Aviation Human Factors: Protecting Us from Ourselves

1. Aviation Human Factors
Protecting Us from Ourselves
Jason Quisling
Aviation Compliance Evaluator
EC145/EC135
Air Methods Corporation
jquisling@airmethods.com
IHST/USHST – Training Work Group and SMS Work Group

2. Protecting Us from Ourselves
Weather report: Vertical visibility zero.
Pilot: Is that in feet or meters?

3. Please don’t try this in your helicopter!!!

4. Ground Rules
• The purpose here is to develop awareness
and educate.
• We are here to learn from others very
costly mistakes.
• Comments and ideas presented here are
mine personally and do not necessarily
reflect the opinions of my employer.

5. House of Pain
Est. circa 1939
• Fuel Mismanagement
• LTE
• Vortex Ring State
• Dynamic Rollover
• Autorotation
• IIMC/ Flight in DVE
• Loss of SA
• Miscommunication
• Overconfidence
• Lack of Planning
• Lack of Proficiency
• Violating regulation
or SOP

6. A Little About The Numbers
– www.ihst.org or www.ushst.org
1
Unacceptable
rise: Average of
181 annual
accidents during
this period.
IHST begins
Average of
148 annual
accidents.
Average of fatal accidents down
from 31 to 25 annually.
Source: NTSB data as of 8/01/2012

7. Analysis of US Accidents:
2000, 2001, 2006 by US Joint Helicopter Safety Analysis Team
Effect (OGE) operations. For identification purposes Maneuvering was considered a Phase
of Flight which was NOT classified as Landing, Enroute, Hover, Take-off, Approach,
Standing and Taxi. In general, Maneuvering is considered to be a change of direction
whether in low speed or high speed flight. Figure 10 identifies Enroute as the Phase of
Flight where the majority of fatal accidents occurred. These fatalities can be attributed to
potentially higher velocity speeds at impact.
Phase of Flight
2
4
3
11
28
34
4
2
18
32
63
78
72
68
104
0 20 40 60 80 100 120
Taxi
Standing
Approach
Take-off
Hover
Maneuvering
Enroute
Landing
Accidents
Note: 86 Fatal Accidents in Red, 437 Non-Fatal Accidents in Yellow
Figure 10. Phase of Flight (523 Accidents)
Note: 86 Fatal Accidents in Red, 437 Non-Fatal Accidents in Yellow
9
US JHSAT 2011 Compendium Report Volume I

8. IIMC in Alaska
• Lack of FRAT
• Inadequate SOP’s
• Punitive Culture
• Flight Data Monitoring

9. Hubris
Helicopter pilots are inherently teenagers…
They will consistently tend to overestimate their
abilities and underestimate the risks in a
particular operation.
This is your greatest threat to maintaining SA!!

10. exposure rates were unknown for this analysis, comparison of these statistics alone should
not be used to rank the relative safety record between different segments. If Industry
segment flight hour models were available in the future, analyses may allow for those
comparisons to be made.
Accidents by Industry (523 Total Accidents)
3
3
7
5
6
3
3
5
7
10
4
7
19
6
78
85
50
30
32
29
28
22
16
17
12
10
14
8
0 10 20 30 40 50 60 70 80 90 100 11
Electronic News Gathering
Utilities Patrol/Construction
External Load
Logging
Firefighting
Offshore
Aerial Observation
Business
Air Tour / Sightseeing
Law Enforcement
Commercial
Emergency Medical Services
Aerial Application
Instructional/Training
Personal/Private
Total Accidents
Note: 86 Fatal Accidents in Red, 437 Non-Fatal Accidents in Yellow
0
Figure 6. Accidents by Industry (523 Total Accidents)
Note: 86 Fatal Accidents in Red, 437 Non-Fatal Accidents in Yellow
Accidents by Activity
During the analysis, the team also grouped the data by “Activity”. This additional
category describes what specific activity the helicopter was completing on the specific flight
US JHSAT 2011 Compendium Report Volume I

11. 1. Distraction
-Talking/ Wx/ Listening/ Workload/
Warning light/ Etc.
2. Time – involved in a task there is always
too much or too little.
3. Illusion/Misinterpretation
-You can talk yourself into some pretty
dumb things, when you know you are
right.
3 Basic Elements of Disorientation

12. Night – Degraded Visual
Environments
• Lack of visual cues = IIMC in visual
conditions
• Technology to the rescue?
• New emergencies??
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13. Video by Dave Duncan

14. Safety Management Systems -
SMS
! Organizational Cultures and Safety
! Leadership and Teamwork
! Metrics – Recording, Reporting, Evaluating
and Fixing
! Data driven decision making will show where
to spend the dollars.
Safety Policy
Risk
Management
Safety
Assurance
Safety
Promotion

15. Culture is Key
Reporting Culture + Just Culture + Flexible Culture + Learning Culture =
Informed Culture which equates to “Safety Culture”
It’s Power is derived from not forgetting to be
afraid.

