAF pilot trainees – aged between 18 and 25 – are streamed to take part in
the £12 million ($17m), four year course. The training is exhaustive in the detail
of its assessment processes; flying skills are tested and honed through over
400 hours supervised flying time with additional training and testing in flight
simulators.
Unlike other areas of the military where a willingness to follow orders is
essential, the RAF needs to develop the tactical, decision-making capabilities
of their pilots. Even when flying in formation with other aircraft, a fighter pilot’s
role is predominantly a solo one where there is huge pressure on the individual
to perform.
Fast jet trainees are trained to carry out independent evaluations of external
factors (wingmen, weather, threats, etc) and determine their own actions using
decision-making models such as RAPDAR (Recognize, Analyze, Prioritize,
Decide, Act, Review).
Human Factors research and its incorporation into RAF training means that
trainee pilots are also schooled in the psychological aspects of flying.
Well-established psychometric tests such as the Myers–Briggs Type Indicator
(MBTI) and Strength Deployment Inventory (SDI) are used by RAF instructors
to support their evaluation of how pilots perform and any blind spots or
personality traits that may be displayed. (Interestingly in Sweden, trainee pilots
have their MBTI personality type printed on the back of their helmet so that
an instructor sitting behind them can also evaluate their performance in this
Fast jet pilots
are regularly
pushed to the
limits of their
ability to cope.
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psychological context)
2
.
A pilot’s self-awareness of his state of mind when flying is also developed so he
can understand and manage the effect this can have on his decision-making
and flying performance.
Below, I review some of the main behavioral factors that are explored in
the training and which are material to fast jet flying throughout an airman’s
career. As you’ll see, some of the awareness and performance management
approaches are often more commonly associated with non-military fields such
as elite sports.
Behavioral factors in fast jet flying
Visualization
Also called guided imagery, mental rehearsal and performance meditation,
visualization is now an important technique used by many pilots as they prepare
for a sortie. After the pre-flight briefing, pilots will move to a designated area on
base which is free from distraction and interruption and where they can get in a
‘Mission Bubble’ and ready themselves mentally for the operation ahead.
Pilots are also known to ‘arm-chair fly’, sometimes with their hands in the
positions they will be when flying. It’s not unusual to see pilots sitting quietly in
the cockpit in the minutes before take off, visor down, quietly going through the
mission they are about to perform.
Going back as far as the 1920’s, professional investors have been
aware of the importance of psychology and behavioral factors
in determining successfully they invest. More recently, academic
research begun to quantify that impact.
Yet the financial services industry has been very slow to look at how
to best optimize the “highly capable, though error-prone, resource”
that is the trader or fund manager.
The natural inclination of investors is to focus on the behavior of
other market participants. But as the RAF has recognized, in what
is ultimately a solo pursuit, managing the ‘inner game’ is of critical
importance, as is the disciplined implementation of an intelligent
and comprehensive feedback loop.
9. The Human in the Loop | Page 9
Tracking Juice
Once in the air, pilots are trained to recognize that their ability to perform at the
highest levels is limited and needs to be managed carefully. Known colloquially
as ‘Tracking Juice’, the mental and physical concentration with which a fighter
pilot can pursue and accurately keep in his sights an enemy jet is known to be
as low as 15 minutes when pilots first start their training. After this surprisingly
short time, pilots typically display a marked weakening in their tracking
sharpness and aircraft handling. With greater experience and more measured
self-control, concentration levels - whilst remaining finite - can be significantly
extended.
Stress vs. Arousal
Stress and fear can be triggered by air-to-air combat as well as the risk of attack
from the ground. It also has non-combat sources: control displays can suddenly
go blank, landing gear can fail, fuel may leak or birds be ingested in an engine,
partially destroying it.
Because stress is a key risk in pilot performance, instructors focus a lot on the
‘spare mental capacity’ a pilot has at a given moment and how this affects their
ability to respond correctly to any threats or conditions that confront them.
A degree of stress - or arousal - is useful in keeping sharp a pilot’s observation
and responses to such events. Too much stress, however, and judgement will be
blurred, compromising performance and potentially escalating to panic.
Just how well a pilot performs under pressure is understood to be a function of
the Arousal Curve. This is derived from the Yerkes Dodson Law
3
, which states
that optimal task performance occurs at an intermediate level of arousal, with
relatively poorer performance at both lower and higher arousal levels. This
leads to an inverted U relation between arousal and performance, with the
proposition that the peak occurs at a lower level of arousal for easy than for
difficult tasks.
Graph: the relationship between arousal and performance.
The ability to
perform at
the highest
levels is limited
and needs to
be managed
carefully.
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In training, pilot stress can be addressed and better understood through
coaching techniques. For instance, if a student pilot is getting too stressed and
overwhelmed, the instructor sitting in the seat behind may remove one or more
tasks from the student (such as radio communication and navigation) allowing
the student to focus on just one or two aspects.
When flying solo, pilots are taught to monitor and be aware of their emotional
state. The onus is on the pilot to recognize if he is becoming overwhelmed and
to prioritize according to a set and well-ingrained priority hierarchy known as
‘Aviate-Navigate-Communicate’:
• AVIATE: Fly the aeroplane first and make sure you’re safe,
ignoring everything else if need be – (after all, if you crash or lose
control then everything else is moot). Then…
• NAVIGATE: Think about where you’re going and what you need
to do - this is the next level of safety. Then, when you’ve got
yourself together…
• COMMUNICATE: Talk to air traffic control, your formation, or
whatever is required.
This order of actions is necessary because a natural reaction under stress is to
have trouble prioritizing what needs doing. The Aviate-Navigate-Communicate
hierarchy prevents, for example, a pilot from talking to someone (eg air traffic
control) when they haven’t first properly controlled their aircraft.
Atul Gawande has documented in The Checklist Manifesto (Profile Books, 2010)
how checklists have been used extensively in aviation since the Second World
War when a new generation of increasingly complex jet engines entered into
service.
In his work analyzing the risk-taking behavior of traders
4
, John
Coates, of Cambridge University, has found a similar “ -shaped
dose–response curve”. His studies show that “traders experience a
rise in testosterone when their trades make money, which increases
their confidence and appetite for risk, so that in the next round of
trading they put on even larger trades. If they win again, as they
are likely to during a rising market, their profits will increase their
testosterone once more, until at some point confidence becomes
overconfidence, trading positions grow to a dangerous size and the
risk–reward profiles of the trades start to stack the odds against
them”.
U
A natural
reaction under
stress is to
have trouble
prioritizing what
needs doing.
11. The Human in the Loop | Page 11
A checklist will often contain items that a pilot would ordinarily be expected to
remember but, in times of high stress, they are effective because they ease the
path to responding semi-automatically and in the right way.
Fatigue
Whilst procedural or routine activities are relatively resistant to the effects of
fatigue, those which require creative thinking or real-time evaluation are more
susceptible to the detrimental effects of fatigue and therefore the risk of error.
The military generally makes an effort to select people with a certain degree of
fatigue resistance but this resilience can be easily stretched beyond its limits in
situations of unrelenting operational activity with little down time to recuperate.
Tours in hot countries also bring the de-energizing effects of dehydration and
heat stress
5
.
In managing this, pilots are expected to monitor their own condition and
consider the risks created by their fatigue. Unless in a total war scenario, it’s
totally accepted that a pilot will flag when he feels unfit to fly. (Indeed, a wider
awareness of the operational importance of sleep is reflected in RAF initiatives
to provide better on-base sleeping accommodation for pilots and encourage
power-napping during the day when needed).
Sensory detachment
Whilst the increased sophistication in the range and digital presentation of
data has clear advantages, it also creates the risk of negative side effects such
as sensory detachment and information saturation; every pilot will know the
feeling of being drawn into the screens and losing awareness of what’s going on
around them.
Risk Tolerance
Prolonged exposure to operational action can become a risk in itself. Once
deployed, pilots can quickly adapt to the norms of their new environment and
Pilots pilots are
expected to
monitor their
own condition
and consider
the risks created
by their fatigue.
Compared to military aviation, the risk for commercial airline pilots
is very often the opposite: the risk of too-low arousal. Accident
investigators have discovered that, due to autopilot functionality,
pilots are often very calm at the moment before they realize there is
a danger. As a result, their arousal levels increase very – too – quickly
and they go past the point of medium arousal to panic. (Avoiding
this risk-exaggerating lethargy is why commercial pilots tend to
rotate every 1.5 to 2 hours).
12. Even when flying on a mission with other aircraft, there can be
intense pressure on the individual pilot. Photo: Geoffrey H. Lee
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become anaesthetized to risk, often failing to notice a progressive shift towards
becoming more comfortable with greater and possibly unacceptable risks.