16. Role of Aviation Human Factors
• Asking and understanding the ‘Why’…
• Provides a means of understanding the
individual, as well as the organizational,
institutional, and other social factors that are vital
to error management and increased safety.
• Human Error accidents, which most are, can
then be controlled cost-effectively.

17. Error Management 101
1. ALL HUMAN BEINGS MAKE
MISTAKES.
2. Maintain Situational Awareness
3. Miscommunication is a reoccurring problem.
4. You do not know what you don’t know!!!
5. Technology and training cannot prevent ALL errors.
6. Human decision-making failures begin at the top of an
organization.
7. Accidents will result from NOT breaking the Error Chain.

18. Fuel Exhaustion
• Plan Continuation Bias
• AS350 US
• EC135 UK
LOW FUEL light(s) = “LAND THE DAMN HELICOPTER!!!”
- Matt Zucarro

19. Safety
Reliability is invisible in the sense
that reliable outcomes are
constant, which means there is
nothing to pay attention to.
Operators see nothing, and seeing
nothing presume that nothing is
happening.
-Karl Weick

20. Wire Strike Protection System
All systems have limitations – including those designed
to protect us.

21. Swiss Cheese Theory
• Every defense we put up is littered with holes.
• Multiple defenses may prevent accidents for
awhile.
• Over time drift occurs…
– we can find the right
combination that lines up
all the holes in our defenses.
• This results in an accident.

22. EC135 EMS Crash

23. Obstacles are always closer than you think.
Wires are present near any road or structure.
Communication frequently results in misidentifying a known obstacle.

25. Known Hazards are often Forgotten or Overlooked

26. Sometimes People Do Stupid
Things
While it’s true that you can’t fix
stupid…

27. Sometimes ..it Just Happens!!

28. Unintended Actions
Dr. James Reason
Slips – Error of Commission
Lapses – Error of Omission

29. Intended Acts
“Watch This…”
Mistakes or Violations

30. Hazardous Attitude?

31. Along for the ride…
Enroute IFR - on top at 7000MSL:
• In descent at about 6400MSL - IMC for about 3 minutes.
• Needed to add power to maintain A/S – IN THE DESCENT.
• Vy and Max Continuous Power with ROD above 1200fpm.
• Just below 3000msl (~1200AGL) descent was arrested and
aircraft is VMC between layers.

32. Every accident, no matter how minor, is
a failure of the organization.
Flight Safety Foundation reports that for every single accident,
there are on average 360 previous incidents, that if corrected,
may have prevented the accident.

33. Bell 407 Icing Encounter
• Surface observations MVFR
• AIRMET for Icing in effect

34. It is Important to Have a Little…

35. It may not be sexy…but we still
bend metal through:
• Vortex Ring State – Settling with Power
• Dynamic Rollover
• Loss of Tailrotor Effectiveness
• Flight in Degraded Visual Environments

36. It can happen to you
• Video of Mil 17 VRS crash

37. S-92 MGB Loss of Oil Pressure
• Training is only as good as the info going
in.
• Know your aircraft systems, but remember,
• You never know what you don’t know

38. CRM – SRM – AMRM – Etc.
• System for maintaining highest operating efficiency,
during periods of greatest STRESS.

39. F-16 Birdstrike

40. CRM for Dummies – “What s Our Plan?”

41. Maintenance and Preflight

43. BREAKING NEWS:
Captain America Training New Pilots

44. Be A Professional Aviator
Excerpts on professionalism by Tony Kern:
A mere pilot logs hours, a professional aviator logs lessons.
Experience does not automatically equate to wisdom, skill or judgment.
Debrief every flight for its inherent lessons, even if it’s just to yourself.
A mere pilot meets minimum standards; a professional aviator
redefines them upward.
Measure yourself against your God-given potential, not some arbitrary
regulatory minimum.
A mere pilot shows up; a professional aviator shows up ready.
Readiness is far more than showing up on time; it is preparing for
optimum performance against the day where you have to be at your
very best just to survive.

45. Situational Awareness
…or lack thereof.

46. Fly Smart!!And You Think You Have
Stress?