Cognitive Bias
Recent developments in behavioral science have also found their way into
aviation.
Behavioral science is the systematic analysis and investigation of human
behavior. Cognitive science, a subset, focuses on how information is
represented, processed, and how decisions are made.
Research has revealed the presence of cognitive biases which can filter the
perception of information and hinder our ability to make accurate or rational
decisions. Such biases are unconscious and can be triggered or exacerbated by
environmental, physiological or psychological cues.
Trainee pilots are taught about aviation specific cognitive biases and this is
ingrained through refresher courses and continuous peer reviews.
Below are listed some of the more well-known cognitive biases known to exist
within military aviation
6
:
Awareness of
cognitive biases
is ingrained
through
education and
continuous peer
review.
13. Table: Cognitive biases common to commercial and military aviation. Source: Capt Shem Malmquist
The Human in the Loop | Page 13
Ambiguity effect
Describes where a person is more likely
to select something that has an intuitively
clear risk as opposed to one that seems
relatively less certain. This could lead
someone to choosing a more risky option,
albeit a more certain risk.
Attentional bias
Humans pay more attention to things that
have an emotional aspect to them. This
may lead to a person making a decision
based on a perceived threat which is due to
a past experience or ‘thermal scar’.
Attentional tunnelling
The focus and allocation of attention to a
particular channel of information, diagnostic
hypothesis, or task for a duration that is
longer than optimal, given the expected
cost of neglecting other events or tasks.
Confirmation bias
Describes a situation where a person
ignores facts or information that do not
conform to their preconceived model or
understanding of the situation.
Automation bias
Automated aids and decision-support tools
are rapidly becoming indispensable tools in
high-technology cockpits and replacing a
cognitively vigilant information seeking and
processing, leaving one more exposed to
making errors.
Availability heuristic
Describes how people will over-estimate
the likelihood of an event based upon the
emotional influence the event may have
had, or how much personal experience
a person may have had with that type
of event. This can lead to incorrect
assessments of risk.
Optimism bias
This is a situation in which people are overly
optimistic about outcomes. This can be a
common issue in aviation where pilots may
have seen many bad situations turn out
“okay”. As a result, their sense of urgency
and risk can be reduced when it is not
warranted by the circumstances at the time.
Plan continuation
This might be considered a subset of
confirmation bias. Describes a strong
tendency to continue to pursue the same
course of action once a plan has been
made. May also be influenced by some
of the issues behind the ‘sunk cost effect’,
where there is a greater tendency to
continue an endeavour once an investment
in money, effort, or time has been made.
The Debrief
In creating and maintaining awareness of these and other behavioral factors,
one piece of old-school RAF process is critical: the debrief.
It is during their training that fighter jet pilots first learn the value of this
structured feedback loop. For every hour flown, pilots can expect a debrief that
will last twice as long with every aspect of their aircraft handling and mission
management passed under an unforgiving microscope.
Using visual aids, video footage, and comments from instructors and peers, the
intensely granular review process exists to identify mistakes and performance
issues with a big emphasis on ‘lessons learnt’ and the Human Factor aspects of
the sortie.
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The Birth of Military Human Factors
Early insights into the impact of pilot mindset were realized during
World War One when aerial warfare was first used both in a
concentrated way and as a tactical military tool.
James Birley, a wartime pilot, neurologist and early pioneer of
aviation psychology, observed that psychological effects could be
just as important as the physical in determining whether a pilot was
fit to fly. Flyers, he observed, became ‘stale’ or ‘burnt out’ if not
properly rested, with a negative impact on their ability to maneuver
and perform other tasks.
One factor generating stress in those early days of aviation was
the sheer strain caused in trying to control poorly designed and
temperamental aircraft. As aircraft flew higher, other stresses were
introduced such as the effect of cold and hypoxia (lack of oxygen).
Combat brought additional pressures. Though often far from the
dangers of the front line, airmen worked alone under extreme
pressure and lacked the comradeship and inspiration that came from
leading men. Allan English wrote about the extreme contrasts in a
pilot’s life: long spells of idle waiting on base punctured by urgent
calls to action and dogfights during which pilots reported feeling
“moments of intense fear”
7
.
World War Two saw marked advances in aviation technology, with
increases in speeds, altitudes, mission ranges and bomber payloads.
These brought commensurate increases in the risks faced by pilots.
However, by this time, understanding about their impact on pilot
performance had widened from concerned individuals to the RAF
itself. It was now accepted that pilots could be pushed beyond their
limits; studies at the time concluded that ‘human error’ accounted
for 70-80% of all aircraft accidents and shortages of men deemed
men fit to fly became a real issue as the war progressed.
Allied Jenny biplanes in World War One.
During the
1914-18 War,
awareness
grew that
psychological
factors were
critical in
determining
whether a pilot
was fit to fly.
15. VIDEO: The success of the debrief as an appraisal tool means
it is now used in non-aviation sectors. In this video, Flt Lt Simon
Stevens, a former Red Arrows pilot, talks about how it is used
to improve performance. www.vimeo.com/86602145
The Human in the Loop | Page 15
The debrief typically takes place in a private room and is organized as a
rankless forum in which everyone can speak. The flat structure is a significant
precondition because it allows lower-ranking airman to comment openly on
the performance of more senior officers without fear of punishment. Criticism
is encouraged and accepted because this is a forum dedicated to improving
the safety and performance of both the individual pilot and the squadron as a
whole.
The debriefs become less granular once a pilot has passed his training but
remain a key tool in maintaining awareness of process and behavioral risks.
Embracing Error
Fundamental to these Human Factor initiatives is the RAF’s willingness to
identify and explore performance risk wherever it exists.
Historically, there was little or no ‘organizational self-awareness’ of this kind;
non-mechanical accidents were typically attributed to ‘pilot error’, with the pilot
closest to the event sanctioned as a warning to others against making the same
mistake.
However, with developments in psychology, ergonomics and aeronautics, the
RAF gradually came to a more refined understanding of why accidents and
underperformance occur. Rather than seeing them isolation, the RAF now
tackles such performance weakness by looking for information about the chain
of contributing factors that led to it – factors which need to be understood and
managed before consistently better outcomes can be achieved.
The formal framework in which this feedback loop operates is the RAF’s
Safety Management System (SMS). Increasingly adopted by organizations in
non-aviation sectors looking to improve their performance, the SMS is based
The RAF has
emerged as an
organization
that is willing
to identify
and explore
performance
risk wherever it
exists.
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on four key components, or pillars: Policy, Risk management, Assurance and
Promotion. Together, these components define a dynamic risk management
approach that continuously refines itself to take account of new information and
performance data:
A Just Culture
Central to the success of this approach is the RAF’s ability to capture good data
about where underlying performance risk and error occur.
Collecting such information comes with very real challenges. In all organizations,
there is some degree of stigma and fear attached to coming clean about
mistakes and admitting the real reasons for underperformance. This is especially
Below: Graphical representation of the RAF’s Safety Management System.
Risk management is an area of utmost importance to the
investment management industry, not least due to the rising tide of
regulatory requirements. But how rich a picture are risk managers
actually seeing? And to what extent are data and feedback
brought back into the risk management program, so that it can be
improved and updated to better reflect the real drivers of error or
underperformance?
POLICY
RISK
MANAGEMENT
ASSURANCE
Establishes the organiza-
tional commitment to
continually improving
performance and safety;
defines processes and
resources available to
achieving this.
Promotion and training that creates
a risk-aware, performance-oriented
mindset within the organization. This whole process is enabled by an
operational culture in which people
feel comfortable admitting to error
or areas of performance weakness -
aka a ‘Just Culture’.
Builds a framework by
which underperformance
and Error Promoting
Conditions (EPCs) can be
measured and understood.
Initiates preventative
measures to control their
impact.
Evaluation, using data and
feedback, of implemented
risk control strategies.
Identification of new
hazards.
PROMOTION
17. The Human in the Loop | Page 17
the case when those reasons may be personal in nature, involve an admission of
perceived weakness of impact negatively on relations with colleagues.
The RAF has sought to tackle this through its adoption of a ‘Just Culture’.
Developed by James T. Reason, a Just Culture is characterized by the principle
that members of an organization should feel comfortable and safe about raising
their hand when they have made a ‘bad decision’ or see a mistake being made.
Negligence or deliberate mistakes are not excused in this environment but
neither is there blame for ‘honest errors’. Consequently, through transparency
at the individual and team level, an organization can hope to gather the
information it needs to identify the real causes of collective underperformance,
as well as monitor previously hidden or developing occurrence trends.
How receptive are the confident and invariably competitive pilots to this kind
of culture? RAF fast jet trainees are told from the beginning that they are the
best but it’s also drilled into them - through activities such as the Debrief and a
highly visible internal communications program - that there is always room for
improvement and ‘incremental gains’.
This also chimes with the disciplined, respectful approach to risk and
developing skill that is found throughout the more elite echelons of the military.
Andy McNab said it well when he observed that the SAS weren’t looking for
James Bond types but rather the kind of person who was “obsessive about their
craft”.
8
Trainee pilots
are told that
they are the
best but that
there is always
room for further
improvement.
“The dichotomy we face is the long held view that good
commanders are the bold leaders that take risk in order to achieve
success. Military history is littered with the accounts of distinguished
commanders who were known for their apparent disregard for
danger and who took great risks in the course of achieving success.
However, this view may, in many situations, be an over simplification.
I would suggest that in many cases it was less their daring that
brought about success, but more their innate understanding of the
risks involved.”
1
Major General G R Coward, OBE
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The adoption of a culture where there is an open identification and
review of ‘honest errors’ is far easier said than done, particularly in
an industry as traditionally opaque as investment management. As
the RAF has found, however, it starts with conveying constantly and
visibly the message that self-reflection and an ethos of continuous
improvement are to be lauded.
Conclusion
Despite impressive levels of innovation, military aviation remains an essentially
human endeavor – one that is dependent on the psychology and decision-
making ability of the individual pilot.
In optimizing this performance (and mitigating its inherent risk), the RAF has
over time come to adopt a shrewd and realistic understanding of the physical
and behavioral principles driving human performance.
A major part of this is the implementation of a culture in which error and
underperformance - in all its varied and often hidden forms - can be examined
and incorporated into an effective, systematic feedback loop. One can note
that, just as the RAF looked to elite sports and cognitive science for some of
its self-improvement techniques, so elements of its own organizational outlook
and approach are now being adopted by businesses in non-aviation sectors,
including investment management.
What will the future hold? Technology always advances and conceivably we
could soon see widespread adoption of aircraft handling through eye-tracking
or gesture control. Augmented reality is finding increasingly real-word
applications and maybe pilots will come to be assisted by digital avatars that
assist them with their decision-making.
However, even with this deepening of the relationship between man and
machine, the human remains very much in the loop. Technology allows us to do
more - how successfully it is exploited can still be very dependent on our own
performance.
19. The Human in the Loop | Page 19
References & Sources
1. Risk Appetite in Enduring Operations - by Major General G R Coward OBE,
Commander Joint Helicopter Command (JHC) - Defence Aviation Safety
Centre Journal 2008.
2. The Swedish Flying Training Philosophy - by Lt Col Robert Persson, Head
of Flight Safety, Swedish Armed Forces - Air Clues Magazine / Issue
15 - http://www.raf.mod.uk/rafcms/mediafiles/6547C11A_5056_A318_
A8E29A8B2A7F8407.pdf
3. http://wikiofscience.wikidot.com/quasiscience:yerkes-dodson-law
4. The Hour Between Dog and Wolf: Risk-taking, Gut Feelings and the Biology
of Boom and Bust - by John Coates - Published in 2012 by Fourth Estate (UK)
5. Fatigue and Human Performance - by Dr David Stevenson Colonel, USAF
(Rtd) - Air Clues Magazine / Issue 1 (October 2009) - http://www.raf.mod.uk/
rafcms/mediafiles/807515EC_5056_A318_A81019921CF3F852.pdf
6. I’m grateful to Captain Shem Malmquist, Air Safety and Accident
Investigator, for his work in compiling examples of some of the
cognitive bias found to be active in military and commercial aviation.
His excellent survey on behavioral factors and related aviation incidents
can be found at https://airlinesafety.wordpress.com/2014/04/21/
the-role-of-cognitive-bias-in-aircraft-accidents/
7. Cream of the Crop Canadian Aircrew, 1939-1945 - by Allan D. English -
Published 1996 by McGill-Queen’s University Press.
8. The Good Psychopath’s Guide to Success - by Andy McNab & Professor
Kevin Dutton - Published 2014 by the Bantam Press.
20. Despite the dramatic technological advances of recent years,
military aviation still faces the challenge of getting the most
from its pilots whilst also respecting their psychological limits.
In this Essentia white paper, David Taudevin, former RAF
fighter pilot, explores the psychological pressures faced by
elite military aviators and examines some of the cultural and
organisational initiatives taken to optimise their flying skill and
decision-making performance.
www.essentia-analytics.com